Short-Term Memory Deficit Associates with miR-153-3p Upregulation in the Hippocampus of Middle-Aged Mice

The early stages of ageing are a critical time window in which the ability to detect and identify precocious molecular and cognitive markers can make the difference in determining a healthy vs unhealthy course of ageing. Using the 6-different object task (6-DOT), a highly demanding hippocampal-dependent recognition memory task, we classified a population of middle-aged (12-month-old) CD1 male mice in Impaired and Unimpaired based on their short-term memory. This approach led us to identify a different microRNAs expression profile in the hippocampus of Impaired mice compared to Unimpaired ones. Among the dysregulated microRNAs, miR-153-3p was upregulated in the hippocampus of Impaired mice and appeared of high interest for its putative target genes and their possible implication in memory-related synaptic plasticity. We showed that intra-hippocampal injection of the miR-153-3p mimic in adult (3-month-old) mice is sufficient to induce a short-term memory deficit similar to that observed in middle-aged Impaired mice. Overall, these findings unravel a novel role for hippocampal miR-153-3p in modulating short-term memory that could be exploited to prevent early cognitive deficits in ageing.

Freehand power-assisted pedicle screw placement in scoliotic patients: results on 5522 consecutive pedicle screws

Pedicle screws is the current gold standard in spine surgery, achieving a solid tricolumnar fixation which is unreachable by wires and hooks. The freehand technique is the most widely adopted for pedicle screws placing. While freehand technique has been classically performed with manual tools, there has been a recent trend toward the use of power tools. However, placing a pedicle screw remains a technically demanding procedure with significant risk of complications. The aim of this article is to retrospectively evaluate safety and accuracy of free-hand power-assisted pedicle screw placement in a cohort of patients who underwent correction and fusion surgery for scoliosis (both idiopathic and non-idiopathic) in our department. A retrospective review of all patients with scoliosis who underwent surgery and received a postoperative CT scan in our department in a 9-year period was undertaken. Screw density, number and location of pedicle screws were measured using pre and postoperative full-length standing and lateral supine side-bending radiographs. Then, postoperative CT scan was used to assess the accuracy of screw placement according to Gertzbein-Robbins scale. Malpositioned screws were divided according to their displacement direction. Finally, intra and postoperative neurological complications and the need for revision of misplaced screws were recorded. A total of 205 patients were included, with a follow-up of 64.9 ± 38.67 months. All constructs were high density (average density 1.97 ± 0.04), and the average number of fusion levels was 13.72 ± 1.97. A total of 5522 screws were placed: 5308 (96.12%) were grade A, 141 (2.5%) grade B, 73 (1.32%) grade C. Neither grade D nor grade E trajectories were found. The absolute accuracy (grade A) rate was 96.12% (5308/5522) and the effective accuracy (within the safe zone, grade A + B) was 98.6% (5449/5522). Of the 73 misplaced screws (grade C), 59 were lateral (80.80%), 8 anterior (10.95%) and 6 medial (8.22%); 58 were in convexity, while 15 were in concavity (the difference was not statistically significant, p = 0.33). Intraoperatively, neither neurological nor vascular complications were recorded. Postoperatively, 4 screws needed revision (0.072% of the total): Power-assisted pedicle screw placing may be a safe an accurate technique in the scoliosis surgery, both of idiopathic and non-idiopathic etiology. Further, and higher quality, research is necessary in order to better assess the results of this relatively emerging technique.

Incidental dural tears do not affect the overall patients' reported outcome of spine surgery at long-term follow-up: results of a systematic review

To conduct a systematic review of the literature in order to establish if there is an overall adverse effect of accidental durotomy on the long-term patients' reported outcome after elective spine surgery. A systematic literature search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about pre- and postoperative clinical outcomes of patients with accidental durotomy and patients without were extracted and analysed. After screening, eleven studies were included with a total of 80,541 patients. About 4112 of these patients (5.10%) had incidental dural tear. When comparing patients with dural tear to patients without, 9/11 authors found no patients' reported differences at last follow-up. One author found a slightly worse VAS back pain in dural tear patients, and another author found inferior SF-36 and ODI scores in dural tear patients (both below minimal clinically important difference). Accidental dural tear did not have a significant adverse effect on clinical outcome of elective spine surgery. More studies are needed to better demonstrate this result.

High-grade dysplastic spondylolisthesis: surgical technique and case series

PURPOSE

The aim of the present study is to evaluate the results of our all posterior-one stage surgical technique for the reduction and fusion of high-grade high-dysplastic spondylolisthesis.

METHODS

Patients over 11 years old with high-grade spondylolisthesis treated by reduction and circumferential fusion with a posterior-only approach were reviewed. Data about operative time, blood loss, length of stay, intra- and postoperative complications were collected. Meyerding grade (M), lumbar lordosis (LL), thoracic kyphosis (TK), pelvic incidence (PI), pelvic tilt (PT), lumbosacral angle (LSA), slip angle (SLIP), lumbar index (LI) and severity index were measured on preoperative and last follow-up. Sagittal vertical axis (SVA) was used to assess sagittal balance.

RESULTS

Of the 14 included patients, L5-S1 arthrodesis was performed in 12 cases, and L4-S1 was performed in 2 cases. Average surgical time was 275 ± 65 min; average blood loss was 635 ± 375 mL. Average length of stay of was 3.9 ± 1.5 days. The SLIP angle improves from 33.8° ± 7.3° to 6.4° ± 2.5°, (p = 0.002); the lumbosacral angle improves from 68.8° ± 18.6° to 100.7° ± 13.2°, (p = 0.01); and the SVA decreased from 49.4 ± 22.1 mm to 34.4 ± 8.6 mm (p = 0.02). No significant changes were observed in PI, PT and SS. Thoracic kyphosis (TK) and lumbar lordosis (LL) did not change significantly. At last follow-up, no patient had surgical site infection or mechanical complications; no pseudoarthrosis was observed. No revision surgery was performed.

CONCLUSION

Although technically demanding, reduction and fusion with one stage all posterior approach prove to be a safe and effective.

Development of a strategy to control COVID-19 in hard-to-reach migrant communities

Issue/Problem

The risk of SARS-Cov-2 infection and its adverse health effects proved to be higher among socially disadvantaged groups, including migants and ethnic minorities. Hard-to-reach (HTR) migrants, such as undocumented people, those living in informal settelments (e.g squats) or roma people have experienced severe barries to access COVID-19 information, testing and vaccination services.

Description of the problem

During 2020 and 2021, the Migrants'Health Unit of Roma 2 Local Health Unit (ASL) developed different strategies to control the COVID-19 epidemics in HTR communities, addressing both the containment of clusters in informal settelments and access to COVID-19 vaccination for these population.

Methods

A multicomponent and multidisciplinary strategy was implemented, based on a strong collaboration of different services across the ASL and with Non Governmental Organizations (NGOs). Starting from a mapping of the settlements and the identification of the main critical issues for the control of the epidemic in the target populations, interventions were carried out that included the involvement of NGOS in active surveillance, reporting of suspected cases of COVID-19 to the ASL and information to the communities, and the reorganization of health interventions (eg, swabs, epidemiological investigations, COVID-19 vaccinations) directly in HTR communities’ life places.

Results

In the period from April 2020 to February 2021, 15 outbreaks were controlled, for a total of over 4500 persons reached, and 265 COVID-19 cases identified. From July to November 2021, vaccinations were offered in outreach or with dedicated vaccination sessions, which reached 1664 people. The intervention model, based on a deep context analysis, strong multisectoral collaboration, community involvement, lays the foundations for the design of public health strategies, not only aimed at HTR populations.

Key messages

• Controlling COVID-19 in Hard- to- reach migrant populations was possible thanks to a strong collaboration between public health services and NGOs.

• Public health interventions addressed complex groups should envisage intersectoral collaborations, reorientation of services in order to meet target groups’ need and community involvement.

Predictors of late gadolinium enhancement development and extension in myocardial infarction with non-obstructive coronary arteries

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinical entity and in its complex diagnostic approach cardiovascular magnetic resonance (CMR) plays a pivotal role.

Purpose

To characterize the differences of MINOCA patients with and without late gadolinium enhancement (LGE) at CMR and to identify the predictors for ischemic LGE development and extension.

Methods

We assessed 461 MINOCA cases from January 2016 to June 2021. MINOCA were defined according to the current European guidelines criteria. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR imaging findings, our cohort was divided into two CMR phenotypes based on regional myocardial necrosis detected throughout LGE (“LGE-positive MINOCA”) or regional ischemic injury without LGE (“LGE-negative MINOCA”). Extended LGE was considered as the presence of >2 segments with transmural LGE. Multivariate logistic regression analysis was used to determine the predictors of LGE and extended LGE.

Results

The final cohort included 175 MINOCA: 121 (69.1%) constituted the LGE-positive group. The mean time delay between acute clinical presentation and CMR was 6±2.9 days. At admission MINOCA LGE-patients more frequently presented angina and ST segment elevation (24% vs 7.4%, p=0.01), compared to LGE negative ones. Furthermore, the LGE positive group had a significantly greater infarct size, measured by peak hs-Troponin I values and left ventricular function (LVEF). The only predictor of LGE was the peak troponin value (OR 1.64, 95% CI 1.18–2.28, p=0.003), while predictors of extended LGE were ST-segment elevation at admission (OR 7.44, 95% CI 1.57–35.22, p=0.01), peak troponin values (OR 1.07, 95% CI 1.02–1.13, p=0.01) and the presence of non-obstructive coronary artery disease at coronary angiography (OR 5.49, 95% CI 1.20–25.09, p=0.028).

Conclusion

The presence and extension of LGE at early CMR evaluation is an important feature in the setting of MINOCA. In addition, simple baseline characteristics (such as ST elevation, peak troponin value and LVEF) may aid the identification of a greater ischemic necrosis burden at CMR and therefore these high-risk MINOCA subjects could be benefit from a stricter management effort.

Funding Acknowledgement

Type of funding sources: None.

Development and validation of a diagnostic echocardiographic mass (DEM) score in the complex approach to cardiac masses

Background

Cardiac masses (CM) are an extremely heterogeneous clinical entity, including benign and malignant neoformations. 2D Echocardiography is nowadays the first-line approach to define nature and management of CM.

Purpose

The purpose of our study was to identify the echocardiographic predictors of malignancy and create a multiparametric score to further increase the diagnostic yield and accurately suggest the nature of CM.

Material and methods

249 consecutive patients undergoing a complete echocardiographic assessment for suspected cardiac mass were enrolled from January 2004 to December 2020. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. Logistic regression was performed to evaluate the ability of echocardiography to discriminate benign versus malignant masses.

Results

A scoring system was developed in a derivation cohort of 178 (70%) and validated in 71 (30%) patients. A weighted score [Diagnostic Echocardiographic Mass (DEM) Score] ranging from 0 to 9 was obtained from 6 variables: infiltration, polylobate mass, moderate-severe pericardial effusion, inhomogeneity, sessile and non-left localization. The AUC for the score was 0.965 (95% CI 0.938–0.993). In a logistic regression analysis using the DEM score as a predictor, the likelihood of malignancy increased more than 4 times for a 1-unit increase of the score (OR=4.468; 95% CI 2.733–7.304). The prognostic validity of the score was confirmed by its ability to predict survival during follow-up (median time of 31 months).

Conclusions

The application of a multiparametric echocardiographic score in the approach to CM accurately predicts mass malignancy thereby reducing the need for second-level investigations, and minimizing the diagnostic delay in such a complex clinical scenario.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of early cardiac magnetic resonance in myocardial infarction with non-obstructive coronary arteries

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a significant proportion of acute myocardial infarction (AMI) population. MINOCA is a working diagnosis and an accurate investigation of the underlying causes should always be performed. In this setting, cardiac magnetic resonance (CMR) imaging plays a pivotal diagnostic role. However, a prognostic stratification based on the CMR findings in ischemic MINOCA is still unavailable.

Purpose

To evaluate the potential prognostic impact of specific CMR findings - especially ischemic late gadolinium enhancement (LGE) patterns - in order to look for measurable parameters that may guide the management of this still troubled clinical entity.

Methods

We assessed 461 MINOCA from January 2016 to June 2021. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR findings, MINOCA were classified in two phenotypes: LGE-positive (an ischemic subendocardial or transmural LGE pattern) or LGE-negative (cases without LGE but exhibiting regional myocardial injury defined by myocardial edema in a coronary territory with a typically ischemic “wave-front” and/or regional wall motion abnormality consistent with coronary distribution).

All-cause mortality, re-infarction, stroke, heart failure (HF) and the composite endpoint (MACE) were evaluated. Extended LGE was considered as the presence of >2 segments with transmural LGE. The mean follow-up was 36.1±15.2 months and CMR was performed at a mean of 6±2.9 days from the acute presentation.

Results

The final cohort included 175 MINOCA with a likely-ischemic etiology: 121 (69.1%) constituted the LGE-positive group. The mean age of the study population was 62.3±12.9 years and more than 61% were females. During follow-up, HF (15.7% vs 1.9%, p=0.008) and MACE (20.7% vs 7.4%, p=0.029) occurred more frequently in MINOCA “LGE-positive” compared to the “LGE-negative” ones. Extended LGE was significantly more prevalent in patients with versus without subsequent HF. On multivariable Cox regression, extended LGE was an independent predictor of HF occurrence (HR 18.49, 95% CI 4.65–73.61, p<0.001) and MACE (HR 14.64, 95% CI 3.91–54.86, p<0.001).

Conclusions

Our data suggest that in MINOCA patients the detection of LGE is correlated with the incidence of major cardiovascular events and heart failure during long-term follow-up. In fact, LGE extension was identified as the strongest predictor of cardiac adverse events. The early execution of CMR is useful in the prognostic stratification of MINOCA and this could guide the subsequent clinical and therapeutic management.

Funding Acknowledgement

Type of funding sources: None.

Antisenescence Effect of REAC Biomodulation to Counteract the Evolution of Myelodysplastic Syndrome

About 30 percent of patients diagnosed with myelodysplastic syndromes (MDS) progress to acute myeloid leukemia (AML). The senescence of bone marrow‐derived mesenchymal stem cells (BMSCs) seems to be one of the determining factors in inducing this drift. Research is continuously looking for new methodologies and technologies that can use bioelectric signals to act on senescence and cell differentiation towards the phenotype of interest. The Radio Electric Asymmetric Conveyer (REAC) technology, aimed at reorganizing the endogenous bioelectric activity, has already shown to be able to determine direct cell reprogramming effects and counteract the senescence mechanisms in stem cells. Aim of the present study was to prove if the anti-senescence results previously obtained in different kind of stem cells with the REAC Tissue optimization – regenerative (TO-RGN) treatment, could also be observed in BMSCs, evaluating cell viability, telomerase activity, p19ARF, P21, P53, and hTERT gene expression. The results show that the REAC TO-RGN treatment may be a useful tool to counteract the BMSCs senescence which can be the basis of AML drift. Nevertheless, further clinical studies on humans are needed to confirm this hypothesis.

P212 PROGNOSTIC ROLE OF ACUTE MYOCARDIAL INFARCTION DIAGNOSTIC CRITERIA IN NON–ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Background

Although the majority of patients with NSTEMI share similar risk factors and similar pathophysiology, their outcomes differ considerably. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined acute myocardial infarction (AMI) by an acute myocardial injury together with clinical evidence of acute myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored.

Purpose

To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI in NSTEMI patients.

Methods

We enrolled all consecutive patients with AMI undergoing coronary angiogram at our Centre. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high–sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST–T changes or new LBBB); development of pathological Q waves in the ECG; echocardiographic evidence of new loss of viable myocardium or new regional wall motion abnormality. Patients with STEMI and very high risk NSTEMI were excluded. A composite endpoint of all–cause mortality, re–hospitalization for heart failure, and myocardial reinfarction was collected. The predictive value of diagnostic criteria alone and their association were evaluated using Kaplan–Meier survival curves and subsequent Cox–regression analysis to find independent predictors of adverse events.

Results

2791 patients with NSTEMI were evaluate. At admission 196 had clinical criteria alone, 187 had clinic + ECG and 829 had clinic + ECG + echo. The total number of events was 689. The median follow–up was 23.3±14.5 months. We found that patients with clinical criteria alone had a better prognosis at 2 years follow–up (p < 0.001). No other significant prognostic correlation was found. Multivariable Cox–regression model demonstrated that clinical criteria was the only independent predictor of better prognosis in patients with NSTEMI (HR = 0.48; CI 95% 0.31–0.74; p < 0.001).

Conclusions

Our data suggest that in NSTEMI the prognosis is considerably better if clinical criteria alone is present at admission. We hypothesize that the absence of electrocardiographic and echocardiographic alterations in NSTEMI could indirectly indicate smaller infarct sizes or other causes of acute myocardial injury.

P322 A MISLEADING SAM

A 66–year–old woman with a history of anxious–depressive syndrome and osteoporosis, without significant cardiological history, reported onset of cardiopalmus and dyspnoea for a few days due to moderate efforts, in conjunction with a period of strong emotional stress. Due to the persistence of these symptoms and the onset of epigastric pain, she underwent a cardiological examination which found low blood pressure values associated with the presence of a systolic murmur. The ECG showed diffuse changes in repolarization compatible with ischemia. Access to the emergency room (ER) was recommended. In ER, the first high–sensitivity troponin value was significantly high (1542 ng/L). Therefore, in the suspect of ACS, the patient was transferred to the cardiological intensive care unit. Echocardiogram showed akinesia of the mid–apical segments, hypercontractility of the bases (EF 35%) and a SAM (systolic anterior motion) with a dynamic outflow tract pressure gradient of 80 mmHg which resulted in severe mitral regurgitation. During the first days of hospitalization, persistent hypotension was observed requiring intravenous infusion of fluids to maintain systolic blood pressure values between 90–100 mmHg. Coronary angiography showed only severe ostial stenosis of a branch of the first diagonal branch. At the same time, ventriculography was performed which showed basal hypercontractility with muscle salience at the base and systolic obliteration of the outflow tract with a small apical aneurysm. 5 days after admission, another echocardiogram showed the almost complete normalization of the global systolic function (EF 68%) with apical hypokinesia and hypercontractility of the basal segments. However, the SAM persisted with a dynamic outflow tract pressure gradient of 140 mmHg with the presence of multiple and dislocated papillaries, accessory tendon cords and insertion of muscle tendon at the level of the septum. To complete the diagnosis, cardiac MRI was performed which documented a diffuse increase in T2 relaxation times more evident in the apical area, absence of LGE areas and normalization of contractility of the left ventricle with disappearance of the SAM. These findings, together with the absence of significant hypertrophy and the complete regression of the ECGgraphic changes, allowed us to exclude the presence of an unrecognized hypertrophic cardiomyopathy and to diagnose Takotsubo syndrome.

P215 PROGNOSTIC IMPACT OF EARLY VERSUS DEFERRED CORONARY ANGIOGRAPHY IN MINOCA PATIENTS

Background

Although an early invasive strategy (coronary angiography performed < 24 hours) is associated with a lower risk of recurrent/refractory ischaemia among patients with acute myocardial infarction (AMI) and obstructive coronary arteries, the optimal timing of invasive examination in patients with non–obstructive coronary arteries and non–ST–segment elevation presentation (NSTE–MINOCA) has not been explored.

Purpose

This study tested the hypothesis that, compared to early (< 24 h) invasive strategy, deferred (≥ 24 h) coronary angiography has an equivalent prognostic impact in patients with NSTE–MINOCA.

Methods

From 2016 to 2020, all consecutive MINOCA patients diagnosed according to the current ESC diagnostic criteria (angiographic conventional cut–off of < 50% coronary stenosis without a clinically apparent alternative diagnosis) and admitted to our Centre with non–ST–segment elevation myocardial infarction (NSTEMI) presentation were enrolled. Very high–risk NSTEMI patients had been excluded from the study. The prognostic value of an early (< 24 h) vs. deferred (≥ 24 h) coronary angiography was assessed. All–cause mortality and a composite endpoint (MACE) of all–cause mortality, stroke, re–hospitalization for heart failure and myocardial re–infarction were evaluated.

Results

198 NSTE–MINOCA patients were enrolled, of which 79 underwent coronary angiography < 24 hours and 119 ≥ 24 hours. MINOCA patients were more frequently females (64%) and the mean age was 66.8±13.2 years. After a median follow–up of 26 [14–40] months, the overall all–cause mortality was 13,6% and the composite endpoint (MACE) was achieved in 27.3% of the entire population. Kaplan–Meier curves showed that there was no statistically significant difference (p = 0.88) between the two study groups depending on the time of invasive strategy adopted. Specifically, rates of death (11.4% vs. 15.1%) and MACE (25.3% vs. 28.6%) were similar in MINOCA patients undergoing early versus deferred coronary angiography.

Conclusions

We demonstrated for the first time that in the MINOCA population the prognosis is not influenced by an early versus deferred coronary angiography, as opposed to AMI patients with obstructive coronary arteries. These results add another piece to the puzzle and pave the way for the initial use of a non–invasive imaging strategy (eg. Coronary–CT), mostly in patients with NSTEMI and high clinical suspicion of non–obstructive coronary arteries.

P176 MITRAL FISTULA IN PATIENT WITH OUTCOMES OF TRANSCATHETER AORTIC VALVE IMPLANTATION: A CASE REPORT

Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a poor prognosis. The development of an aorto–atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transesophageal echocardiography. A 55–year–old man, asthmatic and allergic (Penicillin and ASA) went to the emergency room for therapy–resistant hyperpyrexia and was admitted to Medicine Department for the necessary investigations and treatment. In remote pathological history: ischemic heart disease with dilated–hypokinetic evolution, already revascularized by CABG in 1996 and by PTCA in 2006 and in 2016; transcatheter aortic valve replacement with biological prosthesis in 2018. In the next medical history: admission to neurosurgery about 9 months before for cerebral haemorrhage and implantation of CRT– ICD about 6 months before On the echocardiogram performed at the entrance, evidence of isoechoic formation on the mitral flap for which further study with TEE was recommended. Blood cultures performed during hospitalization were positive for S. Epidermidis Oxacillin resistant. Few days after the admission, due to a sudden worsening of the respiratory picture, the patient was subjected to oro–tracheal intubation and transferred to Intensive Care Unit. The transesophageal echocardiogram (figure) performed in urgency documented: “fistula on the anterior flap of the mitral with medium–severe flow directed from the outflow tract of the left ventricle to the posterolateral wall of the left atrium.” On the recommendation of the infectious disease consultant, intravenous antibiotic therapy with Vancomycin and Gentamicin was started. In the following days, there was a progressive improvement in hemodynamics and the respiratory picture, for which the patient was transferred to Cardiac Surgery to undergo mitral valve replacement surgery. In literature, patients with perivalvular extension of infective endocarditis show very high early and late mortality rates, and surgery during hospitalization for IE appeared to be associated with better outcomes.

P210 VENTRICULAR FIBRILLATION IN AN ELDERLY WOMAN WITH APPARENTLY UNREMARKABLE PAST CARDIOLOGICAL HISTORY: AN UNEXPECTED CULPRIT

An 85–year–old woman experienced cardiac arrest while she was at the supermarket. Cardiopulmonary resuscitation was promptly performed with ROSC after DC shock on ventricular fibrillation and immediate hemodynamic and neurological recovery. The first ECG performed by the rescuers did not show acute ischemic changes and the patient was admitted to the Cardiological Intensive Care Unit. Past medical history revealed only a previous episode of acute pulmonary embolism for which she was on oral anticoagulant therapy for a limited period of time. She had not family history of sudden cardiac death or cardiomyopathies. Before admission she was completely asymptomatic and she never complained of angina pectoris, palpitation or dyspnoea. The echocardiogram at admission showed moderate left atrial enlargement and hypokinesia of left ventricle apex and mid–apical lateral wall with global EF of 50%. Pulmonary and aortic CT angiography showed no pathological findings. In order to rule out an ACS, the patient underwent a coronary angiography which documented the absence of critical coronary stenosis. Finally, a cardiac MRI with gadolinium was performed, revealing the presence of two small areas of transmural LGE affecting inferior basal and lateral mid–apical segments with no edema, consistent with ischaemic myocardial scars. In light of this findings and to rule out paradoxical coronary artery embolism we decided to perform a transcranial echocolordoppler that showed the absence of a patent foramen ovale. Furthermore, continuous ECG monitoring during the hospital stay did not document arrhythmic recurrences. In consideration of the high probability of ischemic heart disease, therapy with antiplatelet agent, beta–blocker, ace–inhibitor and statin was introduced and the patient was discharged after ICD implantation. Three months later, during her first follow–up visit, we documented short episodes of atrial fibrillation at ICD interrogation. This was in line with the hypothesis of a ventricular fibrillation and cardiac arrest in the contest of an ischemic heart disease with myocardial scars probably due to undatale coronary artery embolism. Oral anticoagulant therapy was started in addition to previous therapy.

The stakeholder's perception of socio-economic impacts generated by COVID-19 pandemic within the Italian aquaculture systems

From the beginning of March 2020 and for the following two and half months, many European countries comprising Italy have been forced into an unprecedented lockdown, allowing only the opening of essential economic activities needed to address the problems created by the pandemic (e.g. sanitary, food provision). Like many sectors of the Italian economy, aquaculture has also slowed down due to the ongoing emergency and the consequent closure of business. In our study we provided a 'snapshot' of the socio-economic effects of the lockdown on the aquaculture sector in Italy, immediately following the adoption of the COVID-19 restrictions as they were perceived by the workers. Although it was surveyed for a short-time period, differences in perception have been detected both in relation to the type of aquaculture as well as to the geographic locations where farms were placed, partially reflecting the economic gaps already existing within the northern and the southern part of the country before the lockdown.

The starving heart

Funding Acknowledgements

Type of funding sources: None.

Background

Anorexia Nervosa (AN) is a psychiatric disorder that can lead to cardiac complications, especially in severely malnourished patients. Cardiovascular involvement includes autonomic dysfunction (increased vagal tone, bradycardia, orthostatic hypotension, syncope), arrhythmias, pericardial effusion, heart failure and sudden death. A few studies have examined the echocardiographic abnormalities secondary to AN, reporting mainly a decreased cardiac mass and an increased incidence of pericardial effusion. No previous studies examined the changes of Global Longitudinal Strain (GLS), which has been shown to be an early marker of myocardial damage in other subsets.

Purpose

This study aimed to characterize echocardiographic abnormalities in AN, and to assess impairment of global and regional longitudinal strain (LS) and its clinical value in this context.

Methods

We prospectively enrolled 42 consecutive patients (1 male) admitted to a highly specialized AN unit between November 2020 and July 2021 with AN (Mental Disorders, 4th Edition-DSM IVr). We also selected 34 healthy controls, matched for age and sex. In all subjects, we reported the cardiac frequency, systolic and diastolic blood pressure, blood examinations, and we performed an echocardiography, including GLS measurement. Eighteen patients were treated with enteral or parenteral feeding. A subset of 26 AN patients performed a second echocardiography after one month of follow up; 14 of them received forced feeding.

Results

Compared with healthy subjects, AN patients had significantly lower albumin levels (45.1 ± 10.3 vs 66.0 ± 4.8 mg/dl, p = 0.031), lower FT3 levels (3.7 ± 1.0 vs 7.9 ± 6.4 pg/mL, p = 0.001), higher FT4 levels (13.8 ± 1.8 vs 9.6 ± 8.1 pg/mL, p = 0.008), a lower cardiac frequency (63 ± 18 vs 73 ± 12 bpm, p = 0.004), a higher incidence of pericardial effusion (9/42 vs 0/34, p = 0.008), a lower myocardial mass (62.3 ± 15.0 vs 98.5 ± 28.5 g, p < 0.001), a lower absolute value of GLS (-18.8 ± 2.8 vs -20.3 ± 2.0 %, p = 0.014) and basal LS (-15.4 ± 6.1 vs -19.6 ± 2.8 %, p < 0.001). The bull’s eye mapping showed a plot pattern with blue basal areas in 17/42 AN patients vs 1/34 healthy subjects (p < 0.001). The 17 anorexic patients with a blue basal pattern needed forced feeding in a higher proportion (11/17 vs 7/25, p = 0.018) and presented more frequently amenorrhea (14/17 vs 11/25, p = 0.046). During the follow up (26 AN patients performed a second echocardiography), of 13 patients with blue areas in the first bull’s eye mapping, 11 recovered a completely red pattern, and of 13 patients with a red bull’s eye in the first examination, no one presented blue areas on the second one.

Conclusions

GLS is significantly altered in AN patients and a basal blue pattern on bull’s eye mapping individuates more severe cases. These changes seem to be reversible (Figure 1), although further studies are necessary to understand which factors influence this pattern besides BMI. Abstract Figure 1

Usefulness of CHA2DS2-VASc scoring system for predicting risk of embolism in patients with cardiac tumours: a single-centre study

Background

The CHA2DS2-VASc score is the most used in predicting thromboembolic risk in patients with atrial fibrillation (AF). However, a higher CHA2DS2-VASc score predicts cardiovascular events even in patients without AF. Up to date, there is limited evidence about the association between CHA2DS2-VASc score and the embolic risk in patient with cardiac tumours (CT).

Purpose

To evaluate the role of the CHA2DS2-VASc score in predicting embolism and to identify other markers of embolization in patients with CT.

Methods

We included all patients with a CT who had a complete echocardiographic evaluation and a histologic diagnosis. We excluded patients with cardiac thrombi because of their higher embolic risk.

Results

Our sample consisted of 221 patients (mean age 60.9±15.6, 7% female). 132 (59.7%) patients had benign CT, usually left-sided (84.8%). In the malignant tumours, 28 (31.5%) were primary and 61 (68.5%) were metastasis. Compared to benign tumours, malignant ones were predominantly right-sided (47.2%) or with pericardial (20.2%) or great-vessels involvement (16.9%). A total of 59 patients (26.6%) experienced an embolic event, of which 33 patients had peripheral embolism, while 28 had pulmonary embolism (PE), 2 patients had both. Patients with embolism were older (p=0.013), had a higher prevalence of diabetes or previous stroke (p=0.019 and p<0.001), had left-sided and not-infiltrating CT (p=0.001 and p=0.04). We did not find any differences in AF prevalence, atrium volumes or other CT characteristics. Moreover, patients who developed an embolic event had a higher CHA2DS2-VASc score than those without embolism (p<0.001). In particular, a CHA2DS2-VASc score >3 had an AUC=0.835 in predicting a peripheral embolic event in the overall population (p<0.001). At multivariate analysis, only CHA2DS2-VASc and left-side localization were significantly associated with embolization (p<0.001 and p=0.009).

Also in patients with right-sided CT, CHA2DS2-VASc score (p=0.017), together with some tumours characteristics (mobility, pericardial effusion and absence of myocardial infiltration (p<0.04 for all) was associated with PE.

Embolization did not impact survival when considering the overall population. Otherwise, when focusing on patients with malignant CT, those who had an embolic event had a worse prognosis (p=0.02), as well as those with PE (p=0.037).

Conclusions

CHA2DS2-VASc and left-side localization are the best markers of embolism. In particular, CHA2DS2-VASc seems to predict embolization in CT, regardless of histology or localization. Many patients with CT and embolism may not be offered surgical treatment given their assumed high-risk profile. By contrast, our analysis showed that survival is not related to the embolic event per se, but by histology. In patients with CT and high CHA2DS2-VASc score, further studies are needed to evaluate the best therapeutic strategy to minimize the embolic risk.

Funding Acknowledgement

Type of funding sources: None.

Cancer incidence during follow-up in patients with new-onset atrial fibrillation treated with DOACs and its impact on bleeding risk

Background

Cancer is increasingly recognized as strictly related to atrial fibrillation (AF). In patients with AF, the relationship between cancer and cardioembolic or bleeding risk during oral anticoagulant therapy is unknown.

Purpose

To assess the bleeding and ischaemic burden of a baseline or newly diagnosed cancer in patients treated with direct oral anticoagulants (DOACs) for non-valvular atrial fibrillation (NVAF).

Methods

All consecutive patients treated with DOACs were enrolled among those with new-onset atrial fibrillation and indication for oral anticoagulant between January 2017 and March 2019. During follow-up, bleeding events, newly diagnosed primitive or metastatic malignancy and major cardiovascular events (MACE) were evaluated. At baseline, CHA2DS2-VASc, HAS-BLED, ATRIA, and ORBIT scores were used to assess the hemorrhagic and ischaemic risk. Major bleedings (MB) were defined according to the ISTH definition. Anemia was defined as haemoglobin levels below 11 g/dL in women and 12 mg/dL in men.

Results

1258 patients constituted the study population and followed for a mean time of 21.6±9.5 months. Overall, 66 patients (5.2%) were affected by malignant neoplasia at baseline, whereas 59 (4.7%) were diagnosed with a malignancy during follow-up. Among baseline characteristics, anemia was associated with cancer at enrolment (43.9% vs 22.5%, p<0.001) but not at follow up (29.3% vs 23.4%, p=0.341). MACEs were not associated with cancer at baseline (5.3% vs 5.2%, p=1.0) and at follow up (5% vs 4.9%, p=1.0). No association was observed between major ischaemic events and cancer at enrolment or follow up (5.3% vs 4.4%, p=0.83 and 4.4% vs 5%, p=0.82). Despite no statistically significant differences in haemorrhagic risk at baseline, the overall bleeding events and MB were associated with newly diagnosed cancer (9.2% vs 3.9%, p=0.001 and 13.8% vs 4.5%, p=0.001, respectively) but not at baseline (5.2% vs 5.5%, p=0.82 and 9.2% vs 5.2%, p=0.162). At multivariate analysis adjusted for age, hypertension and renal function, anemia and a newly diagnosed cancer during follow up remained independent predictors of MB (respectively, HR 1.27, 95% CI 1.52–1.06, p=0.009 and HR 3.53, 95% CI 7.71–1.62, p=0.001).

Conclusion

Bleeding risk assessment is an ongoing challenge in patients with NVAF on DOACs. During follow-up, newly diagnosed primitive or metastatic cancer is a strong predictor of bleeding regardless of baseline haemorrhagic risk assessment. In contrast, such association is not observed with malignancy at baseline. A proper diagnosis and treatment could therefore decrease cancer-related bleeding risk. On the contrary, our study shows that cancer is not an ischaemic risk modifier, either diagnosed at baseline or follow-up.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of diagnostic criteria of acute myocardial infarction

Background

The term acute myocardial infarction (AMI) reflects cell death of cardiac myocytes caused by ischaemia. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined AMI by a typical rise and fall in the level of biochemical markers of myocardial necrosis together with criteria of myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored.

Purpose

To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI.

Methods

We enrolled all consecutive patients with AMI admitted from 2016 to 2019. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST-T changes or new LBBB); development of pathological Q waves in the ECG; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality, in our study evaluated by transthoracic echocardiogram. All-cause mortality and a composite endpoint of all-cause mortality, re-hospitalization for heart failure and myocardial re-infarction were collected. The predictive value of diagnostic criteria alone and its association were evaluated using Kaplan-Meier survival curves and subsequent Cox-regression analysis to find independent predictors of adverse events.

Results

2386 patients were evaluated. The median follow-up time was 23.3±14.5 months. The total number of events was 703 (29.3%). Kaplan-Meier curves showed that major adverse cardiac events (MACE) were statistically different depending on the diagnostic criteria of AMI at admission. Particularly, clinical criteria alone showed a better predictive value (p<0.001) than other diagnostic AMI criteria. Multivariable Cox-regression model demonstrated that clinical criteria was the independent predictor of good prognosis in patients with AMI (HR=0.43; CI 95% 0.28–0.67; p<0.001). Conversely, the others diagnostic criteria (electrocardiographic and echocardiographic) and the combination of all diagnostic criteria were not independent prognostic factors of MACE (HR=1.1 CI 95% 0.6–2.4, p=0.6; HR=1.1 CI 95% 0.7–1.2, p=0.6; HR=0.9 CI 95% 0.7–1.0, p=0.8 respectively).

Conclusions

Our data suggest that the prognosis is considerably better among patients with a diagnosis of AMI if clinical criteria alone are present at admission. We also demonstrated that clinical criteria are a strong prognostic predictor of good outcomes in patients with AMI. We hypothesize that the absence of electrocardiographic and echocardiographic alterations could indirectly indicate a smaller infarct sizes that contribute to patients' outcome.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): None

Worsening renal function as an outcome predictor in patients with new onset atrial fibrillation on direct oral anticoagulant

Background

In patients with atrial fibrillation (AF), baseline kidney function is used to guide oral anticoagulant (OA) selection and dosing, and chronic kidney disease (CKD) is a significant outcome predictor. However, the incidence of worsening renal function (WRF) and its prognostic role during treatment with direct oral anticoagulants (DOACS) has been poorly explored.

Purpose

To assess the prognostic role of WRF in terms of bleedings and major adverse cardiovascular events (MACEs) in a cohort of patients with newly diagnosed non-valvular AF (NVAF) treated with DOACs.

Methods

Between January 2017 and March 2019, we enrolled all the patients with newly diagnosed NVAF and OA indication, treated with DOACs. Renal function was assessed using the mean value of the estimated glomerular filtration rates (eGFR) calculated using Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. CHA2DS2-VASc and HAS-BLED scores were used at baseline to estimate the ischemic and hemorrhagic risk, respectively. At follow-up, WRF was identified as a decrease in eGFR of at least 20% while bleedings were classified according to the international society of thrombosis and hemostasis (ISTH) criteria. Finally, we defined AF progression as the transition from paroxysmal to persistent or permanent AF or from persistent to permanent AF.

Results

1009 patients with newly diagnosed NVAF started on DOAC were enrolled. They were followed-up for 21.6±9.5 months. Overall, WRF was observed in 181 cases (18%). Patients with WRF had higher rates of progression of atrial fibrillation (18.5% vs 11.8%, p=0.02), MACEs (20.4% vs 12.9%, p=0.09) and major bleedings (MB) (9,4% vs 4,7%, p=0.013). WRF did not correlate with all bleedings, stroke, or acute coronary syndrome (ACS). However, those who presented WRF using CKD-EPI formula had higher ACS incidence (6.1% vs 2.5%, p=0.015), and generally better-predicted MACEs. At multivariate analysis adjusted for age, hypertension, baseline HAS-BLED score and WRF, the latter emerged as an independent predictor of MB (OR 1.9 95% C.I, 1,059–3,51).

Conclusion

In patients with newly diagnosed NVAF treated with DOACs, WRF is associated with atrial fibrillation progression and MACEs, and emerged as an independent predictor of major bleedings. WRF evaluated with CKD-EPI formula better predicted MACEs.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular ejection fraction as an imaging biomarker to guide cardiac resynchronisation therapy in heart failure patients: a multimodal comparison of 2D and 3D echocardiography and CMR

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The authors acknowledge financial support from the Department of Health through the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre award to Guy’s & St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust and by the NIHR MedTech Co-operative for Cardiovascular Disease at Guy’s and St Thomas’ NHS Foundation Trust. This work was supported by the Wellcome/EPSRC Centre for Medical Engineering [WT 203148/Z/16/Z]. MSN was funded by a clinical lectureship awarded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the DoH, EPSRC, MRC or the Wellcome Trust.

Introduction – Imaging derived left ventricular ejection fraction (LVEF) has an important role to guide initiation of medical therapy and device insertion in patients with heart failure and reduced ejection fraction (HFrEF). Previous studies have reported the correlation and agreement of LVEF in various patient populations, but sparse evidence exists on patients with heart failure referred for Cardiac Resynchronisation Therapy (CRT) using 2D and 3D echocardiography (2DE & 3DE) and cardiovascular magnetic resonance (CMR).

Objectives – To determine the correlation and agreement of LVEF as determined by 2DE, 3DE and CMR in a cohort of HF patients referred for assessment of CRT.

Methods – Patients with suspected HFrEF referred for assessment for CRT therapy were included in this single centre study. Patients underwent 2DE, 3DE and CMR to derive LVEF, LVESV and LVEDV. Correlation was determined with Pearson’s correlation, agreement with Bland-Altman analysis and Cohen’s kappa analysis for agreement using a dichotomous cut off of LVEF ≤35% as a threshold for CRT insertion (Ponikowski, 2016).

Results - 55 patients (mean age 71 ± 9.2, 76% male) were included. The mean LVEF for 2DE, 3DE, CMR and were 32.4 ± 8.6, 32.1 ± 9.6 and 30.3 ± 9.5 respectively. CMR had a significantly lower LVEF compared to 2DE (p = 0.03).

There was good correlation between 3DE & CMR and 2DE & CMR, and excellent correlation between 3DE and 2DE for LVEF (Table 1). There was for trend for CMR to underestimate LVEF compared to 2DE and 3DE, with small biases although wide limits of agreement (Figure 1). There was excellent correlation of LVEDV and LVESV across all 3 techniques. CMR underestimated volumes compared to 2DE and 3DE with large biases and wide LOA.

The kappa coefficient agreement at threshold level for CRT insertion (LVEF ≤35%) was fair for 3DE and CMR (0.379, p = 0.004) and 2DE and CMR (0.462, p = 0.001), and moderate for 3DE and 2DE (0.575, p ≤ 0.001).

Conclusion – Whilst LVEF is not the only indicator to guide CRT insertion, it remains an important imaging parameter for clinical decision making. We observed large biases in left ventricular volumes between 2D, 3D and CMR. However, whilst the overall bias in LVEF is small, the wide limits of agreement (LOA) observed may represent an area of clinical uncertainty, which may impact on the dichotomous imaging threshold for CRT insertion.

Comparison of indices between modalities LVEF Correlation (r) LVEF Bias & LOA (%±SD) EDV Correlation (r) EDV Bias & LOA (mL ± SD) ESV Correlation (r) ESV Bias & LOA (mL ± SD) 3DE vs CMR 0.676 (p < 0.001) +1.75 ± 15.4 0.896 (p < 0.001) -82.16 ± 42.8 0.937 (p < 0.001) -61.3 ± 34.9 3DE vs 2DE 0.872 (p < 0.001) +0.48 ± 4.5 0.909 (p < 0.001) -10.31 ± 28.3 0.936 (p < 0.001) -8.42 ± 20.5 2DE vs CMR 0.675 (p < 0.001) +2.35 ± 14.6 0.876 (p < 0.001) -67.35 ± 36.3 0.898 (p < 0.001) -51.42 ± 30.1 Abstract Figure. Bland-Altman Plot LVEF by 3DE & CMR

Application of RNA-sequencing to identify biomarkers in broiler chickens prophylactic administered with antimicrobial agents

Antimicrobial (AM) resistance is largely acknowledged as one of the biggest global health and food safety challenges and the overuse of AMs is known to generate resistance in bacteria that may affect both animals and humans. Poultry meat is the second most-produced meat in the European Union and in recent years consumers are becoming more concerned about food safety, traceability, and animal welfare in poultry rearing system, increasingly requiring meats from broilers reared without AMs. In the present study, we performed RNA sequencing to analyze 64 liver and 54 muscle transcriptomic profiles in broilers reared without treatment or treated with different classes of AMs. Moreover, we validated the most differentially expressed genes among the treated groups to detect putative novel biomarkers able to discriminate meats of broilers reared without AMs. The PDK4, IGFBP1, and RHOB genes were identified as putative novel hepatic biomarkers, discriminating broilers treated with AMs compared to broilers reared without treatments. The whole transcriptome changes revealed the liver as a valuable target organ for AM administration screening. In addition, our results suggest a leading effect of the coccidiostat when associated with AMs, influencing several biological processes. Our study showed that RNA sequencing is a powerful and valuable method to detect aberrant regulated genes and to identify biomarker candidates for AM misuse detection in farm animals. Further validation on larger sample size and a wider spectrum of AMs are needed to confirm the viability of the aforementioned biomarkers in poultry population.

Admission blood glucose level as an ischemic stroke risk modifier in patients with new-onset non-valvular atrial fibrillation

Background

Several scores have been proposed to assess the stroke risk in patients with non-valvular atrial fibrillation (NVAF). However, type 2 diabetes mellitus (T2DM) is considered a major stroke risk factor regardless of glycemic control. Whether basal blood glucose level modifies the risk of stroke in NVAF is still unclear.

Purpose

To evaluate the risk of ischemic stroke according to the presence of T2DM and admission blood glucose (ABG) level in patients with new-onset NVAF starting direct oral anticoagulants (DOACs).

Methods

We analyzed all consecutive patients with NVAF at our outpatient clinic from January to December 2018. The study population was constituted by 1014 patients with new-onset NVAF starting DOACs. Baseline characteristics were evaluated in the overall cohort whereas outcomes were assessed for 915 patients. The median follow-up time was 19.6±12.9 months.

Results

Overall, 50.3% were male with a mean age of 73.9±12.5 years. Diabetic NVAF patients were more frequently male (p=0.04) with higher prevalence of dyslipidemia (p<0.001), hypertension (p<0.001), severe renal impairment (p=0.02), peripheral vasculopathy (p=0.007) and history of myocardial infarction (p<0.001) compared to non-diabetic NVAF. Conversely, no differences were observed between subgroups in terms of age (p=0.8). Baseline blood glucose level was significantly higher in the diabetic NVAF population (160±67 mg/dL vs 119±39 mg/dL; p<0.001). As expected, the mean CHA2DS2-VASc score was significantly higher in diabetic NVAF compared to non-diabetic group (4.7±1.4 vs 3.2±1.5; p<0.001).

During a 2 year-follow up period, we collected 27 (3.0%) ischemic stroke. As expected, the rates of stroke were significantly higher in diabetic NVAF (7.6% vs 2.3%, p<0.001). Also, the ABG was significantly greater in NVAF who had an ischemic stroke compared to others (160±68 mg/dL vs 119±39 mg/dL, p=0.005). The incidence of stroke was almost five-time greater in NVAF with ABG level major than 150 mg/dl (9.8% vs 1.9%, p<0.001).

At multivariate Cox-regression model adjusted for age, sex and presence of T2DM, blood glucose level at admission was the only independent predictor of ischemic stroke at follow up (HR 1.01, 95% CI 1.001–1.02; p=0.03). Finally, another multivariate Cox-regression model, adjusted for the mean CHA2DS2-VASc score, showed that the ABG level still remained a strong independent predictor of ischemic stroke at follow up (HR 1.012, 95% CI 1.003–1.02; p=0.01).

Conclusions

Diabetic NVAF had a worse baseline profile and higher stroke risk compared to non-diabetic NVAF. Baseline blood glucose level was an independent predictor of stroke regardless of the presence of T2DM or stroke risk profile. These findings underline the role of basal blood glucose level as a potential stroke risk modifier and therefore emphasize the importance of its routine determination to better stratify the stroke risk in NVAF starting DOACs.

Funding Acknowledgement

Type of funding source: None

Diagnostic accuracy of cardiac computed tomography and 18F-fluorodeoxyglucose with positron emission tomography/computed tomography in cardiac masses

Background

Understanding the nature of cardiac masses represents a challenge for clinicians in order to select the appropriate therapeutic strategies. The diagnostic accuracy of cardiac computed tomography (CT) and 18F-fluorodeoxyglucose (18F-FDG) with positron emission tomography/CT (PET/CT) in identifying the nature of cardiac masses has not been evaluated before in a large population.

Purpose

To assess the diagnostic value of CT and 18F-FDG PET/CT in defining the nature of cardiac masses, integrating morphologic features and metabolic activity.

Methods

Out of 223 we selected a final cohort 60 patients which underwent cardiac CT scan and 18F-FDG PET/CT. All masses had histological certain, apart from thrombi, in which was defined radiologic resolution after adequate anticoagulant treatment. For each mass, eight morphologic CT signs and standardized uptake value (SUVmax, SUVmean), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) in 18F-FDG PET, were evaluated.

Results

Twenty patients had benign cardiac masses and 40 patients malignant cardiac masses. Irregular tumour margins, pericardial effusion, invasions, solid nature of the mass, mass diameter, TC contrast up-take and pre-contrast characteristics were strongly associated with the malignant nature of cardiac masses (p<0.001). Additionally, the presence of at least four CT signs was able to discriminate malignancies, withsensitivity of 95% and specificity of 95% (AUC=0.988, 95% CI 0.969–1). The mean value of SUVmax, SUVmean, MTV and TLG was significantly higher in malignant cardiac masses than in benign lesions (p<0.001). ROC curve for diagnostic accuracy of 18F-FDG PET/CT parameters in detecting malignant lesions showed an excellent performance of SUV (AUC=0.948, 95% CI 0.891–1), MTV (AUC=0.928, 95% CI 0.841–1) and TLG (AUC=0.961, 95% CI 0.902–1).

Conclusions

In patients with cardiac masses, cardiac computed tomography and 18F-FDG PET/CT findings provide independent and incremental prognostic information regarding their nature. A systematic use of CT and 18F-FDG PET/CT is therefore useful for diagnostic and therapeutic purposes.

PET-CT evaluation of cardiac masses

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): S. Orsola Malpighi Hospital, University of Bologna

Coronary blood flow in myocardial infarction with nonobstructive coronary arteries

Background

Myocardial infarction (MI) is mainly caused by atherosclerotic plaque thrombosis but several registries show that in 1–13% of cases MI occurs in the absence of obstructive coronary artery disease (MINOCA) utilizing the conventional cut-off of <50% stenosis. MINOCA is generally related to coronary arteries abnormalities (epicardial or microvascular dysfunction – MINOCA-co). However, non-coronary conditions may underlie MINOCA as a consequence of supply-demand mismatch (MINOCA-nco). The TIMI flow gradient (TFG) and the corrected TIMI frame count (CTFC) are established methods able to respectively provide a qualitative and semiquantitative estimation of epicardial blood flow at rest. No studies have yet evaluated these indices in patients with MINOCA.

Purpose

To evaluate the clinical characteristics of patients with MINOCA and the angiographic indices in MINOCA-co versus MINOCA-nco.

Methods

Among all consecutive patients undergoing coronary angiogram at our Centre for MI based on the 4th Definition of Myocardial Infarction, the ones showing <50% coronary artery stenosis were retrospectively analyzed; patients with previous coronary stenting were excluded from the study. According to the presence or absence of pre-specified criteria of supply-demand mismatch (SAP >180 mmHg, DAP >110 mmHg, HR >110 bpm, Hb <6 gr/dl, SatO2 <91% or P/F ratio <300), the study cohort was divided into MINOCA-nco and MINOCA-co, respectively. We defined as slow flow phenomenon a TFG < = 2 and/or a CTFC >40 for the left anterior descending artery, >27 for the right coronary artery and >24 for the left circumflex.

Results

453 patients were retrospectively evaluated and 112 (24.7%) met the inclusion criteria. Mean age was 68±13.2 years and 41 (36.6%) were males. MINOCA-co was the more prevalent entity accounting for 73 (65.2%) patients while 39 (34.8%) were MINOCA-nco. The two subgroups presented similar baseline characteristics with regards to gender and classic cardiovascular risk factors including hypertension, hypercholesterolemia, diabetes and smoking habit. Peripheral vasculopathy was more prevalent in MINOCA-nco patients (MINOCA-nco=15.4% vs. MINOCAco= 4.2%; p=0.04). Regarding the angiographic indices, there was no statistically significant difference in TFG between subgroups; conversely, the number of patients with a slow flow phenomenon as defined by CTFC was significantly higher in the MINOCA-nco group (MINOCAnco= 25.7% vs. MINOCA-co=9.8%; p=0.039).

Conclusions

Our data suggest that among patients with MINOCA clinical characteristics were not useful in differentiating between the two disease entities (MINOCA-nco vs. MINOCA-co). However, MINOCA-nco patients had higher coronary flow impairment as evaluated by CTFC. The pathophysiological reason is still not clear; we hypothesized that, in this clinical setting, an increased heart rate, systemic arterial pressure or low oxygen supply might worsen unbalanced coronary perfusion.

Funding Acknowledgement

Type of funding source: None

Myocardial infarction with non-obstructive coronary artery disease: the prognostic role of infarct size predictors

Background

In patients with Acute Myocardial Infarction (AMI) the levels of cardiac troponin T and absolute neutrophil count have been shown to correlate with infarct scar size and left ventricular ejection fraction (LVEF) as well as conferring a risk for major cardiovascular adverse events (MACE). In the context of myocardial infarction with non-obstructive coronary arteries (MINOCA) the prognostic role of such indicators has never been explored.

Purpose

To evaluate the prognostic role of known myocardial infarct size indicators in a MINOCA population compared to patients with obstructive AMI (Ob – AMI).

Methods

Among 1990 patients admitted to our coronary care unit from 2016 to 2019 with AMI, we enrolled 186 consecutive MINOCA patients according to the current ESC diagnostic criteria. We compared troponin peak levels, absolute neutrophil count at the time of hospital admission and LVEF in MINOCA patients versus Ob–AMI. Furthermore we assessed the prognostic value of these indicators. All-cause mortality and a composite end - point of all-cause mortality and myocardial re-infarction were evaluated. The median follow-up time was 19.6±12.9 months.

Results

MINOCA patients were more frequently females (64,9% vs 35,1%; p<0.001), non-smokers (42,3% vs 61,8%; p<0.001) with a lower prevalence of diabetes (9.9% vs 23.7%; p<0.001) compared to the Ob-AMI population. Conversely, no differences were found in hypertension and dyslipidemia. As far as infarct size predictors are concerned, MINOCA patients showed lower levels of troponin value and absolute neutrophil count measured at the time of hospital admission (1838.27±601.0 ng/L vs 13543±3350.6 ng/L; p<0.001, 6.7±1.36x109/L vs 7.1±1.29x109/L; p=0.001, respectively). Moreover, these patients exhibited a higher LVEF (56.1±10% vs 49.3±11%; p<0.001) as compared to Ob-AMI.

Among our MINOCA patients, 13 (10.6%) all-cause deaths and 3 (4.3%) myocardial re-infarction were observed during follow-up. Multivariable Cox-regression model demonstrated that mean troponin level, absolute neutrophil count and LVEF were not independent predictors of MACE (HR = 1.0, 95% CI: 0.9–1.1, p=0.6; HR = 0.96, 95% CI: 0.9–1.1, p=0.187; HR = 0.9, 95% CI: 0.79–1.02, p=0. 12 respectively).

Conclusion

MINOCA patients show a similar prognosis compared to the worldwide AMI population.

However, in this study the outcome in the MINOCA population was not influenced by commonly used infarct size predictors, in contrast to what is observed in Ob-AMI patients. These results once again emphasize both the complexity of MINOCA patients and the importance of a better understanding of the different underlying pathophysiological mechanisms.

Funding Acknowledgement

Type of funding source: None

The predictor role of worsening renal function in patients with new onset atrial fibrillation on direct oral anticoagulant

Background

Chronic kidney disease (CKD) is an important outcome predictor in patients with atrial fibrillation (AF). Moreover, renal function at baseline is used to guide oral anticoagulant (OA) selection and dosing at initial treatment. The prognostic role of worsening renal function (WRF) during treatment with direct oral anticoagulants (DOACS) has been poorly explored.

Purpose

To estimate the prognostic role of WRF in terms of major adverse cardiovascular events (MACEs) in a series of patients with newly diagnosed non-valvular AF (NVAF) treated with DOACs.

Methods

Among all patients with newly diagnosed NVAF and indication for OA between January 2017 and December 2018, we enrolled those treated with DOACs. Renal function at baseline and during follow-up was assessed with estimated glomerular filtration rates (eGFR). eGFR was calculated as a mean value of Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. The hemorrhagic risk at baseline was estimated with the main available scores (HAS-BLED, ATRIA and ORBIT). WRF was defined as a decrease in eGFR of at least 20%. MACEs were evaluated according to the type of DOAC and the WRF. Major bleedings (MB) were defined according to the ISTH definition.

Results

The study population was constituted by 249 patients with newly diagnosed NVAF started on DOAC and followed for a median time of 14.1±8.6 months. Overall, WRF was observed in 58 cases (23.3%). Patients with WRF had significative higher rates of death (10.3% versus 3.1%, p=0.025) and MB (13.8% versus 4.7%, p=0.016). The incidence of bleeding events, acute coronary syndromes and stroke was not affected by WRF. Interestingly, CG formula better predicted the incidence of MB as compared to the other formulas (p=0.006). The type of DOAC did not significantly impact the observed renal impairment and had no effect on the occurrence of MACEs in patients showing WRF. The predictors of WRF were found to be age, female sex, low hemoglobin level and left ventricle end telediastolic volume. At multivariate analysis, WRF was identified as an independent predictor of MB (OR 3.1, 95% C.I, 1.12–8.58), regardless of the baseline bleeding risk.

Conclusion

This is the first prospective study to evaluate the impact of worsening renal function on cardiovascular events in patients with atrial fibrillation treated with DOACs. A significant WRF emerged as an independent predictor of death and MB. The specific DOAC did not affect either the entity of worsening renal function or the incidence of cardiovascular events.

Funding Acknowledgement

Type of funding source: None

Impact of type 2 diabetes mellitus and blood glucose admission levels in patients with myocardial infarction with non obstructive coronary artery disease (MINOCA)

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinically entity and represents 5% to 10% of all patients with myocardial infarction (MI). Besides type 2 diabetes mellitus (DM), which is a common comorbidity in patients hospitalized for an acute coronary syndrome, high glucose levels (HGL) at admission are frequently observed in this context. The risk of major adverse cardiovascular events following acute coronary syndrome is increased in people with DM and HGL. However, evidence regarding diabetes and high glucose level among MINOCA patients is lacking.

Purpose

To examine the incidence of major adverse cardiovascular events (MACEs) in diabetic and non-diabetic MINOCA patients as well as according to HGL at presentation.

Methods

Among 1995 patients with acute MI admitted to our coronary care unit from 2016 to 2018, we enrolled 186 consecutive MINOCA patients according to the current ESC diagnostic criteria. HGL at admission was defined as serum glucose level above 180 mg/dl. All-cause mortality and a composite end-point of all-cause mortality and myocardial re-infarction were compared. The median follow-up time was 19.6±12.9 months.

Results

Diabetic MINOCA patients were older (mean age 75.5±9.6 vs 66.5±14.7; p=0.002) and with higher prevalence of hypertension (p=0.016). Conversely, there were no significant differences in gender, BMI, dyslipidemia and atrial fibrillation. Similarly, no significant differences were observed regarding clinical and ECG presentation, echocardiographic features and laboratory tests. The rates of death (30.8% vs 8.3%; p=0.013) and MACEs (22.2% vs 6.8%; p=0.025) were significantly higher in MINOCA-DM patients; conversely, no significant differences were observed for re-MI (p=0.58). At multivariate regression model adjusted for age and sex, type 2 DM was not an independent predictor of all cause deaths (p=0.36) and MACE (p=0.24).

Patients with admission HGL had similar baseline characteristics, cardiovascular risk factors, clinical presentations, echocardiographic features and troponin values as compared to patients with no-HGL. HGL at admission was associated with higher incidence of all-cause-death (p<0.001) and MACE (p=0.003) during follow-up compared to patients with no HGL; conversely, no significant differences were observed in the incidence of re-MI (p=0.7). Multivariate analysis adjusted for age and sex demonstrated that HGL was an independent predictor of death (HR 6.25; CI 1.64–23.85; p=0.007) and MACEs (HR 6.17; CI 1.79–21.23, p=0.004).

Conclusion

In MINOCA patients, HGL was an independent risk factor for both MACEs and death while type 2 DM was not correlated with these hard endpoints. As a consequence, HGL could have a still unexplored pathophysiological role in MINOCA. Properly powered randomized trials are warranted.

Funding Acknowledgement

Type of funding source: None

Outcomes in patients with cardiac masses: the underestimated burden of pseudotumours

Background

Cardiac masses (CMs) include benign and malignant formations. So far, clinical presentation and prognosis have been reported only in small series without discriminating between subtypes. We investigated the clinical presentation and long-term prognosis of patients with cardiac masses stratifying our results according to the lesions' nature.

Methods

We enrolled all consecutive patients admitted to our Institution between 1999 and 2018 with imaging evidence of CMs. Definitive diagnosis was achieved by histologic examination or by radiological evidence of thrombotic resolution after anticoagulant treatment. The study population was classified as benign or malignant and subsequently into 4 subtypes: pseudo-tumours, primary benign tumours, primary malignant tumours and secondary tumours. Cardiovascular and non-cardiovascular mortality was described.

Results

We identified 172 patients with CMs, 125 benign and 47 malignant. Benign lesions were often incidentally diagnosed in the left heart chambers whereas malignancies were usually detected in the pericardium and right sections, resulting in more advanced symptoms. Over time – median follow-up of 48 months - survival of patients with benign formations was three-fold greater than patients with malignancies (p<0.001) with no differences in cardiovascular mortality. Patients with pseudo-tumours showed a significantly lower survival than primary benign tumours (p=0.018) while no difference was found within the malignant stratum between primary and secondary neoplasms.

Conclusions

CMs are a heterogeneous entity where advanced symptoms and a pericardial involvement suggest malignant forms, which exhibit a poor outcome. Among patients with benign lesions, pseudo-tumours were associated with reduced survival, supposedly as a consequence of the different underlying conditions.

Funding Acknowledgement

Type of funding source: None

Listeria monocytogenes clones in Italian food products: virulence and environmental adaptation

Background

Food is the main source of Listeria monocytogenes (Lm) infection. Lm is a highly heterogeneous species composed of hypervirulent and hypovirulent clones. Understanding the distribution of Lm clonal complexes (CCs) in different food categories has strong implications for risk assessment. The aim of this work was to analyse collection of Lm strains of National Reference Laboratory (NRL Lm) in order to assess link between genetic profile and matrices and the level of pathogenicity of circulating strains based on CCs.

Methods

NRL Lm database actually consists of 906 sequenced strains isolated in 10 years from 5 food compartments (meat, fish, dairy, vegetables and composite dishes). Epidata were analysed to remove redundant strains based on the same epidemiological description. After that, WGS data from 465 Lm strains were investigated. In silico MLST was defined and Roary 3.12.0 was used to obtain a pan-genome profile. Genes were later uploaded to Pasteur Institute platform for characterization.

Results

In silico MLST identified 36 CCs and 6 singleton. CC9 (23.0%), CC8 (15.3%) and CC121 (13.3%) were the prevalent CCs. In particular, CC9 was present in 35.2% of meat samples and CC8 in 25.8% of fish samples. Pan genome profile revealed high prevalence (>98%) of genes related to biofilm formation and resistance to environmental stress in CC9 strains and genes involved in tolerance to quaternary ammonium compounds in CC121 strains.

Conclusions

Results, in particular for meat products, confirmed in Italy, the prevalence of hypovirulent Lm strains previously observed at European Union level. The high presence of stress resistance and disinfectant tolerance genes in these strains could make them able to persist in food-production environment and should be taken into account evaluating the health hazards. In fish product is also relevant the prevalence of CC8 strains which are potentially highly pathogenic and have been responsible of recent European multi country outbreak.

Key messages

Pangenome of Listeria monocytogenes isolated from Italian food revealed high presence of disinfectant tolerance and stress resistance genes in meat products and virulence genes in fish products. Listeria monocytogenes CC9 and CC121 prevalence in Italian meat product confirms occurrence of hypovirulent strains detected at European Union level.

Analysis of power from palm oil solid waste for biomass power plants: A case study in Aceh Province

Nowadays, the solid waste produced from palm oil has become one of the essential oils in the world in general and especially in Indonesia. Biomass waste is processed through substantial quantities of palm oil extraction. With the reduction in fossil fuels in recent years, it has had an impact on the deterioration of electricity supply at the National and International levels. Biomass is a renewable energy that can replace conventional energy. Besides, power generation from biomass is environmentally friendly and sustainable. This simulation was conducted to analyze the maximum power from the burning of oil palm biomass for the electricity generation. The novelty of the article is the performance and behavior of palm oil biomass-based co-fuel in the power generation process. The biomass wastes used in this simulation include OPF, EFB, PKS, and OPM. The results of this simulation indicate that the maximum power produced with OPF can produce 49.54 MW with variations in the flow rate of biomass at 8 kg/s. While at the time of recycling up to 100% OPM biomass produces 61.05 MW higher than OPF, EFB and PKS. Meanwhile, the OPF-PKS mixed biomass can produce 106.15 MW of power plants when the airflow rate reaches 171 kg/s. The overall results of the simulation for the analysis of the maximum power that can be used as a power station show suitability and can apply in rural/remote areas. Besides, the availability of oil palm biomass in Aceh Province is also sufficient to overcome electricity shortages and reduce dependence on conventional energy.

863Leadless endocardial pacing improves symptoms in patients with failed conventional CRT implant in long term follow up

Funding Acknowledgements

EBR Systems, Inc

OnBehalf

WiSE-CRT and LV-SELECT study and POST-M REGISTRY

Background

The WiSE-CRT (Wireless stimulation endocardial) system has advantages over conventional epicardial CRT. Whenever conventional CRT failed to implant or failed to echocardiographic response, the WiSE-CRT was implanted as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) over the last 8 years. All these studies have reported high rates of clinical and echocardiographic response compared to conventional CRT.

Objectives

The purpose of this analysis was to determine the safety and clinical response in the largest available number of implanted patients (pts) with long term follow up of 2 years and the first, second and third generation of WiSE-CRT devices.

Method

All pts undergoing a WiSE-CRT implantation as part of the WiSE CRT study (N = 13), as part of the LV-SELECT study (N = 35) or as part of the POST-M REGISTRY (N = 117) were analysed (N = 165). Pts were followed-up for 24 months and considered CRT responders if an improvement in NYHA ≥ 1 class from baseline (pre-implant) was achieved.

Results

In total, 165 pts were implanted, demographics include: 68.2 ± 9.6 year’s old, 81.8% male, 49.7% with history of AFib and 54.5% non-ischaemic aetiology. The mean intrinsic QRS duration was 165.0 ± 32.3 msec (28 pts pace-maker dependent). 161 pts had the system successfully implanted with no major complications, 3 (1.8%) pts developed a pericardial effusion and 1 (0.6%) electrode was lost during implantation and recovered surgically. During the 24-month follow-up period, 20 (12.1%) pts died from any cause, 4 (2.4%) pts developed TIA or Stroke and 15 (9.1%) pts had pocket or transmitter infection. There was a significant improvement in NYHA functional class in 63.6% pts and an average improvement of -26.1 (-45.1, -7.1) msec in QRS duration.

Conclusion

Despite a history of failed conventional CRT implantation, pts undergoing CRT upgrades with a WiSE-CRT have a high success rate and a complication rate similar to previously described. In addition endocardial LV pacing led to symptomatic improvements in 64% of patients reaching the 24 month of follow up.

Abstract Figure 1: Forest Plot NYHA Responder Rat

Social inequalities in the metropolitan area of Rome. A multidisciplinary analysis of the urban segregation of the "formerly-Bastogi" compound

BACKGROUND

This study tries to evaluate, through a multidisciplinary approach, the relationship between urban structure, isolation and distribution of social determinants of health, in the so-called "formerly-Bastogi, a compound, with more than 1,500 inhabitants, located in north-western Rome, Italy.

METHODS

The architectural-urban analysis, conducted through site visits and evaluations of urban situation, showed how strongly the compound is isolated from the neighbourhoods, and structurally degraded. The socio-demographic analysis, based on the National Census data, showed significant differences in the distribution of the social determinants of health between "formerly-Bastogi" and the surrounding areas.

RESULTS

The area under study appears to be isolated from the surrounding urban space, both because of social and architectural factors. This situation could have some association with inhabitants' health.

CONCLUSIONS

If our preliminary investigation was useful for a diagnosis of the situation, a more complete - qualitative and quantitative - investigation of the context will be needed to plan appropriate multidisciplinary health-promoting interventions.

Metagenomic and volatile profiles of ripened cheese obtained from dairy ewes fed a dietary hemp seed supplementation

Chemical and organoleptic properties of dairy products largely depend on the action of microorganisms that tend to be selected in cheese during ripening in response to the availability of specific substrates. The aim of this work was to evaluate the effects of a diet enriched with hemp seeds on the microbiota composition of fresh and ripened cheese produced from milk of lactating ewes. Thirty-two half-bred ewes were involved in the study, in which half (control group) received a standard diet, and the other half (experimental group) took a diet enriched with 5% hemp seeds (on a DM basis) for 35 d. The dietary supplementation significantly increased the lactose in milk, but no variations in total fat, proteins, caseins, and urea were observed. Likewise, no changes in total fat, proteins, or ash were detected in the derived cheeses. The metagenomic approach was used to characterize the microbiota of raw milk and cheese. The phyla Proteobacteria and Firmicutes were in equally high abundance in both control and experimental raw milk samples, whereas Bacteroidetes was less abundant. The scenario changed when considering the dairy products. In all cheese samples, Firmicutes was clearly predominant, with Streptococcaceae being the most abundant family in the experimental group. The reduction of taxa observed during ripening was in accordance with the increment (relative abundance) of the starter culture Lactococcus lactis and Streptococcus thermophilus, which together dominate the microbial community. The analysis of the volatile profile in ripened cheeses led to the identification of 3 major classes of compounds: free fatty acids, ketones, and aldehydes, which indicate a prevalence of lipolysis compared with the other biochemical mechanisms that characterize the cheese ripening.

Psychiatric comorbidity in patients affected by fibromyalgia and/or autoimmune rheumatic diseases: Preliminary results of an observational study

Introduction

Fibromyalgia is characterized by skeletal muscle pain and axial stiffness, with elective multiple points of tenderness (tender points). According to scientific literature, the prevalence of depression, anxiety and a worse quality of life is higher in patients with fibromyalgia. Trauma (sexual abuse and physical aggression) has a key role in the pain perception.

Objectives

To describe the clinical characteristics of patients with fibromyalgia and/or autoimmune rheumatic diseases admitted to O.O.R.R. Foggia (Department of Rheumatology), to detect correlation between fibromyalgia and psychiatric disorders.

Aims

To underline psychiatric comorbidity in patients affected by fibromyalgia and/or autoimmune rheumatic diseases.

Methods

Diagnostic tests at Baseline (T0): Mini International Neuropsychiatric Interview and Structured Clinical Interview for DSM Disorder 2 to assess psychopathology, 12-Item Short Form survey for the quality of life, Diagnostic Criteria for Psychosomatic Research for disorders of somatic symptoms, Insight Scale for the awareness of the disease, Davidson Trauma scales to assess the presence of a post-traumatic stress disorder, Pittsburgh Sleep Quality Index about the quality of sleep. After 3 months (T1): further psychodiagnostic assessment for patients with positive mental status exam in drug treatment.

Results

Affectivity disorders, feelings of anger, irritability, hostility, impaired stress response, increased vulnerability to traumatic events are very frequent in patients affected by fibromyalgia.

Conclusions

The preliminary results of this study show that patients with fibromyalgia have diagnoses of major depression, anxiety disorders, post-traumatic stress disorder and personality disorders (cluster B). Multidisciplinary interventions are needed integrating the rheumatologic therapy with the psychiatric one, based on the detected diagnosis.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

P1248 What are the suspicious echocardiographic features of a malignant cardiac mass?

BACKGROUND

Cardiac Masses (CM) represent a rare and heterogeneous group with a prevalence of 0.3% at autopsy, divided in benign masses - primary tumors and pseudotumors - and malignant ones - primitive tumors and metastasis, either directly invading the heart and pericardium or as a consequence of hematologic spread. 2-D Echocardiography is nowadays the first line approach to define nature and management of CM, but is it enough to guide a therapeutic strategy?

PURPOSE

To evaluate echocardiographic CM malignancy features in patients admitted to our Centre between 1997 and 2017.

MATERIALS AND METHODS

We retrospectively evaluated a population of 180 consecutive patients (45% males; mean age 60 ± 16 years; BMI 25 ± 5 Kg/m2), referred to our echocardiographic lab with suspicion CM. All patients were examined in both left lateral and supine position, and heart was visualized from all available echocardiographic windows. Definite diagnosis was obtained by histologic examination of biopsy, surgical samples or, in cases of cardiac thrombi, by radiological evidence of thrombus resolution after adequate anticoagulant treatment. We excluded normal anatomical variants in the group of pseudotumors due to the impossibility of obtaining histological examination. Comparisons between categorical variables were performed by Chi-square or Fisher exact test. P values ≤ 0.05 were considered significant. Variables with statistical signification lower than p ≤ 0.05 in univariable analysis were included in logistic regression analysis to determinate independent predictors of malignant masses.

RESULTS

We detected 129 benign CM (76% primitive tumors and 24% pseudotumors) and 51 malignant cardiac tumors (45% primitive tumors and 55% metastasis). In 7 cases a poor acoustic window did not allow an optimal examination; in remaining 173 patients, the classical 2-D echocardiogram identified 157 masses with a diagnostic accuracy of 91%. Benign tumors and pseudotumours were localized predominantly in left heart chambers, while malignant primitive tumors and metastasis were mainly detected in right heart, in pericardium or in pulmonary artery branches (p < 0.001). The largest ecocardiographic diameter appeared greater for the malignant masses (mean of 49 ± 26 mm) than benign ones (30 ± 16 mm, p = 0.003). The occurrance of any pericardial effusion (p < 0.001), extension to pericardium (p = 0.01) or to main vessels (p = 0.006) were also associated with malignant masses. Finally, multivariate analysis showed only largest diameter (p = 0.001) and pericardial effusion (p < 0.001) were independent predictors of malignancy.

CONCLUSION

2D Echocardiography is an excellent, non invasive technique for first line evaluation of patients with suspicion CM. It is safe, accurate and have high diagnostic accuracy in identifying CM and their benign or malignant nature. In particular, a large mass associated with any pericardial effusion must pose suspect of malignancy.

Foreign workers’ health in agriculture: assessing health workers’ perception and training needs

Introduction

Health and safety of foreign workers employed in agriculture and zootechny present several critical areas. The multidisciplinary project ’Livingstone’, funded by INAIL and carried out by several Italian universities, aims to address some of these critical issues. One of the project research line focuses on health professionals and has the objective to investigate their perception of the risks to which foreign workers are exposed and their training needs.

Methods

A 33 items questionnaire is being self-administered to social and health professionals of three Italian regions (Lazio, Lombardia and Campania) where agriculture is developed; the administration phase will last 13 months (2018, April - 2019, May). The questionnaire has been built starting from a literature review; a pilot study have been conducted in a pilot sample in Rome in March 2018. The questionnaire is composed by five sections: general, social and professional information; characteristics of the respondents’ foreign patients/users; knowledge about health problems of foreign patients and about possible obstacles in use of health services, with a specific focus on foreign patients working in agriculture and zootechny sector; perception about health and safety risks of these workers; training background and needs, included desired training contents and modalities.

Results

The research is ongoing. 238 answered questionnaires have been collected yet. 65 of the respondents are General Practitioners; the rest are other health and social professionals. The complete results will be shown during the congress.

Conclusions

This study will contribute to widen the knowledge about health professionals’ perceptions about problems and needs of foreign workers employed in agriculture and zootechny sector.

Specific training addressed to social and health professionals will be developed from the observation of their current knowledge and from their reported needs.

Key messages

This study will contribute to widen knowledge about health professionals’ perceptions about problems and needs of foreign workers employed in agriculture and zootechny sector. Specific training addressed to social and health professionals will be developed from the observation of their current knowledge and from their reported needs.

P4688Additional role of unmodifiable risk factors in pulmonary arterial hypertension risk stratification according to current ESC/ERS guidelines

Background

Current pulmonary hypertension (PH) guidelines stratify the risk of patients with pulmonary arterial hypertension (PAH) using a multiparametric approach. Anyway, the role of unmodifiable risk factors is not taken into account.

Purpose

The aim of this study was to evaluate the role of unmodifiable risk factors (age, gender, PAH aetiology) in PAH risk stratification using the recently proposed simplified risk table and to test if these factors influence the response to PAH-specific treatment.

Methods

All patients with PAH referred to a single centre were included from 2003 to 2017. We applied a simplified risk assessment strategy using the following criteria: WHO functional class, 6-min walking distance, right atrial pressure or brain natriuretic peptide plasma levels and cardiac index (CI) or mixed venous oxygen saturation (SvO2). The last 2 criteria were based on which parameter was available; if both were available the worst was chosen. Risk strata were defined as: Low risk= at least 3 low risk and no high-risk criteria; High risk= at least 2 high risk criteria including CI or SvO2; Intermediate risk= definitions of low or high risk not fulfilled. Then we performed multivariate Cox analysis to evaluate what are the independent predictors of survival (age, gender, PAH aetiology together with the recently proposed simplified PAH risk table) and we tested if these factors influence the response to PAH specific therapy comparing the % improvement of hemodynamic parameters from baseline to 3–4 months after starting treatment. Wilcoxon-Mann-Whitney test was used for comparisons.

Results

Six hundreds and twenty-one treatment-naïve patients were enrolled. Age [HR (95% CI) = 1.022 (1.014–1.030); p-value <0.001], male gender [HR (95% CI) = 1.881 (1.479–2.392); p-value <0.001] and connective tissue disease (CTD)-PAH aetiology [HR (95% CI)= 2.278 (1.733–2.995); p-value <0.001] were all independent predictors of prognosis in patients with PAH together with the recently validated simplified PAH risk table [HR (95% CI) = 2.161 (1.783–2.618); p-value <0.001] but they didn't significantly influence the response to PAH specific treatment as shown in the Figure.

Figure 1

Conclusions

Age, gender and CTD-PAH aetiology significantly influence prognosis together with the recently validated simplified PAH risk table but don't significantly influence the response to PAH-specific treatment.

Acknowledgement/Funding

None

P4676Experience of three years of balloon pulmonary angioplasty in a single centre: safety and short term results

Background

Balloon pulmonary angioplasty (BPA) has recently been developed as an alternative and less-invasive treatment strategy for chronic thromboembolic pulmonary hypertension (CTEPH) but therapeutic efficacy and technical safety of the technique have to be established.

Purpose

To examine the effects of BPA on patients with inoperable disease or residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA).

Methods

From June 2015 to January 2019 we enrolled symptomatic (WHO-FC ≥II) inoperable CTEPH patients and patients with residual PH after PEA. At baseline and after 3 months after last BPA session all patients underwent clinical evaluation, six-minute walking distance (6MWD) and right heart catheterization. For comparisons Friedman test (with Bonferroni post-hoc pairwise analysis) was used.

Results

Forty-one patients [male 49%, median age 65 (52–75) years, 34 inoperable and 7 with residual PH after PEA] were treated for a total of 111 sessions (median number of sessions for each patient: 2); during each session we treated 2 (2.0–2.5) vessels. Results are shown in the Table. Forty patients were treated with medical therapy before BPA (16 with combination therapy). Four pulmonary artery dissection and 2 haemoptysis with clinical impairment were documented during the procedures; 27 patients had lung injury (radiographic opacity with/without hemoptysis and/or hypoxemia), none had renal dysfunction, 6 patients had access site complications. Five patients died during follow-up (none within 30 days from the procedure) because of sepsis (1), heart failure (1), cancer (1), arrhythmic storm (1) and sudden death in a patients with severe coronary atherosclerosis (1).

Table 1 Median (interquartile range) Baseline Baseline ÷ Pre-BPA Pre-BPA Pre-BPA ÷ Post-BPA Post-BPA Global (n=41) 8 (3–49) months (n=41) 10 (6–18) months (n=32) p-value WHO-FC III-IV (%) 88 N.S. 83 <0.05 42 <0.001 6MWD (m) 430 (346–560) N.S. 425 (357–500) <0.05 450 (375–605) <0.001 RAP (mmHg) 6 (5–8) N.S. 6 (5–8) N.S. 6 (4–8) 0.023 mPAP (mmHg) 46 (40–52) <0.05 43 (33–50) <0.05 36 (28–41) <0.001 CI (l/min/m2) 2.6 (2.2–3.0) N.S. 2.7 (2.2–3.0) <0.05 3.1 (2.6–3.5) 0.004 PVR (WU) 7.5 (5.6–11.5) <0.05 6.5 (4.7–10.3) <0.05 4.1 (3.3–5.9) <0.001 PA O2 Sat (%) 69 (63–71) N.S. 69 (63–72) N.S. 69 (63–73) 0.002 CI, Cardiac Index; mPAP, mean Pulmonary Arterial Pressure; PVR, Pulmonary Vascular Resistance; PA O2 Sat, Pulmonary Artery Oxygen Saturation; RAP, Right Atrial Pressure; 6MWD, 6 Minute Walking Distance; WHO-FC, World Health Organization Functional Class.

Conclusions

BPA is a safe and effective treatment able to improve symptoms and hemodynamic profile in inoperable CTEPH patients and in patients with residual PH after PEA.

Acknowledgement/Funding

None

P4742Evaluation of the HAS-BLED, ATRIA and ORBIT bleeding risk scores in newly diagnosed non-valvular atrial fibrillation

Background

Several risk scores have been proposed to assess the bleeding risk in patients with Atrial Fibrillation.

Purpose

To compare the efficacy of HAS-BLED, ATRIA and ORBIT scores to predict major bleedings in newly diagnosed non-valvular AF (NV-AF) treated with vitamin K antagonists (VKAs) or new oral anticoagulants (NOACs).

Methods

We analyzed all consecutive patients with AF at our outpatient clinic from January to December 2017. Only those with new diagnosed NV-AF starting new anticoagulant therapy were enrolled. Major hemorrhagic events were defined according to the ISTH definition in non-surgical patients.

Results

Out of the 820 patients admitted with AF, 305 were newly diagnosed with NV-AF starting oral anticoagulation. Overall, 51.3% were male with a mean age of 72.6±13.7 years. Thirty-six patients (11.8%) started VKAs whereas 269 (88.2%) patients were treated with NOACs. The median follow-up time was 10.4±3.4 months. During follow-up, 123 (32.2%) bleeding events were recorded, 21 (17,1%) in the VKA group and 102 (82,9%) in the NOAC group. Eleven (2.9%) major bleeding events occurred: 5 (45.5%) in the VKA group and 6 (54.5%) in the NOAC group.

Overall, patients with major hemorrhagic events showed a mean value of the scores significantly higher when compared to patients without such bleeding complications (HASBLED 3.4 vs 2.4 p=0.007; ATRIA 5.6 vs 2.4 p<0.001; ORBIT 3.6 vs 1.8 p<0,001). Conversely, when analyzing the VKA subgroup, only the ATRIA score was significantly higher in patients with major adverse events (7.4 vs 3.5 p<0.001; HAS-BLED: 4.4 vs 3.6 p=0.27; ORBIT 4.4 vs 2.9 p=0.13). An ATRIA score ≥4 identified patients at high risk of bleeding (29.4% vs. 0% events. respectively, p=0.04). In the NOAC group, patients with major bleeding events had higher mean values of ATRIA (4.0 vs 2.3 p=0.02) and ORBIT (2.8 vs 1.6 p=0,04) but not the HAS-BLED (2.5 vs 2.3 p=0.57) scores. Similarly, patients on NOACs with an ATRIA score ≥4 had higher rates of major bleedings (8.1% vs. 1.6% p=0,02).

Comparing the single elements of the ATRIA score, only glomerular filtration rate <30 ml/min/1.73 mq was associated with major bleedings in the VKA group (p<0.001) whereas, in the NOAC group, anemia was strongly associated with bleeding events (p=0,02). In fact, multivariate analysis in the NOAC group showed that hemoglobin level at admission was an independent predictor for major bleeding events (OR 0.41, 95% CI 0.23–0.75, P=0.003). Conversely, in the VKA group, baseline creatinine level was an independent predictor for these events (OR 12.76, 95% CI 1.6–101.7, P=0.016).

Conclusions

The ATRIA score showed the best efficacy in predicting major bleeding events. Hemoglobin and creatinine levels at admission were independent predictors for major hemorrhagic events in the NOAC and in the VKA groups, respectively. The latter finding might be helpful in stratifying the hemorrhagic risk at the beginning of treatment.

P4680Prognostic value of stroke volume index in patients with pulmonary arterial hypertension at intermediate risk

Background

Current pulmonary hypertension (PH) guidelines stratify the risk of patients with pulmonary arterial hypertension (PAH) using a multiparametric approach. Low, intermediate and high-risk are defined by estimated 1-year mortality of <5%, 5–10% and >10%, respectively. This risk assessment has been recently validated in 3 cohorts of PAH patients and a simplified risk table for patients with idiopathic/heritable (I/H) PAH and PAH associated with connective tissue disease (CTD) and congenital heart disease (CHD) has been recently proposed and validated. However, with this method most of the patients are classified in the intermediate risk category and additional strategies are required to further stratify this group of PAH patients.

Purpose

To evaluate the prognostic value of SVI measured with right heart catheterization (RHC) in patients at intermediate-risk.

Methods

All treatment naïve patients with I/H-PAH, CTD-PAH and CHD-PAH referred to a single centre were included from 2003 to 2017. All patients were assessed at baseline and at the 1st follow-up at 3–4 months after starting PAH-specific therapy (1st F-UP) with RHC, brain natriuretic peptide (BNP) plasma levels, 6-min walking distance (6MWD) and WHO functional class. We applied a simplified risk assessment strategy using the following criteria: WHO functional class, 6MWD, right atrial pressure or BNP plasma levels and cardiac index (CI) or mixed venous oxygen saturation (SvO2). The last 2 criteria were based on which parameter was available; if both were available the worst was chosen. Risk strata were defined as: Low risk= at least 3 low risk and no high-risk criteria; High risk= at least 2 high risk criteria including CI or SvO2; Intermediate risk= definitions of low or high risk not fulfilled. The prognostic value of SVI was assessed using Cox regression analysis. Intermediate risk patients were further stratified in intermediate-low and intermediate-high risk taking into account the value of SVI that best discriminate prognosis (according to ROC curve analysis). Kaplan Meier curves and Log-rank test were used for survival analysis.

Results

Seven hundreds and twenty-five patients were enrolled. SVI is able to stratify the prognosis of PAH patients at 1st F-UP [HR 0.979 (0.964–0.994), p-value= 0.008] but not at baseline [HR 0.986 (0.970–1.002), p-value= 0.085]. The best predictive cut-off value is 38 ml/m2 (AUC= 0.66, sensitivity= 73%, specificity= 59%). Survival curves are shown in the Figure.

Figure 1

Conclusions

SVI assessed at 1st F-UP is predictive of prognosis and the cut off value of 38 ml/m2 is able to further stratify the survival of intermediate risk PAH patients.

Acknowledgement/Funding

None