Migraine as a Disease Associated with Dysbiosis and Possible Therapy with Fecal Microbiota Transplantation

Migraine is a painful neurological condition characterized by severe pain on one or both sides of the head. It may be linked to changes in the gut microbiota, which are influenced by antibiotic use and other factors. Dysbiosis, which develops and persists as a result of earlier antibiotic therapy, changes the composition of the intestinal flora, and can lead to the development of various diseases such as metabolic disorders, obesity, hematological malignancies, neurological or behavioral disorders, and migraine. Metabolites produced by the gut microbiome have been shown to influence the gut-brain axis. The use of probiotics as a dietary supplement may reduce the number and severity of migraine episodes. Dietary strategies can affect the course of migraines and are a valuable tool for improving migraine management. With fecal microbiota transplantation, gut microbial restoration is more effective and more durable. Changes after fecal microbiota transplantation were studied in detail, and many data help us to interpret the successful interventions. The microbiological alteration of the gut microflora can lead to normalization of the inflammatory mediators, the serotonin pathway, and influence the frequency and intensity of migraine pain.

Efficacy of lyophilised bacteria-rich faecal sediment and supernatant with reduced bacterial count for treating patients with Clostridioides difficile Infection - A novel method for capsule faecal microbiota transfer

Background and aims

Faecal microbiota transfer (FMT) has managed to earn its place in the Clostridioides difficile infection (CDI) guidelines by having comparable efficacy and recurrence rate of fidaxomicin. After more than 100 successful FMT administration through nasogastric tube, we started using hard gelatine capsules filled with lyophilised faecal sediment and supernatant. Our main question was whether uncoated capsules (containing faecal sediment or supernatant) are comparable to the widely used nasogastric tubes in CDI. We also investigated the effect of storage and time on the survival rate of bacteria in the samples.

Methods

We compared the efficacy of our capsules to other treatment options of CDI at the Department of Infectology at the University of Pécs (Hungary). For our study, stool was collected from a single donor. We treated 10 patients with relapsing CDI, 5 of them received supernatant, 5 received sediment. Donor samples were stored on 4 different temperatures and tested to determine the survival rates of bacteria. As pilot projects, we also assessed the changes of bacterial taxa, protein- and lipid compositions. Moreover, we selected 4 patients to compare their samples prior and after FMT by using microbiome (16S amplicon sequencing), protein, and lipid analyses.

Results

4 out of the 5 patients who received supernatant became symptomless within 2 days after FMT. In the sediment group 3 out of 5 patients were cured from CDI. Comparing the supernatant to the sediment, we found significantly lower number of colony-forming units in the supernatant. We found that -80°C is the most suitable temperature to store the samples. The stool lipid profiles of recipients showed a more diverse composition after FMT, and changes in the stool protein profiles were observed as well. In the microbiome analysis, we observed an increase in the alpha diversity after FMT.

Conclusions

Our study of 10 patients showed good efficacy of lyophilised faecal supernatant using capsules. The single donor approach proved to be effective in our investigation. A significantly lower CFU number was sufficient for the effect, the separation can be achieved by widely available instruments. For storage temperature, -20°C was sufficient in our clinical practice.

Assessment of the right ventricular-pulmonary circulation unit during stress in ankylosing spondylitis and psoriatic arthritis patients

Background

Cardiopulmonary complications are common in ankylosing spondylitis (AS) and arthritis psoriatica (APs), which have an unfavourable impact on mortality and quality of life. APs may be connected with pulmonary hypertension, while AS is linked to interstitial lung disease and chest wall restriction.

We aimed to assess the response of the pulmonary circulation unit during stress in AS and APs patients.

Methods

A total of 71 patients were enrolled in the study: 28 of them had AS (age 50.8±11.8 years), 17 APs (age 52.1±13.5 years), and 26 were healthy individuals (age 54.23±9.9 years). To the maximally tolerated workload, all subjects underwent resting and exercise stress echocardiography on a supine bicycle ergometer. Echocardiographic measurements were taken at rest, at 50 watts workload, and at maximal exercise.

Results

AS patients had significantly higher pulmonary artery systolic pressure (PASP; AS: 32.6±16.8 mmHg, APs: 21.6±12.7 mmHg, p<0.05) and pulmonary vascular resistance (PVR; AS: 1.3±0.4 WU, PsA: 1.1±0.3 WU, p<0.05) at maximal workload, while the right ventricular-pulmonary arterial (RV-PA) coupling at peak stress was higher in APs patients (AS: 1.2±0.6 mm/mmHg, PsA: 1.8±1.1 mm/mmHg, p<0.05). Comparing to the control group, AS and PsA patients had significantly higher resting PASP (control: 12.6±6.4 mmHg; AS: 22.8±7.6 mmHg, p<0.001; PsA: 21.4±7.0 mmHg, p<0.001), lower resting RV-PA coupling (control: 2.7±1.4 mm/mmHg; AS: 1.3±0.4, p<0.001; PsA 1.3±0.4 mm/mmHg, p<0.001), and higher peak PVR (control: 0.6±0.4 WU; AS: 1.3±0.4, p<0.001; PsA: 1.1±0.3 WU, p<0.005). One-way analysis of variance of the three groups also showed significant differencies in the resting PASP (p<0.001), peak PASP (p<0.05), resting RV-PA coupling (p<0.001), peak PVR (p<0.001).

Conclusion

Stress echocardiography is a promising, radiation-free method for assessing the subclinical cardiopulmonary changes among AS and PsA patients. The changes of PVR during stress may highlight the pulmonary complications in the subclinical stage.

Funding Acknowledgement

Type of funding sources: None.

Radial artery calcification in predicting coronary calcification and atherosclerosis burden

Background

Atherosclerosis is a systemic arterial disease with heterogeneous involvement in all vascular beds, however studies examining the relationship between coronary and radial artery calcification are lacking.

The purpose of this study was to assess the relationship between the two sites and the prognostic value of radial artery calcification (RC) for coronary artery disease.

Methods and results

This is a single-center, retrospective cross-sectional study based on doppler ultrasound of radial artery (RUS) and coronary artery angiography (CAG). We included a total of 202 patients undergoing RUS during distal radial access and CAG at the same procedure, between December 2020 and May 2021, from which 103 were found having RC during RUS (RC-group) and 99 without (NRC-group). Coronary calcifications were evaluated either by angiography examination (moderate and severe), positive CT (>100 Agatson units) or intracoronary imaging (IVUS, OCT). A significant correlation was observed between radial calcification and coronary calcification variables (67.3%, vs 32.7% – p=0.001). The correlation between risk factors such as age, smoking, chronic kidney disease and diabetes mellitus was higher while sex did not play a role. The need of PCI and/or CABG was higher in the RC-group (60% vs 44%, p=0.02). RC therefore predicts the extent and severity of coronary artery disease.

Conclusion

RC may be frequently associated with calcific coronary plaques. These findings highlight the potential beneficial examination of radial arteries whenever CAD is suspected.

Funding Acknowledgement

Type of funding sources: None.

Extension of fitness evaluations with muscle oxygen saturation measurements based on near-infrared spectroscopy analysis during cardiopulmonary exercise testing in elite athletes

Introduction

Many cardiovascular parameters of sport adaptation have become an area of detailed research in recent decades. However, details of local circulatory and metabolic processes ongoing in the working muscles during physical exercise need to be revealed.

Purpose

Our aim was to extend cardiopulmonary exercise testing with near-infrared spectroscopy measurements to focus on observing local changes in the contracting muscles during running.

Methods

Mixed muscle oxygen saturation values (SmO2) measured in the left vastus lateralis muscle of athletes were analyzed by near-infrared spectroscopy during vita maxima treadmill cardiopulmonary exercise testing with 2-min fingertip lactate measurements. Body composition analysis was carried out with bioimpedance method. One-way repeated measures ANOVA, Tukey post-hoc test, Shapiro–Wilk test and Pearson correlation were used for statistical analysis.

Results

The results of 66 elite athletes (male: 40; age: 17.9±3.6 y; training: 17.7±6.6 h/w; water polo player: 56, wrestler: 8, basketball player: 2) were analyzed. The 10-second averaged values of the measured saturation values were examined at rest (65.8±11.1%), at the anaerobic threshold (40.7±22.8%), at maximum load (30.2±20.5%) and after 5 minutes of cool-down (70.9±12.8%). Significant differences were measured between the four measurement time points in all pairings. A negative correlation was found between the achieved maximal oxygen uptake and the muscle oxygen saturation values measured at the anaerobic threshold and at the maximal load (respectively r=−0.30, p<0.02; r=−0.32, p<0.01). Oxygen uptake at the end of cool-down was also negatively correlated with muscle oxygen saturation values measured at the anaerobic threshold and at the peak of exercise (respectively r=−0.27, p<0.05; r=−0.27, p<0.05). The fat-free mass of the identical limb showed negative correlation with the muscle oxygen saturation values measured at the anaerobic threshold, at the maximal load and at the cool-down (respectively r=−0.43, p<0.01; r=−0.44, p<0.01; r=−0.35, p<0.01), while positive interactions were observed between the body-fat mass of the same limb and the muscle oxygen saturation values (respectively r=0.51, p<0.01; r=0.55, p<0.01; r=0.41, p<0.01). Muscle oxygen saturation values showed no significant correlations with exercise time, lactate levels, or heart rate measurements.

Conclusions

By our results, muscle oxygen saturation measurements can be reliably applied during exercise physiological measurements. During exercise, muscle oxygen saturation values negatively correlated with oxygen uptake. At the cool-down phase, a rebound effect could be observed compared to the resting measurements. On the identical limb, the higher the muscle mass was, the higher muscle desaturation could be measured. This easy-to-perform test provides insight into muscle metabolism processes and can help with training planning and athlete follow-up.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 135076). Supported by the ÚNKP-21-3-I-SE-68 New National Excellence Program of the Ministry for Innovation and Technology from the Source of the National Research, Development and Innovation fund.

Hypoattenuated leaflet thickening is associated with silent brain injury

Background

The association between hypoattenuated leaflet thickening (HALT) following transcatheter aortic valve implantation (TAVI) and stroke remains contradictory. Whether HALT carries an increased risk of subclinical brain injury (SBI) has not been investigated.

Purpose

We investigated whether HALT is associated with SBI on MRI. Furthermore, we assessed whether post-TAVR SBI impacts the patients' cognition and outcome.

Methods

153 patients undergoing TAVR were prospectively enrolled. Brain MRI was performed shortly post-TAVR and 6 months (6M) later to assess the occurrence of acute silent cerebral ischaemic lesions (SCIL) and chronic white matter hyperintensities (WMH). HALT was screened by cardiac CT angiography 6M post-TAVR. Neurocognitive evaluation was performed before, shortly after and 6M following TAVR.

Results

At 6M, 115 patients had diagnostic CTA and 10 had HALT. HALT status, baseline and follow-up MRIs were available in 91 cases. At 6M, new SCIL was evident in 16%, new WMH in 66%. New WMH was more frequent (100% vs 62%; p=0.047) with higher median volume (319 vs 50 mm3; p=0.039) among HALT-patients. In uni- and multivariate analysis, HALT was associated with new WMH volume (beta: 0.72; 95% CI: 0.2–1.39; p=0.009).

The patients' cognitive trajectory from pre-TAVR to 6M showed significant association with the 6M SCIL volume (beta: −4.69; 95% CI: −9.13 to −027; p=0.038), but was not related to the presence or volume of new WMH. During a 3.1-year follow-up neither HALT, nor the related WMH burden was related with increased mortality (HALT HR: 0.86, 95% CI: 0,202–3,687; p=0.84; new WMH HR: 1.09; 95% CI: 0,701–1,680; p=0.71).

Conclusions

6M post-TAVR, HALT was linked with greater WMH burden, but did not carry an increased risk of cognitive decline or mortality over a 3.1-year follow-up.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): János Bolyai Scholarship of the Hungarian Academy of Sciences

Assessment of pulmonary circulation unit during exercise in patients with ankylosing spondilitis and sporiatic arthritis

Funding Acknowledgements

Type of funding sources: None.

Background  Ankylosing spondylitis (AS) and psoriatic arthritis (PsA) are chronic multisystem inflammatory disorders that present with articular and extra-articular features. Cardiac dysfunction and pulmonary disease are well-known and commonly reported extra-articular manifestations of AS and PsA.  The inflammatory process can induce respiratory complications, including chest wall restriction, significantly impacting patients" cardiorespiratory status.

We aimed to assess pulmonary circulation and right ventricle behaviour during exercise in patients with AS and PsA and to detect the possible effect of chest wall restriction on right heart function.

Methods  A total of 45 spondylarthritis patients were enrolled in the study (age 51.5 ± 12.3 years, 82.2% men): 27 of them were diagnosed with AS (20 of them had ankylosis at the time of the study), while 18 had PsA (2 of them in ankylosis). According to a standardized protocol, all subjects underwent resting and exercise stress echocardiography on a semi-recumbent cycle ergometer with an incremental workload up to the maximal tolerated workload. Basic echocardiographic measurements were taken, focusing on the right and left ventricular functions and the systolic pulmonary artery pressure (PASP) at rest, at 50 watts workload, and maximal exercise. During the examination, non-invasive blood pressure measurements, transcutaneous capillary oxygen saturation and continuous ECG recording were performed. 

Results PASP did not differ between the AS and PsA patients at rest (15.6 ± 6.7 mmHg vs 13.7 ± 8.3 mmHg; p = ns); however, PASP measured at the maximal workload was significantly higher among AS patients  (31.4 ± 15.9mmHg vs 21.6 ± 12.7mmHg; p < 0.05; Figure 1). PASP did not correlate with the age or the time that passed since the diagnosis. Parameters describing the left and right ventricular systolic and diastolic function did not differ significantly between AS and PsA patients at rest and peak stress. Comparing the LV diastolic parameters of ankylosing patients with non-ankylosing patients irrespective of the underlying disease showed significantly different values in peak E/e"ratio (8.9 ± 3 vs 7.4 ± 1.6; p < 0,05; Figure 2).

Conclusion  Exercise stress echocardiography is a promising diagnostic modality in autoimmune diseases. In AS patients, the chest wall restriction may results in elevation of PASP during the exercise. The noninvasive indice of left ventricular filling pressure increases significantly in patients with ankylosis in both groups, explaining the effect of the rigid chest wall on the left ventricular filling. Abstract Figure.  Abstract Figure.

Nutritional risk factors in Hungarian elderly-Biomarker2019 survey

 

In Hungary, about a quarter of the population is over the age of 60 and their proportion is projected to increase considerably within a few decades. According to the 2009 and 2014 European Health Interview Survey data, 87% of Hungarian older adults suffer from at least one non-communicable disease (NCD). Many of the NCDs are associated with poor nutrition. Reliable data on nutritional status of this age group is scarce. The Biomarker2019 survey provides comprehensive data on the nutritional status of this vulnerable age group. The cross-sectional survey was carried out in western Hungary. Participants aged ≥60y were selected from non-institutionalized patients of general practitioners' practicing in Western Hungary (n = 200). Data collection involved a questionnaire, physical examinations, three-day dietary record, and a collection of biological samples (fasting blood and 24-hour urine). 77% of the participants had high blood pressure diagnosed by a physician. 85% of men and 76% of women were overweight or obese, according to the BMIs. The mean proportion of energy from fat was higher (men: 39 E%, women: 37 E%), that from carbohydrates was lower in men (43 E%) than recommended, while it was adequate in women (47 E%). The mean protein intake was adequate in both sexes. Cholesterol intake was 433 mg/day for men and 317 mg/day for women, both higher than the Hungarian recommendations. The fiber intake was 23.8 g/day for men and 23.6 g/day for women, both below the recommended values. Based on the estimates of salt intake from 24-hour urine, 90% of participants had a higher salt intake than recommended. Nutritional risk factors predisposing to the development of NCDs were identified in the sample. The results of the study contributed to the development of a food-based dietary guideline tailor made to the Hungarian elderly population (60+ Health - Dietary Guideline for the Elderly), its dissemination to the target audience has been started.

Key messages

The identification of nutritional risk factors in a sample of older adults contributed to the development of a new food-based dietary guideline for the elderly population. The results can form the basis of further public health interventions.

Left atrial volume changes during exercise stress echocardiography in heart failure and hypertrophic cardiomyopathy

Background

Left atrial volume (LAV) may dilate acutely during exercise stress echocardiography (ESE) in chronic coronary syndromes.

Purpose

To assess the feasibility and functional correlates of LAV during ESE outside coronary artery disease.

Methods

We performed ESE (semi-supine bike in 159 or treadmill in 105 patients) in 264 patients (155 male, age 58±15 years) with heart failure with preserved ejection fraction (HFpEF, n=82), heart failure with reduced ejection fraction (HFrEF, n=51) or hypertrophic cardiomyopathy (HCM, n=131). LAV was measured with the biplane disk summation method. LAV-dilators were defined as those with stress-rest increase in LAV index ≥6.8 ml/m2, a cutoff derived from a calculated reference change value above the biological, analytical and observer variability of LAV. Average E/e', mitral regurgitation (MR, graded from 0 = absent to 3 = severe), left ventricular ejection fraction, systolic pulmonary arterial pressure (SPAP) from tricuspid regurgitant jet velocity and B-lines (4-sites simplified scan) were also measured.

Results

Measurement success rate was 264/264 (100%) in technically adequate images. At group analysis LAV changes during ESE were heterogeneous, with LAV index increase in HFrEF (rest = 41±26 vs stress = 44±27 ml/m2, p=0.563) and HCM (rest = 39±18 vs stress = 41±17 ml/m2, p=0.444) and mild decrease in HFpEF (rest= 28±12 vs stress = 26±11 ml/m2, p=0.020). At individual patient analysis, LAV dilation occurred in 88 (33%) patients: 9 with HFpEF (11%), 24 with HFrEF (47%), 55 with HCM (42%, p<0.001 vs HFpEF). Prevalence of LAV dilation was 33/105 with treadmill and 55/159 with semi-supine ESE (31 vs 35%, p=0.588). In the overall population, LAV stress-rest change was directly related to stress SPAP (r=0.264, p=0.001), peak E/e'(r=0.288, p<0.001), stress B-lines (r=0.223, p=0.003) and peak MR grade (r=0.295, p<0.0001). LAV-dilators more frequently showed abnormal values of SPAP, B-lines, MR and E/e'during ESE compared to non-dilators (see figure).

Conclusion

LAV assessment during ESE is feasible with high success rate, and LAV dilation is equally frequent with upright treadmill or semi-supine bike exercise. LAV individual response to stress is unpredictable, with a significant dilation occurring more frequently in HCM and HFrEF compared to HFpEF patients. Across all conditions, LAV dilation is correlated to more advanced pulmonary and hemodynamic congestion, higher left ventricular filling pressures and more severe MR during stress.

Funding Acknowledgement

Type of funding sources: None. LAV dilators vs non-dilators comparison. SPAP value ≥40 mm Hg; E/e' ≥15; MR grade ≥2; B-lines >10 in patients with (blue bars) and without (red bars) LAV dilation.

Comprehensive diastolic exercise stress echocardiography in heart failure with preserved ejection fraction

Background

In heart failure with preserved ejection fraction (HFpEF), diastolic exercise stress echocardiography (ESE) is currently recommended with E/e' and systolic pulmonary artery pressure (SPAP) from tricuspid regurgitant jet velocity (TRV).

Purpose

To evaluate conventional and advanced ESE parameters in patients with HFpEF.

Methods

We prospectively screened 124 patients with suspected HFpEF (dyspnea, resting EF >50%, increased natriuretic peptide levels) and HFA-PEFF score ≥1. Of these 124, 10 patients were excluded for history of coronary artery disease, 3 for severe mitral regurgitation (MR), 12 for inducible ischemia. The final study population consisted of 99 patients (mean age 63±7 yrs, 57 females). All underwent ESE, with semi-supine bike (n=35), upright bike (n=20) or treadmill (n=44 patients) in 11 accredited labs from 9 countries (Argentina, Brazil, Bulgaria, Hungary, Italy, Lithuania, Mexico, Russia and Spain). In addition to E/e' average (abnormal stress response ≥15 units) and TRV (abnormal stress response >3.4 m/s), we measured 8 additional criteria: B-lines (4-site simplified scan, abnormal stress value ≥2); cardiac index (CI) reserve (increase from rest to stress, abnormal <1.63 l/min/m2), ejection fraction (EF, abnormal increase <5%), global longitudinal strain (GLS, abnormal increase <2%), end-diastolic volume (EDV, abnormal stress < rest); heart rate reserve (HRR, abnormal <1.80); left atrial volume index, (LAVI, abnormal increase >6.8 ml/m2); MR (abnormal, stress value more than mild).

Results

Technical success rate during stress ranged from 100% for B-lines to 75% for GLS: see Table. At individual criteria analysis, positivity rate in interpretable studies ranged from 67% of HRR to 10% of peak MR: see table. At individual patient analysis, an abnormal response in 1 ESE criterion occurred in 4 pts (4%), of 2 to 4 criteria in 71 pts (72%) and of ≥5 criteria in 24 (24%).

Conclusion

In suspected HFpEF, ESE is helpful in the screening phase to identify extra-diastolic causes of dyspnea such as myocardial ischemia or severe MR. In the diagnostic phase, a comprehensive ESE captures the functional heterogeneity of HFpEF, with variable association of multiple phenotypes, the most frequent represented by reduced chronotropic, cardiac or contractile reserve and pulmonary congestion.

Funding Acknowledgement

Type of funding sources: None.

How to Apply FMT More Effectively, Conveniently and Flexible - A Comparison of FMT Methods

Purpose

Metronidazol and vancomycin were long the two best options against Clostridioides (formerly Clostridium) difficile infections (CDI). Now, the cost of new drugs such as fidaxomicin directs us towards alternative treatment options, such as faecal microbiota transplant (FMT). Its effectiveness is similar to fidaxomicin. There are questions regarding its safety, but the biggest challenges are prejudice and inconvenience. Most protocols refer to FMT applied in the form of a solution. We investigated different modalities of FMT.

Methods

Instead of using nasoenteric tubes or colonoscopy, we place frozen or lyophilised stool in non-coated, size “00”, hard gelatine capsules or enterosolvent, size “0” capsules.

Results

We found that non-coated, size “00”, hard gelatine capsules are appropriate for conducting FMT. Capsules containing lyophilised supernatant with a low number of bacteria have been proven to be non-inferior to other FMT modalities. The primary cure rate in the supernatant group was 93.75%, and 66.67% in the sediment group. The overall cure rate was 82.14%. Depending on the protocol, 4–7 capsules are sufficient per patient. Capsules can be stored for up to one year at -20°C.

Conclusions

FMT is a feasible alternative to antibiotic treatments in CDI. Our method makes the process flexible and less inconvenient to patients. Long storage time allows a consistent supply of capsules, while small volume and formulation make the procedure tolerable.

The prognostic value of B-lines in heart failure with preserved ejection fraction

Funding Acknowledgements

Type of funding sources: None.

Background

 Heart Failure with Preserved Ejection Fraction (HFpEF) is a growing healthcare burden, and its prevalence is steadily increasing. Despite its common occurrence, HFpEF remained a challenge in every aspect. The evaluation of B-lines with lung ultrasound (LUS) is a promising diagnostic and prognostic tool in this population.

Objectives

The aim of our study was to assess the diagnostic and prognostic performance of B-lines compared with traditional clinical, echocardiographic parameters and natriuretic peptide levels in patients with clinical suspicion of HFpEF.

Methods

78 consecutive patients (70.45 ± 6.75 years, 72% female) with suspected HFpEF were prospectively enrolled. Exclusion criteria were: ejection fraction ≤55%, more than mild mitral and/or aortic valve disease, cardiomyopathy, pulmonary disease, pulmonary arterial hypertension, renal failure and anemia. All patients underwent comprehensive echocardiography, lung ultrasound exam and NT-proBNP measurement during their first appointment. Our endpoint was a composite of acute heart failure (HF),  hospitalization for the worsening HF symptoms and intensification of diuretic therapy. Also, traditional major cardiac adverse events such as death, myocardial infarction, stroke and revascularization were collected.

Results

We detected 11 events during 12 ± 6 months follow up. The number of B-lines showed a good correlation with NT-proBNP levels (p < 0,001, r = 0.693). B-lines were found to have similar performance to NT-proBNP in predicting events (AUC = 0.778 vs. 0.770, respectively). Those who had more than 30 B-lines on LUS had significantly worse event-free survival p = 0.004. Having more than 30 B-lines at baseline was associated with 7 times greater hazard of adverse outcomes.

Conclusions

LUS is a simple, feasible tool to detect pulmonary congestion in patients with HFpEF. In our prospective cohort study, LUS was found to be a useful tool for prognostic stratification.

Abstract Figure. Prognostic value of B-lines

Clinical, functional and prognostic correlates of blunted heart rate reserve during exercise stress echocardiography in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Background

Blunted heart rate reserve (HRR) during exercise is associated with cardiac autonomic dysfunction and poor outcome.

Purpose

To evaluate the anatomical, functional and prognostic correlates of HRR during exercise stress echocardiography (ESE) in hypertrophic cardiomyopathy (HCM).

Methods

We prospectively recruited a consecutive sample of 121 HCM patients [age 47 ± 13 years, 67 males; NYHA class 1.7 ± 0.7; left ventricular (LV) ejection fraction 71 ± 9 %; LV maximal wall thickness 24 ± 5 mm; 58 (48%) with LV outflow tract obstruction (LVOTO, gradient ≥ 50 mmHg) at rest] who underwent semi-supine bicycle ESE from January 2006 to September 2019. HRR was calculated as the peak/rest heart rate (HR) ratio. All patients were followed-up for a median of 7.5 years.

Results

HR was 68 ± 11 bpm at rest and 105 ± 19 bpm at peak stress. Receiver-operating characteristic analysis was used to determine the best cut-off value of HRR (≤ 1.48, blunted) to predict all-cause death. A blunted HRR was present in 52 patients (43 %, Group 1). Patients with blunted HRR had more frequently hypertension (Group 1= 41/52 vs Group 2= 40/69, 79 vs 58 %, p = 0.019), resting systolic anterior motion of the mitral valve [(SAM) , Group 1= 41/52 vs Group 2= 40/69, 79 vs 58 %, p = 0.019] and rest LVOTO (Group 1= 31/52 vs Group 2= 27/69, 60 vs 39 %, p = 0.029).  Patients in Group 1 had larger left atrial diameter (48.8 ± 6.5 vs 46.5 ± 7.6, p = 0.076), lower LV end-diastolic [(EDD) , 44.8 ± 4.6 vs 46.7 ± 4.6 mm p = 0.02] and LV end-systolic diameter [(ESD), 25.2 ± 5.3 vs 27.6 ± 5.5 mm p = 0.02] at rest. Patients in Group 1 had higher NYHA class (1.9 ± 0.6 vs 1.6 ± 0.7, p = 0.009), resting HR (71.5 ± 11.4 vs 64.6 ± 10.6 bpm p < 0.001), and shorter total exercise time (6.3 ± 3.1 vs 9.1 ± 2.8 min, p < 0.001) compared to patients in Group 2.

During the follow-up, 13 patients died. All-cause death was observed in 10/52 patients of Group 1 and 3/69 patients of Group 2 (19 vs 4 %, p < 0.05). Cox multivariate regression survival analysis revealed that HRR ≤ 1.48 (Hazard ratio 3.7, 95% CI 0.96-14.5, p = 0.048) and left atrial diameter (Hazard ratio 1.15, 95% CI 1.04-1.28, p = 0.003) were independent predictors of all-cause mortality, either on or off beta-blocker therapy.

Conclusion

HRR is a simple non-imaging biomarker of cardiac autonomic function and is frequently abnormal in HCM. The blunted increase in frequency is associated with NYHA functional class, exercise time, rest HR, rest LVOTO, SAM, LV EDD and ESD. HRR independently predicts survival in HCM. The lower the HRR, the worse the outcome.

Abstract Figure.

Simple and additive diagnostic modalities for the screening of heart failure with preserved ejection fraction

Background

Nearly half of all patients with heart failure (HF) symptoms have an EF that is preserved (HFpEF). The prevalence of HFpEF is rising, with high morbidity, mortality. The diagnosis of HFpEF is particularly challenging. Lung ultrasound (LUS) and left atrial strain are promising screening and diagnostic tools to assess pulmonary congestion and left atrial dysfunction in patients with suspected HFpEF.

Aim

To evaluate the relationship between patients symptoms, pro-BNP level with LUS and left atrial strain, as well to assess the diagnostic power of B-lines in HFpEF population.

Methods

82 consecutive patients (57 women, mean age 70±6 years) with clinical signs of heart failure were prospectively enrolled. Exclusion criteria were: ejection fraction <55%, more than mild mitral and/or aortic valve disease, pulmonary disease, pulmonary arterial hypertension. Within one hour all patients underwent comprehensive echocardiographic evaluation including left atrial strain analysis (peak atrial longitudinal strain-LASr), lung ultrasound assessment of B-lines on the anterolateral and posterior chest wall, and NT-proBNP levels.

Results

In 45 patients (54%) a significant number of B-lines (≥15) were observed. We found a positive correlation between the number of B-lines and NT-proBNP levels (p<0.0001, r=0.67), left atrial volume (p<0.0001, r=0.45), and LASr (p<0.005, r=−0.4). We also found week correlation between the number of B-lines and E/e' ratio (p<0.003, r=0.3), and between E/e' ratio and NT-proBNP level (p<0.05, r=0.2). We also assessed the diagnostic ability of B-lines to predict markedly elevated pro-BNP level (≥125pg/ml), AUC was 0.85, with specificity of 64% and sensitivity of 85% (Figure 1). The number of B lines also correlated with the H2FPEF score (p<0.001, r=0.4).

Conclusion

LUS is a simple, feasible tool to detect pulmonary congestion in HFpEF and it has an adequate diagnostic power to predict elevated NTpro-BNP level. LASr is promising too, which better reflects pulmonary congestion and elevated NT-proBNP values than the conventional echocardiographic parameters.

Figure 1. ROC curve Blines predict high NTproBNP

Funding Acknowledgement

Type of funding source: None

Predictors of cerebral embolisation after percutaneous transfemoral aortic valve implantation (TAVI) in the RETORIC substudy

Purpose

To evaluate the predictors, occurrence and distribution of TAVI-related silent ischemic brain lesions using diffusion MRI.

Methods and materials

We investigated 109 consecutive patients with severe aortic stenosis from the prospective arm of the RETORIC study who underwent brain MRI one week afterpercutaneous transfemoral aortic valve implantation TAVI. To determine the occurrence and distribution of periprocedural cerebral ischemic lesions averaged diffusion-weighted images (trace) and mean diffusivity (MD) maps from the DTI dataset were used. To evaluate the aortic valve calcium score (AVCS), we assessed the preoperative prospectively ECG-triggered cardiac CT (256-slice MDCT). We also assessed the periprocedural factors such as periprocedural time, pre- and postdilatation. Multivariate linear regression analysis was performed to identify the independent predictors of TAVI-related ischemic lesions.

Results

After TAVI, a total of 918 new cerebral ischemic lesions were detected in 100/109 patients (92%). The median ischemic lesion volume was 237 μl (interquartile range 89.5–650) with a median lesion number of 6 (2–10) per patient. 759/918 lesions (83%) were supratentorial (389 left vs 370 right). Most lesions (628/918, 68%) were subcortical; the left and right MCA territories were the most affected (190. The vast majority of ischemic lesions were clinically silent (96%); 4% of patients had stroke which was proven by MRI. The median AVCS was 2769 (interquartile range 1858–4537). Balloon predilatation during TAVI procedure showed significant correlation with increased total ischemic lesion volume (p<0.001, β = 0.370) on univariate analysis, AVCS, periprocedural time, or postdilatation were not associated with ischemic load on MRI (p<0.05).

Conclusions

Periprocedural ischemic lesions are frequent (92%), most of them are clinically silent, however. Only balloon dilatation during TAVI was a predictor of increased ischemic load.

Aortic valve Ca scoring and DWI MRI

Funding Acknowledgement

Type of funding source: None

Left atrial volume stress echocardiography in chronic coronary syndromes

Background

An enlarged left atrial volume index (LAVI) at rest mirrors increased LA pressure and/or impairment of LA function. A cardiovascular stress may acutely modify LAVI within minutes.

Purpose

To assess the feasibility and functional correlates of LAVI-stress echocardiography (SE)

Methods

Out of 514 subjects referred to 10 quality-controlled labs, LAVI-SE was completed in 490 (359 male, age 67±12 yrs, ejection fraction 60±10%) with suspected or known chronic coronary syndromes (n=462) or asymptomatic controls (n=28). The utilized stress was exercise in 177, vasodilator in 167, dobutamine in 146. LAVI was measured with the biplane disk summation method. SE was performed with the ABCDE protocol. In a single center sub-study in 50 subjects, including 28 controls and 22 patients, also peak longitudinal atrial strain (PALS, %) was measured as an index of LA reservoir function.

Results

The intra-observer and inter-observer LAVI variability were 5% and 8%, respectively. Δ-LAVI changes (stress-rest) were negatively correlated with resting LAVI (r=−0.271, p<0.001), heart rate reserve (r=−0.239, p<0.001), and Δ-PALS (n=50, r=−0.374, p=0.007).LAVI-dilators were defined as those with stress-rest increase ≥6.8 ml/m2, a cutoff derived from a calculated reference change value above the biological, analytical and observer variability of LAVI. LAVI dilation (see figure) occurred in 56 patients (11%). At multivariable logistic regression analysis, B-lines ≥2 (OR: 2.586, 95% CI =1.1293–5.169, p=0.007) and abnormal left ventricular contractile reserve (OR: 2.207, 95% CI=1.111–4.386, p=0.024) were associated with LAVI dilation.

Conclusion

LAVI-SE is feasible, with high success rate and low variability, in patients with chronic coronary syndromes. A wet (increased B-lines) and weak (reduced LV contractile reserve and LA reservoir function) heart frequently portends LAVI dilation during stress.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic role of coronary flow velocity reserve in hypertrophic cardiomyopathy

Background

A reduction in coronary flow velocity reserve (CFVR) related to coronary microvascular dysfunction is a major mechanism for ischemia in hypertrophic cardiomyopathy (HCM).

Hypothesis

To assess the functional correlates and prognostic value of CFVR during stress echocardiography (SE) in HCM.

Methods

We enrolled 201 HCM patients (age 51±14 years, 105 male, 52%; maximal wall thickness: 18±3 mm) studied with CFVR during exercise (n=33, 16.4%), dipyridamole (n=89, 44.3%) or adenosine (n=79, 39.3%) SE in 6 certified centers. CFVR was assessed using pulsed wave Doppler sampling in left anterior descending coronary artery. All patients completed the clinical follow-up.

Results

During SE mean value of CFVR was 2.11±0.46. No patients showed regional wall motion abnormalities during stress. LV outflow tract obstruction (LVOTO) was present in 34 (16.9%) patients at rest and in 47 (23.4%) at peak stress. CFVR was inversely related to age (r=−0.229, p=0.001) and maximal wall thickness (r=−0.197, p=0.031). During a median follow-up of 26 months (IQ range: 12–48 months), 75 events in 63 patients occurred: 10 deaths, 33 new hospital admission for acute heart failure, 8 sustained ventricular tachycardias and 24 atrial fibrillations. Patients in the lowest tertile (≤1.88) showed the worse prognosis with higher incidence of follow-up events compared to median tertile (1.89–2.29) and highest tertile (≥2.30) (see figure). At multivariable analysis, NYHA functional class (HR: 2.234, 95% CI: 1.398–3.517, p=0.001), presence of LVOTO at rest (HR: 2.958, 95% CI: 1.074–3.570, p=0.028) and lowest tertile of CFVR (HR: 2.144, 95% CI: 1.126–4.081, p=0.011) were the independent predictors of follow-up events.

Conclusions

In HCM patients, reduction in CFVR is associated to a clearly worse outcome. The spectrum of prognostic stratification is expanded if the response is titrated according to a continuous scale.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact assessment of the public health product tax in Hungary

Many countries apply fiscal policies to promote healthy diets to reduce the risk factors of NCDs. In 2011, a public health product tax (PHPT) was introduced in Hungary, taxing non-staple food products that carry proven health risks when consumed. The objectives of PHPT were to promote healthier eating habits by increasing the availability of healthy choices; to encourage reformulation; and to increase revenues for public health. With the purpose of evaluating the social and economic effects of PHPT, impact assessments (IAs) were conducted in 2012, 2014, and in 2018. The IA in 2018 was conducted within the framework of an EU-cofunded development project. To measure the awareness of the population on the law; to assess the population's attitude towards PHPT; to map the consumption patterns and to examine the major factors influencing food choices were fundamental parts of the IAs. We aim to present the findings of the latest IA and compare them to the results of the previous studies. Population surveys with questionnaires including the same questions were applied in the three assessments, hence changes during the 6 years could be detected. A sample of the adult population was involved in form of personal interviews in each IA. Based on the results, the awareness of PHPT was less (66%) in 2018 than in 2012 (72%). The adult population's consumption of the taxed products increased in all categories between 2012 and 2018 (except for salty condiments). Sociodemographic factors and awareness of the law correlated with the consumption of certain PHPT products. Taste was the primary determinant of food choice both in 2012 and 2018. The role of the price and the energy content in food choices were decreased significantly by 2018. A higher proportion of people identified the aims of PHPT correctly and agreed with them in 2018. The results draw attention to the importance of further interventions and the need of targeted health communication.

Key messages

The impact of the PHPT should continue to be monitored and evaluated. To achieve the aims of PHPT in the long term, it is needed to use more effective health communication, furthermore harmonized intersectoral actions should be also implied to promote healthy diet.

Impact assessment of the TFA regulation on fatty acid composition of foods in Hungary

Trans fatty acids are formed during the industrial processing of food, and are proven to be harmful for the human body. They have been associated with increased risk of cardiovascular disease, abdominal obesity, diabetes, and certain types of cancer. Decree 71/2013. (XI. 20.) of the Ministry of Human Capacities, which has been in force since 2014, defines the highest permitted amount of trans fats in food products placed on the market in Hungary. The impact of the decree on the industrially produced trans fatty acids (iTFA) availability and population intake was assessed in 2017. Results demonstrated that iTFA were replaced by other fatty acids due to the legislation. In 2019, we investigated food groups which had high measured TFA content before the regulation entered into force and compared the total fat and fatty acid profiles to the same brand or similar products being on the market afterwards. In collaboration with the World Health Organization, this was the first assessment to determine to which extent manufacturers increased saturated fat (SFA) content of foodstuffs to reduce iTFA content. In those product groups, which were identified as significant food sources of iTFA before introducing the regulation (biscuits, coffee creamers and flavorings, sweets, bakery products, confectionary, wafers, margarines) we found no significant changes in the total fat content, while in most foodstuffs the average proportion of SFA was higher after reformulation, as iTFA were mainly substituted with SFA in 61% of the products, with cis-MUFA in 25% and cis-PUFA in 14% of the products, respectively. Evidence from this analysis supports concerns that eliminating iTFA in certain foodstuffs leads to unwanted substitution with saturated fat, hence reducing the possible health benefits. Given the high SFA intake and the unfavourable cardiovascular statistics in Hungary, the consumption frequency and portion size control of these products are advised.

Key messages

Monitoring the changes of food composition is important in order to evaluate the effect of the regulation. Manufacturers should be encouraged to reduce the SFA content to a technologically feasible level.

Is it Necessary to Perform Sentinel Lymph Node Biopsy in Thin Melanoma? A Retrospective Single Center Analysis

Sentinel lymph node biopsy (SLNB) is a standard procedure for regional lymph node staging and still has the most important prognostic value for the outcome of patients with thin melanoma. In addition to ulceration, SLNB had to be considered even for a single mitotic figure in thin (<1 mm) melanoma according to AJCC7th guideline, therefore, a retrospective review was conducted involving 403 pT1 melanoma patients. Among them, 152 patients suffered from pT1b ulcerated or mitotic rate ≥ 1/ mm2 melanomas according to the AJCC7th staging system. SLNB was performed in 78 cases, of which nine (11.5%) showed SLN positivity. From them, interestingly, we found a relatively high positive sentinel rate (6/78-8%) in the case of thin primary melanomas ˂0.8 mm. Moreover, the presence of regression increased the probability of sentinel positivity by 5.796 fold. After reassessing pT stage based on the new AJCC8th, 37 pT1b cases were reordered into pT1a category. There was no significant relation between other characteristics examined (age, gender, Breslow, Clark level, and mitosis index) and sentinel node positivity. Based on our data, we suggest that mitotic rate alone is not a sufficiently powerful predictor of SLN status in thin melanomas. If strict histopathological definition criteria are applied, regression might be an additional adverse feature that aids in identifying T1 patients most likely to be SLN-positive. After reassessing of pT1b cases according to AJCC8th regression proved to be independent prognostic factor on sentinel lymph node positivity. Our results propose that sentinel lymph node biopsy might also be considered at patients with regressive thin (˂0.8 mm) melanomas.

0090 Stage-Specific Sleep Disruption and its Effect on Spatial Navigational Memory

Introduction

The mechanisms by which sleep disruption impact memory may depend on sleep stage, as rapid eye movement (REM) and slow wave sleep (SWS) differ in several significant ways, including degree of neuronal synchrony and frequency of cortical local field potential oscillations. Here we sought to examine the relationship between stage-specific disruption of sleep and its effect on spatial navigational memory.

Methods

9 healthy adult subjects participated in this study which involved 3 in-lab polysomnograms (normal, REM-disruption, and SWS-disruption) accompanied by pre- and post-sleep functional neuroimaging of brain during a spatial navigational memory task. Graded auditory stimuli consisting of 0.5 second bursts of high-frequency tones (300-3000Hz) were used to disrupt sleep (REM/SWS) in real time. Primary metrics to ascertain the effect of these auditory tones on sleep were time in sleep stage (REM/SWS) as a % of total sleep time (TST), bout length. The primary metric for spatial navigational memory was %change in overnight completion time on a first-person-experience 3D maze task.

Results

Sleep macrostructure was normal during the normal night (TST:379.9±56.6 min; SWS:19.5±7.6%; REM:19.4±5.3%; mean±std). Stage-specific disruption of sleep was achieved using auditory tones during a) SWS-disruption condition (TST:388.9±47.4 mins; SWS:6.6±4.8%; REM:18.7±5.2%) and b) REM-disruption condition (TST:365.3±69.8 mins; SWS:17.1±7.7%; REM:12.1±6.6%). SWS-disruption reduced mean bout length of SWS as compared to no disruption (1.3±0.8 mins vs. 10.3±8.2 mins; p&lt;0.01) and REM-disruption reduced mean bout length of REM as compared to no disruption (2.2±1.7 vs. 10.6±5.2 mins; p&lt;0.01). When sleep was not disrupted, subjects achieved overnight improvements in performance (25.3±17%) which remained unchanged during REM-disruption (18.8±29.6%, p=0.5) and during SWS-disruption (38.8±24.4%; p=0.2). Morning psychomotor vigilance was also unaffected by condition.

Conclusion

Stage specific disruption of sleep can be achieved using graded auditory tones. While performance on a virtual 3D maze remain unchanged with stage specific sleep disruption, lower sample size may have limited our ability to detect the change. Activation patterns from functional neuroimaging that were acquired during the spatial navigation task may elucidate the interaction between stage-specific sleep disruption and performance.

Support

NIH R21AG059179

0418 Effect of Acute Administration of DORA-12 on Sleep Impairment in the Aged PS19 Mouse Model of Tauopathy

Introduction

Aged PS19 mice (MAPT P301S), a mouse model of tauopathy and neurodegeneration, display reduced NREM and REM sleep starting around 8-9 months before death around 12 months. Here, we tested the acute effect of a dual orexin receptor antagonist (DORA-12) on sleep in 11 mice (5 male, 6 female) at 10.3±1.8 months.

Methods

Two consecutive 24-hour recordings (12/12hr L:D cycle) were scored semi-automatically for non-REM sleep, REM sleep, and wake in mice implanted with EEG/EMG. Mice were treated with either vehicle (day 1) or 100mg/kg of DORA-12 (day 2) by oral gavage at both ZT0 and ZT9.

Results

After the first dose at ZT0, both latency to the first NREM sleep episode (paired t-test p=0.002) and to the first REM sleep episode (paired t-test p=0.005) was significantly shorter with DORA-12 (NREM: 20.8±17.8 min.; REM: 23.5±21.2 min.) compared to vehicle (NREM: 49.2±22.3 min.; REM: 127.0±93.3 min.). There was no difference in NREM or REM sleep latency observed after the second dose at ZT9. DORA-12 treatment increased NREM duration across the 24hr period (DORA-12: 664±52 min.; Veh: 601±54 min., paired t-test p=0.007) and also after the 2nd dose (DORA-12: 311±65 min.; Veh: 263±84 min., paired t-test p=0.009). DORA-12 treatment also increased REM duration across 24hrs (DORA-12: 61±30 min.; Veh: 48±29 min., paired t-test p=0.014) but not after the 2nd dose alone (DORA-12: 22±14 min.; Veh: 20±15 min., paired t-test p=0.388). Notably in both vehicle and DORA-12 conditions, we observed apparent dream enactment behavior including mastication, paw grasp, and fore limb extension during REM in 3 of 11 PS19 mice (all male), not typically observed in younger PS19 or age-matched non-transgenic mice, suggestive of a possible REM behavior disorder (RBD) phenotype. Wake-like behaviors occurred during theta-dominant EEG but with an EMG amplitude &gt;4SD the preceding NREM sleep baseline for at least &gt; 1sec.

Conclusion

In aged PS19 mice, DORA-12 was found to decrease the latency to NREM and REM after the first dose while also increasing NREM and REM duration across the entire 24hr recording period. We also capture a heretofore undescribed RBD-like phenotype in aged PS19 tauopathy mice.

Support

Merck MISP

P817 Lung ultrasound in the evaluation of pulmonary congestion in patients with aortic stenosis

Background

Aortic stenosis (AS) has a prolonged latent period, as AS worsens, the left ventricular adaptations become inadequate and impaired systolic and/or diastolic dysfunction, may lead to clinical heart failure (HF). The development of HF is an inflexion point in the natural history of AS. Pulmonary congestion is a nearly universal pathophysiological finding in HF, and may precede symptoms. Lung ultrasound (LUS) evaluation of B-lines has been proposed as a simple, non-invasive tool to assess pulmonary interstitial edema.

Aim

To assess pulmonary interstitial edema with LUS in patients with moderate and severe aortic stenosis, to define performance of LUS compared with clinical assessment and echocardiographic parameters.

Methods

Sixty-eight consecutive patients (36 women, mean age 74 ± 9 years) with moderate or severe aortic stenosis were enrolled. Exclusion criteria were as follows: moderate or severe aortic regurgitation, moderate or severe mitral regurgitation, cardiomyopathies and pulmonary disease. All patients underwent comprehensive echocardiography examination and LUS according to a previously validated 28 scanning-site assessment.

Results

we found a significant number of B-lines (≥15) in 79% of patients. B-lines were positively correlated with left atrial volume index (p &lt; 0,05, r = 0,3) and estimated pulmonary pressure ( p &lt; 0,0001, r= 0,62 Figure 1.) The number of B-lines didn’t correlate with the severity of AS (mean gradient vs. B-lines: p = 0,2, valve area vs. B-lines: p = 0,2.), however properly reflects different functional status of the patients (p &lt; 0,0001, Figure 2.)

Conclusion

Lung ultrasound is a promising tool to detect lung congestion related to AS. The severity of congestion doesn’t correlate with the severity of AS, albeit B-lines better reflect the deteriorating functional status of the patients and the haemodynamic consequences related to AS.

Abstract P817 Figure. Correlation PASP vs Blines, NYHA/B-lines

P944 From systolic pulmonary arterial pressure to pulmonary vascular resistance and reserve: a simplified method for exercise stress echocardiography

OnBehalf

On behalf of Stress Echo 2020 study group of the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI).

Background

The potential of exercise stress echocardiography (ESE) seems to be still underused especialy in the assessment of pulmonary hemodynamics.

Aim

To assess the feasibility and compare pulmonary vascular resistance (PVResistance) and reserve (PVReserve) during ESE in patients at risk of pulmonary hypertension (PH) and controls.

Methods

We performed semi-supine ESE, in 97 subjects (age 49 ± 16 yrs, 63 females): 58 patients (Group 1) at risk for PH (systemic sclerosis and other connective tissue diseases) and 39 healthy controls (Group 2). Rest and stress assessment included: tricuspid regurgitant velocity (TRV), pulmonary acceleration time (ACT), cardiac output (CO), SPAP estimation with Bernouilli equation or from ACT with formula: log10 SPAP= - 0.004 (ACT) + 2.1. We estimated PVResistance from Abbas formula, and PVReserve as ΔCO/ ΔSPAP or (when CO was not available) as minutes of exercise/ΔSPAP. When ΔSPAP was &lt;10 mmHg, it was considered equal to 1.

Results

With TRV or ACT to estimate pressures, and cardiac output or its proxy to estimate flow, PVResistance or PVReserve could be measured in all patients. At peak exercise, PVResistance was higher and PVReserve lower in Group 1 : see Table.

Conclusion

Estimation of PVResistance and/or PVReserve can be obtained in all patients during ESE, integrating TRV with ACT, and using exercise-time as a proxy of CO when the latter is not available. These indices may be useful for a better, noninvasive characterization of the heterogeneity of pulmonary hemodynamics.

Pulmonary hemodynamics ESE data Parameter Group 1, PH (n = 58) Group 2, normals (n = 39) P value TRV rest (cm/s) 243 ± 63 204 ± 31 =0.0147 TRV peak (cm/s) 344 ± 68 204 ± 53 &lt;0.0001 ACT rest (ms) 113 ± 33 128 ± 20 =0.0205 ACT peak (ms) 86 ± 19 94 ± 22 ns SPAP rest (mm Hg) 26 ± 10 21 ± 4 =0.0039 SPAP peak (mm Hg) 45 ± 19 28 ± 13 &lt;0.0001 CO rest (mL/min) 4.9 ± 1.7 5.1 ± 1.7 ns CO peak (mL/min) 7.8 ± 2.8 7.6 ± 2.9 ns Exercise time (min) 7 ± 2 13 ± 3 &lt;0.0001 PVResistance (WU) rest 1.63 ± 0.52 1.54 ± 0.34 ns PVResistance (WU) peak 2.01 ± 0.89 1.27 ± 0.42 =0.0219 PVReserve (ΔCO/ΔSPAP) 1.38 ± 1.13 3.55 ± 2.45 =0.001 PVReserve (Extime/ΔSPAP) 4.69 ± 2.67 10.96 ± 4.39 &lt;0.0001 Legends: WU -Wood Unit, Ex time - exercise time

P1586 Lung ultrasound and left atrial deformation analysis: a promising methods for the diagnosis of heart failure with preserved ejection fraction

Background

Heart Failure with Preserved Ejection Fraction (HFpEF) is a growing healthcare burden and its prevalence is increasing. Diagnosing HFpEF is challenging. Lung ultrasound (LUS) and left atrial strain are promising screening tools to assess pulmonary congestion and left atrial dysfunction in patients with suspected HFpEF.

Aim

To evaluate the relationship between LUS, left atrial strain and NT-proBNP level in patients with HFpEF. Also to assess the diagnostic power of B-lines in HFpEF population.

Methods

Forty-seven consecutive patients (24 women, mean age 69 ± 11 years) with clinical signs of heart failure were prospectively enrolled. Exclusion criteria were: ejection fraction &lt;55%, more than mild mitral and/or aortic valve disease, pulmonary disease, pulmonary arterial hypertension. Within one hour all patients underwent comprehensive echocardiographic evaluation including left atrial strain analysis (peak atrial longitudinal strain-PALS), lung ultrasound assessment of B-lines on the antero-lateral and posterior chest wall, and NT-proBNP levels.

Results

In 34 patients (72%) a significant number of B-lines (≥15) were observed. We found a positive correlation between the number of B-lines and NT-proBNP levels (p &lt; 0,0001, r = 0,74, Figure 1.), left atrial volume (p &lt; 0,05, r = 0,45), and PALS (p &lt; 0,02, r = 0,4 ). We didn’t found any correlation between the number of B-lines and E/e’ ratio (p = 0,1, r = 0,28), or between E/e’ ratio and NT-proBNP level (p = 0,1, r = 0,2). We also assessed the diagnostic ability of ≥15 B-lines to predict markedly elevated pro-BNP level (≥ 220pg/ml), AUC was 0.89. If the total number of B-lines was greater or equal to 28, the sensitivity was 68% with the specificity of 100%, but if we changed the cut-off value to 12, the sensitivity grew to 89% with the specificity of 71%. (Figure 2.).

Conclusion

LUS is a simple, feasible tool to detect pulmonary congestion in HFpEF and it has a strong diagnostic power to predict elevated NTpro-BNP level. B-lines correlate with parameters of left atrial dysfunction. PALS is promising too, which better reflects pulmonary congestion and elevated NT-proBNP values than the conventional echocardiographic parameter E/e’.

Abstract P1586 Figure. NT-pBNP vs B-lines, AUC of Blines

P1454 A rare case of unexpected right atrial mass following aortic valve replacement

Funding Acknowledgements

This work was supported by the University of Medicine, Pharmacy, Science and Technology of Targu Mures Research Grant number 615/13/17.01.2019

Background

An early appearance of cardiac masses after valve replacement raises differential diagnosis problems. The specific therapeutic approach of autoimmune comorbidities enhances the risk of infective endocarditis or inflammatory reactions. Among systemic disorders leading to cardiac complications, rheumatoid arthritis is cited. Leflunomide is a synthetic disease-modifying antirheumatic drug (DMARD) with immunomodulatory actions as it inhibits the de novo synthesis of pyrimidine, hence suppressing T cell activation and proliferation. It is used as first line treatment strategy for rheumatoid arthritis (RA) patients, with contraindication or non-tolerance of Methotrexate.

Case presentation

We present the case of a 63-year old Caucasian male with seropositive RA, treated with Leflunomide 20 mg od, with history of severe calcified aortic stenosis and permanent atrial fibrillation. The patient underwent an aortic valve replacement with a St. Jude Regent 25 mechanical valve and ascending aorta replacement with a Dacron 30mm graft. Leflunomide was forthwith discontinued before surgery. Five months after surgery, in a routine check-up, including proper adherence to the anticoagulation regimen (regular INR 2.6-3.2), and stable hemodynamic status, a right atrial mass was identified by transthoracic echocardiography (figure). The mobile hyperechogenic mass appeared to be attached by a narrow stalk to the atrial septum, presenting a quasi-parallel movement to the septal cusp. The haemodynamic of the tricuspid valve was not affected. A suspicion of early infective endocarditis was ruled out. Cardiac CT identified a well-defined, pedunculated, mobile mass measuring 2.8x3.1 cm originating above the tricuspid annulus, attached to the atrial septum without hemodynamic impact. An inflammatory pseudotumor was identified and a granulomatous mass was diagnosed. Consecutively, Leflunomide 20 mg od along with adjusted doses of corticosteroids were initiated with progressively diminished dimensions of the tumour three months after the ultrasound and CT diagnosis. One year after complete resolution of the mass, the patient continues his immunosuppressive and cardiac pharmacological regimen. Repeated echocardiograms showed standard functionality of the aortic prosthesis, without recurrent intracardiac mass.

Conclusion

Management of an intracardiac mass after cardiac surgery in patients with systemic inflammatory diseases may be challenging. Cardiac imaging is mandatory to differentiate among thrombi, vegetations, primary or metastatic cardiac tumours.

In RA patients DMARD and immunosuppressive therapy should not be discontinuing during perioperative procedures as they do not increase the risk of infectious complications. Sequential imaging studies in patients presenting systemic inflammatory comorbidities should be used to assess and identify the immunological responses in the absence of targeted therapy.

Abstract P1454 Figure.

P1481B-lines and left atrial strain in outpatients with suspected heart failure with preserved ejection fraction

Background

Heart Failure with Preserved Ejection Fraction (HFpEF) is a growing healthcare burden and its prevalence is increasing. Diagnosing HFpEF is challenging. Lung ultrasound (LUS) and left atrial strain are promising tools to assess pulmonary congestion and left atrial dysfunction in outpatient settings in patients with suspected HFpEF.

Aim

To evaluate the correlation of LUS B-lines with left atrial strain in patients with HFpEF.

Methods

Thirty-six consecutive patients (24 women, mean age 70±6 years) with clinical signs of heart failure were prospectively enrolled. Exclusion criteria were: ejection fraction <55%, more than mild mitral and/or aortic valve disease, pulmonary disease, pulmonary arterial hypertension. Within one hour all patients underwent comprehensive echocardiographic evaluation including left atrial strain analysis (peak atrial longitudinal strain-PALS), lung ultrasound assessment of B-lines on the antero-lateral and posterior chest wall, and NT-proBNP levels.

Results

The mean ejection fraction was 65.5±8.6%. In 28 patients (85%) a significant number of B-lines (≥15) was observed. We found a positive correlation between the number of B-lines and NT-proBNP levels (p<0.0001, r: 0.76, Figure 1.), left atrial volume (p<0.05, r: 0.45), and PALS (p<0.05, r: −0.5, Figure 2.). We didn't found any correlation between the number of B-lines and E/e'ratio (p=0.1, r: 0.28), or between E/e' ratio and NT-proBNP level (p=0.2, r: 0.2).

Conclusion

LUS is a simple, feasible tool to detect pulmonary congestion in HFpEF and it seems to better characterize these patients. B-lines correlate well with NT-proBNP values and with parameters of left atrial dysfunction. PALS is a promising too which better reflects pulmonary congestion and elevated NT-proBNP values than the conventional echocardiographic parameter E/e'.

Anti-Haemophilus Activity of Selected Essential Oils Detected by TLC-Direct Bioautography and Biofilm Inhibition

Essential oils (EOs) are becoming increasingly popular in medical applications because of their antimicrobial effect. Direct bioautography (DB) combined with thin layer chromatography (TLC) is a screening method for the detection of antimicrobial compounds in plant extracts, for example, in EOs. Due to their lipophilic character, the common microbiological assays (etc. disk diffusion) could not provide reliable results. The aim of this study was the evaluation of antibacterial and anti-biofilm properties of the EO of cinnamon bark, clove, peppermint, thyme, and their main components against Haemophilus influenzae and H. parainfluenzae. Oil in water (O/W) type Pickering nano-emulsions stabilized with silica nanoparticles from each oil were prepared to increase their water-solubility. Samples with Tween80 surfactant and absolute ethanol were also used. Results showed that H. influenzae was more sensitive to the EOs than H. parainfluenzae (except for cinnamon bark oil). In thin layer chromatography-direct bioautography (TLC-DB) the ethanolic solutions of thyme oil presented the best activity against H. influenzae, while cinnamon oil was the most active against H. parainfluenzae. Pickering nano-emulsion of cinnamon oil inhibited the biofilm formation of H. parainfluenzae (76.35%) more efficiently than samples with Tween80 surfactant or absolute ethanol. In conclusion, Pickering nano-emulsion of EOs could inhibit the biofilm production effectively.

P13.14 Use of Foundation one CDx for molecular screening in patients with primary brain tumors: Gustave Roussy Experience

BACKGROUND

Patients with primary brain tumors usually have poor prognosis and few therapeutic options. However recent report showed that they may benefit from molecular screening to improve treatment benefit and enrollment in clinical trials. We aimed to evaluate if molecular screening using Foundation One Dx may help therapeutic strategies in primary brain tumor patients.

MATERIAL AND METHODS

Between October 2018 and December 2018, we enrolled prospectively patients in the MOSCATO (Molecular Screening for cancer Treatment Optimization) 02 trial using the Foundation One Dx test. Patients were eligible if they had good Performans status (PS) (0 or 1) and tumor tissue material available. Results were reviewed during a molecular multidisciplinary meeting weekly at the Drug Development Department at Gustave Roussy to decide on orientation and matched therapy according to molecular alterations.

RESULTS

Finally thirty-three patients were enrolled in the study. Twenty six tumor tissues were analysed and 7 patients were screen failures due to tumor tissue unavailability. Median age was 49 years old (19 - 72). Patients had a good PS with a median of 1 (0–2) and were mostly males (76%). The most common tumor type was glioblastoma (79%). Five patients had a high grade tumor including 2 medulloblastomas. Median time between consent and multidisciplinary meeting was 70 days (49 - 156). Median percentage of tumor cells was 78% (30–80%). The tumor mutational burden (TMB) was available in 26 patients. The median TMB was 4 mutations per megabase (0 - 277). The most frequent alterations were TERT promoter mutation 22/26 (85%), CDKN2A loss 14/26 (54%), MTAP loss 11/26 (42%), EGFR amplification (38%) including 4 EGFRvIII amplification, TP53 mutation and PTEN deletion 9/26 (35%) respectively, PIK3CA mutation 5/26 (19%), CDK4 or 6 amplification 4/26 (15%), NF1 mutation 3/26 (12%), 2 IDH1 mutations, 2 MET amplifications, 2 HGF amplifications, 1 FGFR2 mutation, 1 BRAF V600E mutation, 1 PDGFRA amplification, 1 EZH2 mutation and 1 SMARCA4 mutation. Finally 11 patients (42%) were oriented according to molecular alterations (EGFR amplifications, BRAF mutation), 1 patient was treated and is ongoing with a BRAF inhibitor and 1 patient is in screening in atrial with an EGFR inhibitor.

CONCLUSION

Molecular screening with Foundation One Dx test is feasible in patients with primary brain tumors and can help therapeutic strategies. However the time between consent and multidisciplinary meeting was the main limitation to our study and affected enrollment in clinical trials.