Prognostic implications of paradoxical low gradient severe aortic stenosis: a comprehensive analysis from a large multicentric registry

Background

Up to 40% of patients with severe aortic stenosis (SAS; indexed aortic valve area (AVAi) <0.6 cm2/m2) present with low transvalvular mean gradient (MG) despite a normal left ventricular ejection fraction (EF). There is intense debate about the prognostic significance of such entity, with some referring to it as an advanced form of the disease, others as an intermediate form between a moderate and a severe form.

Objectives

To compare outcome of patients with paradoxical low gradient SAS (PLG-SAS; i.e., mean gradient <40 mmHg and AVAi <0.6 cm2/m2) vs. moderate aortic stenosis (MAS; i.e. mean gradient <40 mmHg and AVAi >0.6 cm2/m2) and high gradient SAS (HG-SAS; i.e. mean gradient >40 mmHg and AVAi <0.6 cm2/m2).

Methods

2582 consecutive patients with aortic stenosis (PLG-SAS, n=933; MAS, n=876 and HG-SAS, n=773) and a preserved EF (>50%) from an international multicentric registry were studied. Five years mortality between groups was compared using Kaplan Meier analysis. Inverse probability weighting was used to adjust for clinical and imaging baseline characteristics. Additionally, to explore the impact of MG (<40 mmHg vs. >40 mmHg) in patients with AVAi <0.6 cm2/m2 (PLG-SAS vs. HG-SAS) and to explore the impact of AVAi (<0.6 cm2/m2 vs. >0.6 cm2/m2) in patients with MG <40 mmHg (PLG-SAS vs MAS) we performed 2 different propensity score analyses. Patients were censored at the time of surgery.

Results

Overall, during 23 [IQR,10–47] months of follow-up 1003 patients died and 770 patients underwent aortic valve replacement. IPW-adjusted natural history was significantly better in patients with MAS, intermediate for patients with PLG-SAS and worst in patients with HG-SAS (59 vs. 47 vs. 41%, p<0.001, see Figure 1A). Furthermore, at equal MG (448 pairs), survival was significantly better in patients with MAS compared with PLG-SAS (54% vs. 39% p<0.001, see Figure 1B) and at equal AVAi (377 pairs), survival was significantly better in patients with PLG-SAS compared with HG-SAS (43% vs. 32% p<0.001, see Figure 1C).

Conclusions

In this large multicentric cohort, survival of PLG-SAS patients was better than that of HG-SAS patients and worse than that of MAS patients. Furthermore, with a comparable mean gradient, the smaller the calculated AVAi, the worse the prognosis whereas with a comparable AVAi, the higher the mean gradient, the worse the prognosis. Taking together, these data demonstrate that PLG-SAS is an intermediate form in the disease continuum, HG-SAS being the most malignant form of AS.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fonds National de la Recherche Scientifique (F.R.S.–FNRS)

Clinical use of mean platelet volume and neutrophil-to-lymphocyte ratio to predict prognosis in heart failure with preserved ejection fraction patients

Background

Over the last decade, a new paradigm for heart failure with preserved ejection (HFpEF) development has been proposed. High burden of comorbidities would lead to a systemic inflammatory state and enhanced platelet activation. High platelet reactivity could be associated with higher mean platelet volume (MPV) due increased circulating immature platelets. Moreover, neutrophil-to-lymphocyte (NLR) reflects systemic inflammation. Both parameters have been associated with morbidity and mortality in heart failure (HF). However, data in HFpEF are limited.

Purpose

We aim to investigate the use of MPV and NLR to predict clinical outcome in HFpEF patients.

Methods

We prospectively enrolled 228 patients with HFpEF (79±9 years, 66% female patients) and 38 controls of similar age and gender (78±5, 63% female patients). All subjects underwent a complete two-dimensional echocardiography. Mean platelet volume and NLR were measured at baseline. Patients were followed over time for a primary end point of all-cause mortality or first HF hospitalization. The prognosis impact of MPV and NLR were determined with Cox proportional hazard models.

Results

Mean MPV and median NLR were significantly higher in HFpEF patients compared to controls (MPV: 11.7±1.1 fL vs 10.0±1.1 fL, p=0.005; NLR: 3.3 [2.2; 5.0] vs 2.2 [1.9; 2.9], p<0.001). HFpEF patients with MPV >75th percentile (n=56) had more frequently a history of ischemic cardiomyopathy (46%, p=0.04). HFpEF patients with NLR >75th percentile (n=57) were more frequently in New York Heart Association functional (NYHA) III or IV class (58%, p=0.02) and had higher levels of NT-proBNP (2152 [1336; 6397] pg/mL vs 1690 [705; 3304] pg/mL, p=0.02). Over a median follow-up of 26 months [11.5–56.7 months], 136 HFpEF patients (60%) reached the composite end point (87 deaths and 107 hospitalizations for HF). In univariate Cox regression analysis for the primary end point, MPV >75th percentile (HR: 1.45 [0.99; 2.13], p=0.05) and NLR >75th percentile (HR: 1.59 [1.11; 2.28], p=0.01) were predictors of the primary composite endpoint. In multivariate Cox regression analysis, mean platelet volume >75th percentile (χ2=8.11, P=0.004), continuous MPV (χ2=4.64, P=0.03) provided significant additional prognostic value over a baseline model created using independent predictors of the primary composite end point: body mass index (BMI), NYHA class III or IV, chronic obstructive pulmonary disease (COPD), loop diuretics, estimated glomerular filtration rate (eGFR) and NT-proBNP. By contrast, NLR did not provide any additional information (Figure 1 and 2).

Conclusion

MPV level and NLR were significantly higher in HFpEF patients compared with controls of similar age and gender. Elevated MPV offers an additional prognostic indication for clinicians and more interestingly it supports the hypothesis that of platelet activation could be involved in disease pathophysiology in HFpEF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fondation Saint-Luc

Impact of recent 2021 ESC guideline changes on postoperative survival of patients with severe aortic regurgitation: insights from the AVIATOR registry

Background

Until 2021, the strongest guidelines on surgical correction of severe aortic regurgitation (AR) focused on the left ventricular systolic function (LVEF) and the presence of symptoms. However, those situations lead to an outcome penalty, even after surgical correction. Left ventricle end-systolic diameter (LVESD) gained in strength in 2021 European guidelines. Moreover, more inclusive cut-off values are now recommended (class IIb) in patients at low surgical risk, reflecting the will to recommend surgery before developing heart failure and its consequences on post-operative outcome.

Purpose

We sought to evaluate the impact of guidelines triggers and their recent changes on postoperative survival of patients with severe AR from a large multicentric international registry.

Method and results

Postoperative overall survival of 1899 patients operated for severe and chronic AR (mean age 49±15 years, 85% male) in the international multicenter surgery registry for aortic valve surgery, AVIATOR, was evaluated over a median of 37 months. Twelve patients (0.6%) died postoperatively, and 68 within 10 years. By multivariable Cox analysis, presence of heart failure symptoms (HR 2.60; 95% CI [1.20–5.66]; p=0; 016), and either LVESD >50 mm or >25 mm/m2 (HR 1.64; 95% CI [1.05–2.55]; p=0.029) predicted survival independently over and above age (HR 2.25 per SD, 95% CI [1.67–3.03], p<0.001), female gender and bicuspid phenotype. Therefore, patients operated on when meeting either old or new 2021 class I triggers had worse adjusted survival (respectively 86±2% and 87±2%) than patients operated on without meeting triggers (97±2%, p<0.01). However asymptomatic patients operated on while meeting new 2021 ESC class IIb triggers (ie LVESD >20 mm/m2 or LVEF between 50–55%, 10-year survival 97±3%). Moreover, the sub-group of patients having a dilated LVESD >50 mm or >25 mm/m2 but a preserved LVEF >50% had excellent survival (10-year survival 95±3%).

Conclusions

In severe AR, patients operated on when meeting any class I trigger have postoperative survival penalty. Asymptomatic patients operated on earlier have better survival. This supports early surgery in AR as encouraged by the recent ESC/EACTS guidelines.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Fondation Nationale de la Recherche Scientifique of the Belgian Government

Myocardial functional and structural abnormalities after adjuvant radiotherapy for breast cancer. Relation to cardiac radiation exposure

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Funds Pierre Masure, Alphonse and Marie Walckiers & De Winter-Vermant, by King Baudouin Foundation

Background

Radiation therapy (RXT) is a keystone in breast cancer (BC) treatment which allows to reduce risk of local recurrence and cancer related mortality. Yet these benefits may be offset by increases in cardiovascular mortality due to late radiation induced cardiotoxicity. Indeed, prior works in patients exposed to high cardiac radiation dose demonstrated development of diffuse and focal myocardial fibrosis by cMR. However, whether such effects may also occur after contemporary BC-RXT with lower cardiac dose exposure, has not yet been evaluated.

Purpose

To evaluate the long-term cardiac safety of contemporary RXT for BC, we sought to estimate the prevalence of cardiac functional and structural focal and myocardial abnormalities in BC survivors treated by RXT 10 years earlier, in direct relation to measured local radiation dose exposure.

Methods

In a prospective cross-sectional study, we studied 27 women (mean age 62 ± 7 years) treated with adjuvant RXT but without chemotherapy for a first left (n= 12) or right sided (n= 15) BC between 2009 and 2011, which had no history of coronary artery or cardiac disease and compared them to 20 age matched (64 ± 10 years) healthy female controls (without history of BC or RXT). All subjects underwent 3T cMR to measure LV volumes, function, global longitudinal (GLS), circumferential (GRS) and radial strains (GRS) as well as extracellular volume (ECV) and late gadolinium enhancement (LGE). Functional and structural abnormalities in women with BC were compared to healthy controls. We also compared abnormalities among patients with left vs right BC and related them to mean heart radiation dose measured at the time of RXT (Figure).

Results

Mean cardiac radiation exposure in BC survivors was 1.87 ± 1.7 Gy (range 0-7.9 Gy). Exposure was significantly (p < 0.001) higher in left (3.3 ± 0.66 Gy) than in right (0.84 ± 0.65 Gy) sided BC. Indexed LV mass was slightly lower in BC patients than in controls (46 ± 6 vs 51 ± 9 g/m2, p = 0.03), whereas indexed end-diastolic (66 ± 11 vs 66 ± 12 ml/m2, p = NS) and end-systolic volumes (25 ± 8 vs 24 ± 7 ml/m2, p = NS) were similar. Also, LV ejection fraction (63 ± 6 vs 64 ± 6, p = NS), GLS (-14.7 ± 1.9 vs -15.5 ± 1.8, p = NS), GCS (-20.0 ± 3.6 vs -19.3 ± 5.9, p = NS) and GRS (40.9 ± 10.7 vs 37.0 ± 9.0, p = NS) were not statistically different in BC survivors than in controls. No patient presented LGE, and ECV was similar in BC patients exposed to RXT (28.3 ± 2.8) than in controls (29.3 ± 2.4, p = 0.58). Also, no differences in ECV between left and right sided BC and no statistical correlation between ECV and mean heart dose (r = 0.01, p = NS) was observed.

Conclusions

In this preliminary work, patients with BC treated by adjuvant RXT 10 years ago, presented no significant structural or functional abnormalities in relation to cardiac dose exposure nor in comparison to healthy controls. This suggests that current RXT protocols for BC are safe without long-term functional or morphological cardiac side effects.

Evaluation of Drug Abuse by Hair Analysis and Self-Reported Use Among MSM Under PrEP: Results From a French Substudy of the ANRS-IPERGAY Trial

BACKGROUND

We used the Agence nationale de Recherches sur le sida et les hépatites virales (ANRS)-IPERGAY trial to qualitatively and quantitatively measure drug use among men who have sex with men under preexposure prophylaxis using 2 different methods, to better understand and collectively respond to risky practices.

METHOD

We included 69 volunteers of the ANRS-IPERGAY trial. We measured drug use by 2 methods: (1) drug detection by hair analysis and (2) reported drug use by self-reported drug consumption.

RESULTS

New psychoactive substances (NPS) and conventional drugs were detected in 53 of the 69 (77%) volunteers by hair analysis and in 39 of the 69 (57%) volunteers by questionnaires. On the 219 hair segments analyzed, the most commonly used drugs were cocaine in 47 of the 69 (68%), 3,4-methylenedioxymethamphetamine/ecstasy in 31 of the 69 (45%), and NPS in 27 of the 69 (39%). On the 1061 collected questionnaires, the most commonly used drugs were cocaine in 31 of the 69 (45%), 3,4-methylenedioxymethamphetamine/ecstasy in 29 of the 69 (42%), and NPS in 16 of the 69 (23%). Hair analysis detects more conventional drugs and/or NPS use (P < 0.05). Drug use identified by hair was significantly associated with a higher number of sexual partners in the past 2 months (P ≤ 0.001), more often casual partners (P ≤ 0.001), condomless anal sex (P ≤ 0.005), hardcore sexual practices (P ≤ 0.001), a higher number of sexually transmitted infections, and chemsex (P ≤ 0.05).

CONCLUSIONS

Self-report drug use by questionnaires remains the reference tool for harm reduction at the individual level because of its feasibility and low cost. However, hair analysis is more sensitive, objectively assessing consumption, and interesting to understand uses and to be able to collectively respond to risky practices with adapted messages.

Myocardial strain imaging: review of general principles, validation, and sources of discrepancies

Myocardial tissue tracking imaging techniques have been developed for a more accurate evaluation of myocardial deformation (i.e. strain), with the potential to overcome the limitations of ejection fraction (EF) and to contribute, incremental to EF, to the diagnosis and prognosis in cardiac diseases. While most of the deformation imaging techniques are based on the similar principles of detecting and tracking specific patterns within an image, there are intra- and inter-imaging modality inconsistencies limiting the wide clinical applicability of strain. In this review, we aimed to describe the particularities of the echocardiographic and cardiac magnetic resonance deformation techniques, in order to understand the discrepancies in strain measurement, focusing on the potential sources of variation: related to the software used to analyse the data, to the different physics of image acquisition and the different principles of 2D vs. 3D approaches. As strain measurements are not interchangeable, it is highly desirable to work with validated strain assessment tools, in order to derive information from evidence-based data. There is, however, a lack of solid validation of the current tissue tracking techniques, as only a few of the commercial deformation imaging softwares have been properly investigated. We have, therefore, addressed in this review the neglected issue of suboptimal validation of tissue tracking techniques, in order to advocate for this matter.

P1393 Intervendor difference in global and regional 2D speckle tracking strain. comparison against cMR tagging

Funding Acknowledgements

Fondation de Recherche Scientifique Belge FRSM PDR 19488731

BACKGROUND

2D-speckle-tracking (ST) echocardiography is currently widely used for estimation of global (G) and regional myocardial deformation. In previous works, we showed good correlation between global longitudinal (LS) and circumferential strain (CS) from one 2DST vendor with cMR-Tagging, however with significant bias between both methods. Also, we found poorer agreement between 2DST and cMR-Tagging on regional basis. However it is unknown how 2DST from other vendors would comparte to cMR tagging.

PURPOSE

To asssess vendor differences in global and regional strain assessment and compare 1) the agreement of 2 different 2DST softwares for global and regional LS and CS among each other and against cMR-Tagging as reference; and 2) the accuracy of both softwares to detect infarcted segments.

METHODS

100 subjects with different cardiac disease (among which 31 with chronic infarct) underwent 2DST and tagging and LGE cMR on the same day. Global and regional CS (16 AHA segments) and LS (18 AHA segments) was computed using 2 different ST vendor softwares and compared to cMR-Tagging with HARP. Accuracy of regional 2D-ST by both vendors to detect infarcted segments (ie &gt;75% transmurality of late gadolinium) was compared using ROC analysis.

RESULTS

Global LS (ICC = 0.87) and CS 2DST (ICC = 0.83, p &lt; 0.001) agreed well between both vendors, but GCS values of vendor2 were significantly greater than that of vendor 1. Also we fond good correlation between ST of both vendors and cMR-Tagging for GLS (ICC = 0.80 and ICC = 0.69 for vendor 1 and 2 respectively) and GCS (ICC = 0.64 and ICC = 0.50 for vendor 1 and 2 respectively). Bias for GLS (-4.6 ± 2.9% and -6.1 ± 3.8% for vendor 1 and 2 respectively) vs cMR-Tagging was similar, however GCS of vendor 2 had higher bias vs cMR-Tagging (-16.0 ± 8.5%) than vendor 1 (-5.1 ± 5.8%).

Agreement for regional strains is shown in the figure below. Overall, regional LS and CS agreed adequately among both vendors. Agreement of regional LS and CS vs cMR-tagging was slightly better for vendor 1, with less bias than for vendor 2, and disagreement was similarly located (ie agreement with cMR-Tagging for LS in inferolateral inferior and inferoseptal basal segments). The predictive accuracy of regional CS and LS for detecting segments with infarct was higher for vendor 2 (AUC 0.76 and 0.68) than for vendor 1 (AUC 0.70 and 0.63) .

CONCLUSION

GLS agreed well among both vendors and with cMR-Tagging, confirming the universal validity of this measurement. However vendor 2 provided significantly greater GCS values and had higher bias against cMR-Tagging than vendor 1. On regional basis CS and LS agreed moderately well among both vendors, however vendor 2 agreed less with cMR-Tagging than vendor 1, but astoundingly had higher diagnostic accuracy for detecting infarct. Overall this findings call for further efforts in standardization of 2DST CS and regional strain.

Abstract P1393 Figure.

P324Impact of impaired right ventricular strain on the prognosis of HFpEF

Background

Right ventricle (RV) strain has emerged as an accurate and sensitive tool for RV function assessment and is a powerful predictor of survival in heart failure with reduced ejection fraction. The impact of impaired RV strain on prognosis of HFpEF patients however, remains unclear.

Purpose

We sought to analyze RV global longitudinal strain (RV-GLS) by 2D speckle tracking echocardiography (STE) in controls and HFpEF patients and determine its prognostic value.

Methods

Between January 2015 and June 2017, we prospectively enrolled 163 consecutive patients with HFpEF (78±9 years, 62% women) and 27 age and sex matched controls (76±5 years, 67% women). All patients underwent complete 2D echography. Myocardial deformation was assessed on a dedicated four chambers view, with a speckle tracking software. Due to poor tracking quality, RV-GLS could not be analyzed in 14 patients (7.4%). Impaired RV-GLS was defined as a GLS above −17.5% corresponding to the mean + 2 SD of age and sex matched controls. HFpEF patients were followed up for a combined outcome of all-cause mortality and first HF hospitalization.

Results

Mean RV-GLS was significantly altered in HFpEF patients compared to controls (−21.7±4.9% vs −25.9±4.2%; p<0.001). 28 HFpEF patients (19%) had an impaired RV-GLS.

During a mean follow-up of 19±9months, 73 HFpEF patients (49%) reached the combined outcome (15 all cause deaths and 58 first HF hospitalization). In univariate Cox regression analysis, loop diuretic medication (HR 1.92 [1.10–3.32], p=0.021), low hemoglobin (HR 0.85 [0.75–0.97], p=0.013), low eGFR (HR 0.97 [0.96–0.99], p<0.001), E wave velocity (HR 1.01 [1.00–1.02], p<0.001), septal E/e' (HR 1.03 [1.00–1.05], p=0.011) and impaired RV-GLS (HR 2.01 [1.19–3.40], p=0.009) were significantly associated with worse prognosis.

In multivariate Cox analysis, hemoglobin levels (HR 0.83 [0.72–0.96], p=0.01), eGFR (HR 0.98 [0.97–0.99]; p=0.009) and impaired RV-GLS (HR 2.48 [1.38–4.44], p=0.002), were independent predictors of the combined outcome. Kaplan-Meier event free survival curves show that HFpEF patients with RV-GLS above −17.5% had worse prognosis than those with better myocardial deformation (p=0.009, Figure).

Conclusions

RV-GLS is significantly different between controls and HFpEF patients. In HFpEF, impaired RV-GLS is associated with worse prognosis.

Community-Based Care in the ANRS-IPERGAY Trial: The Challenges of Combination Prevention

ANRS-IPERGAY was a community-based randomized trial investigating the efficacy of sexual activity-based HIV pre-exposure prophylaxis (PrEP) in a population of males and transgender females who had sex with men and were at high risk of HIV infection. We qualitatively analyzed the support provided to participants by community-based health workers (CBHW) throughout the trial's double-blind and open-label extension phases. In particular, we showed that the relationship between participants and CBHW strongly influenced self-managed pill intake. The delicate construction of this relationship, balanced between trust and dependence, played an important role in PrEP adherence. CBHW had to deal with various issues surrounding participants' feelings of empowerment regarding their role in the trial, as well as related tensions between various logics and rationalities. They were essential to participants' continued involvement.

Concordance between superficial swab and deep sampling in post-sternotomy mediastinitis: Single center experience

OBJECTIVES

Deep sampling (DS) is the gold standard for microbiological diagnosis of post-sternotomy mediastinitis (PSM), however superficial swab (SS) are frequently performed in some centers and antibiotherapy initiated base on their results. We analysed the concordance between superficial swab and deep sampling in PSM.

MATERIALS AND METHODS

We analysed retrospectively patients with a PSM between 2010 and 2014 at Saint-Luc University hospital (Belgium). We considered that there was a concordance between SS and DS when the same microorganism was found in the two sampling method in each patient. Patients were stratified in six groups according to microbiology results as Staphylococcus Aureus (SA) sensitive or resistant, coagulase negative Staphylococcus (CoNS), Gram negative bacilli (GNB), other Gram positive bacteria (GPB) and fungi.

RESULTS

Thirty-six patients were included. Twenty-five men (69%) and a mean age of 66 years old. The overall concordance between SS and DS was 57%. SA and GNB showed high concordance (100% and 85.7% respectively). For the other groups the concordance was low. The sensitivity and specificity of SS was 97% and 33% respectively. The PPV and NPV of superficial swab was 96% and 50% respectively.

CONCLUSION

Microbiological results from SS, even with flocked swabs, except for SA and GNB have low concordance with those obtained from deep sampling. Our data confirm that in PSM, deep sampling is the gold standard for microbiological assessment.

1029. Outcome of Candida Graft Vascular Infection: Results From a Prospective Cohort

Background

Candida graft vascular infections (CGVI) are rare events and little data are available in the literature. The aim of this study was to describe the characteristics and outcome of patients admitted for fungal graft vascular infections, in a reference center for CGVI treatment.

Methods

Patients admitted for a CGVI in our center from 1 January 2000 to 1 February 2018 were prospectively included. Clinical, biological, and outcome data were recorded.

Results

Two hundred patients were admitted with graft vascular infections (GVI) in our center, and 11 of them (6%) presented CGVI. They were mainly men (7; 64%), and median age was 74 years old [min–max: 39–83]. All patients had benefited from prosthetic bypass surgery prior to CGVI, and infection was considered as an early disease in six patients (55%). Candida albicans was found in 72% of cases. Infection was plurimicrobial in 10 patients (92%), involving Staphyloccocus aureus in only one case and Bacille gram negatif in six (55%) cases. The management consisted in a total or partial graft replacement for five patients (45%), and surgical revision was required in four of them (30%). The empirical antifungal therapy included an echinocandin (Caspofungine) for eight patients (73%), and was changed to fluconazole or voriconazole according to antifungigram. Two patients received Amphotericin B therapy, complicated by acute kidney injury. Intensive care unit admittance was required for nine patients (82%). After the curative treatment period, antifungal therapy could not be removed in two patients and was long-continued using fluconazole. Finally, six patients (55%) died, all within the year after CGVI.

Conclusion

To our knowledge, we report here the biggest CGVI cohort. CGVI resulted in very high morbidity and mortality, requiring ICU admission for a long time. Despite multidisciplinary management involving anesthesiologists, surgeons, intensive care, and infectious disease physicians, outcome of CGVI patients remains poor.

Disclosures

All authors: No reported disclosures.

2141. Characteristics and Prognosis of Patients with a Prosthetic Vascular Graft Infection (PVGI): A Prospective Cohort of 200 patients

Background

The aim of the present study was to describe the characteristics and prognosis of patients admitted for a PVGI and to assess the factors associated with the death of these patients.

Methods

All consecutive patients admitted in our department between January 1, 2000 and January 1, 2018 for a PVGI were enrolled in the present prospective cohort study. PVGIs were divided into extracavitary (femoro-femoral, femoro-popliteal and axillo-femoral) and cavitary (aorto-iliac, aorto-femoral, ilio-femoral, aortic); into “early” infection (<4 months) and late. Patients’ baseline characteristics and their follow-up were described, and factors associated with death were assessed by using a logistic multivariate regression model.

Results

Overall, 200 patients were included during this period. The median age of patients was 69 years [IQR: 61–78], mainly of men (86%). One hundred and sixteen patients had an intracavitary PVGI (58%). Enterobacteriaceae and MSSA were the most frequent pathogens (n = 60 and 59), followed by coagulase negative staphylococci (n = 30), Streptococcus (n = 26) and enterococcus (n = 25). Surgery with replacement of the infected prosthesis was performed in 102 patients (53%). Culture of material samples taken during surgery were plurimicrobial in 67 patients (34%). After surgery, the median follow-up of patients was 7.5 months [IQR: 2–19] during which 30 presented a failure (15%) and 85 patients died, 41 due to the PVGI (21%). Factors independently associated with death in multivariate analysis were: to be over 70 years old (OR = 8.2; P < 0.01), to stay in ICU for more than 6 days (OR = 5.9; P = 0.01) and to have an intracavitary PVGI (OR = 9.0; P = 0.02). Antibiotic therapy regimen combining rifampicin to another antibiotic was associated with a decreased mortality (OR = 0.11; P < 0.01).

Conclusion

Our results suggest that the prognostic of patients admitted for PVGI depends on the site of infection and the occurrence of a shock after the admission. We found a better prognosis for patients with an extracavitary PVGI, without sepsis. Finally, PVGI treated with an antibiotic combination including rifampicin had a better outcome.

Disclosures

All authors: No reported disclosures.

Assessment of HIV Screening Tests for Use in Preexposure Prophylaxis Programs

Preexposure prophylaxis programs involve frequent human immunodeficiency virus (HIV) testing. We evaluated the sensitivity of 2 antigen/antibody immunoassays (Architect and Bioplex), 2 antibody-based rapid tests (Vikia-HIV-1/2 and Autotest-VIH), and 1 antigen/antibody rapid test (Alere HIV Combo) for the diagnosis of HIV infection. Among the 31 HIV-1-infected participants in the ANRS-IPERGAY trial, HIV-1 RNA was detected alone in only 2. The sensitivities of the Architect and Bioplex assays were 83% (95% confidence interval [CI], 76%-99%) and 82% (95% CI, 63%-94%), respectively. The sensitivities of the Vikia, Autotest, and Alere tests were 54% (95% CI, 34%-72%), 50% (95% CI, 31%-69%), and 78% (95% CI, 58%-91%), respectively. Antigen/antibody tests should be preferred to avoid missing cases of acute HIV infection and to decrease the related risks of viral transmission and emergence of drug resistance.

On-Demand Preexposure Prophylaxis in Men at High Risk for HIV-1 Infection

BACKGROUND

Antiretroviral preexposure prophylaxis has been shown to reduce the risk of human immunodeficiency virus type 1 (HIV-1) infection in some studies, but conflicting results have been reported among studies, probably due to challenges of adherence to a daily regimen.

METHODS

We conducted a double-blind, randomized trial of antiretroviral therapy for preexposure HIV-1 prophylaxis among men who have unprotected anal sex with men. Participants were randomly assigned to take a combination of tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC) or placebo before and after sexual activity. All participants received risk-reduction counseling and condoms and were regularly tested for HIV-1 and HIV-2 and other sexually transmitted infections.

RESULTS

Of the 414 participants who underwent randomization, 400 who did not have HIV infection were enrolled (199 in the TDF-FTC group and 201 in the placebo group). All participants were followed for a median of 9.3 months (interquartile range, 4.9 to 20.6). A total of 16 HIV-1 infections occurred during follow-up, 2 in the TDF-FTC group (incidence, 0.91 per 100 person-years) and 14 in the placebo group (incidence, 6.60 per 100 person-years), a relative reduction in the TDF-FTC group of 86% (95% confidence interval, 40 to 98; P=0.002). Participants took a median of 15 pills of TDF-FTC or placebo per month (P=0.57). The rates of serious adverse events were similar in the two study groups. In the TDF-FTC group, as compared with the placebo group, there were higher rates of gastrointestinal adverse events (14% vs. 5%, P=0.002) and renal adverse events (18% vs. 10%, P=0.03).

CONCLUSIONS

The use of TDF-FTC before and after sexual activity provided protection against HIV-1 infection in men who have sex with men. The treatment was associated with increased rates of gastrointestinal and renal adverse events. (Funded by the National Agency of Research on AIDS and Viral Hepatitis [ANRS] and others; ClinicalTrials.gov number, NCT01473472.).