Potential impact of replacing SCORE with SCORE-2 on risk classification and statin eligibility – a coronary calcium score correlation study

Background

Recently, the European Society of Cardiology issued new algorithms to estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD), along with new age-specific thresholds to classify individuals as low-to-moderate, high, or very-high risk.

The aim of this study was to compare the latest SCORE-2 model with the older SCORE (Systematic COronary Risk Evaluation) in their ability to identify individuals with high coronary artery calcium score (CACS), and assess the relationship between potential eligibility for statin therapy and CACS.

Methods

Individuals 40–69 years old without diabetes or known ASCVD were identified in a single center registry of patients undergoing CACS and coronary CT angiography for suspected coronary artery disease. SCORE and SCORE-2 were calculated and used with each patient's untreated LDL-C values to assess eligibility for statin therapy. High CACS was defined as an Agatston score ≥100.

Results

A total of 389 pts (46% men, mean age 58±8 years) were included, of which 15% (n=60) were active smokers. The mean systolic blood pressure and untreated LDL-C values were 136±17 mmHg and 155±65 mg/dL, respectively.

The proportion of patients classified as low-to-moderate risk, high risk, and very high risk was 93%, 6% and 1% using the SCORE algorithm, and 42%, 44%, and 14% using SCORE-2, respectively. Overall, 218 patients (56%) would have their risk category revised upwards, while no patients would be downgraded.

The median CACS was 5 (IQR 0–71 AU), with 166 patients (43%) having CACS = 0, and 81 (21%) presenting CACS values ≥100.

SCORE and SCORE-2 showed similar discriminative power to identify patients with CACS ≥100 (C-statistic 0.77, 95% CI 0.71–0.82, vs. 0.75, 95% CI 0.69–0.80, P=0.109 for comparison]. The up-reclassification of risk conveyed by SCORE-2 affected patients across all categories of CACS (Fig. 1).

The proportion of patients in whom statin therapy would generally be indicated was higher with the SCORE-2 criteria vs. the SCORE algorithm (61% vs. 29%, respectively, p<0.001). The broadening of potential indication for statin therapy spanned all categories of CACS, including patients with CACS = 0 (Fig. 2).

Conclusion

Even though the discriminative power of SCORE-2 is similar to the older SCORE, the introduction of age-specific thresholds results in the up-reclassification of risk in roughly half of the patients. The application of SCORE-2 will broaden statin eligibility overall, not only in patients with high atherosclerotic burden, but also in those with CACS = 0. These findings support the use of risk modifiers in selected patients to improve the effectiveness of statin therapy.

Funding Acknowledgement

Type of funding sources: None.

Evaluating the value of the timing of recurrence during blanking period after atrial fibrillation ablation

Introduction

In the first weeks after atrial fibrillation (AF) ablation, the arrythmia may recur theoretically due to transient local inflammation and not due to treatment failure. This is defined as the blanking period, with a proposed duration of 3 months. Recently, this time period has been brought into question. The aim of this work was to evaluate the correlation between the timing of blanking recurrence and late AF recurrence.

Methods

This was a single-centre retrospective study including patients without structural heart disease that underwent first AF ablation and were subsequently enrolled in the post ablation structured program between 2018 and 2021. Patients were excluded if they had <6 months follow-up. Appointment with ECG and Holter monitoring was performed at 1, 3, 6 and 12 months after ablation.

Results

We included a total of 193 patients (56% male, mean age 63±12 years). Of these, 79% had paroxysmal AF and mean left atrial volume index was 58±18 mL/m2. During the 3-month blanking period, there were 39 (21%) recurrences, 18 (9%) of which in the first month. After blanking period, at 6 months, 25 (13%) patients had AF recurrence, 56% of which had already recurred during blanking period. AF recurrence in the 2nd and 3rd month of blanking increased the odd of recurrence at 6-month by more than 5-fold (odds ratio (OR) 8,944; CI 95% 2,817–28,400, p<0.001 and OR 5,591; 95% CI 1,173–26,651; p=0.031). On the other hand, recurrence of AF during the 1st month of blanking was not associated with increased chance of 6-month AF recurrence (OR 2,095, 95% CI 0,630–6,964, p=0.227) (figure 1). There were no significant differences in clinical variables, including LA volume, between patients with 1-month recurrence and patients without recurrences. However, patients with AF recurrence in the 2nd and 3rd month of blanking had significantly increased LA volume.

Conclusion

Our study suggests that patients with AF recurrence in the 2nd and 3rd month of blanking have structurally different atria and are at a significantly higher risk of post blanking AF recurrence, in contrast with patients with AF recurrence in the 1st month of blanking, thus questioning the appropriate duration of the blanking period.

Funding Acknowledgement

Type of funding sources: None.

Use of coronary calcium score to refine the cardiovascular risk classification of the new SCORE2 and SCORE2-OP algorithms in patients undergoing coronary CT angiography

Introduction

Recently, the European Society of Cardiology issued new algorithms (SCORE-2 and SCORE2-OP) to estimate the 10-year risk of atherosclerotic cardiovascular disease (ASCVD). CACS has been shown to reclassify a significant proportion of patients when applied on top of several scores, but data on its use with these new algorithms are lacking.

The aim of this study was to assess the risk reassignment that can be attained by using CACS as a risk modifier of the SCORE-2 / SCORE2-OP classification, in patients referred for coronary CT angiography (CCTA).

Methods

Individuals without diabetes or known ASCVD were included in a single center registry of patients undergoing CCTA for suspected coronary artery disease (CAD). The 10-year risk of cardiovascular disease was calculated for each patient using SCORE-2 (ages 40–69) or SCORE2-OP (ages 70–89), and categorised as low-to-moderate, high, or very-high risk, according to guideline-recommended age-specific thresholds. CACS was considered to reclassify risk one level downward if = 0 in high or very-high risk patients, and reclassify risk upward if >100 (or >75th percentile) in those with low-to-moderate risk, or >1000 in those with high-risk.

Results

A total of 529 patients (43% men, mean age 63±10 years) were included, of which 13% (n=69) were active smokers. The mean systolic blood pressure and non-HDL-C values were 137±18 mmHg and 140±37 mg/dL, respectively.

A total of 47 patients (9%) had obstructive CAD on CCTA, classifying them as very-high risk. In the remainder 482 patients without obstructive CAD, the median CACS was 8 (IQR 0–80 AU), with 194 patients (40%) having CACS = 0, and 111 (23%) presenting CACS values ≥100.

The proportion of patients classified as low-to-moderate risk, high risk, and very high risk was 36%, 46% and 19% using the SCORE-2 / SCORE2-OP algorithm.

Using CACS would reclassify 150 patients (31%): 107 patients (22%) downward, and 43 patients (9%) upward. The extent of risk reclassification conveyed by CACS was 33% in patients assessed with SCORE-2, and 25% with SCORE-2 OP (p=0.082). Overall, most of the risk reassignment (42%, n=93) would occur in patients originally classified as high-risk – Fig. 1.

At the time of testing, 32% (n=61) of patients with CACS = 0 were being treated with statins, whereas 52% (n=58) of those with CACS ≥100 were not.

Conclusion

Even when the most recent SCORE-2 / SCORE-2 OP algorithms are used, risk refinement with CACS leads to the reclassification of nearly one third of the patients undergoing CCTA, mostly from downgrading risk. This opportunistic use of CACS may be employed to improve the allocation of primary prevention therapies.

Funding Acknowledgement

Type of funding sources: None.

Late gadolinium enhancement is a strong predictor of life threatening arrhythmias in patients with dilated cardiomyopathy undergoing ICD implantation for primary prevention of sudden cardiac death

Background

The usefulness of implantable cardioverter defibrillators (ICD) for primary prevention of arrhythmic sudden cardiac death (SCD) in patients with non-ischemic dilated cardiomyopathy (DCM) has been questioned. Efforts to improve risk stratification have included scores such as the “MADIT-ICD benefit score”, and the use of late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

The purpose of this study was to evaluate the potential usefulness of these two tools to assess the risk of life-threatening arrhythmias in patients with non-ischemic DCM undergoing ICD implantation for primary prevention of SCD.

Methods

We conducted a single-center retrospective study of consecutive patients who underwent contrast-enhanced CMR before ICD implantation for primary prevention of SCD. Patients with ischemic cardiomyopathy were used as reference. Patients with non-dilated cardiomyopathies were excluded.

The arrhythmic component of the MADIT-ICD benefit score (VT/VF score) was calculated for each patient, and considered high if ≥7, as recommended.

The primary endpoint was the occurrence of SCD or life-threatening arrhythmias (VF or VT >200 bpm). Follow-up was performed by device interrogation in all patients except those who suffered SCD.

Results

A total of 151 patients (93 ischemic, mean age 62±13 years, 75% male) with mean left ventricular ejection fraction (LVEF) of 27±8% were included. Overall, 72% (n=67) ischemic and 45% (n=26) non-ischemic patients had scores ≥7 and were considered high-risk. LGE was present in all patients with ischemic cardiomyopathy, and in 76% (n=44) of patients with non-ischemic DCM.

During a median follow-up of 21 (8–38) months, 21 patients (13.9%, 11 ischemic and 10 non-ischemic) met the primary endpoint.

Overall, the event-free survival of non-ischemic patients was similar to that of ischemic patients (log rank p=0.269). In patients with non-ischemic DCM, there were 7 arrhythmic events (26.9%) in those with MADIT-ICD VT/VF scores ≥7, and 3 events (9.4%) in those with scores <7 (log rank p=0.104).

In the same population, there were 10 arrhythmic events (23%) in patients with LGE, but no events in patients without LGE (log rank p=0.036).

LVEF was similar in patients with and without arrhythmic events (26±8% vs. 27±7%, p=0.717), and in those with and without LGE (26±7% vs. 28±9%, p=0.342).

Conclusion

The presence of LGE is a strong predictor of life threatening arrhythmias in patients in non-ischemic DCM undergoing ICD implantation for primary prevention, seemingly outperforming the clinical MADIT-ICD benefit score.

Funding Acknowledgement

Type of funding sources: None.

Late gadolinium enhancement is a strong predictor of life threatening arrhythmias in patients with non-ischemic dilated cardiomyopathy undergoing ICD implantation for primary prevention of sudden card

Funding Acknowledgements

Type of funding sources: None.

Background

The usefulness of implantable cardioverter defibrillators (ICD) for primary prevention of arrhythmic sudden cardiac death (SCD) in patients with non-ischemic dilated cardiomyopathy (DCM) has been questioned. Efforts to improve risk stratification have included scores such as the ‘MADIT-ICD benefit score’, and the use of late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

The purpose of this study was to evaluate the potential usefulness of these two tools to assess the risk of life-threatening arrhythmias in patients with non-ischemic DCM undergoing ICD implantation for primary prevention of SCD.

Methods

We conducted a single-center retrospective study of consecutive patients who underwent contrast-enhanced CMR before ICD implantation for primary prevention of SCD. Patients with ischemic cardiomyopathy were used as reference. Patients with non-dilated cardiomyopathies were excluded.

The arrhythmic component of the MADIT-ICD benefit score (VT/VF score) was calculated for each patient, and considered high if ≥ 7, as recommended.

The primary endpoint was the occurrence of SCD or life-threatening arrhythmias (VF or VT >200 bpm). Follow-up was performed by device interrogation in all patients except those who suffered SCD.

Results

A total of 151 patients (93 ischemic, mean age 62±13 years, 75% male) with mean left ventricular ejection fraction (LVEF) of 27±8% were included. Overall, 72% (n=67) ischemic and 45% (n=26) non-ischemic patients had scores ≥ 7 and were considered high-risk. LGE was present in all patients with ischemic cardiomyopathy, and in 76% (n=44) of patients with non-ischemic DCM.

During a median follow-up of 21 (8-38) months, 21 patients (13.9%, 11 ischemic and 10 non-ischemic) met the primary endpoint.

Overall, the event-free survival of non-ischemic patients was similar to that of ischemic patients (log rank p=0.269) – Fig 1A. In patients with non-ischemic DCM, there were 7 arrhythmic events (26.9%) in those with MADIT-ICD VT/VF scores ≥7, and 3 events (9.4%) in those with scores <7 (log rank p= 0.104) – Fig 1B.

In the same population, there were 10 arrhythmic events (23%) in patients with LGE, but no events in patients without LGE (log rank p=0.036) – Fig 1C.

LVEF was similar in patients with and without arrhythmic events (26±8% vs. 27±7%, p=0.717), and in those with and without LGE (26±7% vs. 28±9%, p=0.342).

Conclusion

The presence of LGE is a strong predictor of life threatening arrhythmias in patients in non-ischemic DCM undergoing ICD implantation for primary prevention, seemingly outperforming the clinical MADIT-ICD benefit score.

The peri-infarct gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than dense core fibrosis in patients with previous myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct "gray zone" of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction.

Methods

We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into "core" DCF and "peri-infarct" GZF zones based on signal intensity (>5 SD, and 2-5 SD above the mean of reference myocardium, respectively).

The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device.

Results

A total of 88 patients (median age 61 years [IQR 54-73], 84% male, median LVEF 30% [IQR 23-36%], 14% secondary prevention) were included. During a median follow-up of 23 months [IQR 9-38], 13 patients reached the primary endpoint (10 appropriate ICD shock, 2 sustained VT or VF, and 1 sudden arrhythmic death). Patients who attained the primary endpoint had similar DCF (30.4g ± 14.7 vs. 28.0g ± 15.3; P = 0.601) but a greater amount of GZF (18.1g ± 9.6 vs. 11.9g ± 6.7; P = 0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95%CI: 1.02-1.15; P = 0.006), whereas DCF was not (HR: 1.01 per gram; 95%CI: 0.98-1.05; P = 0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01-1.12; P = 0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9g, but in only 2 of the 53 patients (3.8%) with GZF <11.9g – Figure.

Conclusions

The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events.

Prognostic impact of subcutaneous implantable cardioverter-defibrillator appropriate and inappropriate shocks

Funding Acknowledgements

Type of funding sources: None.

Background

Previous studies have shown an adverse prognosis for patients with transvenous implantable cardioverter-defibrillators (ICD) who receive both appropriate and inappropriate shocks. There is a paucity of data regarding the prognosis of inappropriate shocks in patients with a subcutaneous ICD (S-ICD).

Purpose

To assess and characterize S-ICD appropriate (AS) and inappropriate shocks (IAS) and their impact on mortality.

Methods

Single center observational registry of 162 consecutive patients who underwent S-ICD implantation for primary and secondary prevention between November 2009 and September 2020. Only follow-up data of at least 6 months was analysed to identify predictors of both IAS and AS and their mortality impact.

Results

A total of 144 patients were included in the analysis. Mean age was 42.2 ± 16.6 years and 75% of the patients were male. One hundred and four patients (72.2%) implanted the S-ICD in primary prevention. The most common etiology was ischemic cardiomyopathy (22.9%) followed by hypertrophic cardiomyopathy (18.8%) and dilated idiopathic cardiomyopathy (14.6%). During a mean follow-up of 42.3 ± 29.9 months a total of 48 patients (33.3%) experienced at least one S-ICD shock. Twenty-nine (20.1%) patients received AS due to VT/VF and 31 patients (21.5%) received IAS. Eighteen (58.1%) of the IAS were due to oversensing/noise/discrimination errors and the remaining due to supraventricular tachycardia. Overall, patients with AS (HR 4.93, 95% CI 1.58-15.36, p = 0.006) and higher number of total AS (HR 1.10, 95% CI 1.00-1.20, p = 0.044) were associated with higher mortality during follow-up. S-ICD IAS therapy did not affect overall mortality (HR 1.71, 95% CI 0.21-14.0, p = 0.616). Conclusions: In patients with S-ICD, those who receive AS, in contrast to IAS, seem to have a worse prognosis. Large scale studies are needed to confirm this hypothesis and to explain this findings. Abstract Figure. Survival curves for AS and IAS

Efficient choice of colored noise in the stochastic dynamics of open quantum systems

The stochastic Liouville-von Neumann (SLN) equation describes the dynamics of an open quantum system reduced density matrix coupled to a non-Markovian harmonic environment. The interaction with the environment is represented by complex colored noises which drive the system, and whose correlation functions are set by the properties of the environment. We present a number of schemes capable of generating colored noises of this kind that are built on a noise amplitude reduction procedure [Imai et al., Chem. Phys. 446, 134 (2015)CMPHC20301-010410.1016/j.chemphys.2014.11.014], including two analytically optimized schemes. In doing so, we pay close attention to the properties of the correlation functions in Fourier space, which we derive in full. For some schemes the method of Wiener filtering for deconvolutions leads to the realization that weakening causality in one of the noise correlation functions improves numerical convergence considerably, allowing us to introduce a well-controlled method for doing so. We compare the ability of these schemes, along with an alternative optimized scheme [Schmitz and Stockburger, Eur. Phys. J.: Spec. Top. 227, 1929 (2019)1951-635510.1140/epjst/e2018-800094-y], to reduce the growth in the mean and variance of the trace of the reduced density matrix, and their ability to extend the region in which the dynamics is stable and well converged for a range of temperatures. By numerically optimizing an additional noise scaling freedom, we identify the scheme which performs best for the parameters used, improving convergence by orders of magnitude and increasing the time accessible by simulation.

Epicardial adipose tissue and atrial fibrillation: guilty as charged or guilty by association?

Background

Epicardial adipose tissue (EAT) has been linked to the presence and burden of atrial fibrillation (AF). However, it is still unclear whether this relationship is causal or simply a surrogate marker of other risk factors commonly associated with AF.

Purpose

The purpose of this study was to assess the relationship between these factors and EAT, and to compare their performance in predicting AF recurrence after an ablation procedure.

Methods

We assessed 575 consecutive patients (mean age 61±11 years, 62% male) undergoing AF ablation preceded by cardiac CT in a high-volume ablation center. EAT was measured on cardiac CT using a modified simplified method. Patients were divided into 2 groups (above vs. below the median EAT volume). Cox regression was used to assess the relationship between epicardial fat, risk factors, and AF relapse.

Results

Patients with above-median EAT volume were older (p<0.001), more often male (OR 1.7, p=0.002), had higher body mass index, and higher prevalence of smoking, hypertension, diabetes and dyslipidemia (p<0.05). Non-paroxysmal AF was also more common in those with above-median EAT volume. During a median follow-up of 18 months, 232 patients (40.3%) suffered AF recurrence. After adjustment for BMI and other univariate predictors of relapse, three variables emerged independently associated with time to AF recurrence: non-paroxysmal AF (HR 2.1, 95% CI: 1.5–2.7, p<0.001), indexed left atrial (LA) volume (HR 1.006 per mL/m2, 95% CI: 1.002–1.011, p<0.001), and indexed epicardial fat volume (HR 1.87 per mL/m2, 95% CI: 1.66–2.1, p<0.001). None of the classic cardiovascular risk factors were an independent predictor of AF recurrence (all p>0.10).

Conclusion

Classic cardiovascular risk factors are more prevalent in patients with higher amounts of epicardial fat. However, unlike these risk factors, EAT is a powerful predictor of AF recurrence after ablation. These findings suggest that EAT is not merely a surrogate marker, but an important participant in the pathophysiology of AF.

EAT, cvrf and AF burden

Funding Acknowledgement

Type of funding source: None

Who is too old for epicardial fat volume quantification?

Introduction

Epicardial adipose tissue has been implicated in the pathophysiology of atrial fibrillation (AF) and was recently shown to be an independent predictor of AF relapse rate and severity after pulmonary vein isolation (PVI). However, its impact in older patients hasn't been analyzed. The aim of this study was to assess the relative importance of pericardial fat in an older population of patients undergoing pulmonary vein isolation (PVI).

Methods

Single-center retrospective study of symptomatic drug-resistant AF patients undergoing PVI from November/2015 to June/2019. Baseline demographics, clinical and imaging data including cardiac CT and clinical outcomes were collected and analyzed. Population was dichotomized according to age above or below 70 years of age and groups were compared. Epicardial fat volume was quantified by contrast-enhanced cardiac CT using a semi-automated method. The study endpoint was symptomatic and/or documented AF recurrence after a 3-month blanking period.

Results

We assessed 575 patients (354 males, mean age 61±11 years, 449 paroxysmal AF), 145 of which were 70 or older. Compared to the younger cohort, these patients had an higher prevalence of women, lower BMI (27 kg/m2 [IQR 24–30] vs 28 kg/m2 [IQR 25–30] kg/m2, p=0.012), higher CHA2DS2-VASc score (3 [IQR 2–4] vs 1 [IQR 1–2], p<0.001) and larger indexed left atrial volumes (61mL [IQR 52–84] vs 54mL [IQR 47–66], p<0.001).

Median epicardial fat volume was 2.96 cm3/m2 [IQR 2.99–4.00] in the overall population and was higher in older patients (HR 2.21 cm3/m2 [IQR 1.44–3.17] vs HR 1.87 cm3/m2 [IQR 1.24–2.90]; p=0.016).

During follow-up, 232 patients relapsed (40%), with similar recurrence rates between younger and older patients (40% vs 42%, p=0.63) according to Kaplan-Meier survival curve analysis (HR 1.10, 95% CI 0.82–1.48; log-rank p=0.519). Epicardial fat volume remained an independent predictor of AF relapse in the older subset of patients (HR 1.06 for every 1 cm3/m2 increase in epicardial fat volume [95% CI 1.28–2.00]; p<0.001), as did the presence of non-paroxysmal AF (HR 2.78 [95% CI 1.48–5.21]; p=0.001).

Conclusion

Patients over 70 years old with drug-refractory symptomatic AF presented with higher epicardial fat volume. Epicardial fat burden showed similar predictive power for AF relapse after PVI in this subset of patients, representing a useful tool for intervention decision across this age spectrum.

Funding Acknowledgement

Type of funding source: None

Idiopathic HFrEF. Is there room left for defibrillators?

Background and aim

Prophylactic implantation of an implantable cardioverter-defibrillator (ICD) is class 1 recommendation for heart failure (HF) patients with reduced ejection fraction (HFrEF) even though its proven advantage is weaker among nonischemic aetiology. In fact, in an era where both optimal medical therapy (OMT) and cardiac resynchronization therapy (CRT) significantly reduce sudden cardiac death (SCD), it is questionable whether ICD still have additional value. The aim of this study was to assess the current benefit of ICDs in preventing sudden cardiac death through resuscitated cardiac arrest (RCA), appropriate therapy for sustained ventricular tachycardia (VT) or fibrillation (VF) in a contemporary population of idiopathic HFrEF patients.

Methods

Single-centre retrospective study of consecutive symptomatic (NYHA class II to IV) idiopathic HFrEF patients with an ICD (either alone or in association with CRT), and remote monitoring with the corresponding software (MerlinTM, LatitudeTM, CarelinkTM, MicroPortTM or BiotronikTM) to assure appropriate event supervising. Idiopathic aetiology was assumed after excluding other probable causes. Coronary angiogram was required to exclude ischemic aetiology. Only those with prophylactic ICD implantation were included. RCA was defined as collapse with clinical signs of cardiac arrest and VF or VT appropriately terminated by ICD. In order to be sustained, VT episode had to have last at least 30 seconds.

Results

From 781 remote monitoring controlled patients, a total of 187 consecutive symptomatic idiopathic HFrEF patients with an ICD (125 men, mean age 64±18 years) were enrolled. Patients were on optimal medical therapy (ACEi/ARB: n=168, 90%; BB: n=154, 82%; mineralocorticoid antagonists: n=91, 49%; CRT: n=130, 70%; see Table). After a median follow-up of 99 months (IQR 62.2), RCA occurred in 10.7% (n=20) and 36.9% (n=69) had appropriately terminated VT. Both left ventricular ejection fraction (LVEF) improvement and CRT implantation did not independently reduce the incidence of RCA and VT requiring ICD therapy (OR, 1.02; 95% CI, 0.99–1.05; P=0.146 and OR, 0.85; 95% CI, 0.34–2.13; P=0.728; respectively). All cause mortality was 20 (10.7%). Inappropriate therapy was given as shocks to 41 patients (21.9%) and as antitachycardia pacing (ATP) to 30 (16%), opposing with appropriately given therapy to 43 (23%) and 63 (33.7%) patients, respectively (see Figure), contributing to a net clinical benefit (NCB) of 18.8%, favouring ICD implantation.

Conclusion

In this contemporaneous real-world population of symptomatic idiopathic HFrEF patients, episodes of impending cardiac death were frequent. Prophylactic ICD implantation seems to have added further benefit reducing SCD on top of optimal medical therapy, LVEF improvement and coexisting CRT.

Funding Acknowledgement

Type of funding source: None

Catheter ablation in atrial fibrillation: comorbidities and mortality from high-volume centers

Background

Catheter ablation (CA), has gained wider acceptance as an attractive option for treating symptomatic AF. Although traditionally seen as a safe procedure, there is limited and conflicting data on procedure-related early morbimortality, with new evidence suggesting early mortality may be as high as 0.5%-1%.

Purpose

We aimed to assess the rates of early and late morbimortality of post-atrial fibrillation (AF) ablation in high-volume centers.

Methods

Prospective registry of 2 high-volume ablation centers, comprising 3722 consecutive patients (mean age 61.1±11.2, 66.4% male, n=2471), who underwent AF ablation from 2005 to 2019. Early mortality was defined as death during initial admission or during the first 45 days after ablation. Median follow-up time was 5.4 years.

Results

Most patients were treated with radiofrequency (97%) while 3% were treated with cryoablation. Early mortality was 0.08% (n=3), with a median time from ablation to death of 22 days. Cumulative mortality at 3, 6 and 12 months was 0.08%, 0.16% and 0.19%, respectively. At 3 and 5 years, mortality remained low at 0.48% and 0.73%, respectively. Early mortality was higher among patients who had suffered procedural complications (fistula and stroke, p<0.001). Among the latter, pericardial effusion and tamponade were the most frequently found (0.6%, n=24), only 1 of which required emergent surgical drainage and myocardial repair. Early ischemic stroke occurred in 2 patients (0.1%). Other less frequent complications were atrio-esophageal fistula (0.1%, n=2), phrenic nerve palsy (0.1%, n=2), anoxic encephalopathy following cardiac arrest (0.03%, n=1) and pulmonary vein stenosis (0.03%, n=1).

Conclusion

Early mortality following ablation is very low (<0.1%), when performed by an experienced high-volume team. Severe complications are rare (<1%) and mostly amenable to treatment. Our findings reaffirm the overall safety of AF ablation.

AF catheter ablation morbimort

Funding Acknowledgement

Type of funding source: None

459Direct oral anticoagulants are an effective therapy for left ventricular thrombus formation

Background and aim

Left ventricular thrombus is a frequent complication of myocardial infarction (MI) and heart failure with severely depressed ejection fraction. Once diagnosed, anticoagulation for up to 6-months is recommended, but clinical experience with direct oral anticoagulation (DOAC) is limited to a few case reports. Our aim is to test DOAC LV thrombus resolution efficacy against warfarin.

Methods

Single-centre retrospective cohort study of consecutive patients with recently diagnosed LV thrombus, either after acute myocardial infarction or heart failure with reduced ejection fraction, from January 2009 till December 2018. Thrombus diagnosis and subsequent assessments were performed with echocardiography and complemented with cardiac magnetic resonance, when appropriate. Decisions regarding the type, dose and duration of anticoagulation and any concomitant antiplatelet therapy were left to physician's judgement.

Results

In a population of 66 patients (51 male, mean age 69±12 years), 13 received DOAC therapy, with the remainder receiving vit. K antagonists. One from each group was lost to follow up. The DOAC subgroup had higher prevalence of atrial fibrillation, higher left ventricular end-diastolic volumes and worse wall motion severity score index (WMSI). The duration of anticoagulant therapy, concomitant single or dual antiplatelet therapy and overall follow up were similar between strategies. Thrombus remission was observed in 91.7% (n=11) and 59.6% (n=31) patients within DOAC and warfarin group, respectively. Risk of unsuccessful resolution was reduced by 35% relative to the warfarin group (RR 0.65; 95% CI [0.491–0.862]; p-value 0.035) (figure).

figure

Conclusion

DOAC seems to be an effective alternative to vitamin-K antagonists in patients with LV thrombus.

P5693Critical sites for scar-related ventricular tachycardias treatment: an approach based on sinus rhythm late activation zones

Introduction

Despite advances in antiarrhythmic and device therapy, ventricular tachycardia (VT) is a major cause of increased morbidity and mortality. During scar-mediated monomorphic VT ablation, the search for critical isthmus sites continues to be the primary goal during successful ablative procedures. However, catheter ablation based on conventional mapping techniques is associated with low success rates and is limited to patients with stable VT.

Objective

The aim of the study was to evaluate, in patients with history of VT, the success of a strategy based on substrate mapping and ablation during sinus rhythm.

Methods

Retrospective single center analysis of patients undergoing VT ablation from November 2015 to November 2017. Clinical profiles and procedural details were determined. We used high-density structural map to identify voltage abnormalities as well a functional map of sinus rhythm activation to identify the regions of late potentials. Radiofrequency applications were performed in the areas with the latest activation. Recurrence of VT was considered the end-points of the follow-up.

Results

A total of 22 patients were included in the analysis, 95% male, with an median age of 65,5 (57–71) years old. The majority of the patients (18) with ischemic cardiomyopathy, 3 with nonischemic cardiomyopathy, and 1 with arrhythmogenic right ventricular cardiomyopathy were included. Epicardial mapping was performed in 27% of the cases. CARTO mapping system was used in 10 patients and Rhythmia in the remaining cases. Areas with the latest activation corresponded to regions of abnormal voltage in 21 patients. During a 26,5 (21,5–29,3) months of follow-up, the observed VT recurrence rate was 35%. 25% of the patients needed hospital admission due to arrhythmias and one patient died due to an arrhythmic cause. Treatment success was higher in epicardial approach (100% VS 50%, p=0,03). The location of the scar in the left ventricle was not a determinant of success (anterior-66,7% VS lateral/inferior-61,5%, p=0,806).

Conclusion

A substrate-based approach that targets regions of late activation within the scar seems attractive and may be a simple way to perform VT ablation with success. In our population, this strategy seams successful, especially in epicardial approach. Substrate modification strategies aiming to eradicate all potential reentrant circuits may be the most successful way to treat VT and avoid recurrences.

P1922Ablation index-guided ablation versus second-generation cryoballoon for first pulmonary vein isolation in atrial fibrillation

Background

In a recent trial, cryoballoon (CB) ablation was non-inferior to radiofrequency ablation regarding effectiveness in atrial fibrillation (AF). Ablation index (AI) provides a more accurate estimation of ablation quality using three variables: power delivered with time, contact force and catheter stability. The additional benefit of AI-guided ablation versus CB ablation is unknown.

Objective

To compare AI-guided ablation and CB ablation for first pulmonary vein isolation (PVI) in patients with AF.

Methods

We assessed 141 patients (62±12 years old, 76 men and 126 paroxysmal AF) with drug refractory symptomatic AF submitted to AI-guided PVI or second-generation CB catheter. Endpoint was AF/AT/AFL recurrence after a 3-month blanking period with a minimum follow-up of 6 months. Cox regression was used to assess the relationship between type of ablation and AF recurrence.

Results

Fifty-seven patients underwent AI-guided PVI and 84 patients underwent CB ablation. The baseline characteristics are described in table 1. Procedure duration was significantly higher in AI group (150 vs 111 min, P<0.001) although requiring significant less fluoroscopy time (5 min vs 20 min; P<0.001). There was a transient phrenic nerve palsy in CB group and a cardiac tamponade in AI group. During a mean follow-up of 10±3 months there were 23 recurrences (27%) in CB group vs 7 recurrences (12%) in AI group (log rank 0.042) (Fig B). When adjusted for CHA2DS2-VASc score, left atrium diameter (mm) and type of AF (Cox regression), there was lower arrhythmia recurrence in AI group (HR 0.42; 95% CI 0.18–0.99; p=0.047).

Table 1. Baseline characteristics

Conclusion

In this analysis, AI-guided ablation was associated with lower arrhythmia recurrence when compared with CB ablation. This hypothesis should be further evaluated in a prospective randomized trial.

Relationship between Mesenteric and Peripheral Blood Levels of CA 19-9 in Patients with Colorectal Cancer

Introduction

CA19-9 is one of the most important tumor markers used in patients with colorectal cancer, mainly in radical surgery follow-up. Aim: The purpose of this study was to evaluate the preoperative CA19-9 level obtained from a peripheral vein (PV) and compare it to the level obtained from the mesenteric vein (MV).

Materials and methods

Blood was collected from a PV of the arm and from the MV of 59 patients with colorectal cancer before primary surgery. Of these 59 patients fourteen had stage I disease, 10 stage II, 22 stage III, and 13 stage IV. CA19-9 was determined in serum by immunoenzymatic assay (Abbott Diagnostica).

Results

Fifteen patients (24%) had elevated serum levels of CA19-9 in the MV and 13 (22%) in the PV. None of the stage I or II patients had elevated serum levels of CA19-9. There were no differences between marker levels in blood collected from the MV or PV, independent of clinical stage. The CA19-9 values obtained from the MV differed significantly in the different stages of the disease according to the Kruskal-Wallis analysis (p=0.026); this difference was not statistically significant (p=0.08) in serum from the PV. There was no correlation between venous infiltration by the tumor and positivity of CA19-9 serum levels collected from the mesenteric vein. We observed a close correlation between the serum levels of CA19-9 collected from the PV and from the MV (r=0.9).

Conclusion

The current study demonstrates a close correlation between the serum levels of CA19-9 collected from a peripheral vein and from the mesenteric vein. Our results confirmed the poor sensitivity of serum CA19-9 at diagnosis, independent of the collection site.

Assessment of the Value of Preoperative Serum Levels of CA 242 and CEA in the Staging and Postoperative Survival of Colorectal Adenocarcinoma Patients

Introduction

CEA is the most frequently used tumor marker in colorectal cancer. There may be an improvement in its efficacy when used in association with CA 242.

Aim

The purpose of this study was to evaluate the efficacy of preoperative serum levels of the tumor markers CA 242 and CEA in the staging and postoperative follow-up of colorectal adenocarcinoma patients.

Patients and Methods

Of a series of 134 patients with colorectal adenocarcinomas 90 underwent radical surgery and 44 palliative surgery. The control group consisted of 22 organ donors. The cutoff serum levels utilized were 5 ng/mL for CEA and 20 U/mL for CA 242. The mortality during follow-up was recorded in order to determine the duration of survival. The data were submitted to statistical analysis using diagnostic tests, the chi-square test, survival analysis (Kaplan and Meier) and ROC curves. A significance level of p ≤ 0.05 was applied.

Results

The sensitivity of CEA in Dukes’ stages A, B, C and D was 27.8%, 32.4%, 32.1% and 66.7%, respectively. The sensitivity of CA 242 was 11.1%, 16.2%, 30.8% and 50%. When both markers were combined, the sensitivity was 33.3%, 48.6%, 40.7% and 72.5%. In the group of patients who underwent radical surgery the mean survival was 60.47 months for those with high preoperative CEA levels, 52.22 months for those with high preoperative CA 242 levels, and 44.80 months for those with elevated levels of both markers. There was a statistically significant difference in survival between patients undergoing radical surgery with elevated CA 242 levels, especially when CEA was also elevated, and patients without elevated CA 242.

Conclusion

Preoperative serum levels of CA 242 showed less efficacy than CEA levels for the staging of colorectal adenocarcinoma patients. Elevated preoperative serum levels of CA 242 alone were related to poor survival, especially in association with high levels of CEA.

Experimental study comparing meshes made of polypropylene, polypropylene + polyglactin and polypropylene + titanium: inflammatory cytokines, histological changes and morphometric analysis of collagen

PURPOSE

Incisional hernia occurs in approximately 11% of all laparotomies. Changes in collagen have been closely implicated in its pathogenesis. The high recurrence rate (45-54%) after primary suture has stimulated the development of meshes. Currently, meshes are the biomaterials implant group most used in medicine. This study aims to compare the serum and tissue inflammatory responses and collagen deposition caused by meshes made of polypropylene, polypropylene + polyglactin and polypropylene + titanium.

METHODS

Thirty Wistar rats were divided into three groups. In group I, a high-density polypropylene mesh was positioned on the abdominal wall. In groups II and III, low-density meshes were used in associations with polyglactin and titanium, respectively. Immediately before the operation and on the first, third and fortieth postoperative days, pro-inflammatory cytokines were assayed. On the 40th postoperative day, the region of the inserted prosthesis was biopsied. The tissue inflammatory reaction was evaluated using a scale for objective scoring. For collagen, picrosirius was used with data reading using the Image Tool computer software.

RESULTS

Cytokines: there were no statistically significant differences between the groups.

HISTOLOGY

on the 40th postoperative day in group I, there were fewer inflammatory tissue response and greater collagen deposition (P < 0.01). In group II, there were greater inflammatory tissue response and less collagen deposition (P < 0.01). Group III presented intermediate values between groups I and II.

CONCLUSIONS

There were no significant differences in cytokine levels between the groups in the present study. In the animals with the polypropylene + polyglactin mesh implant there was the most intense inflammatory process with lower tissue maturation and collagen deposition on the 40th postoperative day. The polypropylene mesh presented a less severe late inflammatory process, with greater tissue maturation and collagen deposition. The polypropylene + titanium mesh presented intermediate values between the others.

Intragastric balloon for obesity

BACKGROUND

Obesity is one of the major public health problems of modern society. Intragastric balloon (IGB) treatment for obesity has been developed as a temporary aid. Its primary objective is the treatment of obese people, who have had unsatisfactory results in their clinical treatment for obesity, despite of being cared for by a multidisciplinary team, and super obese patients with a higher surgical risk. However, the effects of different IGB procedures compared with conventional treatments and with each other are uncertain.

OBJECTIVES

To assess the effects of intragastric balloon in people with obesity.

SEARCH STRATEGY

Studies were obtained from computerised searches of MEDLINE, EMBASE, LILACS, The Cochrane Library and other electronic databases. Furthermore, reference lists of relevant articles and hand searches of selected journals were performed. Experts in the field were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials fulfilling the inclusion criteria were used. Short term weight loss is common, so studies were included if they reported measurements after a minimum of four weeks follow-up.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed the quality of trials.

MAIN RESULTS

Nine randomised controlled trials involving 395 patients were included. Six out of nine studies had a follow-up of less than one year, the longest study duration was 24 months. Only a third of the analysed studies revealed a low risk of bias. No information was available on quality of life, all-cause mortality and morbidity. Compared with conventional management, IGB did not show convincing evidence of a greater weight loss. On the other hand, complications of intragastric balloon placement occurred, however few of a serious nature. The relative risks for minor complications like gastric ulcers and erosions were significantly raised.

AUTHORS' CONCLUSIONS

Evidence from this review is limited for decision making, since there was large heterogeneity in IGB trials, regarding both methodological and clinical aspects. However, a co-adjuvant factor described by some authors in the loss and maintenance of weight has been the motivation and the encouragement to changing eating habits following a well-organized diet and a program of behavioural modification. The IGB alone and the technique of positioning appear to be safe. Despite the evidence for little additional benefit of the intragastric balloon in the loss of weight, its cost should be considered against a program of eating and behavioural modification.

Evaluation of Sequential Perfusion With Euro-Collins and Belzer Solutions for Pancreas Preservation in Rats

OBJECTIVE

To investigate the effect of Euro-Collins and Belzer solutions in a sequential preservation of the pancreas.

METHODS

Forty-five Wistar-EPM rats were divided into four groups, according to the solution used during preservation: (1) saline solution (SF): animals perfused and preserved with saline solution; (2) Euro-Collins group (C): animals perfused and preserved with Euro-Collins solution; (3) Belzer group (B): animals perfused and preserved with Belzer solution; (4) Euro-Collins/Belzer group (CB): animals perfused with equal parts of Euro-Collins and Belzer solutions sequentially and preserved with Belzer solution. After perfusion, the animals underwent pancreas resection and preservation with the respective substance at 4 degrees C. Amylase was measured in the preservation solution after 12, 24, 36, or 48 hours. Finally, the pancreas was analyzed histologically, and a statistical analysis was performed.

RESULTS

Groups SF and C showed the highest amylase levels in the preservation solution during all periods. The levels were higher than in groups C and CB (P = .05). Amylase levels were similar in groups B and CB to 24 hours (P = .05). Histological analysis was significant for analysis of pancreas islet cells and edema. Groups B and CB were histologically similar (P = .001) and different from groups SF and C.

CONCLUSION

Sequential perfusion using Euro-Collins and Belzer solutions was effective for pancreas preservation in rats up to 24 hours.

Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis

BACKGROUND

There is little agreement on prophylactic use of drains in anastomoses in elective colorectal surgery despite many randomized clinical trials. Once anastomotic leakage occurs it is generally agreed that drains should be used for therapeutic purposes. However, on prophylactic use no such agreement exists.

AIM

To compare the safety and effectiveness of routine drainage and nondrainage regimes after elective colorectal surgery. The primary outcome was clinical anastomotic leakage.

METHODS

A systematic search was undertaken to identify randomized clinical trials. Of the 1140 patients who were enrolled (six randomized controlled trials), 573 were allocated for drainage and 567 for no drainage. Outcome measures were: (i) mortality: 3% (18 of 573 patients) compared with 4% (25 of 567 patients); (ii) clinical anastomotic dehiscence: 2% (11 of 522 patients) compared with 1% (7 of 519 patients); (iii) radiological anastomotic dehiscence: 3% (16 of 522 patients) compared with 4% (19 of 519 patients); (iv) wound infection: 5% (29 of 573 patients) compared with 5% (28 of 567 patients); (v) reintervention: 6% (34 of 542 patients) compared with 5% (28 of 539 patients); (vi) extra-abdominal complications: 7% (34 of 522 patients) compared with 6% (32 of 519 patients). None of these differences in outcome was significant.

CONCLUSION

There is insufficient evidence showing that routine drainage after colorectal anastomoses prevents anastomotic and other complications.

Pre-operative mechanical bowel cleansing or not? an updated meta-analysis

OBJECTIVES

Pre-operative mechanical bowel preparation has been considered an efficient regimen against leakage and infectious complications, after colorectal resections. This dogma is based only on observational data and experts' opinions. The aim of this study was to evaluate the efficacy and safety of prophylactic pre-operative mechanical bowel preparation before elective colorectal surgery.

METHODS

EMBASE, LILACS, MEDLINE and The Cochrane Library and abstracts from major gastroenterological congresses were searched. No language restrictions were applied. The selection criterion used was randomised clinical trials (RCT) comparing any kind of mechanical bowel preparation with no preparation in patients submitted to elective colorectal surgery and where anastomotic leakage, mortality, and wound infection were outcome measurements. Data were independently extracted by the reviewers and cross-checked. The methodological quality of each trial was assessed by the same reviewers. For meta-analysis the Peto-Odds ratio was used.

RESULTS

Of 1592 patients (9 RCTs), 789 were allocated to mechanical bowel preparation (Group A) and 803 to no preparation (Group B) before elective colorectal surgery. Anastomotic leakage developed in 48 (6%) of 772 patients in A compared with 25 (3.2%) of 777 patients in B; Peto OR 2.03, 95% (CI: 1.28-3.26; P = 0.003). Wound infection occurred in 59 (7.4%) of 791 patients in A and in 43 (5.4%) of 803 patients in B; Peto OR 1.46, 95% (CI: 0.97-2.18; P = 0.07); Five (1%) of 509 patients died in group in A compared with 3 (0.61%) of 516 patients in group B; Peto OR 1.72, 95% (CI: 0.43-6.95; nonsignificant).

CONCLUSION

There is no evidence that patients benefit from mechanical bowel preparation. On the contrary taking colorectal surgery as a whole, pre-operative bowel cleansing leads to a higher rate of anastomotic leakage. The dogma that mechanical bowel preparation is necessary before elective colorectal surgery has to be reconsidered.

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

For over a century the presence of bowel content during surgery has been linked to anastomotic leakage. Mechanical bowel preparation has been considered an efficient agent against leakage and infectious complications. This dogma is not based on solid evidence, but on observational data and expert's opinions.

OBJECTIVES

To determine the effectiveness and safety of prophylactic mechanical bowel preparation for morbidity and mortality rates in elective colorectal surgery.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials. We also searched relevant medical journals, and conference proceedings from major gastroenterological congresses and contacted experts in the field. We used the search strategy described by the Colorectal Cancer Review Group, without limitations for date of publication and language. I SELECTION CRITERIA: Randomised, clinical trials that compared any strategy in mechanical bowel preparation with no mechanical bowel preparation.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by the reviewers and cross-checked. The same reviewers assessed the methodological quality of each trial. Details of the randomisation (generation and concealment), blinding, whether an intention-to-treat analysis was done, and the number of patients lost to follow-up was recorded. For analysis the Peto odds ratio (OR) was used as defaults.

MAIN RESULTS

Of the 1592 patients (9 trials), 789 were allocated to mechanical bowel preparation (Group A) and 803 to no preparation (Group B) before elective colorectal surgery. For anastomotic leakage (main outcome) the results were: - Low anterior resection: 9.8% (11 of 112 patients in Group A) compared with 7.5% (9 of 119 patients in Group B); Peto OR 1.45, 95% confidence interval (CI): 0.57 to 3.67 (non-significant); - Colonic surgery: 2.9% (Group A) compared with 1.6% (Group B) ; Peto OR 1.80, 95% CI: 0.68 to 4.75 (non-significant); Overall anastomotic leakage: 6.2% (Group A) compared with 3.2% (Group B); Peto OR 2.03, 95% CI: 1.276 to 3.26 (p=0.003). For the secondary outcome of wound infection the result was: 7.4% (Group A) compared with 5.4% (Group B); Peto OR 1.46, 95% CI: 0.97 - to 2.18 (p=0.07); Sensitivity analyses excluding studies with dubious randomisation, studies published as abstracts only, and studies involving children did not change the overall conclusions

AUTHORS' CONCLUSIONS

There is no convincing evidence that mechanical bowel preparation is associated with reduced rates of anastomotic leakage after elective colorectal surgery. On the contrary, there is evidence that this intervention may be associated with an increased rate of anastomotic leakage and wound complications. It is not possible to be conclusion on the latter issue because of the clinical heterogeneity of trial inclusion criteria, methodological inadequacies in trial (in particular, poor reporting of concealment and allocation), potential performance biases, and failure of intention-to-treat analyses. Nevertheless, the dogma that mechanical bowel preparation is necessary before elective colorectal surgery should be reconsidered.

Formoterol delivered via the dry powder Aerolizer inhaler versus albuterol MDI and placebo in mild-to-moderate asthma: a randomized, double-blind, double-dummy trial

The objectives of this study were to compare the efficacy and tolerability of twice-daily formoterol dry powder 12 microg and 24 microg (Foradil) delivered via Aerolizer inhaler with four times daily albuterol (salbutamol) 180 microg delivered via metered dose inhaler (MDI) and placebo. A total of 554 adolescents and adults (ages 12-75 years) with mild-to-moderate asthma were randomized to this 12-week, multicenter, double-blind, double-dummy, placebo-controlled, parallel-group study. Twelve-hour spirometry measurements were taken at weeks 0, 4, 8, and 12. A total of 484 patients completed the study (122, 116, 127, and 119 given formoterol 12 microg, formoterol 24 microg, albuterol, and placebo, respectively). For the primary efficacy variable, the forced expiratory volume in 1 second (FEV1), both formoterol 12 microg and 24 microg were statistically superior to placebo at all time points on all test days (p < or = 0.017) and to albuterol at most time points on all test days (p < or = 0.001). The onset of improvement in FEV1 was rapid, with 15% increase within 5 min in 57%, 71%, and 65% of formoterol 12 microg, formoterol 24 microg, and albuterol patients, respectively. Formoterol was also superior to placebo and albuterol in terms of secondary efficacy variables: FEV1 area under the curve, percentage of predicted FEV1, forced vital capacity and forced expiratory flow, asthma symptom scores, and peak expiratory flows. In conclusion, both formoterol doses were superior to placebo in all lung function measurements. Overall, compared with albuterol, both formoterol doses produced superior bronchodilation. Formoterol and albuterol were safe and well-tolerated.

Mechanical bowel preparation for elective colorectal surgery

BACKGROUND

For more than a century the presence of bowel content during surgery has been related to anastomotic leakage. Mechanical bowel preparation has been considered an efficient agent against leakage and infections complications. This dogma is not based on solid evidence, but more on observational data and expert's opinions.

OBJECTIVES

To determine the security and effectiveness of prophylactic mechanical bowel preparation for morbidity and mortality rates in colorectal surgery. The following hypothesis was tested: "The use of mechanical bowel preparation before elective colorectal surgery reduces the incidence of postoperative complications".

SEARCH STRATEGY

All publications describing mechanical bowel preparation before elective colorectal surgery was sought through computerized searches of EMBASE, LILACS, MEDLINE, and Cochrane Library; by hand-searching in relevant medical journals, from major gastroenterological congresses, without limitation for date and language, using the search strategy described by the Colorectal Cancer Review Group. In addition, randomised clinical trials will be searched through personal communication with colleagues and from conference proceedings

STUDIES

All randomised, clinical trials, that were performed in order to answer the hypothesis.

PARTICIPANTS

Patients submitted elective colorectal surgery.

INTERVENTIONS

Any strategy in mechanical bowel preparation compared with no mechanical bowel preparation.

PRIMARY OUTCOME MEASURES

1. Anastomosis leakage- stratified for rectum and colon 2. Overall anastomotic leakage

SECONDARY OUTCOME MEASURES

3. Mortality 4. Peritonitis 5. Re operation 6. Wound Infection 7 Infectious extra-abdominal complication 8. Non-infection extra-abdominal 9. Overall surgical site infections

DATA COLLECTION AND ANALYSIS

Data was independently extracted by two reviewers and cross-checked. The methodological quality of each trial was assessed by the same two reviewers. Details of the randomisation (generation and concealment), blinding, whether an intention-to-treat analysis was done, and the number of patients lost to follow-up was recorded. The results of each RCT was summarised in 2 x 2 tables for each outcome. For analysis the Peto-Odds ratio was used as defaults (no statistical heterogeneity was observed)

MAIN RESULTS

Of the 1159 patients with anastomosis (6 RCTs), 576 were allocated for mechanical bowel preparation (groups 1) and 583 for no preparation (groups 2) before elective colorectal surgery. Of 1204 patients totally enrolled 595 were in groups 1 and 609 in groups 2.

PRIMARY OUTCOMES

1) Anastomotic leakage - stratified:A) Low anterior resection: 12.5% (6 of 48 patients in 1) compared with 12% (6 of 50 patients in 2); Peto OR 1.17, 95% CI: 0.35 - 3.96 (non-significant) B) Colonic surgery: 1.16% (2 of 172 patients in 1) compared with 0.6% (1 of 166 patients in 2); Peto OR 1.75, 95% CI: 0.18 - 17.02 2) Overall anastomotic leakage: 5.5% (32 of 576 patients in 1) compared with 2.9% (17 of 583 patients in 2); Peto OR 1.94, 95% CI: 1.09 - 3.43 (P=0.02) SECONDARY OUTCOMES: 3) Mortality: 0.6% (2 of 329 patients in 1) compared with 0% (0 of 326 patients in 2); Peto OR 7.95, 95% CI: 0.49 - 128.34 (non-significant) 4) Peritonitis: 5.1% ( 13 of 254 patients in 1) compared with 2.8% (7 of 252 patients in 2); Peto OR 1.90, 95% CI: 0.78 -4.64) (non significant) 5) Reoperation: 3.3% ( 11 of 329 patients) compared with 2.5% (8 of 326 patients); Peto OR 1.40, 95% CI: 0.56 - 3.49) (non-significant) 6) Wound infection: 7.4% (44 of 595 patients in 1) compared with 5.7% (35 of 609 patients in 2); Peto OR 1.34, 95% CI: 0.85 - 2.13 (non-significant) 7) Infectious extra-abdominal complication: 8.3% ( 14 of 168 patients in 1) compared with 9.4% (15 of 159 patients in 2); Peto OR, 95%: 0.87 (0.41 - 1.87) 8) Non-infection extra-abdominal complication: 8.0% ( 20 of 250 patients in 1) compared with 7.0% (17 of 246 patients in 2); Peto OR 1.19, 95% CI: 0.61 - 2.32 (non-significant) - 9) Surgical site infection: 9.8% (31 of 325 patients in 1) compared with 8.3% (27 of 322 patients in 2); Peto OR 1.20, 95% CI: 0.70 - 2.05 (non-significant) -

REVIEWER'S CONCLUSIONS

The results failed to support the hypothesis that bowel preparation reduces anastomotic leak rates and other complications. There was no a priori hypothesis that bowel preparation may increase anastomotic leak rates, so this was not stated. Thus, the routine use of mechanical bowel preparation in patients undergoing elective colorectal surgery is questioned.

Value of CEA level determination in gallbladder bile in the diagnosis of liver metastases secondary to colorectal adenocarcinoma

CONTEXT

The relevance of colorectal adenocarcinoma lies in its high incidence, with the liver being the organ most frequently affected by distant metastases. Liver metastases occur in 40 to 50% of patients with colorectal adenocarcinoma, accounting for approximately 80% of deaths in the first three postoperative years. Nevertheless, despite this, they are occasionally susceptible to curative treatment.

OBJECTIVE

The present investigation focused on the relationship between the level of carcinoembryonic antigen (CEA) in gallbladder bile and the presence of liver metastases secondary to colorectal adenocarcinoma.

DESIGN

Diagnostic test study.

SETTING

Surgical Gastroenterology Discipline at the São Paulo Hospital, São Paulo, Brazil.

SAMPLE

Forty-five patients with colorectal adenocarcinoma were studied, 30 without liver metastases (group I), and 15 with liver metastases (group II). Diagnosis of liver metastases was made through computed tomography, magnetic resonance imaging and computed tomography during arterial portography. Samples of peripheral blood, portal system blood, and gallbladder bile were collected from patients during the surgical procedure. A control group composed of 18 organ donors underwent the same material collection procedures. CEA level determination was made through fluoroimmunoassay.

RESULTS

Mean CEA value in peripheral serum was 2.0 ng/ml (range: 0.7 to 3.8 ng/ml) in the control group, 11.4 ng/ml (range: 0.5 to 110.3 ng/ml) in group I, and 66.0 ng/ml (range: 2.1 to 670 ng/ml) in group II. In the portal system, serum mean values found were 1.9 ng/ml (range: 0.4 to 5.0 ng/ml) in the control group, 15.3 ng/ml (range: 0.8 to 133.3 ng/ml) in group I, and 70.8 ng/ml (range: 1.8 to 725 ng/ml) in group II. Mean values found in gallbladder bile were 4.1 ng/ml (range: 1.0 to 8.6 ng/ml) in the control group, 14.3 ng/ml (range: zero to 93.0 ng/ml) in group I, and 154.8 ng/ml (range: 14.0 to 534.7 ng/ml) in group II.

CONCLUSIONS

The CEA level in gallbladder bile is elevated in patients with liver metastases. Determination of CEA both in peripheral serum and in gallbladder bile enabled patients with liver metastases to be distinguished from those without such lesions. The level of CEA in gallbladder bile, however, seems to lead to a more accurate diagnosis of liver metastases secondary to colorectal adenocarcinoma.

[Squamous cell carcinoma of the canal anal]

BACKGROUND

Anal cancer is an uncommon malignancy accounting for only a small (4%) percentage of intestinal cancer. The authors described the clinical aspects and the treatment of the patients with squamous cell carcinoma of the canal anal.

PATIENTS

Eleven patients with squamous cell carcinoma treated among 1995 and 1999, were analyzed retrospectively. Nine were women and two were men. The mean age was 57.6 years old (range 35-82 years old).

RESULTS

The most common symptoms were rectal bleeding, local tumor and pain. Six of them had previous anal benign disease and two had metastases at the diagnosis. All were submitted to systemic chemotherapy with 5-fluorouracil and mitomycin and radiotherapy with 4500 cGy. Four patients had residual disease after chemo radiation and salvage surgery with abdominoperineal resection was done. Three patients had recurrence and four died from the disease.

CONCLUSION

Most of our patients were women. The chemo radiation can be a curable treatment in patients with local disease; conversely in patients with residual disease, abdominoperineal resection must be done. Although anal cancer is an often curable disease, four patients died because the diagnosis was done in advanced stage.

Stapled versus handsewn methods for colorectal anastomosis surgery

BACKGROUND

Randomized controlled trials comparing stapled with handsewn colorectal anastomosis have not shown either technique to be superior, perhaps because individual studies lacked statistical power. A systematic review, with pooled analysis of results, might provide a more definitive answer.

OBJECTIVES

To compare the safety and effectiveness of stapled and handsewn colorectal anastomosis. The following primary hypothesis was tested: the stapled technique is more effective because it decreases the level of complications.

SEARCH STRATEGY

The RCT register of the Cochrane Review Group was searched for any trial or reference to a relevant trial (published, in-press, or in progress). All publications were sought through computerised searches of EMBASE, LILACS, MEDLINE, the Cochrane Controlled Clinical Trials Database, and through letters to industrial companies and authors. There were no limits upon language, date, or other criteria.

STUDIES

All randomized clinical trials (RCTs) in which stapled and handsewn colorectal anastomosis were compared.

PARTICIPANTS

Adult patients submitted electively to colorectal anastomosis.

INTERVENTIONS

Endoluminal circular stapler and handsewn colorectal anastomosis.

OUTCOMES

a) Mortality b) Overall Anastomotic Dehiscence c) Clinical Anastomotic Dehiscence d) Radiological Anastomotic Dehiscence e) Stricture f) Anastomotic Haemorrhage g) Reoperation h) Wound Infection i) Anastomosis Duration j) Hospital Stay.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by the two reviewers (SASL, DM) and cross-checked. The methodological quality of each trial was assessed by the same two reviewers. Details of the randomization (generation and concealment), blinding, whether an intention-to-treat analysis was done, and the number of patients lost to follow-up were recorded. The results of each RCT were summarised on an intention-to-treat basis in 2 x 2 tables for each outcome. External validity was defined by characteristics of the participants, the interventions and the outcomes. The RCTs were stratified according to the level of colorectal anastomosis. The Risk Difference method (random effects model) and NNT for dichotomous outcomes measures and weighted mean difference for continuous outcomes measures, with the corresponding 95% confidence interval, were presented in this review. Statistical heterogeneity was evaluated by using funnel plot and chi-square testing.

MAIN RESULTS

Of the 1233 patients enrolled ( in 9 trials), 622 were treated with stapled, and 611 with manual, suture. The following main results were obtained: a) Mortality: result based on 901 patients; Risk Difference - 0.6% Confidence Interval -2.8% to +1.6%. b) Overall Dehiscence: result based on 1233 patients; Risk Difference 0.2%, 95% Confidence Interval -5.0% to +5.3%. c) Clinical Anastomotic Dehiscence : result based on 1233 patients; Risk Difference -1.4%, 95% Confidence Interval -5.2 to +2.3%. d) Radiological Anastomotic Dehiscence : result based on 825 patients; Risk Difference 1.2%, 95% Confidence Interval -4.8% to +7.3%. e) Stricture: result based on 1042 patients; Risk Difference 4.6%, 95% Confidence Interval 1.2% to 8.1%. Number needed to treat 17, 95% confidence interval 12 to 31. f) Anastomotic Hemorrhage: result based on 662 patients; Risk Difference 2.7%, 95% Confidence Interval - 0.1% to +5.5%. g) Reoperation: result based on 544 patients; Risk Difference 3.9%, 95% Confidence Interval 0.3% to 7.4%. h) Wound Infection: result based on 567 patients; Risk Difference 1.0%, 95% Confidence Interval -2.2% to +4.3%. i) Anastomosis duration: result based on one study (159 patients); Weighted Mean Difference -7.6 minutes, 95% Confidence Interval -12.9 to -2.2 minutes. j) Hospital Stay: result based on one study (159 patients), Weighted Mean Difference 2.0 days, 95% Confidence Interval -3.27 to +7.2 days.

REVIEWER'S CONCLUSIONS

The evidence found was insufficient to demonstrate any superiority of stapled over handsewn techniques in colorectal anastomosis, regardless of the level of anastomosis.

[Study of preoperative risk factors for bacteriobilia in patients with acute calculosis cholecystitis]

OBJECTIVE

to determine an association between the preoperative clinical status and the result of bile and gallbladder wall cultures.

MATERIAL AND METHODS

28 variables regarding history, physical examination and labatorial assessment in 38 patients with acute calculosis cholecystitis submitted to urgency surgery were prospectively studied during a 19-month period, between November 1995 and May 1997. Cultures for aerobic and anaerobic agents from both the gallbladder wall and the bile were performed, in three different culture media (BACTEC 9240, BHI and HEMOBAC).

RESULTS

bacteria were isolated in at least one culture medium, in 68.2% of the patients. At univariate analysis, five preoperative factors were identified as predictors of bactibilia: over 55 years of age, a greater than 0.4 degrees C difference in the axillary-rectal temperature, a greater than 12.000 cels/m3 blood leukocyte count, a greater than 75% neutrophil percentage and a greater than 4% rod neutrophil percentage. Owing to the small sample size, statistical significance of the series could not be noted by logistic regression, although a trend to preoperative determination could be observed in 98% of the subjects with positive culture, by means of the model based on age and percentage of rod neutrophil. By analyzing predictive factors jointly, it was noted that patients with more than one predictive factor have a significantly greater possibility to yielding positive culture when compared to those with up to one predictive factor for bactibilia.

CONCLUSIONS

We concluded that, in patients with acute calculosis cholecystitis, bactibilia may be predicted yet at the preoperative period, by using simple and easily obtained data.

[Comparative study of intestinal anastomosis with manual suture and biofragmentable ring in dogs under corticosteroid administration]

BACKGROUND

This study analyzed intestinal anastomoses by manual suture and by compression with biofragmentable ring under delay of cicatrization administering parenteral corticoids.

MATERIAL AND METHODS

Twenty dogs were divided into two groups: control and test, the latter submitted to intramuscular administration of hydrocortisone hemisuccinate, 25 to 33 mg/kg/day, on the 30th preoperative and 7th postoperative days. During surgery, each animal underwent two colon sections with anastomosis by manual suture in a single extramucous plane and compression with biofragmentable ring. The animals were sacrificed 7 days after the procedure to evaluate the anastomoses.

RESULTS

In the postoperative period, one death occurred in the test group and two in the control group, caused by nonblocked fistula in the anastomoses by ring compression. Statistically, there was a similar incidence of adherences, fistulas, afferent dilatation and obstruction using comparison methods. On microscopy, deficiency in mucous regeneration of the anastomoses by compression was observed. Computerized histological analysis evidenced in the anastomoses by compression, a greater inflammatory reaction, greater edema of the submucous membrane and enlarged scars.

CONCLUSIONS

It was concluded that, with the biofragmentable ring, in colonic anastomosis under delay of cicatrization induced by corticoids, similar results to manual suture regarding to postoperative complications incidence were obtained; ring, however, determined worse mucous regeneration and greater cicatricial inflammatory reaction.

[Computer-assisted image processing for quantifying histopathologic variables in the healing of colonic anastomosis in dogs]

BACKGROUND

The authors present the experimental results of the computerized quantifying of tissular structures involved in the reparative process of colonic anastomosis performed by manual suture and biofragmentable ring. The quantified variables in this study were: oedema fluid, myofiber tissue, blood vessel and cellular nuclei.

MATERIAL AND METHODS

An image processing software developed at Laboratório de Informática Dedicado à Odontologia (LIDO) was utilized to quantifying the pathognomonic alterations in the inflammatory process in colonic anastomosis performed in 14 dogs. The results were compared to those obtained through traditional way diagnosis by two pathologists in view of counterproof measures. The criteria for these diagnoses were defined in levels represented by absent, light, moderate and intensive which were compared to analysis performed by the computer.

RESULTS

There was significant statistical difference between two techniques: the biofragmentable ring technique exhibited low oedema fluid, organized myofiber tissue and higher number of alongated cellular nuclei in relation to manual suture technique.

CONCLUSION

The analysis of histometric variables through computational image processing was considered efficient and powerful to quantify the main tissular inflammatory and reparative changing.

Distinct effects of recombinant desulfatohirudin (Revasc) and heparin on plasma levels of fibrinopeptide A and prothrombin fragment F1.2 in unstable angina. A multicenter trial

BACKGROUND

Thrombin plays an important role in the pathogenesis of acute coronary thrombosis. We studied the effects of a direct thrombin inhibitor, recombinant desulfatohirudin, and heparin on plasma levels (at 0, 4, 12, and 24 hours) of fibrinopeptide A (FPA), which reflects thrombin action, and prothrombin fragment F1.2, which reflects thrombin generation, in patients with unstable angina.

METHODS AND RESULTS

Patients were randomized to one of two doses of heparin (n = 50) (target activated partial thromboplastin time, 65 to 90 seconds or 90 to 110 seconds) or one of four doses of r-hirudin (n = 113) (0.05, 0.10, 0.20, or 0.30 mg.kg-1.h-1 by infusion). r-Hirudin induced a dose-dependent decline in plasma FPA. At 24 hours, FPA levels with 0.1- to 0.3-mg.kg-1.h-1 r-hirudin regimens were significantly lower than with 0.05 mg.kg-1.h-1 r-hirudin; levels with 0.1- to 0.2-mg.kg-1.h-1 r-hirudin regimens were lower than with both heparin regimens. Plasma F1.2 did not decline significantly during therapy with heparin or hirudin except at 0.3 mg.kg-1.h-1 hirudin. At 24 hours, they were higher with the 0.05-mg.kg-1.h-1 r-hirudin regimen than with other regimens. For comparable levels of thrombin generation (F1.2 levels), FPA levels were higher in heparin patients than in hirudin patients. For the same FPA values, the corresponding F1.2 values were higher in the hirudin group.

CONCLUSIONS

Our findings provide evidence for distinct in vivo effects of the two agents and suggest that r-hirudin is a relatively more potent inhibitor of thrombin action but a less effective inhibitor of thrombin generation than heparin. The lower FPA levels in hirudin patients may reflect its ability to inactivate clot-bound thrombin. The relative clinical efficacies of the two agents need to be defined by clinical trials in progress.

[Comparative experimental study of colocolic anastomosis with manual suture and biofragmentable ring]

BACKGROUND

The authors undertook an experimental trial, in order to compare one layer interrupted sutured large bowel anastomosis with that of biofragmentable anastomotic ring (BAR). This device creates an inverted serosa-to-serosa anastomosis. It is designed to fragment after hydrolysis and it is passed within the faeces after healing of the anastomosis. Fourteen dogs were operated on, having been performed 28 anastomoses, 14 with conventional way and 14 with the BAR, both in the same bowel, on alternate sequence and 10cm from each other.

MATERIAL AND METHODS

Performing time, technical difficulties, postoperative complications and the healing anastomotic quality were studied. Histological examination was done not only by traditional technique but also by using computerized program, in order to measure the amount of inflammatory infiltration at the anastomosis site.

RESULTS

All dogs tolerated the operation well and postoperative period was uneventful. At laparotomy, after an average time of 33 days, perianastomotic adherence was mostly noted in the sutured anastomosis. Anastomotic index had no significant difference in both methods, but inflammatory change was mostly detected in sutured anastomosis, on which the amount of edema infiltration was significantly higher.

CONCLUSIONS

Based on these results, the authors conclude that the BAR anastomosis appears to be a safe alternative, uniform, more rapid and easy technique, with better healing. No difference in the clinical results was noted.

Total sphincter conservation in high fistula in ano: results of a new approach

An intersphincteric approach has been developed that allows complete sphincter preservation in some patients with high fistulas. This operation in 13 patients (eight trans-sphincteric, five suprasphincteric tracks) has resulted in complete success in seven, partial success (ultimate sacrifice of the internal anal sphincter) in two and failure in four. When the operation is successful continence is better than after failed procedures.

[Initial experience with the AKA-2 and AKA-4 device for intestinal compression anastomosis in colorectal surgery]

A prospective study was undertaken to analyse the results of sutureless colorectal anastomosis, by using an anastomotic compression device designed by Russians, the AKA gun. Ten patients were submitted do colorectal resection, 5 for retrosigmoid cancer, 3 for familial adenomatous polyposis and 2 for rectal procidentia. No mortality. Anastomotic leakage occurred in 1 patient which was treated by a defunctioning colostomy and had a good recovery. Clinical, radiologic and endoscopic postoperative controls were within normality. Comparisons are made between the sutureless anastomosis technique and the traditional ones. Initial results are regarded, by the authors, as encouraging and so they intend to go on the study.