Prognostic value of left atrial stiffness estimated using echocardiography in dogs with myxomatous mitral valve disease

INTRODUCTION

No studies have investigated the prognostic value of left atrial stiffness (LASt) estimated using echocardiography in dogs with myxomatous mitral valve disease (MMVD).

ANIMALS

Seventy-two dogs had MMVD and 46 dogs were healthy dogs.

MATERIALS AND METHODS

Clinical retrospective cohort study. The survival information of MMVD dogs that underwent echocardiographic examination was obtained. The peak velocities of early diastolic transmitral flow (E) and mitral annular motion as determined by pulsed wave Doppler (E') were determined. The left atrial reservoir strain (ε_S) was determined by two-dimensional speckle tracking echocardiography of the left atrium. The LASt was estimated by the formula: E/E'/ε_S. The 95% prediction interval of LASt was computed from the data of the healthy dogs.

RESULTS

Seventeen dogs having MMVD died of cardiac-related causes with 55 MMVD dogs censored. The MMVD dogs with LASt > its 95% upper prediction limit (LASt > 0.56; n = 26; median survival time, 484 days; 95% confidence interval, 283 days-indeterminable) had shorter survival times (P<0.001) than those with LASt ≤ its 95% upper prediction limit (LASt ≤ 0.56; n = 46; median survival time, >1112 days; 95% confidence interval, indeterminable). Multivariable Cox's proportional hazard analysis demonstrated that the ratio of the left atrial dimension to the aortic annulus dimension and LASt were independent predictors of cardiac-related death among conventional echocardiographic indices, ε_S and LASt in MMVD dogs.

CONCLUSIONS

In dogs with MMVD, increased LASt estimated using echocardiography is an independent predictor of cardiac-related death, and LASt can be more useful for prognostication than ε_S.

Conceptual design of a heavy ion beam probe for the QUEST spherical tokamak

A heavy ion beam probe (HIBP) has been designed for the QUEST spherical tokamak to measure plasma turbulence and the profiles of electric potential profiles. Using a cesium ion beam with an energy of several 10 keV, the observable region covers most of the upper half of the plasma. Although the probe beam is deflected by the poloidal magnetic field produced by plasma current and poloidal coil currents, it can be detected under plasma current up to 150 kA by modifying the trajectories with two electrostatic sweepers. According to the numerical estimation of the intensity of the detected beam, sufficient signal intensity for measuring plasma turbulence can be obtained over almost the measurable area when the electron density is up to 1 × 10¹⁹ m^-3, which is larger than the cut-off density of electron cyclotron heating in QUEST. The performance of the designed HIBP is sufficient to explore the mechanisms of heat and particle transport in magnetically confined plasmas, including the influence of plasma wall interactions, which is a goal of the QUEST project.

Remimazolam anaphylaxis confirmed by serum tryptase elevation and skin test

Anaphylactic reactions during the induction of general anaesthesia are rare. Anaesthetists should determine the pathogenesis of anaphylaxis in order to establish appropriate treatment and prevent recurrence. Very little clinical information has been published to date about anaphylaxis induced by the recently launched drug remimazolam. A 78-year-old man, scheduled for elective surgery for colon cancer, became profoundly hypotensive and hypoxic shortly following the induction of general anaesthesia with remimazolam, remifentanil and rocuronium. His physiological derangement was successfully managed with adrenaline, vasopressors and intravenous fluid resuscitation. His serum tryptase level was significantly elevated and an intradermal test with diluted remimazolam revealed a positive reaction, confirming the diagnosis of anaphylaxis. We believe this is the first case report of remimazolam-induced anaphylactic shock diagnosed with a serum tryptase elevation and positive skin test.

Hyperacute postprocedural high platelet reactivity: a novel predictor for in-hospital adverse events in acute coronary syndrome with prasugrel loading

Introduction

Postprocedural High platelet reactivity (HPR) seems to associate long term adverse cardiovascular events, mainly intrastent thrombosis. However, the relationship between hyper-acute postprocedural HPR with prasugrel loading and clinical outcomes in acute coronary syndrome (ACS) is still unclear. Moreover, factors contributing HPR in ACS with prasugrel loading are also unknown.

Purpose

This study aimed to assess the impact of hyper-acute postprocedural HPR with prasugrel loading on clinical outcomes in ACS during hospitalization, as well as to define appropriate cut-off values and identify contributing factors of HPR.

Methods

We performed a single-centre, retrospective observational study that enrolled 207 patients who underwent emergent PCI for ACS with prasugrel loading. The P2Y12reaction unit (PRU) value was measured immediately after PCI with the VerifyNow System. The primary endpoint was major adverse cardiac events (MACE, defined as the composite of death, myocardial infarction, stroke, heart failure, ventricular arrhythmia needing defibrillation).

Results

Mean patient age (standard deviation) was 70.5 (±13.0) years, 78.7% were male, and average time from prasugrel intake to PRU calculation was 98.3 (±49.1) min. During a mean hospital stay of 15.9 (±9.3) days, there were 34 in-hospital MACE (16.4%) and 10 deaths (4.8%). Thrombosis events, didn't stand out and mechanical complications, such as cardiac rupture and cardiac tamponade occupies most of cardiovascular death which occurred before 10 days on admission. PRU was significantly higher in MACE group than Non-MACE group (279±65 vs 227±72, p&lt;0.001 respectively). The ROC curve analysis of PRU for discriminating significant in-hospital MACE showed the cut off value of 293 (sensitivity:52.9%, specificity:83.2% [AUC=0.709, p&lt;0.0001]). 47patients (29.4%) were thus categorized as HPR (PRU&gt;293) immediately after emergent PCI. Kaplan-Meyer curve showed MACE events occurred in HPR group than non-HPR group (38.2% vs 10.0%, p&lt;0.001). Multiple cox analysis demonstrated that HPR was independent predictors of MACE in patients with ACS underwent PCI (OR 5.416, 95% CI 2.157–13.598, p&lt;0.0001). Multiple logistic regression model showed female sex, low haemoglobin value, and large mean platelet volume were independent predictors of HPR.

Conclusion

PRU was significantly higher in MACE group, and appropriate cut-off value of HPR in this study was 293. HPR was independent predictor of MACE during hospitalization, however thrombosis event was not significant. Evidence of clinical impact with postprocedural HPR within 120 minutes after prasugrel loading is scarce. This study shows post-procedural HPR, even without sufficient time after prasugrel intake, can be a useful predictive marker of adverse events during hospitalization.

Funding Acknowledgement

Type of funding sources: None. PRU between Non-MACE and MACE groupKaplan-Meyer curve

Cardio-ankle vascular index is useful screening method to detect obstructive coronary artery disease in asymptomatic diabetes patients with subclinical atherosclerosis

Background

Patients with diabetes mellitus are at very high risk for obstructive coronary artery disease; however, invasive coronary angiography is not allowed to apply in all patients. Cardio-ankle vascular index (CAVI), a marker of arterial stiffness has been reported to reflect atherosclerotic burden.

Purpose

To assess the diagnostic performance of CAVI vs. coronary calcium score for detecting obstructive coronary artery disease determined by Coronary CT angiography (CCTA) in asymptomatic diabetes patients.

Methods

During May 2015 to December 2019, 816 patients with diabetes mellitus were evaluated. First, intima-media thickness of carotid artery was measured in all subjects. Then, patients with intima-media thickness over 11mm underwent CAVI. Finally, 209 patients who have one or more cardiovascular risk factors other than diabetes mellitus were enrolled (68±11 years, 68% men). Patients were excluded if they had a disorder of the kidney, a prior history of coronary artery revascularization, atrial fibrillation, LV ejection fraction &lt;50%, ABI &lt;0.9 or allergy to contrast. Diagnostic performance of CAVI was evaluated with coronary stenosis &gt;50% by CCTA.

Results

CAVI, Agatston score, and intima-media thickness of carotid artery were 9.2±1.3, 396±621 and 2.0±0.7mm, respectively. CAVI was significantly correlated with age (r=0.530, p&lt;0.001), coronary artery calcification (r=0.182, p=0.008), and intima-media thickness of carotid artery (r=0.195, p=0.005). Among them, 108 patients (48%) had coronary stenosis. CAVI, Agatston score and intima-media thickness of carotid artery in patients with coronary stenosis were higher than that without coronary stenosis, respectively (9.8±1.1 vs 8.5±1.0, p&lt;0.001, 526±676 vs. 255±525, p=0.001, 2.2±0.7 vs. 1.8±0.6, p&lt;0.001). The ROC curve analysis of CAVI for discriminating coronary stenosis showed that the sensitivity 75.0% and specificity 77.2% at the cut off value of 9.23 (AUC=0.812, p&lt;0.001). Contrastingly, diagnostic performance of coronary calcium score and intima-media thickness of carotid artery were less than CAVI (sensitivity: 91.7%, specificity: 56.4%, AUC=0.753, p&lt;0.05 vs. CAVI, sensitivity: 68.5%, specificity: 59.4%, AUC=0.663, p&lt;0.05 vs. CAVI). Multivariate logistic analysis demonstrated that CAVI was significantly associated with coronary stenosis (OR=4.133, p&lt;0.001) after adjustment of conventional risk factors, although coronary calcium score was not correlated with coronary stenosis.

Conclusion

CAVI could be informative to select patients having obstructive coronary artery disease in asymptomatic diabetes patients with thick intima-media thickness.

Funding Acknowledgement

Type of funding sources: None.

Impact of high platelet reactivity on left ventricular remodeling in patients with acute coronary syndrome

Background/Introduction

Previous studies demonstrated that high platelet reactivity (HPR) predicts future cardiovascular death and coronary events in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). However, few studies have focused on the impact of HPR on left ventricular remodeling (LVR) and each echocardiographic parameter.

Purpose

The purpose of this study was to investigate the impact of HPR in ACS patients on LVR and changes in echocardiographic volume indexes and LV ejection fraction.

Methods

This is a retrospective cohort study of prospectively collected data in a single center that enrolled patients who underwent emergency PCI for ACS including STEMI and NSTEMI with prasugrel loading. The primary outcome of the study was LVR associated with HPR. Secondary endpoints were changes in indexed LVESV, LVEDV, LVEF, E/e' and LAVI between baseline and follow-up. The P2Y12 reaction unit (PRU) value in response to prasugrel was assessed by the VerifyNow P2Y12 assay. Blood samples were collected once per procedure immediately after PCI. LVR index was calculated as the relative change in LVEDV observed at follow-up compared with baseline. LVR was defined as a relative increase in LVEDV ≥20%, measured at follow-up visit compared with the baseline value before discharge.

Results

A total of 196 ACS patients who underwent emergency PCI between January 2016 and July 2020 were enrolled in the study. The mean age of the study population was 69.9 years, and 76.0% were male. On echocardiography at follow up visit of mean duration of 7.0±4.0 months, LVR was found in 38 patients (19.4%). The optimal cutoff for PRU associated with increased LVR assessed by receiver-operating characteristic curve analysis was 245.5 (AUC: 0.656; 95% CI: 0.564 to 0.749; p=0.003). On the basis of this cutoff, HPR was found in 82 patients (42.1%) and the prevalence of LVR was significantly higher in the HPR group compared to the non-HPR group (30.5% vs. 11.4%; p=0.001). Multiple Cox regression analysis showed that HPR was an independent predictor of LVR (OR 4.22, 95% CI 1.83–9.71, p=0.001). In addition, Δ% EDV and Δ% ESV increased in the HPR group, and decreased in the non-HPR group with significant differences (5.8±32.6% vs. −8.0±26.2% in Δ% EDV; p=0.002, 2.0±37.5% vs. −13.3±33.0% in Δ% ESV; p=0.004, respectively). Δ%EF, Δ%E/e', Δ%LAVI were numerically improved in the non-HPR group compared with the HPR group, but this difference did not reach statistical significance.

Conclusion

In patients with ACS, HPR defined as PRU ≥246 immediately after emergency PCI was an independent predictor of LVR in the chronic phase.

Funding Acknowledgement

Type of funding sources: None. Predictors of the presence of LVRChanges (Δ%) of LVEDV and LVESV

Post-procedural high platelet reactivity with prasugrel loading predicts in-hospital adverse events in ACS patients

Background/Introduction

High platelet reactivity (HPR) is associated with adverse cardiovascular events, primarily intrastent thrombosis, after a percutaneous coronary intervention (PCI). However, the relationship between hyperacute postprocedural HPR with prasugrel loading and clinical outcomes in acute coronary syndrome (ACS) remains unclear. Moreover, factors contributing to HPR in ACS with prasugrel loading are also unknown.

Purpose

To assess the effects of post-procedural HPR with prasugrel loading on clinical outcomes in ACS during hospitalization, and to define the appropriate cut-off values and identify factors contributing to HPR.

Methods

A single-center, retrospective observational study that enrolled 154 patients who underwent emergent PCI for ACS with prasugrel loading was performed. The P2Y12 reaction unit (PRU) value was measured immediately after PCI using the VerifyNowR system. The primary end-point was major adverse cardiac events (MACE, defined as the composite of death, myocardial infarction, stroke, heart failure, ventricular arrhythmia needing defibrillation).

Results

The mean patient age (standard deviation) was 70.7 (±12.5) years, 76.6% were men, and the average time from the prasugrel intake to PRU calculation was 103.2 (±48.5) min. During the mean hospital stay of 15.6 (±8.5) days, 24 in-hospital MACE (15.5%) and 8 deaths (5.2%) occurred. Thrombosis events, including myocardial infarction recurrence, did not occur (only one case of spontaneous coronary artery dissection was considered as myocardial infarction recurrence). PRU was significantly higher in the MACE group than that in Non-MACE group (287±55 and 232±64, respectively, p&lt;0.001). The ROC curve analysis of PRU for discriminating the significant in-hospital MACE showed the cut-off value of 293 (sensitivity: 62.5%, specificity: 83.1% [AUC=0.756, p&lt;0.0001]). A total of 37 patients (24%) were thus categorized as HPR (PRU&gt;293) immediately after the emergent PCI. Kaplan-Meier curve showing MACE events occurred in the HPR group than that in the non-HPR group (40.5% vs 7.6%, p&lt;0.001). Multiple cox analysis demonstrated that HPR was independent predictors of MACE in patients with ACS who underwent PCI (OR 11.01, 95% CI 2.39–20.2, p&lt;0.0001). Multiple logistic regression model showed old age, female sex, low systolic blood pressure, short prasugrel intake to measure time, and large acute gain were independent predictors of HPR.

Conclusion

PRU was significantly higher in the MACE group, with an appropriate cut-off value of HPR of 293 in this study. HPR was an independent predictor of MACE during hospitalization; however, thrombosis events were not significant. HPR predictors were old age, female sex, low systolic blood pressure, short prasugrel intake to measure time, and large acute gain. This study shows the post-procedural HPR with prasugrel loading in patients with ACS can be a useful predictive marker of adverse events during hospitalization.

Funding Acknowledgement

Type of funding source: None

Cardio-ankle vascular index as an arterial stiffness marker improves on cardiovascular events by adding to framingham risk score

Background

The cardio-ankle vascular index (CAVI) is a non-invasive measurement that evaluates arterial stiffness using the analysis of oscillometric waveform during cuff-Inflation. Several studies reported that CAVI is associated with cardiovascular risk factors, while the clinical prognostic value of CAVI as a surrogate marker of atherosclerosis has not been fully elucidated. Meanwhile, the Framingham risk score (FRS) is an established marker of cardiovascular outcomes.

Purpose

To investigate whether adding CAVI to Framingham risk score improves the prediction of cardiovascular events.

Methods

This prospective observational study included consecutive 422 patients with cardiovascular risk factors but without known coronary artery disease (69±8 years, 63% men). CAVI was measured by the oscillometric method with VaSera vascular screening system. Patients with atrial fibrillation, left ventricular ejection fraction &lt;50%, both ABI&lt;0.9, severe valvular diseases, or hemodialysis were excluded. Primacy outcomes were cardiovascular death, myocardial infarction, stroke, hospitalization for heart failure and revascularization.

Results

During a median follow-up of 3.1 years, cardiovascular events occurred in 12.8% (3.3%, 15.7%, and 19.1% in the low, intermediate and high-risk group of stratification by FRS, respectively). The ROC curve analysis for discriminating cardiovascular events showed that the AUC of CAVI added to Framingham risk score was the highest compared to Framingham risk score and CAVI alone (CAVI added to Framingham risk score: AUC 66.9, 95% CI 59.6–74.2, Framingham risk score alone: AUC 61.5, 95% CI 53.8–69.1, CAVI alone: AUC 62.3, 95% CI 54.1–70.6). The logistic regression analysis demonstrated that CAVI and Framingham risk score were independent predictors of cardiovascular events (CAVI: OR 1.381, 95% CI 1.164–1.597, p=0.004, Framingham risk score: OR 1.135, 95% CI 1.044–1.225, p=0.007). Next, when logistic regression analysis was performed simultaneously on Framingham risk factor and CAVI, CAVI was an independent predictor of cardiovascular events (OR 1.347, 95% CI 1.124–1.569, p=0.009). Furthermore, in the likelihood ratio test, CAVI added to Framingham risk score significantly improved the cardiovascular event prediction ability than Framingham risk factor alone. Next, when patients with intermediate risk (n=217) were divided into two groups based on CAVI of 9.0, the Kaplan-Meier estimate showed that events occurred more frequently in higher CAVI group (9.3% and 29.1%, log-rank, P=0.009) and the C-statistic was 0.662. Multiple Cox analysis showed that, in the intermediate risk group, CAVI was an independent predictor of primary outcomes (HR 1.387 per 1 index, 95% CI 1.081–1.779, p=0.010).

Conclusion

The measurement of CAVI could be a useful predictor for cardiovascular events. In addition, the combination of CAVI and Framingham risk score could improve the predictability compared to the Framingham risk score alone.

Funding Acknowledgement

Type of funding source: None

Nature of the Dirac gap modulation and surface magnetic interaction in axion antiferromagnetic topological insulator [Formula: see text]

Modification of the gap at the Dirac point (DP) in axion antiferromagnetic topological insulator [Formula: see text] and its electronic and spin structure have been studied by angle- and spin-resolved photoemission spectroscopy (ARPES) under laser excitation at various temperatures (9-35 K), light polarizations and photon energies. We have distinguished both large (60-70 meV) and reduced ([Formula: see text]) gaps at the DP in the ARPES dispersions, which remain open above the Neél temperature ([Formula: see text]). We propose that the gap above [Formula: see text] remains open due to a short-range magnetic field generated by chiral spin fluctuations. Spin-resolved ARPES, XMCD and circular dichroism ARPES measurements show a surface ferromagnetic ordering for the "large gap" sample and apparently significantly reduced effective magnetic moment for the "reduced gap" sample. These observations can be explained by a shift of the Dirac cone (DC) state localization towards the second Mn layer due to structural disturbance and surface relaxation effects, where DC state is influenced by compensated opposite magnetic moments. As we have shown by means of ab-initio calculations surface structural modification can result in a significant modulation of the DP gap.

Publisher Correction: A weak topological insulator state in quasi-one-dimensional bismuth iodide

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Radial Spin Texture in Elemental Tellurium with Chiral Crystal Structure

The chiral crystal is characterized by a lack of mirror symmetry and inversion center, resulting in the inequivalent right- and left-handed structures. In the noncentrosymmetric crystal structure, the spin and momentum of electrons are expected to be locked in the reciprocal space with the help of the spin-orbit interaction. To reveal the spin textures of chiral crystals, we investigate the spin and electronic structure in a p-type semiconductor, elemental tellurium, with the simplest chiral structure by using spin- and angle-resolved photoemission spectroscopy. Our data demonstrate that the highest valence band crossing the Fermi level has a spin component parallel to the electron momentum around the Brillouin zone corners. Significantly, we have also confirmed that the spin polarization is reversed in the crystal with the opposite chirality. The results indicate that the spin textures of the right- and left-handed chiral crystals are hedgehoglike, leading to unconventional magnetoelectric effects and nonreciprocal phenomena.

Basement membrane zone IgE deposition is associated with bullous pemphigoid disease severity and treatment results

BACKGROUND

A subset of patients with bullous pemphigoid (BP) show deposition of IgE in the basement membrane zone (BMZ), yet the relationship between BMZ IgE and the clinical presentation of BP remains unclear.

OBJECTIVES

To investigate the relationship between IgE deposition, IgE levels in serum, and disease severity in patients with BP.

METHODS

We investigated IgE autoantibodies in 53 patients with BP by direct immunofluorescence (DIF), indirect immunofluorescence and enzyme-linked immunosorbent assay.

RESULTS

Of 53 patients with BP, 23 (43%) had IgE deposition, 10 (19%) of whom were IgE+ and 13 (25%) IgE± according to DIF analyses. Erosion/blister (E/B) Bullous Pemphigoid Disease Area Index (BPDAI) scores were significantly higher in IgE+ patients than in IgE- patients (n = 15), while no significant differences were found for urticaria/erythema BPDAI scores. IgE+ and IgE± patients took longer to reduce their E/B BPDAI score by 75% after systemic corticosteroid treatment. BP180-IgE levels were significantly higher among IgE+ patients than IgE± or IgE- patients (n = 10). Total IgE levels in the serum and blood eosinophil counts did not differ between IgE+, IgE± and IgE- patients. A significant correlation was detected between BP180-IgG and BP180-IgE, but not between BPDAI scores and any of BP180-IgG, BP180-IgE or blood eosinophil count.

CONCLUSIONS

IgE deposition in the BMZ is associated with higher E/B BPDAI scores and longer treatment periods. We conclude that IgE binding in the BMZ may contribute to BP pathogenesis by promoting blister formation. What's already known about this topic? BP180-IgE autoantibodies have an important role in the pathogenesis of bullous pemphigoid (BP). A subset of patients with BP display deposition of IgE within the basement membrane zone (BMZ) of skin tissue. What does this study add? Patients with in vivo IgE deposition in the BMZ displayed higher erosion/blister Bullous Pemphigoid Disease Area Index (BPDAI) scores, while urticaria/erythema BPDAI scores were not significantly different. Patients with in vivo IgE deposition in the BMZ took longer to reduce their erosion/blister BPDAI score by 75% after systemic corticosteroid treatment. BP180-specific IgE levels in serum were higher among patients with linear IgE deposition in the BMZ than in those with granular or no IgE deposition.

P4634Acute-phase high platelet reactivity with prasugrel loading is correlated with clinical outcomes during hospitalization in acute coronary syndrome

Background/Introduction

Although high platelet reactivity (HPR) seems to be associated with adverse cardiovascular events after percutaneous coronary intervention (PCI), the relationship between post-procedure HPR with prasugrel loading and clinical outcomes in acute coronary syndrome (ACS) is still unclear. Moreover, factors contributing to HPR in ACS with prasugrel loading are also unknown.

Purpose

This study aimed to assess the impact of post-procedure HPR with prasugrel loading on clinical outcomes in ACS during hospitalization, as well as to define appropriate cut-off values and identify factors contributing to HPR.

Methods

We performed a single-centre, retrospective observational study that enrolled 132 patients who underwent emergent PCI for ACS with prasugrel loading. The P2Y12 reaction unit (PRU) value was measured immediately after PCI with the VerifyNowR System. The primary endpoint was major adverse cardiac events (MACE, defined as the composite of death, myocardial infarction, stroke, heart failure, ventricular arrhythmia needing defibrillation).

Results

Mean patient age (standard deviation) was 70.7 (±12.5) years, 76% were male, and average time from prasugrel intake to PRU calculation was 101 (±48.8) min. During a mean hospital stay of 15.4 (±8.0) days, there were 22 (16%) MACE events and 6 (4%) deaths. The post-procedure PRU value was 241±66. HPR was significantly higher in MACE group than non-MACE group [287 (±55) vs 232 (±64), p<0.001]. The ROC curve analysis of PRU for discriminating significant in-hospital MACE showed a cut off value of 293 (sensitivity: 64%, specificity: 84% [AUC=0.764, p<0.0001]). Thus, 33 patients (25%) were found to have HPR (PRU>293) immediately after emergent PCI. Kaplan-Meier curve analysis showed MACE events occurred more frequently in the HPR group than in the non-HPR group (42% vs 8%, log rank p<0.001). Multiple Cox regression analysis showed that peak creatine phosphokinase >3,000 U/L and HPR were independent predictors of MACE in patients with ACS who underwent PCI (OR 4.96, 95% CI 1.86–13.26, p=0.001, and OR 7.52, 95% CI 2.73–20.7, p<0.0001, respectively). HPR was significantly correlated with age, female sex, and reference lumen short diameter (pre-dilation) used in PCI.

Conclusion

HPR was significantly associated with adverse event during hospitalization in ACS patients. Female patients with large culprit lesion diameter were more likely to have HPR. Appropriate cut-off value of HPR in this study was 293. HPR in early-phase of ACS with prasugrel loading is a useful predictor of adverse events during hospitalization.

P767Survey of palliative sedation at the end-of-life in terminally ill heart failure patients - a five year experience in national cardiovascular center

Background

Palliative sedation is a therapeutic option when symptom relief is difficult to achieve at the end-of-life. However, little is known regarding palliative sedation in terminally ill heart failure (HF) patients.

Purpose

To survey the practice of palliative sedation in terminally ill HF patients at a tertiary referral cardiovascular center, and to investigate the efficacy and safety of sedative agents in HF patients.

Methods

We retrospectively reviewed consecutive patients who were referred to palliative care team at our institution between September 2013 and August 2018. Patients who were hospitalized for HF and died during hospitalization despite optimal medical therapy were selected and defined as terminally ill HF. We investigated the practice of palliative sedation in terminally ill HF patients and analysed the vital signs and sedation scale before starting sedative agents and about 1 hour afterward.

Results

Among 95 terminally ill HF patients, 37 were prescribed palliative sedation at the end-of-life (Picture). Of 37 patients (mean age: 70 years, median B-type natriuretic peptide: 1018 pg/ml, median creatinine: 3.0 mg/dl, intravenous inotrope: 81%), 25 were prescribed dexmedetomidine, and 12 were prescribed midazolam as first agent for sedation. Patient's backgrounds were comparable between the two groups. Richmond Agitation-Sedation Scale was significantly reduced (P<0.01), whereas blood pressure and heart rate were not altered after treatments in both groups. In midazolam group, significant decreases were noted regarding respiratory rate (P=0.01) and oxygen saturation (P=0.02); however, these parameters were not changed in dexmedetomidine group (Table).

Table 1. Vital signs and sedation scale Dexmedetomidine group (n=25) Midazolam group (n=12) Baseline After P value Baseline After P value Richmond Agitation-Sedation Scale 1 (0, 1) −1 (−2, 0) <0.01 1 (0, 1) −2 (−3, −1) <0.01 Vital signs   Systolic blood pressure (mmHg) 90±15 89±16 0.51 89±21 84±23 0.33   Diastolic blood pressure (mmHg) 52±13 54±11 0.34 60±14 56±23 0.48   Heart rate (beats per minute) 95±20 91±22 0.17 90±21 90±19 0.70   Respiratory rate (breaths per minute) 22±5 20±5 0.24 21±5 17±2 0.01   Oxygen saturation (%) 97±3 96±6 0.59 96±5 94±5 0.02

Picture. Study flowchart

Conclusions

Dexmedetomidine and midazolam were commonly used in real-word practice for HF patients at the end-of-life. Although impact on respiratory system differed by treatments, both agents could be prescribed effectively and safely in terminally ill HF patients.

P1671Subclinical persistent hemolysis may affect late renal function deterioration after HeartMateII implantation

Background

Late renal function dysfunction is an increasingly recognized complication in continuous flow left ventricular assist device (CF-LVAD) patients. Although hemolysis is prevalent in CF-LVAD patients and hemolysis may deteriorate renal function, the influence of persistent hemolysis on renal function in CF-LVAD patients remains to be investigated.

Purpose

To investigate the influence of persistent hemolysis on renal function in CF-LVAD patients, using lactate dehydrogenase (LDH) as a sensitive marker of hemolysis.

Methods

Excluding patients who died or underwent pump exchange for pump thrombosis, we retrospectively reviewed 65 consecutive adults who underwent HeartMateII implantation in our center from May 2011 to October 2017. Patient characteristics, chronotropic change of estimated glomerular filtration rate (eGFR) and LDH values weekly for 4 weeks and every 4 weeks between 4 and 48 weeks after implantation were collected. Then, calculating mean LDH during 48 weeks after implantation, study population was divided into low and high mean LDH groups at the median value of mean LDH.

Results

The median value of mean LDH was 304 U/l. Compared with low LDH patients, though high LDH patients were more likely female and had smaller body surface area, there were no significant difference in pre-operative eGFR between the groups (66.0±23.7 vs. 70.2±25.7 ml/min/1.73m2, p=0.495). After 40 weeks after implantation, high LDH patients had significantly lower eGFR than low LDH patients (71.0±23.7 vs. 87.1±31.4 ml/min/1.73m2, p=0.024). In multivariate linear regression analysis, mean LDH [parameter estimate: −0.10 (95% CI: −0.17 to −0.04), p=0.003] and post-operative pulse pressure [parameter estimate: 0.71 (95% CI: 0.05 to 1.37), p=0.036] were significantly associated with eGFR change during 48 weeks after HeartMateII implantation.

Univariate and multivariate linear regression analysis for eGFR change Univariate parameter estimate 95% CI p value Multivariate parameter estimate 95% CI p value Bilirubin, mg/dl 9.97 3.82 to 16.13 0.002 6.55 −0.43 to 13.53 0.065 BNP, pg/ml 0.01 0.00 to 0.02 0.044 0.00 −0.01 to 0.01 0.528 Mean LDH during 4 to 48 weeks, U/l −0.11 −0.18 to −0.05 <0.001 −0.10 −0.17 to −0.04 0.003 Pre-operative right atrial pressure, mmHg 1.43 0.35 to 2.51 0.010 −0.06 −1.52 to 1.40 0.935 Post-operative pulse pressure, mmHg 0.77 0.03 to 1.52 0.042 0.71 0.05 to 1.37 0.036

Conclusions

High mean LDH and low pulse pressure were associated with a significant decrease in eGFR late after HeartMateII implantation. Subclinical persistent hemolysis may be associated with late renal function deterioration in CF-LVAD patients.

Terminal Ileac Ulcers Mimicked Post-transplantation Lymphoproliferative Disorder in a Heart Recipient Treated With Everolimus: A Case Report

Post-transplant lymphoproliferative disorder (PTLD) is a well-recognized and potentially fatal complication of cardiac transplantation that commonly involves the gastrointestinal tract. Herein, we report a case of life-threatening gastrointestinal bleeding from recurrent terminal ileac ulcers mimicking PTLD in a heart recipient treated with everolimus (EVL). A 40-year-old man underwent heart transplantation for dilated cardiomyopathy 3 years prior to the current admission and was treated with tacrolimus and EVL. He was admitted to a local hospital because of fever, abdominal pain, and diarrhea. His symptoms persisted and, 3 weeks later, hematochezia occurred; thus, he was transferred to our hospital. As computed tomography and ¹⁸F-fluorodeoxyglucose positron emission tomography showed bowel-wall thickening of the terminal ileum, gastrointestinal PTLD was initially suspected. However, although colonoscopy- performed after switching EVL to mycophenolate mofetil (MMF)-showed terminal ileac ulcers, the histologic examination revealed no findings corresponding to PTLD. As EVL may delay ulcer healing, MMF was maintained for 3 months. After repeated colonoscopy showed ulcer healing, MMF was switched back to EVL for cardiac allograft vasculopathy prevention. Three weeks later, he was emergently admitted to a local hospital for life-threatening gastrointestinal bleeding from a recurrent terminal ileal ulcer, which required hemostatic forceps hemostasis. As EVL is suspected to be associated with recurrent ileal ulcers, EVL was again switched back to MMF. The ileal ulcers resolved, without recurrence in 3 months of clinical follow-up. This case demonstrates that cases of life-threatening gastrointestinal bleeding from recurrent terminal ileac ulcers can mimic PTLD in a heart recipient treated with EVL.

Biological and Mechanical Evaluation of Novel Prototype Dental Composites

The breakdown of the polymeric component of contemporary composite dental restorative materials compromises their longevity, while leachable compounds from these materials have cellular consequences. Thus, a new generation of composite materials needed to be designed to have a longer service life and ensure that any leachable compounds are not harmful to appropriate cell lines. To accomplish this, we have developed concurrent thiol-ene-based polymerization and allyl sulfide-based addition-fragmentation chain transfer chemistries to afford cross-linked polymeric resins that demonstrate low shrinkage and low shrinkage stress. In the past, the filler used in dental composites mainly consisted of glass, which is biologically inert. In several of our prototype composites, we introduced fluorapatite (FA) crystals, which resemble enamel crystals and are bioactive. These novel prototype composites were benchmarked against similarly filled methacrylate-based bisphenol A diglycidyl ether dimethacrylate / triethylene glycol dimethacrylate (bisGMA/TEGDMA) composite for their cytotoxicity, mechanical properties, biofilm formation, and fluoride release. The leachables at pH 7 from all the composites were nontoxic to dental pulp stem cells. There was a trend toward an increase in total toughness of the glass-only-filled prototype composites as compared with the similarly filled bisGMA/TEGDMA composite. Other mechanical properties of the glass-only-filled prototype composites were comparable to the similarly filled bisGMA/TEGDMA composite. Incorporation of the FA reduced the mechanical properties of the prototype and bisGMA/TEGDMA composite. Biofilm mass and colony-forming units per milliliter were reduced on the glass-only-filled prototype composites as compared with the glass-only-filled bisGMA/TEGDMA composite and were significantly reduced by the addition of FA to all composites. Fluoride release at pH 7 was greatest after 24 h for the bisGMA/TEGDMA glass + FA composite as compared with the similarly filled prototypes, but overall the F^- release was marginal and not at a concentration to affect bacterial metabolism.

Selective release of miRNAs via extracellular vesicles is associated with house-dust mite allergen-induced airway inflammation

BACKGROUND

MicroRNAs (miRNAs) may facilitate cell-to-cell communication via extracellular vesicles (EVs). The biological roles of miRNAs in EVs on allergic airway inflammation are unclear.

METHODS

Airway-secreted EVs (AEVs) were isolated from bronchoalveolar lavage fluid (BALF) of control and house-dust mite (HDM) allergen-exposed HDM-sensitized mice. The expression of miRNAs in AEVs or miRNAs and mRNAs in lung tissue was analysed using miRNA microarray.

RESULTS

The amount of AEV increased 8.9-fold in BALF from HDM-exposed mice compared with that from sham-control mice. HDM exposure resulted in significant changes in the expression of 139 miRNAs in EVs and 175 miRNAs in lung tissues, with 54 miRNAs being common in both samples. Expression changes of these 54 miRNAs between miRNAs in AEVs and lung tissues after HDM exposure were inversely correlated. Computational analysis revealed that 31 genes, including IL-13 and IL-5Ra, are putative targets of the miRNAs up-regulated in AEVs but down-regulated in lung tissues after HDM exposure. The amount of AEV in BALF after HDM exposure was diminished by treatment with the sphingomyelinase inhibitor GW4869. The treatment with GW4869 also decreased Th2 cytokines and eosinophil counts in BALFs and reduced eosinophil accumulation in airway walls and mucosa.

CONCLUSION

These results indicate that selective sorting of miRNA including Th2 inhibitory miRNAs into AEVs and increase release to the airway after HDM exposure would be involved in the pathogenesis of allergic airway inflammation.

Reversible Cerebral Vasoconstriction Syndrome After Heart Transplantation: A Case Report

BACKGROUND

Reversible cerebral vasoconstriction syndrome (RCVS) is a transient cerebrovascular disorder putatively caused by some immunosuppressive agents.

CASE REPORT

We recently encountered a 47-year-old female patient diagnosed with dilated cardiomyopathy who developed RCVS after heart transplantation. A triple-drug regimen consisting of tacrolimus, mycophenolate mofetil, and a corticosteroid was started after surgery. On postoperative day (POD) 11, the patient developed a severe headache, although computed tomography of the head demonstrated no signs of hemorrhage or infarction. At first, both a painkiller and migraine drugs were regularly administered to the patient. On POD 21, however, she developed an unbearable headache with a visual field defect and mild hemiparesis of the right hand. Magnetic resonance imaging (MRI) of the brain revealed a cerebral infarction in the left occipital lobe with diffuse vasoconstriction of both the middle and posterior cerebral arteries. A diagnosis of RCVS was made and tacrolimus, a drug suspected to cause RCVS, was discontinued. In its place, two doses of basiliximab followed by everolimus, both of which are alternatives for tacrolimus, were given. The corticosteroid dose was also increased. Furthermore, to release vasoconstriction, both verapamil and diltiazem were administered. On POD 27, cerebrovascular constrictions were shown to be relieved on brain MRI and the patient's neurological symptoms subsequently almost completely diminished.

CONCLUSION

RCVS should always be considered as a cause of headache in heart transplant recipients because tacrolimus, an immunosuppressive agent, may trigger RCVS. This will allow rapid intervention that is essential for avoiding irreversible neurological deficits.

Paradoxical Reaction of Tuberculosis in a Heart Transplant Recipient During Antituberculosis Therapy: A Case Report

INTRODUCTION

Tuberculous paradoxical reactions (PRs) are excessive immune reactions occurring after antituberculosis (TB) treatment and are commonly observed in immunocompromised hosts such as patients infected with the human immunodeficiency virus.

CASE REPORT

We recently encountered a 63-year-old male heart transplant recipient who developed tuberculous PR after treatment for miliary TB. The patient had been receiving immunosuppressive therapy with cyclosporine and mycophenolate mofetil for over 15 years. The diagnosis of miliary TB was made based on the presence of intermittent fever and fatigue; thus, anti-TB treatments (isoniazid, levofloxacin, ethambutol, and pyrazinamide) were started, which led to rapid defervescence and regression of the granular shadow and pleural effusion. However, a new persistent fever and confused state developed 1 month after the anti-TB therapy was started. After excluding possible etiologies of the patient's symptom, a PR was suspected, and anti-TB drugs were continued; corticosteroids were added as anti-inflammatory agents. After that, he has shown a favorable course with long-term anti-TB chemotherapy.

CONCLUSION

A PR should always be considered when the patients' symptoms of tuberculosis re-exacerbate after an appropriate anti-TB therapy. A PR commonly occurs in patients with various immunologic conditions including heart transplant recipients.

Clinical Outcomes of Patients With the HeartMate II Left Ventricular Assist Device: A Single-center Experience From Japan

BACKGROUND

Left ventricular assist device (LVAD) therapy is the "gold standard" alternative therapy for patients with advanced heart failure. However, LVAD therapy is still uncommon in the Asia-Pacific region. Therefore, we aimed to elucidate the clinical outcomes of patients from Japan supported with the HeartMate II (HM-II) LVAD at our institution.

METHODS

Ninety-two patients (mean 44.3 ± 12.1 years, 68 men, average body mass index 1.65 ± 0.28 m²; 81 with nonischemic cardiomyopathy) who underwent HM-II implantation for bridge to transplantation (n = 91) or for destination therapy in a clinical study (n = 1) at the National Cerebral and Cardiovascular Center between April 2013 and October 2017 were enrolled in this analysis. Preoperatively, most patients (n = 73, 79%) had an INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profile of between level 2 and 4. Postoperatively, the average pump speed was 8602 ± 258 rpm and the hemodynamics were well compensated.

RESULTS

Adverse events consisted of 38 (41.3%) hemolysis, 30 (32.6%) major infection, 27 (29.3%) major bleeding (6 [6.5%] with gastrointestinal bleeding), and 18 (19.6%) neurologic dysfunction events. Eighteen patients underwent heart transplantation (HTx) after an average of 32.9 ± 8.9 months of VAD support, and overall survival at both 6 months and 3 years was 96.3%.

CONCLUSION

Clinical outcome among patients with HM-II at our institution is satisfactory for both survival and adverse events. The HM-II can provide effective hemodynamic support during the extremely long waiting period for HTx in Japan.

Prospects for observing and localizing gravitational-wave transients with Advanced LIGO, Advanced Virgo and KAGRA

We present possible observing scenarios for the Advanced LIGO, Advanced Virgo and KAGRA gravitational-wave detectors over the next decade, with the intention of providing information to the astronomy community to facilitate planning for multi-messenger astronomy with gravitational waves. We estimate the sensitivity of the network to transient gravitational-wave signals, and study the capability of the network to determine the sky location of the source. We report our findings for gravitational-wave transients, with particular focus on gravitational-wave signals from the inspiral of binary neutron star systems, which are the most promising targets for multi-messenger astronomy. The ability to localize the sources of the detected signals depends on the geographical distribution of the detectors and their relative sensitivity, and [Formula: see text] credible regions can be as large as thousands of square degrees when only two sensitive detectors are operational. Determining the sky position of a significant fraction of detected signals to areas of 5-[Formula: see text] requires at least three detectors of sensitivity within a factor of [Formula: see text] of each other and with a broad frequency bandwidth. When all detectors, including KAGRA and the third LIGO detector in India, reach design sensitivity, a significant fraction of gravitational-wave signals will be localized to a few square degrees by gravitational-wave observations alone.

Evidence for magnetic Weyl fermions in a correlated metal

Weyl fermions have been observed as three-dimensional, gapless topological excitations in weakly correlated, inversion-symmetry-breaking semimetals. However, their realization in spontaneously time-reversal-symmetry-breaking phases of strongly correlated materials has so far remained hypothetical. Here, we report experimental evidence for magnetic Weyl fermions in Mn₃Sn, a non-collinear antiferromagnet that exhibits a large anomalous Hall effect, even at room temperature. Detailed comparison between angle-resolved photoemission spectroscopy (ARPES) measurements and density functional theory (DFT) calculations reveals significant bandwidth renormalization and damping effects due to the strong correlation among Mn 3d electrons. Magnetotransport measurements provide strong evidence for the chiral anomaly of Weyl fermions-namely, the emergence of positive magnetoconductance only in the presence of parallel electric and magnetic fields. Since weak magnetic fields (approximately 10 mT) are adequate to control the distribution of Weyl points and the large fictitious fields (equivalent to approximately a few hundred T) produced by them in momentum space, our discovery lays the foundation for a new field of science and technology involving the magnetic Weyl excitations of strongly correlated electron systems such as Mn₃Sn.

Appropriate hinge position for prevention of unstable lateral hinge fracture in open wedge high tibial osteotomy

AIMS

Open wedge high tibial osteotomy (OWHTO) for medial-compartment osteoarthritis of the knee can be complicated by intra-operative lateral hinge fracture (LHF). We aimed to establish the relationship between hinge position and fracture types, and suggest an appropriate hinge position to reduce the risk of this complication.

PATIENTS AND METHODS

Consecutive patients undergoing OWHTO were evaluated on coronal multiplanar reconstruction CT images. Hinge positions were divided into five zones in our new classification, by their relationship to the proximal tibiofibular joint (PTFJ). Fractures were classified into types I, II, and III according to the Takeuchi classification.

RESULTS

Among 111 patients undergoing OWHTOs, 22 sustained lateral hinge fractures. Of the 89 patients without fractures, 70 had hinges in the zone within the PTFJ and lateral to the medial margin of the PTFJ (zone WL), just above the PTFJ. Among the five zones, the relative risk of unstable fracture was significantly lower in zone WL (relative risk 0.24, confidence interval 0.17 to 0.34).

CONCLUSION

Zone WL appears to offer the safest position for the placement of the osteotomy hinge when trying to avoid a fracture at the osteotomy site. Cite this article: Bone Joint J 2017;99B10:1313-18.