Prognostic Value of Galectin-3 after Left Atrial Appendage Occlusion for Predicting Peri-Device Leakage

Echocardiographic detection of residual peri-device leakage (PDL) after percutaneous left atrial appendage occlusion (LAAO) is crucial for managing anticoagulation. Galectin-3, a protein involved in tissue-foreign body interactions, may hold significance in understanding PDL and cardiac tissue remodeling after LAAO. This study aimed to analyze galectin-3 serum levels in relation to PDL using a novel echo-morphological classification. LAAO eligible patients were included in the study. Galectin-3 serum levels were measured before LAAO, at 45 days (45D), and at 6 months (6M) after the procedure. Transesophageal echocardiography was used to assess LAAO success. A new echo-morphological classification categorized the degree of LAAO into three different types (A: homogenous echodensity, indicating completely thrombosed device; B: inhomogeneous echolucencies (<50% of device); and C: partially thrombosed device with echolucencies > 50%). Among 47 patients, complete LAAO was achieved in 60% after 45D and in 74% after 6M. We observed a significant increase and distribution of serum levels of galectin-3 [ng/mL] after 45D among the three types (baseline: 13.1 ± 5.8 ng/mL; 45D: 16.3 ± 7.2 ng/mL (Type A) vs. 19.2 ± 8.6 ng/mL (Type B) vs. 25.8 ± 9.4 ng/mL (Type C); p = 0.031), followed by a drop in galectin-3 for Types A and B after 6M toward and below the baseline levels (6M: 8.9 ± 3.1 ng/mL (Type A) vs. 12.4 ± 5.5 ng/mL (Type B)), whereas Type C persisted in showing elevated galectin-3 levels compared to all other types (6M: 17.5 ± 4.5 ng/mL (Type C); p < 0.01). Increased galectin-3 serum levels after LAAO likely reflect the transition from thrombus formation to fibrotic scar development in the LAA lumen. Successful occlusion is associated with a time-restricted decrease in galectin-3 levels after 6 months, while relevant PDL leads to persistently elevated levels, making galectin-3 a potential predictor of occlusion success.

Use of Autotransfusion following Percutaneous Thrombectomy for Cardiogenic Shock Due to Pulmonary Embolism in a Single Session-A Case Report

A 64-year-old male patient was admitted to the catheterization laboratory with a suspected myocardial infarction and in cardiogenic shock. Upon further investigation, a massive bilateral pulmonary embolism with signs of right heart dysfunction was discovered, leading to a decision to perform a direct interventional treatment with a thrombectomy device for thrombus aspiration. The procedure was successful in removing almost the entirety of the thrombotic material from the pulmonary arteries. The patient's hemodynamics stabilized and oxygenation improved instantly. The procedure required a total of 18 aspiration cycles. Each aspiration contained approx. 60 mL blood amounting to a total of approx. 1080 mL of blood. During the procedure, a mechanical blood salvage system was used to resupply 50% of the blood via autotransfusion that would otherwise have been lost. The patient was transferred to the intensive care unit for post-interventional care and monitoring. A CT angiography of the pulmonary arteries after the procedure confirmed the presence of only minor residual thrombotic material. The patient's clinical, ECG, echocardiographic, and laboratory parameters returned to normal or near normal ranges. The patient was discharged shortly after in stable conditions on oral anticoagulation.

Prognostic relevance of mitral regurgitation at different follow-up timepoints after transcatheter aortic valve implantation (TAVI): implications for therapeutic decision making?

Background

Transcatheter aortic valve implantation (TAVI) has developed rapidly in the last decade and is now recommended as state-of-the-art treatment for elderly patients suffering from severe symptomatic degenerative aortic stenosis (AS). The extent of mitral regurgitation (MR) following TAVI is likely to be of prognostic relevance. This raises the question whether treating MR following TAVI improves outcome of patients with significant MR.

Purpose

The current study was aimed to elucidate the prognostic value of MR at different follow-up (FU) timepoints after TAVI in a prospective real-world single-center registry study.

Methods

A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included and a wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed. Mortality was recorded at 30 days, 1 year and 2 years after TAVI. Complete FU data including echocardiography were available at 6 to 8 weeks (n=334) as well as 6 months (n=235) after TAVI.

Results

All patients (mean age: 78.7±7.3 years, 52% female, mean STS score: 5±3.9%) were successfully treated by transfemoral TAVI using balloon- or self-expanding prostheses and showed mortality rates of 3.6% after 30 days, 16.4% after 1 year and 22.6% after 2 years. Moderate or severe (relevant) MR was detectable in 39% of the patients at baseline, in 27% of patients after 6 weeks (p=0.001) and in 28% of patients after 6 months (p=0.036, compared to baseline). Multivariate analysis identified independent predictors of 2-year mortality: clinical frailty scale and PAPsys at 6 to 8 weeks post-TAVI as well as BNP and relevant MR 6 months post TAVI. Among those parameters, MR after 6 months was the strongest predictor of long-term mortality (OR 3.192, CI 0.971–10.487, p=0.056). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant MR at 6 months (12.1% versus 4.8%, p=0.042).

Conclusions

Taken together, this real-life single-center experience underlines the prognostic value of relevant MR 6 months after TAVI with respect to long-term survival. Interestingly, MR was not predictive at the 6 to 8 weeks FU suggesting that early remodeling includes MR with prognostic relevance in those patients. Whether MR treatment, e.g., by transcatheter edge-to-edge repair, will improve patient outcomes post-TAVI has to be tested in prospective trials.

Funding Acknowledgement

Type of funding sources: None.

Tricuspid regurgitation and atrial fibrillation at baseline independently predict two-year survival after transcatheter aortic valve implantation (TAVI)

Background

Transcatheter aortic valve implantation (TAVI) is the accepted state-of-the-art treatment for elderly patients suffering from severe symptomatic aortic stenosis (AS). Co-morbidities at baseline are of great impact not only for individual peri-procedural risk stratification but also for the determination of long-term prognosis. The latter is of certain clinical interest, since a variety of co-existing disorders can be effectively treated in addition to TAVI.

Purpose

The current study aimed to elucidate the prognostic value of a wide range of baseline characteristics and co-morbidities with respect to long-term survival of TAVI patients in a prospective real-world single-center registry study.

Methods

A total of 445 patients with severe AS, which were treated by transfemoral TAVI, were included. A wide range of clinical, laboratory, functional and imaging parameters were prospectively assessed at baseline prior to TAVI. Mortality was recorded at 30 days, 1 year and 2 years after TAVI.

Results

The mean age of patients in this typical TAVI cohort was 78.7±7.3 years, 52% were female and the mean STS score was 5±3.9%. The mortality rates were as follows: 3.6% after 30 days, 16.4% after 1 and 22.6% after 2 years. Multivariate analysis could identify the following independent predictors of 2-year mortality assessed at baseline: sex, age, AS entity other than high-gradient, atrial fibrillation (Afib), renal function, relevant TR, systolic pulmonary artery pressure (PAPsys) and six-minute walk distance (SMWD). Among those, the strongest predictive value could be shown for Afib (OR 2.505, CI 1.509–4.157, p&lt;0.001) and TR (OR 2.179, CI 1.105–4.299, p=0.025). Kaplan-Meier survival analysis displayed significantly worse 2-year survival rates in patients suffering from relevant TR (31.6% versus 17.4%, p&lt;0.001) and Afib (29.4% versus 14.8%, p&lt;0.001).

Conclusions

Taken together, the results of the current study demonstrate the prognostic value of cardiovascular co-morbidities assessed prior to TAVI. We identified relevant TR and Afib as the strongest independent predictors of long-term mortality in our cohort. Since both conditions are effectively treatable, special emphasis should be placed on the question, which patient might benefit from treatment, e.g., by transcatheter edge-to-edge repair of TR or rhythm control, in addition to TAVI.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Else Kröner-Fresenius-Stiftung, Research Program “Else Kröner-Forschungskolleg AntiAge”

Rationale and Design of JenaMACS-Acute Hemodynamic Impact of Ventricular Unloading Using the Impella CP Assist Device in Patients with Cardiogenic Shock

INTRODUCTION

Cardiogenic shock due to myocardial infarction or heart failure entails a reduction in end organ perfusion. Patients who cannot be stabilized with inotropes and who experience increasing circulatory failure are in need of an extracorporeal mechanical support system. Today, small, percutaneously implantable cardiac assist devices are available and might be a solution to reduce mortality and complications. A temporary, ventricular, continuous flow propeller pump using magnetic levitation (Impella^®) has been approved for that purpose.

METHODS AND STUDY DESIGN

JenaMACS (Jena Mechanical Assist Circulatory Support) is a monocenter, proof-of-concept study to determine whether treatment with an Impella CP^® leads to improvement of hemodynamic parameters in patients with cardiogenic shock requiring extracorporeal, hemodynamic support. The primary outcomes of JenaMACS are changes in hemodynamic parameters measured by pulmonary artery catheterization and changes in echocardiographic parameters of left and right heart function before and after Impella^® implantation at different support levels after 24 h of support. Secondary outcome measures are hemodynamic and echocardiographic changes over time as well as clinical endpoints such as mortality or time to hemodynamic stabilization. Further, laboratory and clinical safety endpoints including severe bleeding, stroke, neurological outcome, peripheral ischemic complications and occurrence of sepsis will be assessed. JenaMACS addresses essential questions of extracorporeal, mechanical, cardiac support with an Impella CP^® device in patients with cardiogenic shock. Knowledge of the acute and subacute hemodynamic and echocardiographic effects may help to optimize therapy and improve the outcome in those patients.

CONCLUSION

The JenaMACS study will address essential questions of extracorporeal, mechanical, cardiac support with an Impella CP^® assist device in patients with cardiogenic shock. Knowledge of the acute and subacute hemodynamic and echocardiographic effects may help to optimize therapy and may improve outcome in those patients.

ETHICS AND DISSEMINATION

The protocol was approved by the institutional review board and ethics committee of the University Hospital of Jena. Written informed consent will be obtained from all participants of the study. The results of this study will be published in a renowned international medical journal, irrespective of the outcomes of the study. Strengths and Limitations: JenaMACS is an innovative approach to characterize the effect of additional left ventricular mechanical unloading during cardiogenic shock via a minimally invasive cardiac assist system (Impella CP^®) 24 h after onset and will provide valuable data for acute interventional strategies or future prospective trials. However, JenaMACS, due to its proof-of-concept design, is limited by its single center protocol, with a small sample size and without a comparison group.

Interventional Treatment of Access Site Complications During Transfemoral TAVI: A Single Center Experience

Introduction: Transcatheter aortic valve implantation (TAVI) has rapidly developed over the last decade and is nowadays the treatment of choice in the elderly patients irrespective of surgical risk. The outcome of these patients is mainly determined not only by the interventional procedure itself, but also by its complications. Material and Methods: We analyzed the outcome and procedural events of transfemoral TAVI procedures performed per year at our institution. The mean age of these patients is 79.2 years and 49% are female. All the patients underwent duplex ultrasonography of the iliac arteries and inguinal vessels before the procedure and CT of the aorta and iliac arteries. Results: Transfemoral access route is associated with a number of challenges and complications, especially in the patients suffering from peripheral artery disease (PAD). The rate of vascular complications at our center was 2.76% (19/689). Typical vascular complications (VC) include bleeding and pseudoaneurysms at the puncture site, acute or subacute occlusion of the access vessel, and dissection or perforation of the iliac vessels. In addition, there is the need for primary PTA of the access pathway in the presence of additional PAD of the common femoral artery (CFA) and iliac vessels. Balloon angioplasty, implantation of covered and uncovered stents, lithoplasty, and ultrasound-guided thrombin injection are available to treat the described issues. Conclusion: Interventional therapy of access vessels can preoperatively enable the transfemoral approach and successfully treat post-operative VC in most of the cases. Training the heart team to address these issues is a key focus, and an interventional vascular specialist should be part of this team.

Crucial role of extra-domain A containing fibronectin for the development of pulmonary hypertension and associated right heart failure

Background

Pulmonary vascular and right ventricular myocardial remodelling are unique phenomena in PH progression. Both processes are accompanied by an abundant re-expression of the extra-domain A of fibronectin (ED-A+ Fn) therefore qualifying as promising biomarker or even therapeutic target. Nevertheless, its functional role in PH pathogenesis remains unclear until now. Objective: The purpose of our study was to analyse the development of PH and RHF in a mouse model of monocrotaline (MCT)-induced PH comparing C57BL/6 ED-A+ Fn knockout (KO) and wild-type (WT) mice.

Methods

PH was induced by subcutaneous injection of a single dose of MCT (60 mg/kg body weight). Subgroups were additionally treated with the dual endothelin receptor antagonist Macitentan (MAC, 15mg/kg body weight per day from day 14 to 28). There were 6 experimental groups: sham-treated control WT mice (WTco, n=4); MCT induced PH WT mice (WTPH, n=6); MCT induced PH WT mice treated with MAC (WTPH_MAC, n=6); sham-treated control KO mice (KOco, n=4); MCT induced PH KO mice (KOPH, n=6); MCT induced PH KO mice treated with MAC (KOPH_MAC, n=6). Between day 26 and 28, transthoracic echocardiography and right heart catheterization were performed. Both, lung and cardiac tissue samples were subjected to histological analyses.

Results

Right heart catheterization revealed significantly increased RVPsys values in WTPH (87.0±16.4mmHg) compared to WTco (36.1±9.4mmHg; p=0.034) animals, which showed, at least in trend, a diminution in the WTPH_MAC group (67.1±20.9mmHg; p=n.s.). There was a non-significant increase in RVPsys in the KOPH (55.6±14.9mmHg) compared to KOco mice (37.2±5.6mmHg; p=n.s.) without any differences compared to the KOPH_MAC group (60.9±14.0mmHg; p=n.s.). When comparing the WTPH and the KOPH group, RVPsys was significantly lower in the KO animals (p=0.014), while there were no differences between the WTPH_MAC and the KOPH_MAC group (p=n.s.). Echocardiographic evaluation including surrogate parameters of right ventricular (RV) overload and failure were significantly altered in WTPH compared to WTco animals (p&lt;0.05) and could not be shown to be relevantly improved in the WTPH_MAC group (p=n.s.). The majority of echocardiographic parameters did not significantly differ between the KOPH and the KOco group (p=n.s.). Lung tissue analysis revealed significant alterations in both, the WTPH and the KOPH group, each compared to the corresponding control (p&lt;0.05). The level of lung tissue damage was significantly decreased in KOPH compared to WTPH mice (p&lt;0.05). In RV, the amount of interstitial fibrosis was increased in the WTPH (p=0.009) but not in the KOPH group (p=n.s.), each compared to the corresponding controls.

Conclusions

The findings of the current study underline the hypothesis that ED-A+ Fn is a key player in the pathogenesis of PH and associated RHF. Thus, it might represent a promising therapeutic target, e.g., by the administration of neutralizing antibodies.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Jena

A novel echocardiographic-derived classification after LAA closure can accurately predict incomplete ostial closure and significant peri-device leaks

Background

The assessment of residual peri-device leaks (PDL) after percutaneous left atrial appendage closure (LAAC) remains crucial in the post-procedural management. Clinical significance of PDL is still poorly understood and echocardiographic recognition of PDL remains challenging. This study aimed to verify a novel proposed echocardiographic classification for prediction of clinically significant PDL following LAAC.

Methods

We retrospectively evaluated our echocardiographic data of 72 patients who underwent percutaneous LAAC at the University Hospital Jena between September 2015 - 2018. All echo images were transferred to a workstation for offline analysis by two independent investigators. Total number of studies was 127. We proposed a morphological classification of LAA devices (Fig. 1A-C) based on the amount of echodensity and luceny inside the devices into three types: type A: homogenous echodensity in 0, 45, 90 and 135°; indicating completely thrombosed device, type B with inhomogeneous echo-lucencies (&lt;50% of device) and type C: partially thrombosed device with echo-lucencies &gt;50% of total, which we labeled “ice-cream cone” sign. Each type was then matched to the degree of PDL and other clinical and paraclinical parameters.

Results

Tab.1 shows patient's characteristics. PDL was found in 21% of patients. Four patients showed regression of PDL after 160 days. Patients with type C had the most percentage of PDL in three types at 6 months follow-up (type A: 7%, type B: 33%, type C 100%, p&lt;0.001). Device size in patients with type C was largest in three types (type A: 25.9±3.6mm, type B: 25.8±3.4mm, type C 29.8±3.0mm, type A vs. B, p=0.018; type B vs. C, p=0.007). Mean compression rate after 45 days was 21±9.3% in type A vs. 14±7.4% in type C (p=0.022). Ice cream sign showed a sensitivity of 53.1%, specificity of 100% and positive predictive value of 100% for prediction of PDL.

Conclusion

Our data demonstrate that: 1) This novel classification irrespective of anticoagulation regimen, can accurately discriminate among various degrees of PDL, in such that type C or “ice cream sign” has a very high positive predictive value for PDL (100%). 2) Type A, the ideal type, is associated with smaller landing zones and a higher compression rate.

Funding Acknowledgement

Type of funding source: None

Improvement in Left Atrial Strain among Patients Undergoing Percutaneous Left Atrial Appendage Closure

Background

Various clinical trials provide evidence about the safety, effectiveness, and therapeutic success of percutaneous left atrial appendage closure (LAAC) using various occlusion devices. These devices are foreign materials implanted into the left atrium and may deteriorate left atrial (LA) function. The aim of this study was to evaluate the change in transesophageal echocardiography (TEE)-derived LA strain after LAAC.

Methods and Results

The study included 95 patients (age: 75 ± 6.7 years, 67% male) who underwent percutaneous LAAC. LA strain was evaluated at three different time intervals by TEE (baseline, 45 days, and 180 days after the procedure). All data were analyzed using the software Image-Arena (TomTec^®). Seventy patients had atrial fibrillation, whereas 25 were in sinus rhythm at baseline and during follow-up. Analysis was performed for peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) from segments of the lateral wall in mid-esophageal four-chamber view. PACS was obtained in patients with sinus rhythm during examinations. Compared to baseline, PALS increased at 45 days after the procedure (12.4% ± 8.4% at baseline vs. 16.0% ± 10.6% after 45 days, P = 0.001) and remained stable from 45 days to 180 days after procedure (13.8% ± 9.1% after 45 days vs. 17.2% ± 12.6% after 180 days, P = 0.092). Similarly, PACS increased at 45 days after the procedure (5.8% ± 3.9% at baseline vs. 10.6% ± 7.6% after 45 days, P = 0.001) and remained stable from 45 days to 180 days after the procedure (7.6% ± 4.5% after 45 days vs. 7.9% ± 3.1% after 180 days, P = 0.876).

Conclusions

Our study demonstrated for the first time the improvement in TEE-derived LA strain following LAAC within 45 days of implantation. The findings suggest improved LA function following LAAC.

P3731The improvement in left atrial strain among patients undergoing percutaneous left atrial appendage closure

Background

Percutaneous left atrial appendage closure (LAAC) is being established as an alternative option for atrial fibrillation (AF) patients with high bleeding risk. Few studies reported the influence of percutaneous LAAC on left atrial (LA) performance, but most of the studies demonstrated no remarkable changes in their parameters after the procedure.

Method

The study included 95 patients (age: 75±6.7 years, 67% male) whom underwent percutaneous LAAC in a single center between September 2012 and November 2018. LA strain was evaluated at three different time intervals by transesophageal echocardiography (baseline, 45 days and 180 days after procedure). All data were analyzed using a dedicated. 70 patients had atrial fibrillation whereas 25 were in sinus rhythm. Analysis was performed for peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) from segment of lateral wall in mid-esophageal 4 chamber view. The validity of lateral wall left atrial analysis was recently shown by our group. PACS was obtained in patients with sinus rhythm during exams.

Results

Compared to baseline, PALS was significantly increased after 45 days (12.4±8.4% vs 16.0±10.7%, p=0.001) and remained stable after 180 days (13.8±9.0% vs 17.0±12.4%, p=0.098). Even in only patients with atrial fibrillation during exams, it was increased (10.8±7.7% vs 13.4±7.1%, p=0.012 and 8.5±5.1% vs 13.9±8.1%, p=0.014). Similarly, compared with the baseline, PACS was significantly increased after 45 days and 180 days (5.8±3.9% vs 10.6±7.6%, p=0.001 and 4.5±2.6% vs 7.9±3.1%, p=0.036).

The Changes in PALS and PACS

Conclusion

Our study has demonstrated for the first time the improvement in LA strain following LAAC within 45 days of implantation by transesophageal echocardiography and these values were maintained at least for 6 months. Further appraisal is warranted for confirmation of these preliminary findings.

P5579Pre-existing depression significantly improves after transcatheter aortic valve implantation (TAVI): analysis of long-term effects and screening for novel biomarkers

Background and aims

Depression negatively affects symptom tolerance as well as clinical endpoints in cardiovascular diseases. For aortic stenosis (AS) patients undergoing Transcatheter Aortic Valve Implantation (TAVI), a reduction of pre-existing depression and anxiety in short term follow-up could be recently shown by our group. The current study was aimed to evaluate these effects in long-term follow-up and to screen for promising biomarkers, e.g., 5-Hydroxytryptamin (5-HT), Endothelin-1 (ET-1), neutrophil gelatinase associated lipocalin (NGAL) and Tenascin-C (Tn-C) variants. These molecules might reflect a pathophysiological link between reverse cardiac remodelling and mental state.

Methods

The study included 182 out of 226 patients who underwent TAVI at the University Hospital Jena since August 2016. Besides clinical parameters, the EuroQol questionnaire (EQ-5D), the Visual Analog Scale (VAS), the Clinical Frailty Scale (CFS) and, to specifically detect depression and anxiety, the Hospital Anxiety and Depression Scale (HADS-D) were assessed directly before TAVI, at 6-weeks, 6-month as well as 12- months follow-up. Blood samples were withdrawn before TAVI and during 6-weeks and 6-month follow-up.

Results

Study patients represented a typical moderate- to high-risk TAVI collective (n=182, mean age 78,1±7.9 years, 46,9% male, mean STS-Score 4.6±2,8). Before TAVI, analysis of HADS revealed ≥8 points, defined as pathologic, for depression and/or anxiety in 71 patients (39%) and for depression only in 46 patients (25.3%). In the depressive subgroup, there was a significant improvement after 6 weeks for depression (p<0.001) and anxiety (p=0.006). BNP serum levels were significantly reduced (p=0.007) and 6-minutes' walk distance was significantly increased from a low level (p=0.008), VAS, CFS and 2 out of 5 parameters of the EQ-5D were significantly improved (p<0.05). All observed short-term effects continued at stable levels over time. A pre-existing depression state was not associated with an increased long-term mortality rate, which was 14.8%. Circulating biomarker levels in depressive patients before and 6 weeks after TAVI revealed no significant differences. At the 6 months follow-up, only for C+ Tn-C there was a significant increase compared to both, the timepoint before TAVI (p=0.046) and the 6 weeks follow-up (p=0.033).

Conclusions

Already in short-term follow-up after successful TAVI, a remarkable decrease in depression could be detected using HADS. Especially in the depressive subgroup, the patients showed benefit also with respect to other surrogate parameters of mental health and functional performance. Interestingly, these effects were completely maintained not only in mid-term but also in long-term follow-up. We could show that the improvement of depression after TAVI is reflected by a delayed decrease of C+ Tn-C serum levels. C+ Tn-C can be suggested as promising biomarker possibly linked to reactive depression in somatic diseases.

P6345Chronic cardiac allograft rejection after heterotopic rat heart transplantation: ed-a but not ed-b domain containing fibronectin as novel serum biomarker of cardiac allograft vasculopathy

Background and aims

Diagnosis of Cardiac Allograft Vasculopathy (CAV) following heart transplantation (HTX) is still challenging but of prognostic relevance. Thus, the identification of biomarkers non-invasively detecting the disease is an hitherto unmet clinical need. Fetal variants of the cell adhesion modulating protein Fibronectin (Fn) could be proven to re-occur in the context of chronic rejection in rat and human cardiac tissue after HTX in spatial association to CAV and fibrosis. This study was aimed to determine serum levels of fetal Fn variants in a heterotopic rat HTX model of chronic rejection.

Methods

Chronic cardiac allograft rejection was induced by heterotopic rat HTX using inbred male Lewis (LEW) rats as donors and Fisher (F344) rats as recipients (n=24). After microsurgical modifications, the allograft was implanted into the abdomen of the recipient animal. Rats were sacrificed after 70 days. Untreated F344 rats were used as controls (n=6). Cardiac tissue was subjected to histological analysis according to a recently established sum-score system between 0 and 10 (0 = no detectable rejection; 1 to 3 = weak rejection; 4 to 7 = moderate rejection; and 8 to 10 = severe rejection). The score includes all relevant parameters of chronic rejection (CAV, lymphocyte infiltration, cardiomyocyte degeneration, fibrosis). Brain natriuretic peptide (BNP) was determined by a commercially available ELISA. Serum levels of both, ED-A domain containing Fn (ED-A+ Fn) and ED-B domain containing Fn (ED-B+ Fn) were quantified using ELISA protocols established in our group.

Results

Final experiments were performed on day 70, mortality rate was 0%. Histological analysis revealed a chronic cardiac allograft rejection in all transplanted animals (mean sum-score 6.92±1.94) while controls did not exhibit relevant alterations (mean sum-score 0.1±0.2; p<0.001). There were significantly elevated BNP levels in HTX rats (76.16±23.22 pg/ml) compared to controls (352.23±132.09 pg/ml; p<0.001). BNP showed a strong positive correlation to the histological sum-score (r=0.653; p<0.001). Serum levels of ED-A+ Fn (HTX: 34.42±11.4 μg/ml, controls: 17.3±6.13 μg/ml; p=0.009) but not ED-B+ Fn (HTX: 8.58±4.12 μg/ml, controls: 9.4±2.61 μg/ml; p=0.804) were significantly increased in HTX rats qualifying ED-A+ Fn for further analysis with respect to histological signs of chronic rejection. Interestingly, there is a noticeable association to the occurrence of CAV representing 1 out of 4 parameters included in the histological sum-score (r=0.51; p=0.006).

Conclusions

Chronic cardiac allograft rejection and, in particular, CAV as major long-term prognosis-limiting factor after HTX are accompanied by both, a re-expression and vessel associated tissue deposition of ED-A+ Fn and also a relevant liberation into blood. These results underline the potential impact of ED-A+ Fn as biomarker or potential therapeutic target patients that underwent HTX.

P917Transcatheter treatment of severe tricuspid regurgitation: first experiences with the edge-to-edge technique using the MitraClip

Background

Due to increased operative mortality in high-risk patients treated for severe tricuspid regurgitation (TR), there is a growing interest in interventional therapy in these patients that are otherwise solely treated with medication. The edge-to edge technique with implantation of one or more MitraClips is an therapeutic interventional option for these patients. So far, data for transcatheter TR treatment are sparse.

Purpose

The present cohort study investigates safety, feasibility and effectiveness of the edge-to-edge technique treating severe TR after starting a transcatheter TR treatment program at our institution in 2017.

Methods

A total of 17 high-risk patients (79.18±8.76 years, EUROScore II 9.31±8.23%, table) with symptomatic, severe TR were treated using the MitraClip system from 12/2017 until 12/2018. All patients received pre-interventional clinical, echocardiographic and invasive evaluation and were entered into a database. Safety and feasibility of the procedure, reduction of TR grade and clinical outcomes were collected and analyzed at the day of discharge and at 30-day follow-up.

Results

MitraClip device was successfully implanted in 16 of 17 patients (94.1%). In one patient grasping of the leaflets was impossible due to bad echo conditions by abdominal air. 76.5% of the patients had severe or massive and 23.5% had a torrential TR (figure). A total of 25 Clips were used (22 in anteroseptal, 3 in posteroseptal commissure). No intraprocedural deaths, emergency surgery or major vascular complications occurred. Postprocedural TR was significantly reduced (TR reduction ≥1 grade) from a mean TR grade of 3.8±0.8 at baseline to 1.74±0.59 postprocedural (p<0.001, table and figure). One patient had device detachment before discharge. There was one death due to progressive cardiogenic shock 4 days after the procedure. However, the procedure was planned as a last therapeutic option in this terminally ill patient. Echocardiography at discharge showed reduction of TR in 82,4% of patients (mean TR grade at discharge 2.21±0.66, p<0.001). At 30 day f/u symptoms were significantly improved from inital mean NYHA class of 3.06±0.56 to a mean NYHA class of 2.55±0.52 (p=0.002) and patients presented with reduced TR (mean TR grade at 30 day f/u 2.58±0.57, p<0.001).

Conclusion

Interventional treatment of severe TR in high-risk and mostly inoperable patients using the MitraClip technique is safe and effectivly reduces TR grade leading to clinical improvement. However, further investigations are needed to identify clear parameters highly predictive for a favorable acute and midterm procedural success. Also, more data and clinical trials are needed to determine the long-term course in these patients.

RISING SUN: Prioritized Outcomes for Suicide Prevention in the Arctic

The Arctic Council, a collaborative forum among governments and Arctic communities, has highlighted the problem of suicide and potential solutions. The mental health initiative during the United States chairmanship, Reducing the Incidence of Suicide in Indigenous Groups: Strengths United Through Networks (RISING SUN), used a Delphi methodology complemented by face-to-face stakeholder discussions to identify outcomes to evaluate suicide prevention interventions. RISING SUN underscored that multilevel suicide prevention initiatives require mobilizing resources and enacting policies that promote the capacity for wellness, for example, by reducing adverse childhood experiences, increasing social equity, and mitigating the effects of colonization and poverty.

The effect on pCR of bevacizumab and/or antimetabolites added to standard neoadjuvant chemotherapy: NSABP protocol B-40

LBA1005

Background: The addition of capecitabine (X), gemcitabine (G), and bevacizumab (B) to taxanes have each improved PFS in metastatic breast cancer. The primary aims of this trial were to determine if adding X or G to docetaxel (T) → AC will increase breast pathologic complete response (pCR) rates in operable, HER2-negative breast cancer and if adding B to T-based regimens →AC will increase pCR rates. Secondary aims included assessment of clinical complete response (cCR) rates. Methods: Pts received one of 3 T-based regimens, with or without B, 15mg/kg, q3wks x 4: T 100 mg/m2 day 1; T 75 mg/m2 day 1 and X 825 mg/m2 BID days 1-14; or T 75 mg/m2 day 1 and G 1000 mg/m2 days 1 and 8. Pts then received preoperative AC x 4, with or without B for the initial 2 cycles of AC. Pts randomized to B resumed B for 10 postop doses. The primary endpoint was pCR in the breast. The maximum of the standardized pairwise differences between pCR rate for the T → AC regimen and for the other 2 T-based regimens was used as the test statistic to adjust for multiple comparisons. Fisher’s exact test was used to compare the arms with and without B. Results: The groups were balanced, with 47% clinically node+, 56% poorly differentiated, and 59% HR+. Assessments for pCR were available from 1180 of 1206 randomized patients. pCR for TX and TG were 29.7% and 32% vs. 32.7% for T. Neither TX nor TG increased cCR rates relative to T (58.3% and 60.4% vs. 61.5%). TX and TG increased toxicity. Addition of B increased the pCR rate (28.4 vs. 34.5%, p=0.027) and the cCR rate (55.8 vs. 64.3%, p=0.007). The effect of B was predominantly in the HR+ subset (15.2 vs. 23.3%, p=0.008) with minimal effect in the HR- subset (47.3% vs. 51.3%, p=0.44). Grades 2/3/4 toxicities increased with B were HTN (1/<1/0% vs. 13/9/<1%), HFS (11/7/0% vs. 15/11/0%), and mucositis (10/3/0% vs. 20/5/0%). Conclusions: The addition of B to neoadjuvant chemotherapy improved pCR and cCR rates, but the addition of X or G to T did not improve outcomes. Follow-up for wound healing issues and DFS will help define the role of B in the treatment of early breast cancer. Funded by NCI PHS grants U10-CA-37377, U10-CA-69974, U10-CA-12027, U10-CA-69651, and U10-CA-44066, and F. Hoffmann La-Roche, Ltd., Genentech, USA, and Eli Lilly.

Survey of disease and treatment-related symptoms in outpatients with invasive cancer of the breast, prostate, lung, or colon/rectum (E2Z02, the SOAPP study)

9619

Background: The full spectrum and impact of symptoms experienced by ambulatory patients (pts) in medical oncology clinics throughout their care trajectory is poorly understood. Methods: This large prospective study by the Eastern Cooperative Oncology Group (ECOG) enrolled pts with invasive cancer of the breast, prostate, colon/rectum or lung regardless of phase of care or stage of disease. The study was conducted between 3/06 and 5/08 at multiple academic (n=7) and community (n=32) medical oncology clinics. Pre-defined sampling algorithms were used to reduce selection bias. At baseline and again 4 weeks later, pts completed a 25-item measure of symptoms and functional interference (M.D. Anderson Symptom Inventory-ECOG). Patients’ providers simultaneously prioritized their symptoms. Results: 3124 patients were enrolled (90% from community clinics) and 3077 were analyzable with 1524 breast (50%), 715 colorectal (23%), 518 lung (17%), and 320 prostate (10%) pts. The most prevalent moderate-to-severe symptoms of the full cohort at baseline (B) and follow-up (F) were: fatigue (B34% to F32%), disturbed sleep (B27% to F21%), drowsiness (B22% to F21%), hair loss (B20% to F19%), pain (B19% to F18%), dry mouth (B19% to F15%), and numbness/tingling (B19% to F17%). At baseline, 40% of the cohort had at least 3 moderate-to-severe symptoms and 36% had this attribute at follow-up. Clinician perception of symptoms was strongly correlated with patient symptom survey results regardless of disease site, race, or ethnicity. Of the 849 pts receiving anti-cancer treatment for metastatic disease, half had 2 or more metastatic sites with 75% receiving cytotoxic chemotherapy. Clinicians judged lung cancer patients’ symptoms to be the most difficult to manage (p<0.01). Conclusions: Non-pain symptoms, particularly fatigue and sleep disturbance, are a major source of symptom distress in ambulatory medical oncology practice. Overall, symptom burden remains substantial and difficult to resolve. These data will help guide future interventional studies.

No significant financial relationships to disclose.

Randomized phase 2 trial of ketoconazole and ketoconazole/doxorubicin in androgen independent prostate cancer

Eighty-nine patients with progressive prostate cancer despite suppression of testosterone and withdrawal of anti-androgens were studied. This was a relatively advanced population, with 63 of 89 having either osseous metastases (mets) beyond the axial skeleton or visceral mets. Patients were randomly assigned to receive either ketoconazole alone, or ketoconazole with weekly doxorubicin. All patients received replacement hydrocortisone. The primary endpoints were response and survival. Based on PSA reduction criteria (>/= 80% maintained for at least 8 weeks), 14 of 45 patients (31%) in the single-agent ketoconazole arm responded. Sixteen of 44 patients (36%) in the combination ketoconazole/doxorubicin arm responded. There were no important differences between the two treatments in any outcome measure. The median overall survival for all patients was 12.5 months; median time to progression was 3.3 months. Toxicity was significant with both regimens, and more severe in the doxorubicin arm. Fully 20% of patients in each arm discontinued therapy due to intolerable side effects.Each of these regimens is toxic, and produced responses in fewer than half of treated patients. Although the observed median survival does compare favorably with reports from similar cohorts treated in the community, the potential benefit is only modest. In our view, neither of these regimens is sufficiently promising to justify phase 3 evaluation.

Treatment of squamous cell esophageal cancer with topotecan: an Eastern Cooperative Oncology Group Study (E2293)

Seventeen patients with enhanced measurable squamous cell carcinoma of the esophagus were treated with topotecan 1.5 mg/m2 daily for 5 days repeated every 21 days. Toxicity was severe, with 1 death from myelotoxicity and 10 patients with life-threatening myelotoxicity. Severe gastrointestinal toxicity consisting of vomiting was also seen in three patients. No response was seen in any of the patients in the study. Topotecan given in this manner has no activity in squamous cell carcinoma of the esophagus.

Randomized trial of 3-hour versus 24-hour infusion of high-dose paclitaxel in patients with metastatic or locally advanced breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-26

PURPOSE

Paclitaxel is an active drug for the treatment of breast cancer; however, the appropriate duration of administration is unknown. We assessed and compared the response rate, event-free survival, survival, and toxicity of paclitaxel 250 mg/m(2) delivered every 3 weeks as a 3-hour or 24-hour infusion.

PATIENTS AND METHODS

A total of 563 women with stage IV or IIIB breast cancer were randomized into one of two groups: 279 received 3-hour paclitaxel and 284 received 24-hour paclitaxel. Patients were stratified by age, stage of disease, and prior therapy.

RESULTS

A significantly higher rate of tumor response occurred in the first four cycles of therapy in patients who received the 24-hour infusion of paclitaxel (51% v 41%, respectively; P =.025). Tumor response over all cycles was also significantly higher in the group that received 24-hour infusion (54% v 44%, respectively; P =.023). There were no significant differences in event-free survival or survival between the two arms of the study (P =.9 and.8, respectively). No treatment by stage or by age interactions were observed. During the first four cycles of therapy, at least one episode of >/= grade 3 toxicity (excluding nadir hematologic values, alopecia, and weight change) occurred in 45% of patients who received the 3-hour paclitaxel infusion and in 50% of those who received the 24-hour paclitaxel infusion. Febrile neutropenia, >/= grade 3 infection, and >/= grade 3 stomatitis were less frequent, and severe neurosensory toxicity was more frequent in those who received the 3-hour paclitaxel infusion. Ten treatment-related deaths occurred in the first four cycles. Age, stage, and prior chemotherapy did not influence the effect of treatment.

CONCLUSION

When administered as a continuous 24-hour infusion, high-dose paclitaxel results in a higher tumor response rate than when administered as a 3-hour infusion but does not significantly improve event-free survival or survival. Paclitaxel as a 24-hour infusion results in increased hematologic toxicity and decreased neurosensory toxicity.

Spanish language translation and initial validation of the functional assessment of cancer therapy quality-of-life instrument

OBJECTIVES

There is a need in the United States for culture-equivalent assessment of health-related quality of life, particularly among people who speak different languages and among those with low literacy skills. This report summarizes the adaptation of the Functional Assessment of Cancer Therapy (FACT) Scales for use with Spanish-speaking cancer patients, including those with low literacy.

METHODS

The Spanish language version of the general Functional Assessment of Cancer Therapy scale plus five disease-specific subscales (breast, lung, colorectal, head and neck, HIV infection) were translated, reviewed, and revised, then evaluated in interviews with Spanish-speaking patients from the mainland United States and Puerto Rico. An iterative forward-backward-forward sequence of item translation, expert bilingual/bicultural advisor review, pretesting interviews with 92 patients, and further expert advisory input were used to establish semantic, content, and partial technical equivalence.

RESULTS

The Functional Assessment of Cancer Therapy-General and five disease-specific subscales were translated successfully into wording that was easily understood and answered, leading to psychometric and scoring data similar to that of the English version. All but one of the 28 Functional Assessment of Cancer Therapy-General items and all of the disease-specific items were seen as culturally relevant. The result is a document that underwent iterative forward-backward translation and evaluation and was pretested successfully with native Spanish-speaking oncology patients living in the Central United States and Puerto Rico.

CONCLUSIONS

The Functional Assessment of Cancer Therapy-General and five disease-specific subscales have been translated successfully into Spanish using a thorough translation and initial validation methodology. The methods and data provide a model for preparing a health status questionnaire for cross-cultural validation. The questionnaire is available for use in clinical trials and clinical practice.

Pain and treatment of pain in minority patients with cancer. The Eastern Cooperative Oncology Group Minority Outpatient Pain Study

BACKGROUND

Clinics that primarily see members of ethnic minority groups have been found to provide inadequate treatment of cancer-related pain. The extent of undertreatment of pain in these patients and the factors that contribute to undertreatment are not known.

OBJECTIVES

To evaluate the severity of cancer-related pain and the adequacy of prescribed analgesics in minority outpatients with cancer.

DESIGN

Prospective clinical study.

SETTING

Eastern Cooperative Oncology Group.

PATIENTS

281 minority outpatients with recurrent or metastatic cancer.

MEASUREMENTS

Patients and physicians independently rated severity of pain, pain-related functional impairment, and pain relief obtained by taking analgesic drugs. Analgesic adequacy was determined on the basis of accepted guidelines.

RESULTS

77% of patients reported disease-related pain or took analgesics; 41% of patients reporting pain had severe pain. Sixty-five percent of minority patients did not receive guideline-recommended analgesic prescriptions compared with 50% of non-minority patients (P < 0.001). Hispanic patients in particular reported less pain relief and had less adequate analgesia.

CONCLUSIONS

The awareness that minority patients do not receive adequate pain control and that better assessment of pain is needed may improve control of cancer-related pain in this patient population.

Recent advances in cancer therapy

The treatment of cancer has developed substantially from its conception in the first years of the 20th century. Since the introduction of alkylating agents during second World War, the oncology specialty has markedly grown. In the recent years, new drugs have been approved for the treatment of cancer. Such examples include the taxanes (Docetaxel and Paclitaxel), Vinorelbine, Irinotecan, Topotecan, Gemcitabine and Gliadel. We will discuss these new chemotherapuetic agents, their pharmacology, indications, toxicity and appropriate dosing. There is no doubt that further clinical research is needed to determine the optimal use of these agents.

Phase II study of carboplatin and continuous infusion bleomycin followed by cisplatin and 5-fluorouracil in recurrent head and neck cancer

BACKGROUND

Recurrent squamous cell carcinoma of the head and neck is poorly responsive to most chemotherapy regimens. Carboplatin and bleomycin are effective single agents with non-overlapping toxicity; therefore, we sought to explore the efficacy of this regimen in a phase II study. In the second stage of the study, patients who did not respond to carboplatin and bleomycin were given treatment with cisplatin and 5-fluorouracil (5-FU).

PATIENTS AND METHODS

Patients with recurrent squamous cell carcinoma of the head and neck were treated with carboplatin 400 mg/m2 followed by bleomycin 15 units intravenously as a continuous infusion for 4 days. Patients with no tumor response after 3 cycles of carboplatin and bleomycin were crossed-over to receive cisplatin 100 mg/m2 and 5-FU 1000 mg/m2/day continuous infusion for 5 days.

RESULTS

Among the 20 carboplatin-bleomycin patients evaluable for toxicity, no cases of grade 4 granulocytopenia were reported and grade 3 or 4 thrombocytopenia developed in only three patients. Three partial responses occurred among the 19 patients (16%) [95% C.I. 0% to 32%] evaluable for response to carboplatin-bleomycin. None of the 11 patients crossed-over to cisplatin and 5-FU had a major response.

CONCLUSION

The combination of carboplatin and bleomycin is well tolerated in patients with recurrent head and neck cancer, but the activity does not appear to be superior to the activity of either agent alone. Patients who did not respond to carboplatin and bleomycin were also resistant to the cisplatin and 5-FU regimen.

Phase II study of merbarone (NSC 336628) in patients with advanced gastric carcinoma

Merbarone, 5-(N-phenylcarboxamido)-2-thiobarbituric acid (NSC 336628), is a derivative of barbituric acid and represents a unique class of antineoplastic agents. We treated 16 patients with advanced gastric carcinoma in a phase II study of merbarone. All patients were previously untreated with chemotherapy or biological therapy. The starting dose of merbarone was 1000mg/m2 infused over 24 hr for 5 consecutive days every 21 days. A median of two courses (range, 1-7) was given. None of the patients achieved a complete or partial response; however, 3 patients achieved a transient minor response. Toxicity was mild to moderate in most patients, but 1 patient died of treatment-related neutropenia and sepsis. Our data suggest that merbarone at this dose and schedule is inactive against gastric carcinoma. The evidence of minor response suggests that analog research may be worthwhile to pursue.

Gallium imaging of esophageal carcinoma: increased sensitivity with lateral views of the thorax

Ga-67 imaging has not been very successful in the detection of esophageal carcinoma. In most reports, sensitivity for the primary tumor ranged from 25-61%, but imaging had been done only in anterior and posterior (A-P) projections. We performed gallium scans in 30 patients with esophageal carcinoma, adding lateral views to the routine A-P projections, to study the effect of lateral views on tumor detection. The A-P views detected only 57% of the tumors while the right lateral visualized 89%, and the left lateral detected 100%. Some lesions may be hidden by the sternum and the spine in the routine A-P views. Previous disappointments with Ga-67 imaging of esophageal carcinoma were probably due to this technical factor. Being gallium-avid, esophageal tumors deserve further studies with this agent to determine the role of Ga-67 imaging in this condition. These studies should be performed with multiple views of the thorax or, better yet, with SPECT imaging of the chest, to circumvent the problem of sternum and spine interference.

Thrombotic thrombocytopenic purpura associated with human immunodeficiency virus type 1 (HIV-1) infection

The cases of 14 patients with thrombotic thrombocytopenic purpura admitted to one institution after 1980 were reviewed. Three of the fourteen cases occurred in patients with the acquired immunodeficiency syndrome (AIDS)-related complex and one occurred in a patient with probable human immunodeficiency virus (HIV) infection. The diagnosis in all four cases had been made after 1985. The association of thrombotic thrombocytopenic purpura with HIV infection was judged to be statistically significant on the basis of the proportion of patients with AIDS among the general population of patients admitted to the same institution during the same period. The fact that this association is only now being recognized suggests that there may be a long incubation period for thrombotic thrombocytopenic purpura or that the association is a rare one recognized now only because of the increased number of persons with AIDS.

Reed-Sternberg cells cultured from morphologically unidentifiable precursors in the blood of patients with Hodgkin's disease

In order to examine whether morphologically unidentifiable precursors of Reed-Sternberg cells (RSC) may circulate in the blood of patients with untreated Hodgkin's Disease (HD), mononuclear leukocytes were isolated from the blood of 33 consecutive patients and cultured in soft agar. Abnormal colonies containing multinucleated giant cells developed in the specimens of 12 patients. These cells had the light and electron microscopic appearance of RSC. They were positive for alpha-naphthyl acetate and alpha-naphthyl butyrate esterases, acid phosphatase and lysozyme, bespeaking their monocyte/macrophage lineage. The observations suggest that unidentifiable precursors of RSC could be responsible for hematogenous spread of the disease in some cases. Moreover, since RS-like cells developed in the specimens of 8 patients with stage I and II HD, it may be useful to evaluate whether soft agar colony culture would yield data of prognostic significance in patients with early disease.