Not all uncivil behaviours are equal: exploring responses to incivility in veterinary practice using vignettes

Workplace incivility is considered a common workplace stressor, linked to a range of adverse impacts such as reduced wellbeing. However, there is a lack of research focused on how targets of incivility respond. The current study addresses that gap by examining responses to incivility within veterinary practice. Veterinarians and veterinary nurses (n = 132) evaluated six scenarios depicting two types of incivility (direct e.g. demeaning comments/indirect, for example, ignoring someone) across three instigators (clients, co-workers, senior colleagues), reporting their perception and appraisal of the uncivil behaviour depicted along with potential responses. Direct incivility was linked to responses such as reciprocation, exit, and support seeking, whereas indirect incivility was associated with affiliative and ignoring responses. Negative appraisal of incivility predicted a higher likelihood of exit, avoidance, support seeking and reporting responses. These findings suggest that incivility targets utilise a broad range of response options and adapt their response dependent on the situation.

Recommendations of the Spanish-Portuguese Internal Medicine services in the fight against climate change and environmental degradation

Facing the severity of the impact of climate change and environmental degradation on human health, 32 Internal Medicine societies, colleges, and associations of 29 Spanish and Portuguese-speaking countries issue a consensus document in which they call for the implication of doctors and all health professionals in the global fight against the causes of these changes. This commitment requires the cooperation of health-related organizations, elaboration and implementation of good environmental sustainability practices, greater awareness of professionals and population, promotion of education and research in this area, increasing climate resilience and environmental sustainability of health systems, combating inequalities and protecting the most vulnerable populations, adopting behaviors that protect the environment, and claiming Internal Medicine as a core specialty for empowerment of the health system to respond to these challenges.

Remifentanil for tracheal intubation without neuromuscular blocking drugs in adult patients: a systematic review and meta-analysis

There is increasing interest in the use of short-acting opioids such as remifentanil to facilitate tracheal intubation. The aim of this systematic review was to determine the efficacy and safety of remifentanil for tracheal intubation compared with neuromuscular blocking drugs in adult patients. We conducted a systematic search for randomised controlled trials evaluating remifentanil for tracheal intubation. Primary outcomes included tracheal intubation conditions and adverse events. Twenty-one studies evaluating 1945 participants were included in the analysis. Use of remifentanil (1.5-4.0 μg.kg-1 ) showed no evidence of a difference in tracheal intubation success rate compared with neuromuscular blocking drugs (risk ratio (95%CI) 0.97 (0.94-1.01); six studies; 1232 participants; I2 28%; p = 0.16; moderate-certainty evidence). Compared with neuromuscular blocking drugs, the use of remifentanil (2.0-4.0 μg.kg-1 ) makes little to no difference in terms of producing excellent tracheal intubation conditions (risk ratio (95%CI) 1.16 (0.72-1.87); two studies; 121 participants; I2 31%, p = 0.54; moderate-certainty of evidence). There was no evidence of an effect between remifentanil (2.0-4.0 μg.kg-1 ) and neuromuscular blocking drugs for bradycardia (risk ratio (95%CI) 0.44 (0.01-13.90); two studies; 997 participants; I2 81%; p = 0.64) and hypotension (risk ratio (95%CI) 1.05 (0.44-2.49); three studies; 1071 participants; I2 92%; p = 0.92). However, the evidence for these two outcomes was judged to be of very low-certainty. We conclude that remifentanil may be used as an alternative drug for tracheal intubation in cases where neuromuscular blocking drugs are best avoided, but more studies are required to evaluate the haemodynamic adverse events of remifentanil at different doses.

Daptomycin and Ceftaroline Combination Therapy in Complicated Endovascular Infections Caused by Methicillin-Resistant Staphylococcus epidermidis

Background In complicated endovascular infections by methicillin-resistant Staphylococcus aureus (MRSA) or Staphylococcus epidermidis (MRSE), when first-line therapy with vancomycin (VAN) or daptomycin (DAP) fails, combination therapy with ceftaroline (CFT) and DAP has been shown to be a useful approach as salvage therapy for persistent MRSA bacteremia. Objectives This study aimed to describe experience with daptomycin and ceftaroline combination therapy in MRSE-complicated endovascular infections. Methods A single-center retrospective review of consecutive patients with MRSE-complicated endovascular infections treated with ≥72 hours of DAP+CFT at any time during the course of treatment, from January 1, 2016 to December 31, 2020, at Centro Hospitalar Universitário São João (CHUSJ), Porto, Portugal, was conducted. The exclusion criteria were known resistance to daptomycin or ceftaroline, total time of combination therapy <72 hours and loss to follow-up. Results We identified seven cases that matched our criteria: five endocarditis and two central venous catheter infections. Six patients switched to combination therapy due to treatment failure with first-line agents - three due to persistent bacteremia and three due to progression of infection despite negative blood cultures. Effective surgical source control took one to four weeks to occur. Three patients died during the treatment, one from progression of the disease and two due to another infection. Conclusions We consider the DAP+CFT combination therapy to be a valid and safe therapeutic choice in complicated patients, such as those with severe infection, poor functional status, and impossibility or delay of surgical source control. However, conclusions on the role of combination therapy should be careful due to the low number of patients and the several confounding factors.

Understanding clinical outcomes and factors influencing mortality in intensive care unit patients with COVID-19-associated candidemia

BACKGROUND

During the COVID pandemic, research has shown an increase in candidemia cases following severe COVID infection and the identification of risk factors associated with candidemia. However, there is a lack of studies that specifically explore clinical outcomes and mortality rates related to candidemia after COVID infection.

OBJECTIVES

The aim of this international study was to evaluate the clinical outcomes and identify factors influencing mortality in patients who developed candidemia during their COVID infection.

PATIENTS/METHODS

This study included adult patients (18 years of age or older) admitted to the intensive care unit (ICU) and diagnosed with COVID-associated candidemia (CAC). The research was conducted through ID-IRI network and in collaboration with 34 medical centres across 18 countries retrospectively, spanning from the beginning of the COVID pandemic until December 2021.

RESULTS

A total of 293 patients diagnosed with CAC were included. The median age of the patients was 67, and 63% of them were male. The most common Candida species detected was C. albicans. The crude 30-day mortality rate was recorded at 62.4%. The logistic regression analysis identified several factors significantly impacting mortality, including age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.07, p < .0005), SOFA score (OR 1.307, 95% CI 1.17-1.45, p < .0005), invasive mechanical ventilation (OR 7.95, 95% CI 1.44-43.83, p < .017) and duration of mechanical ventilation (OR 0.98, 95% CI 0.96-0.99, p < .020).

CONCLUSIONS

By recognising these prognostic factors, medical professionals can customise their treatment approaches to offer more targeted care, leading to improved patient outcomes and higher survival rates for individuals with COVID-associated candidemia.

Excited-State Phase Diagram of a Ferromagnetic Quantum Gas

The ground-state phases of a quantum many-body system are characterized by an order parameter, which changes abruptly at quantum phase transitions when an external control parameter is varied. Interestingly, these concepts may be extended to excited states, for which it is possible to define equivalent excited-state quantum phase transitions. However, the experimental mapping of a phase diagram of excited quantum states has not yet been realized. Here we present the experimental determination of the excited-state phase diagram of an atomic ferromagnetic quantum gas, where, crucially, the excitation energy is one of the control parameters. The obtained phase diagram exemplifies how the extensive Hilbert state of quantum many-body systems can be structured by the measurement of well-defined order parameters.

Predictors of early and long-term mortality after ICU discharge in critically ill COVID-19 patients: A prospective cohort study

BACKGROUND

To mitigate mortality among critically ill COVID-19 patients, both during their Intensive Care Unit (ICU) stay and following ICU discharge, it is crucial to measure its frequency, identify predictors and to establish an appropriate post-ICU follow-up strategy.

METHODS

In this multicentre, prospective cohort study, we included 586 critically ill COVID-19 patients.

RESULTS

We observed an overall ICU mortality of 20.1% [95%CI: 17.1% to 23.6%] (118/586) and an overall hospital mortality of 25.4% [95%CI: 22.1% to 29.1%] (149/586). For ICU survivors, 30 days (early) post-ICU mortality was 5.3% [95%CI: 3.6% to 7.8%] (25/468) and one-year (late) post-ICU mortality was 7.9% [95%CI: 5.8% to 10.8%] (37/468). Pre-existing conditions/comorbidities were identified as the main independent predictors of mortality after ICU discharge: hypertension and heart failure were independent predictors of early mortality; and hypertension, chronic kidney disease, chronic obstructive pulmonary disease and cancer were independent predictors of late mortality.

CONCLUSION

Early and late post-ICU mortality exhibited an initial surge (in the first 30 days post-ICU) followed by a subsequent decline over time. Close monitoring of critically ill COVID-19 post-ICU survivors, especially those with pre-existing conditions, is crucial to prevent adverse outcomes, reduce mortality and to establish an appropriate follow-up strategy.

Adenitis as Initial Mycobacterium marinum Presentation

Mycobacterium marinum is a ubiquitous and opportunist agent that may cause infections related to water activities in humans. It causes mainly skin and soft tissue infections, and other forms of presentation are uncommon. A 27-year-old man presented to the Emergency Department of a tertiary hospital due to a cervical foreign-body sensation that evolved into right cervical swelling and consumption symptoms. He was a waiter on a cruise in the Douro river. Weeks after the initial presentation, the diagnosis of Mycobacterium marinum infection was made by positive nucleic acid amplification tests (NAAT) in tissues obtained by excisional biopsy of cervical adenopathy. Treatment with rifampicin and clarithromycin was started. The symptoms improved, and there was a decrease in the adenopathy number and size. Although Mycobacterium marinum adenitis as initial presentation of the disease is rare, the identification of the agent by NAAT and favorable response to treatment supported the diagnosis.

Cutaneous Tuberculosis in Heart Transplant

Tuberculosis is a disease with a significant global burden in terms of morbidity and mortality. It usually presents as a pulmonary disease but can occasionally have extrapulmonary presentations. Immunosuppressed people are at an increased risk of tuberculosis and more frequently have atypical manifestations of the disease. Cutaneous involvement is estimated to occur in only 2% of extrapulmonary presentations. We report a case of a heart transplant recipient with disseminated tuberculosis who initially presented with cutaneous manifestations in the form of multiple abscesses that were mistaken for a community-acquired bacterial infection. The diagnosis was made after positive nucleic acid amplification testing and cultures for Mycobacterium tuberculosis from the drainage of the abscesses. After initiating antituberculous treatment, the patient had 2 instances of immune reconstitution inflammatory syndrome. A combination of diminished immunosuppression due to discontinuation of mycophenolate mofetil in the setting of acute infection, rifampin drug interactions with cyclosporine, and the beginning of treatment of tuberculosis all contributed to this paradoxical worsening. The patient responded favorably to increased glucocorticoid therapy and showed no signs of treatment failure after 6 months of antituberculous therapy.

An Unexpected Cause of Acute Abdomen Late After Heart Transplantation-A Case Report

Cytomegalovirus (CMV) infection is a frequent complication after a solid organ transplant, and in 86% of the cases, CMV disease occurred during the first 6 months after transplantation. Invasive CMV infections may be present as ulcerative infections of the upper gastrointestinal tract with esophagitis, gastritis, and ulcerations of the duodenum and the small bowel; however, CMV infections of the pancreatobiliary system, especially papillitis, are rarely observed. We present a case report of a man who underwent a heart transplant 6 years before, with a clinical picture of duodenitis and a simultaneous pseudotumor of major duodenal papilla who developed signs of acute abdomen caused by gastrointestinal CMV infection, successfully treated with medical therapy with valganciclovir. There is an urgent need for developments in CMV and solid organ transplantation to stratify the risk of late-onset CMV disease.

Spontaneous splenic rupture due to falciparum malaria successfully treated with a conservative approach

Malaria is frequently associated with splenomegaly. However, spontaneous splenic rupture is a rare and life-threatening complication. It is mostly seen in acute infection in non-immune adults and Plasmodium vivax and Plasmodium falciparum have been associated with the majority of cases. We describe a case of splenic rupture in an adult with complicated malaria by Plasmodium falciparum in which a conservative approach was used.

Effects of forest residue mulching on organic matter and nutrient exports after wildfire in North-Central Portugal

The quick implementation of emergency stabilization measures is vital for minimizing post-fire soil erosion and the associated fertility loss. Mulching has proven to be highly effective in minimizing post-fire soil erosion, however few studies have investigated its impacts on organic matter (OM) and nutrient mobilization from burned forest areas. This study evaluates the effectiveness of forest residue mulching at reducing OM, N and P losses within the sediments after a moderate-severity wildfire over a period of 5 years (Ermida, North-central Portugal). Untreated and mulched plots of ca. 100 m² were bounded with geotextile fabric and sediments were collected from silt fences after a total of 29 periods. During the first five years after the fire, the accumulated OM, N and P exportations in the untreated plots were, respectively, 199, 5.2 and 0.38 g m^-2; and mulch significantly reduced these figures in, respectively, 91 %, 94 % and 95 % (p < 0.05). The overall OM content in the sediments of the untreated plots (45 %) was not different from the OM content of the mulched plots (34 %, p = 0.16). However, the N (8.9 g kg^-1) and P_av contents (0.62 g kg^-1) in the untreated plots were significantly higher than the N (5.6 g kg^-1; p < 0.05) and P_av contents (0.36 g kg^-1; p < 0.05) in the mulched plots. This effect was especially noticeable in the first year after fire. OM and TN contents in the sediments were highly variable throughout the study period, whereas P_av contents declined sharply in the first post-fire rainfall events, maintaining low values afterwards. The main factors driving nutrient exports were ash and litter cover, whereas no significant relationship was observed for OM exports. The present work has shown that forest residues application can be a sustainable strategy for the conservation of soil carbon and nutrients in fire-affected areas.

Long-Term Sequelae of severe COVID-19: outpatient assessment of radiological and pulmonary function tests

Objective: Identify lung sequelae of COVID-19 through radiological and pulmonary function assessment.

Design: Prospective, longitudinal, cohort study from March 2020 to March 2021.

Setting: Intensive Care Units (ICU) in a tertiary hospital in Portugal.

Patients: 254 patients with COVID-19 admitted to ICU due to respiratory illness.

Interventions: A chest computed tomography (CT) scan and pulmonary function tests (PFT) were performed at 3 to 6 months.

Main variables of interest: CT-scan; PFT; decreased diffusion capacity of carbon monoxide (DLCO).

Results: All CT scans revealed improvement in the follow-up, with 72% of patients still showing abnormalities, 58% with ground glass opacities and 62% with evidence of fibrosis. PFT had abnormalities in 94 patients (46%): thirteen patients (7%) had an obstructive pattern, 35 (18%) had a restrictive pattern, and 58 (30%) had decreased DLCO. There was a statistically significant association between abnormalities in the follow-up CT scan and older age, more extended hospital and ICU stay, higher SAPS II and APACHE scores and invasive ventilation. Mechanical ventilation, especially with no lung protective parameters, was associated with abnormalities in PFT. Multivariate regression showed more abnormalities in lung function with more extended ICU hospitalization, chronic obstructive pulmonary disease (COPD), chronic kidney disease, invasive mechanical ventilation, and ventilation with higher plateau pressure, and more abnormalities in CT-scan with older age, more extended ICU stay, organ solid transplants and ventilation with higher positive end-expiratory pressure (PEEP).

Conclusions: Most patients with severe COVID-19 still exhibit abnormalities in CT scans or lung function tests three to six months after discharge.

Analyzing central-line associated bloodstream infection prevention bundles in 22 countries: The results of ID-IRI survey

BACKGROUND

Because central line-associated bloodstream infections (CLABSIs) are a significant complication of central venous access, it is critical to prevent CLABSIs through the use of central line bundles. The purpose of this study was to take a snapshot of central venous access bundles in various countries.

METHODS

The participants in intensive care units (ICUs) completed a questionnaire that included information about the health center, infection control procedures, and central line maintenance. The countries were divided into 2 groups: those with a low or low-middle income and those with an upper-middle or high income.

RESULTS

Forty-three participants from 22 countries (46 hospitals, 85 ICUs) responded to the survey. Eight (17.4%) hospitals had no surveillance system for CLABSI. Approximately 7.1 % (n = 6) ICUs had no CLABSI bundle. Twenty ICUs (23.5%) had no dedicated checklist. The percentage of using ultrasonography during catheter insertion, transparent semi-permeable dressings, needleless connectors and single-use sterile pre-filled ready to use 0.9% NaCl were significantly higher in countries with higher and middle-higher income (P < .05).

CONCLUSIONS

Our study demonstrated that there are significant differences in the central line bundles between low/low-middle income countries and upper-middle/high-income countries. Additional measures should be taken to address inequity in the management of vascular access in resource-limited countries.

Flow-status and survival in severe aortic stenosis treated with TAVI – is flow rate superior to stroke volume index?

Background

Low-flow status, currently defined as a stroke volume index (SVi) &lt;35 mL/m2, is an important prognostic predictor for mortality after Transcatheter Aortic Valve Implantation (TAVI) for severe aortic stenosis (SAS). However, transaortic flow rate (FR) – defined as stroke volume divided by left ventricle ejection time - has recently been suggested to be superior to SVi in defining low-flow states, as it reflects more closely valvular resistance, while being independent of body surface area. Low FR is most consistently defined as FR&lt;200 mL/s.

Purpose

Determine the prognostic impact of FR and SVi before TAVI in survival after intervention for SAS.

Methods

A single-centre retrospective database of all TAVI performed between 2011 and 2019 was analyzed, and cases with pre-intervention echocardiograms available were included. Low-flow patients were identified according to basal FR (&lt;200 mL/s) or SVi (&lt;35 mL/m2), and compared with normal-flow cases. The primary endpoint was defined as time to all-cause death or last follow-up. The impact of flow-status (using FR or SVi) in survival was assessed using Kaplan-Meier curves and log-rank test, as well as Cox proportional hazard model adjusted for EuroSCORE II, using FR or SVi either as categorical or continuous variables. A subanalysis further compared patients with preserved and reduced ejection fraction (EF, &lt;52%). p&lt;0.05 was considered statistically significant.

Results

From 657 TAVI performed, 490 (74.6%) cases were included, with a median follow-up of 43 months. From those, 59.6% were defined as low-flow according to FR, and 43.3% using SVi. Low-flow patients, using each parameter, were of higher surgical risk (EuroSCORE II and STS scores), had more advanced NYHA classes, worse estimated creatinine clearance, and suffered more frequently from coronary artery disease. Low-FR patients were also older, and more predominantly female. Atrial fibrillation was more prevalent among low SVi cases. Functional aortic valve area was lower in low-flow patients using both assessments, but low-SVi was also associated with lower transaortic gradients, as well as lower EF before and after TAVI. Regarding all-cause mortality, low-SVi was associated with worse survival [p=0.02, hazard ratio (HR) 1.43 (1.05–1.94)], but not low-FR (p=0.4). However, low-SVi, when adjusted for EuroScore II, was no longer a predictor of all-cause mortality (p=0.08). When considering FR and SVi as continuous variables, a higher SVi (but not FR) was associated with better survival (HR 0.98, p=0.047) in multivariable analysis adjusted for EuroSCORE II. When stratifying according to preserved and reduced EF, both FR and SVi did not predict all-cause mortality.

Conclusions

Low-flow states are common in SAS population treated with TAVI, being frequently associated with worse symptoms and higher procedural risk. Low-SVi, but not low-FR, negatively impacts survival after intervention, representing a marker for prognosis after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Aortic valve calcium score: does it correlate with mean transaortic gradient?

Introduction

Aortic valvular calcium score (AVCS) is useful in patients with aortic stenosis for whom echocardiography was not conclusive in grading its severity. Transcatheter aortic valve implantation (TAVI) is an established procedure of treatment in symptomatic severe AS. The burden of aortic valve calcification has been associated with some TAVI related complications (as perivalvular leaks), but at the same time it is well accepted that some degree of calcification is needed to ensure stable anchoring of the prosthesis to the aortic annulus.

Purpose

To assess if there is a correlation between aortic valve calcium score and mean transvalvular gradient 6 months after TAVI – is a higher AVCS correlated with lower mean transaortic gradient after TAVI?

Methods

We performed a single-center, retrospective cohort study including patients who underwent TAVI with a preoperative standardized contrast enhanced MSCT with AVCS available. Clinical and echocardiographic data were collected previously to TAVI (pre-TAVI) and at 6 months follow up (6M-FUP).

Results

A total of 187 patients were included, with 54% female and a mean age of 79.4±9.0 years old. Most patients had tricuspid aortic valve (95.7%); 5 patients had aortic bicuspidy and 3 had aortic valve bioprothesis. Concerning the valve type, 73.3% had new generation prosthesis and the main valve used was the CoreValve Evolut Pro (33.7%). Also, 38,5% needed balloon pre-dilation before TAVI. The mean pre-TAVI aortic transvalvular maximum and mean gradients were 76.5±23.2 mmHg and 48.3±15.5 mmHg, respectively; mean aortic valve area was 0.75±0.16 cm2. The mean AVCS was 2851±1524 AU (Agaston Units); 81.2% of women had AVCS&gt;1300 AU and 74.4% men had AVCS &gt;2000 AU. Comparing transvalvular aortic gradients previously and 6M-FUP after TAVI, there was an average differential of maximum gradient of 61±22 mmHg and of mean gradient of 40±15 mmHg. A negative and weak correlation was found between the AVCS and the maximum gradient (pearson coefficient of −0.181, p=0.02) and between mean gradient at 6M-FUP (pearson coefficient of −0.191, p=0.014).

Discussion and conclusion

AVCS is a significant predictor for death, stroke and perivalvular leaks after TAVI. On the other hand, high AVCS is associated with better seating in the native annulus during deployment. Nevertheless, high AVCS did not strongly correlated with mean transaortic gradient 6 months after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Predictors for NYHA recovery and 1-year mortality after mitral TEER

Background

Mitral regurgitation (MR) is the second-most frequent valvular heart disease in Europe and frequently aggravates heart failure (HF) symptoms. Mitral transcatheter-edge-to-edge repair (TEER) can be considered in eligible patients, for both primary (in inoperable cases) or secondary severe MR. However, intervention is not advised in severe comorbid patients in whom it is not expected to prolong survival for over 1 year.

Purpose

Evaluate characteristics associated with HF New York Heart Association (NYHA) class recovery, and one-year all-cause mortality after mitral TEER for severe MR.

Methods

All mitral TEER procedures for primary and secondary MR conducted in a single-centre between 2014 and 2020 were retrospectively analyzed. The primary endpoint was defined as a reduction of at least one NYHA class in the first month after intervention, and a secondary endpoint considered a recovery of at least two NYHA classes. Survival status 12 months after mitral TEER was also consulted. Clinical, echocardiographic and blood-analysis data were explored as characteristics associated with the endpoints defined, using Pearson's Chi-squared test, Wilcoxon rank sum test and Fisher's exact test, as appropriate. A p&lt;0.05 was considered statistically significant.

Results

From 103 mitral TEER procedures, 86 (83%) had full information about pre- and post-intervention NYHA class, as well as survival status at 12 months. There was a higher proportion of primary MR among NYHA non-responders (47% versus 25%, p=0.034), but no differences for secondary MR. Higher surgical risk patients (EuroSCORE II) tended to have exhibit more NYHA recovery, though not reaching statistical significance (p=0.068). Both a more advanced NYHA class at baseline and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels were linked to a higher symptomatic recovery (2048 versus 5676pg/ml, p&lt;0.001). Also, persisting MR after TEER of at least grade 3/4 was more frequent in non-NYHA responders. Regarding NYHA improvement of at least two classes, it was observed in 13% patients, and these also had a more advanced NYHA class at baseline and lower NTproBNP basal levels, and exhibited a lower estimated systolic pulmonary artery pressure and inferior vena cava (IVC) diameter. Finally, 10 (11.6%) of mitral TEER patients died in the first 12 months, and no statistically significant associations were found regarding pre-intervention characteristics and survival.

Conclusions

This study suggests that three-fifths of severe MR improve their NYHA class after TEER, but only one-fourth for primary MR. Earlier intervention – with lower NTproBNP levels, less severe pulmonary hypertension, and lower IVC diameters – is associated with more symptomatic HF improvement. All-cause mortality in the first year is still significant, exposing a need for better patient selection. However, these findings represent exploratory deductions of a relatively low number, single-centre, patients.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous valve commissurotomy in mitral stenosis patients: a 20 years follow-up

Background

Percutaneous valve commissurotomy (PMC) is a viable alternative to mitral valve surgery in the treatment of patients with clinically significant mitral stenosis (MS). Although rheumatic MS incidence has decreased in developed countries, it remains a prevalent healthcare problem in Cardiology clinics

Purpose

To evaluate the early and long-term results of PMC in patients with rheumatic MS and to compare long-term events between patients with and without pulmonary hypertension (PH).

Methods

We retrospectively analysed all consecutive patients between 1991 and 2008 with clinically significant rheumatic MS undergoing PMC. Clinical and echocardiographic data were collected at baseline and during long-term follow-up. MACE was a composite of adverse events defined as all-cause mortality, mitral valve re-intervention or hospitalization for a cardiovascular cause.

Results

A total of 124 patients were enrolled: 87% were female, with a mean age at the time of repair of 46±11 year-old and a mean follow-up of 20±6 years. Before the procedure, 34% were in NYHA class ≥ III and 81% had a Wilkins score ≤8; all patients had preserved biventricular systolic function, 83% presented PH, mean transvalvular gradient (TVG) and mitral valve area (MVA) were 12.8 mmHg and 1.0 cm2, respectively. Most of the procedures were successful (91%) and without complications (94%), with a mean MVA improvement of 0.9 cm2 and reduction of 8.5 mmHg in TVG and 9.7 mmHg in pulmonary artery systolic pressure (PASP) after PMC.

During long-term follow-up, 42% of patients were submitted to re-intervention (most of them surgically) and 24% died. In patients non-submitted to re-intervention, TVG and PASP remained similar with early post-procedure evaluation (p=0.109 and p=0.777, respectively), while MVA reduced over time, yet still statistically superior to baseline MVA (1.6 cm2 vs 1.0 cm2, p&lt;0.001). Concerning time-to-event analysis, approximately 80% of patients kept uneventful after 10 years; after 30 years, more than 20% continued MACE-free and approximately 50% were alive. Regarding PH presence at time of PMC, there was no significant difference in MACE events and all-cause mortality between the two groups (Log Rank, p=0,846 and p=0.661, respectively).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS. After a long-term follow-up patients maintained the reduction in TVG and PASP and a smaller but significative improvement in MVA. Most of the patients were free from adverse events after 10 years and half were alive after 30 years. There was no difference in all-cause mortality and in a composite of all-cause death, mitral valve re-intervention or cardiovascular hospitalization concerning PH presence.

Funding Acknowledgement

Type of funding sources: None.

Reduced 3D-left atrium ejection fraction predicts development of atrial fibrillation in patients with hypertrophic cardiomyopathy

Introduction

Atrial fibrillation (AF) is the most common sustained arrhythmia in hypertrophic cardiomyopathy (HCM), occurring in approximately 25% of patients, related to left atrial (LA) dilatation and remodeling. HCM patients who develop AF have increased risk of HCM-related death, functional impairment, and stroke. Accurate risk stratification for AF in this population is crucial as contemporary treatments are highly successful.

Purpose

To assess if new echocardiographic parameters can predict the development of AF in HCM patients.

Methods

HCM patients who underwent comprehensive echocardiographic examination during 2011 were followed and checked for “de novo” AF until November 2021. We searched for associations between AF development and novel echocardiographic parameters such as LA Volume index, Left Atrioventricular Coupling Index (LACI, as LAVI/a'), 3D LA volumes and 3D LA ejection fraction (3D-LAEF).

Results

A total of 43 patients were included, with 62.8% male and mean age 56,1±6,2 years old. 55.8% had the septal asymmetric HCM type and mean LV mass was 326±127g. Mean LA diameter and biplane 2D volume was 46±7 mm and 78±37 mL, respectively. 11.6% of patients already had AF. During a median follow-up of 9.4 years, the incidence of “de novo” AF was 31,6%. Within the total 17 patients with AF, 35,2% took warfarin and the remaining direct oral anti-coagulation. No stroke was documented. There were 3 deaths (mortality rate of 7,0%), none from cardiac causes.

No association was found between AF development and LAVI, LACI or 3D LA volumes. We only found a statistically significant difference regarding 3D-LAEF, which was lower in patients who developed AF compared with those without AF (26±12% VS 39±19%, p=0.04).

Binary logistic regression analysis found that reduced 3D-LAEF predicts the development of AF (p=0.019, odds ratio [OR] 2.6, 95% confidence interval [CI] 1.0 to 1.1). The area under a receiver operating characteristic curve using 3D-LAEF as a predictive marker for AF development in HCM patients was 0.743 (p=0.004). When the cut-off value of 3D-LAEF was set at 34,5%, the sensitivity and specificity for AF diagnosis were 66% and 86%, respectively.

Conclusion

In our study, 3D LAEF predicted the development of AF in HCM patients – this may be a useful tool to identify patients at high risk of future AF who may benefit from more intensive rhythm monitoring and a lower threshold for oral anticoagulation.

Funding Acknowledgement

Type of funding sources: None.

Long-term success in percutaneous valve commissurotomy – is Wilkins score over 9 a definitive limit?

Background

Percutaneous valve commissurotomy (PMC) is an established treatment in patients with significative mitral stenosis (MS). Although rheumatic MS incidence has decreased in the last century, it remains a prevalent pathology worldwide. The Wilkins score (WS) is a reference in echocardiographic assessment of MS; a score ≤8 is considered a predictor of treatment success and score between 9 and 11 is a “grey zone” (WGZ) in which doubts persists regarding PMC success.

Purpose

To evaluate the early and long-term results of PMC in patients with rheumatic MS and to compare long-term events between patients with WS ≤8 and patients in WGZ.

Methods

We retrospectively analysed all patients between 1991 and 2008 with significative rheumatic MS undergoing PMC. Data were collected at baseline and during long-term follow-up. M ACE was defined as a composite of all-cause mortality, mitral valve re-intervention or cardiovascular hospitalization.

Results

In our cohort, 124 patients were included. Most were female (87%), mean age at the time of repair was 46±11 year-old and mean follow-up was 20±6 years. Before the procedure, 81% had WS ≤8 and 19% were in WGZ. Both groups had similar baseline characteristics, namely age at first intervention, NYHA class and follow-up time. All patients had preserved biventricular systolic function, 83% presented PH, mean transvalvular gradient (TVG) and mitral valve area (MVA) were 12.8 mmHg and 1.0 cm2, respectively. Most of the procedures were successful (91%) and without complications (94%). Mean MVA improvement was similar in both groups [0.9 cm2 in WS ≤8 and 0.8 cm2 in WGZ, t(102)=0.173, p=0.863]; there was also no significative difference in TVG and PASP reduction after PMC. During long-term follow-up, re-intervention and mortality occurred in 40% and 23% in WS ≤8 and in 50% and 29% in WGZ, respectively, and none of these differences was statistically significant (p=0.389 and p=0.544, respectively). Concerning time-to-event analysis, approximately 80% of patients kept uneventful and &gt;90% alive after 10 years in both groups and no significant difference in M ACE events and all-cause mortality between WS ≤8 and WGZ was observed (Log Rank, p=0,419 and p=0.950, respectively).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS in both WS ≤8 and WS 9–11, with similar MVA improvement. After 10 years, approximately 80% of patients were MACE-free and &gt;90% alive in both groups. There was no difference in all-cause mortality and in a composite of all-cause death, mitral valve re-intervention or cardiovascular hospitalization concerning WS groups.

Funding Acknowledgement

Type of funding sources: None.

Patient delay in acute myocardial infarction: a long journey still ahead

Background

It is overly known that time delays in acute myocardial infarction (AMI) strongly influence its outcomes. Patient delay (PD) is repeatedly pointed out as the longer one in this context, as well as it is the less modifiable one by organizational measures. Therefore, it is crucial to understand the reasons for longer PD in our population, to define proper strategies to improve PD and, ultimately, AMI-outcomes.

Methods

In this six-month prospective study of patients (pts) admitted in a tertiary hospital due to type-1 AMI, 194 pts were consecutively enrolled between May and October 2021. Data was based on a pts well-structured interview within 48h after admission and review of medical records.

Results

Our work spotted several aspects significantly influencing PD in AMI context (Figure 1). Concerning pts cardiovascular background, a trend towards a shorter PD was found in pts with at least one cardiovascular risk factor (CVRF) (p=0,08) and with a previous history of AMI (p=0,08). Regarding clinical presentation, a significantly shorter PD was found in pts presenting with associated symptoms (p=0,02), higher chest pain intensity (chest pain intensity ≥7 vs &lt;7 in a 0–10 scale; p=0,03) and symptoms onset on weekdays rather than weekends (p=0,003). Regarding pts knowledge, significant differences were found when pts recognized their symptoms as AMI, presenting a shorter PD in this context (p=0,006). Curiously, pts ability to correctly identify AMI symptoms, when asked, or to acknowledge their CVRF (when present), did not influence PD. Considering sociodemographic factors, higher incomes (p=0,03) and non-rural residence (p=0,03) significantly translated into shorter PD. No differences were found in PD according to pts age, gender or educational level. After this initial univariate analysis, multiple linear regression was performed to identify possible predictors of PD. Four variables were identified: pts ability to recognize their symptoms as AMI (β −0.199; 95% CI: −277 to −34,87; p=0.012), living in a non-rural residence (β 0.154; 95% CI: 0.12–161.44; p=0.05), presenting associated symptoms (β −0.194; 95% CI: −257.43 to −28.84; p=0.014) and occurrence of symptoms on weekdays (β 0.170; 95% CI: 12.73–259.49; p=0.031) predicted shorter patient delays.

Conclusion

Our study clearly points to the need for increasing public awareness and educational measures, mainly in pts living in rural areas, in order to: 1) Improve pts knowledge about AMI symptoms, clarifying that atypical symptoms can happen; 2) Reinforce the importance of shortening AMI time delays, clearly explaining the concept “time is muscle”.

Funding Acknowledgement

Type of funding sources: None.

20 year-follow up of mitral stenosis patients after percutaneous valve commissurotomy: moderate disease of other valves as predictor for re-intervention

Background

Percutaneous valve commissurotomy (PMC) is a viable alternative to mitral valve (MV) surgery in the treatment of patients with clinically significant mitral stenosis (MS). About 40% of patients treated with PMC will require at least one reintervention (either PMC or MVS) along time.

Purpose

To evaluate the long-term results of PMC in patients with rheumatic MS.

Methods

We retrospectively analysed all consecutive patients between 1991 and 2008 with clinically significant rheumatic MS undergoing PMC. Clinical and echocardiographic data were collected at baseline and during early and long-term follow-up. MACE was a composite of adverse events defined as all-cause mortality, MV re-intervention or cardiovascular hospitalization.

Results

A total of 124 patients were enrolled: 108 (87%) were female, with a mean age at the time of PMC of 46±11 years.

At baseline, 34% patients were in NYHA class ≥ III and 81% had a Wilkins score ≤8; all patients had preserved biventricular systolic function and 83% presented pulmonary hypertension. Regarding associated valve disease, 46 patients had mild tricuspid regurgitation (TR), 19 mild aortic regurgitation (AR), 14 moderate IT and 5 moderated AR.

Most of the procedures were successful (91%) and without complications (94%), with median improvement in MV area of 0.9 cm2 (IQR 0.5) and median reductions in mean transmitral gradient (MTG) of 6 mmHg (IQR 6) and in pulmonary artery systolic pressure (PASP) of 8 mmHg (IQR 10) early after PMC.

During the mean follow-up of 20±6 years, 52 (42%) of patients had MV re-intervention (86% surgery and 14% re-PMC), 37 (30%) were hospitalized and 30 (24%) died. Concerning time-to-event analysis, approximately 80% of patients kept MACE-free after 10 years; after 30 years, more than 20% continued MACE-uneventful, approximately 50% were alive and about 45% were free from re-intervention.

Considering patients submitted to surgical re-intervention, 9 underwent MV valvuloplasty and the others MV replacement with mechanical (32) or biological prothesis (11). At the same procedure, 23 patients were submitted to tricuspid annuloplasty, 9 to other valve replacement and one to coronary artery bypass graft.

Using Cox regression, we found that the presence of moderate disease of other valves at PMC time was associated with a 2.3-fold greater rate of re-intervention compared to patients with none or mid disease of other valves (HRcrude 2.3; 95% IC 1.221–4.331, p=0.017). After adjusting for the success of the PMC and for mitral regurgitation after PMC, the observed effect remained significant (HRadjusted = 2.7; 95% CI 1.417–5.233, p=0.003).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS. Most of the patients were free from adverse events after 10 years and half were alive after 30 years. Still, about 40% required re-intervention, with moderate disease of other valves as its independent predictor.

Funding Acknowledgement

Type of funding sources: None.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

AB0173 MORPHOLOGICAL PARAMETERS ASSESSED BY ULTRASOUND IN QUADRICEPS MUSCLE WERE ASSOCIATED WITH CLINICAL FEATURES, MUSCLE STRENGTH, FUNCTIONAL CAPACITY AND PHYSICAL FUNCTION OF RHEUMATOID ARTHRITIS PATIENTS

Background

Rheumatoid arthritis (RA) patients usually present extra-articular manifestations (1,2), which affect muscle mass and, consequently, physical function (3). Among the various methods to assess muscle mass we tested muscle morphology by ultrasound (MU) to verify the associations of the quadriceps muscle with clinical features, muscle strength, functional capacity and physical function.

Objectives

To assess the MU of the quadriceps muscle and verify the muscle quality assessed by the pennation angle and its associations with clinical features, muscle strength, functional capacity and physical function in RA patients.

Methods

RA women, age ≥18years and who met 2010 American College of Rheumatology (ACR) criteria were included. Morphological parameters in quadriceps muscle consisted of the pennation angle of rectus femoris (RF), vastus intermedius (VI) and vastus lateralis (VL). RA activity was measured by 28-joint disease activity score (DAS28), muscle strength by handgrip and chair stand tests, functional capacity by health assessment questionnaire (HAQ), and physical function by timed-up-and-go (TUG) test and short physical performance battery (SPPB). Pearson’s or Spearman’s correlation coefficients were explored. The significance level was set at p ≤ 0.05 for all analyzes.

Results

Eighty-one patients were included (age: 58.64±9.52 years old; DAS28: 3.24±1.34). Smaller pennation angle in rectus femoris (RF) were associated with lower handgrip strength (r= 0.224, p=0.044), chair stand test (r= -0.372, p=0.004), HAQ (r= -0.404, p=0.001), SPPB (r= 0.262, p=0.047), as well as higher disease activity by DAS-28 (r= -0.415, p<0.0001) and age (r= -0.290, p=0.009). Smaller pennation angle in vastus intermedius (VI) were associated with worse chair stand (r= -0.281, p=0.033), HAQ (r= -0.302, p=0.015) and higher disease activity by DAS-28 (r= -0.304, p=0.006). Lastly, smaller pennation angle in vastus lateralis (VL) were associated with worse chair stand (r= -0.290, p=0.027), as well as higher DAS-28 (r= -0.237, p=0.033) and age (r= -0.272, p=0.014).

Conclusion

The pennation angles of the quadriceps muscle evaluated by ultrasound (RF, VI and VL muscles) were associated with chair stand test and DAS-28. In addition, the level of disease activity assessed by DAS-28 also appears to be affecting the quadriceps muscle. Finally, MU may be a useful method to evaluate the impact of the disease on skeletal muscle.

References

[1]Summers GD, Deighton CM, Rennie MJ, Booth AH. Rheumatoid cachexia : a clinical perspective. 2008;(April):1124–31.

[2]da Rocha OM, Batista A de AP, Maestá N, Burini RC, Laurindo IMM, Kayser C. Sarcopenia in rheumatoid cachexia: Definition, mechanisms, clinical consequences and potential therapies. Rev Bras Reum. 2009;49, 294–30.

[3]de Santana FS, da Cunha Nascimento D, de Freitas JPM, Miranda RF, Muniz LF, Neto LS, et al. Assessment of functional capacity in patients with rheumatoid arthritis: Implications for recommending exercise. Rev Bras Reumatol. 2014;54(5):378–85.

Table 1.

Associations between the quadriceps muscle morphology by ultrasound (pennation angle) with clinical features, muscle strength, functional capacity and physical function in rheumatoid arthritis patients.

VariablesnComponents of the quadriceps muscleRp-valueAge (y)81RF-0.2900.009VINSNSVL-0.2720.014Disease duration (y)81RFNSNSVINSNSVLNSNSDas-28 (CRP)81RF-0.415<0.0001VI-0.3040.006VL-0.2370.033Handgrip strength test (kg)81RF0.2240.044VINSNSVLNSNSChair stand test (s)58RF-0.3720.004VI-0.2810.033VL-0.2900.027HAQ (score)65RF-0.4040.001VI-0.3020.015VLNSNSTUG test (s)68RFNSNSVINSNSVLNSNSSPPB (score)58RF0.2620.047VINSNSVLNSNS

RF: rectus femoris; VI: vastus intermedius; VL: vastus lateralis; n: number; y: years; s: seconds; kg: kilogram; DAS28: Disease Activity Score 28; CRP: C-reactive protein; TUG: Timed-up-and-go; SPPB: Short Physical Performance Battery; NS: Not significant.

Acknowledgements

We thank the Coordination for the Improvement of Higher Level Personnel (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—CAPES) institution, the Foundation for Research Support of the Rio Grande do Sul State (Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul-FAPERGS), the Research and Events Incentive Fund (Fundo de Incentivo à Pesquisa e Eventos-FIPE) of HCPA and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq).

Disclosure of Interests

None declared

AB0681 The 2-year impact of COVID-19 pandemic on muscle strength and physical performance in patients with systemic sclerosis: a cohort study

Background

Systemic sclerosis (SSc) patients are particularly prone to developing loss of muscle strength and worsening of physical performance due to decreased physical activity1. The lifestyle changes imposed by the SARS-CoV-2 outbreak have increased the incidence of sarcopenia in at-risk individuals2. However, the literature is scarce on the impacts of the COVID-19 pandemic on muscle strength and physical performance of SSc patients.

Objectives

(1) To assess the impact of the COVID-19 pandemic on muscle strength and physical performance of SSc patients and (2) to verify the associations of muscle strength and physical performance with inflammatory markers in a cohort study.

Methods

SSc patients who met the ACR / EULAR 2013 classification criteria were included. Patients followed between 2019 and 2021. Muscle strength was measured by handgrip strength (kg) and sit and stand (SST, seconds) tests. Physical performance was measured by timed up and go (TUG, seconds) and short physical performance battery (SPPB, points). Inflammatory markers were measured by C-reactive protein (CRP). T test for independent samples, Mann-Whitney U test of independent samples and Spearman’s correlation coefficients were explored. The significance level was set at p ≤ 0.05 for all analyses.

Results

Forty SSc patients concluded this study. At baseline, the mean age was 59 ±11.1 years old and the median disease duration was 13.1 (6.4-19.2) years. Patients had a median of 4.5 clinic visits (3.0-6.0) over the 2 years. The majority of patients were women (37, 92.5%). Ten patients (25%) had diffuse cutaneous disease, 30 patients (75%) non-diffuse cutaneous disease [25 patients (62.5%) had limited cutaneous disease, and 5 (12.5%) had sine scleroderma SSc]. The median of CRP was 2.9 (1.2-5.3). The median of handgrip strength was 20.0 (10.3-25.8) kg to the right hand and 19.0 (12.0-22.8) kg to the left hand. The median of SST was 14.4 (11.9-18.7) seconds. The median of TUG was 8.6 (7.7-9.5) seconds and the median of SPPB was 9.8 (9.0-11.0) points. The CRP was positively associated with SST (r=0.3, p=0.047) and TUG (r=0.3, p=0.029), and negatively with SPPB (r=-0.4, p=0.016). After 2 years of follow-up, the patients showed improvement in the left handgrip strength test (p=0.049) and SST (p=0.001). In physical performance, they showed improvement in the TUG test (p=0.005) and SPPB (p=0.001). The CRP was associated positively with TUG (r=0.4, p=0.033), no other associations were found.

Conclusion

Despite the COVID-19 pandemic and the restrictions imposed, in this population of patients with SSc, we did not detect any worsening in muscle strength and physical performance. Some of these parameters of muscle strength and physical performance were associated with the inflammatory marker CRP. More investigations are needed to assess the actual impact and possible associations.

Table 1.

Baseline comparison and after 2 years of patients with SSc

BaselineAfter 2 yearspCRP (mg/L),median (IQR)2.9 (1.2-5.3)2.3 (1.0-5.1)0.361Handgrip (kg),right, median (IQR)20.0 (10.3-25.8)20.5 (14.3-27.0)0.072left, median (IQR)19.0 (12.0-22.8)19.0 (14.0-26.0)0.049*SST (seconds),median (IQR)14.4 (11.9-18.7)11.6 (9.9-13.1)0.001*TUG (seconds),median (IQR)8.6 (7.7-9.5)7.9 (7.1-9.2)0.005*SPPB (points),median (IQR)9.8 (9.0-11.0)11.0 (10.0-12.0)0.001*

SSc: systemic sclerosis; IQR: interquartile range; mg: milligram; L: liter; kg: kilograms grams; TUG: timed and up go; SST: sit and stand test; SPPB: short physical performance battery; PCR: C-reactive protein; and * significant difference of ≤0.05.

References

[1]Zaghlol, Rabab S et al. “Functional Disability Among Systemic Sclerosis Patients: Relation to Disease Characteristics and Quality of Life Parameters.” Current rheumatology reviews, 2021.

[2]Bakaloudi, Dimitra Rafailia et al. “Impact of the first COVID-19 lockdown on body weight: A combined systematic review and a meta-analysis.” Clinical nutrition (Edinburgh, Scotland), 2021.

Disclosure of Interests

None declared

POS0845 ASSESSING FRAILTY IN SYSTEMIC SCLEROSIS: A CROSS-SECTIONAL STUDY COMPARING FRAIL AND EDMONTON FRAILTY SCALES WITH PHYSICAL FRAILTY PHENOTYPE

Background

Systemic sclerosis (SSc) is a chronic disease characterized by autoimmunity, vasculopathy and fibrosis. During the disease course, patients with SSc are prone to accumulate multiple organ damage, increasing their vulnerability to adverse outcomes in comparison with individuals of the same age: a phenomenon called frailty. One of the most used definitions of frailty is the physical frailty phenotype (PFP) by Fried, et al. The PFP consists of 5 components: unintentional weight loss, exhaustion, muscle weakness, slow walking speed, and low physical activity. There is scarce data about frailty in patients with SSc.

Objectives

To study the prevalence and clinical aspects of PFP in a sample of patients with SSc. Also, we aim to investigate the diagnostic accuracy of the Fatigue, Resistance, Ambulation, Illness and Loss of weight (FRAIL) scale and the Edmonton frailty scale (EFS) using the PFP as the reference standard.

Methods

Cross-sectional study, including patients with SSc according to the 2013 ACR-EULAR classification criteria or the criteria suggested by Le Roy and Medsger for early disease. PFP assessment was according to the original definition, except for physical activity domain, assessed with the International Physical Activity Questionnaire (IPAQ). Patients were classified according to Fried’s criteria in robust (0), pre-frail (1-2), and frail (≥3). FRAIL scale and EFS were also applied to the same individuals. The FRAIL score ranges from 0 to 5 and patients were classified as robust (0), pre-frail (1-2), or frail (≥3). The EFS score ranges from 0–17 and categorizes patients as not frail (0–4), vulnerable (5–6), mild frailty (7–8), moderate frailty (9–10), and severe frailty (≥11). For the diagnostic assessment of FRAIL scale and EFS, we estimated the area under the receiver operating characteristic curve (AUC), considering PFP as the reference standard and dichotomizing the results in frail vs. non-frail.

Results

Between March and December 2019, 82 SSc patients were consecutively included. The mean age and disease duration were 60.4 (±10.6) and 13.4 (±8.2) years, respectively; 91.5% were women, and 19.5% with diffuse cutaneous SSc. The PFP distribution was: 8 (9.8%) robust, 47 (57.3%) pre-frail and 27 (32.9%) frail patients. The PFP domains´ frequencies were: low physical activity in 57 (69.5%), muscle weakness in 41 (50%), exhaustion in 34 (41.5%), unintentional weight loss in 15 (18.3%) and slow walking speed in 8 (9.8%) patients. Using the FRAIL scale, 44 (53.7%) patients were considered pre-frail and 25 (30.5%) frail. According to the EFS, 26 patients (31.7%) were classified as vulnerable and 12 (14.6%) as frail: mild in 6 (7.3%), moderate in 4 (4.9%) and severe in 2 (2.4%). The AUC against PFP was: 0.871 (95% CI 0.789-0.954, p<0.001) for FRAIL scale and 0.870 (95% CI 0.791-0.948, p<0.001) for EFS (Figure 1).

Conclusion

Frailty is prevalent in patients with long-standing SSc, and most of them are considered pre-frail or vulnerable. Low physical activity, muscle weakness and exhaustion are among the most frequent clinical aspects of the frailty phenotype. Both FRAIL scale and EFS showed overlapping diagnostic accuracy against PFP as the reference standard, and FRAIL scale seems to be more feasible than EFS.

References

[1]Rockwood MR, MacDonald E, Sutton E, Rockwood K, Baron M. Frailty index to measure health status in people with systemic sclerosis. J Rheumatol. 2014;41(4):698-705.

[2]Morley JE, Vellas B, Abellan van Kan G, et al. Frailty consensus: a call to action. J Am Med Dir Association. 2014;14(6):392-7.

[3]Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56.

[4]van Kan GA, Rolland YM, Morley JE, Vellas B. Frailty: Toward a Clinical Definition. J Am Med Dir Assoc. 2008;9(2):71-2.

[5]Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-9.

Disclosure of Interests

None declared

Hepatitis E in a Portuguese cohort of human immunodeficiency virus positive patients: High seroprevalence but no chronic infections

Introduction

Hepatitis E virus (HEV) infection causes zoonotic hepatitis in Europe, with a higher risk of complications in immunocompromised hosts. HEV natural history in human immunodeficiency virus (HIV) positive patients is not fully understood, and its prevalence is unknown.

Objectives

To study the seroprevalence of HEV and prevalence of chronic HEV in HIV‐positive patients from Porto, Portugal.

Methods

We randomly selected patients from the cohort of HIV‐positive patients followed in our hospital. We performed an enzyme‐linked immunosorbent assay to search for immunoglobulin G for HEV. When the absorbance/cut‐off was inferior to 3.5, the test was repeated, and a confirmatory test executed in that sample. For reactive tests and for immunosuppressed patients (CD4 count < 200/mm³) with nonreactive test, a polymerase chain reaction (PCR) test was also performed.

Results

We included 299 patients. The mean age was 48 and 75.3% were men. Regarding HIV infection, the median follow‐up time was 10 years, the acquisition was mainly heterosexual contact, and 94% were on antiretroviral therapy. Seventy‐six patients (25.4%) had reactive immunoglobulin G (IgG) hepatitis E serology. Patients with a reactive test were older (statistically significant difference). Otherwise, there was no difference between groups concerning birthplace, rural residence, chronic viral hepatitis coinfection, or cirrhosis. Nadir and actual T_CD4+ lymphocyte counts did not differ significantly from patients with HEV reactive and nonreactive serology. Gamma‐glutamyl‐transferase (GGT) was higher in patients with reactive IgG HEV. All serum HEV PCR tests were negative.

Conclusions

Seroprevalence of HEV was 25.4% in HIV‐positive patients. Older age and higher GGT correlated to HEV reactive IgG test. No cases of current hepatitis E were found.

Impact of the use of cusp overlap projection technique in the incidence of post-TAVR permanent pacemaker implantation with self-expanding valves

Funding Acknowledgements

Type of funding sources: None.

Introduction

Current rates of new Permanent Pacemaker (PPM) Implantations in the context of Transcatheter Aortic Valve Replacement (TAVR) range from 2-36% and that necessity is related to worse prognosis. The use of self-expanding valves and a lower valve implantation depth are two factors associated with an increased risk of conduction disturbances post-TAVR. Theoretically, cusp overlap implantation technique has the potential to enable a higher valve deployment by eliminating parallax of the delivery catheter.

Aim

To compare the in-hospital incidence of PPM post-TARV using self-expandable valve according to the fluoroscopic guidance technique.

Methods

Retrospective, single-centre study, with evaluation of patients consecutively submitted to TAVR with self-expanding CoreValveTM between July 2020 and December 2021 dichotomized according to the use of cusp overlap implantation technique for fluoroscopic valve implantation guidance.

Results

138 patients were included, predominantly women (57.2%), with a mean age of 78.4±8.0 years old, with severe aortic stenosis of the native valve being the most common indication for TAVI (85.5%). Cusp overlap view technique was applied in 50.7% of the patients (n=70). Frailty and co-morbidities were the most common cause for surgical refusal (54.3%). There was a significantly higher percentage of hypertensive patients (92.9% vs. 77.9%), lower previous aortic valve surgery (2.9% vs. 16.2%) and lower percentage of patients previously medicated with b-blockers in the group of patients in whom was used the cusp overlap technique; there were no other relevant differences related to the baseline characteristics. First degree atrioventricular block was present in 19.6% and complete right bundle block in 13.6% of the patients. Incidence of in-hospital post-TAVR PPM implantation wasn’t significantly different between the two cohorts of patients (cusp overlap vs. standard approach: 24.3% vs. 26.5%, p=0.77) (71.4% implanted in the context of complete heart block). Likewise, there were similar proportions of in-hospital new-onset of complete left bundle branch block (35.8% vs. 37.3%, p=0.86), volume of contrast used (140.6±37.5 mL vs. 145.2±51.5 mL, p=0.12), fluoroscopy time (15.6±8.8 min vs. 19.6±8.9 min, p=0.40) and radiation dose (556.3±320.6 mGy vs. 859.4±531.2 mGy, p=0.06).

Conclusions

This study shows that using the cusp overlap view for self-expanding valve implantation does not seem to achieve a significant reduction in in-hospital PPM implantation rate in comparison with the traditional 3 cusp co-planar fluoroscopic view. A larger and probably randomized clinical trial is needed to confirm these results.

Supraventricular arrhythmias in MINOCA patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

De novo atrial fibrillation (AF) is a frequent complication of acute coronary syndromes (ACS). However, 5-15% of patients (pts) admitted with suspected acute myocardial infarction have no significant lesions on coronary angiography (&gt;50%) (MINOCA). Contrary to initial beliefs, MINOCA is not a benign disease, given that mortality and incidence of adverse events is similar to ACS.

Objective

To evaluate predictors and prognosis of AF in the setting of MINOCA.

Methods

Based on a multicenter retrospective study, data collected from admissions between 2013 and 2020. Pts without data on cardiovascular history or uncompleted clinical data were excluded. We included 7590 pts with non-ST elevation myocardial infarction (NSTEMI). Between those, 1561 (19.2%) were MINOCA. We divided MINOCA pts in 2 groups (G): GA – MINOCA with de novo AF; GB – MINOCA without de novo AF during in-hospital stay.

Results

MINOCA pts’ mean age was 65±13, 62% were male and 2.1% had de novo AF. GA pts were older (76±10 vs 65±13, p&lt;0.001), had higher rates of Killip-Kimball class (KKC) &gt;I (27.8% vs 9.7%, p=0.027) and kidney function impairment (50% vs 10.2%, p&lt;0.001), lower haemoglobin at admission (13±1.5 vs 13.7±1.8, p=0.038), higher rates of diuretics (56.3% vs 17.6%, p&lt;0.001) and amiodarone usage during hospitalization (31.3% vs 3.6%, p&lt;0.001) and higher rates of left ventricle ejection fraction (LVEF)&lt;50% (47.1% vs 19.1%, p=0.009). The Gs were similar regarding gender, times from symptoms to admission, cardiovascular risk factors and past history of heart failure, stroke or ACS, and heart rate and systolic arterial tension at admission. In the global population, older age (p=0.001, OR 1.87, CI 1.23-2.72), KKC&gt;I (p=0.004, OR 1.76, CI 1.19-2.61) and LVEF&lt;50% (p&lt;0.001, OR 2.25, CI 1.5-3.38) were predictors of AF during hospitalization. In MINOCA pts, only older age (p=0.014, OR 4.2, CI 1.34-13.2) and LVEF&lt;50% (p&lt;0.001, OR 7.44, CI 2.17-25.47) were predictors of de novo AF. Regarding 1 year-prognosis, the occurrence of AF in MINOCA pts was associated with worse outcomes, namely 1year-mortality (log rank=0.002) and 1-year all cause readmission (log rank 0.028)

Conclusion

As expected, AF in the setting of MINOCA is associated with poorer prognosis. Pts with older age and LV dysfunction are at higher risk of de novo AF in this population.

Two-Dimensional Supersolid Formation in Dipolar Condensates

Dipolar condensates have recently been coaxed to form the long-sought supersolid phase. While one-dimensional supersolids may be prepared by triggering a roton instability, we find that such a procedure in two dimensions (2D) leads to a loss of both global phase coherence and crystalline order. Unlike in 1D, the 2D roton modes have little in common with the supersolid configuration. We develop a finite-temperature stochastic Gross-Pitaevskii theory that includes beyond-mean-field effects to explore the formation process in 2D and find that evaporative cooling directly into the supersolid phase-hence bypassing the first-order roton instability-can produce a robust supersolid in a circular trap. Importantly, the resulting supersolid is stable at the final nonzero temperature. We then experimentally produce a 2D supersolid in a near-circular trap through such an evaporative procedure. Our work provides insight into the process of supersolid formation in 2D and defines a realistic path to the formation of large two-dimensional supersolid arrays.

Transcatheter aortic valve implantation (balloon-expandable versus self-expandable valves) - what echocardiographic parameters should we evaluted?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) is currently the recommended treatment for aortic stenosis (AS) in high or intermediate-risk or inoperable patients. Balloon-expandable valve (BEV) and self-expanding valve (SEV) are the two major types of transcatheter heart valves (TTHV). Despite major diferences, both designs are recomended, however, there are only limited data available for the comparison of newer generation BEV and SEV.

Purpose

Compare echocardiographic and clinical parameters, during 1 year of follow-up of a balloon-expandable (BS) versus self-expanding (SE) transcatheter aortic valve implantantation, with emphasis on the composite endpoits proposed by uptade Valve Academic Researc Consortium (VARC-2).

Methods

Retrospective, comparative study in patients with symptomatic severe AS with a high operative risk, who implanted BEV or SEV between January 2016 and December 2019. All patients underwent echocardiographic study before an after the procedure (on the day , 6 months and 1 year of follow up), clinical data were collected. The following ecocardiographic parameters were evaluated: transvalvular and prosthetic aortic gradientes and paravalvular leak (PVL).

Results

We studied 106 patients (81 ± 8 years, 60% female) with severe AS (mean gradient of 49 ± 12 mmHg), who were threated with BE or SE transcatheter aortic valve. Comparative analysis between BEV vs SEV, showed: there were no statistically significant in mean transprosthetic gradients (9.5 ± 4.8 vs 10 ±6.2; p = 0.49). There were no statistically significant differences between BE and SE valves in the cumulative incidence of death from any cause (21% vs. 28%; p = 0.49), death from cardiovascular causes (3.3% vs. 0%; p= 0.26), all strokes (1.6% vs. 1.6%; p = 0.85), pacemaker implatation (18% vs. 15% p = 0.79); major bleeding (3.3% vs 6.5%; p = 0.18) and renal injury (1.6% vs. 2.1%: p = 0.67). There were statistically significant differences between BE and SE valves in the cumulative incidence of moderate or severe PVL (5% vs. 23.9%; p = 0.009) and repeat hospitalization (11.6% vs. 28%;p = 0.04). Device sucess was achieved in 97 % for BEV vs 91% for SEV (p = 0,39). The early safety at 30 days was observed in 5% for BVE vs. 4.3% for SVE (p = 0.87). The clinical efficacy after 30 days was achieved in 1,6% for BVE vs. 4.3% for SVE (p = 0.03), with higher incidence of moderate or severe PVL. The composite endpoint valve safety occured in 3,3 % for BVE vs 26% for SVE (p &lt; 0,001), with moderate or severe PVL in 23%.

Conclusion(s): In patients with symptomatic severe aortic stenosis who implanted BEV or SEV transcatheter aortic valve there was a significant improvement in the hemodynamic status. The present study suggests that use of SEV was associated with a higher risk of PVL and repeat hospitalization, with a endpoint clinical efficacy after 30 days (4,3%) and time-related valve safety (26%).

Regression of left ventricular mass after transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Regression of left ventricular mass (LVM) after transcatheter aortic valve implantation (TAVI) is an important parameter of left ventricular reverse remodeling and is associated with less hospitalizations 1year after TAVI. The association between LVM índex (LVMi) at 6 months and outcome 1 year after TAVI is unclear.

Purpose

Evaluate and compare LVMi, before TAVI and 6 months after, and determine the association between LVMi regression and clinical outcomes at 1-year follow-up.

Methods

Retrospective, comparative study in patients with symptomatic severe aortic stenosis with a high operative risk, after TAVI. All patients underwent echocardiographic study before TAVI and 6 months of follow-up, the LVMi (by the Devereux formula) was evaluated. Associations between LVMi regression (percent change between baseline and 6 months after TAVI), rehospitalization rate and death at 1 year of follow-up were examined.

Results

We studied 50 patients, 82% with moderade or severe LVMi before TAVI. Comparative analysis between ecocardiography study before and 6 months after TAVI, showed there was statistically significant decrease in LVMi (150,7 ± 38 g/m2 vs 132 ± 36 g/m2; p = 0.03). LVMi moderate or severe (between 130 and 154 g/m2) at 6 months was associated with biggest hospitalization rate (p = 0,03).Comparative analysis between regression of LVMi (before and 6 months after TAVI) and death, showed: decrease of 5% and 10% in LVMi was independently associated with death at 1 year (p = 0,77 vs p = 0,4).

Conclusions

Patients with severe symptomatic aortic stenosis treated with TAVI who had a significant decrease of LVMi after 6 months of follow-up had lower hospitalization rates, but decrease of LVMi is independently associated with death at 1 year of follow-up.

Acute severe hepatitis outbreak in children: A perfect storm. What do we know, and what questions remain?

During the first half of 2022, the World Health Organization reported an outbreak of acute severe hepatitis of unknown aetiology (AS-Hep-UA) in children, following initial alerts from the United Kingdom (UK) where a cluster of cases was first observed in previously well children aged <6 years. Sporadic cases were then reported across Europe and worldwide, although in most countries incidence did not increase above the expected baseline. There were no consistent epidemiological links between cases, and microbiological investigations ruled out known infectious causes of hepatitis. In this review, we explore the evidence for the role of viral infection, superimposed on a specific host genetic background, as a trigger for liver pathology. This hypothesis is based on a high prevalence of Human Adenovirus (HAdV) 41F in affected children, together with metagenomic evidence of adeno-associated virus (Adeno-associated viruses)-2, which is a putative trigger for an immune-mediated liver injury. Roles for superantigen-mediated pathology have also been explored, with a focus on the potential contribution of SARS-CoV-2 infection. Affected children also had a high frequency of the MHC allele HLA-DRB1*04:01, supporting an immunological predisposition, and may have been vulnerable to viral coinfections due to disruption in normal patterns of exposure and immunity as a result of population lockdowns during the COVID-19 pandemic. We discuss areas of ongoing uncertainty, and highlight the need for ongoing scrutiny to inform clinical and public health interventions for this outbreak and for others that may evolve in future.

Septic shock due to co-infection with Legionella pneumophila and Saprochaete clavata

Septic shock is the most dreaded presentation of an infection, carrying a reserved prognosis. Appropriate antimicrobial therapy is therefore the mainstay of treatment, alongside organ support as needed. Legionnaires' disease is mainly due to Legionella pneumophila serogroup 1 but it can be caused by other serogroups and species not detected by the urinary antigen test. Anti-tumour necrosis factor α therapy may increase the risk of invasive fungal infection, which carry a poor prognosis. We present a challenging case of a septic shock due to Legionella pneumophila and Saprochaete clavata infections, with a review of the two infections presented.

SARS-CoV-2-related Multisystem Inflammatory Syndrome in Adults

Adults infected with SARS-CoV-2 may develop a multisystem inflammatory syndrome (MIS-A) characterized by elevated inflammatory markers and multisystem organ involvement. We report the case of a patient who presented with fever and vomiting at hospital admission. He tested positive for SARS-CoV-2 infection and blood tests showed elevated inflammatory markers. The patient developed acute cardiac dysfunction and shock in less than 24 hours and the echocardiogram revealed an LVEF of 30%. He was discharged 3 weeks later fully recovered. MIS-A should be considered if a compatible syndrome is observed in patients with evidence of SARS-CoV-2 infection by PCR test or serology.

Extra Corporeal Membrane Oxygenation in the Treatment of Human Immunodeficiency Virus-Related P. jirovecii Pneumonia

Despite the undeniable complexity one may encounter while managing critically ill patients with human immunodeficiency virus infection (HIV), intensive care unit-related mortality has declined in recent years, not only because of more efficacious antiretroviral therapy (ART) but also due to the advances in critical support. However, the use of extracorporeal membrane oxygenation (ECMO) in these patients remains controversial. We report four cases of HIV-infected patients with Pneumocystis jirovecii pneumonia (PJP) and acute respiratory distress syndrome (ARDS) treated with ECMO support and discuss its indications and possible role in the prevention of barotrauma and ventilator- induced lung injury (VILI). The eventually favorable clinical course of the patients that we present suggests that although immune status is an important aspect in the decision to initiate ECMO support, this technology can provide real benefit in some patients with severe HIV-related refractory ARDS.

Diagnostic and prognostic contribution of 99mTc-DPD scintigraphy in transthyretin V30M cardiac amyloidosis

Background

Early diagnosis and prognostic stratification of hereditary transthyretin amyloidosis (ATTR) are crucial. Previous findings suggested that 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scintigraphy presents suboptimal accuracy to detect ATTR cardiomyopathy caused by V30M mutation, particularly in patients with onset of symptoms under 50 years of age. Furthermore, its prognostic value has never been evaluated in ATTR caused by this mutation.

Purpose

To assess the diagnostic value of DPD scintigraphy to detect cardiomyopathy in a large cohort of patients with ATTR-V30M mutation and to explore its prognostic value regarding mortality.

Methods

Of the 305 ATTR-V30M mutation carriers followed prospectively and who underwent DPD scintigraphy, 288 individuals [median age 46 (39–56); 49% male] without myocardial thickening attributable to other causes were enrolled in the study. Amyloid cardiomyopathy was defined by septal thickness ≥13mm not attributable to other causes plus at least one of the following criteria: (1) late heart-to-mediastinum (H/M) 123I-metaiodobenzylguanidine (MIBG) ratio &lt;1.60; (2) electrical heart disease (arrhythmia or cardiac conduction defect); or (3) amyloid infiltration documented in biopsy.

Results

Amyloid cardiomyopathy was identified in 41 (14.2%) patients and 44 (15.3%) individuals presented abnormal cardiac DPD uptake. Individuals with cardiac DPD retention had 27-fold higher likelihood of having amyloid cardiomyopathy (OR: 27.4; 95% CI 11.6–65.0; P&lt;0.001). However, DPD scintigraphy presented suboptimal accuracy to detect ATTR cardiomyopathy (89.9%) with limitations in sensitivity (56.1%), specificity (95.6%), positive predictive value (67.7%) and negative predictive value (92.9%).

During a mean follow-up 33.6±1.2 months, 16 patients died (5.6%). Mortality was 14 times higher in patients with amyloid cardiomyopathy (HR: 14.1; 95% CI 4.9–40.7; P&lt;0.001), 13 times higher in those with abnormal cardiac DPD uptake (HR: 12.59; 95% CI % 4.56–34.72; P&lt;0.001) and 10 times higher in those with H/M MIBG ratio &lt;1.60 (HR: 10.40; 95% CI 2.95–36.69; P&lt;0.001). The prognostic value of ventricular thickness and cardiac DPD uptake was additive: patients without septal thickening and no cardiac DPD retention had excellent prognosis (5-year mortality of 0.75%), while those with septal thickening and/or abnormal DPD retention presented 5-year mortality rates ranging from 39.9 to 53.3%.

Conclusions

DPD scintigraphy is valuable in the evaluation of ATTR-V30M mutation carriers, particularly for prognostic stratification purposes, identifying patients at higher risk of death.

Funding Acknowledgement

Type of funding sources: None.

Single stenting versus double stenting technique in true bifurcation coronary lesions

Introduction

The ideal treatment technique for coronary bifurcation lesions remains unknown. Although single-stenting strategy has been recommended by default, little evidence exists regarding clinical outcomes between single versus double-stenting in current practice.

Purpose

To compare procedural details and clinical outcomes between single vs double-stenting techniques in true bifurcation coronary lesions.

Methods

Retrospective study of all patients (pts) referred for percutaneous coronary intervention (PCI) of true bifurcation lesions between June 2018 and June 2020. Only Medina X,X,1 lesions were included. Pts were split in 2 groups: group 1 (single-stenting) and group 2 (double-stenting). Procedural details and clinical outcomes were assessed. Acute and long-term adverse events included procedural complications (a composite outcome of side branch occlusion, coronary iatrogenic dissection and type 4 acute myocardial infarction (AMI)) and a composite of cardiovascular death, AMI, stroke, re-restenosis and reintervention, respectively.

Results

A total of 118 pts were included, 74,6% male, mean age of 66,4±11 years.

Ninety-five pts (80,5%) were treated with single-stenting (G1) and 23 pts (19,5%) with double-stenting technique (G2). Both groups were well matched regarding baseline characteristics and clinical presentation. T and protrusion (TAP) and minicrush were the most frequent double-stenting techniques (43,5% and 21,7%).

G2 lesions mainly involved the left main (LM) and proximal left anterior descendent artery (LAD) (52,2%) and in G1 mid LAD (34,7%). LM lesions were more common in G2 (26,1% vs 8,4%; p=0,030). G1 had more lesions Medina 1,1,1 (75,8% vs 52,2%; p=0,025) and less Medina 0,1,1 (9,5% vs 30,4%; p=0,015). Proximal optimization technique and kissing balloon occurred more in G2 (p&lt;0,05). G2 had more intravascular ultrasound guided PCI (p=0,046). Femoral access, heparin, contrast and radiation dose, and fluoroscopy time were higher in G2 (p&lt;0,05). Acute adverse composite outcome was similar in both groups (G1 13% vs G2 14,3%; p=0,855).

Median follow-up was similar (G1 16,8±7,9 and G2 19,7±8,8 months; p=0,127). G1 had less occurrence of long-term adverse composite outcome (7,4% vs 26,3%; p=0,032). Excluding interventions in LM, G2 had more significant incidence of acute events (20% vs 2,6%; p=0,028), and higher rate of long-term adverse events (20% vs 4,2%; p=0,056). In interventions of the LM only, no differences were noticed in acute and long-term composite events between groups.

Conclusions

Double-stenting techniques in true coronary bifurcation lesions included more often LM lesions and were complex procedures requiring frequently intracoronary imaging. Although acute adverse events were similar to those of single-stenting, long-term adverse outcomes were more frequent in double-stent group, except for LM lesions.

Funding Acknowledgement

Type of funding sources: None.

Feasibility of coronary angiography after TAVR

Background

The prevalence of coronary artery disease (CAD) is high among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR).

Indications for TAVR are now expanding to younger and lower risk patients. During their lifetime, these patients will be at risk of developing CAD and it is expected an increase in coronary angiography and percutaneous coronary intervention (PCI). Aortic prosthesis, particularly if in supra-annular position, may pose important technical difficulties in coronary re-engagement after TAVR.

Purpose

To evaluate the feasibility to reengage the coronary ostia after TAVR, describe complications and compare technical differences between coronary procedures performed before and after TAVR.

Methods

Retrospective analysis of 714 patients submitted to TAVR from August 2007 to December 2019. Patients who needed coronary angiography after TAVR were selected.

The primary endpoint was the rate of successful coronary ostia cannulation after TAVR, defined by the possibility to selectively cannulate and inject both coronary ostia.

Secondary endpoint was complications associated with coronary catheterization after TAVR.

Results

Among 714 patients, 25 (3.5%) patients were submitted to a total of 28 coronary angiography after TAVR. 14 patients were male (56%), mean age 78.2±6.2 years and 9 (36%) had history of previous coronary revascularization.

From the 28 coronary angiographies (balloon-expandable Edwards-Sapien n=11, 44%; self-expandable CoreValve n=10, 40%; Portico n=2, 8%; Symetis n=2, 8%), 25 (89%) met the primary endpoint. Only three was semiselective (Symetis, CoreValve Evolut R and CoreValve TAVR in TAVR), with impossibility to cannulate both coronary arteries, right coronary artery and left coronary artery, respectively. 13 (46%) patients had also indication for PCI and all were successfully performed (Edwards-Sapien n=4, 31%; CoreValve n=6, 46%; Portico n=2, 15%; Symetis n=1, 8%). The main indications for coronary angiography was chronic coronary syndrome (n=12, 43%) and acute coronary syndrome without ST segment elevation (n=7, 25%). Circumflex artery was the most frequently treated vessel (n=6), followed by left anterior descending artery (n=4), right coronary artery (n=3) and left main (n=2).

There were no complications reported during or post-procedure. Comparing coronary angiographies before and after TAVR, there were no significant differences regarding arterial access site, catheter diameter, fluoroscopy time and quantity of contrast used in coronary angiography.

Conclusion

Although the need for coronary angiography was rare in patients after TAVR, selective diagnostic coronary angiographies were possible in 89% (25/28) and PCI was feasible in all patients in whom it was indicated, without any reported complications.

Further prospective studies are needed to confirm the great feasibility of performing coronary angiography after TAVR.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho

Management of ibrutinib treatment in patients with B-cell malignancies: clinical practice in Portugal and multidisciplinary recommendations

OBJECTIVES

Ibrutinib, a potent inhibitor of the Bruton tyrosine kinase, has revolutionized the treatment of many B-cell malignancies. Ibrutinib has an established favorable toxicity profile with up to 8 years of experience in clinical trials; however, despite ibrutinib's favorable toxicity profile, dose reductions and treatment discontinuations are becoming more evident in clinical practice, particularly in the setting of specific clinical contexts and patient characteristics. This manuscript is set to provide practical recommendations on the management of patients treated with this agent in daily practice.

METHODS

A group of multidisciplinary experts from Portugal met to discuss and highlight practical recommendations, supported on both literature and clinical insights, for the management of the treatment with ibrutinib.

RESULTS/DISCUSSION

Handling of both toxicities and drug-drug interactions during ibrutinib treatment poses several challenges to healthcare providers and can benefit from a multidisciplinary approach. The involvement of specialties, such as cardiology, infectiology and pharmacology, can bring an added value to patient care, not only in anticipating/managing safety issues and dose adjustments but also in enhancing adherence to treatment, ultimately improving the risk/benefit balance.

CONCLUSION

By involving a multidisciplinary group of experts, this work provides a set of key recommendations to optimize care and outcomes for ibrutinib-treated patients. Despite not being a fully comprehensive review on the topic, it is intended as a framework to hematologists and other healthcare professionals who manage these patients in their daily clinical practice.