Assessment of technology-based options for climate neutrality in Austrian manufacturing industry

The goals set forth by the European Green Deal require extensive preparation and coordination of all stakeholders. As a valuable tool, energy scenarios can generate the necessary information for stakeholders to envision the right steps in preparing this transition. The manufacturing industries represent an especially important sector to investigate. They are responsible for both high energy consumption and GHG emission figures on the one hand side and provide great economic value for member countries on the other. We aim to provide a close investigation of all thirteen industrial subsectors that can be used as a solid information basis both for stakeholders within the manufacturing industries and policymakers. Our approach includes all industrial production processes. We achieve this by considering both transformation processes, such as blast furnaces or industrial power plants, and final energy-application. In addition, both scope 1 and 2 emissions of manufacturing industry are assessed in an effort to transparently indicate the interdependencies of industrial decarbonisation efforts with the overall energy system. We propose the integration of a novel stakeholder-based scenario, that puts special emphasis on first-hand information on mid to long-term planning of key industrial representatives, thereby going beyond existing scenario narratives (e.g., scenarios according to the European Monitoring Mechanism). Thus, a balanced deep decarbonisation scenario using best-available technologies can be compared with existing industry plans. To address these points, we have chosen Austria as a case study. Results indicate that industry stakeholders are in general agreement on their subsector-specific technology deployment and already envision investments towards a low-carbon pathway for their respective subsectors. While today's manufacturing industries rely at large on a great diversity of (mostly fossil) energy carrier supply, deeply decarbonised manufacturing industries of the future may be based on the following main energy carriers; electricity, CO2-neutral gases, and biomass. To mitigate emissions from geogenic sources, carbon capture technologies are needed. On the other hand, the synthesis of olefins in the chemical industry may provide a sink for CO2 assuming long-term use after production. In addition to the option of using it across subsectors, captured CO2 will have to be stored or sold to other economies. Comparison of the developed scenarios allows the identification of no-regret measures to enable climate neutrality by 2050 that should be deployed as soon as possible by push and pull incentives. The model results of the two transition scenarios show the need for technology promotion as well as infrastructure development needs and allow the identification of possible corridors, focal points, and fuel shifts - on the subsector level as well as in energy policy. Among others, the modelled magnitude of renewable energy consumption shows the need for swift expansion of existing national renewable energy potentials and energy infrastructure, especially for energy intensive industry regions. In light of the current energy consumption in other economic sectors (most notably in buildings or transport) and limited renewable potentials, large import shares of national gross domestic energy consumption are likely for Austria in the future.

Effect of alirocumab added to high-Intensity statin therapy on endothelial function in patients with acute myocardial infarction: a sub-study of the randomized placebo-controlled PACMAN-AMI trial

Background

Endothelial dysfunction is involved early in the development of vascular dysfunction leading to atherosclerosis and cardiovascular diseases. Statins have shown to improve endothelial function. The role of the protein convertase subtilisin/kexin type 9-inhibitor (PCSK9) alirocumab on endothelial function among patients with acute myocardial infarction (AMI) remains unknown.

Purpose

We investigated the effect of alirocumab on endothelial function among AMI patients receiving PCSK9i alirocumab in addition to high intensity statin therapy.

Methods

This is a pre-specified, sub-study nested within the PACMAN-AMI (effects of the PCSK9 antibody AliroCuMab on coronary Atherosclerosis in patieNts with Acute Myocardial Infarction) trial, a randomized trial that compared the effects of biweekly PCSK9-inhibitor alirocumab 150 mg vs. placebo, initiated within 24h of presentation in patients with AMI on top of high-intensity statin. Patients recruited at Bern University Hospital and adherent to the study drug (alirocumab or placebo) were analysed for the current study. Endothelial function was assessed by flow mediated dilation (FMD) of the brachial artery at week 4 and 52 after treatment initiation.

Results

Among 139 patients (68 alirocumab, 71 placebo) completing the sub-study, baseline characteristics were well balanced between groups (alirocumab vs. placebo: mean age 57.5±10.1 years vs. 58.7±8.4 years, p=0.45; mean LDL-C 4.03±0.93 mmol/L vs. 4.05±0.74 mmol/L, p=NS). At week 52 LDL-C levels decreased to 0.65±0.71 mmol/L in the alirocumab group and to 1.98±0.71 mmol/L in the placebo group (p<0.001). There was no difference in FMD at 52 weeks in the alirocumab (5.44±2.24%) versus placebo (5.45±2.19%) group (between groups difference FMD, −0.21% (95% CI −077 to 0.35), p=0.47). Compared to baseline, follow-up FMD was improved in both groups (from 4.52±1.87 to 5.44±2.24%, p<0.001 in the alirocumab group and from 4.32±1.62 to 5.45±2.19%, p<0.001 in the placebo group).

Conclusion

Among patients with acute myocardial infarction, the addition of subcutaneous biweekly alirocumab, compared with placebo, to high-intensity statin therapy did not result in additional improvement of endothelial function after 52 weeks of treatment.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The PACMAN-AMI study was supported by a research grant from Sanofi, Regeneron and Infraredx. This substudy was funded by the University of Bern.

Frequency and prognostic impact of periprocedural myocardial infarction determined by various MI definitions in patients with chronic coronary syndromes undergoing percutaneous coronary intervention

Background

Several definitions of peri-procedural myocardial infarction (MI) requiring different biomarker thresholds with or without ancillary criteria for myocardial ischemia are currently recommended without being fully validated in real-world patients with chronic coronary syndrome (CCS) undergoing percutaneous coronary intervention (PCI).

Objectives

We aimed to evaluate the prevalence and prognostic value of high-sensitivity cardiac troponin-based peri-procedural MI according to contemporary MI definitions using a large real-world PCI cohort.

Methods

In CCS patients undergoing elective PCI enrolled to the Bern PCI registry (NCT02241291) between 2010 and 2018, peri-procedural myocardial injury and infarction were assessed according to the 4th and 3rd universal definition of MI (UDMI), academic research consortium (ARC)-2, and Society for Cardiovascular Angiography and Interventions (SCAI) criteria. The primary endpoint was cardiac death at 1 year.

Results

Among 4404 CCS patients, peri-procedural MI defined by the 4th UDMI, 3rd UDMI, ARC-2, and SCAI were observed in 14.9%, 18.0%, 2.0%, and 2.0% of patients, respectively. Cardiac mortality at 1 year in patients with peri-procedural MI defined by 4th UDMI, 3rd UDMI, ARC-2, and SCAI were 3.0%, 2.9%, 5.8%, and 10.0%, respectively. After multivariate adjustments, peri-procedural MI defined by the ARC-2 and SCAI were independently associated with cardiac death at 1 year, while those defined by the 4th and 3rd UDMI were not.

Conclusion

Among CCS patients undergoing PCI, periprocedural MIs defined by theARC-2 and SCAI occurred 7 to 9 times less frequently as compared with the 4th and 3rd UDMI, and were the only definitions significantly associated with cardiac mortality.

Funding Acknowledgement

Type of funding sources: None. Cardiac death at 1 year

Infective endocarditis after transcatheter or surgical aortic valve implantation: pooled results from three randomized controlled trials

Background

Infective endocarditis is a rare complication of aortic valve replacement with high morbidity and mortality. Data of randomized trials comparing the incidence and outcomes between surgical (SAVR) and transcatheter aortic valve replacement (TAVR) are scarce.

Purpose

To compare the frequency, timing and outcomes of infective endocarditis after TAVR and SAVR from 3 prospective randomized trials and examine the clinical outcomes.

Methods

Clinical data from the CoreValve Pivotal High-Risk, the intermediate-risk SURTAVI and the Evolut Low Risk randomized trials, which compared TAVR with a supra-annular, self-expanding transcatheter valve to SAVR, was pooled. Cases of infective endocarditis were independently adjudicated based on Duke's criteria necessitating 2 major criteria, or 1 major and 3 minor criteria, or 5 minor criteria. Baseline clinical and procedural characteristics for patients with and without endocarditis were obtained. The cumulative incidence of endocarditis through 5 years after TAVR or SAVR was determined using death as a competing risk. Kaplan-Meier estimates of all-cause mortality and the composite of all-cause mortality or stroke through 2 years were calculated for both treatment groups.

Results

Among 2249 TAVR patients, 12 cases of endocarditis (0.5%) were documented and among 1828 SAVR patients, 21 (1.1%) over a mean follow-up time of 2.25±1.58 years. Baseline characteristics were well-balanced between the TAVR and SAVR patients with endocarditis. The cumulative incidence of endocarditis at 5 years was significantly different between the two groups (figure). The prevalence of diabetes was significantly higher in patients with endocarditis than in those without (57.6% vs. 34.2%, p=0.005). In endocarditis patients the rate of all-cause mortality was 39.4% for TAVR patients and 67.8% for SAVR patients at 2 years (log-rank p=0.133). The rates of all-cause mortality or stroke were 55.0% for TAVR and 64.6% for SAVR patients (log-rank p=0.078).

Conclusions

In this pooled analysis of three randomized trials comparing TAVR with a supra-annular, self-expanding bioprosthesis to SAVR, overall rates of endocarditis were low. The cumulative incidence of infective endocarditis at 5 years was lower in the TAVR group. Mortality after endocarditis was high.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Medtronic

Age-related clinical and hemodynamic outcome following transcatheter aortic valve replacement: a swiss TAVI registry analysis

Background

Transcatheter aortic valve implantation (TA) is the preferred treatment modality for patients with severe aortic valve disease at high surgical risk and is expanding into lower risk populations. Therefore age range of treated patients is increasing.

Purpose

The aim of this study is to analyze age-related clinical and hemodynamic outcome of patients following TAVI in a nationwide, prospective, multicentre cohort (Swiss TAVI registry).

Methods

We retrospectively analyzed prospectively collected data from all patients included in the Swiss TAVI registry between February 2011 and December 2018. In an adjusted analysis, in-hospital, 30-days and 1-year outcome between four age groups were compared.

Results

Overall, 7097 patients underwent TAVI (<70 years: n=324, 70–79 years: n=1913, 80–89 years: n=4353, 90–100 years n=507). Median STS risk score for mortality was 5.23±4.13% and differed significantly between age groups (3.46±4.10%, 3.97±3.73%, 5.57±3.97%, 8.22±4.74%; p=0.001). Valve predilatation was more often performed in older patients (54.3% vs. 54.3% vs. 60.7% vs. 69.6%; p≤0.001). Difference in hospital stay was statistically sigificant between age groups, numerically however not relevant (10.01±7.56 days vs. 9.25±6.38 days vs. 9.55±5.70 days vs 10.03±5.77 days; p=0.02). Post-procedural acute kidney injury stage 3 was highest in the youngest age group (3.4% vs. 1.6% vs. 1.1% vs. 1.0%; RR [95% CI] 0.65 (0.48–0.87); p=0,004) and rate of new pacemakers for conduction abnormalities increased significantly with age (10.2% vs. 13.7% vs. 17.1% vs. 18.7%; RR [95% CI] 1.22 (1.12–1.32); p<0.001). There was no significant difference in life threatening/major bleeding (p=0.288/0.197) or major vascular complications (p=0.083).

All-cause mortality and cardiovascular mortality in hospital, at 30 days and at 1 year were highest in nonagenarians and higher in the patients <70 years compared to patients of 70–79 years: in hospital all-cause mortality 2.2% vs. 1.6% vs. 2.9% vs. 5.5% (RR [95% CI] 1.64 (1.28–2.10), p<0.001); 30 day all-cause mortality 3.1% vs. 2.0% vs. 3.7% vs. 6.7%; (HR [95% CI] 1.59 (1.30–1.96); p<0.0001); 1-year all-cause mortality 10.9% vs. 10.4% vs. 12% vs. 19.5% (HR [95% CI] 1.27 (1.14–1.41); p<0.001); in hospital cardiovascular mortality 1.5% vs. 1.5% vs. 2.6% vs. 5.1% (RR [95% CI] 1.70 (1.31–2.20), p<0.001); 30 day cardiovascular mortality 2.2% vs. 1.9% vs. 3.3% vs. 6.3%; (HR [95% CI] 1.68 (1.35–2.09); p<0.001); 1-year cardiovascular mortality 7.2% vs. 6.9% vs. 8.3% vs. 15.3% (HR [95% CI] 1.36 (1.19–1.55); p<0.001). This held true, when hazard ratio was corrected for STS PROM score, femoral access vs other access and year of procedure.

Conclusion

In-hospital, 30-day and 1-year clinical outcome of nonagenarians undergoing TAVI are less favorable compared to lower age groups. Interestingly, clinical outcome of the patients group 70–79 years was the most favorable.

Mortality at 30 according to age

Funding Acknowledgement

Type of funding source: None

P5500Acute coronary syndrome in young patients: frequency, mechanisms and clinical outcomes following percutaneous coronary intervention

Introduction

Acute coronary syndromes (ACS) mainly affect older patients and little is known on the frequency, the underlying causes and outcomes following ACS in young.

Purpose

To investigate the frequency, mechanisms and clinical outcomes of young patients suffering from ACS and undergoing percutaneous coronary intervention (PCI).

Methods

Between February 2009 and December 2016, 6720 consecutive patients undergoing PCI for an ACS were prospectively enrolled. We defined young patients as male <45 years or female <50 years. The primary endpoint was the patient-oriented composite endpoint (POCE) defined as the composite of all-cause death, myocardial infarction or any revascularization at 12 months. The mechanisms of ACS in young patients (atherosclerotic vs. embolic vs. spontaneous coronary artery dissection) were retrospectively assessed by an adjudication committee based on clinical and angiographic criteria.

Results

Among 6720 ACS patients, 378 (5.6%) patients were young (41±5 years, 73% male). Young patients, as compared to old patients, presented more frequently with STEMI (64% vs. 45%; p<0.001) and single vessel disease (85% vs. 74%; p<0.001). Cardiovascular risk factors were more frequent in young patients including BMI>30 kg/m2 (34% vs. 22%; p<0.001), smoking (68% vs. 31%; p<0.001), positive family history of coronary artery disease (35% vs. 23%; p<0.001) and baseline LDL-C levels (3.3±1.1 mmol/l vs. 2.9±1.1 mmol/l; p<0.001). Diabetes mellitus was less frequent in the young patient group (10% vs. 21%; p<0.001). The mechanisms of ACS in young patients were atherosclerotic in 87%, coronary embolism in 9%, and spontaneous coronary artery dissection in 4%. At 12 months, the primary endpoint POCE occurred less frequently in young patients (9.3% vs. 17%; HR 0.52, 95% CI 0.37–0.73; p<0.001). The rates of the individual components of the primary endpoint were lower in young patients including all-cause death (3.4% vs. 9.4%; HR 0.36, 95% CI 0.21–0.62; p<0.001), myocardial infarction (1.9% vs. 3.7%; HR 0.48, 95% CI 0.22–1.01; p=0.053) and any revascularization (5.6% vs. 7.7%; HR 0.68, 95% CI 0.44–1.05; p=0.083). Young patients with coronary embolism or spontaneous coronary artery dissection had a higher rate of cardiac death at 12 months as compared to young patients with atherosclerotic disease (embolic vs. atherosclerotic: 9.4% vs. 2.2%; HR 4.3, 95% CI 1.11–16.71; p=0.02; spontaneous coronary artery dissection vs. atherosclerotic: 17.6% vs. 2.2%; HR 8.1, 95% CI 2.1–31.1; p<0.001).

Conclusions

Approximately one out of 20 ACS patients undergoing PCI was young and the main presumed mechanism of ACS was atherosclerosis (87%) followed by coronary embolism (9%) and spontaneous coronary artery dissection (4%). While young ACS patients carry a lower risk for future cardiovascular events as compared with older patients, the high cardiac death rates following embolic disease or spontaneous coronary artery dissections deserves particular attention.

98Mitral annular calcification, mitral valve diseases and clinical outcomes in patients undergoing transcatheter aortic valve replacement for severe aortic stenosis

Background

Mitral annular calcification (MAC) and mitral valve diseases (MVD) have been identified as strong predictors of mortality in patients undergoing transcatheter aortic valve replacement (TAVR). However, the association between MAC and MVD, and the prognostic implications in these patients remain unclear.

Purpose

This study sought to investigate the association between severity of MAC and the prevalence of MVD as well as to assess the prognostic impact of MAC depending on the presence or absence of MVD in patients undergoing TAVR.

Methods

We identified 967 patients who have comprehensive echocardiographic and computed tomographic assessment of MVD and MAC from our institutional registry that is a part of the Swiss TAVI registry (NCT01368250) between August 2007 and June 2017.

Results

Among these patients, mild or moderate MAC was present in 45.2% and severe MAC was present in 17.8%. The prevalence of MVD was significantly higher in severe MAC patients, while the prevalence in patients with mild and moderate MAC was similar to patients without MAC. Compared to patients without severe MAC and MVD, an increased risk of all-cause death at 1 year was observed in patients with severe MAC and MVD (hazard ratio [HR]: 2.81, 95% confidence interval [CI]: 1.72–4.59, p<0.001) as well as in patients with non-severe MAC and MVD (HR: 2.80, 95% CI: 1.87–4.20, p<0.001) but not in patients with severe MAC and non-MVD (HR: 0.68, 95% CI: 0.27–1.70, p=0.409). In a multivariable analysis, severe MAC concomitant with MVD was found to be an independent predictor of new permanent pacemaker implantation after TAVR (Odds ratio: 2.08, 95% CI: 1.27–3.41, p=0.004).

Conclusions

Severe MAC was associated with higher prevalence of MVD. Severe MAC concomitant with MVD was associated with increased risks of mortality at 1 year and conduction abnormalities after TAVR, whereas severe MAC without MVD was not.

Coronary revascularization and TAVI: before, during, after or never?

Aortic valve stenosis and coronary artery disease (CAD) frequently coexist in elderly patients selected for transcatheter aortic valve implantation (TAVI). Therapeutic strategies to manage concomitant obstructive CAD are therefore an important consideration in the overall management of patients with severe aortic stenosis (AS) undergoing TAVI. Conventional surgical aortic valve replacement and coronary artery bypass grafting is the treatment of choice for low and intermediate risk patients with symptomatic severe AS and concomitant obstructive CAD. However, TAVI and percutaneous coronary intervention (PCI) are viable alternative options for high-risk or inoperable patients presenting with symptomatic severe AS. PCI has been shown to be feasible and safe in selected high-risk or inoperable patients with symptomatic severe AS. However, the optimal timing of PCI relative to the TAVI procedure has been a subject of debate. The most frequent approch is staged PCI typically performed a few weeks prior to TAVI. However, concomitant PCI has also been shown to be a feasible and safe approach, particularly in patients with a low level of CAD complexity and an absence of severe renal impairment. Conversely, staged PCI should be considered in patients with higher degrees of CAD complexity, particularly in the presence of severe renal impairment. The aim of the present review is to discuss the safety and feasibility of performing PCI in elderly patients with severe AS and the optimal timing of PCI relative to the TAVI procedure using the most up-to-date available evidence.

Transcatheter aortic valve implantation: patient selection

Transcatheter aortic valve implantation (TAVI) is a disruptive technology as it satisfies a previously unmet need which is associated with a profound therapeutic benefit. In randomized clinical trials, TAVI has been shown to improve survival compared with medical treatment among patients considered not suitable candidates for surgical aortic valve replacement (SAVR), and to provide similar outcomes as SAVR in selected high-risk patients. Currently, TAVI is limited to selected elderly patients with symptomatic severe aortic stenosis. As this patient population frequently suffers from comorbid conditions, which may influence outcomes, the selection of patients to undergo TAVI underlies a complex decision process. Several clinical risk score algorithms are routinely used, although they fall short to fully appreciate the true risk among patients currently referred for TAVI. Beyond traditional risk scores, the clinical assessment by an interdisciplinary Heart Team as well as detailed imaging of the aortic valve, aortic root, descending and abdominal aorta as well as peripheral vasculature are important prerequisites to plan a successful procedure. This review will familiarize the reader with the concepts of the interdisciplinary Heart team, risk scores as well as the most important imaging algorithms suited to select appropriate TAVI patients.

[Abdominal dressing -- a new standard in therapy of the open abdomen following secondary peritonitis?]

INTRODUCTION

The management of patients with a laparostoma due to peritonitis is a challenge for every surgeon and intensivist. The goal of this study was to compare the different treatment strategies for the open abdomen: Abdominal Dressing (AD), the classic V.A.C. therapy (CV) and conventional open therapy (CT).

METHODS

Between 2001 and 2005 we identified 62 patients in 4 surgical departments in Austria who had to be treated with a laparostoma due to peritonitis. 27 patients were conventionally treated, 16 with the Classic V.A.C. therapy and 19 patients with V.A.C. abdominal dressing.

RESULTS

The mortality was 3/16 (14 %) in the AD group vs. 4/12 (21 %) patients in the CV group and 18/9 (59 %) in conventional therapy. There was no significant difference for survivors in the length of ICU stay: 26.6 +/- 23.0 days in the CT group, 34.6 +/- 30.2 days in the CV group and 38.9 +/- 27.2 days in the AD group. Apache II Score and Mannheimer Peritonitis Score showed no difference between the groups.

CONCLUSION

We found a reduction of mortality in the V.A.C. Abdominal Dressing group by approximately 40 % (AD: 14 %, CT: 59 %). Although we could identify a difference in age in our retrospective study we believe that V.A.C. Abdominal Dressing is the important factor for the different clinical outcome. These first results indicate the need for further prospective evaluation of the V.A.C. Abdominal Dressing therapy, to prove if a new standard in the therapy of the open abdomen is created.