Growth control of Marchantia polymorpha gemmae using nonthermal plasma irradiation

Several studies have documented that treatment by cold atmospheric pressure plasma (CAPP) on plants foster seed germination and growth in recent years. However, the molecular processes that underlie the action of CAPP on the seeds and plants remain mostly enigmatic. We here introduce gemmae of Marchantia polymorpha, a basal liverwort, as a novel model plant material suitable for CAPP research. Treating the gemmae with CAPP for a constant time interval at low power resulted in consistent growth enhancement, while growth inhibition at higher power in a dose-dependent manner. These results distinctly demonstrate that CAPP irradiation can positively and negatively regulate plant growth depending on the plasma intensity of irradiation, offering a suitable experimental system for understanding the molecular mechanisms underlying the action of CAPP in plants.

Tailoring Interfacial Physicochemical Properties in Cu2O-TiO2@rGO Heterojunction: Insights from EXAFS and Electron Trap Distribution Analysis

In this study, a solution-based synthesis technique was utilized to produce Cu2O nanoparticles (NPs) on TiO2 nanofibers (TNF), which were then subsequently coated with reduced graphene oxide (rGO) nanosheets. In the absence of any cocatalyst, CTNF@rGO-3% composite displayed an ideal photocatalytic H2 evolution rate of 96 μmol g-1 h-1 under visible light irradiation, this was 10 times higher than that of pure TNF. At 420 nm, the apparent quantum efficiency of this composite reached a maximum of 7.18%. Kelvin probe force microscopy demonstrated the formation of an interfacial electric field that was oriented from CTNF to rGO and served as the driving force for interfacial electron transfer. The successful establishment of an intimate interface between CTNF@rGO facilitated the efficient transfer of charges and suppressed the rate of recombination of photogenerated electron-hole pairs, leading to a substantial enhancement in photocatalytic performance. X-ray photoelectron spectroscopy, photoluminescence spectra, and electrochemical characterization provide further confirmation that formation of a heterojunction between CTNF@rGO leads to an extension in the lifetimes of the photogenerated charge carriers. The experimental evidence suggests that a p-n heterojunction is the mechanism responsible for the significant photocatalytic activity observed in the CTNF@rGO composite during H2 evolution.

Health assessment of rice cultivated and harvested from plasma-irradiated seeds

This study provides the health effects assessment of rice cultivated from plasma-irradiated seeds. The rice (Oryza sativa L.) cultivated from seeds with plasma irradiation showed a growth improvement (slope-ratios of with plasma to without plasma were 1.066, 1.042, and 1.255 for tiller, and earing, and ripening periods, respectively) and an 4% increase in yield. The cultivated rice was used for repeated oral administrations to mice for 4-week period. Distilled water and rice cultivated from seeds without plasma irradiation were also used as control. The weights of the lung, kidney, liver, and spleen, with corresponding average values of 0.22 g, 0.72 g, 2.1 g, and 0.17 g for w/ plasma group and 0.22 g, 0.68 g, 2.16 g, and 0.14 g for w/o plasma group, respectively, showing no effect due to the administration of rice cultivated from plasma-irradiated seeds. Nutritional status, liver function, kidney function, and lipid, neutral fat profiles, and glucose metabolism have no significant difference between with and without plasma groups. These results show no obvious subacute effects were observed on rice grains cultivated and harvested from the mother plant that experienced growth improvement by plasma irradiation. This study provides a new finding that there is no apparent adverse health effect on the grains harvested from the plasma-irradiated seeds.

Proton Beam Therapy for HCC Exceeding up-to-Seven Criteria

PURPOSE/OBJECTIVE(S)

Whilst standard treatment for intermediate-stage hepatocellular carcinoma (HCC) is transcatheter arterial chemoembolization (TACE), those exceeding "up-to-seven" criteria don't respond as such as those within, and systemic therapy is suggested to be more beneficial. This is sought to be both because of the limited efficacy of TACE and its hepatic toxicity. Proton beam therapy (PBT) offers high local control and low toxicity rates, and we hypothesize that the same can be said in this patient group also. We here present the outcome of PBT for primary HCC exceeding "up-to-seven" criteria.

MATERIALS/METHODS

Primary HCC treated with PBT between 2010 and 2018 were extracted from an all-in treatment database and retrospectively reviewed. (Maximum diameter of the largest tumor in centimeters) + (tumor count) > 7 was considered as exceeding "up-to-seven" criteria. Local recurrence was defined as tumor re-enlargement or the appearance of arterial phase hyperenhancement. Adverse events were evaluated by CTCAE v5.0. Overall survival and recurrence-free survival were determined by the Kaplan-Meier method, and local recurrence was analyzed as cumulative incidence with death as a competing risk. All statistical analyses were done using R.

RESULTS

Out of 202 primary cases, 79 exceeded the "up-to-seven" criteria. The median tumor diameter was 8.0 cm (range 3.1 - 20 cm) and macroscopic vascular invasion (MVI) was observed in 26 cases. For tumor count, 36 were solitary, 28 were between 2 - 3, and 15 had 4 or more. According to the modified ALBI grade, 38 were grade 1, 18 were grade 2a and 23 were 2b. The prescribed dose was 66 Gy / 10 Fr for 6, 72.6 Gy / 22 Fr for 60, 74 Gy / 37 Fr for 12 and 60 Gy / 15 Fr for one case after relative biological effect weighting of 1.1. With a median follow-up period of 33 months (IQR 15 - 57 months), 2-year overall survival was 62% (95% C.I. 50 - 72%) and median survival time was 37 months (95% C.I. 30 - 52 months). 2-year recurrence-free survival and local recurrence rate were 42% (95% C.I. 30 - 53%) and 8% (95% C.I. 3 - 15%) respectively. Cox regression analysis revealed modified ALBI grade as the only significant risk factor for survival (hazard ratio 1.80, 95% C.I. 1.27 - 2.55, p = 0.0010) among age, sex, alpha-fetoprotein level, MVI, tumor count, and size. Other than one case of early death (2 weeks after treatment) with an unknown causal relationship, there were no adverse events of grade 4 or higher observed.

CONCLUSION

PBT for primary HCC exceeding "up-to-seven" criteria appears to be safe and effective. Local control of intrahepatic lesions may be beneficial even in intermediate-stage cases, while results of this study suggests that suppression of out-of-field recurrence is required for further survival prolongment.

Outcome of Proton Beam Therapy for Primary Hepatocellular Carcinoma with "Unfavorable" Macroscopic Classification

PURPOSE/OBJECTIVE(S)

Transcatheter arterial chemoembolization (TACE) is the standard treatment for early to intermediate-stage hepatocellular carcinoma (HCC) unfit for hepatectomy or radiofrequency/microwave ablation (RFA/MWA). Putting aside its hepatic toxicity, local control of TACE is far from satisfactory, especially with non- "simple nodular type" appearances, to an extent where systemic therapy is suggested to be more beneficial. We here analyzed the outcome of proton beam therapy (PBT) for primary HCC by macroscopic classification.

MATERIALS/METHODS

Primary HCC treated with PBT between 2010 and 2018 were extracted from an all-in treatment database. The macroscopic classification was defined by CT or MRI prior to PBT. Local recurrence was defined as tumor re-enlargement or the appearance of arterial phase hyperenhancement. Adverse events were evaluated by CTCAE v5.0. Overall survival, local control, intrahepatic recurrence-free survival, and extrahepatic recurrence-free survival were determined by the Kaplan-Meier method, and the association with treatment factors was analyzed by log-rank and cox regression model.

RESULTS

A total of 202 primary HCC cases were extracted, all not a candidate for hepatectomy nor RFA/MWA. Out of them, 75 cases were simple nodular type, 79 were simple nodular type with extranodular growth, 38 were confluent multinodular type, and 10 were infiltrative type. 26 cases were HBV positive, and 84 cases were HCV positive. 35 cases had macroscopic vascular invasion (MVI). With a median follow-up period of 3.72 years (IQR: 1.79-5.85years), the 3-year overall survival rate was 68.1% (95% CI 61.0 - 74.3%), the 3-year local control rate was 89.6% (95% CI 83.4-93.5), the 3-year intrahepatic recurrence-free survival rate was 53.7% (95% CI 45.9-60.8%), and the 3-year extrahepatic recurrence-free survival rate was 87.4% (95% CI: 81.5-91.6%). Simple nodular type had better overall survival (73.2% vs 65.2% p = 0.012) and extrahepatic recurrence free survival (96.9% vs 81.9% p<0.01), but there was no statistically significant difference in local control (92.7% vs 87.6% p = 0.06) and intrahepatic recurrence-free survival (62.0% vs 48.5% p = 0.114). Multivariate analysis of risk factors against OS, including age, sex, AFP, MVI, and macroscopic classification, revealed age and macroscopic classification as independent risk factors. Adverse events of grade 3 included 2 cases of gastrointestinal bleeding, 7 cases of liver function disorder, 1 cases of biliary hemorrhage, and 1 case of pleural effusion. Other than one case of early death (2 weeks after treatment) with an unknown causal relationship, there were no adverse events of grade 4 or severe.

CONCLUSION

PBT for non- "simple nodular type" primary HCC appears to be safe and effective, whilst suppression of out-of-field recurrence is needed for further survival prolongment.

Influence of electric potential-induced by atmospheric pressure plasma on cell response

Plasma irradiation leads not only active species, but also reactive chemical species, ultraviolet light, electric fields, magnetic fields, and shock waves. To date the effects of reactive chemical species have been mainly discussed. To understand the biological effect caused by an electric potential induced with an atmospheric-pressure plasma, the behavior of cell stimulated by electric potential was investigated using HeLa cell. The cell concentration assay revealed that less than 20% of cells inactivated by potential stimulation and the remained cells proliferate afterward. Fluorescent microscopic observation revealed that potential stimulation is appreciable to transport the molecules through membrane. These results show that potential stimulation induces intracellular and extracellular molecular transport, while the stimulation has a low lethal effect. A possible mechanism for this molecular transport by potential stimulation was also shown using numerical simulation based on an equivalent circuit of the experimental system including adhered HeLa cell. The potential formation caused by plasma generation is decisive in the contribution of plasma science to molecular biology and the elucidation of the mechanism underlying a biological response induction by plasma irradiation.

Proof-of-Principle Experiment for Testing Strong-Field Quantum Electrodynamics with Exotic Atoms: High Precision X-Ray Spectroscopy of Muonic Neon

To test bound-state quantum electrodynamics (BSQED) in the strong-field regime, we have performed high precision x-ray spectroscopy of the 5g-4f and 5f- 4d transitions (BSQED contribution of 2.4 and 5.2 eV, respectively) of muonic neon atoms in the low-pressure gas phase without bound electrons. Muonic atoms have been recently proposed as an alternative to few-electron high-Z ions for BSQED tests by focusing on circular Rydberg states where nuclear contributions are negligibly small. We determined the 5g_{9/2}- 4f_{7/2} transition energy to be 6297.08±0.04(stat)±0.13(syst)  eV using superconducting transition-edge sensor microcalorimeters (5.2-5.5 eV FWHM resolution), which agrees well with the most advanced BSQED theoretical prediction of 6297.26 eV.

Frailty and use of treatment in patients with heart failure and reduced ejection fraction

Background

In heart failure with reduced ejection fraction (HFrEF), drugs including angiotensin-converting enzyme inhibitors (ACEi)/ angiotensin receptor blockers (ARB), beta-blockers, and mineralocorticoid receptor antagonists (MRA) have been shown to have robust survival benefits. However, these guideline-recommended therapies remain underutilized in clinical practice. Frailty is common in HFrEF and may lead to underprescription of life-saving therapy.

Purpose

We aimed to investigate the association between physical frailty and the use of evidence-based pharmacological therapy for HFrEF, and the impact of this on prognosis

Methods

The FLAGSHIP study included patients hospitalized for acute HF and data on physical frailty were collected prospectively. Of the total 3,272 patients registered in the FLAGSHIP study, 1,041 HFrEF patients (70 years; 73% male) with left ventricular ejection fraction ≤40% were analyzed and were divided into 4 groups by severity of frailty: category I (n=371) [least frail], II (n=275), III (n=224), and IV (n=171) [most frail].

Results

An ACEi/ARB was prescribed in 76% of category I and 53% of category IV patients; for a beta-blocker these proportions were 94% and 76%, respectively; for an MRA they were 55% and 46%, respectively. The proportion of patients using receiving all 3 drugs decreased as frailty increased, with approximately twice the rate of use of triple therapy in category I patients (40.2%) compared to category IV patients (23.4%) [p&lt;0.001] (Figure 1). In adjusted analyses, the severity of frailty was an independent predictor for non-use of an ACEi/ARB (Odds ratio (OR): 1.23, 95% CI: 1.05–1.43, per 1 category increase) and a beta-blocker (OR: 1.32, 95% CI: 1.06–1.64), but not an MRA (OR: 0.97, 95% CI: 0.84–1.12). Risk of the composite outcome of all-cause death or HF rehospitalization increased with decreasing use of treatment across frailty categories: category I-II (Hazard ratio (HR): 1.80, 95% CI: 1.08–2.98, in 0–1 drug with 3 drugs as reference) and III–IV (HR: 1.53, 95% CI: 1.01–2.32). The relationship between the number of HF drugs prescribed and the composite outcome did not differ across frailty categories (p-interaction=0.86). The HRs for all 12 groups, reflecting frailty categories and a number of HF drugs is depicted in Figure 2. The HRs for composite outcome increased with increasing frailty category and with decreasing number of drugs, with an almost 4-fold difference in risk between the least frail patients receiving all three evidence-based therapies and the most frail receiving only 0–1 drug.

Conclusions

Prescription of guideline-recommended therapy decreased as the severity of frailty increased in patients with HFrEF. Sub-optimal medical therapy was associated with a worse outcome and underprescription of guideline-recommended therapy may contribute to the poor prognosis associated with frailty. An effective strategy is needed to improve the medical treatment of frail patients with HFrEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study issupported by a Grant-in-Aid for Scientifi c Research (A) from the Japan Society for the Promotion of Science (16H01862). ToruKondo receives grants from the Uehara Memorial Foundation and the Japanese Heart Failure Society Tsuchiya Foundation forthe research activities at the University of Glasgow.

Derivation and validation of a machine learning-based risk prediction model for in-hospital mortality in patients with acute heart failure

Background

Although risk stratification is important in patients with acute heart failure (AHF) to predict patient prognosis, pre-existing risk models have not often been used due to its complexity. Recently, machine learning methods have been presented as an alternative approach to analyzing the predictive probability of large clinical datasets.

Purpose

The aim of this study is to develop a user-friendly risk score developed by one of machine learning methods and compare the performance of the new risk score to the existing conventional risk models.

Methods

A machine-learning-based risk model was developed using least absolute shrinkage and selection operator (LASSO) regression by identifying predictors of in-hospital mortality in the derivation cohort (REALITY-AHF) and externally validating and comparing its performance with two pre-existing risk models: the Get With The Guidelines risk score incorporating brain natriuretic peptide and hypochloremia (GWTG-BNP-Cl-RS) and the acute decompensated heart failure national registry (ADHERE) risk model.

Results

In-hospital deaths in the derivation and validation (NARA-HF) cohorts were 76 (5.1%) and 61 (4.9%), respectively. The risk score comprised four variables (systolic blood pressure, blood urea nitrogen, serum chloride, and C-reactive protein) and was developed according to the results of the LASSO regression weighting the coefficient for selected variables using a logistic regression model (4V-RS). Even though 4V-RS comprised fewer variables, In the validation cohort, it showed a higher area under the receiver operating characteristic curve (AUC) than the ADHERE risk model (AUC, 0.783 vs. 0.740; P=0.059) and a significant improvement in net reclassification (0.359; 95% CI, 0.10–0.67; p=0.006). 4V-RS performed similarly to GWTG-BNP-Cl-RS in terms of discrimination (AUC, 0.783 vs. 0.759; p=0.426) and net reclassification (0.176; 95% CI, −0.08–0.43; p=0.178).

Conclusions

The 4V-RS model comprising only four readily available data points at the time of admission performed similarly to the more complex pre-existing risk model in patients with AHF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiovascular Research Fund

Effect of RNAi therapeutics patisiran and vutrisiran on orthostatic hypotension due to dysautonomia in patients with hereditary transthyretin-mediated amyloidosis with polyneuropathy

Background

Hereditary transthyretin-mediated (hATTR) amyloidosis, also known as ATTRv amyloidosis, is a rapidly progressive, multisystem disease. Orthostatic hypotension, due to autonomic neuropathy, is a common yet hard-to-treat disease manifestation in patients with hATTR amyloidosis. Fatigue, muscle weakness, and deterioration in cardiac function further exacerbate orthostatic symptoms. Efficacy of RNAi therapeutics patisiran and vutrisiran was assessed in patients with hATTR amyloidosis with polyneuropathy across the APOLLO (NCT01960348), Global Open-Label Extension (OLE) (NCT02510261), and HELIOS-A (NCT03759379) studies, respectively.

Purpose

Evaluate the quantitative effect of patisiran and vutrisiran on orthostatic hypotension in patients with hATTR amyloidosis with polyneuropathy.

Methods

In APOLLO, patients were randomised 2:1 to patisiran 0.3 mg/kg or placebo, IV q3w. Patients who completed APOLLO (APOLLO-placebo, APOLLO-patisiran) were eligible to enrol into the ongoing Global OLE (patisiran 0.3 mg/kg IV q3w). In HELIOS-A, patients were randomised 3:1 to vutrisiran (25 mg SC q3m) or patisiran (0.3 mg/kg IV q3w; reference group). Primary endpoint for APOLLO and HELIOS-A was change from baseline in the modified Neuropathy Impairment Score+7 (mNIS+7) vs APOLLO placebo at M18 (APOLLO) and M9 (HELIOS-A). Orthostatic hypotension was evaluated using the postural blood pressure (PBP) component of mNIS+7, calculated as the mean of 2 supine readings of systolic BP [SBP, mmHg] taken 15 min apart minus the lowest SBP upon standing at 1, 3, and 5 min. A smaller reduction in observed SBP between supine and upright readings indicated an improved PBP.

Results

APOLLO enrolled 225 patients (placebo, n=77; patisiran, n=148), Global OLE 211 and HELIOS-A 164 (vutrisiran, n=122; patisiran, n=42). At baseline, the severity of orthostatic hypotension was similar between within-study treatment arms in APOLLO and HELIOS-A. In APOLLO, patisiran-treated patients showed PBP improvement or stabilization from baseline to M18 (mean [SD] change in SBP: baseline, −17.6 [19.4]; M18, −13.5 [16.8]) and was maintained at Global OLE 36m (−13.4 [15.6]). In contrast, placebo-treated patients in APOLLO had an increased change in PBP over 18m (baseline, −17.5 [16.5]; M18, −20.4 [16.9]); their PBP improved after patisiran initiation (Global OLE 36m, −16.6 [18.1]). In HELIOS-A, stabilization in PBP was observed in the vutrisiran arm (baseline, −11.2 [14.0], M18, −11.7 [14.6]). In the smaller patisiran arm, while the change in PBP increased, the value remained in the normal range (baseline, −11.6 [17.2]; M18, −14.2 [15.5]). Patisiran and vutrisiran have acceptable safety profiles.

Conclusions

PBP analyses quantify the benefits of RNAi therapeutics patisiran and vutrisiran on autonomic function in patients with hATTR amyloidosis with polyneuropathy. The increase in change in PBP to a symptomatic range without treatment indicates the importance of early intervention.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Alnylam Pharmaceuticals

Detection of NO3- introduced in plasma-irradiated dry lettuce seeds using liquid chromatography-electrospray ionization quantum mass spectrometry (LC-ESI QMS)

Discharge plasma irradiates seeds with reactive oxygen and nitrogen species (RONS). However, RONS introduced in seeds by plasma irradiation have not been successfully detected thus far. This study provides experimental evidence that nitrate ion NO3- is introduced in lettuce seeds as RONS upon irradiation with atmospheric-pressure air dielectric barrier discharge plasma. Plasma irradiation for 5 min promotes seed germination. The components of the plasma-irradiated seeds were examined using electrospray ionization quantum mass spectrometry (ESI QMS), which revealed that the plasma irradiation introduced an ion with a mass of 62 m/z in detectable amounts. This ion was identified as NO3- by liquid chromatography (LC), multiple wavelength detector (MWD), and LC-ESI QMS. A one-dimensional simulation at electron temperature Te = 1 eV, electron density Ne = 1013/m3, and gas temperature Tg = 300 K indicated the introduction of NO3-, involving nitric oxide NO. NO3- is one of the most important ions that trigger signal transduction for germination when introduced in seeds. The scanning electron microscopy (SEM) images revealed that there was no change on the surface of the seeds after plasma irradiation. Plasma irradiation is an effective method of introducing NO3- in seeds in a dry process without causing damage.

Clinical value of the HATCH score for predicting adverse outcomes in patients with heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

The HATCH score is employed as a risk assessment tool for atrial fibrillation (AF) development. However, the impact of the HATCH score on the long-term adverse outcomes in patients with acute heart failure (AHF) is unknown.

Aimes

To investigate the clinical value of the HATCH score in AHF.

Methods

From a multicenter AHF registry, we retrospectively evaluated 1,543 consecutive patients admitted with AHF (median age, 78 [69–85] years; 42.3% women) from 2012 to 2019. These patients were divided into five groups based on their HATCH score at admission (scores 0, 1, 2, 3, and 4–7). The correlation between the HATCH score and composite outcome, including all-cause mortality and re-hospitalization due to HF, was analyzed using Kaplan-Meier and Cox proportional-hazard analyses.

Results

The median HATCH score was 2 [1-3]. During the follow-up period (median, 16.8 months), the composite endpoint occurred in 691 patients (44.8%), including 416 (27%) patients who died and 455 (29.5%) patients requiring re-hospitalizations due to HF. The Kaplan-Meier analysis showed a significant increase in the composite endpoint with increasing HATCH score (log-rank, p &lt; 0.001). The multivariate Cox regression model revealed that the HATCH score was an independent predictor of the composite endpoint (hazard ratio [HR] 1.181; 95% confidence interval [CI]: 1.111–1.255; p &lt; 0.001) with all-cause mortality (HR 1.153, 95% CI: 1.065–1.249; p &lt; 0.001) and re-hospitalizations due to HF (HR 1.21; 95% CI: 1.124–1.303; p &lt; 0.001) in patients with AHF.

Conclusions

The HATCH score is an independent predictor of adverse outcomes in patients with AHF. Abstract Figure. Kaplan-Meier analysis for outcome

Serum autotaxin level predicts future cardiac events in patients with dilated cardiomyopathy

Background

Autotaxin (ATX) has been reported to promote myocardial inflammation and subsequent cardiac remodeling through lysophosphatidic acid (LPA) production. However, the prognostic impact of ATX has not been clarified in dilated cardiomyopathy (DCM).

Purpose

We aimed to investigate the prognostic impact of ATX in patients with DCM.

Methods

We enrolled 104 DCM patients (49.8 years, 76 males). The subjects underwent blood sampling, echocardiography, cardiac catheterization, and endomyocardial biopsy. Gender differences in serum ATX levels have been reported, thus we divided the subjects into two groups using median serum ATX levels for men and women: High-ATX group and Low-ATX group. All patients were followed up by expert cardiologists. The cardiac event was defined as a composite of cardiac death and hospitalization for worsening heart failure.

Results

Eighty-nine percent of the subjects were classified as New York Heart Association functional class I or II. Female patients had higher serum ATX levels than male patients, with median values of 257.0 ng/mL and 203.5 ng/mL, respectively (Figure A). The average left ventricular ejection fraction and brain natriuretic peptide levels were 30.6% and 122.5 pg/mL. In survival analysis, cumulative event-free probability was significantly lower in High ATX group (p=0.007, Figure B). In Cox proportional hazards analysis, High-ATX was one of the independent predictors of composite cardiac events (Hazards Ratio, 2.575; p=0.043). On the other hand, high sensitive C-reactive protein and collagen volume fraction in myocardial samples were not significant predictors.

Conclusion

High serum ATX level was associated with poor prognosis in patients with DCM.

Funding Acknowledgement

Type of funding sources: None. Gender difference in autotaxin levelsSurvival analysis of cardiac events

Clinical significance of spleen size in patients with heart failure

Background

The spleen is an important organ that stores blood, releases erythrocytes or monocytes, and destroys no-longer-needed platelets. It can reserve 20–30% of the total blood volume, and its size is reduced in hypovolemic shock. However, the clinical significance of the spleen size in patients with heart failure (HF) remains unclear.

Purpose

The purpose of this study was to investigate the relationship between spleen size, hemodynamic parameters, and prognosis in patients with HF.

Methods

A total of 219 patients with clinically stable HF were enrolled. All patients underwent right heart catheterisation and computed tomography. The spleen size was measured using computed tomography volumetry. In addition, spleen volume was assessed using the spleen volume index (SVI), corrected for body surface area. Cardiac events were composite endpoints of cardiac death, hospitalisation for worsening HF, fatal arrhythmias, implantation of cardiac devices, implantation of left ventricular assist devices, and unexpected percutaneous coronary intervention or cardiac surgery. Spearman's rank correlation coefficient was used to examine the relationship between spleen volume and hemodynamic parameters. Multivariate Cox hazard regression models were used to investigate whether SVI was an independent determinant of cardiac events.

Results

Of the 219 patients (median age, 54 [interquartile range] 46–64 years), 145 (66%) were males. The median (interquartile range) spleen volume and SVI was 118.0 (91.5–156.0) mL and 67.8 (54.9–87.2) mL/m2, respectively. SVI was positively correlated with cardiac output (r=0.269, P&lt;0.001), and negatively correlated with systemic vascular resistance (r=−0.302, P&lt;0.001) (Figure 1). A total of 70 cardiac events were observed, and the optimal cut-off value of SVI for cardiac events was 68.9 mL/m2 in the receiver operating characteristic analysis. Patients were divided into two groups: low-SVI (n=107, &lt;68.9 mL/m2) and high-SVI groups (n=112, ≥68.9 mL/m2). Blood adrenaline concentration was higher in the low-SVI group than in the high-SVI group (0.039 [0.020–0.057] ng/mL vs 0.026 [0.014–0.044] ng/mL, P=0.004). The low-SVI group had more cardiac events than the high-SVI group (log-rank test, P&lt;0.001) (Figure 2). In the multivariate Cox proportional hazard model, the low-SVI group was an independent predictor of cardiac events, even when adjusted for the conventional validated HF risk score, blood catecholamine levels, and hemodynamic parameters.

Conclusion

The spleen size may affect the prognosis in patients with HF, reflecting haemodynamics, including systemic circulating blood volume status and sympathetic nerve activity.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Clinical impact of pulmonary artery to aorta diameter ratio on left ventricular reverse remodeling in patients with dilated cardiomyopathy

Background

Left ventricular reverse remodeling (LVRR) is an important predictor for a good prognosis in patients with dilated cardiomyopathy (DCM). Previous reports indicated the pulmonary artery diameter (PAD) to ascending aortic diameter (AoD) ratio as a predictor of adverse outcomes in heart failure patients. However, the impact of the PAD/AoD ratio for predicting LVRR in patients with DCM is unknown.

Aim

The aim of this study is to investigate the association between PAD/AoD ratio and LVRR in patients with DCM.

Methods

From a prospective study, clinically stable DCM patients who were investigated the LVRR on echocardiography and underwent CT at baseline were enrolled. LVRR is defined as left ventricular (LV) ejection fraction increase of 10% and a decrease in indexed LV end-diastolic diameter of 10% compared to those at baseline. PAD and AoD data was collected with nonenhanced computed tomography images at baseline.

Results

In sixty-nine patients (mean age 50.0±13.3 years), the mean LV ejection fraction was 29.8%, and mean LV end-diastolic dimension was 64.5mm, and both of which data was no significant difference between patients with or without LVRR. LVRR was observed in 23 (33.3%) patients. The PAD/AoD ratio was significantly lower in patients with LVRR than without LVRR (81.4% vs. 92.4%, p=0.003). By ROC analysis, the best cut-off for the detection of LVRR was found for a PAD/AoD ratio of 0.9. From multivariate analyses, PAD/AoD ratio was identified as a significant predictor of LVRR. After a median follow-up duration of 2.5 years, the DCM patients with PAD/AoD≥0.9 revealed a significant higher cardiac event than those with PAD/AoD&lt;0.9 (log-rank, p=0.007)

Conclusions

The PAD/AoD ratio is useful for predicting LVRR in patients with DCM. The DCM patients with high PAD/AoD ratio had a poor long-term outcome.

Funding Acknowledgement

Type of funding sources: None. ROC curve for LVRR predictionKaplan-Meier survival curves

Green route for ammonium nitrate synthesis: fertilizer for plant growth enhancement

Soil fertility management is of great importance for farmers. The use of synthetic nitrogen (N)-fertilizer increased by 20 fold in the last 50 years to feed the increasingly hungry population. This study aims to enrich the plant soil with nitrogen content (NH₄NO₃ fertilizer in soil) using the low-temperature and low-pressure plasma [without H₂ and catalyst]. Subsequently, we used plasma N-enriched soil for plant (radish and tomato) growth. We investigated the germination percentage, seedling growth, seedling weight, phytohormones and antioxidant activity of radish and tomato plants after treatment with plasma N-enriched soil and compared with control soil and soil + commercial N-fertilizer. The plasma N-enriched soil treatment results in significant growth enhancement for both radish and tomato plants. Further, substantial changes in phytohormone and antioxidant levels were observed for the plants grown in plasma N-enriched soil compared to control soil and soil + commercial N-fertilizer. The energy consumption (EC) for total N-fixation was 12 MJ mol⁻¹. EC for ammonia and nitrate fixation was 17 and 41 MJ mol⁻¹, respectively, without H₂ gas. Further to understand the plasma chemistry, we performed 1D simulation using COMSOL Multiphysics® software. This study showed that direct N-fixation in the soil by plasma could be used as fertilizer for the plants and open a new window for future decentralized N-fertilizer production at the farm site.

Green route for synthesis of ammonium nitrate fertilizer and used plasma N-enriched soil for plants (radish and tomato) growth.

Deexcitation Dynamics of Muonic Atoms Revealed by High-Precision Spectroscopy of Electronic K X Rays

We observed electronic K x rays emitted from muonic iron atoms using superconducting transition-edge sensor microcalorimeters. The energy resolution of 5.2 eV in FWHM allowed us to observe the asymmetric broad profile of the electronic characteristic Kα and Kβ x rays together with the hypersatellite K^{h}α x rays around 6 keV. This signature reflects the time-dependent screening of the nuclear charge by the negative muon and the L-shell electrons, accompanied by electron side feeding. Assisted by a simulation, these data clearly reveal the electronic K- and L-shell hole production and their temporal evolution on the 10-20 fs scale during the muon cascade process.

Impact of seed color and storage time on the radish seed germination and sprout growth in plasma agriculture

The use of low-temperature plasma for the pre-sowing seed treatment is still in the early stage of research; thus, numerous factors affecting germination percentage, seedling growth, and yield remains unknown. This study aimed to estimate how two critical factors, such as harvest year and seed coat color, affect the percentage of germination and seedling growth after plasma treatment. Radish seeds stored for 2 and 1 year after harvesting (harvested in 2017 and 2018) were sorted into two colors (brown and grey) to investigate the plasma effect on harvest year and seed coat color. We analyzed the amounts of seed phytohormones and antioxidant (γ-tocopherol) were analyzed using mass spectrometry, and physical changes were studied using SEM, EDX, and EPR to understand the mechanism of plasma-induced changes in radish seeds. The obtained results revealed that plasma treatment on seeds affects the germination kinetics, and the maximal germination percentage depends on seed color and the time of seed storage after harvest. Through this study, for the first time, we demonstrated that physical and chemical changes in radish seeds after plasma treatment depends upon the seed color and harvest year. Positive effects of plasma treatment on growth are stronger for sprouts from seeds harvested in 2017 than in 2018. The plasma treatment effect on the sprouts germinated from grey seeds effect was stronger than sprouts from brown radish seeds. The amounts of gibberellin A3 and abscisic acid in control seeds strongly depended on the seed color, and plasma induced changes were better in grey seeds harvested in 2017. Therefore, this study reveals that Air scalar-DBD plasma's reactive oxygen and nitrogen species (RONS) can efficiently accelerate germination and growth in older seeds.

The prognostic impact of right ventricular dysfunction in patients with septic cardiomyopathy

Background

Sepsis is a systemic condition of profoundly impaired health in which an infection leads to a dysregulated host response, and consecutively causes organ dysfunction, shock, and even death. Septic cardiomyopathy (SCM) is one of the multiple organ dysfunctions. SCM is typically defined as left ventricular (LV) dysfunction, presented by decreased LV ejection fraction (LVEF). However, it remains unclear about the detailed mechanism of cardiac dysfunction. In addition, the prognostic impact of right heart dysfunction in SCM patients has not been fully investigated.

Purpose

The purpose of this study was to investigate the prognostic impact of right heart dysfunction in patients with SCM.

Methods

We used the MIMIC-III (Medical Information Mart for Intensive Care III) critical care database, which is a large, freely-available database comprising deidentified health-related data associated with over forty thousand patients who stayed in critical care units of the Beth Israel Deaconess Medical Center between 2001 and 2012. We retrospectively analyzed data of patients with septic shock on admission to intensive care unit (ICU). Septic shock was defined as the presence of any suspected infections, the need for vasopressors, and the lactate level exceeding 2 mmol/L, based on the Sepsis-3 criteria. Patients were performed portable transthoracic echocardiography (TTE) during hospitalization. LVEF and right ventricular (RV) function were determined predominately by visual estimation in the parasternal long-axis view. SCM was defined as having a minimum LVEF of 50% or less during hospitalization. Patients with hyperdynamic motion of LVEF &gt;70% were excluded.

Results

In total, there were 2254 patients with septic shock. Of these, 604 patients who underwent TTE were enrolled, and 314 patients were diagnosed with SCM. At baseline, age, gender, Sequential Organ Failure Assessment (SOFA) score, maximum lactate levels, and maximum norepinephrine dosage were 70 [59–79] years, 194 males, 13 [11–15], 4.0 [2.7–6.2] mmol/L, and 0.20 [0.10–0.31] mcg/kg/min, respectively. All patients were treated with vasopressors. In Kaplan-Meier survival analysis, patients with SCM had increased 28-day mortality compared with those without SCM (log-rank, p=0.09). In addition, we divided SCM patients into two groups; SCM with and without RV dysfunction. SCM patients with RV dysfunction had significant increased 28-day mortality compared with those without RV dysfunction (log-rank, p=0.01) (Figure). In Cox proportional hazard regression analysis adjusted for age, male sex, SOFA score, and maximum lactate levels, RV dysfunction was an independent determinant of 28-day mortality (hazard ratio, 1.59; 95% confidence interval, 1.03–2.46; p=0.03).

Conclusions

The presence of RV dysfunction increased 28-day mortality in patients with SCM. It might be useful for predicting the prognosis of SCM to evaluate not only left heart function but also right heart function.

Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

Associations between spleen volume and exercise capacity in advanced heart failure patients with left ventricular assist device

Background

The spleen has been recognized as an important organ with several functions such as a reservoir of blood volume, and an involvement in iron metabolism by processing of aged red blood cells and recycling iron. During exercise, spleen contracts, and red blood cells pooled in the spleen are recruited into the systemic circulation. So far, we reported that spleen size changed in advanced heart failure (HF) with left ventricular assist device (LVAD). In addition, spleen volume was related to pulmonary capillary wedge pressure (PCWP) or right atrial pressure (RAP) as parameters of cardiac preload. However, it remains unclear about the relationship between spleen volume and exercise capacity in advanced HF with LVAD.

Purpose

The purpose of this study was to investigate the associations between spleen volume and exercise capacity in advanced HF patients with LVAD.

Methods

We enrolled 27 HF patients (21 males, 45±12 years) with LVAD (HeartMate II™; Abbott, Chicago, IL, USA) for use as a bridge to heart transplantation. All patients underwent blood test, echocardiography, right heart catheterization, computed tomography (CT) and cardiopulmonary exercise testing (CPET). Spleen size was measured by CT volumetry. We excluded patients with splenic infarction or aortic valve closure surgery.

Results

At baseline, body mass index, blood brain natriuretic peptide levels, hemoglobin levels, left ventricular ejection fraction were 21.4±3.1 kg/m2, 73.8 (51.9–165.8) pg/mL, 12.1 (10.6–13.4) g/dL, 24.8±14.7%, respectively. Total cardiac output (CO), the sum of pump flow and CO of native heart was 4.6±0.9 L/min, and spleen volume was 184.9±48.8 mL. As for parameters of CPET, peak heart rate (HR), peak VO2, and peak O2 pulse were 128±25 beats/min, 14.2±3.3 mL/kg/min, and 6.6±1.9 mL/beat. At rest, there were significant correlations between spleen volume and PCWP (r=0.382, p=0.049), RAP (r=0.406, p=0.035) or pulsatility index (r=0.384, p=0.047), despite no correlations with total CO or pump flow. During exercise, there were significant interrelations of spleen volume with peak VO2 (r=0.451, p=0.018) and peak O2 pulse (r=0.427, p=0.026). Furthermore, peak VO2 was interrelated with peak HR (r=0.481, p=0.011) or hemoglobin levels (r=0.649, p&lt;0.001). Remarkably, spleen volume was significantly correlated with hemoglobin levels (r=0.391, p=0.043) (Figure). Interpreting these results based on Fick's formula, the proportion of native CO to total CO is very small at rest, but increases during exercise. The spleen during exercise may contribute to increased native CO, especially stroke volume. Moreover, the spleen may be related to both cardiac preload and oxygen carrying capacity, resulting in a significant association between spleen volume and peak VO2.

Conclusion

Spleen volume could be a useful predictor of exercise capacity in advanced HF patients with LVAD, reflecting splenic function to modulate cardiac preload and blood hemoglobin levels.

Spleen volume and exercise parameters

Funding Acknowledgement

Type of funding source: None

Efficacy of right ventricular dysfunction estimated by pulmonary artery pulsatility index in stable phased dilated cardiomyopathy

Background

Dilated cardiomyopathy (DCM) is characterized by a reduction in left and/or right ventricular myocardial contraction, dilatation of biventricular cavity and major cause of heart failure with high morbidity and mortality rates. Right ventricular dysfunction (RVD) recently have been received attention because of 34% of DCM had RVD and considered as a powerful predictor of impaired prognosis in DCM. Pulmonary Artery Pulsatility index (PAPi) is a novel hemodynamic index shown to predict RVD in advanced heart failure, however, it is unknown that even at early phase, PAPi can reflects latent right myocardial damage and predict long-term prognosis in stable DCM patients.

Methods

From April 2000 to March 2018, we enrolled 566 consecutive patients with cardiomyopathy. All patients underwent laboratory measurement, echocardiography, and cardiac catheterization to evaluate their general conditions. After excluded secondary cardiomyopathy, ischemic cardiomyopathy, and valvular heart disease, finally 162 DCM patients were enrolled. All enrolled patients had NYHA I/II/III and NYHA I/II were 150 patients (92.6%). PAPi was calculated as (systolic pulmonary artery pressure – diastolic pulmonary artery pressure (Pulmonary artery pulse pressure: PAPP)) / right atrial pressure. Median followed up for 4.85 years. In this study 149 patients were performed endomyocardial biopsy in order to exclude secondary cardiomyopathies and 95 patients were assessed using Sirius red staining. Myocardial fibrosis in biopsy specimen was assessed using Sirius red staining, and the positive region was quantified as the collagen volume fraction (CVF).

Results

The mean age and LV ejection fraction (EF) was 50.9±12.6 years and 30.5±8.3%, respectively. When divided into two groups by median PAPi value [PAPi &lt;3.06 (L-PAP) and PAPi ≥3.06 (H-PAP)], even though there were no significant difference in BNP, pulmonary vascular resistance and right ventricular stroke work index between two groups, the probability of cardiac event-survival was significantly higher in L-PAP than H-PAP by Kaplan-Meier analysis (P=0.012). Furthermore, cox proportional hazard regression analysis revealed that PAPi was independent predictor of cardiac events (hazard ratio: 0.624, P=0.025). In pathological analysis, there was no difference between H-PAPi and L-PAPi in CVF.

Conclusion

In the calculation of PAPi, PAPP reflects both RV contractility and left atrial filling pressure and this index considered as RV adaptive response to afterload. The denominator of the PAPP is defined by RA pressure, which serves as a marker of RV preload. Thus, PAPi reflect both preload and afterload of RV at the same time and even though estimated patients at early phase, RVD exists in DCM patients without severe myocardial fibrosis, and PAPi may help stratify DCM and predict cardiac events.

Kaplan-Meier analysis

Funding Acknowledgement

Type of funding source: None

The efficacy of methotrexate for intolerance to prednisolone therapy in cardiac sarcoidosis

Background and purpose

Fluorine-18-flurodeoxyglucose positron emission tomography (18FDG-PET) is a useful examination assessing active inflammatory myocardium noninvasively in patients with cardiac sarcoidosis (CS). Though immunosuppression like prednisolone (PSL) and Methotrexate (MTX) as alternative therapy is used to suppress the inflammation, little is known about the rate of response and efficacy of MTX for intolerance to PSL therapy.

Methods

From Aug 2016, we prospectively enrolled CS with positively accumulated of FDG in the heart. The initial dose of PSL was 30mg/day, wherefrom the dose was tapered down 5mg/month until 6 months. After 6 months, follow-up 18FDG-PET was performed. Using 18FDG-PET images, we calculated total lesion glycolysis (TLG; SUVmeam x metabolic volume) and calculated the reduction rate of TLG. In order to estimate the response rate to PSL therapy, responder group (R-group) was defined as TLG reduction rate ≥70% and poor-responder group (PR-group) was defined as TLG reduction rate &lt;70% after PSL therapy. After prescribed PSL, subjects with PR-group randomized to PSL (maximum dose 30mg daily and tapered down 5mg/month until 6 months) or to MTX (6mg weekly).

Results

In 64 CS patients, 55 patients had serial 18FDG-PET before and 6 months after PSL therapy. 18FDG-PET images were acquired following 7 day's carbohydrate limitation and after at least 18-h fasting (mean free fatty acid level right before 18FDG-PET acquisition was 1.05 mEq/L). The mean age was 63.4 years old and 42 (76.4%) patients were female. Because of 6 months PSL therapy, even though there were no significant difference in BNP (from 59.9 (26.2–137.6) to 60.4 (18.5–122.0) (P=0.593), LV-Dd (from 50.9 (44.5–59.5) to 49.7 (45.5–61.3) (P=0.666) and LV-EF (from 49.5 (34.4–62.5) to 49.9 (38.0–62.0) (P=0.792) at pre and post therapy, respectively, TLG were detected significant reduction from 216.4 (74.2–411.6) to 0.8 (0.0–8.2), (p&lt;0.001). In response to PSL therapy, 47 (85.5%) CS patients were classified to R-group and 8 (14.5%) were classified to PR-group. Furthermore, when performed block randomization and divide 8 PR-group patients into MTX (n=3) and re-increased PSL (n=5) for more 6 months, MTX group is prone to high rate of TLG reduction than re-increased PSL-group (89.4% vs 59.9%) and one patient belonged to re-increased PSL group showed that the further elevation of TLG level at additional 6-months PSL therapy (349⇒483) (Figure).

Conclusions

1) By immunosuppression therapy using PSL for CS, about 86% patients showed significant reduction of myocardial FDG accumulation. 2) When detected intolerance for PSL therapy, MTX might be effective for reduction of inflammation of sarcoidosis in the heart, which might be effective as an alternate therapy in CS.

The TLG level after randomization

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Grant-in-aid for scientific research

Does preoperative enhanced CT predict requirement of intestinal resection in the patients with incarcerated myopectineal hernias containing small bowel?

PURPOSE

Bowel wall enhancement on CT imaging is considered one of the useful features for the prediction of the presence of irreversible ischemic change in patients with small bowel obstruction. However, the applicability of CT imaging in patients with incarcerated hernias has not been investigated in detail. The aim of this retrospective study was to evaluate the feasibility of preoperative CT findings for the prediction of the presence of irreversible ischemic change in patients with incarcerated hernias containing small bowel.

METHODS

Included in this study were 76 patients who underwent surgery for preoperatively diagnosed incarcerated hernias containing small bowel (27 inguinal hernias, 37 femoral hernias and 12 obturator hernias) at our hospital between January 2011 and June 2020. The preoperative clinicoradiological features were compared between the groups, and predictors for intestinal resection were evaluated.

RESULTS

Nineteen patients required intestinal resection (Resection group), and the other 57 patients did not require intestinal resection (Nonresection group). Multivariate analyses revealed that age ≥ 80 years (p = 0.018, odds ratio = 6.604) and the absence of bowel wall enhancement (p = 0.032, odds ratio = 51.200) were independent predictors for intestinal resection. In resected specimens, all patients with an absence of bowel wall enhancement on preoperative enhanced CT had ischemic changes extending beyond the muscularis propria.

CONCLUSIONS

Preoperative enhancement CT yields useful information for the prediction of the presence of irreversible ischemic change in patients with incarcerated hernias containing small bowel.

P6452Circulating human epididymis protein 4 is a novel prognostic predictor in ambulatory patients with non-ischemic dilated cardiomyopathy

Background

Myofibroblasts, which are activated fibroblasts, play an important role in interstitial fibrosis in non-ischemic dilated cardiomyopathy (NIDCM). Recently, human epididymal body protein 4 (HE4) has attracted attention as a marker specific to myofibroblasts. However, the prognostic impact of HE-4 on cardiovascular events in NIDCM patients has not been reported.

Purposes

The purpose of this study was to investigate the impact of circulating serum HE4 on the prognosis in patients with NIDCM.

Methods

Forty-four NIDCM patients underwent echocardiography, laboratory measurements, cardiac catheterization, and endomyocardial biopsy within one week under stable heart failure condition. Patients with cancer were excluded from this study. We collected blood samples from peripheral vain, ascending aorta, and coronary sinus during cardiac catheterization and measured serum HE4 level. They were divided into two groups at the median of HE4 level: High-HE4 group (HE4 >69 pmol/L); n=22, Low-HE4 group (HE4 <69 pmol/L); n=22. Cardiac composite event was defined as cardiac related deaths and hospitalization due to worsening heart failure.

Results

The mean age, left ventricular ejection fraction (LVEF), and plasma brain natriuretic peptide level were 56 years, 32%, and 205 pg/mL. Between two groups, there were no significant differences in age, gender, LVEF, left ventricular end-diastolic diameter, cardiac index, and pulmonary capillary wedge pressure. However, estimated glomerular filtration rate was significantly lower in the High-HE4 group (p=0.025). Kaplan-Meier survival analysis revealed that the High-HE group had a higher rate of cardiac composite event (p=0.011, see Figure). However, as for the pathological analysis, not only the peripheral HE4 level but also HE4 value subtracting coronary sinus from ascending aorta did not significantly correlate with collagen volume fraction in biopsy samples.

Circulating HE4 level and prognosis

Conclusion

Elevated circulating HE4 is associcated with poor prognosis in ambulatory patients with NIDCM.

P3534Optimal dosing of initial bolus of intravenous furosemide in acute heart failure: insights from REALITY-AHF

Background

Although intravenous diuretics are a cornerstone in the treatment of patients with acute heart failure (AHF), optimal dosing of initial bolus of IV diuretics has not been well elucidated.

Methods

The initial IV bolus dose of furosemide and its association with outcomes were analyzed in 1290 AHF patients (median age, 81 years, 55% were male) derived from REALITY-AHF (Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure). The patients were divided into 3 groups; lower dose (lower than recommended dose, n=371), standard dose (same as recommended dose, n=807), and higher dose (higher than recommended dose, n=112) groups according to the recommended initial IV bolus furosemide dose derived from the maintenance loop diuretics dose (for those without taking oral loop diuretics or taking ≤40mg/day oral furosemide-equivalent loop diuretics, 20mg IV bolus furosemide; those on >40mg/day oral furosemide-equivalent loop diuretics, IV bolus furosemide at the same dose as oral loop diuretic dose). Outcomes were length of hospital stay, diuretic response (urine output achieved within 48 hours of admission per 40 mg furosemide-equivalent diuretics dose), and 60-day all-cause mortality.

Results

Median amount of first IV bolus furosemide dose were 10, 20, and 40 mg for lower, standard, and higher dose groups, respectively. After adjustment for other covariates, length of hospital stay was significantly longer by 2.6 days (p=0.018) in the lower dose group compared to the standard dose group, and there was no difference between the standard and high dose groups (p=0.221). Diuretic response within 48 hours of admission was significantly better in the lower dose group (beta coefficient: 244 mL, p=0.025) and significantly worse in the higher dose group (beta coefficient: - 1098 mL, p<0.001) compared to the standard dose group after adjustment for covariates. During 60 days of admission, 91 deaths were observed, and 60-day mortality was significantly higher in the higher dose group (HR: 2.80, 95% CI: 1.49–5.26, p=0.001), but not in the lower dose group (HR: 1.18, 95% CI: 0.67–2.08, p=0.571) compared to the standard dose group after adjustment for other prognostic factors.

Conclusion

Treatment with the recommended initial bolus of IV furosemide is associated with a shorter hospital stay compared to lower dose regimen and better diuretic response and better 60-day survival compared to higher dose regimen in patients with AHF.

Acknowledgement/Funding

This study was funded by The Cardiovascular Research Fund, Tokyo, Japan.

428In-hospital coronary angiography is associated with increased evidence based medications and better survival in patients hospitalized with acute heart failure - results from REALITY-AHF

Background

Coronary artery disease is a major cause of heart failure (HF). Urgent coronary angiography (CAG) is recommended for patients with acute HF (AHF) complicated with acute coronary syndrome (ACS); however, clinical usefulness of in-hospital CAG in AHF patients without ACS remains unknown.

Purpose

To investigate the association between in-hospital CAG and all-cause mortality at 1-year after hospital discharge and effects of medications at discharge on this association.

Methods

From the REALITY-AHF study, 1344 patients hospitalized with AHF were enrolled in this study and followed up for 1-year after hospital discharge.

Results

In-hospital CAG was undergone in 511 patients (38%). CAG group had a significantly lower 1-year mortality compared with non-CAG group (unadjusted hazard ratio [HR]; 0.30, 95%-confidence interval [CI] 0.21–0.43, P<0.001, after adjustment for MAGGIC score; HR 0.45, 95%-CI 0.29–0.70, P<0.001, in propensity-score matched 296 pairs; HR 0.60, 95%-CI 0.37–0.98, P=0.04). At discharge, aspirin, statins and beta blockers were prescribed more in CAG group compared with non-CAG group (aspirin 46% versus 30%, P<0.001, statins 51% versus 35%, P<0.001, and beta blockers 76% versus 65%, P=0.007). The prescription of aspirin or statins at discharge was associated with a better 1-year survival in patients with multivessel disease (P<0.001), but not in patients without significant stenosis or single vessel disease (P=0.95) (Figure).

CAG results, medications and mortality

Conclusions

In patients hospitalized with AHF, in-hospital CAG was associated with increased evidence based medications at discharge and a better long-term survival. Aspirin and statins at discharge might improve outcomes in AHF patients with multivessel disease.

Acknowledgement/Funding

This study was funded by The Cardiovascular Research Fund, Tokyo, Japan.

2422Outcome of histologically-proven fulminant versus acute non-fulminant myocarditis with left ventricular systolic dysfunction. Evidence from the International Registry on Acute Myocarditis

Background

Fulminant myocarditis (FM) is a form of acute myocarditis characterized by severe left ventricular (LV) dysfunction requiring inotropes and/or mechanical circulatory support. Based on a retrospective single-center study published in 2000, patients with FM were considered to have better outcomes than those affected by acute non-fulminant myocarditis (NFM) presenting with LV systolic dysfunction (LVSD). Recently, this tenet was challenged, though substantial disagreement still exists.

Purpose

Aim of the present study is to provide additional evidence on the outcome of FM and to ascertain if patient stratification based on the main histologic subtypes can provide additional prognostic information.

Methods

Two hundred and twenty patients (median age 42 years, 46.3% female) with histologically proven acute myocarditis (onset of symptoms <30 days) presenting with LVSD were included in a retrospective, international registry comprising 16 tertiary hospitals in the United States, Europe, and Japan. The primary endpoint was the occurrence of cardiac death or heart transplant (HTx) within 60 days from admission and at long-term follow-up.

Results

Patients with FM (N=165) had significantly higher rates of cardiac death and HTx compared with those with NFM (N=55), both at 60 days (28.0% vs. 1.8%, p=0.0001) and at 7-year follow up (47.7% vs. 10.4%, p<0.0001; Figure). At Cox-multivariate analysis, the histologic subtype emerged as a further variable affecting outcome in FM patients, with giant cell myocarditis having a significantly worse prognosis compared with eosinophilic and lymphocytic myocarditis both at 60 days (62.5% vs. 26.3% vs. 21.0%) and at 3 years (81.3% vs. 39.9% vs. 37.3%, overall p<0.0001). In a sub-analysis including only adults with lymphocytic myocarditis, the main endpoints occurred more frequently in FM compared with NFM both at 60 days (19.5% vs. 0%, p=0.005) and up to 7 years (41.4% vs. 3.1%, p=0.0004).

Outcome of FM vs NFM

Conclusions

The results of this international registry confirm that patients with FM have higher rates of cardiac death and HTx both in the short and long-term compared with patients with NFM. Furthermore, we provide evidence that the histologic subtype of FM carries independent prognostic value, highlighting the need for timely endomyocardial biopsy in this condition.

Acknowledgement/Funding

None

2421Immunosuppressive therapy and prognosis in biopsy-proven fulminant lymphocytic myocarditis requiring veno-arterial extracorporeal membranous oxygenation support

Background

Fulminant myocarditis is one of the fatal diseases for which effective management has not yet been established. Immunosuppressive therapy (IST) using corticosteroid has been actively applied to giant cell or eosinophilic myocarditis, there is no consensus on the efficacy of lymphocytic myocarditis, which is suspected of involving viral infection. Actually, IST for lymphocytic myocarditis is not recommended in the European Society of Cardiology guidelines, but in the Japanese Circulation Society guidelines, it is approved for use in refractory cases in the absence of curative therapy for myocarditis established.

Purpose

The purpose of this study was to explore the potential efficacy of immunosuppressive therapy on acute phase in fulminant lymphocytic myocarditis (FLM) requiring veno-arterial extracorporeal membranous oxygenation (VA-ECMO) support.

Method

We conducted CHANGE-PUMP study that was retrospectively enrolled 99 patients with fulminant myocarditis required VA-ECMO support in the Tokai area (central part of Japan) for the past 20 years. Lymphocytic myocarditis was defined by pathological category. Patients were divided into two groups depending on whether IST using corticosteroid was performed in the clinical course. Results: Sixty-six patients were pathologically diagnosed as fulminant myocarditis by endomyocardial biopsy, of which only 49 patients were FLM. IST were indicated in 8 (16%) out of 49 patients of FLM (IST group; n=8, non-IST group; n=41). Kaplan-Meier survival analysis showed a lower survival rate in the IST group than in the non-IST group (p=0.073). However, in all cases, based on our guidelines, IST was initiated after becoming refractory to MCS treatment.

Immunosupressive therapy and prognosis

Conclusion

In the retrospective analysis, biopsy-proven FLM patients with IST required VA-ECMO support had low survival rates. However, the timing of IST introduction was late and concerned. In the present era when advanced mechanical support appears and the survival rate of fulminant myocarditis is expected to improve, a multicenter prospective study is needed to establish an indication of IST in the acute phase of fulminant myocarditis.

P5417Splenic volume changes as a hemodynamic parameter in advanced heart failure with left ventricular assist device

Background

The spleen has been recognized as an important organ to reserve 20–30% of the total blood volume. Generally, splenomegaly has been thought to be related to congestion. However, in the setting of hypovolemic shock or hypoxemia, it has been reported that spleen contracted and splenic volume decreased. On the other hand, in advanced heart failure (HF), the hemodynamics is characterized by both low cardiac output (LO) and systemic congestion, and patients sometimes need support of left ventricular assist device (LVAD). However, it remains unclear about the association between spleen size and hemodynamic parameters in patients with LO who need LVAD support.

Purpose

The purpose of this study was to investigate the relationship between spleen size and hemodynamic parameters in advanced HF before and after LVAD implantation.

Methods

We enrolled 12 advanced HF patients with LVAD (11 males, 45±10 years). All patients underwent blood test, echocardiography, right heart catheterization, and computed tomography (CT) before and after LVAD implantation. Spleen size was measured by CT volumetry. We excluded patients with splenic infarction, or any infections, or mean right atrial pressure (RAP) <5mmHg because of a possibility of hypovolemic status. LO was defined as CI less than 2.2L/min/m2.

Results

At pre- and post-LVAD implantation, cardiac output, cardiac index (CI), mean RAP, and mean pulmonary capillary wedge pressure were 3.1±0.6 vs. 4.9±0.9L/min, p=0.002; 1.7±0.3 vs. 2.8±0.3L/min/m2, p=0.002; 14±5 vs. 9±3mmHg, p=0.059; and 30±7 vs. 10±3mmHg, p=0.002, respectively. The serum brain natriuretic peptide level had significantly decreased (1101 [517–1446] vs 74 [35–216] pg/mL, p=0.002). In all patients, CI had increased to over 2.2L/min/m2. The splenic volume significantly increased from pre- to post-LVAD implantation (172±48 vs. 233±78mL, p=0.002) (Figure). Furthermore, all patients were divided into two groups; elevated RAP group (n=4) and non-elevated RAP group (n=8) after LVAD support. In elevated RAP group, there were no significant changes in the spleen size between pre- and post-LVAD implantation (167±45 vs. 223±111mL, p=0.068). On the other hand, in non-elevated RAP group, the spleen volume had significantly increased from pre- to post-LVAD support (172±53 vs. 231±62mL, p=0.011). In addition, there was one patient whose hemodynamic state had changed to LO again because of LVAD failure due to pump thrombosis. In this case, the splenic volume was 212mL before LVAD implantation with LO, and increased to 418mL after LVAD implantation with non-LO, although decreased to 227mL after LVAD pump failure with LO again.

Splenic volume changes

Conclusions

The spleen may change its size in order to keep cardiac output by regulating cardiac preload depending on the systemic perfusion in advanced HF with LVAD.

Acknowledgement/Funding

None

P1581Early blood pressure reduction by intravenous vasodilators associates with acute kidney injury in patients with hypertensive acute decompensated heart failure

Background

In patients with hypertensive acute decompensated heart failure (ADHF), intravenous vasodilators are commonly used. However, little is known about optimal use in blood pressure (BP) management to avoid acute kidney injury (AKI).

Purpose

To investigate the association between systolic BP (SBP) changes in first 6 h and incidence of AKI within 48 h in patients with hypertensive ADHF.

Methods

Post-hoc analysis was performed on a prospectively enrolled cohort. We investigated 245 patients with ADHF and SBP >140 mmHg on arrival (mean age, 76 years; 40% female). We defined “SBP-fall” as maximum percent reduction in SBP 6h after intravenous treatment. AKI was defined as serum creatinine (SCr) ≥0.3 mg/dL, or urine output <0.5 mL/kg/h at 48 h.

Results

Mean SBP, SBP-fall and SCr level at arrival were 180 mmHg, 29.4%, and 1.21 mg/dL, respectively. Sixty-six patients experienced AKI. There were no significant differences in age, NYHA functional class, SBP and SCr at admission between AKI and Non-AKI group. AKI group had the greater SBP-fall compared with Non-AKI (36.7%versus 27.2%, p≤0.0001). Logistic regression analyses revealed that SBP-fall had an independent predictor of AKI (Table). In addition, SBP-fall had positive association with the number of concomitant used intravenous vasodilators in first 6 h (Figure).

Logistic regression analyses for AKI Univariate Multivariate AUC OR 95% CI P OR 95% CI P Ages, years, per 10 years 1.04 0.82–1.33 0.17 0.75 SBP at arrival, per 10 mmHg 1.01 0.93–1.11 0.77 SBP-fall, per 10% 1.49 1.22–1.81 <0.001 1.54 1.24–1.91 <0.001 HR, per 10 beat/min 1.12 1.00–1.25 0.049 1.07 0.95–1.21 0.28 COPD 2.95 1.06–8.21 0.04 3.06 0.99–9.43 0.054 SCr, per 1 mg/dL 1.40 0.83–2.37 0.21 Furosemide i.v. 1.12 0.42–2.95 0.82 Carperitide 3.22 1.69–6.13 0.0002 4.39 2.16–8.93 <0.001 NTG/ISDN i.v. 0.97 0.54–1.74 0.92 CCB i.v. 1.86 0.76–4.53 0.18 OR, odds ratio; CI, confidence interval; AUC, area under the curve; SBP, systolic blood pressure; COPD, chronic obstructive pulmonary disease; SCr, serum creatinine; i.v., intravenous; NTG, nitroglycerin; ISDN, isosorbide dinitrate; CCB, calcium channel blocker.

SBP-fall odds ration for AKI

Conclusion

In the first 6h of management for hypertensive ADHF patients, aggressive SBP reduction by the combination use of vasodilator agents predicted the incidence of AKI.

Structure and Function of Platelet Glycocalicin

Present knowledge of the structure and function of platelet glycocalicin is reviewed. Glycocalicin (M,. 150,000) is a glycoprotein component of the outer surface of intact platelets which is released in soluble form following platelet homogenization. Glycocalicin has been purified and shown to inhibit platelet aggregation induced by thrombin or by ristocetin. Thrombin binding activity is associated with the peptide “tail” of the molecule (Mr 45,000), the macroglycopeptide portion (Mr 120,000) being without effect. Glycocalicin and membrane-bound glycoprotein I have been shown to be functionally and immunologically identical. Studies with platelets modified by chymotrypsin, and with platelets from patients with Bemard-Soulier disease and an ill-defined bleeding abnormality show that the amount of thrombin bound is proportional to the total amount of glycocalicin and glycoprotein I present. These results support the concept of a single class of binding site for thrombin in platelets.