Depth of the cutting plane with underwater and conventional endoscopic mucosal resection: Post-hoc analysis of a randomized study

BACKGROUND AND AIM

A multicenter randomized controlled trial reported a better R0 resection rate for intermediate-sized (10-20 mm) colorectal polyps with underwater endoscopic mucosal resection (UEMR) than conventional endoscopic mucosal resection (CEMR). To clarify whether UEMR removes enough submucosal tissue in the removal of unpredictable invasive cancers, we investigated the cutting plane depth with UEMR versus CEMR.

METHODS

This was a post-hoc analysis of a randomized controlled trial in which 210 intermediate-sized colorectal polyps were removed in five Japanese hospitals. One pathologist and two gastroenterologists independently reviewed all resected specimens and measured the cutting plane depth. The cutting plane depth was evaluated as (i) maximum depth of submucosal layer and (ii) mean depth of submucosal layer, calculated using a virtual pathology system.

RESULTS

We identified 168 appropriate specimens for the evaluation of the cutting plane depth, resected by UEMR (n = 88) and CEMR (n = 80). The median resection depth was not significantly different between UEMR and CEMR specimens, regardless of the measurement method ([i] 1317 vs 1290 μm, P = 0.52; [ii] 619 vs 545 μm, P = 0.32). All specimens in the UEMR and CEMR groups contained substantial submucosa and no muscularis propria.

CONCLUSIONS

The cutting plane depth with UEMR was comparable with that with CEMR. UEMR can be a viable alternative method that adequately resects the submucosal layer for the histopathological assessment of unpredictable submucosal invasive cancers.

Trans-stenotic pressure gradient as derived from CT improves patient management: ADVANCE registry

Background

The change in fractional flow reserve derived from CT (FFRCT) value across a coronary stenosis (ΔFFRCT) improves the physiological characterization of coronary artery disease (CAD). The role of ΔFFRCT in guiding risk-stratification and downstream testing in patients with stable CAD is unknown.

Purpose

To investigate the incremental value of ΔFFRCT at predicting early revascularization and improving efficacy of resource utilization.

Methods

Patients with CAD on CT coronary angiography (CTCA) were enrolled in an international multicenter registry. Patients with non-evaluable FFRCT analysis were excluded. The CTCA was assessed for: stenosis severity as per CAD-Reporting and Data System (CAD-RADS), lesion length and lesion-specific FFRCT measured 2 cm distal to stenosis. Risk factors and actual treatment (revascularization vs medical therapy) at 90-day follow-up were recorded. Multivariable logistic regression analysis for early revascularization was conducted. The incremental discrimination for revascularization prediction was compared among 3 models (model 1: risk factors + lesion length and location + CAD-RADS; model 2: model 1 + lesion-specific FFRCT; model 3: model 2 + ΔFFRCT). Simulating ICA referral for patients with CAD-RADS ≥3 and lesion-specific FFRCT ≤0.8, the potential impact of ΔFFRCT at reducing ICA referral and improving the ratio of subsequent revascularization was assessed.

Results

Of 4730 patients (66±10 years; 34% female), 2092 (42.7%) underwent ICA and 1168 (24.7%) underwent early revascularization. With increasing ΔFFRCT, a higher incidence of revascularization (Figure 1A) and an increase in the revascularization to ICA ratio was observed (Figure 1B). ΔFFRCT >0.13 was the optimal cut-off for predicting revascularization as determined by the Youden index. ΔFFRCT remained an independent predictor for early revascularization (odds ratio per 0.05 increase with 95% CI, 1.31 [1.26–1.35]; p<0.0001) after adjusting for risk factors, CAD-RADS, lesion length and location, and FFRCT. Among the 3 models, model 3, which included ΔFFRCT showed the highest AUC and improved discrimination power compared to model 2 (0.87 [0.86–0.88] vs 0.85 [0.84–0.86]; p<0.0001] (Figure 2), with the greatest incremental value for ΔFFRCT observed in patients with lesion-specific FFRCT between 0.71–0.80. In patients with CAD-RADS ≥3 and lesion-specific FFRCT ≤0.8, a diagnostic strategy incorporating ΔFFRCT >0.13 would potentially reduce ICA referral by 32.2% (1638 to 1110) and improve the revascularization to ICA ratio from 65.2% [1068/1638] to 73.1% [811/1110].

Conclusions

The characterization of CAD with ΔFFRCT improves the identification of patients requiring early revascularization as compared to a standard diagnostic strategy of CTCA with FFRCT, particularly for those with lesion-specific FFRCT of 0.71–0.80. ΔFFRCT has the potential to aid decision making for ICA referral and improve the efficiency of resource utilization.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): HeartFlow, Inc., Redwood City, CA, USA ΔFFRCT and actual treatmentROC curve for early revascularization

Impact of transcatheter aortic valve implantation on coronary flow reserve by transthoracic Doppler echocardiography 1-year after the intervention in severe aortic stenosis patients

Background

Coronary flow reserve (CFR) which is one of indexes reflecting coronary microcirculation in patients without significant epicardial coronary lesions can be impaired in patients with severe aortic stenosis (AS). It has been shown that CFR is an independent predictor for future cardiovascular events in AS patients. Transcatheter aortic valve implantation (TAVI) has rapidly become widespread and is becoming the standard treatment for severe AS. This procedure may have a good effect on CFR due to reduction of severe afterload in patients with severe AS. Although the recent reports evaluated change in CFR immediately and 6 months after TAVI, it has not been evaluated whether impaired CFR improves 1-year after TAVI in AS patients with preserved left ventricular ejection fraction (LVEF).

Purpose

The purpose of the present study was to investigate whether impaired CFR improves 1-year after TAVI in severe AS patients with preserved LVEF.

Methods

The study population consists of consecutive 105 patients with severe AS undergoing TAVI. Exclusion criteria were atrial fibrillation, old myocardial infarction, history of coronary artery bypass grafting, significant lesions in the left anterior descending artery (LAD), moderate or severe mitral valve disease, history of valve replacement, LVEF <50% and preoperative CFR >2.2. CFR was obtained from coronary flow velocity by transthoracic echocardiography at rest and maximal hyperemia in LAD before, immediately and 1-year after TAVI. We compared CFR between before and after TAVI in the study patients who did not meet the exclusion criteria.

Results

After exclusion of 76 patients who met the exclusion criteria, the final study patients consist of 29 patients (8 male, 84.9±5.2 years). There was no significant difference in LVEF (61.3±3.4% vs 61.6±4.4%, P=0.667) and LV end-diastolic volume (LVEDVI; 58.2±9.2 mL/m2 vs 55.8±9.0 mL/m2, P=0.089) between before and immediately after TAVI. LVEF (61.0±2.8%, P=0.721) and LVEDVI (58.0±9.1 mL/m2, P=0.949) 1-year after TAVI were similar to those before TAVI. There was no significant difference in coronary flow velocity at rest between before and immediately after TAVI (27.4±8.9 vs 24.4±7.0 cm/s, P=0.051) and between before and 1-year after TAVI (25.9±8.3 cm/s, P=0.396). Coronary flow velocity at maximal hyperemia 1-year after TAVI significantly increased compared with that before TAVI (from 48.8±13.9 to 67.9±21.0 cm/s, P<0.001) while there was no significant difference between before and immediately after TAVI (52.0±12.0 cm/s, P=0.186). Impaired CFR before TAVI (1.82±0.28) increased immediately (2.03±0.39, P=0.009) and 1-year after TAVI (2.69±0.57, P<0.001).

Conclusions

The present results suggest that impaired CFR in patients with preserved LVEF improves 1-year after TAVI. TAVI may have a good effect on CFR in severe AS patients with preserved LVEF.

Funding Acknowledgement

Type of funding sources: None.

Diagnostic Accuracy of Diastolic Fractional Flow Reserve for Functional Evaluation of Coronary Stenosis

Background

In the resting conditions, narrowing the window of coronary pressure measurements from the whole cardiac cycle to diastole improves diagnostic performance of coronary pressure–derived physiological index. However, whether this also applies to the hyperemic conditions has not yet been thoroughly evaluated.

Objectives

The purpose of this study was to assess whether diastolic fractional flow reserve (diastolic FFR) has better diagnostic performance in identifying ischemia-causing coronary lesions than conventional FFR in a prospective, multicenter, and independent core laboratory–based environment.

Methods

In this prospective multicenter registry at 29 Japanese centers, we compared the diagnostic performance of FFR, diastolic FFR, resting distal to aortic coronary pressure (Pd/Pa), and diastolic pressure ratio (dPR) using myocardial perfusion scintigraphy (MPS) as the reference standard in 378 patients with single-vessel coronary disease.

Results

Inducible myocardial ischemia was found on MPS in the relevant myocardial territory of the target vessel in 85 patients (22%). In the receiver-operating curve analyses, diastolic FFR had comparable area under the curve (AUC) compared with FFR (AUC_{diastolic FFR}: 0.66; 95% confidence interval [CI]: 0.58-0.73, vs AUC_FFR: 0.66; 95% CI: 0.58-0.74, P = 0.624). FFR and diastolic FFR showed significantly larger AUCs than resting Pd/Pa (0.62; 95% CI: 0.54-0.70; P = 0.033 and P = 0.046) but did not show significantly larger AUCs than dPR (0.62; 95% CI: 0.55-0.70; P = 0.102 and P = 0.113).

Conclusions

Diastolic FFR showed a similar diagnostic performance to FFR as compared with MPS. This result reaffirms the use of FFR as the most accurate invasive physiological lesion assessment. (Diagnostic accuracy of diastolic fractional flow reserve (d-FFR) for functional evaluation of coronary stenosis; UMIN000015906)

Helicobacter pylori eradication prevents secondary gastric cancer in patients with mild-to-moderate atrophic gastritis

BACKGROUND AND AIM

Whether Helicobacter pylori eradication prevents metachronous recurrence after endoscopic resection (ER) of early gastric cancer remains controversial. This multicenter retrospective study aimed to evaluate the long-term (> 5 years) effects of H. pylori eradication by stratifying patients' baseline degrees of atrophic gastritis.

METHODS

A total of 483 H. pylori-positive patients who had undergone ER for early gastric cancer were divided into two groups-(i) those having undergone successful H. pylori eradication within 1 year after ER (eradicated group, n = 294) and (ii) those with failed or not attempted H. pylori eradication (non-eradicated group, n = 189). The cumulative incidences of metachronous gastric cancer between the two groups were compared for all patients, for patients with mild-to-moderate atrophic gastritis (n = 182), and for patients with severe atrophic gastritis (n = 301).

RESULTS

During a median follow-up of 5.2 years (range 1.1-14.8), metachronous cancer developed in 52 (17.7%) patients in the eradicated group and in 35 (18.5%) patients in the non-eradicated group (P = 0.11, log-rank test). In patients with mild-to-moderate atrophic gastritis (111 and 71 in the eradicated and non-eradicated groups, respectively), the cumulative incidence of metachronous cancer was significantly lower in the eradicated group than that in the non-eradicated group (P = 0.03, log-rank test). However, no significant intergroup difference was observed in patients with severe atrophic gastritis (P = 0.69, log-rank test).

CONCLUSIONS

Helicobacter pylori eradication had a preventive effect on the development of metachronous gastric cancer in patients with mild-to-moderate atrophic gastritis.

Retrograde endoscopic submucosal dissection for early thoracic esophageal carcinoma

Although the standard treatment for intramucosal esophageal cancer without lymph node metastasis is endoscopic submucosal dissection (ESD), we sometimes encounter patients who are not able to undergo a transoral endoscopic examination. Here, we report a surgical procedure consisting of transgastric retrograde ESD to treat early esophageal cancer (T1a-EP, N0, M0) because of a stricture after hypopharyngeal cancer surgery. This retrograde ESD procedure can be a safe and effective treatment option for early esophageal cancer. This is the first report of a surgical retrograde ESD method for esophageal cancer.

Prophylactic clipping not effective in preventing post-polypectomy bleeding for < 20-mm colon polyps: A multicenter, open-label, randomized controlled trial

BACKGROUND AND AIM

Prophylactic clipping (PC) after polypectomy has the potential to prevent post-polypectomy bleeding (PPB). We aimed to evaluate the effectiveness of PC in preventing PPB for < 20-mm polyps.

METHODS

This multicenter, open-label, randomized controlled trial conducted from December 2013 to June 2017 at 10 institutions randomly assigned 1080 patients with < 20-mm colon polyps to the non-PC and PC groups. Allocation factors were institution, antiplatelet drug use, and polyp number. The primary endpoint was differences in PPB rates between the groups. The severity of PPB and post-procedural abdominal symptoms were also investigated. These endpoints in intention-to-treat and per-protocol (PP) analyses were evaluated.

RESULTS

We investigated 1039 patients with 2960 lesions. There was no significant difference between the groups in characteristics including age, sex, hypertension, diabetes, hyperlipidemia, antiplatelet drug use, and lesion characteristics such as type and size. Excluding the clip used in the non-PC group, intraoperative bleeding, and deviation of protocol, 903 patients were investigated in PP analysis. There was no significant difference in the PPB rate between the non-PC and PC groups (2.7% vs 2.3%, P = 0.6973 [intention-to-treat analysis]; 3.0 vs 2.4%, P = 0.7353 [PP analysis]). Severe PPB (≥ grade 3) was similar between the groups. Total procedure time was significantly shorter in the non-PC group than in the PC group (31 vs 36 min, P = 0.0002). Post-procedural abdominal fullness was less common in the non-PC group than in the PC group (20.8% vs 25.6%, P = 0.0833).

CONCLUSION

Prophylactic clipping is not effective in preventing PBB for < 20-mm colon polyps (UMIN000012163).

[A case of idiopathic thrombocytopenic purpura development after total colectomy for ulcerative colitis]

Ulcerative colitis (UC) is known to be associated with extraintestinal manifestations. However, idiopathic thrombocytopenic purpura (ITP) has rarely been reported as one of the extraintestinal manifestations in UC. In most cases, ITP develops as an extraintestinal manifestation during the treatment for UC. After treatment with medications or colectomy, there is often a remission of UC and ITP. However, we experienced a case of ITP development after total colectomy for UC. An 83-year-old man was diagnosed as having UC and started treatment with medications. After 3 years, total colectomy and ileostomy were performed to prevent UC remission. Subsequently, no further treatment was provided. Two years later, he presented to the hematology department in our hospital with the chief complaint of thrombocytopenia and was diagnosed as having ITP. ITP was treated with steroids, and his platelet count increased to within the normal range. Immunological abnormalities may be involved in the development of extraintestinal manifestation, including UC-associated ITP. In previous reports, ITP was cured by colectomy for UC. In contrast, peripheral arthritis is a common extraintestinal manifestation of UC, and it is known that 75% of these patients develop or continue to experience such symptoms after colectomy. Some extraintestinal manifestations may equally persist after colectomy. However, the underlying mechanisms are poorly understood. Ileitis and small intestinal and duodenal inflammation are all known bowel complications associated with colectomy, and some immunological mechanisms have been suggested to be involved. Therefore, careful monitoring in these patients is necessary to detect any possibility of developing extraintestinal manifestations after colectomy. Further studies to examine the mechanisms underlying the immunological abnormality between UC and extraintestinal manifestations such as ITP are needed.

Diagnostic accuracy of left ventricular diastolic transverse strain imaging by speckle tracking echocardiography for diagnosing chest pain in diabetic patients

Background

Two-dimensional speckle tracking echocardiography (2D-STE) has been reported to be useful for the diagnosis of myocardial ischemia by detecting delayed relaxation (diastolic stunning) after an episode of angina. 2D-longitudinal strain is not specific besides ischemia such as diastolic dysfunction, and diabetes have been associated with abnormal longitudinal fibers. The aim is to evaluate the diagnostic accuracy of Left ventricular (LV) diastolic transverse strain imaging by STE to detect the presence of acute coronary syndrome (ACS) in diabetic patients with acute chest pain.

Methods

385 consecutive patients with acute chest pain and without wall motion abnormality, who were admitted to an emergency department (ED) at 1 of 12 clinical sites in Japan, were enrolled and underwent 2D-STE at ED. Left ventricular (LV) transverse strain values at aortic valve closure (A) and one-third of diastole duration (B) were measured. The strain imaging diastolic index (SI-DI) was value was determined as: (A − B)/A × 100% to assess the LV diastolic strain imaging and was used to identify the regional LV delayed relaxation. All patients underwent coronary CT or coronary angiography to establish the diagnosis of ACS. Clinicians were blinded to the 2D-STE results.

Results

Out of 385 patients, 2D-STE analysis was possible in 365 patients (94%). 76 patients were diabetic (DM+), and 289 patients were non-diabetic (DM-). With assessment of coronary CT or coronary angiography, ACS was diagnosed in 125 patients (34%). 2D-STE was obtained at a mean of 5.3 hours after chest pain episode. Transverse SI-DI of ischemic segments were significantly lower than those of non-ischemic segments (p value &lt;0.001) in both diabetic and non-diabetic patients, and transverse SI-DI of both diabetic and non-diabetic patients demonstrated high area under curve (AUC) for detection of myocardial ischemia (Figure: RCA; right coronary artery, LAD; left anterior descending artery, LCX; left circumferencial artery). In diabetic patients, sensitivity, specificity, and negative predictive value for ACS of transverse SI-DI are 100%, 95%, 100% in RCA (a cut-off value of 36.2), and 86.4%, 95%, 93% in LAD (a cut-off value of 50.2), and 75%, 85%, 94% in LCX (a cut-off value of 52), respectively.

Conclusion

LV diastolic transverse strain imaging by 2D-STE at ED increase the sensitivity, specificity and accuracy to predict the presence of ACS in diabetic patients with chest pain, as well as non-diabetic patients. (UMIN000013859).

Figure 1. Transverse Strain (SI-DI): AUC (95% CI)

Funding Acknowledgement

Type of funding source: None

Delayed hyperenhancement obtained by non-contrast computed tomography following coronary angiography in patients of extracorporeal cardiopulmonary resuscitation

Background/Introduction

Extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to improve survival and neurologic outcome as compared to conventional CPR in refractory cardiac arrest. Although prognostic factors of these patients have been reported, predicting of outcome is difficult in real world. Recently, early evaluation of myocardial viability in acute myocardial infarction by non-contrast computed tomography (CT) post coronary angiography (CAG) has been reported. And myocardial contrast delayed enhancement obtained by this method related to higher risk of cardiac events. However, few studies have reported delayed enhancement on left ventricular wall findings in non-contrast CT after CAG in terms of patients performed ECPR.

Purpose

To investigate the impact of delayed hyperenhancement obtained by non-contrast CT following CAG in patients performed ECPR.

Methods

We investigated 79 patients treated by ECPR for refractory cardiac arrest regardless of whether in-hospital or out-hospital in our institute from Apr 2009 to Feb 2018. Thirty-two in these patients received non-contrast CT following CAG with ECPR were enrolled. All ECPR cases underwent VA-ECMO in the catheter laboratory using percutaneous procedure while maintaining conventional CPR. Non-ECG-gated and non-contrast CT was performed using a 64-row multidetector CT scanner.

Results

Survival rate was 18.8% in this cohort. There was no significant difference between survive and in-hospital death group in terms of patient characteristics, clinical time courses, initial blood samples and procedure characteristics. Only delayed hyperenhancement showed significant difference between 2 groups (p=0.04). All delayed hyperenhancements were detected in only in-hospital death group. Delayed hyperenhancement was detected in 12 cases (37.5%). Initial shockable rhythm was less common in cases with delayed hyperenhancement. Cardiac death tended to be more frequent in patients with delayed hyperenhancement. The major causes of death were bleeding (41.7%) and heart failure (33%).

Conclusion(s)

Delayed hyperenhancement in patients treated ECPR was strong predictor of in-hospital death.

Image of delayed hyperenhancement

Funding Acknowledgement

Type of funding source: None

P1518 Relationship between post-operative asymptomatic status and reverse remodeling of large left atrium in patients with aortic stenosis who underwent aortic valve replacement

Introduction

Recently, we have reported that large left atrial volume (minimum left atrial volume index : LAVImin ≥30ml/m²) at end-diastole determined by direct exposure of left ventricular (LV) end-diastolic pressure can predict post-operative symptomatic status after aortic valve replacement (AVR) in aortic stenosis (AS) patients with high sensitivity and modest specificity. Reverse remodeling of large LAVImin after AVR may contribute to false positive for the prediction of post-operative symptomatic status in patients with AS.

Purpose

The purpose of this study was to evaluate relationship between post-operative symptomatic status and reverse remodeling of large LAVImin in patients with AS who underwent AVR.

Methods

The study population consisted of 75 patients with AS who underwent AVR and were followed up for 600 days after AVR, after the exclusion of the followings; atrial fibrillation, significant coronary artery disease, significant mitral valve disease, pacemaker rhythm, and inadequate echocardiographic images. We measured LAVImin by biplane Simpson"s method before and after AVR. Preoperative large LAVImin (≥30ml/m²) according to the previous study was observed in 32 (43%) of 75 patients. We divided these 32 patients into two groups according to the post-operative symptomatic status during the follow-up period.

Results

There was no significant difference in pre-operative LAVImin between patients with and without post-operative symptom (46.5 ± 13.4 vs 40.4 ± 8.6 ml/m²). On the other hand, post-operative LAVImin in patients without post-operative symptom was significantly smaller than that in patients with post-operative symptom (31.5 ± 8.6 vs 54.8 ± 14.0 ml/m², p &lt; 0.01). While significant regression in LAVImin after AVR was observed in patients without post-operative symptom (40.4 ± 8.6 to 31.5 ± 8.6 ml/m², p &lt; 0.05), no regression in LAVImin after AVR was observed in patients with post-operative symptom (46.5 ± 13.4 to 54.8 ± 14.0 ml/m²).

Conclusions

Reverse remodeling of large LAVmin in patients with AS who underwent AVR was observed in post-operative asymptomatic group, but not in symptomatic group. These results suggest that reverse remodeling of large LAVImin after AVR could contribute to the post-operative asymptomatic status in patients with AS who underwent AVR.

Differentiation between duodenal neoplasms and non-neoplasms using magnifying narrow-band imaging - Do we still need biopsies for duodenal lesions?

OBJECTIVES

Endoscopic biopsies for nonampullary duodenal epithelial neoplasms (NADENs) can induce submucosal fibrosis, making endoscopic resection difficult. However, no biopsy-free method exists to distinguish between NADENs and non-neoplasms. We developed a diagnostic algorithm for duodenal neoplasms based on magnifying endoscopy findings and evaluated the model's diagnostic ability.

METHODS

Magnified endoscopic images and duodenal lesion histology were collected consecutively between January 2015 and April 2016. Diagnosticians classified the surface patterns as pit, groove or absent. In cases of nonvisible surface patterns, the vascular pattern was evaluated to determine regularity or irregularity. The correlation between our algorithm (pit-type or absent with irregular vascular pattern) and the lesion histology were evaluated. Four evaluators, who were blinded to the histology, also classified the endoscopic findings and evaluated the diagnostic performance and interobserver agreement.

RESULTS

Endoscopic images of 114 lesions were evaluated (70 NADENs and 44 non-neoplasms, 31 in the superior and 83 in the descending and horizontal duodenum). Of the NADEN surface patterns, 88% (62/70) were pit-type, while 79% (35/44) of the non-neoplasm surface patterns were groove-type. Our diagnostic algorithm for differentiating NADENs from non-neoplasms was high (sensitivity 96%, specificity 95%) in the descending and horizontal duodenum. The evaluators' diagnostic performances were also high, and interobserver agreement for the algorithm was good between each diagnostician and evaluator (κ = 0.60-0.76).

CONCLUSION

Diagnostic performance of our algorithm sufficiently enabled eliminating endoscopic biopsies for diagnosing the descending and horizontal duodenum.

P91 Prognostic value of tissue-tracking mitral annular displacement by speckle-tracking echocardiography in asymptomatic patients with aortic stenosis with preserved left ventricular ejection fraction

Background

  Management of asymptomatic severe aortic stenosis (AS) patients with preserved left ventricular (LV) ejection fraction (EF) remains controversial. Recent studies using have shown that decreased LV longitudinal deformation assessed by global longitudinal strain analysis can predict adverse cardiac events in AS patients with preserved EF. Tissue-tracking mitral annular displacement (TMAD) by speckle-tracking echocardiography provides rapid and simple assessment of LV longitudinal deformation even when the acoustic window is poor (Fig.1).

Purpose

 The purpose of this study was to examine the value of TMAD to predict occurrence of the cardiac events in asymptomatic severe AS patients with preserved EF.

Methods

  We studied 103 patients with severe AS and preserved EF [aortic velocity &gt;4m/s or aortic valve area (AVA) &lt;1.0 cm2, EF &gt;50%]in whom TMAD was measured, and a total of 44 patients were included in the final data setaccording to the exclusion criteria. Using TMAD analysis software, the base-to-apex displacement of automatically defined mid-point of mitral annular line in four-chamber view was quickly assessed, and the percentage of its displacement to LV length at end-diastole (%TMAD) was calculated (Fig.1). We investigated the association between %TMAD and the cardiac events including implementation of hospitalization due to heart failure, decreased EF (&lt; 50%), aortic valve replacement or transcatheter aortic valve implantation due to appearance of symptoms and cardiac death, 

Results

 In all the final study patients, %TMAD was successfully and quickly (within 10 seconds) evaluated. During a follow-up, the cardiac events developed in 16 (36%) of 44 patients. Tableshows echocardiographic parameters in patients with and without the cardiac events. %TMAD was significantly impaired in patients with the cardiac events compared with those without the cardiac events (9.6 ± 0.6 vs 12.1 ± 0.4%, p= 0.002). The other parameters were not involved in the event occurrence; age, LV mass index, EF, aortic velocity, AVA, tricuspid regurgitation pressure gradient (TR-PG), early diastolic /atrial filling velocity (E/A), early diastolic velocity of the mitral valve annulus (e’) and E/e’. In multiple variable analysis, %TMAD was an independentpredictor of the cardiac events (HR; 12.1, p= 0.001). ROC analysis revealed that the area under the curve of %TMAD was 0.81 for the cardiac events. Kaplan-Meier analysis showed %TMAD (cut-off: 11.9) provides a significant difference in the cardiac event (Fig. 2). Conclusions.  The present results suggests that TMAD easily and rapidly estimated by speckle-tracking echocardiography can be used as a simple method to predict occurrence of the cardiac events in asymptomatic severe AS patients with preserved EF.

Abstract P91 Figure 1,2 and Table

1225 Diagnostic accuracy of left ventricular diastolic strain imaging by speckle tracking echocardiography in detecting ischemic etiology of acute chest pain

Funding Acknowledgements

none

OnBehalf

A TRAC-SI Multicenter Trial

Background

Two-dimensional speckle tracking echocardiography (2D-STE) has been reported to be useful for the diagnosis of myocardial ischemia by detecting delay in regional myocardial expansion (diastolic stunning) up to many hours after an episode of angina. The aim is to evaluate the diagnostic accuracy of Left ventricular (LV) diastolic longitudinal, circumferential, transverse and radial strain imaging by STE to detect the presence of acute coronary syndrome (ACS) in patients with acute chest pain.

Methods

388 consecutive patients with acute chest pain and without wall motion abnormality, who were admitted to an emergency department (ED) at 1 of 12 clinical sites in Japan, were enrolled and underwent 2D-STE at ED. Left ventricular (LV) longitudinal, circumferential, transverse and radial strain values at aortic valve closure (A) and one-third of diastole duration (B) were measured. The strain imaging diastolic index (SI-DI) was value was determined as: (A-B)/A × 100% to assess the LV diastolic strain imaging and was used to identify the regional LV delayed relaxation. All patients underwent coronary CT or coronary angiography to establish the diagnosis of ACS. Clinicians were blinded to the 2D-STE results.

Results

Out of 388 patients, 2D-STE analysis was possible in 358 patients (92%). With assessment of coronary CT or coronary angiography, ACS was diagnosed in 118 patients (33%). 2D-STE was obtained at a mean of 5.3 hours after chest pain episode. SI-DI of longitudinal, circumferential, transverse and radial strain of ischemic segments were significantly lower than those of non-ischemic segments (p value &lt; 0.001), and transverse and radial SI-DI demonstrated high diagnostic accuracy, compared with longitudinal SI-DI (Figure 1). Sensitivity, specificity, and negative predictive value for ACS of transverse SI-DI are 87%, 88%, % and 95%, respectively, using a cut-off value of 63.3.

Conclusion

LV diastolic strain imaging by 2D-STE at ED increase the sensitivity, specificity and accuracy to predict the presence of ACS in patients with chest pain. Compared with longitudinal diastolic strain imaging, transverse diastolic strain imaging is more sensitive marker to detect the myocardial ischemic episode (UMIN000013859).

Abstract 1225 Figure 1

P1252Diagnostic performance of quantitative flow ratio from coronary angiography versus fractional flow reserve from computed tomography

Background

QFR and FFRCT are recently developed, less-invasive techniques for functional assessment of coronary artery disease.

Objectives

We compared the diagnostic performance between fractional flow reserve derived from computed tomography (FFRCT) and quantitative flow ratio (QFR) derived from coronary angiography, using FFR as the standard reference.

Methods

We measured FFRCT, QFR and FFR in 152 patients (233 vessels) with stable coronary artery disease.

Results

QFR was highly correlated with FFR (r=0.78, p<0.001), while FFRCT was moderately correlated with FFR (r=0.63, p<0.001). Both QFR and FFRCT showed good agreements with FFR, presenting small values of mean difference and root-mean-squared deviation (FFR -QFR: 0.02±0.09 and FFR -FFRCT: 0.03±0.11). The AUC of QFR was significantly greater than that of 3D-QCA-derived %DS (0.93 vs. 0.78; difference: 0.15; 95% CI: 0.09 to 0.20; p<0.001). The AUC of FFRCTwas significantly greater than that of CCTA-derived %DS (0.82 vs. 0.70; difference: 0.12; 95% CI: 0.05 to 0.19; p<0.001). The AUC of QFR was significantly greater than that of FFRCT (0.93 vs. 0.82; difference: 0.11; 95% CI: 0.05 to 0.16; p<0.001). The sensitivity, specificity, positive predictive value, and negative predictive valueof QFR ≤0.80 for predicting FFR ≤0.80 were 90%, 82%, 81%, and 90%, respectively. Those of FFRCT ≤0.80 for predicting FFR ≤0.80 were 82%, 70%, 70%, and 82%, respectively. The diagnostic accuracy of QFR ≤0.80 for predicting FFR ≤0.80 was 85% [95% confidence interval: 81% to 89%], while that of FFRCT≤0.80 for predicting FFR ≤0.80was 76% [95% confidence interval: 70% to 80%].

Figure 1. Comparison of FFR ≤0.80 predictors

Conclusions

Both QFR and FFRCTpossessed the ability to accurately evaluate the functional severity of coronary stenosis.

P2700Impact of instantaneous wave-free ratio on graft failure after coronary artery bypass graft surgery

Background

It has been reported that preoperative fractional flow reserve (FFR) is associated with graft patency after coronary artery bypass graft (CABG) and the patency is excellent when a bypass graft is anastomosed on a vessel with positive FFR. However, the association with graft patency has not yet been investigated in its novel counterpart, instantaneous wave-free ratio (iFR), and iFR sometimes contradicts FFR results.

Purpose

The purpose of this study is to assess an impact of preoperative iFR on a graft failure after CABG in patients with coronary arteries showing positive FFR (≤0.80).

Methods

We retrospectively identified patients who had undergone preoperative coronary angiography in conjunction with resting and hyperemic intra-coronary pressure measurements, CABG, and graft evaluation by coronary computed tomography angiography. After excluding vessels with negative FFR (>0.80), vessels were divided into two groups: negative iFR group (iFR >0.89) and positive iFR group (iFR ≤0.89). The rate of graft failure within 1 year after CABG was compared between the two groups.

Results

We analyzed 131 vessels in 89 patients (35 vessels in the negative iFR group and 96 vessels in the positive iFR group). The negative iFR group showed significantly higher iFR (0.92±0.02 vs. 0.74±0.13, P<0.0001) and FFR (0.72±0.06 vs. 0.63±0.09, P<0.0001) than the positive iFR group, although percent diameter stenosis (%DS) was comparable (57±10 vs. 56±9, P=0.47). The graft failure significantly often occurred in the negative iFR group than in the positive iFR group (28.6% vs. 8.3%, P=0.0029). In order to reduce the imbalance in the baseline characteristics except for iFR, 70 vessels were selected by using propensity score matching (n=35 in each group). The propensity score matched vessels also demonstrated significantly higher rate of graft failure in the negative iFR group than in the positive iFR group (28.6% vs. 5.7%, p=0.026) despite much more balanced FFR (0.72±0.06 vs. 0.69±0.07, p=0.02) and %DS (57±10 vs. 57±9, p=1.000).

Conclusions

Even when FFR is positive, the graft failure is likely to occur when a bypass graft is anastomosed on a vessel with negative iFR compared to a vessel with positive iFR.

Acknowledgement/Funding

None

P3576Histopathological validation of optical coherence tomography assessment for cholesterol crystals

Background

Cholesterol crystals (CCs) are well recognized as one of important components of advanced atherosclerotic plaques. Whilethe consensus document for intravascular optical coherence tomography (OCT) has proposed that CCs are appeared as thin, linear regions of high-signal intensity within a plaque, no study has validated CCs assessment by OCT in comparison with histopathology.

Purpose

Thepurpose of this study was to validate OCT assessments of CCs with histopathology.

Methods

A total of 27 diseased coronary artery samples (10–20 mm length) were resected from 7 randomly selected cadavers. OCT imaging was performed for the samples. Then, arterial samples were fixed in 10% formalin for ≥48 hours, decalcified and processed for standard paraffin embedding. Sections 5μm thick were sliced at the ink-marked imaging sites and stained with hematoxylin and eosin, and Masson's Trichrome. An independent pathologist blinded to the OCT results diagnosed all of the plaques. Subsequently, the OCT images were interpreted by an observer blinded to the histological results. In the OCT assessment, CCs were defined as thin, linear regions of high-signal intensity within a plaque.

Results

We obtained 27 pairs of OCT/ histopathology. CCs were diagnosed by histology in 10 (37%) of the 27 pairs. The sensitivity and specificity of OCT for detecting CCs were 60% and 94%, respectively.

Conclusion

OCT has a high specificity but modest sensitivity for detection of CCs in comparison with histopathology. CCs diagnosed with OCT would help the identification of advanced atherosclerotic plaques.

Acknowledgement/Funding

JSPS KAKENHI 17K09557

P3387Cholesterol crystals in superficial plaque layer detected by optical coherence tomography as a new morphological feature for plaque rupture

Background

While plaque rupture (PR) is the leading cause of acute myocardial infarction (AMI), other etiologies are also involved in the onset of AMI. Cholesterol crystals (CCs) are usually present abundantly in atherosclerotic plaques, especially in the culprit site of AMI. However, the relationship between in vivo CCs and PR is unclear. Optical coherence tomography (OCT) is a high-resolution imaging technique that allows for the in vivo identification of various plaque characteristics including PR and CCs.

Purpose

The aim of this study was to investigate prevalence and distribution of CCs between patients with AMI with PR, AMI without PR, and SAP.

Method

This study consisted of 146 patients with coronary artery disease (AMI with PR; n=64, AMI without PR; n=41, and SAP; n=41) who underwent OCT prior to percutaneous coronary intervention. Plaque characteristics in OCT images were assessed according to the consensus document. We classified the distribution of CCs as follows; superficial type CCs were defined by any of the CCs invading the fibrous cap and remaining CCs as deep type CCs.

Result

There was no statistical difference in clinical characteristics among the three groups. The % diameter stenosis was significantly smaller in the SAP group than others (AMI with PR 91±12% vs. AMI without PR 86±13% vs. SAP 65±9%, p<0.001). The prevalence of CCs was significantly higher in the AMI with PR group than others (AMI with PR 78% vs. AMI without PR 41% vs. SAP 39%, p<0.001). The prevalence of superficial type CCs was significantly different among the groups (AMI with PR 72% vs. AMI without PR 24% vs. SAP 7%, p<0.001). Multivariable logistic analysis demonstrated that lipid plaque (OR 84.5, 95% CI [6.30–11332.33], p<0.001) and superficial type CC (OR 9.5, 95% CI [2.61–34.89], p<0.001) were independent predictors of PR.

Conclusion

Plaque with CCs invading the fibrous cap is frequently associated with PR in patients with AMI, suggesting. In vivo CC detection is a new morphological feature for plaque rupture.

Acknowledgement/Funding

This study was supported by a grant from JSPS KAKENHI (17K09557).

P3365Relationship between early diastolic intra-ventricular pressure gradient shortly after aortic valve closure estimated by vector flow mapping and left ventricular diastolic untwisting rate in humans

Background

Early diastolic suction is an important determinant of early diastolic function. Previous studies using color Doppler M-mode and speckle-tracking echocardiography have shown left ventricular (LV) early diastolic LV untwisting rate is directly related to LV intra-ventricular pressure gradient (IVPG) between LV base and apex during early diastole. Recent introduction of vector flow mapping (VFM) using combination of color Doppler and speckle-tracking echocardiography provides noninvasive and feasible assessment of early diastolic IVPG shortly after aortic valve closure including isovolmic relaxation period (ED-IVPG) in humans. However, relationship between VFM–derived ED-IVPG and early diastolic LV untwisting rate has not been well investigated.

Purpose

The purpose of this study was to examine relationship between ED-IVPG estimated by VFM and LV untwisting rate by speckle-tracking echocardiography.

Methods

The study population consists of 66 patients without segmental wall motion abnormality, significant valvular diseases, and atrial fibrillation who underwent echocardiography for evaluation of LV function (age: 60±15 years, LVEF: 49±16%). From the apical long-axis views by color Doppler echocardiography, we analyzed peak ED-IVPG between LV base and apex just after aortic valve closure (figure) using commercially available VFM analysis software (DAS-RS1, Hitachi). We assessed peak early diastolic LV untwisting rate and LV torsion from LV basal and apical short-axis view by speckle-tracking echocardiography. We evaluated correlation between ED-IVPG and LV untwisting rate. We also evaluated correlation between ED-IVPG and peak systolic LV torsion, LV end-diastolic (EDV) and end-systolic volumes (ESV), ejection fraction (EF), early diastolic velocity (E) of LV inflow, average early diastolic velocity (e') of mitral annulus, and average E/e'.

Results

In all the study patients, ED-IVPG was successfully and quickly evaluated. 1) ED-IVPG correlated well with peak LV untwisting rate (r=0.64, p<0.0001). 2) ED-IVPG significantly correlated with LV torsion, LVEDV, LVESV, and LVEF (r=0.47, r=−0.48, r=−0.46, and r=0.48, respectively, p<0.001). 3) There were no significant correlations between ED-IVPG and other indexes including E, average e', and average E/e'. According to receiver operating characteristic analysis, the best cut-off value of ED-IVPG for determining impaired LV untwisting rate (<80 degrees/s) was found at 0.42 mmHg (sensitivity 81%, specificity 76%, and area under the curve 0.86)

ED-IVPG measurement by VFM

Conclusions

The present results showed that noninvasive VFM-derived peak ED-IVPG shortly after aortic valve closure is related to early diastolic peak LV untwisting rate. ED-IVPG easily and quickly estimated by VFM may be used as an additional index for LV diastolic function.

P2453Value of pre-operative left atrial minimum volume as a surrogate for post-operative symptoms in patients with aortic stenosis who underwent aortic valve replacement

Background

Previous reports have shown that symptoms after aortic valve replacement (AVR) are not uncommon depending on severity of myocardial fibrosis in patients with severe aortic stenosis (AS). Pre-operative minimum left atrial volume (LAVmin) at end-diastole determined by direct exposure of left ventricular end-diastolic pressure may be used as a surrogate for post-operative symptoms in patients with severe AS undergoing AVR.

Purpose

The purpose of this study was to examine the value of pre-operative echocardiographic LAVmin index (LAVImin) to predict post-operative symptomatic status after AVR in patients with severe AS.

Methods

The study population consisted of 219 patients with severe AS who underwent AVR and were followed up for 1000 days after AVR. Pre-operative maximum LAV index (LAVImax), LAVImin, LA emptying fraction (LAEF), LV volume indexes, LV ejection fraction (LVEF) by biplane Simpson's method, aortic valve area index (AVAI), mean aortic valve pressure gradient (mAV-PG), E/A, mean E/e' from LV inflow and mitral annular velocity, and pulmonary artery systolic pressure (PASP) were evaluated by Doppler echocardiography.

Results

After exclusion of 136 patients who met the exclusion criteria (atrial fibrillation, significant coronary artery disease, significant mitral valve diseases, pacemaker rhythm, and inadequate echocardiographic images), the final study population consisted of 75 patients (75±7 years old, 46 female). During a follow-up, 19 patients (25%) complained post-operative symptoms. There were no significant differences in pre-operative serum hemoglobin, creatinine, BNP, chronic obstructive pulmonary disease, hypertension, diabetes, LV volume indexes, LVEF, AVA, mAV-PG between patients with and without post-operative symptoms. There were significant differences in pre-operative LAVImax, LAVImin, and LAEF between patients with and without post-operative symptoms. (60±15 vs 47±15 ml/m2, 45±15 vs 28±1 ml/m2, and 29±12 vs 42±11 ml/m2, respectively). E/A, mean E/e', and PASP in patients with symptoms were significantly greater compared with patients without symptoms (1.0±0.3 vs 0.7±0.2, 25±3 vs 18±2, 44±17 vs 32±9 mmHg, respectively). In the multivariate analysis, pre-operative LAVImin was the independent predictor of the post-operative symptomatic status after AVR (odds ratio: 1.11, 95% confidence interval: 1.04 - 1.18). Receiver operating characteristic analysis revealed that area under the curve (AUC) of LAVImin (cutoff: 30ml/m2) for post-operative symptoms was the largest (0.84) among the other echocardiographic parameters, and significantly larger than that of mean E/e' (0.67, *p<0.01) and LVEF (0.53, **p<0.05) (figure).

Figure 1. ROC analysis

Conclusions

The present results suggest that pre-operative echocardiographic LAVImin may be used as a surrogate for post-operative symptomatic status after AVR in patients with severe AS.

Endoscopic appearance of esophageal xanthoma

Background and study aims  Esophageal xanthomas are considered to be rare, and their endoscopic diagnosis has not been fully elucidated. The aim of the present study was to determine the characteristics of the endoscopic appearance of esophageal xanthomas. Patients and methods  This was a retrospective study of consecutive patients with histologically diagnosed esophageal xanthomas at a referral cancer center in Japan. The endoscopic appearance, by magnifying or image-enhanced endoscopy, and histological findings of esophageal xanthomas were investigated. Results  Seven patients (six men and one woman) were enrolled. All of the patients had a solitary lesion, and the median size was 2 mm (range, 1 - 5 mm). Conventional white-light endoscopy showed the lesions as flat areas with yellowish spots in four cases and slightly elevated yellowish lesions in three cases. Magnifying endoscopy, performed in six patients, revealed the lesions as areas with aggregated minute yellowish spots with tortuous microvessels inside. Magnifying narrow-band imaging contrasted the yellowish spots and microvessels better than white-light endoscopy. In all lesions, histological examination showed that the yellowish spots corresponded to papillae filled with foam cells. The foam cells were strongly immunopositive for CD68, and in all lesions, CD34-positive intrapapillary capillaries surrounded the aggregated foam cells. The different morphologies of the flat and slightly elevated lesions corresponded to different densities of papillae filled with foam cells. Conclusions  Magnifying endoscopy revealed minute yellowish spots with tortuous microvessels inside. These correspond well with histological findings and so may be useful in the diagnosis of esophageal xanthomas.

102Diagnosis of coronary plaque rupture, plaque erosion, and calcified nodule by using near-infrared spectroscopy intravascular ultrasound

Objectives

This study sought to investigate the ability of near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) to differentiate among plaque rupture (PR), plaque erosion (PE), and calcified nodule (CN) in acute myocardial infarction (AMI) using an optical coherence tomography (OCT) diagnosis as a reference standard.

Background

In vivo, precise differentiation among PR, PE and CN is a major challenge for intravascular imaging.

Methods

The study enrolled 156 AMI patients who had a de novo culprit lesion in a native coronary artery. The culprit lesions were assessed by both NIRS-IVUS and OCT.

Results

OCT identified 112 PR, 29 PE, and 15 CN. IVUS-detected plaque ulceration showed a high specificity (100%) to identify OCT-PR although the sensitivity (62%) was intermediate. IVUS-detected convex calcium showed a high sensitivity (93%) and specificity (100%) to identify OCT-CN. In NIRS, the maximum lipid core burden index in 4 mm (maxLCBI4mm) was greatest in OCT-PR (values are median [interquartile range]) (671 [530 to 853]), followed by OCT-CN (355 [303 to 432]) and OCT-PE (283 [89 to 357]) (p<0.001). MaxLCBI4mm of <422 was the best cut-off to discriminate OCT-PE from OCT-PR and OCT-CN. The NIRS-IVUS classification algorithm using plaque ulceration, convex calcium, and maxLCBI4mm <422 showed a sensitivity and specificity of 96% and 95% for identifying OCT-PR, 93% and 95% for OCT-PE, and 93% and 100% for OCT-CN, respectively.

NIRS-IVUS classification algorism

Conclusion

Lipid component assessed by NIRS-IVUS was different among OCT-PR, OCT-PE and OCT-CN. The NIRS-IVUS classification algorism was highly sensitive and specific for differentiating these unstable lesion types in AMI.

Acknowledgement/Funding

None

P4349Simple and rapid estimation of left ventricular longitudinal deformation by tissue-tracking mitral annular displacement in single apical view

Background

Noninvasive assessment of left ventricular (LV) deformation using global longitudinal strain (GLS) has prognostic value in patients with and without preserved ejection fraction (EF). Application of speckle-tracking technology to the mitral annulus provides rapid and easy assessment of displacement of septal and lateral mitral annulus and mid-point of mitral annular line in single apical view (TMAD) even in poor echo-image quality. TMAD may be used as a simple index of LV longitudinal deformation in patients with and without preserved EF (Figure).

Purpose

The purpose of this study was to examine whether TMAD can be used as a simple index of LV longitudinal deformation in patients with and without preserved EF.

Methods

The study population consists of 95 patients without segmental wall motion abnormality, significant valvular diseases, and atrial fibrillation in whom both TMAD and GLS measurements were applied by QLAB software (Philips). We estimated GLS from apical 4- and 2-chamber views and apical longitudinal views, and TMAD from apical 4-chamber view. TMAD was automatically and quickly evaluated as the base-to-apex displacement of septal (TMADsep), lateral (TMADlat), and mid-point of annular line (TMADmid) (Figure). The percentage of M-TMAD to LV length from the mid-point of mitral annuls to the apex at end-diastole (%TMADmid) was also calculated. We compared each TMAD values with GLS values by linear regression analysis, and evluated TMAD values by a receiver operating characteristic (ROC) analysis to detect impaired LV longitudinal deformation (|GLS|<12.0%).

Results

TMAD was successfully assessed in 94 of 95 patients (99%) while GLS was measured in 84 of 95 patients (87%, p=0.0082 vs TMAD). There were good correlations between each TMAD index and |GLS| (TMADsep:r=0.77, TMADlat:r=0.81, TMADmid:r=0.82, %TMADmid:r=0.87). According to ROC curve, the best cut-off values for TMADsep, TMADlat, TMADmid, and %TMADmid in determining LV longitudinal deformation were 6.8mm, 8.0mm, 7.8mm, and 9.5% respectively (Table).

Conclusions

The present results suggest that rapid and easy assessment of TMAD in single apical view may be used as a simple index of LV longitudinal deformation.

[A case of refractory pouchitis following surgery for ulcerative colitis successfully treated with adalimumab]

Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is widely accepted as the operation of choice for refractory ulcerative colitis (UC), UC with dysplasia or cancer, or familial adenomatous polyposis. Pouchitis is the most frequent complication after IPAA for UC. Although the pathogenesis of pouchitis remains unclear, current evidence suggests that dysbiosis and mucosal immune response are important mechanisms. Antibiotics are the first-line treatment for the condition, but some patients develop chronic refractory pouchitis. Such cases can be treated with regimens such as longer courses of antibiotic combinations, mesalazine, corticosteroids, probiotics, or biologics. But if pouch inflammation is not ameliorated, a permanent ileostomy may be required. A 40-year-old man had undergone IPAA for UC and was diagnosed with pouchitis according to the Pouchitis Disease Activity Index. Antibiotics, mesalazine, and corticosteroids were given, but the inflammation was difficult to control. He developed chronic refractory pouchitis associated with perianal abscesses and anal fistulae. Following a seton procedure for fistulae, adalimumab (ADA) was administered. After 42 weeks, the ulcers in the pouch became scarred, and the anal fistulae were closed endoscopically. After remission was induced, it has been maintained. ADA is a fully human anti-tumor necrosis factor-α (TNF-α) monoclonal antibody that has been successfully used to treat refractory Crohn disease of the ileoanal pouch. Although some studies report that infliximab, a chimeric anti-TNF-α monoclonal antibody, is efficacious in patients with refractory pouchitis, clinical evidence for the use of ADA is limited. This case illustrates achievement of induction and maintenance of remission of refractory pouchitis with ADA. It is possible that patients with this condition can avoid a permanent ileostomy with anti-TNF-α therapy. In the near future, further study of long-term clinical outcomes of anti-TNF-α therapy is expected.

Favorable outcome with direct-acting antiviral treatment in hepatitis C patients coinfected with HIV

AIM

To investigate the efficacy and safety of all-oral direct-acting antiviral treatments in patients coinfected with hepatitis C virus (HCV) and HIV.

METHODS

In all, 35 patients with HCV/HIV coinfection (22 patients with HCV genotype 1 infection, 6 with genotype 2, and 7 with genotype 3) were treated with sofosbuvir and ledipasvir (for genotype 1 patients) or sofosbuvir and ribavirin (for genotypes 2 and 3). Sustained virological response (SVR) at 24 weeks after end of treatment and adverse events were assessed.

RESULTS

The overall SVR rate was 91.4% (32/35). One patient with genotype 1 infection discontinued treatment on day 2 due to severe headache, which subsided after the cessation of medication; all other patients completed their treatment without severe adverse events. Two patients who had a relapse of HCV were infected with a genotype 3 strain. We observed hyperbilirubinemia in a patient with genotype 3, who was under antiretroviral therapy including atazanavir. He completed the treatment and achieved SVR.

CONCLUSION

Direct-acting antiviral treatment for patients coinfected with HCV/HIV is as effective as in patients infected only with HCV. It was generally well tolerated, except in one patient who discontinued the treatment due to severe headache.

Comparison of Underwater vs Conventional Endoscopic Mucosal Resection of Intermediate-Size Colorectal Polyps

BACKGROUND & AIMS

Endoscopic mucosal resection (EMR) with submucosal injection is an established method for removing colorectal polyps, although the en bloc resection rate decreases when polyp size exceeds 10 mm. Piecemeal resection increases local recurrence. Underwater EMR (UEMR) is an effective technique for removal of sessile colorectal polyps and we investigated whether it is superior to conventional EMR (CEMR).

METHODS

We conducted a multicenter randomized controlled trial at 5 institutions in Japan. Patients with endoscopically diagnosed, intermediate-size (10-20 mm) sessile colorectal lesions were randomly assigned to undergo UEMR or CEMR. Only the most proximal lesion was registered. The UEMR procedure included immersion of the entire lumen in water and snare resection of the lesion without submucosal injection of normal saline. We analyzed outcomes of 108 colorectal lesions in the UEMR group and 102 lesions in the CEMR group. R0 resection was defined as en bloc resection with a histologically confirmed negative resection margin. The primary endpoint was the difference in the R0 resection rates between groups.

RESULTS

The proportions of R0 resections were 69% (95% confidence interval [CI] 59%-77%) in the UEMR group vs 50% (95% CI 40%-60%) in the CEMR group (P = .011). The proportions of en bloc resections were 89% (95% CI 81%-94%) in the UEMR group vs 75% (95% CI 65%-83%) in the CEMR group (P = .007). There was no significant difference in median procedure time (165 vs 175 seconds) or proportions of patients with adverse events (2.8% in the UEMR group vs 2.0% in the CEMR group).

CONCLUSIONS

In a multicenter randomized controlled trial, we found that UEMR significantly increased the proportions of R0 resections for 10- to 20-mm sessile colorectal lesions without increasing adverse events or procedure time. Use of this procedure should be encouraged. Trials registry number: UMIN000018989.

Self-study of the non-extension sign in an e-learning program improves diagnostic accuracy of invasion depth of early gastric cancer

Background and study aims  We developed an e-learning program for endoscopic diagnosis of invasion depth of early gastric cancer (EGC) using a simple diagnostic criterion called non-extension sign, and the contribution of self-study quizzes to improvement of diagnostic accuracy was evaluated. Methods  We conducted a prospective randomized controlled study that recruited endoscopists throughout Japan. After completing a pretest, the participants watched video lectures and undertook post-test 1. The participants were then randomly allocated to either the self-study or non-self-study group, and participants in the first group completed the self-study program that comprised 100-case quizzes. Finally, participants in both groups undertook post-test 2. The primary endpoint was the difference in post-test 2 scores between the groups. The perfect score for the tests was set as 100 points. Results  A total of 423 endoscopists completed the pretest and were enrolled. Post-test 1 was completed by 415 endoscopists and 208 were allocated to the self-study group and 207 to the non-self-study group. Two hundred and four in the self-study group and 205 in the non-self-study group were included in the analysis. Video lectures improved the mean score of post-test 1 from 72 to 77 points. Participants who completed the self-study quizzes showed significantly better post-test 2 scores compared with the non-self-study group (80 vs. 76 points, respectively, P  < 0.0001). Conclusions  Our e-learning program showed that self-study quizzes consolidated knowledge of the non-extension sign and improved diagnostic ability of endoscopists for invasion depth of EGC.

A prospective multicenter observational study evaluating the risk of periendoscopic events in patients using anticoagulants: the Osaka GIANT Study

Background and study aims  An increasing number of patients have been using anticoagulants including anti-vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs); however, in patients using anticoagulants, limited data are available with regard to the risks of gastrointestinal bleeding and thromboembolic events during the peri-endoscopic period. We aimed to evaluate the peri-endoscopic bleeding and thrombotic risks in patients administered VKAs or DOACs. Patients and methods  Consecutive patients using anticoagulants who underwent endoscopic biopsy, mucosal resection, or submucosal dissection were prospectively enrolled across 11 hospitals. The primary outcome assessed was difference in incidence of post-procedural gastrointestinal bleeding in patients using VKAs and DOACs. Duration of hospitalization and peri-procedural thromboembolic events were also compared. Results  We enrolled 174 patients using VKAs and 37 using DOACs. In total, 16 patients using VKA were excluded from the analysis because of cancellation of endoscopic procedures and contraindications to the use of DOACs; 128 (81 %) patients using VKAs and 17 (46 %) using DOACs received heparin-bridging therapy (HB). The rate of post-procedural gastrointestinal bleeding in DOAC users was similar to that in VKA users (16.2 % vs. 16.4 %, P  = 1.000). Duration of hospitalization was significantly longer in patients using VKAs than in those using DOACs (median 15 vs. 7 days, P  < 0.0001). Myocardial infarction occurred during pre-endoscopic HB in one patient using VKAs. Conclusion  DOAC administration showed similar post-procedural gastrointestinal bleeding risk to VKA administration in patients undergoing endoscopic procedures, but it shortened the hospital stay.

Efficacy of vonoprazan in prevention of bleeding from endoscopic submucosal dissection-induced gastric ulcers: a prospective randomized phase II study

BACKGROUND

Vonoprazan, potassium-competitive acid blocker, is expected to reduce incidence of delayed bleeding after gastric endoscopic submucosal dissection (ESD); however, preliminary data to design a large-scale comparative study are lacking. This study aimed to assess the efficacy of vonoprazan in preventing delayed bleeding after gastric ESD.

METHODS

In this single-center randomized phase II trial, a modified screened selection design was used with a threshold non-bleeding rate of 89% and an expected rate of 97%. In this design, Simon's optimal two-stage design was first applied for each parallel group, and efficacy was evaluated in comparison with the threshold rate using binomial testing. Patients were randomly assigned in a 1:1 ratio to receive either vonoprazan 20 mg (VPZ group) or lansoprazole 30 mg (PPI group) for 8 weeks from the day before gastric ESD. The primary endpoint was the incidence of delayed bleeding, defined as endoscopically confirmed bleeding accompanied by hematemesis, melena, or a decrease in hemoglobin of ≥ 2 g/dl.

RESULTS

Delayed bleeding occurred in three of 69 patients (4.3%, 95% CI 0.9-12.2%, p = 0.047) in the VPZ group, and four of 70 (5.7%, 95% CI 1.6-14.0%, p = 0.104) in the PPI group. As only vonoprazan showed significant reduction in delayed bleeding compared with the threshold rate, it was determined to be efficacious treatment.

CONCLUSIONS

Vonoprazan efficaciously reduced the delayed bleeding rate in patients with an ESD-induced gastric ulcer. A large-scale, randomized, phase III study is warranted to definitively test the effectiveness of vonoprazan compared with proton pump inhibitors.

Line-assisted complete closure for a large mucosal defect after colorectal endoscopic submucosal dissection decreased post-electrocoagulation syndrome

BACKGROUND AND AIM

The incidence of post-endoscopic submucosal dissection (ESD) coagulation syndrome (PECS) can be decreased by closing mucosal defects. However, large mucosal defects after colorectal ESD cannot be closed endoscopically. We established line-assisted complete clip closure (LACC), a novel technique for large mucosal defects after colorectal ESD. We evaluated the prophylactic efficacy of LACC for preventing PECS.

METHODS

Sixty-one consecutive patients on whom LACC after colorectal ESD was attempted from January 2016 to August 2016 were analyzed. After exclusion of patients with incomplete LACC and adverse events during ESD, 57 patients comprised the LACC group. In contrast, 495 patients who did not undergo closure of a mucosal defect comprised the control group. Propensity score matching was used to adjust for patients' backgrounds. Treatment outcomes were evaluated between the groups.

RESULTS

Median resected specimen size in the LACC-attempted group was 35 mm (range, 20-72 mm), and LACC success rate was 95% (58/61). Median procedure time of LACC was 14 min. In the LACC group, incidence of PECS was only 2%, and no delayed bleeding or perforation occurred. Propensity score matching created 51 matched pairs. Adjusted comparisons between the LACC and control groups showed a lower incidence of PECS (0% vs 12%, respectively; P = 0.03) and shorter hospitalization (5 vs 6 days, respectively; P < 0.001) in the LACC group.

CONCLUSION

This study suggests that LACC can effectively reduce the incidence of PECS, although further large-scale studies are warranted.

Efficacy of traction-assisted colorectal endoscopic submucosal dissection using a clip-and-thread technique: A prospective randomized study

BACKGROUND AND AIM

Colorectal endoscopic submucosal dissection (ESD) remains challenging because of technical difficulties, long procedure time, and high risk of adverse events. To facilitate colorectal ESD, we developed traction-assisted colorectal ESD using a clip and thread (TAC-ESD) and conducted a randomized controlled trial to evaluate its efficacy.

METHODS

Patients with superficial colorectal neoplasms (SCN) ≥20 mm were enrolled and randomly assigned to the conventional-ESD group or to the TAC-ESD group. SCN ≤50 mm were treated by two intermediates, and SCN >50 mm were treated by two experts. Primary endpoint was procedure time. Secondary endpoints were TAC-ESD success rate (sustained application of the clip and thread until the end of the procedure), self-completion rate by the intermediates, and adverse events.

RESULTS

Altogether, 42 SCN were analyzed in each ESD group (conventional and TAC). Procedure time (median [range]) for the TAC-ESD group was significantly shorter than that for the conventional-ESD group (40 [11-86] min vs 70 [30-180] min, respectively; P < 0.0001). Success rate of TAC-ESD was 95% (40/42). The intermediates' self-completion rate was significantly higher for the TAC-ESD group than for the conventional-ESD group (100% [39/39] vs 90% [36/40], respectively; P = 0.04). Adverse events included one intraoperative perforation in the conventional-ESD group and one delayed perforation in the TAC-ESD group.

CONCLUSION

Traction-assisted colorectal endoscopic submucosal dissection reduced the procedure time and increased the self-completion rate by the intermediates (UMIN000018612).

Transoral endoscopic examination of head and neck region

Transoral endoscopy with narrow band imaging (NBI) is useful for early detection of head and neck (HN) cancer. However, the lateral and anterior walls of the oropharynx, postcricoid area, and posterior wall of the hypopharynx are difficult to observe using transoral endoscopy. Advanced cancers in these regions may be missed even when NBI is used. This report highlights a method of transoral endoscopic examination of the HN region. For observation of the oral cavity and oropharynx, it is important to observe these regions without using a mouthpiece. Wide opening of the mouth facilitates observation of the oral cavity and oropharynx. Moreover, visibility of the oropharynx, including the anterior wall, is dramatically improved, when the patient positions the tongue forward and says 'aaah.' This technique also facilitates observation of the dorsum of the tongue, which is difficult to observe from a tangential view when using a mouthpiece. To observe the hypopharynx, the Valsalva maneuver is very useful. Patient cooperation is important when observing the HN region thoroughly to gain clear endoscopic views. Narcotic drugs, such as pethidine hydrochloride, are ideal for conscious sedation and reduce the gag reflex while still allowing patient cooperation. From the oral cavity to the hypopharynx, including the lateral and anterior walls of the oropharynx, postcricoid area, and posterior wall of the hypopharynx, most of the HN region can be observed during routine examination using transoral endoscopy without any special devices.

Safety of cold snare polypectomy for duodenal adenomas in familial adenomatous polyposis: a prospective exploratory study

BACKGROUND

Cold snare polypectomy (CSP) to remove multiple duodenal adenomas (MDAs) in patients with familial adenomatous polyposis (FAP) could be an effective and less invasive method than more extensive surgery. The aim of the present study was to determine the safety of this procedure.

METHODS

This prospective exploratory study included 10 consecutive patients with FAP and MDAs who underwent CSP for as many as 50 duodenal adenomas. The primary outcome was the incidence of severe adverse events.

RESULTS

10 patients were enrolled and underwent 332 CSPs from June 2016 to January 2017. The median procedure time was 33 minutes (range 25 - 53), and the median number of polyps removed during a single session was 35 (range 10 - 50). Most of the removed polyps were ≤ 10 mm. None of the 10 patients experienced a severe adverse event. One patient developed arterial bleeding during the procedure, but it was easily managed using hemoclips.

CONCLUSIONS

CSP for MDAs in patients with FAP was safe. The long-term efficacy of this procedure should be investigated.

Impact of electrosurgical unit mode on post esophageal endoscopic submucosal dissection stricture in an in vivo porcine model

BACKGROUND AND AIM

 Strictures are a major complication of esophageal endoscopic submucosal dissection (ESD) for superficial esophageal carcinoma. Post ESD, stricture develops during the process of scar formation, which is related to inflammation caused by ESD. We planned a study to evaluate whether certain electrosurgical unit modes could attenuate strictures after esophageal ESD.

METHODS

 A total of 16 ESD, three-quarters of the esophageal circumference, were performed in four live pigs. A ball-tip Flush knife was used for mucosal incision. Submucosal dissection was performed using a Hook knife in monopolar mode and a ball-tip Jet B-knife in bipolar mode. Applied electrosurgical unit modes were FORCED COAG, SWIFT COAG, SPRAY COAG, ENDO CUT in monopolar mode, and FORCED COAG in bipolar mode. One month after ESD, the pigs were killed humanely and the severity of strictures and fibrosis was assessed.

RESULTS

 The resected site in the esophagus showed complete mucosal regrowth and scar formation in all pigs. The quotients of stricture following ENDO CUT, SWIFT COAG, FORCED COAG effect2, FORCED COAG effect3, FORCED COAG effect4, SPRAY COAG, and Bipolar FORCED COAG mode were 16 %, 28 %, 38 %, 33 %, 51 %, 39 %, and 47 %, respectively. The equivalent quotients of fibrosis were 7 %, 28 %, 31 %, 30 %, 35 %, 63 %, and 100 %, respectively. ENDO CUT mode was associated with the lowest mean quotients of stricture and fibrosis.

CONCLUSION

 ENDO CUT mode showed promising results to attenuate fibrosis and strictures after esophageal ESD.

Underwater endoscopic mucosal resection for superficial nonampullary duodenal adenomas

BACKGROUND AND STUDY AIM

Underwater endoscopic mucosal resection (UEMR) was recently developed in a Western country. A prospective cohort study to investigate the effectiveness of UEMR was conducted in patients with small superficial nonampullary duodenal adenomas.

PATIENTS AND METHODS

Patients with duodenal adenomas ≤ 20 mm were enrolled. After the duodenal lumen had been filled with physiological saline, UEMR was performed without submucosal injection. Endoclip closure was attempted for all mucosal defects after UEMR. Follow-up endoscopy with biopsy was performed 3 months later. The primary end point was the complete resection rate, defined as neither endoscopic nor histological residue of adenoma at the follow-up endoscopy.

RESULTS

30 patients with 31 lesions were enrolled. The mean (SD) tumor size was 12.0 mm (7.3). The complete resection rate was 97 % (90 % confidence interval, 87 % - 99 %). The en bloc resection rate was 87 %. All mucosal defects were successfully closed by endoclips. No adverse events occurred except for one case of mild aspiration pneumonia.

CONCLUSIONS

UEMR is efficacious for the treatment of small duodenal adenomas, but further large-scale trials are warranted to confirm these results.

Efficacy and prognostic factor analysis in second-line chemotherapy for elderly patients with metastatic gastric cancer

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Background: Recently, the proportion of elderly patients (pts) with advanced gastric cancer has increased in Japan. Survival benefits of second-line chemotherapy (CTX) such as weekly paclitaxel (PTX)±Ramucirumab (RAM) or irinotecan (CPT) were shown in several phase 3 trials for metastatic gastric cancer (mGC). However, efficacy and prognostic factors in the second line CTX for elderly pts are not well studied. Methods: We retrospectively reviewed for mGC pts aged ≥ 70 years who underwent PTX+RAM, PTX or CPT as second-line CTX. Eligibility criteria were as follows: PS 0-2, refractory to an S-1containing CTX. Response rate (RR), overall survival (OS), progression-free survival (PFS), and adverse events (AEs) were evaluated. Univariate and multivariate analyses were performed to determine prognostic factors of survival. Results: There were 250 pts with mGC treated at our institution between April 2007 and March 2017. Of all, total of 85 pts were eligible. Median age was 75 years (71-85). The RR was 28.0% in the PTX+RAM group (n=28), 17.2% in the PTX group (n=29) and 18.5% in the CPT group (n=28). Median PFS was 5.1 months(M) and MST was 12.2 M in the PTX+RAM group, compared with 4.1 M and 9.7 M in the PTX group, or 3.3M and 9.8M in the CPT group. The ORR, PFS and OS were better in the PTX+RAM group though differences between groups were not statistically significant. Grade 3 or higher non-hematological AEs such as fatigue or diarrhea were more frequent in the CPT group on the other hand, hematological AEs were more frequent in the PTX+RAM group. On multivariate analysis, PS (HR,3.13; 95%CI, 1.60-5.77), LDH (HR,3.19; 95%CI, 1.80-5.57), and CEA (HR,2.35; 95%CI, 1.30-4.16) were found to be significant prognostic factors for elderly pts with mGC who underwent second-line CTX. Conclusions: PTX+RAM therapy seemed to be more effective than the other regimens. Furthermore, this analysis for prognostic factors may help clinicians to better select elderly pts who may benefit from a second-line CTX.

Erratum: Dive to the Underwater World: A Water Immersion Technique for Endoscopic Submucosal Dissection of Gastric Neoplasms

This corrects the article DOI: 10.1038/ajg.2016.595.