Incidence and molecular characteristics of deficient mismatch repair conditions across nine different tumors and identification of germline variants involved in Lynch-like syndrome

BACKGROUND

Based on molecular characteristics, deficient DNA mismatch repair (dMMR) solid tumors are largely divided into three categories: somatically MLH1-hypermethylated tumors, Lynch syndrome (LS)-associated tumors, and Lynch-like syndrome (LLS)-associated tumors. The incidence of each of these conditions and the corresponding pathogenic genes related to LLS remain elusive.

METHODS

We identified dMMR tumors in 3609 tumors from 9 different solid organs, including colorectal cancer, gastric cancer, small-bowel cancer, endometrial cancer, ovarian cancer, upper urinary tract cancer, urinary bladder cancer, prostate cancer, and sebaceous tumor, and comprehensively summarized the characterization of dMMR tumors. Characterization of dMMR tumors were performed as loss of at least one of MMR proteins (MLH1, MSH2, MSH6, and PMS2), by immunohistochemistry, followed by MLH1 promotor methylation analysis and genetic testing for MMR genes where appropriate. Somatic variant analysis of MMR genes and whole exome sequencing (WES) were performed in patients with LLS.

RESULTS

In total, the incidence of dMMR tumors was 5.9% (24/3609). The incidence of dMMR tumors and the proportion of the three categorized dMMR tumors varied considerably with different tumor types. One to three likely pathogenic/pathogenic somatic MMR gene variants were detected in 15 out of the 16 available LLS tumors. One patient each from 12 patients who gave consent to WES demonstrated non-MMR germline variants affect function (POLQ or BRCA1).

CONCLUSIONS

Our data regarding the LS to LLS ratio would be useful for genetic counseling in patients who are suspected to have LS, though the genetic backgrounds for the pathogenesis of LLS need further investigation.

Prevention of symptomatic pulmonary embolism for gynecologic malignancies with preoperative asymptomatic venous thromboembolism: GOTIC-VTE trial

OBJECTIVE

In Japan, perioperative prophylaxis of pulmonary embolism (PE) in gynecologic cancer patients with preoperative asymptomatic venous thromboembolism (VTE) has not been well established yet. The GOTIC-VTE trial was a prospective, multi-center, single-arm clinical trial to investigate the prevention of postoperative symptomatic PE onset by seamless anticoagulant therapy from the preoperative period to 4 weeks after surgery instead of using intermittent pneumatic compression.

METHODS

Anticoagulant therapy was started immediately after asymptomatic VTE diagnosis and stopped preoperatively according to the rules of each institution. Unfractionated heparin administration was resumed within 12 hours postoperatively, and this was followed by the switch to low-molecular-weight heparin and subsequently, edoxaban; this cycle was continued for 28 days. Primary outcome was the occurrence of symptomatic PE in 28 days postoperatively. Secondary outcomes were the incidence of VTE-related events in 28 days and 6 months postoperatively and protocol-related adverse events.

RESULTS

Between February 2018 and September 2020, 99 patients were enrolled; of these, 82 patients were assessed as the full analysis set, including 58 for ovarian cancer, fallopian tube, or peritoneal cancer; 21 for endometrial cancer; and 3 for cervical cancer. No symptomatic PE was observed within 28 days postoperatively; two patients had bleeding events (major bleeding and clinically relevant nonmajor bleeding) and three had grade 3 adverse events (increased alanine transaminase, aspartate aminotransferase, or gamma-glutamyl transferase).

CONCLUSION

The multifaceted perioperative management for gynecologic malignancies with asymptomatic VTE effectively prevented postoperative symptomatic PE.

TRIAL REGISTRATION

JRCT Identifier: jRCTs031180124.

Neutron resonance absorption imaging of simulated high-level radioactive waste in borosilicate glass

We performed a preliminary study of neutron resonance absorption imaging to investigate the spatial distribution of constituent elements in borosilicate glasses containing simulated high-level radioactive waste, in which elemental inhomogeneities affect the physical and chemical stabilities of the glass. Dips generated by the resonance absorptions of Rh, Pd, Na, Gd, Cs, and Sm were observed in the neutron transmission spectra of the glass samples. The spatial distributions of these elements were obtained from the neutron transmission images at the resonance energies. The distributions of Rh and Pd visualized the sedimentation of these platinum group elements. In contrast, the lanthanides (Gd and Sm) and Cs were uniformly dispersed. These results show that neutron resonance absorption imaging is a promising tool for characterizing borosilicate glasses and investigating the vitrification mechanism of high-level radioactive waste.

Intraperitoneal Carboplatin for Ovarian Cancer - A Phase 2/3 Trial

Intraperitoneal Carboplatin for Ovarian CancerThis trial compared intravenous weekly paclitaxel administered with intraperitoneal or intravenous carboplatin. There was a statistically significant increase in progression-free survival in patients with ovarian cancer treated with intraperitoneal versus intravenous carboplatin and paclitaxel, with no difference in overall survival between groups.

Impact of right ventricular reserve on exercise capacity and quality of life in patients with left ventricular assist device

Background

Right heart failure following left ventricular assist device (LVAD) implantation is a major complication which significantly impairs functional capacity and quality of life (QoL). Right ventricular (RV) reserve function may limit exercise capacity and QoL in LVAD patients; however, most patients show normal RV haemodynamics at rest.

Purpose

The aim of this study was to investigate whether RV reserve assessed by the changes of RV function during exercise is correlated with exercise capacity and QoL in patients with LVAD.

Methods

We prospectively examined 20 consecutive LVAD patients who were admitted to our university hospital between June 2020 and November 2021 after excluding those who were unable to perform exercise (n=8). All patients underwent invasive exercise right heart catheterisation with simultaneous echocardiography in the supine position. RV stroke work index (RVSWI) was calculated as 0.0136 × stroke volume index × (mean pulmonary artery pressure [mPAP] − right atrial pressure [RAP]) at rest and during exercise. Exercise capacity and QoL were assessed by 6-minute walk distance (6MWD) and peak oxygen consumption (VO2) in cardiopulmonary exercise testing, and the EuroQol visual analogue scale (EQ-VAS), respectively. The patients were divided into two groups according to the median ΔRVSWI (RVSWI change from rest to peak exercise) of 1.45 (interquartile range [IQR] −0.31 to 8.25) g/m2.

Results

Patients were predominantly male (75%) and the median age was 47 (IQR 38–60) years. Patients with lower ΔRVSWI had significantly higher change on RAP (P=0.019), but significantly lower change on mPAP (P<0.001) compared to those with higher ΔRVSWI. There were no significant differences in age, gender, primary aetiology of heart failure, type of LVAD devices, or echocardiographic parameters including tricuspid annular plane systolic excursion, and RVSWI at rest between the groups. ΔRVSWI during exercise were positively correlated with 6MWD (R=0.69, P<0.01) and peak VO2 (R=0.66, P<0.01) (Figure A). In addition, ΔRVSWI during exercise were positively correlated with the EQ-VAS (R=0.48, P=0.031). On the other hand, there was no significant correlation between RVSWI at rest and 6MWD (R=−0.11, P=0.63) and peak VO2 (R=0.13, P=0.95), and the EQ-VAS (R=0.11, P=0.61). During a median follow-up period of 312 (IQR 176–369) days, adverse events occurred in 3 patients (15%), including 1 death and 2 hospitalisations for major bleeding and right heart failure. Kaplan-Meier analysis revealed that the adverse events more frequently occurred in patients with lower ΔRVSWI compared to those with higher ΔRVSWI (Figure B).

Conclusions

ΔRVSWI was positively correlated with 6MWD, peak VO2 and EQ-VAS irrespective of RV function at rest. Our findings suggest that the assessment of RV reserve function using ΔRVSWI would be useful for risk stratification in patients with LVAD.

Funding Acknowledgement

Type of funding sources: None.

The safety and effectiveness of elective laparoscopic surgery for benign ovarian cysts during pregnancy-Comparison with emergency surgery

AIM

Relatively small benign ovarian cysts are conservatively managed in early pregnancy. However, emergency surgery is required should acute abdomen occur. Our study aimed to examine and compare the outcomes of benign ovarian cysts treated with elective laparoscopic surgery or emergency surgery during pregnancy.

METHODS

From 2004 to 2017, we treated 135 pregnant patients (110 elective and 25 emergencies) with benign ovarian cysts at our tertiary perinatal center and compared their surgical and perinatal outcomes.

RESULTS

There was no significant difference in cyst diameter (7.6 ± 2.5 vs. 6.8 ± 2.1 cm), but cysts <6 cm were significantly more common in emergency (36%) than in elective (15%) cases. Mature teratomas were significantly more common in elective cases (89% vs. 52%) but corpus luteum cysts were more common in emergency cases (0% vs. 32%). The rates of laparoscopic surgery (98.2% vs. 52.0%) and ovarian conservation (99.1% vs. 80.0%) were significantly higher, and post-surgical hospitalization (4.6 ± 1.3 vs. 9.8 ± 10.5 days) was significantly shorter in elective than in emergency cases. There was no significant difference in the gestational age for delivery (38.9 ± 1.9 vs. 38.4 ± 2.7 weeks), preterm birth rate (12% vs. 20%), or birth weight (2939 ± 469 vs. 3019 ± 510 g).

CONCLUSIONS

We cannot state that an emergency surgery during pregnancy is rarely required for small benign ovarian cysts. However, the surgical outcomes were significantly better for elective than for emergency surgery, with no difference in perinatal outcomes. If a benign ovarian cyst is found early in pregnancy, elective laparoscopic surgery may be considered with adequate informed consent.

Pathophysiological mechanism of worsened clinical outcome by lowered left ventricular cardiac power output in heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac power output (CPO) is a measure of cardiac pumping function, and CPO during exercise is known to be a powerful prognostic marker of heart failure. Despite its prognostic significance, pathophysiological mechanism of the association between reduced CPO and worse clinical outcome is unknown. We hypothesized that reduced CPO is associated with worse outcome through the reduced exercise capacity and enhanced ventilatory response.

Methods

Cardiopulmonary exercise testing and exercise stress echocardiography were performed in consecutive 64 patients with chronic heart failure who admitted to our department for the management of heart failure [60 ± 14 years old, left ventricular (LV) ejection fraction 39 ± 16%, ischemic etiology 16%, brain natriuretic peptide 124 pg/ml (51-313)]. Peak oxygen uptake (peak VO2) and the lowest minute ventilation / carbon dioxide production ratio (VE/VCO2) were measured as a parameter of exercise tolerance and that of ventilatory response, respectively. LV ejection fraction was measured by disk summation method at peak exercise. By using Doppler images, E/e" at peak exercise was measured as a marker of LV filling pressure, and CPO normalized by LV mass was obtained as 0.222 × cardiac output × mean blood pressure / LV mass [W/100 g]. Cardiac events defined as hospitalization for heart failure, cardiac death, or implantation of a LV assist device after the examinations were recorded.

Results

CPO at rest was weakly correlated with peak VO2 (r = 0.25, p = 0.046) but not with VE/VCO2. In contrast, CPO at peak exercise was positively correlated with peak VO2 (r = 0.50, p &lt; 0.001) and inversely correlated with VE/VCO2 (r=-0.40, p = 0.002). Moreover, CPO at peak exercise determined both peak VO2 (b = 0.50) and VE/VCO2 (β=-0.54) independently of LV ejection fraction and E/e" at peak exercise. During a median follow-up period of 1211 days, 12 cardiac events were observed. Each of reduced peak VO2 (hazard ratio 0.78, 95% confidence interval 0.66-0.90) and increased VE/VCO2 (hazard ratio 1.10, 95% confidence interval 1.02-1.18) was associated with worse clinical outcome.

Conclusions

In patients with chronic heart failure, CPO during exercise was associated with prognosis of heart failure through the reduced exercise capacity and enhanced ventilatory response.

A fatal case of acute encephalopathy in a child due to coxsackievirus A2 infection: a case report

Background

Certain types of enteroviruses, including coxsackieviruses, cause encephalitis, and other neurological complications. However, these pathogens rarely cause fatal infections, especially in immunocompetent infants. In this study, we present a rare case of acute encephalopathy caused by coxsackievirus A2 (CV-A2), which progressed rapidly in a previously healthy female child.

Case presentation

In June 2013, a 26-month-old female child from Kanagawa, Japan, was found unresponsive during sleep. She was healthy until that morning. Her temperature was 37 °C at 08:00. She was feeling fine and went to the nursery that same morning. However, her condition worsened around noon. Therefore, she went home and slept at around 13:00. Surprisingly, after 2 h, her parents checked on her and found that she was lying on her back and was not breathing. Hence, she was immediately taken to a hospital by ambulance, but she was declared dead on arrival at the hospital. Subsequently, pathological autopsy and pathogenetic analysis, including multiple pathogen detection real-time PCR, were conducted to investigate the cause of death. The examination results revealed that she had an infectious respiratory disease and acute encephalopathy due to a CV-A2 infection.

Conclusions

Based on our findings, we concluded that a previously healthy girl who had no immediate history of underlying medical condition were susceptible to death by acute encephalopathy due to CV-A2 infections. We proposed this conclusion because the patient’s condition progressed rapidly in less than 2 h and eventually led to her death. This is the first report on an acute encephalitis-dependent death in a child due to CV-A2 infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06858-2.

Undifferentiated Carcinoma After Laparoscopic Surgery for a Cystic Ovarian Tumour: A Case Study

BACKGROUND

Laparoscopic surgery for malignant tumours occasionally results in recurrence at the trocar insertion site or port-site metastasis (PSM). We report on a patient requiring emergency laparoscopic surgery for an ovarian tumour with a review of the relevant literature.

CASE REPORT

A 42-year-old woman developed sudden abdominal pain and underwent laparoscopic right adnexectomy because of a suspected ovarian cystic tumour rupture. The postoperative histological diagnosis was a mucinous borderline ovarian tumour; however, an undifferentiated carcinoma was detected at the port site eight months after the initial surgery. The histopathological diagnosis of the abdominal wall tumour at the port site differed from intraoperative pathological findings, which was contradictory to PSM definition. Postoperatively, she received three systemic chemotherapy courses but died consequent to tumour metastasis.

CONCLUSION

This is an atypical PSM case with histopathological differences from the initial tumour. Careful preoperative diagnosis and intraoperative attention are essential in such cases.

Validation of the HFA-PEFF and the H2FPEF scores for the diagnosis of heart failure with preserved ejection fraction in Japanese patients:a report from the Japanese multicentre registry

Background

The standard diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF) is based on the following: 1) symptoms of HF, 2) preserved left ventricular (LV) ejection fraction (LVEF, &gt;50%), and 3) presence of LV diastolic dysfunction confirmed by echocardiography or cardiac catheterisation. However, there are limits to the diagnostic accuracy of individual parameters, and what cut-off values should be applied and how they should be combined remain unclear. Diagnostic algorithms for HFpEF such as the HFA-PEFF algorithm and the H2FPEF score have been proposed; however, previous validation studies were conducted in stable chronic HF and did not include an invasive haemodynamic assessment. Thus, the diagnostic accuracy for HFpEF lacked robustness. Moreover, information on their applicability in the Asian population is limited.

Purpose

The aim of this study was to investigate these scores' diagnostic validity for HFpEF in Japanese patients recently hospitalised due to acute decompensated HF.

Methods

We examined patients with HFpEF recently hospitalised with acute decompensated HF whose HFA-PEFF and H2FPEF scores could be calculated at discharge from a nationwide HFpEF-specific multicentre registry (HFpEF group) and control patients who underwent echocardiography to investigate the cause of dyspnoea in our hospital (Non-HFpEF group). We calculated the HFA-PEFF and the H2FPEF scores among the studied population. Receiver operating characteristic (ROC) curves and area under the curve (AUC) were computed to compare the diagnostic accuracy of these scores.

Results

The studied population included 372 consecutive patients (194 HFpEF group and 178 Non-HFpEF group; HFpEF prevalence, 52%). The HFA-PEFF score classified 155 (42%) of all patients into the high likelihood category (5–6 points) and only 19 (5%) into the low likelihood category (0–1 point). A high HFA-PEFF score could diagnose HFpEF with a high specificity of 84% and a positive predictive value (PPV) of 82%, and a low HFA-PEFF score could rule out HFpEF with a high sensitivity of 99% and a negative predictive value (NPV) of 89%. The H2FPEF score classified 86 (23%) of all patients into the high likelihood category (6–9 points) and 84 (23%) into the low likelihood category (0–1 point). HFpEF could be diagnosed with a high H2FPEF score (specificity, 97%; PPV, 94%) or ruled out with a low H2FPEF score (sensitivity, 97%; NPV, 93%). The diagnostic accuracy for the HFA-PEFF and H2FPEF scores was 0.82 (95% confidence interval [CI] 0.78–0.86) and 0.89 (95% CI 0.86–0.93), respectively, by the AUC of the ROC curve (P=0.004) (Figure 1A). In the HFA-PEFF sub-scores, the functional score showed little diagnostic value, while the morphological and biomarker scores showed moderate diagnostic value (Figure 1B).

Conclusions

The H2FPEF score may be more useful than the HFA-PEFF score in diagnosing HFpEF in Japanese patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science (JSPS KAKENHI) Figure 1

Left atrial dysfunction still exists in patients who obtain normal left atrial volume after successful ablation of atrial fibrillation

Introduction

Atrial fibrillation (AF) promotes left atrial (LA) remodeling and vice versa. LA volume index (LAVI) ≥34 mL/m2 is an established cut-off value for identifying an enlarged left atrium. Catheter ablation has become an established therapy for AF and provides a reduction of LA volume by maintaining sinus rhythm (reverse remodeling). However, the definition of LA reverse remodeling after AF ablation is undetermined.

Purpose

We hypothesized that patients with LA dilatation who obtain normal LA volume (LAVI &lt;34 mL/m2) after AF ablation would have better long-term outcomes than those who do not. Furthermore, we investigated whether patients with a normal LA volume could also obtain normal LA function with AF ablation.

Methods

We enrolled 140 AF patients with baseline LAVI ≥34 mL/m2, without AF recurrence for 1 year after the initial AF ablation. We acquired conventional and speckle-tracking echocardiographic parameters within 24 h and at 1 year after the procedure. Late recurrence was defined as AF recurrence &gt;1 year after the initial ablation. To define the normal range of LA function, age-and sex-matched 140 controls without a history of AF were also enrolled.

Results

After restoration of sinus rhythm, overall LA structural and functional parameters were significantly improved, and 75 patients (54%) had normal LA volume at the time of follow-up (Table). During a median follow-up of 44 (31–61) months, 32 patients (23%) experienced a late recurrence of AF. Patients who obtained normal LA volume after AF ablation had fewer late recurrences than those who did not (P&lt;0.01) (Figure). However, LA functional abnormalities still existed in AF patients, even if LA volume was normalized as in controls (Table).

Conclusion

Patients who obtain normal LA volume have better long-term outcomes of AF ablation than those who do not. Although AF ablation promotes beneficial effects on LA structure and function, LA function cannot be normalized even in patients who obtain normal LA volume after successful ablation. Thus, physicians should carefully consider long-term follow-up and residual AF risks, regardless of sinus rhythm restoration by catheter ablation.

Funding Acknowledgement

Type of funding sources: None.

Applicability of the AHA/ACC/HRS guideline for implantable cardioverter defibrillator implantation in Japanese patients with cardiac sarcoidosis

Background

Sarcoidosis is a systemic granulomatous disease that affects multiple organs. Cardiac involvement is a key determinant of poor clinical outcomes in the patients with sarcoidosis, as it causes congestive heart failure, conduction abnormalities, ventricular tachycardia and fibrillation (VT/VF), and sudden cardiac death (SCD). Although implantable cardioverter defibrillators (ICDs) are used to prevent SCD from VT/VF in patients with cardiac sarcoidosis (CS), the generalizability of the AHA/ACC/HRS guidelines for the Japanese CS patients remains unclear.

Purpose

We aimed to assess, among Japanese patients with CS, the ICD recommendations from the 2017 AHA/ACC/HRS Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death.

Methods

We examined 188 consecutive patients with CS in two tertiary hospitals between 1979 and 2020. The primary outcome was defined as a composite outcome involving SCD or ventricular arrhythmic events. Ventricular arrhythmic events were defined as either emergency treatment for VF or sustained VT, which included appropriate ICD therapy.

Results

During a median follow-up period of 5.68 (IQR: 4.87–6.70) years, the primary outcome occurred in 44 patients (23%), which included 6 cases of SCD and 38 cases of VT/VF. ICD implant was indicated based on left ventricular ejection fraction (LVEF) of ≤35% (class I recommendation) in 62 patients, with an annualized event rate of 3.93%. A LVEF of &gt;35% with a need for a permanent pacemaker (class IIa recommendation) was observed for 53 patients, with an annualized event rate of 2.54%. A LVEF of &gt;35% with late gadolinium enhancement (LGE) during cardiovascular magnetic resonance (class IIa recommendation) was observed for 62 patients, with an annualized event rate of 2.38% (Figure A). Kaplan-Meier analyses revealed that patients with a class I recommendation for ICD implantation had a significant higher incidence of the primary outcome, compared to patients with a class IIa recommendation and patients with no indication for ICD implantation (P=0.03). However, there were no significant differences in the incidence of the primary outcome between patients with a LVEF of &gt;35% and a need for a permanent pacemaker and patients with a class I recommendation (P=0.08) or patients with a LVEF of ≤35% (P=0.31). Moreover, there was no significant difference in the incidence of the primary outcome between patients with a LVEF of &gt;35% and LGE on cardiovascular magnetic resonance and patients with a class I recommendation (P=0.054) or patients with a LVEF of ≤35% (P=0.22) (Figure B).

Conclusions

The American guideline recommendations for ICD implantation might be applicable to Japanese patients with CS. Implantation of an ICD may need to be considered in these patients if they require a permanent pacemaker or have LGE, regardless of LVEF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Society for the Promotion of Science

Association of high serum soluble interleukin 2 receptor levels with risk of adverse events in patients with cardiac sarcoidosis

Background

Sarcoidosis is a systemic granulomatous disease that affects multiple organs. Among these, the presence of cardiac involvement is recognised as a determinant of worse clinical outcomes. Soluble interleukin 2 receptor (sIL-2R) is a potentially useful biomarker in the diagnosis and evaluation of disease severity in patients with sarcoidosis. However, it remains to be seen whether sIL-2R is associated with the severity and activity of disease in patients with cardiac sarcoidosis (CS).

Purpose

The aims of this study were to investigate whether sIL-2R was associated with clinical outcomes and to clarify the relationship between sIL-2R levels and disease activity evaluated by 18F-fluorideoxyglucose in positron emission tomography/computed tomography (18F-FDG PET/CT) in patients with CS.

Methods

We examined 101 consecutive patients with CS who were admitted to our University HospitalbetweenMay 2003 and February 2020. Patients who had no data of serum sIL-2R levels before initiation of immunosuppressive therapy (n=18) were excluded. Ultimately, 83 patients were examined in this study. The primary outcome was a composite of advanced atrioventricular block (AVB), ventricular tachycardia or ventricular fibrillation (VT/VF), heart failure hospitalisation, and all-cause death. Inflammatory activity in the myocardium and lymph nodes were assessed by18F-FDG PET/CT. We used a published program to analyse the cardiac metabolic activity (CMA), and total lymph node glycolysis (TLyG), which are quantitative measures of FDG volume-intensity.

Results

During a median follow-up period of 2.96 (interquartile range 2.24–4.27) years, the primary outcome occurred in 24 patients (29%), including 1 advanced AVB, 13 VT/VF, 5 hospitalisations for heart failure, and 5 all-cause deaths. Kaplan-Meier analyses showed that the primary outcome occurred more frequently in patients with higher sIL-2R levels (&gt;538 U/mL, the median) than in those with lower sIL-2R levels (Figure). A multivariable Cox regression analysis revealed that a higher sIL-2R level was independently associated with an increased subsequent risk of adverse events (hazard ratio 3.71, 95% confidence interval 1.63–8.44, p=0.002), even after adjustments for age, plasma B-type natriuretic peptide, estimated glomerular filtration rate, left ventricular ejection fraction, and late gadolinium enhancement, which are known to be strong determinants of worse clinical outcomes in patients with CS (Table). Furthermore, sIL-2R levels were significantly correlated with TLyG, the inflammatory activity in lymph nodes (r=0.346, p=0.003) but not with CMA, the inflammatory activity in myocardium (r=0.131, p=0.27).

Conclusions

Increased sIL-2R is associated with worse long-term clinical outcomes accompanied by increased systemic inflammatory activity in CS patients. These findings suggest the importance of assessing sIL-2R as a surrogate marker for further risk stratification in these patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Japan Society for the Promotion of Science

Exploring rare cellular activity in more than one million cells by a transscale scope

In many phenomena of biological systems, not a majority, but a minority of cells act on the entire multicellular system causing drastic changes in the system properties. To understand the mechanisms underlying such phenomena, it is essential to observe the spatiotemporal dynamics of a huge population of cells at sub-cellular resolution, which is difficult with conventional tools such as microscopy and flow cytometry. Here, we describe an imaging system named AMATERAS that enables optical imaging with an over-one-centimeter field-of-view and a-few-micrometer spatial resolution. This trans-scale-scope has a simple configuration, composed of a low-power lens for machine vision and a hundred-megapixel image sensor. We demonstrated its high cell-throughput, capable of simultaneously observing more than one million cells. We applied it to dynamic imaging of calcium ions in HeLa cells and cyclic-adenosine-monophosphate in Dictyostelium discoideum, and successfully detected less than 0.01% of rare cells and observed multicellular events induced by these cells.

Chance diagnosis of mixed gonadal dysgenesis in an adult case of malignant gonadal germ cell tumor: a case report

Background

Mixed gonadal dysgenesis (MGD) is a subtype of the disorders of sex development (DSD) associated with sex chromosome abnormalities characterized by abnormal external genitalia, short stature, and primary amenorrhea. This disease is generally diagnosed from the neonatal stage to early childhood, and by puberty at the latest. Cases that are phenotypically female or those with ambiguous genitalia experience a high risk of gonadal tumor formation. As tumor risk is known to increase with age, prophylactic bilateral gonadectomy is recommended following early diagnosis.

Case presentation

Here we report a case of an adult Japanese woman diagnosed with MGD during treatment for a giant pelvic tumor. The patient initially visited a gynecology clinic during puberty for primary amenorrhea, at which time an abnormality was found with the external genitalia. However, a diagnosis of MGD was not made at this time, resulting in the development of a malignant gonadal germ cell tumor in adulthood.

Conclusions

For early diagnosis of MGD and the prevention of gonadal tumor formation, it is essential that gynecologists fully understand MGD and other DSD.

Influence of left ventricular systolic dysfunction on occurrence of pulsus tardus in patients with aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Background

The time between left ventricular (LV) and aortic systolic pressure peaks (TLV-Ao) which could reflect pulsus tardus (PT) is reported to be a marker of severity and be associated with poor prognosis in patients with aortic stenosis (AS). Despite its worldwide recognition, physiological mechanism of PT has not been well elucidated. We hypothesized that not only severity of the AS but also LV systolic dysfunction could be associated with occurrence of PT.

Methods

TLV-Ao and mean trans-aortic valvular pressure gradient (mean PG) were measured by simultaneous pressure tracing of left ventricle and basal aorta in 74 AS patients with at least moderate severity (78 ± 8 years old). Effective orifice area index (EOAI) was estimated by using continuity equation from transthoracic echocardiography and severe AS was defined as EOAI ± 0.60 cm²/m². Global longitudinal strain (GLS) was measured by using speckle-tracking method and expressed as an absolute value.

Results

TLV-Ao, mean PG, and EOAI was 87 ± 30 msec, 51 ± 21 mmHg, and 0.51 ± 0.14 cm² respectively. A weak correlation was observed between EOAI and TLV-Ao (Figure). In 9 out of 17 moderate AS patients (A in Figure), TLV-Ao was prolonged over the previously reported cut-off value (≥66 msec), on the other hand, it was not prolonged in 11 out of 57 severe AS patients (D in Figure). When the patients were divided by TLV-Ao of 66 msec, mean PG was not different between patients with prolonged TLV-Ao and those without in moderate AS patients (Figure, A vs B; NS), whereas GLS was significantly reduced in prolonged TLV-Ao group (P = 0.0383). In patients with severe AS, mean PG was significantly higher (P &lt; 0.0001) in patients with prolonged TLV-Ao than in those without (Figure, C vs D), whereas GLS was comparable between the groups. In overall patients, multivariable analysis revealed that not only mean PG (β=0.54) but also GLS (β=-0.23) was an independent determinant of TLV-Ao.

Conclusion

The occurrence of pulsus tardus could be associated not only with severity of the AS but also with LV systolic dysfunction in patients with AS.

Abstract Figure

Presence and significance of mid-systolic notch on right ventricular outflow tract velocity envelopes in pulmonary hypertension due to heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

 A mid-systolic notch (MSN) of the right ventricular outflow tract (RVOT) pulsed-wave Doppler envelope, which is recognized as a characteristic finding in pre-capillary pulmonary hypertension (PH), is often observed in heart failure (HF) patients. However, clinical significance of MSN formation in HF has not been elucidated.

Methods

 Consecutive 233 HF patients who underwent right heart catheterization and echocardiography within 24 hours were enrolled. Isolated post-capillary PH (IpcPH) was defined as mean pulmonary arterial pressure (mPAP) &gt;20 mmHg, mean pulmonary artery wedge pressure (mPAWP) &gt;15 mmHg, and pulmonary vascular resistance (PVR) &lt;3 Wood units and combined pre- and post-capillary PH (CpcPH) was as mPAP &gt;20 mmHg, mPAWP &gt;15 mmHg, and PVR ≥3 Wood units. Pulmonary arterial capacitance (PAC) was calculated as stroke volume / pulmonary arterial pulse pressure [mL/mmHg]. MSN was defined as formation of notch within first half of the RVOT pulsed-wave Doppler envelope.

Results

 Prevalence of IpcPH, CpcPH, and without PH were 87 (37%), 45 (19%), and 101 (43%), respectively and MSN was observed in 8 (9%) of IpcPH, 17 (38%) of CpcPH, and 1 (1%) of patients without PH. Among the hemodynamic and echocardiographic parameters, mPAP and PAC independently determined occurrence of MSN in all the multivariable models (Table). Interestingly, when the PH patients were dimidiated according to median PAC (3.2 mL/mmHg), 25 out of 102 PH patients (25%) with low PAC showed MSN whereas any of PH patients with high PAC did not (Figure).

Conclusion

 MSN was frequently observed in HF patients showing CpcPH. Combination of elevated pressure and reduced compliance of the pulmonary circulation could determine occurrence of MSN in HF.

Determinants of MSN occurrence Univariable analysis Multivariable analysis Model 1 Model 2 Model 3 Model 4 variables OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p OR (95% CI) p LV ejection fraction 0.97 (0.94-0.99) 0.007 1.00 (0.96-1.03) 0.795 LV mass index 1.00 (1.00-1.02) 0.143 PAW pressure 1.13 (1.08-1.18) &lt;0.001 0.92 (0.82-1.03) 0.135 Mean PA pressure 1.14 (1.09-1.19) &lt;0.001 1.08 (1.02-1.14) 0.006 1.15 (1.04-1.27) 0.004 1.08 (1.00-1.17) 0.030 1.07 (1.01-1.14) 0.025 Mean RA pressure 1.14 (1.06-1.22) &lt;0.001 1.00 (0.90-1.11) 0.978 Pulmonary vascular resistance 1.97 (1.45-2.67) &lt;0.001 1.20 (0.88-1.63) 0.225 Pulmonary arterial capacitance 0.27 (0.15-0.48) &lt;0.001 0.49 (0.26-0.92) 0.010 0.44 (0.23-0.85) 0.004 0.47 (0.24-0.93) 0.011 0.49 (0.26-0.93) 0.011 Abstract Figure.

Prevalence and molecular characteristics of DNA mismatch repair deficient endometrial cancer in a Japanese hospital-based population

BACKGROUND

The prevalence and molecular characteristics of defective DNA mismatch repair endometrial cancers in the Japanese population have been underexplored. Data supporting clinical management of patients with Lynch-like syndrome and germline variant of uncertain significance of mismatch repair genes are still lacking.

METHODS

Immunohistochemistry of mismatch repair proteins (MLH1, MSH2, MSH6 and PMS2) was performed on formalin-fixed paraffin-embedded sections prepared from resected primary endometrial cancers in 395 women with a median age of 59 years. Genetic and/or epigenetic alterations of the mismatch repair genes were also investigated.

RESULTS

Loss of expression of one or more mismatch repair proteins was observed in 68 patients (17.2%). A total of 17 out of 68 patients (25%, 4.3% of all cases) were identified as candidates for genetic testing for Lynch syndrome after excluding 51 patients with MLH1 hypermethylated cancer. Fourteen of these 17 patients subjected to genetic testing were found to have Lynch syndrome (n = 5), germline variant of uncertain significance (n = 2) or Lynch-like syndrome (n = 7). Compared with patients with Lynch syndrome, those with germline variant of uncertain significance and Lynch-like syndrome tended to demonstrate an older age at the time of endometrial cancer diagnosis (P = 0.07), less fulfillment of the revised Bethesda guidelines (P = 0.09) and lower prevalence of Lynch syndrome-associated tumors in their first-degree relatives (P = 0.01).

CONCLUSIONS

This study provides useful information for management in patients with DNA mismatch repair endometrial cancer. Specifically, cancer surveillance as recommended in patients with Lynch syndrome might not be necessary in patients with germline variant of uncertain significance and Lynch-like syndrome and their relatives.

High-density lipoprotein cholesterol does not predict future cardiovascular events in patients treated with statins for secondary prevention: an observation from the REAL-CAD study

Background

The relation between high-density lipoprotein cholesterol (HDL-C) level after statin therapy and cardiovascular events in patients with stable coronary artery disease remains unclear.

Purpose

We sought to determine the association of the HDL-C level after statin therapy with cardiovascular events in stable coronary artery disease patients.

Methods

This study was a post-hoc analysis of the Randomized Evaluation of Aggressive or Moderate Lipid Lowering Therapy with Pitavastatin in Coronary Artery Disease (REAL-CAD) study, which is randomised, open-label, blinded endpoint, physician-initiated, superiority clinical trial. Enrollment was from January 2010 to March 2013, and follow-up was through January 2016. From the main study, we excluded the patients without either HDL-C data at baseline or 6 months, with occurrence of the primary outcome at 6 months and reported poor adherence for pitavastatin. The primary outcome of interest was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal ischemic stroke, or unstable angina requiring emergent admission after 6 months from randomisation, consistent with the primary analysis of the trial. We constructed landmark Cox proportional hazards regression models with the 18 selected clinically relevant risk-adjusting variables during the entire follow-up period starting at 6 months after randomisation. Absolute and relative changes of HDL-C level were defined as (6 months value – baseline value) and (absolute change / baseline value) × 100, respectively.

Results

Among 14,774 participants in the REAL-CAD study, 9,221 patients were included in this analysis (7652 [83.0%] male; median [IQR] age, 70 [63–75] years; median [IQR] HDL-C, 49 [42–57] mg/dL; median [IQR] low-density lipoprotein cholesterol [LDL-C], 88 [75–101] mg/dL). During a median follow-up period of 4.0 (IQR 3.2–4.7) years, the primary outcome occurred in 417 (4.5%) patients. There was no significant difference in crude and adjusted cumulative incidence of the primary outcome among the quartiles of HDL-C level at 6 months (Figure 1). The adjusted risks of all the HDL-C related variables (baseline value, 6 months value, absolute and relative changes) for the primary outcome were not significant (Figure 2). Furthermore, the adjusted hazard ratio (HR) as HDL-C level at 6 months increased by 10 mg/dL remained non-significant for the primary outcome for each on-treatment LDL-C level at 6 months (&lt;70 mg/dL [HR 0.97, 95% CI 0.82–1.15], 70–100 mg/dL [HR 1.10, 95% CI 0.98–1.24], and ≥100 mg/dL [HR 0.94, 95% CI 0.78–1.13]). There was also no significant association between HDL-C level at 6 months and the primary outcome both in the low (1 mg/day [HR 1.02, 95% CI 0.91–1.14], increased by 10 mg/dL) dose and high (4 mg/day [HR 1.04, 95% CI 0.91–1.19]) dose pitavastatin groups

Conclusion

After statin therapy with modestly controlled LDL-C, HDL-C level has little prognostic value in patients with stable coronary artery disease.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Comprehensive Support Project for Clinical Research of Lifestyle-Related Disease of the Public Health Research Foundation

Impact of right ventricular contractile reserve on exercise capacity in patients with heart failure: clinical application of low-load exercise stress echocardiography

Background

The peak oxygen uptake (VO2) evaluated by the cardiopulmonary exercise test (CPX) is an established marker of exercise capacity in patients with heart failure (HF). In particular, peak VO2 &lt;14 ml/kg/min is used to be one of the criteria for heart transplantation. However, given exercise intolerance in patients with HF, it is difficult for refractory HF patients to reach sufficient exercise load. A recent report has highlighted significant impact of right ventricular (RV) function on mortality and urgent heart transplantation. Taken together, we hypothesized that the assessment of RV function was helpful to predict exercise capacity by using low-load exercise stress echocardiography (low-load ESE) in patients with HF.

Purpose

We evaluated whether RV dysfunction assessed by the low-load ESE determined a low peak VO2 &lt;14 ml/kg/min in patients with HF.

Methods

We studied 67 consecutive hospitalized patients with HF (mean age, 65 years; 75% male; mean LV ejection fraction, 36%) who underwent ESE and CPX after stabilized HF condition, and the time interval of CPX and ESE tests was within 48 hours. CPX was performed using an upright cycle ergometer by a ramp protocol, while ESE was performed using ergometer in semi-supine position and the workload was generally increased by 25 watts every 3 minutes. The low-load ESE was defined as the 25 watts exercise. The increments of RV s' velocity at tricuspid annulus and RV strain in the free wall were considered as a preservation of RV contractile reserve. Among the study population, 26 patients were performed right heart catheterization and RV dP/dt/Pmax was estimated as an invasive marker of RV contractility.

Results

The achieved intensity of exercise was 50.4±21.0 watts, and all patients completed the low-load ESE. The invasive study showed that the change of RV s' velocity during the low-load ESE significantly correlated with RV dP/dt/Pmax (r=0.706, p&lt;0.001). As shown in Figure, the non-invasive parameters of RV contractile reserve during the low-load ESE were significantly correlated with peak VO2 (RV s' velocity: r=0.787, p&lt;0.001; RV strain: r=0.244, p=0.047). ROC analysis showed that the change of RV s' velocity during the low-load ESE correctly identified patients with peak VO2 &lt;14 ml/kg/min (AUC=0.95, sensitivity 92.3%, specificity 85.2%). In terms of inter- and intra-observer variabilities, ICCs of the change of RV s' velocity were 0.86 and 0.96, and ICCs of the changes of RV strain were 0.63 and 0.70, respectively.

Conclusion

The change of RV s' velocity during the low-load ESE could determine exercise tolerance in patients with HF. The assessment of RV contractile reserve might be clinically useful to discriminate high risk HF patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Simple echocardiographic scoring system to estimate left ventricular filling pressure based on visual assessment of time sequence of mitral and tricuspid valve opening

Introduction

In the presence of elevated left ventricular (LV) filling pressure, mitral valve (MV) becomes to open early and precedes tricuspid valve (TV) opening in early diastole. Accordingly, time-delay of right ventricular inflow relative to LV inflow assessed by dual Doppler system was recently reported as a parameter of LV filling pressure. We assumed that visually-assessed time-delay of TV relative to MV opening could be a simple and alternative marker of elevated LV filling pressure.

Purpose

This study aimed to elucidate the clinical usefulness of the 2-dimensional echocardiographic scoring system, Visual assessment of time-difference between Mitral and Tricuspid valve opening (VMT) score, in patients with heart failure (HF).

Methods

We analyzed 119 consecutive HF patients who underwent echocardiography and cardiac catheterization within a day. Elevated LV filling pressure was defined as mean pulmonary arterial wedge pressure (PAWP) ≥15 mmHg. LV diastolic function was graded according to the ASE/EACVI recommendations. Time sequence of opening of MV and TV was visually assessed in the apical 4-chamber view and scored to 3 grades (0: TV opening first, 1: simultaneous, 2: MV opening first). When the inferior vena cava diameter was &gt;21 mm and collapsed &lt;20% during normal respiration, 1 point was added and VMT score was calculated as 4 grades from 0 to 3. We also investigated 113 patients without worsening HF at VMT scoring for cardiac events defined as worsening HF, LV assist device implantation, or cardiac death for 1 year after the echocardiography.

Results

VMT was scored as 0 in 20 patients, 1 in 50 patients, 2 in 37 patients, and 3 in 12 patients. PAWP was elevated in patients with VMT score of 2 and 3 (0: 10±5, 1: 12±4, 2: 22±8, 3: 28±4 mmHg, ANOVA P&lt;0.001) (Figure). In overall patients, VMT≥2 predicted elevated PAWP with accuracy of 86%. When the accuracy was tested in patients with reduced (&lt;40%, HFrEF) and preserved LV ejection fraction (≥40%) respectively, the accuracy was excellent in HFrEF (96% and 77%, respectively). Importantly, VMT≥2 also had good accuracy of 82% for elevated PAWP in 33 patients in whom recommendations usually cannot grade diastolic function due to monophasic LV inflow. In the sequential Cox models, the addition of VMT score to the model including the plasma brain natriuretic peptide (BNP) level and LV diastolic grading improved the predictive power for elevated PAWP (P&lt;0.001). During the follow-up, 20 cardiac events were observed (6 worsening HF, 9 LV assist device implantation and 5 cardiac death). Kaplan-Meier analysis showed that the patients with VMT≥2 were at higher risk of cardiac events than those with VMT≤1 (log-rank test P&lt;0.001) (Figure).

Conclusions

The VMT score was a simple and accurate marker of elevated LV filling pressure and has an incremental benefit over BNP and LV diastolic function grading. Moreover, it could be a novel prognostic marker in patients with HF.

Figure 1

Funding Acknowledgement

Type of funding source: None

Long-term prognostic significance of dispersion of ventricular repolarization in patients with cardiac sarcoidosis

Background

Although the presence of cardiac involvement is recognised as a determinant of worse clinical outcomes in sarcoidosis patients, the determinants of adverse outcomes in patients with cardiac sarcoidosis (CS) have not been well understood. T-peak to T-end interval (TpTe) on the surface electrocardiogram (ECG) was proposed as a marker of dispersion of ventricular repolarisation. Prolonged TpTe to QT interval ratio (TpTe/QT) represents a period of potential vulnerability to reentrant ventricular arrhythmias. Notably, prolonged TpTe/QT has been associated with increased risk of mortality in hypertrophic cardiomyopathy, congenital long-QT syndrome, and Brugada syndrome. However, its prognostic implication in patients with CS is unclear.

Purpose

We sought to investigate whether TpTe/QT was associated with long-term clinical outcomes in patients with CS.

Methods

A total of 108 consecutive CS patients between August 1986 and March 2019 in two academic hospitals who had ECG data before initiation of immunosuppressive therapy were examined. We excluded patients who received pacemaker (n=15) or cardiac resynchronization therapy (n=3) at the time of ECG. Ultimately, 90 CS patients were included in this study. All standard 12-lead ECGs were recorded at 25 mm/s with an amplification of 10 mm/mV. TpTe was measured from the peak of T wave to the end of T wave which defined as the intersection of the tangent to the down slope of the T wave and the isoelectric line. Lead V5 was selected for the analyses. If V5 is not suitable for analyses, V4 was selected. The primary outcome was the composite of advanced atrioventricular block (AVB), ventricular tachycardia or ventricular fibrillation (VT/VF), heart failure hospitalisation and all-cause death.

Results

During a median follow-up period of 4.70 (interquartile range [IQR] 2.06–7.23) years, adverse events occurred in 21 patients (23.3%), including 2 advanced AVB, 12 VT/VF, 4 heart failure hospitalisation and 3 all-cause death. Events group had higher TpTe/QT compared to no events group (0.231 [IQR 0.193–0.261] vs. 0.282 [IQR 0.263–0.304] P&lt;0.001). Kaplan-Meier analyses revealed that the primary outcome, especially VT/VF or sudden cardiac death more frequently occurred in patients with higher TpTe/QT (≥0.242, the median) compared to those with lower TpTe/QT (Figure 1). Multivariable Cox regression analysis showed that higher TpTe/QT was independently associated with increased subsequent risk of adverse events (hazard ratio 1.09, 95% confidence interval [CI] 1.02–1.17, P=0.014) even after adjustment for age, sex and left ventricular ejection fraction. Furthermore, the optimal cut-off value of TpTe/QT for the discriminatory of primary outcome was 0.257, and c-index was 0.77 (95% CI 0.64–0.89).

Conclusions

Higher TpTe/QT was associated with worse long-term clinical outcomes in patients with CS. Our findings indicate the importance of assessing TpTe/QT for risk stratification in patients with CS.

Figure 1

Funding Acknowledgement

Type of funding source: None

P295 Impact of Pre-existing Mitral Regurgitation on the Mid-Term Left Ventricular Mass Regression following Transcatheter Aortic Valve Implantation for Aortic Valve Stenosis

Background

Transcatheter aortic valve implantation (TAVI) results in an immediate and greater aortic pressure gradient improvement in patients with severe aortic valve stenosis (AS), and induces early left ventricular (LV) mass regression, which may be related to favorable effects on the mid to long term outcomes. However, the extent of LV mass regression after unloading of chronic pressure overload is varying, and its determinants are still unknown. Thus, the study aims to identify echocardiographic determinants of LV mass regression following TAVI.

Methods

We retrospectively screened all TAVI procedures in symptomatic AS from 2017 to 2019, and selected 74 successful TAVI cases that had serial echocardiographic studies both at the baseline and at the mid-term follow-up (4 to 6 months after the procedure). Through the digitalized medical records, clinical and echocardiographic data as well as angiographic grading (0-3) of post-procedure paravalvular leakage (PVL) were obtained. LV mass was calculated by using Cube formula. Thus, the extent of LV mass regression was defined as the differences of left ventricular mas index (LVMI) between at the baseline and at the follow-up (ΔLVMI). Quantification of the baseline mitral valve regurgitant volume was performed by stroke volume method with pulmonic site measurement on the assumption of no pre-existing intra/extra cardiac shunt. Cases with prior mitral valve replacement were excluded.

Results

At the post-procedure angiogram, only 3 cases had significant PVL (grade 2≤). At the mid-term follow–up, average LVMI decreased significantly from the baseline (165 ± 38 g/m2vs 140 ± 37 mg/ m2, P &lt; 0.0001) and 57 cases (70%) experienced the reduction of LVMI, although average relative wall thickness (2 × posterior wall thickness/left ventricular diastolic dimension) did not change (0.565 ± 0.135 vs 0.586 ± 0.168, P = 0.314). Among the baseline clinical and echocardiographic variables, the baseline peak A wave velocity, E/A ratio, mitral valve regurgitant volume and LVMI revealed simple correlation with ΔLVMI (γ=-0.298, p = 0.0188;γ=0.251, P = 0.0417;γ=0.354, p = 0.0041;γ=0.375, p &lt; 0.0010; respectively), whereas no correlation was observed in angiographic PVL grade. Stepwise multiple regression analysis demonstrated baseline mitral valve regurgitant volume and LVMI as the determinants of ΔLVMI (β=0.344, p = 0.032; β=0.335 P &lt; 0.0001; respectively).

Conclusions

Pre-existing mitral regurgitation has an impact on the mid–term left ventricular mass regression following TAVI. In severe AS, mitral regurgitation might be functioning as an afterload adjuster, and thus, produces protective effects on LV structure.

P2634Prognostic value of admission left ventricular outflow tract velocity time integral in hospitalized heart failure patients with preserved ejection fraction: a report from the JASPER registry

Background

There are little effective treatment strategies for heart failure with preserved ejection fraction (HFpEF) to achieve a reduction of morbidity and mortality. Thus, accurate prognostication of patients with HFpEF could help improve their outcomes by identifying high-risk patients who might potentially benefit from intensive inpatient and outpatient monitoring and early referral for advanced HFpEF therapy. The left ventricular outflow tract velocity time integral (LVOT-VTI) is a representative non-invasive parameter for evaluating stroke volume, which can be a determinant of adverse outcomes in hospitalized patients with heart failure. However, the prognostic implication of admission LVOT-VTI for hospitalized HFpEF patients is undetermined.

Purpose

The aim of the present study was to investigate whether admission LVOT-VTI could predict poor clinical outcomes in hospitalized patients with HFpEF.

Methods

We examined consecutive 535 hospitalized HFpEF patients (left ventricular ejection fraction ≥50%) due to acute decompensated heart failure from the JASPER (JApanese heart failure Syndrome with Preserved Ejection fRaction) multicenter registry, obtained between November 2012 and March 2015. Patients without accessible LVOT-VTI data on admission were excluded. Finally, 214 patients were examined. The primary outcome of interest was composite of all-cause death and rehospitalization due to heart failure.

Results

Mean age was 78±11 years, 100 were male, and median plasma brain-type natriuretic peptide level was 400 (interquartile range [IQR] 223–711) pg/ml. During a median follow-up period of 688 (IQR 162–810) days, adverse events occurred in 83 patients (39%), including 47 (22%) all-cause death, 51 (24%) rehospitalization due to heart failure. The c-index of LVOT-VTI for predicting the composite of adverse events was 0.59 (95% CI 0.51 to 0.67), and the optimal cut-off value of LVOT-VTI was 15.8 cm. Low LVOT-VTI (≤15.8 cm) was significantly associated with higher adverse events compared to high LVOT-VTI (>15.8 cm) (Figure). Multivariable Cox regression analysis revealed that lower LVOT-VTI was an independent determinant of adverse events (HR 0.94, 95% CI 0.91 to 0.98, P=0.005) even after adjustment for pre-specified confounders including age, sex, systolic blood pressure, serum sodium, albumin, plasma brain-type natriuretic peptide and renal function.

Figure 1

Conclusions

Lower admission LVOT-VTI was an independent determinant of worse clinical outcomes in hospitalized HFpEF patients, indicating that LVOT-VTI on admission could be a useful marker for risk stratification in these patients.

4089Prognostic value of cardiac metabolic activity assessed by 18F-FDG PET in patients with cardiac sarcoidosis

Background

Sarcoidosis is a systemic granulomatous disease that affects multiple organs. Among these,the presenceof cardiac involvementis recognized as a determinant of worse clinical outcomes. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) is a valuable modality for detecting active inflammatory lesions associated with cardiac sarcoidosis (CS). Generally,the maximum standardized uptake value (SUV) is suitable for evaluating disease activity in CS, but this quantitative method had limitations because it does not integrate both volume and intensity of FDG uptake simultaneously. Cardiac metabolic activity (CMA), which is quantitative measures of FDG volume-intensity, could be a diagnostic tool in the evaluation of CS. However, its prognostic implication in patients with CS is unclear.

Purpose

We sought to investigate whether CMA assessed by FDG-PET was associated with long-term worse clinical outcomes in patients with CS.

Methods

A total of 76 consecutive patients suspected CS who underwent FDG-PET between January 2010 and April 2018 in our university hospital were registered. We excluded patients whodid not meet the Japanese Ministry of Health and Welfare 2007 criteria (n=9) and those who received oral corticosteroids at the time of FDG-PET (n=5). Ultimately, 62 CS patients with definitively diagnosed were included in this study.We used a dedicated software to analyze SUV. Cardiac metabolic volume (CMV) was defined as the volume within the boundary determined by the threshold (SUV mean of blood pool × 1.5). CMA was calculated by multiplying CMV by SUV mean. The primary outcome of interest was the composite of advanced atrioventricular block, ventricular tachycardia, ventricular fibrillation, heart failure hospitalization, and all-cause death.

Results

During a median follow-up period of 1287 (IQR 806–1809) days after the first FDG-PET, the adverse events occurred in 12 patients (19%). Events group had significantly higher CMA compared to no events group (83 [IQR 11–330] vs. 354 [IQR 70–577]) (Figure A). Based on ROC analysis, the optimal cut-off value of CMA for the discrimination of the adverse events was 244 ml, and c-index was 0.71 (95% CI, 0.55–0.87). Patients with high CMA (≥244 ml, n=23) had lower LVEF, and higher prevalence of New York Heart Association functional class III or IV, and higher plasma BNP level compared to those with low CMA (<244 ml, n=39). Kaplan-Meier analysis revealed that composite adverse events more frequently occurred in patients with high CMA compared to those with low CMA (Figure B).Univariable Cox regression analysis showed that higher CMA was associated with increased subsequent risk of adverse events (HR 1.47, 95% CI 1.06–2.24).

Conclusions

Higher CMA assessed by FDG-PET was associated with worse clinical long-term outcomes in patients with CS, suggesting that measurement of the volume-intensity of abnormal FDG uptake may be useful for risk stratification in patients with CS.

P5370Pulmonary pressure overload stimulates cardiac stem or progenitor cell-derived cardiac regeneration in the right ventricular area

Introduction and purpose

The number of patients with right heart failure due to pulmonary hypertension has been increasing. Although several drugs have reportedly improved pulmonary hypertension, no treatments have been established for decompensated right heart failure. The heart has an innate ability to regenerate, and cardiac stem or progenitor cells (e.g., side population [SP] cells) have been reported to contribute to the regeneration process. However, their contribution to right ventricular pressure overload has not been clarified. Here, this regeneration process was evaluated using a genetic fate-mapping model.

Methods and results

We used Cre-LacZ mice, in which more than 99.9% of the cardiomyocytes in the left ventricular field were positive for 5-bromo-4-chloro-3-indolyl-β-D-galactoside (X-gal) staining immediately after tamoxifen injection. Then, we performed either a pulmonary binding (PAB) or sham operation on the main pulmonary tract. In the PAB-treated mice, the right ventricular cavity was significantly enlarged (right-to-left ventricular [RV/LV] ratio, 0.24±0.04 in the sham group and 0.68±0.04 in the PAB group). Increased peak flow velocity in the PAB group (1021±80 vs 1351±62 mm/sec) was confirmed by echocardiography. One month after the PAB, the PAB-treated mice had more X-gal-negative (newly generated) cells than the sham mice (94.8±34.2 cells/mm2 vs 23.1±10.5 cells/mm2; p<0.01). The regeneration was biased in the RV free wall (RV free wall, 225.5±198.7 cells/mm2; septal area, 88.9±56.5/mm2; LV lateral area, 46.8±22.0/mm2; p<0.05). To examine the direct effects of PAB on the cardiac progenitor cells, bromodeoxyuridine was administered to the mice daily until 1 week after the PAB operation. Then, the hearts were isolated and SP cells were harvested. The SP cell population increased from 0.65±0.23% in the sham mice to 1.87% ± 1.18% in the PAB-treated mice. Immunostaining analysis revealed a significant increase in the number of BrdU-positive SP cells, from 11.6±2.0% to 44.0±18%, therefore showing SP cell proliferation.

Conclusions

Pulmonary pressure overload stimulated cardiac stem or progenitor cell-derived regeneration with a RV bias, and SP cell proliferation may partially contribute to this process.

Acknowledgement/Funding

JSPS KAKENHI Grant Number JP 17K17636, GSK Japan Research Grant 2016

P6298Pericardial transplantation of adipose-derived stromal cells with self-assembling peptides scaffold prevents cardiac remodeling after myocardial infarction in mice

Introduction and purpose

Cardiac cell therapy to patients with heart failure after myocardial infarction (MI), has shown little improvement in cardiac function. The rate of engraftment after cell transplantation (TX) to the ischemic heart is low because of the leakage of transplanted cells without scaffold, the friction between the graft and thorax, and poor vascularization to the graft. We created a novel TX method (Figure 1) to transplant adipose-derived stromal cells (ASCs) with scaffold into the pericardial space where the pericardium protected the graft. We evaluated the therapeutic efficacy of pericardial TX of ASCs on the cardiac function and remodeling after MI.

Methods

We isolated ASCs from the brown adipose tissue of donor mice (C57BL6-Tg (CAG-EGFP), five weeks). ASCs increased and differentiated into spontaneously beating myocytes, endothelial cells, and pericytes three weeks after ex vivo culture. Cells were trypsinized and mixed with self-assembling peptides scaffold. Each graft (100μl gel scaffold) had 1×106 ASCs. To make recipient MI mice (C57BL6, 12 weeks), we ligated the left coronary artery through small chest incision without cutting rib bone to avoid postoperative adhesions. We confirmed the deterioration of cardiac function by echocardiography (n=21) and MRI (n=4) three weeks after MI. Then, recipient MI mice had TX (syngeneic, no immunosuppression). We opened the pericardium and transplanted the graft into the pericardial space. By suturing the pericardium, the graft was fixed on the MI scar area (Figure 1). We labeled donor cells with GFP and the scaffold with biotin. We evaluated cardiac function of TX group (n=10) and control group (MI with sham TX, n=11) by echocardiography.

Results

In the scaffold, donor cells increased three days to two weeks after TX, and slightly decreased four weeks after TX. The graft thickness was 0.9±0.2mm (two weeks after TX) and 0.7±0.2mm (four weeks after TX). There were many vWF positive vessels in the scaffold and some of which were GFP positive. Echocardiography showed that left ventricular diastolic dimension (LVDd) of TX group, did not increase four weeks after TX (ΔLVDd = −0.02mm, P=0.80). While, LVDd of control group significantly increased (ΔLVDd = +0.23mm, P=0.02) due to cardiac remodeling after MI. MRI confirmed the increase in left ventricular wall thickness in the MI scar area up to 4 weeks in TX group (n=2).

Conclusions

Pericardial transplantation of ASCs prevents cardiac remodeling. Its beneficial effect might be mediated by improved rate of engraftment, neovascularization, and increased ventricular wall thickness in the MI scar area.

Acknowledgement/Funding

Grants-in-Aid for Scientific Research

Programmed death-1 ligands and tumor infiltrating T lymphocytes in primary and lymph node metastasis of esophageal cancer patients

Neoadjuvant chemotherapy (NAC) is administered to many patients with esophageal squamous cell carcinoma (ESCC) prior to surgery, but it is also true that some of these patients demonstrated no response to the therapy following surgery. In addition, the prognosis of advanced case such as ESCC patients with lymph node metastasis has remained relatively low. Programmed death ligand-1 (PD-L1) in conjunction with tumor-infiltrating lymphocytes (TILs) has been studied as a potential mechanism of "immune escape" in several human malignancies. Therefore, in this study, we studied PD-L1 status in carcinoma cells and forkhead box protein 3 (FOXP3) and CD8 status among TILs in the residual tumors of primary and metastatic sites following NAC. We also studied the association of these factors with the clinicopathological findings in 44 patients with ESCC harboring lymph node metastasis. There was discordance in the pathological response to chemotherapy between the primary tumor and lymph node metastasis, and histologically identified resistance to NAC in lymph node metastases tended to be correlated with an adverse clinical outcome (P = 0.0765) than resistance in the primary tumor. Both univariate and multivariate analyses for disease-specific survival (DSS) revealed that the PD-L1 status of carcinoma cells in metastatic lymph nodes and a higher FOXP3/CD8 ratio in the primary tumor were both significantly correlated with an eventual adverse clinical outcome of the patients (P = 0.0178, P = 0.0463, respectively). These results all indicated that the PD-L1 status of carcinoma cells in metastatic lymph nodes and the FOXP3/CD8 ratio in primary tumors could predict eventual clinical outcomes in ESCC patients with NAC.

36 The effects of E-64 on the developmental competence of porcine oocytes vitrified at the germinal vesicle stage

Previous studies reported the activation of the apoptotic cascade by vitrification in mature porcine oocytes (Vallorani et al. 2012 Anim. Reprod. Sci. 135, 68-74) and that the cathepsin B inhibitor E-64 improved developmental competence of bovine oocytes via an antiapoptotic effect (Balboula et al. 2013 Reproduction 146, 407-417). The present study was carried out to test whether E-64 affected the developmental competency of porcine oocytes vitrified at the germinal vesicle stage. Cumulus-enclosed porcine oocytes were vitrified in microdrops and warmed by our method (Somfai et al. 2015 J. Reprod. Dev. 61, 571-579). Then, the oocytes were subjected to in vitro maturation (IVM) for 46h in a chemically defined porcine oocyte medium supplemented with 10ng mL−1 of epidermal growth factor, 10IU mL−1 of eCG, and 10IU mL−1 of hCG and during the first 22h of IVM with 1mM dibutyryl cyclic adenosine monophosphate. Then, cumulus-oocyte complexes were fertilized in vitro and presumptive zygotes were cultured in 50-µL drops of porcine zygote medium-3 for 7 days in 6-well dishes covered by paraffin oil in an atmosphere of 5% CO2, 5% O2, and 90% N2 at 39°C. On Day 5 (Day 0=IVF), the porcine zygote medium-3 was supplemented with 10% (vol/vol) FCS. The effects of 1.0μM of E-64 supplementation during IVM of non-vitrified and vitrified cumulus-oocyte complexes were investigated in a 2×2 factorial design. Survival rates after IVM, cleavage rates on Day 2, blastocyst rates, and total cell numbers in blastocysts on Day 7 were compared among groups. The experiment was replicated 5 times. Results were analysed by ANOVA and Tukey’s multiple comparison test. The percentages of live oocytes were statistically similar when oocytes were matured in the absence or presence of E-64 both in non-vitrified (99.2% v. 99.6%, respectively) and vitrified (94.3% v. 90.8%, respectively) groups. Similarly, IVM without or with E-64 supplementation had no effect on subsequent cleavage and blastocyst development rates in non-vitrified (67.4% v. 71.2% and 38.7% v. 43.2%, respectively) and vitrified (46.8% v. 48.8% and 14.6% v. 22.8%, respectively) oocytes. Irrespective of E-64 treatment, all survival and developmental rates in the vitrified groups were significantly lower (P&lt;0.05) compared with those of their non-vitrified counterparts except for the blastocyst development rate in the E-64-treated vitrified group, which did not differ significantly from those of the non-vitrified groups with or without E-64 treatment. There was no statistical difference in mean blastocyst cell numbers among the groups, ranging between 86.5±15.8 and 118±10.6. In conclusion, E-64 treatment had no effect on embryo production rates, which suggests that in our system, cathepsin-mediated apoptosis during IVM might not be the factor to limit embryo production using either fresh oocytes or those vitrified at the immature stage. This work was supported by JST/JICA SATREPS.

[A Case of Cecal Cancer Associated with Preoperatively Diagnosed Lynch Syndrome Caused by EPCAM Deletion]

A 43-year-old woman underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrioid adenocarcinoma of the uterine body(Stage ⅢC)at 40 years of age. Screening of the adenocarcinoma samples for Lynch syndrome by immunohistochemistry for mismatch repair proteins indicated a loss of MSH2/MSH6 proteinexpression . A genetic test revealed a deletion of about 20 kb, including exons 8 and 9 of the EPCAM gene. Colonoscopy revealed a type 1 tumor in the cecum. The risk of developing metachronous colorectal cancer and postoperative survival according to the extent of colectomy(total colectomy versus segmental colectomy)and her marked obesity were considered collectively. The patient subsequently selected total colectomy with ileorectal anastomosis. Pathological findings revealed mucinous carcinoma(Stage Ⅱ). Patients with Lynch syndrome caused by deletion of EPCAM are not usually at a high risk of uterine body cancer, but the risk of developing uterine body cancer should be noted when the range of EPCAM deletion extends near to MSH2, as inthis case.

Prevalence and molecular characteristics of defective mismatch repair epithelial ovarian cancer in a Japanese hospital-based population

Background

The prevalence and molecular characteristics of defective mismatch repair epithelial ovarian cancers in the Japanese population have scarcely been investigated.

Methods

Immunohistochemistry for mismatch repair proteins (MLH1, MSH2, MSH6 and PMS2) was performed in formalin-fixed paraffin-embedded sections prepared from resected primary epithelial ovarian cancers in patients who underwent oophorectomy at our institution between April 2005 and September 2014. Genetic and/or epigenetic alterations of the mismatch repair genes were investigated in patients with loss of any mismatch repair proteins in the tumor.

Results

There were 305 patients with a median age of 54 years (range, 18-83 years). Loss of expression in the ovarian tumor of one or more mismatch repair proteins was observed in 3 of the 305 patients (0.98%): 2 patients MLH1/PMS2 loss and 1 patient showed MSH2/MSH6 loss. Genetic testing of these three patients failed to reveal any pathogenic germline mutations of MLH1 or MSH2. One patient with MLH1/PMS2 loss showed hypermethylation of the promoter region of MLH1. Somatic mutations were found in each of the alleles of MLH1 (c.545dupG and deletion of exons 2-19) in the other patient with MLH1/PMS2 loss. In the patient with MSH2/MSH6 loss, two somatic mutations were detected in MSH2 (c.229_230delAG and c.1861C>T), although we could not determine whether these mutations were biallelic or not.

Conclusions

The prevalence of defective mismatch repair epithelial ovarian cancer in the Japanese hospital-based population was extremely low. Molecular mechanism involved in such defective mismatch repair ovarian cancers seems to be epigenetic events through MLH1 promotor hypermethylation or somatically mutated mismatch repair genes without germline mismatch repair mutation.