Topological aspects of multi-kantiferromagnetism in cubic rare-earth compounds

We advertise rare-earth intermetallics with high-symmetry crystal structures and competing interactions as a possible materials platform hosting spin structures with non-trivial topological properties. Focusing on the series of cubicRCu compounds, whereR= Ho, Er, Tm, the bulk properties of these systems display exceptionally rich magnetic phase diagrams hosting an abundance of different phase pockets characteristic of antiferromagnetic order in the presence of delicately balanced interactions. The electrical transport properties exhibit large anomalous contributions suggestive of topologically non-trivial winding in the electronic and magnetic structures. Neutron diffraction identifies spontaneous long-range magnetic order in terms of commensurate and incommensurate variations of(ππ0)antiferromagnetism with the possibility for various multi-kconfigurations. Motivated by general trends in these materials, we discuss the possible existence of topologically non-trivial winding in real and reciprocal space in the class ofRCu compounds including antiferromagnetic skyrmion lattices. Putatively bringing together different limits of non-trivial topological winding in the same material, the combination of properties inRCu systems promises access to advanced functionalities.

CD112 Supports Lymphatic Migration of Human Dermal Dendritic Cells

Dendritic cell (DC) migration from peripheral tissues via afferent lymphatic vessels to draining lymph nodes (dLNs) is important for the organism's immune regulation and immune protection. Several lymphatic endothelial cell (LEC)-expressed adhesion molecules have thus far been found to support transmigration and movement within the lymphatic vasculature. In this study, we investigated the contribution of CD112, an adhesion molecule that we recently found to be highly expressed in murine LECs, to this process. Performing in vitro assays in the murine system, we found that transmigration of bone marrow-derived dendritic cells (BM-DCs) across or adhesion to murine LEC monolayers was reduced when CD112 was absent on LECs, DCs, or both cell types, suggesting the involvement of homophilic CD112-CD112 interactions. While CD112 was highly expressed in murine dermal LECs, CD112 levels were low in endogenous murine dermal DCs and BM-DCs. This might explain why we observed no defect in the in vivo lymphatic migration of adoptively transferred BM-DCs or endogenous DCs from the skin to dLNs. Compared to murine DCs, human monocyte-derived DCs expressed higher CD112 levels, and their migration across human CD112-expressing LECs was significantly reduced upon CD112 blockade. CD112 expression was also readily detected in endogenous human dermal DCs and LECs by flow cytometry and immunofluorescence. Upon incubating human skin punch biopsies in the presence of CD112-blocking antibodies, DC emigration from the tissue into the culture medium was significantly reduced, indicating impaired lymphatic migration. Overall, our data reveal a contribution of CD112 to human DC migration.

Who Benefited the Most? Effectiveness of a Lifestyle Intervention Against Cognitive Decline in Older Women and Men - Secondary Analysis of the AgeWell.de-trial

INTRODUCTION

Differences between women and men matter in the prevalence and risk factors of dementia. We aimed to examine potential sex differences regarding the effectiveness by running a secondary analysis of the AgeWell.de trial, a cluster-randomized multicenter multi-domain lifestyle intervention to reduce cognitive decline.

METHODS

Intention-to-treat analyses of women (n=433) and men (n=386) aged 60 to 77 years were used for models including interactions between intervention group allocation and sex followed by subgroup analysis stratified by sex on primary and secondary outcomes. Further, the same procedure was repeated for age groups (60-69 vs. 70-77) within sex-specific subgroups to assess the effectiveness in different age groups.

TRIAL REGISTRATION

German Clinical Trials Register (ref. number: DRKS00013555).

RESULTS

No differences were found between women and men in the effectiveness of the intervention on cognitive performance. However, women benefitted from the intervention regarding depressive symptoms while men did not. Health-related quality of life was enhanced for younger intervention participants (60-69 years) in both women and men.

CONCLUSION

The AgeWell.de intervention was able to improve depressive symptoms in women and health-related quality of life in younger participants. Female participants between 60 and 69 years benefited the most. Results support the need of better individually targeted lifestyle interventions for older adults.

A Rapid Sterility Method Using Solid Phase Cytometry for Cell-Based Preparations and Culture Media and Buffers

In this article, we demonstrate a rapid sterility testing method for non-filterable cell-based preparations and its in-process control media/buffers. The selected rapid sterility test (RST) in this work is based on the ScanRDI® system, which detects fluorescently labeled microorganisms with solid-phase cytometry. ScanRDI® has been chosen due to its sensitivity for detecting viable microorganisms down to one microbial cell with a shorter time to detection compared with the compendial sterility test (CST) method. The RST was validated for a CAR-T cell-therapy product with 4 days of time to detection (TTD) and evaluated for in-process control of media/buffers with real-time detection method success according to USP <1223>, Ph. Eur. 5.1.6, and PDA Technical Report No. 33. The validation parameters included limit of detection and equivalence in routine operations, specificity, robustness, ruggedness, and repeatability. For the validation, a combination of pharmacopoeial ATCC strains as well as in-house isolates were used. In addition, the evaluation study of this RST for in-process control of media/buffers was assessed by performing the limit of detection and equivalence with four representative microorganisms. Where applicable, results were statistically evaluated to demonstrate equivalence and no significant difference of the rapid method as compared with the CST method have been detected. All acceptance criteria have been met, and the solid-phase cytometry technology was successfully validated as an alternative sterility test for cell-based preparations and for its in-process control of media/buffer.

Optimization and Characterization of Novel ALCAM-Targeting Antibody Fragments for Transepithelial Delivery

Activated leukocyte cell adhesion molecule (ALCAM) is a cell adhesion molecule that supports T cell activation, leukocyte migration, and (lymph)angiogenesis and has been shown to contribute to the pathology of various immune-mediated disorders, including asthma and corneal graft rejection. In contrast to monoclonal antibodies (mAbs) targeting ALCAM's T cell expressed binding partner CD6, no ALCAM-targeting mAbs have thus far entered clinical development. This is likely linked with the broad expression of ALCAM on many different cell types, which increases the risk of eliciting unwanted treatment-induced side effects upon systemic mAb application. Targeting ALCAM in surface-exposed tissues, such as the lungs or the cornea, by a topical application could circumvent this issue. Here, we report the development of various stability- and affinity-improved anti-ALCAM mAb fragments with cross-species reactivity towards mouse, rat, monkey, and human ALCAM. Fragments generated in either mono- or bivalent formats potently blocked ALCAM-CD6 interactions in a competition ELISA, but only bivalent fragments efficiently inhibited ALCAM-ALCAM interactions in a leukocyte transmigration assay. The different fragments displayed a clear size-dependence in their ability to penetrate the human corneal epithelium. Furthermore, intranasal delivery of anti-ALCAM fragments reduced leukocyte infiltration in a mouse model of asthma, confirming ALCAM as a target for topical application in the lungs.

Reassessing the adrenomedullin scavenging function of ACKR3 in lymphatic endothelial cells

Atypical chemokine receptor 3 (ACKR3) is a scavenger of the chemokines CXCL11 and CXCL12 and of several opioid peptides. Additional evidence indicates that ACKR3 binds two other non-chemokine ligands, namely the peptide hormone adrenomedullin (AM) and derivatives of the proadrenomedullin N-terminal 20 peptide (PAMP). AM exhibits multiple functions in the cardiovascular system and is essential for embryonic lymphangiogenesis in mice. Interestingly, AM-overexpressing and ACKR3-deficient mouse embryos both display lymphatic hyperplasia. Moreover, in vitro evidence suggested that lymphatic endothelial cells (LECs), which express ACKR3, scavenge AM and thereby reduce AM-induced lymphangiogenic responses. Together, these observations have led to the conclusion that ACKR3-mediated AM scavenging by LECs serves to prevent overshooting AM-induced lymphangiogenesis and lymphatic hyperplasia. Here, we further investigated AM scavenging by ACKR3 in HEK293 cells and in human primary dermal LECs obtained from three different sources in vitro. LECs efficiently bound and scavenged fluorescent CXCL12 or a CXCL11/12 chimeric chemokine in an ACKR3-dependent manner. Conversely, addition of AM induced LEC proliferation but AM internalization was found to be independent of ACKR3. Similarly, ectopic expression of ACKR3 in HEK293 cells did not result in AM internalization, but the latter was avidly induced upon co-transfecting HEK293 cells with the canonical AM receptors, consisting of calcitonin receptor-like receptor (CALCRL) and receptor activity-modifying protein (RAMP)2 or RAMP3. Together, these findings indicate that ACKR3-dependent scavenging of AM by human LECs does not occur at ligand concentrations sufficient to trigger AM-induced responses mediated by canonical AM receptors.

Chronic hand eczema in Europe: Patient experiences and perspectives (CHEPEP) in qualitative interviews

BACKGROUND

Chronic hand eczema (CHE) is a very common skin disease among the European population. It causes itch and pain and, in more severe cases, seriously impairs hand functioning at work and in private life.

OBJECTIVES

To explore perspectives of people with lived experience on CHE-related problems, wishes and goals.

METHODS

Following a qualitative approach, we conducted topic-guided interviews in five European countries and applied template analysis to identify recurrent themes among patients with CHE.

RESULTS

We interviewed 60 patients in 7 outpatient dermatological and occupational medicine clinics in Croatia, Denmark, Germany, the Netherlands, and Spain. Five main themes were identified: 1) knowledge about the disease and its course, 2) preventive behaviour, 3) hand eczema therapy, 4) impact on everyday life, 5) attitudes towards CHE and healthcare. Participants did not feel well informed about CHE, especially about causes, triggers, and treatment options. Preventive measures were experienced as more or less effective but also cumbersome. Experiences with therapy were diverse. Treatment satisfaction depended on the results and on the perceived support from the treatment teams. Participants found it important to be taken seriously, to receive practical advice, to try out additional treatments or examinations, find new hope, and have occupational perspectives. They wished that others could better understand the physical and emotional burden of CHE. Patient support groups were not mentioned. Participants found it important to learn to take care of themselves and accept life with CHE.

CONCLUSIONS

Due to its annoying symptoms, high visibility, and impaired functioning at work and in private life, CHE has a high emotional and social impact. Some people may require support to learn coping with CHE and its prevention. Patients wish for information about causes and triggers. They value physicians who listen to them and keep looking for solutions.

Temporal trends and outcomes in ST-segment elevation myocardial infarction: a cardiac magnetic resonance imaging study over the course of 15 years

Aims

Development of evidence-based treatments in ST-elevation myocardial infarction (STEMI) patients during the last 30 years have been associated with improved outcome; however, there are data suggesting a plateauing since around 2008 (1). Moreover, contemporary data are very scarce regarding the temporal trends of infarct outcomes. This study sought to describe the temporal trends in infarct severity at myocardial tissue level over the course of 15 years by means of cardiac magnetic resonance imaging (MRI).

Methods

This study analyzed STEMI patients treated with percutaneous coronary intervention (PCI) in our Medical University who underwent a cardiac MRI between 2005 and 2021. The 15-year study period was divided into sequential 2-years blocks. Infarct characteristics were measured using MRI at 3 days [IQR 2–5] after PCI.

Results

A total of 844 STEMI patients (17% female) with a median age of 57 (interquartile range [IQR]: 51–66) years were included. The rate of evidence-based treatments was high for aspirin (99%), P2Y12i (99%), beta-blockers (91%), ACEi/ATi (92%) and statins (100%) and did not change significantly over the study period (p&gt;0.05) with the exception for ACEi/ATi (p=0.03) and prasugrel (p&lt;0.001), which increased and clopidogrel, which decreased during the study course (p&lt;0.001). TIMI risk score did not change over the study period (p=0.43). Overall median infarct size was 16 [9–25]% and did not change (p=0.39) significantly. MVO, a marker of severe reperfusion injury, was also comparable (p=0.16). Accordingly, LV ejection fraction remained virtually unchanged (p=0.23)

Conclusion

Although further implementation of evidence-based treatments was seen also during the last 15 years, there has been no effect on infarct size, reperfusion injury and LV ejection fraction for patients who undergo primary PCI due to STEMI. Novel treatment strategies are needed to address this unmet therapeutic need.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology

Prognostic significance of left ventricular functional parameters in relation to infarct location after ST-elevation myocardial infarction

Aims

In survivors of ST-elevation myocardial infarction (STEMI), the impact of infarct location on the prognostic significance of left ventricular functional parameters is not well established. The aim of this study was to investigate the prognostic relevance of left ventricular (LV) functional parameters in relation to infarct location in STEMI patients treated with contemporary primary percutaneous coronary intervention (PCI).

Methods

This observational study analyzed 803 patients with STEMI that underwent a cardiac magnetic resonance imaging scan in median 3 (interquartile range [IQR]: 2–5) days after primary PCI. The following LV functional parameters were evaluated: LV ejection fraction, LV global longitudinal strain, fast manual long-axis strain (LAS) and mitral annular plane systolic excursion (MAPSE). Primary endpoint was the occurrence of major adverse cardiac events (MACE) defined as composite of death, re-infarction and congestive heart failure.

Results

Three hundred and sixty nine patients (46%) had anterior STEMI. These patients had lower LV functional parameters including LV ejection fraction (p&lt;0.001), LV global longitudinal strain (p&lt;0.001), LAS (p&lt;0.001) and MAPSE (p&lt;0.014). MACE was evaluated at a median of 13 (IQR: 12–37) months after STEMI and occurred in 78 patients (10%). In receiver operating curve analysis, the predictive value of LV ejection fraction, LV global longitudinal strain, LAS and MAPSE was 0.59 (p=0.013), 0.64 (p&lt;0.001), 0.67 (p&lt;0.001) and 0.66 (p&lt;0.001), respectively. When divided according to infarct location, MACE occurred in 47 (13%) anterior STEMI patients, and in 31 (7%) non-anterior STEMI patients, respectively. Area under the curve for the prediction of MACE in anterior vs. non-anterior STEMI was 0.59 vs 0.55 for LV ejection fraction, 0.61 vs 0.63 for LV global longitudinal strain, 0.69 vs 0.62 for LAS and both 0.66 for MAPSE. In multivariable analysis, LAS was independently associated with an increased risk of MACE (hazard ratio: 1.20; 95% confidence interval: 1.10–1.30; p&lt;0.001) in anterior STEMI, whereas in non-anterior STEMI, LV global longitudinal strain was an independent predictor of MACE (hazard ratio: 1.22; 95% confidence interval: 1.08–1.38; p=0.002).

Conclusion

Fast manual LAS emerged as independent predictor of MACE in anterior STEMI treated with contemporary primary PCI whereas LV global longitudinal strain was independently associated with MACE in non-anterior STEMI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology

Periodic Repolarization Dynamics derived from 10-second ECG recordings predicts mortality in patients after myocardial infarction

Background

Periodic repolarization dynamics (PRD) is an electrocardiographic biomarker that quantifies low-frequency (LF), sympathetic-activity associated instabilities of repolarization. PRD is a strong predictor of mortality in patients after myocardial infarction (MI). The main limitation of PRD is the requirement of ECGs with a duration of ≥20 minutes. Calculation of PRD using 10-second ECGs would be advantageous allowing the implementation in everyday clinical practice.

Purpose

We aimed to develop and validate a modified version of PRD, originating from 10-second ECGs, which we called PRDshort.

Methods

First, the beat-to-beat change in the direction of repolarization, called dT° was measured for 30-minute ECGs (Figure 1) and PRD was quantified as the amplitude of LF periodicities (≤0.1 Hz) within dT°. We randomly selected segments with a duration of 10 seconds. For each of these segments we calculated several parameters based on dT° and RR-interval. To overcome the issue that the wavelength of PRD is longer than 10 seconds, we performed signal-simulation and machine learning analysis. We simulated 100.000 dT°-signals using different assumptions for the level of PRD, heart rate, respiratory rate, number of premature ventricular contractions and the level of artifacts. Thereafter we used machine learning to calculate PRD from single 10-second ECG recordings (Figure 1). This method was finally validated in a cohort including 455 patients after MI. The primary endpoint was 3-year mortality. The prognostic power of PRD was evaluated using Kaplan-Meier and Cox-regression analyses.

Results

The Pearson's correlation coefficients between PRD and PRDshort were 0.80 (0.79–0.80) in the simulated data and 0.75 (0.70–0.78) in the post-MI cohort. In the post-MI cohort 47 patients died within 27±11 months of follow-up. The median left-ventricular ejection fraction (LVEF) was 50±15%. PRDshort was significantly higher in non-survivors (6.8±5.7 deg2) than survivors (4.9±3.0 deg2; p&lt;0.001). Dichotomization of PRDshort at the median value of ≥/&lt;5.0 deg2 identified a high-risk group with a 3-year mortality rate of 21.0% (13.4–27.9%) compared to a mortality rate of 6.5% (2.7–10.2%; HR=3.2; 1.6–6.2; p&lt;0.001; Figure 2) among patients with PRDshort &lt;5.0 deg2. In multivariable analysis, PRDshort was independent from GRACE-score &gt;140 and LVEF ≤35% (HR 2.7; 1.4–5.2; p=0.003). In ROC analysis the predictive value of PRDshort didn't differ significantly from that of the original PRD (p=0.263). PRDshort ≥5.0 deg2 detected 33 out of the 34 deaths originally identified by PRD.

Conclusion

This is the first description of a method to calculate PRD from 10-second ECG recordings. The prognostic value of PRDshort was comparable to that of PRD in post-MI patients with preserved LVEF. As normal 12-lead ECG-recordings are ubiquitous in every hospital and doctor's office this method may allow the wide application of PRD as risk stratification tool in everyday clinical practice.

Funding Acknowledgement

Type of funding sources: None.

The effectiveness of a telemedical program for COVID-19 positive high-risk patients in domestic isolation

Background

For almost two years, the Covid-19 pandemic has posed an enormous challenge to healthcare systems. Recurrent waves of disease brought the health systems to the limit of their resilience.

Purpose

The Tele-Covid telemedicine care program was installed in December 2020 to monitor high-risk patients in home isolation. Close monitoring allows early detection of disease deterioration and timely intensification of therapy, ideally avoiding intensive care. Conversely, if the course of the disease is stable, unnecessary hospitalisation can be avoided, thus reducing the burden on the healthcare system.

Methods

Patient acquisition was performed in collaboration with the local public health service and primary care physicians. Covid-19 positive high-risk patients (age >65 years and/or severe comorbidities) from the greater Innsbruck area were fitted with an ear sensor-based home monitoring system. The ear sensor measures SpO2, respiratory rate, body temperature and heart rate. The monitoring team (25 medical students supervised by 6 physicians) provided continuous monitoring of vital signs (24/7).

After validation of the measurements, the collected parameters were evaluated using a specially developed risk score. If a defined risk score was exceeded, the patient was contacted by telephone. The combination of the clinical condition and the risk score determined the further course of action: (a) wait and see, (b) notify the primary care physician, or (c) refer for inpatient admission.

The program was active from December 2020 to March 2022. In Summer 2021, the program was temporarily paused due to the epidemiological situation.

Results

A total of 132 patients (59.8% women) were monitored. The median age was 74 years (IQR: [67.3–80.8]). 91 patients (68.9%) had at least one relevant comorbidity. During the monitoring period, hospitalisation was required in 20 patients (15.2%), 3 of whom were transferred to the intensive care unit. Of the hospitalised patients, 3 (15%) patients died. During the same monitoring period, the Austrian Ministry of Health reported a mortality rate of 20.5% of all hospitalised patients in Austria aged 70–79 years. Subjectively, the patients felt safe due to close monitoring.

Conclusion

The Tele-Covid program is the successful implementation of a remote monitoring system in a pandemic situation. In the future, a broad application of the program is feasible.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Funded by the Region of the Tyrol

Neutrophile-lymphocyte ratio and outcome in takotsubo syndrome

Introduction

Takotsubo syndrome (TTS) is an important form of acute heart failure with significant risk of acute complications and death. In this analysis we sought to identify predictors for in-hospital clinical outcome in TTS patients by concentrating on routine laboratory parameters at admission.

Methods

In this analysis from the Austrian national TTS registry, univariable and multivariable analyses were performed to identify significant predictors for severe in-hospital complications requiring immediate invasive treatment or leading to irreversible damage, such as cardiogenic shock, intubation, stroke, arrhythmias and death. Furthermore, the influence of identified predictors with long-term survival was evaluated.

Results

A total of 338 patients (median age 72 years, 86.9% female) from 6 centres were included. Severe in-hospital complications occurred in 14.5% of patients, including cardiogenic shock (9.8%), death (3.3%) and intubation (1.2%), respectively. Patients with complications during the hospital stay had more prevalent chronic kidney disease (CKD), were less often previous smokers and TTS was less often preceded by an emotional trigger. C-reactive protein and neutrophile lymphocyte ratio (NLR) was higher in patients with complications, and midventricular ballooning and reduced left ventricular ejection fraction (LVEF) were more prevalent. In multivariable analysis, high NLR (OR 1.04 [95% CI 1.02–1.07], p=0.009) and low LVEF (OR 0.92 [0.90–0.95] per %, p&lt;0.001) remained significant predictors for severe in-hospital complications. Both the highest NLR tercile and the lowest LVEF tercile were associated with significantly reduced 5-year survival.

Discussion

Low LVEF and high NLR at admission were independently associated with increased in-hospital complications and reduced long-term survival in TTS patients. NLR is a new easy-to-measure tool to predict worse short and long-term outcome after TTS.

Funding Acknowledgement

Type of funding sources: None.

Association between inflammation and left ventricular thrombus formation following ST-elevation myocardial infarction

Background

Current evidence suggests a link between the inflammatory state and left ventricular thrombus (LVT) formation following ST-elevation myocardial infarction (STEMI). However, a comprehensive study investigating the association between inflammatory biomarkers and LVT diagnosed by cardiac magnetic resonance (CMR) is lacking.

Purpose

The present study aimed to investigate the association of biochemical markers of inflammation with LVT as assessed by CMR imaging among patients with STEMI.

Methods

We studied 309 patients with acute STEMI treated with primary percutaneous coronary intervention (pPCI) from the prospective MARINA-STEMI cohort study. Concentrations of high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), white blood cell count (WBCc), fibrinogen and D-dimer were measured two days after STEMI. Infarct characteristics and presence of LVT were assessed with the use of contrast-enhanced CMR at a median of 4 (interquartile range [IQR] 3–5) days after pPCI.

Results

In total, 309 STEMI patients (18% female) with a median age of 57 (IQR 52–65) years were included. An LVT was observed in 8% (n=24) of the overall cohort and in 15% of patients with an anterior STEMI. Hs-CRP (OR: 2.16, 95% CI: 1.54–3.02, p&lt;0.001), IL-6 (OR: 2.38, 95% CI: 1.48–3.81, p&lt;0.001) and fibrinogen levels (OR: 2.05, 95% CI: 1.40–3.00, p&lt;0.001) were significantly associated with presence of LVT. Among all assessed inflammatory biomarkers, only hs-CRP was independently associated with LVT after adjustment for markers of inflammation and CMR parameters (OR: 1.77, 95% CI: 1.21–2.59, p=0.004).

Conclusion

In patients with STEMI treated with pPCI, inflammatory markers (hs-CRP, IL-6 and fibrinogen) are associated with the presence of LVT. However, only hs-CRP was independently associated with the occurrence of LVT, highlighting the key role of CRP as clinical risk marker for LVT formation in STEMI patients treated with pPCI.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology

Telemedical cardiac risk assessment by implantable cardiac monitors in post-infarction patients with autonomic dysfunction (SMART-MI-DZHK9): gender differences and outcomes

Background

Cardiac autonomic dysfunction identifies high-risk patients after myocardial infarction (MI). Telemedical cardiac risk assessment by implantable cardiac monitors (ICM) after MI was recently identified as an effective method to early detect subclinical, but prognostically relevant serious arrhythmic events (SArE). Clinical complications in female patients after MI usually present with atypical symptoms. Therefore, early detection of prognostically relevant SArE in females would be of great clinical interest.

Purpose

In this pre-specified analysis of the SMART-MI trial we aimed to assess the impact of gender on detection of SArE and subsequent clinical complications.

Methods

SMART-MI was a prospective, randomised trial. Survivors of acute MI with preserved left-ventricular ejection fraction (LVEF 36–50%) and abnormal periodic repolarization dynamics (≥5.75deg2) and/or deceleration capacity (≤2.5ms) were randomly assigned to ICM-based telemedical monitoring or conventional follow-up. Primary endpoint was time to detection of SArE defined as the composite of atrial fibrillation ≥6 minutes, atrioventricular block ≥IIb, or fast non-sustained (&gt;187 bpm;≥40 beats)/sustained ventricular tachycardia/fibrillation. Clinical complications were defined as the composite of mortality, stroke, systemic arterial thromboembolism, and hospitalization for decompensated heart failure. The effect of intervention on the primary endpoint was tested using Cox-regression analysis. The effect of SArE on clinical complications was evaluated by introducing SArE as time-dependent covariate.

Results

Between May 12, 2016, and July 20, 2020, 1305 individuals were screened and 400 patients were randomly assigned to ICM-implantation (N=201; 49 females) or conventional follow-up (control group; N=199; 29 females). During a median follow-up of 21±23 months, SArE were detected in 60 (30%; 12 females) patients in the ICM and 12 (6%; 1 female) patients in the control group. In both males and females ICM-implantation was associated with a higher detection rate of SArE (HR 6.33; 3.28–12.23; p&lt;0.001 in males and HR 8.49; 1.10–65.66; p=0.040 in females; p-interaction = 0.790; Figure 1). In both male and female patients, detection of SArE was prognostic for subsequent clinical complications (HR 3.64; 1.89–7.02; p&lt;0.001 in males and HR 16.19; 4.76–55.11 in females; p&lt;0.001). The association between SArE and clinical complications was significantly higher in females than males. Among the 13 females with detected SArE, 6 developed clinical complications within a median period of 25±18 months, compared to 12 complications out of 59 SArE within 18±13 months among males (Figure 2; p-interaction = 0.030).

Conclusion

Telemedical monitoring with ICM was highly effective in early detection of subclinical, prognostically relevant SArE in both female and male patients. However, the association of a detected SArE with a subsequent clinical complication was significantly higher among females.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum für Herz und Kreislaufforschung (DZHK) and Medtronic Bakken Research Center

QRS duration as an independent risk factor for appropriate shocks and mortality in patients with prophylactic implantable cardioverter-defibrillator

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Community’s 7th Framework Programme FP7/2007-2013

Background

The implantable cardioverter defibrillator (ICD) is an established therapy for the prevention of sudden cardiac death (SCD) in high-risk heart failure patients. However, improvements in risk stratification are necessary to increase the efficiency of ICD use. We performed an analysis of the retrospective EU-CERT-ICD registry with respect to QRS duration and effects of cardiac resynchronisation therapy (CRT) on outcomes.

Methods/Results

A total of 5033 patients (81% males) from 14 European centres had an ICD implanted for primary prophylaxis. Mean age at the time of ICD implantation was 64±11 years and ischemic cardiomyopathy was the underlying pathology in 65% of patients. CRT was used in 43% of the patients. The median follow-up was 2.7 years (IQR 1.4-4.6 years). Predefined primary endpoints were all-cause mortality, first appropriate and first inappropriate shocks. The effect of covariates on the cumulative primary endpoints were assessed through hazard ratios in the Fine and Gray subdistributional hazard models (accounting for the competing risks) stratified by centres.

Because of resynchronization by the device, the analysis considered a different influence of QRS on outcomes in the CRT-D and the ICD groups. We observed an increase in the cumulative incidence of the first appropriate shock with increasing QRS values for patients implanted with only an ICD (HR 1.12 per 10ms increase, p&lt;0.001). In patients with CRT-D, increasing QRS values related to a (statistically non-significant) decrease in the cumulative incidence of the first appropriate shocks (HR 0.96 per 10ms, p=0.299).

Since a wide QRS is an indication for CRT-D therapy, high QRS values cluster among those patients with implanted CRT-D, while among patients with QRS under 130ms standard ICD implantations are more frequent. This can explain the observed increase in the cumulative incidence of the first appropriate shocks for increasing QRS values up to 130ms in the ICD-group and its decrease for increasing QRS values over 130ms in the CRT-D group.

Regarding all-cause mortality, hazard ratios for age, LVEF, NYHA, ICM, AF, diabetes and sex category agreed with the results obtained in previously published meta-analyses.

Increased QRS values are associated with higher mortality in the ICD group (HR 1.09 per 10ms increase, p&lt;0.001), but not in the CRT-D group (HR 0.99 per 10ms increase, p=0.695).

Conclusion

In our study, we confirmed QRS duration as an independent risk factor for appropriate ICD shocks and all-cause mortality in patients with ICD for primary prophylaxis. However, this was only observed in patients with single- or dual-chamber ICD, while there was no correlation in CRT-D patients. The findings suggest that CRT-D exerts a protective effect regarding the occurrence of first appropriate shock and all-cause mortality for patients with QRS values higher than 130 ms and indication for resynchronization.

Leukocyte Trafficking in Lymphatic Vessels

To ensure proper immune function, most leukocytes constantly move within tissues or between them using the blood and lymphatic vessels as transport routes. While afferent lymphatic vessels transfer leukocytes from peripheral tissues to draining lymph nodes (dLNs), efferent lymphatics return lymphocytes from LNs back into the blood vascular circulation. Over the last decades, great progress has been made in our understanding of leukocyte migration into and within the lymphatic compartment, leading to the approval of new drugs targeting this process. In this review, we first introduce the anatomy of the lymphatic vasculature and the main cell types migrating through lymphatics. We primarily focus on dendritic cells (DCs) and T cells, the most prominent lymph-borne cell types, and discuss the functional significance as well as the main molecules and steps involved in their migration. Additionally, we provide an overview of the different techniques used to study lymphatic trafficking.

Topological magnon band structure of emergent Landau levels in a skyrmion lattice

The motion of a spin excitation across topologically nontrivial magnetic order exhibits a deflection that is analogous to the effect of the Lorentz force on an electrically charged particle in an orbital magnetic field. We used polarized inelastic neutron scattering to investigate the propagation of magnons (i.e., bosonic collective spin excitations) in a lattice of skyrmion tubes in manganese silicide. For wave vectors perpendicular to the skyrmion tubes, the magnon spectra are consistent with the formation of finely spaced emergent Landau levels that are characteristic of the fictitious magnetic field used to account for the nontrivial topological winding of the skyrmion lattice. This provides evidence of a topological magnon band structure in reciprocal space, which is borne out of the nontrivial real-space topology of a magnetic order.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Smooth muscle cell specific ablation of CXCL12 downregulates endothelial CXCR7 leading to defective coronary arteries and cardiac hypertrophy

Aims

The chemokine CXCL12 plays a fundamental role in cardiovascular development, cell trafficking, and myocardial repair. Human genome-wide association studies even have identified novel loci downstream of the CXCL12 gene locus associated with coronary artery disease and myocardial infarction. Nevertheless, cell and tissue specific effects of CXCL12 are barely understood. Since we detected high expression of CXCL12 in smooth muscle (SM) cells, we generated a SM22-alpha-Cre driven mouse model to ablate CXCL12 (SM-CXCL12−/−).

Methods and results

SM-CXCL12−/− mice revealed high embryonic lethality (50%) with developmental defects, including aberrant topology of coronary arteries. Postnatally, SM-CXCL12−/− mice developed severe cardiac hypertrophy associated with fibrosis, apoptotic cell death, impaired heart function, and severe coronary vascular defects characterized by thinned and dilated arteries. Transcriptome analyses showed specific upregulation of pathways associated with hypertrophic cardiomyopathy, collagen protein network, heart-related proteoglycans, and downregulation of the M2 macrophage modulators. CXCL12 mutants showed endothelial downregulation of the CXCL12 co-receptor CXCR7. Treatment of SM-CXCL12−/− mice with the CXCR7 agonist TC14012 attenuated cardiac hypertrophy associated with increased pERK signaling.

Conclusion

Our data suggest a critical role of smooth muscle-specific CXCL12 in arterial development, vessel maturation, and cardiac hypertrophy. Pharmacological stimulation of CXCR7 might be a promising target to attenuate adverse hypertrophic remodeling.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): FWF-Austria

C-reactive protein velocity predicts microvascular pathology after acute ST-elevation myocardial infarction

Background

The role of C-reactive protein velocity (CRPv) as an early and sensitive marker of an excessive inflammatory response in the setting of acute ST-elevation myocardial infarction (STEMI) is only poorly understood.

Purpose

The aim of this study was to investigate, in patients with STEMI treated with primary percutaneous coronary intervention (PCI), the association of CRPv with microvascular infarct pathology.

Methods

This prospective cohort study included a total of 316 patients with STEMI undergoing PCI. CRPv was defined as the difference between CRP 24±8h and CRP at hospital admission, divided by the time (in h) that have passed during the two examinations. The association of biomarker levels with cardiac magnetic resonance (CMR)-determined microvascular obstruction (MVO) was evaluated. CMR was performed at a median of 3 [interquartile range 2–4] days after PCI.

Results

After adjustment for cardiac troponin T (cTnT), culprit lesion location and TIMI-flow post-PCI, CRPv (odds ratio 3.36, 95% confidence interval (CI) 1.72–6.57; p&lt;0.001) remained significantly associated with the occurrence of MVO. CRPv (area under the curve [AUC] 0.76, 95% CI 0.71–0.81; p&lt;0.001) was a better predictor for MVO compared to 24h CRP (AUC difference: 0.03, p=0.002). The addition of CRPv to peak cTnT resulted in a higher AUC for MVO prediction than peak cTnT alone (AUC 0.86, 95% CI 0.82–0.90; p&lt;0.001 vs. AUC 0.84, 95% CI 0.79–0.88; p&lt;0.001. AUC difference: 0.02, p=0.042).

Conclusions

In patients with STEMI treated with primary PCI, CRPv was associated with microvascular infarct pathology with a predictive value incremental to cTnT, suggesting CRPv as an early and sensitive biomarker for more severe infarct pathology and outcome.

Funding Acknowledgement

Type of funding sources: None. ROC analysis for the prediction of MVO.CRPv (median) and clinical outcome.

Glycaemic status and reperfusion injury in patients with ST-segment elevation myocardial infarction

Background

Failed myocardial tissue reperfusion due to microvascular injury despite successful culprit lesion percutaneous coronary intervention (PCI) is associated with poor clinical outcome in patients with ST-elevation myocardial infarction (STEMI). A possible influence of dysglycaemia on myocardial reperfusion injury is unclear.

Objectives

To investigate the association between glycaemic status and microvascular injury determined by magnetic resonance imaging in STEMI patients.

Methods

This prospective observational cohort study included 260 consecutive STEMI patients undergoing primary PCI between 2016 and 2019. Peripheral venous blood samples for glucose and HbA1c measurements were drawn on admission. Primary microvascular injury endpoint was defined as presence of intramyocardial haemorrhage (IMH) assessed by cardiac magnetic resonance T2* mapping at 4 (interquartile range [IQR]:2–5) days after PCI.

Results

HbA1c (odds ratio [OR]: 1.73 [95% CI: 1.24–2.40]; p=0.001), pre-diagnosis of diabetes (OR: 2.63 [95% CI: 1.18–5.90]; p=0.02) and glucose concentration (OR: 1.01 [95% CI: 1.00–1.01]; p=0.01) significantly predicted IMH, which was present in 90 (35%) patients. Of these three parameters, only HbA1c remained significantly associated with IMH (OR: 2.12 [95% CI: 1.12–3.99]; p=0.02) after adjusting for total ischemic time, culprit lesion location, pre- and post-interventional TIMI flow and peak biomarker concentrations (troponin, N-terminal pro-B-type natriuretic peptide and C-reactive protein). The rate of IMH was 24% in patients with HbA1c &lt;5.7%, 43% in patients with HbA1c ≥5.7 to 6.4% and 59% in patients with HbA1c ≥6.5% (p&lt;0.001).

Conclusions

In STEMI patients undergoing primary PCI, admission HbA1c was independently associated with reperfusion injury as determined by IMH. These findings suggest that IMH could represent the underlying pathophysiological link between dysglycaemia and adverse outcomes following STEMI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FWF - Austrian Science Fund; ÖKG - Austrian Society of Cardiology Figure 1. This figure illustrates the relation between HbA1c and IMH by two patient examples successfully treated with PCI (intervention with stent implantation schematically shown on the very left side). The first patient (upper line), representing the patient group with HbA1c &lt;5.7% (associated IMH risk 24%), showed an anterior wall STEMI without IMH (T2* mapping on the very right, corresponding schematic picture of the infarct area without IMH next on the left). The second patient (lower line), representing the patients with HbA1c ≥5.7% (associated IMH risk 47%), showed an anterior wall STEMI with large IMH (arrows point to the hypo-intense core on the T2* mapping image and to the corresponding dark-red area in the schematic illustration). The zoomed view of one microvessel indicates the complex pathophysiology of IMH (including endothelial destruction, embolisation of thrombotic material and inflammation). (Created with BioRender)

Evolution of myocardial tissue injury over a decade after ST-elevation myocardial infarction: a cardiac magnetic resonance study

Background

In patients with first ST-elevation myocardial infarction (STEMI), the evolution of myocardial tissue injury parameters over a decade as assessed by cardiac magnetic resonance (CMR) has not yet been described.

Purpose

This study examined long-term myocardial tissue injury dynamics in STEMI patients treated with primary percutaneous coronary intervention (PCI), as well as its association with patient characteristics.

Methods

A total of 104 patients with STEMI were included in this observational study. Sequential late gadolinium enhanced CMR studies (after 3 days [interquartile ranges (IQR) 2–4], 4 months [IQR 4–5] and 9 years [IQR 8–10]) were conducted to assess left ventricular (LV) dimensions and function, infarct size and microvascular obstruction (MVO). T2* mapping was added at 9 year scan to assess the presence of persistent iron within the infarct core.

Results

Infarct size decreased progressively from 13% of LV myocardial mass [IQR 7–21] to 10.2% [IQR 5.2–16.1] to 8% [IQR 2.4–12.3] (p&lt;0.001), with an average reduction rate of 6.4% ± 3.4 per year. Relative reduction of infarct size from baseline to 9y follow-up was 43% [IQR 18–66], 21% [IQR 3–42] during the first 4m and 33% [IQR 8–54] between 4m and 9y after STEMI. Decrease of infarct size was associated with greater baseline infarct size (p&lt;0.004) and extent of MVO (p=0.01). MVO was present in 60% (60/104) of patients at baseline, but in none of the follow-up examinations. Sixteen patients had persistent iron within the infarct core at 9 year CMR. Clinical and imaging associates of persistent iron included younger age at study inclusion (p=0.036), higher peak hs troponin T (p&lt;0.001), higher peak creatine kinase (p&lt;0.001) and higher peak CRP (p=0.036) as well as greater infarct size at any occasion (all p&lt;0.001) and greater MVO (p&lt;0.001). Patients with persistent iron showed less relative infarct size regression (51% [IQR 41–79] versus 46% [IQR 32–54], p=0.009).

Conclusion

In patients with STEMI, the evolution of infarct size is a dynamic process that extends well beyond the first few months after the acute event. MVO vanishes in the first few weeks after the index event in all patients. However, persistence of iron within the infarct core occurs up to a decade after reperfused STEMI, reflecting its irreversibility and is associated with the initial infarct severity and worse infarct healing.

Funding Acknowledgement

Type of funding sources: None. Central Illustration.Evolution of STEMI over a decade.

Aortic stenosis reexpanded – a novel approach to determine aortic valve area with phase contrast cardiovascular magnetic resonance imaging

Background

Transthoracic echocardiography (TTE) has become the diagnostic standard for evaluating aortic stenosis (AS) severity, mainly because of its advantages in comparison to the gold standard of cardiac catheterization. However, its inaccuracies in determining stroke volume (SV) and consequentially computing aortic valve area (AVA) call for a more precise and dependable method. Phase contrast cardiovascular magnetic resonance imaging (PC-CMR) is an aspiring tool to push these boundaries.

Purpose

The aim of this study was to validate a novel and simple approach based on PC-CMR against the invasive and echocardiographic determination of SV and AVA in patients with moderate and severe AS.

Methods

A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR; AVA by PC-CMR was determined via plotting momentary flow across the valve against momentary flow velocity. SV via CMR was measured directly via PC-CMR and volumetrically using cine images. Invasive SV and AVA were determined via Fick principle and Gorlin formula, respectively. TTE yielded SV and AVA using the continuity equation. Finally, gradients were calculated via the modified Bernoulli equation.

Results

SV by PC-CMR showed a strong correlation with cine-CMR with no significant bias (r: 0.730, p&lt;0.001; SV by PC-CMR: 85±31ml; SV by cine-CMR: 85±19ml, p=0.829). Peak gradients determined by PC-CMR were 65±29mmHg and correlated inversely with AVA by PC-CMR (r: −0.371; p=0.008). Mean AVA during the whole systolic phase showed a moderate correlation (r: 0.544, p&lt;0.001) to invasive AVA with a small bias (AVA by CMR: 0.78±0.25cm2 versus invasive AVA: 0.70±0.23cm2, bias: 0.08cm2, p=0.017). Inter-methodical correlation and bias of AVA as measured by TTE and invasive AVA (AVA by TTE: 0.81±0.23cm2, r: 0.580, p&lt;0.001, bias 0.11cm2, p&lt;0.001) were similar to AVA by PC-CMR and invasive AVA.

Conclusion

PC-CMR provides a great option to yield reliable and solid SV values in patients with moderate and severe AS. Furthermore, continuous determination of flow volumes and flow velocities is able to determine AVA in these patients in an easy and reproducible manner. Our novel approach shines a light on the diagnostic potential of PC-CMR for non-invasive AS grading, especially in cases where echocardiography reaches its limits and where clinical findings appear inconclusive.

Funding Acknowledgement

Type of funding sources: None. Central IllustrationCine (l,r) and PC-CMR (m) images in AS

Determinants and prognostic relevance of aortic stiffness in patients with recent ST-elevation myocardial infarction

Background

The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood. We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI.

Methods

We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (PPCI). Aortic pulse wave velocity (PWV), a direct measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 (interquartile range [IQR] 12–31) months. Cox regressionand logistic regression analysis were performed to explore predictors of PWV and MACCE.

Results

Median aortic PWV was 6.6 m/s (IQR 5.6–8.3m/s). In multivariable analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI], 1.08–1.14, p&lt;0.001) and hypertension (OR 2.45, 95% CI, 1.53–3.91, p&lt;0.001) were independently associated with increased PWV. Sex, diabetes, smoking status, dyslipidemia, and obesity were not significantly associated with PWV in adjusted analysis (all p&gt;0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis (hazard ratio [HR] 2.45, 95% CI 1.19–5.04, p=0.014).

Conclusion

In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome post-STEMI, suggesting it as a relevant therapeutic target in this population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology Figure 1. Biorender.com

Epidemiology, comorbidities, and healthcare utilization of patients with chronic urticaria in Germany

BACKGROUND

Comprehensive data on the epidemiology and comorbidities of chronic urticaria (CU) in Germany are either limited, or not contemporary.

OBJECTIVES

To investigate the epidemiology of CU, overall comorbidities and healthcare resource utilized by patients with CU in Germany, using an anonymized statutory health insurance (SHI) database.

METHODS

Anonymized SHI claims research database of the Institute for Applied Health Research, Berlin [InGef] (01 January 2015-30 September 2018) was used to analyse insured individuals with a confirmed diagnosis of CU (ICD-10-GM codes). Twelve-month diagnosed prevalence and incidence, comorbidities (vs. atopic dermatitis and psoriasis), and healthcare utilization by patients with CU were investigated.

RESULTS

Of 4 693 772 individuals of all ages listed in the database, 3 538 540 were observable during 2017. Overall, 17 524 patients (˜0.5%) were diagnosed with CU; chronic spontaneous urticaria (CSU: 71.2%), chronic inducible urticaria (CIndU: 19.7%), CSU+CIndU (9.1%). Females, vs. males, had higher diagnosed prevalence (0.62% vs. 0.37%) and diagnosed incidence (0.18% vs. 0.11%) of CU among all patients. Patients most frequently visited general practitioners (41.3% of total visits). Hypertensive diseases (43.5%), lipoprotein metabolism disorders (32.1%) and affective disorders (26.0%) were the most frequently reported comorbidities of special interest. Rates of most comorbidities of special interests were similar to atopic dermatitis and psoriasis patients, and all higher vs. overall population. More than half (54.1%) of all CU patients were not prescribed any treatment. Second-generation H₁ -antihistamines were the most commonly prescribed medication for adult (17.9%) and paediatric (27.9%) patients. Patients with CIndU (paediatric, 15.5%; adult, 7.8%) were more often hospitalized versus patients with CSU (paediatric, 9.9%; adult, 4.6%).

CONCLUSIONS

In Germany, prevalence of CU along with multiple comorbidities may pose increased burden on the healthcare system. Awareness of adhering to treatment guidelines, and aiming for complete control of urticaria, needs to be driven and may improve outcomes.

[Terbinafine-resistant dermatophytoses and onychomycosis due to Trichophyton rubrum]

BACKGROUND

In recent years, therapy-refractory courses of dermatophytoses have increasingly become the focus of attention. The most frequent pathogens are Trichophyton (T.) rubrum and T. mentagrophytes. In addition to local therapy, first-line treatment includes terbinafine, an allylamine antifungal agent that acts by inhibiting squalene epoxidase and thus interfering with ergosterol synthesis. In refractory cases, terbinafine resistance due to point mutation in the squalene epoxidase gene has been frequently detected.

OBJECTIVES

The aim is to present specific aspects in the epidemiology of dermatophytoses with terbinafine resistance and to illustrate them on the basis of four patient cases including diagnostic procedures.

MATERIALS AND METHODS

A review of handbook knowledge, a selective literature search, and a review of four patient cases were performed.

RESULTS

Detection of the terbinafine resistance was performed by in vitro testing using the breakpoint method as well as sequencing of the Trichophyton isolate and detection of the point mutation with amino acid substitution at position L393F or F397L of squalene epoxidase.

CONCLUSION

In refractory and recurrent dermatophytoses, terbinafine resistance should be considered, especially in T. mentagrophytes and T. rubrum, and in vitro resistance testing of the dermatophyte and point mutation analysis of squalene epoxidase (SQLE) should be performed. Therapeutically, intermittent administration of itraconazole in combination with antifungal local therapy is recommended. Nevertheless, a recurrent course is to be expected and long-term therapy with itraconazole is usually necessary.

Patch test informed consent form: position statement by European Academy of Dermatology and Venereology Task Force on Contact Dermatitis

BACKGROUND

To our knowledge, an international consensus is lacking regarding the development of an adequate informed consent form for a patch test (PT) and the information that should be included in such document.

OBJECTIVES

The aim of the study was to reach a consensus on the specific points that need to be addressed in a PT consent form.

METHODS

A Delphi survey, comprising 2 rounds and 1 final discussion, was used to gather and analyse data, which was conducted over the Internet. Each statement that reached a consensus with the respondents (9 expert dermatologists from Europe) was defined as a median consensus score (MED) of ≥7 and agreement among panelists as an interquartile range (IQR) of ≤3. All study participants were members of the EADV task force on contact dermatitis.

RESULTS

The expert panel addressed several topics that should be included in an informed consent form for a PT: introduction, preparation for PT, testing procedure, allowed activities, adverse events and additional authorizations.

CONCLUSIONS

Our results assess recommendations regarding points to be contained in an informed consent form for a PR. Future actions towards standardization and harmonization of this specific consent form are needed.

Feasibility and effectiveness of a multidimensional post-discharge disease management programme for heart failure patients in clinical practice: the HerzMobil Tirol programme

AIMS

It remains unclear whether transitional care management outside of a clinical trial setting provides benefits for patients with acute heart failure (AHF) after hospitalization. We evaluated the feasibility and effectiveness of a multidimensional post-discharge disease management programme using a telemedical monitoring system incorporated in a comprehensive network of heart failure nurses, resident physicians, and secondary and tertiary referral centres (HerzMobil Tirol, HMT), METHODS AND RESULTS: The non-randomized study included 508 AHF patients that were managed in HMT (n = 251) or contemporaneously in usual care (UC, n = 257) after discharge from hospital from 2016 to 2019. Groups were retrospectively matched for age and sex. The primary endpoint was time to HF readmission and all-cause mortality within 6 months. Multivariable Cox proportional hazard models were used to assess the effectiveness. The primary endpoint occurred in 48 patients (19.1%) in HMT and 89 (34.6%) in UC. Compared with UC, management by HMT was associated with a 46%-reduction in the primary endpoint (adjusted HR 0.54; 95% CI 0.37-0.77; P < 0.001). Subgroup analyses revealed consistent effectiveness. The composite of recurrent HF hospitalization and death within 6 months per 100 patient-years was 64.2 in HMT and 108.2 in UC (adjusted HR 0.41; 95% CI 0.29-0.55; P < 0.001 with death considered as a competing risk). After 1 year, 25 (10%) patients died in HMT compared with 66 (25.7%) in UC (HR 0.38; 95% CI 0.23-0.61, P < 0.001).

CONCLUSIONS

A multidimensional post-discharge disease management programme, comprising a telemedical monitoring system incorporated in a comprehensive network of specialized heart failure nurses and resident physicians, is feasible and effective in clinical practice.

Invasive validation of a novel approach to determine aortic valve area with phase-contrast cardiac magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology

Background. Echocardiography is considered the standard method for screening and diagnosing aortic valve stenosis. However, inaccuracies in the determination of stroke-volumes by the continuity equation might particularly make the evaluation of patients with low-flow states difficult. Phase-contrast cardiac magnetic resonance (PC-CMR) is a promising tool in overcoming these limitations by the simultaneous determination of flow volumes and velocities across the stenotic valve.

Purpose

The aim of this study is to validate a novel approach based on PC-CMR against the invasive determination of the aortic valve area (AVA).

Methods. PC-CMR was performed in 50 patients with moderate or severe AS (n = 52; age 72 years [interquartile range (IQR) 66 - 78], 38% of patients with low-flow states). All of them were referred to invasive evaluation of aortic stenosis by cardiac catheterization. Additionally, transthoracic echocardiography (TTE) was performed. Aortic valve area (AVA) was determined by PC-CMR (AVAPC-CMR) via plotting momentary flow across the valve against momentary flow velocity. AVAPC-CMR at different time points over the entire cardiac cycle was compared to invasively determined AVA, calculated according to the Gorlin-formula. Stroke volumes (SV) were determined by the Fick-principle, pressure gradients according to the modified Bernoulli-equation.

Results. Mean AVA during the whole systolic phase showed a good correlation (r: 0.544, p &lt; 0.001) with invasive AVA with a small bias (AVACMR: 0.78 cm², IQR: [0.60-0.96] versus AVAINVASIVE: 0.70 cm², IQR: [0.52-0.87], bias: 0.08 cm², p = 0.017). Intermethodical correlation and bias of AVA as measured by TTE (AVATTE) and AVAINVASIVE were similar to AVAPC-CMR (AVATTE: 0.81 cm²; IQR: [0.64-0.96] versus AVAINVASIVE: 0.70 cm², IQR: [0.52-0.87] r: 0.580, p &lt; 0.001, bias 0.11 cm², p &lt; 0.001). SV by PC-CMR showed a good correlation with Cine-CMR with no significant bias (r: 0.730, p &lt; 0.001; SVPC-CMR: 86 ± 31 ml; SVCine: 85 ± 19 ml). Maximum gradients determined by PC‑CMR were 65 ± 2 9mmHg and showed a good inverse correlation with AVAPC-CMR (r: ‑0.371; p = 0.008).

Conclusion. PC-CMR with continuous determination of flow volumes and flow velocities is able to determine AVA in patients with severe aortic stenosis with a tendency to overestimate AVA compared to invasively determined AVA.

Evolution of myocardial tissue injury over a decade after ST-elevation myocardial infarction: a cardiac magnetic resonance study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology

Background

In patients with first ST-elevation myocardial infarction (STEMI), the evolution of myocardial tissue injury parameters over a decade as assessed by cardiac magnetic resonance (CMR) has not yet been described.

Purpose

This study examined long-term myocardial tissue injury dynamics in STEMI patients treated with primary percutaneous coronary intervention (PCI), as well as its association with patient characteristics.

Methods

A total of 104 patients with STEMI were included in this observational study. Sequential late gadolinium enhanced CMR studies (after 3 days [interquartile ranges (IQR) 2-4], 4 months [IQR 4-5] and 9 years [IQR 8-10]) were conducted to assess left ventricular (LV) dimensions and function, infarct size and microvascular obstruction (MVO). T2* mapping was added at 9 year scan to assess the presence of persistent iron within the infarct core.

Results

Infarct size decreased progressively from 13% of LV myocardial mass [IQR 7-21] to 10.2% [IQR 5.2-16.1] to 8% [IQR 2.4-12.3] (p &lt; 0.001), with an average reduction rate of 6.4% ± 3.4 per year. Relative reduction of infarct size from baseline to 9y follow-up was 43% [IQR 18-66], 21% [IQR 3-42] during the first 4m and 33% [IQR 8-54] between 4m and 9y after STEMI. Decrease of infarct size was associated with greater baseline infarct size (p &lt; 0.004) and extent of MVO (p = 0.01). MVO was present in 60% (60/104) of patients at baseline, but in none of the follow-up examinations. Sixteen patients had persistent iron within the infarct core at 9 year CMR. Clinical and imaging associates of persistent iron included younger age at study inclusion (p = 0.036), higher peak hs troponin T (p &lt; 0.001), higher peak creatine kinase (p &lt; 0.001) and higher peak CRP (p = 0.036) as well as greater infarct size at any occasion (all p &lt; 0.001) and greater MVO (p &lt; 0.001). Patients with persistent iron showed less relative infarct size regression (51% [IQR 41-79] versus 46% [IQR 32-54], p = 0.009).

Conclusion

In patients with STEMI, the evolution of infarct size is a dynamic process that extends well beyond the first few months after the acute event. MVO vanishes in the first few weeks after the index event in all patients. However, persistence of iron within the infarct core occurs up to a decade after reperfused STEMI, reflecting its irreversibility and is associated with the initial infarct severity and worse infarct healing.

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

BACKGROUND

Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents.

METHODS

Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre.

RESULTS

3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004).

CONCLUSIONS

The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

Validation of a simple ECG score for infarct size estimation in patients with first-time ST-elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund

Background

The magnitude of myocardial damage after acute ST-elevation myocardial infarction (STEMI) is a crucial prognostic determinant. Cardiac magnetic resonance (CMR) imaging offers a precise infarct severity assessment after STEMI; however, limited to restricted availability in daily clinical routine. Recently, a simple ECG score (DETERMINE score) was developed for infarct size (IS) estimation in STEMI patients with prior infarction. We sought to validate this score in patients with first-time STEMI for the assessment of myocardial injury visualized by CMR.

Methods

In this validation study, 423 revascularized first-time STEMI patients (median age 56, 17% women) were included. ECG was conducted at discharge for evaluation of the DETERMINE and Selvester score. CMR imaging was performed at a median of 3 days for the assessment of infarct characteristics (IS and microvascular obstruction [MVO]).

Results

Median DETERMINE score of the overall cohort was 8 points (interquartile range: 5-11). Patients presenting with a score &gt; 8 points had more often anterior infarct localization (64% vs. 29%, p &lt; 0.001) and higher peak hs-TnT levels (6957 ng/l vs. 3117 ng/l, p &lt; 0.001). In linear and binary multivariable logistic regression analysis, the DETERMINE score remained as independent associate of IS (odds ratio [OR]: 1.09, 95% confidence interval [CI] 1.00 to 1.18, p = 0.047) and MVO (OR: 1.09, 95% CI 1.02 to 1.16, p = 0.016), after adjustment for Selvester score and peak hs-cTnT.

Conclusions

In survivors of first-time STEMI, the DETERMINE score provides an easy and inexpensive tool for suitable IS estimation. Moreover, the DETERMINE score showed significant and independent association with MVO. Thus, this simple ECG score might help identify patients at high risk of large infarct burden who might benefit from more aggressive treatment strategies.

Cardiac magnetic resonance derived global longitudinal strain outperforms established functional parameters in prognostication after ST-elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Although left ventricular ejection fraction (LVEF) is recommended for left ventricular (LV) systolic function assessment and risk stratification of patients with ST-elevation myocardial infarction (STEMI), its prognostic value is limited. Other measures of LV function such as global longitudinal strain (GLS) and mitral annular plane systolic excursion (MAPSE) might provide additional prognostic information post-STEMI. However, comprehensive investigations comparing these parameters in terms of prediction of hard clinical events following STEMI are lacking so far.

Purpose

We aimed to investigate the comparative prognostic value of LVEF, MAPSE and GLS by cardiac magnetic resonance (CMR) imaging in acute STEMI patients.

Methods

This observational study included 407 consecutive acute STEMI patients treated with primary percutaneous coronary intervention (PCI). Comprehensive CMR investigations were performed 3 [interquartile range (IQR): 2-4] days after PCI to determine LVEF, GLS and MAPSE as well as myocardial infarct characteristics. Primary endpoint was the occurrence of MACE defined as composite of death, re-infarction and congestive heart failure.

Results

During a follow-up of 21 [IQR: 12-50] months, 40 (10%) patients experienced MACE. Patients with MACE showed significantly lower LVEF (49% vs. 53%, p = 0.005) and MAPSE (7.9 mm vs. 9.1 mm, p = 0.001), as well as higher GLS values (-10.2% vs. -12.3 %, p &lt; 0.001). GLS showed the highest prognostic value with an area under the curve (AUC) of 0.71 (95% CI 0.63-0.79; p &lt; 0.001) compared to MAPSE (AUC: 0.67, 95% CI 0.58-0.75; p = 0.001) and LVEF (AUC: 0.64, 95% CI 0.54-0.73; p = 0.005). After multivariable analysis, GLS emerged as independent predictor of MACE (HR: 1.22, 95% CI 1.11-1.35; p &lt; 0.001). Of note, GLS remained associated with MACE (p &lt; 0.001) even after adjustment for infarct size and microvascular obstruction.

Conclusion

CMR-derived GLS emerged as strong and independent predictor of MACE after acute STEMI with additive prognostic validity to LVEF and parameters of myocardial damage.

Determinants and prognostic relevance of aortic stiffness in patients with recent ST-elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood.

Purpose

We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI.

Methods

We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (pPCI). Aortic pulse wave velocity (PWV), a direct measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 (interquartile range [IQR] 12–31) months. Cox regression- and logistic regression analysis were performed to explore predictors of PWV and MACCE.

Results

Median aortic PWV was 6.6 m/s (IQR 5.6–8.3m/s). In multivariable analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI], 1.08–1.14, p &lt; 0.001) and hypertension (OR 2.45, 95% CI, 1.53–3.91, p &lt; 0.001) were independently associated with higher PWV. Gender, diabetes, smoking status, dyslipidemia, and obesity were not significantly associated with PWV in adjusted analysis (all p &gt; 0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis (hazard ratio [HR] 2.45, 95% CI 1.19–5.04, p = 0.014).

Conclusion

In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome, suggesting it as a relevant therapeutic target in this population.

The prognostic value of preprocedural high-sensitivity troponin T in patients with severe aortic stenosis undergoing valve replacement: a gender analysis

Introduction

Recent studies have demonstrated the predictive value of preprocedural cardiac biomarkers, such as N-terminal pro brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (hsTnT), in patients with severe aortic valve stenosis undergoing valve replacement. Nonetheless, it remains still unclear whether hsTnT may be influenced by gender-specific differences.

Purpose

The aim of this subanalysis was to evaluate sex-related differences of preprocedural hsTnT in predicting postoperative long-term survival in a large cohort undergoing either surgical or transcatheter aortic valve replacement.

Methods

The TASS-2 group, a consortium of four university hospital centers, analysed 3595 consecutively enrolled patients admitted for valve implantation because of severe aortic stenosis between 2007 and 2017.

Results

The study cohort consisted of 1728 (48.1%) female and 1867 (51.9%) male patients. During a median follow-up of 2.9 years, cardiovascular mortality was found in 556 (15.5%) patients, amongst whom were 292 (16.9%) women and 264 (14.1%) men. All-cause mortality was detected in 919 (25.6%) patients dividing into 462 (26.7%) women and 457 (24.5%) men.

Preprocedural hsTnT was significantly higher (p&lt;0.001) in male (19 ng/l, 11.8–34.0) than in female (16 ng/l, 10.0–30.0) patients. In contrary, NT-proBNP was lower (p=0.002) in male (1286 ng/l, 444.5–3225.5) than female (1407 ng/l, 604.5–3217.5) patients. For the univariate analysis of survival, hsTnT was categorized by using predefined subgroups (&lt;5 ng/l; 5–13.99 ng/l; 14–50 ng/l; &gt;50 ng/l). Cardiovascular and all-cause mortality were significantly increased with higher hsTnT plasma levels in women (p&lt;0.001) as well as in men (&lt;0.001).

In two separate multivariate cox regression models, one for either gender - adjusting for STS risk score, NT-proBNP plasma levels, degree of left ventricular systolic dysfunction, atrial fibrillation, age, renal function, chronic obstructive pneumonic disease, arterial hypertension, diabetes mellitus, concomitant significant coronary artery disease and type of procedure – pre-procedural hsTnT was a strong independent predictor for postoperative cardiovascular mortality with an hazard ratio [HR] of 3.34, 95% confidence interval [CI] 1.03–10.80, P=0.044 for mildly to moderately elevated hsTnT (14–50 ng/l) and an HR of 3.98, CI 1.19–13.30, P=0.025 for severely elevated hsTnT (&gt;50 ng/l) in women, whereas an hazard ratio [HR] 4.09, 95% confidence interval [CI] 0.55–29.99, P=0.166 for mildly to moderately elevated hsTnT (14–50 ng/l) and an HR 7.48, CI 0.99–56.12, P=0.050 for severely elevated hsTnT (&gt;50 ng/l) in men was yielded.

Conclusion

Long-term postoperative survival in patients with severe AS admitted for valve implantation was independently predicted by hsTnT, irrespective of gender.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Tiroler Wissenschaftsförderung (Innsbruck, Austria)

High sensitivity C-reactive protein is associated with worse infarct healing after revascularized ST-elevation myocardial infarction

Background

The inflammatory response due to myocardial tissue injury in the setting of acute ST-elevation myocardial infarction (STEMI) is essential for proper local infarct healing. However, an excessive inflammatory response may aggravate myocardial damage and hampers infarct healing processes. The present study aimed to investigate the association of systemic inflammatory biomarkers with infarct size (IS) dynamics post-STEMI, using cardiac magnetic resonance (CMR) imaging.

Methods

This prospective observational study included 245 STEMI patients treated with primary percutaneous coronary intervention (pPCI). Peak values of high-sensitivity C-reactive protein (hs-CRP), white blood cell count (WBCc) and fibrinogen were determined serially until 96 hours after pPCI. Infarct healing, defined as relative IS reduction from baseline to 4 months after STEMI, was assessed using late gadolinium enhanced CMR imaging.

Results

IS significantly decreased from 16% of left ventricular mass (LVM) (Interquartile range [IQR]:8–24) at baseline to 10% (IQR:5–17) at 4 months (p&lt;0.001). Relative IS reduction was 35% (IQR:8–50). Whereas peak WBCc (p=0.926) and peak fibrinogen (p=0.161) were not significantly associated with relative IS reduction, peak hs-CRP showed a significant association with IS reduction (p=0.003). In multivariable logistic regression analysis, the association between peak hs-CRP and relative IS reduction remained significant after adjustment for baseline IS, hypertension, hs-cardiac troponin T and N-terminal pro B-type natriuretic peptide (odds ratio:0.35 [95% confidence interval:0.19–0.63]; p=0.001).

Conclusions

In STEMI patients treated with pPCI, hs-CRP was independently associated with 4 months IS reduction as determined by CMR, suggesting a pathophysiological interplay between inflammation and adverse infarct healing in survivors of acute STEMI.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Austrian Society of Cardiology

Influence of myocardial damage on serum procalcitonin in ST-elevation myocardial infarction

Background

Myocardial tissue injury due to acute ST-elevation myocardial infarction (STEMI) initiates an inflammatory response with a release of systemic inflammatory biomarkers including C-reactive protein (CRP) and white blood cell count (WBCc), which, however, hampers the usefulness of these routine biomarkers to identify concomitant infections. The clinical role of Procalcitonin (PCT), a promising marker of bacterial infections, to detect concomitant infections in acute STEMI is unknown, mainly because it is unclear whether myocardial injury per se induces a systemic PCT release.

Purpose

To investigate release kinetics of serum PCT in the acute setting of STEMI and possible associations with myocardial injury markers as comprehensively assessed by cardiac magnetic resonance (CMR) imaging.

Methods

In this prospective observational study, we included 141 STEMI patients treated with primary percutaneous coronary intervention (PCI). Concentrations of PCT, high-sensitivity CRP (hs-CRP), WBCc and high-sensitivity cardiac troponin T (hs-cTnT) were measured serially at day 1 and day 2 after infarction. CMR imaging to assess infarct size (IS), extent of microvascular injury (MVI) and occurrence of intramyocardial haemorrhage (IMH) was performed within the first week following STEMI.

Results

Median concentrations of PCT were 0.07μg/l at both time points. In 140 patients (99%), both PCT values were within the normal range (≤0.5μg/l). Whereas hs-CRP, WBCc, and hs-TnT were significantly correlated with CMR markers of myocardial damage, PCT did not show significant correlations (all p&gt;0.10) with IS (PCT24h: r=0.07; PCT48h: r=0.13) or MVI (PCT24h: r=−0.03; PCT48h: r=0.09). Furthermore, PCT failed to discriminate between large and small IS or MVI or between presence and absence of IMH (AUC values:0.46–0.55).

Conclusions

In the acute phase after PCI for STEMI, circulating PCT remained unaffected by the extent of myocardial and microvascular tissue damage as visualized by CMR imaging. These data highlight the clinical potential of PCT to identify concomitant infections and to guide antibiotic treatments in STEMI patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund, Tiroler Wissenschaftsförderung

Self-navigated MRI 3D whole heart sequence for non-enhanced aortic root measurement in transcatheter aortic valve intervention: comparison to cardiac CT

Purpose

To evaluate image quality, inter-observer reliability and diagnostic accuracy of self-navigated noncontrast 3D whole-heart magnetic resonance angiography (MRA) for transcatheter aortic valve intervention (TAVI) evaluation in comparison to standardized contrast-enhanced computed tomography angiography (CTA).

Methods

Whole-heart 1.5 T MRA was performed in 33 patients (aged 84 years [IQR 79–86], 48% male) for aortic root sizing and measurements of coronary ostia heights. A subgroup of 18 (55%) patients underwent additional CTA as gold standard for TAVI measurements. Image quality was assessed by a 4-point Likert scale, continuous MRA and CTA measurements were compared with regression and Bland-Altman analysis, valve sizing by kappa statistics.

Results

Median image quality of MRA as rated by two observers according was 1.5 [IQR 1.5–2.5]. In 4 patients (12%) one coronary ostium each (right coronary artery 3, left main artery 1) was not clearly definable on MRA. Inter-observer correlation was substantial to excellent (r=0.61 to 0.92) with a bias of 19 mm2 for annulus area (lower limit of agreement −59 mm2, upper limit of agreement 98 mm2; p=0.009). Aortic root and ostia height measurements by MRA and CTA showed substantial to excellent correlation (r=0.65 to 0.90) with no significant bias (all p≥0.333). Mean annulus area for MRA was 414±71 mm2 and for CTA 422±80 mm2 (r=0.9) with a bias of −8 mm2 (lower limit of agreement −79 mm2, upper limit of agreement −62 mm2; p=0.333). Regarding prosthetic valve sizing there was complete consistency between MRA and CTA-based decisions (κ=1).

Conclusion

Self-navigated noncontrast 3D whole-heart MRA enables reliable aortic root TAVI measurements without significant difference to standardized CTA. Prosthesis sizing by MRA measurements would completely match to CTA-based choice. However, in some cases coronary ostia may be difficult to define.

Funding Acknowledgement

Type of funding source: None

Cardiac magnetic resonance derived global longitudinal strain outperfoms established functional parameters in prognostication after ST-elevation myocardial infarction

Background

Left ventricular ejection fraction (LVEF) is the parameter of choice for left ventricular (LV) function assessment and risk stratification of patients with ST-elevation myocardial infarction (STEMI); however, its prognostic value is limited. Other measures of LV function such as global longitudinal strain (GLS) and mitral annular plane systolic excursion (MAPSE) might provide additional prognostic information post-STEMI. However, comprehensive investigations comparing these parameters in terms of prediction of hard clinical events following STEMI are lacking so far.

Purpose

We aimed to investigate the comparative prognostic value of LVEF, MAPSE and GLS by cardiac magnetic resonance (CMR) imaging in the acute stage post-STEMI for the occurrence of major adverse cardiac events (MACE).

Methods

This observational study included 407 consecutive acute STEMI patients treated with primary percutaneous coronary intervention (PCI). Comprehensive CMR investigations were performed 3 [interquartile range (IQR): 2–4] days after PCI to determine LVEF, GLS and MAPSE as well as myocardial infarct characteristics. Primary endpoint was the occurrence of MACE defined as composite of death, re-infarction and congestive heart failure.

Results

During a follow-up of 21 [IQR: 12–50] months, 40 (10%) patients experienced MACE. LVEF (p=0.005), MAPSE (p=0.001) and GLS (p&lt;0.001) were significantly related to MACE. GLS showed the highest prognostic value with an area under the curve (AUC) of 0.71 (95% CI 0.63–0.79; p&lt;0.001) compared to MAPSE (AUC: 0.67, 95% CI 0.58–0.75; p=0.001) and LVEF (AUC: 0.64, 95% CI 0.54–0.73; p=0.005). After multivariable analysis, GLS emerged as sole independent predictor of MACE (HR: 1.22, 95% CI 1.11–1.35; p&lt;0.001). Of note, GLS remained associated with MACE (p&lt;0.001) even after adjustment for infarct size and microvascular obstruction.

Conclusion

CMR-derived GLS emerged as strong and independent predictor of MACE after acute STEMI with additive prognostic validity to LVEF and parameters of myocardial damage.

Funding Acknowledgement

Type of funding source: None

Adult T-cells impair neonatal cardiac regeneration

Background

Cardiac remodeling and subsequent heart failure remain critical issues after myocardial infarction (MI). Complete cardiac regeneration was shown recently in a neonatal mouse model of MI. This cardiac regenerative potential is limited to the first few postnatal days and its decline parallels with the maturation of the adaptive immune system.

Purpose

Herein, we hypothesized that the T-cell maturation status critically impacts the myocardial healing outcomes in neonates and contributes to the shift from regenerative to scarring phenotype observed shortly after birth.

Methods

The post-MI immune responses were characterized in postnatal day one (P1, regenerative) compared to seven-day old (P7, scarring) mice subjected to permanent left anterior descending artery (LAD) ligation. The myocardial leukocyte infiltrate was phenotyped by flow cytometry at 36 hours and five days after LAD ligation. Next, we studied neonatal post-MI repair in lymphocyte-deficient Rag2 knock-out (KO) mice subjected to LAD ligation. Moreover, we adoptively transferred syngeneic splenic Thy 1.1+ T-cells obtained from adult donors into P1 versus P7 recipients and then assessed their impact on post-MI healing.

Results

LAD ligation induced a robust early inflammatory response (36h post-MI) in both age groups. The in situ inflammation was, nevertheless, rapidly resolved in P1-, but not in P7-infarcted animals. The distinct age groups showed a similar profile of cardiac myeloid cell infiltration but showed remarkable differences in the lymphoid compartment. P1-infarcted mice showed an early recruitment of γδT-cells, whereas P7-infarcted mice exhibited a prominent infiltration of αβT-cells. Of note, neonatal cardiac regeneration was not altered in neonatal lymphocyte-deficient (Rag2 KO) animals. However, the adoptive transfer of adult T-cells had several consequences in neonatal and one week old mice subjected to ischemic injury. P1-infarcted mice transferred with adult T-cells showed an adult-like healing phenotype, marked by an irreversible cardiac functional impairment (assessed by echocardiography) and increased fibrosis. This is in sharp contrast to the regenerative phenotype typically observed in untreated age-matched controls. Furthermore, P7-infarcted mice transferred with adult T-cell showed significantly decreased survival rate after LAD ligation.

Conclusion

Neonatal hearts demonstrate rapid clearance of the ischemia-induced leukocyte infiltration, further reflecting the known fact of fast cardiac regeneration in newborn rodents. Of note, the adoptive transfer of adult T-cells into neonate recipients partially blocked cardiac regeneration and promoted an irreversible functional impairment. These data indicate that the cardiac repair process, and its related “regeneration vs. scarring” dichotomy, is critically impacted by the T-cell development status.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Innsbruck Medical University, Medizinischer Forschungsfonds Tirol

Impaired heart rate variability triangular index to identify clinically silent strokes in patients with atrial fibrillation

Introduction

The identification of clinically silent strokes in patients with atrial fibrillation (AF) is of high clinical relevance as they have been linked to cognitive impairment. Overt strokes have been associated with disturbances of the autonomic nervous system.

Purpose

We therefore hypothesize that impaired heart rate variability (HRV) can identify AF patients with clinically silent strokes.

Methods

We enrolled 1358 patients with AF without a history of stroke or transient ischemic attack from the multicenter SWISS-AF cohort study who were in sinus rhythm (SR-group, n=816) or AF (AF-group, n=542) on a 5 minute resting ECG recording. HRV triangular index (HRVI), the standard deviation of normal-to-normal intervals (SDNN) and the mean heart rate (MHR) were calculated. Brain MRI was performed at baseline to assess the presence of large non-cortical or cortical infarcts, which were considered silent strokes without history of stroke or transient ischemic attack. We constructed binary logistic regression models to analyze the association between HRV parameters and silent strokes.

Results

At baseline, silent strokes were detected in 10.5% in the SR group and 19.9% in the AF group. In the SR-group, HRVI &lt;15 was the only parameter independently associated with the presence of silent strokes (odds ratio (OR) 1.69; 95% confidence interval (CI): 1.04–2.72; p=0.033) after adjustment for various clinical covariates (age, sex, systolic blood pressure, history of hypertension, history of diabetes, history of heart failure, prior myocardial infarction, prior major bleeding, intake of oral anticoagulation, antiarrhythmics or betablockers). Similarly, in the AF-group, HRVI&lt;15 was independently associated with the presence of silent strokes (OR 1.65, 95% CI: 1.05–2.57; p=0.028). SDNN&lt;70ms and MHR&lt;80 were not associated with silent strokes, neither in the SR group, nor in the AF group (Figure).

Conclusions

Reduced HRVI is independently associated with the presence of clinically silent strokes in an AF population, both when assessed during SR and during AF. Our data suggest that a short-term measurement of HRV in routine ECG recordings might contribute to identifying AF patients with clinically silent strokes.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Swiss National Science Foundation

Clinical risk score for prediction of early left ventricular thrombus after percutaneous coronary intervention for ST-elevation myocardial infarction

Background

Cardiac magnetic resonance (CMR) is the reference standard for left ventricular (LV) thrombus detection in patients with acute ST-elevation myocardial infarction (STEMI). However, routine CMR imaging is currently not recommended post-STEMI.

Objective

This observational study sought to develop a practical risk score for the prediction of early LV thrombus formation after STEMI to identify patients in whom routine CMR might be appropriate.

Methods and results

Five hundred and fifty-six consecutive patients underwent transthoracic echocardiography (TTE) and CMR at 3 [IQR: 2–4] days after primary percutaneous coronary intervention (PCI) for acute STEMI. A LV thrombus was visualized in 12 patients (2.2%) using TTE and in 22 patients (4%) using CMR. A weighted risk score including multivariable associates of LV thrombus formation (LV ejection fraction by TTE, peak high-sensitivity cardiac troponin T and peak high-sensitivity C-reactive protein) and left anterior descending coronary artery as culprit vessel, with a range of 0 to 7 points (median risk score: 2 points) showed a strong and significantly higher area under the curve (0.93 (95% CI 0.88–0.97; p&lt;0.001)) for LV thrombus prediction than each individual risk factor alone (p&lt;0.001). The sensitivity and the specificity of the risk score was 91% and 80%, respectively. The incidence of LV thrombi was 0% in the very low risk group (0 to 1 points, n=248), 1.8% in the low risk group (2 to 4 points, n=219) and 20.2% in the high risk group (5 to 7 points, n=89). Eighty-two percent of all LV thrombi occurred in the high risk group (number needed to scan to detect one LV thrombus=5).

Conclusions

The proposed risk score provides incremental value for the prediction of early LV thrombus and could be useful to identify STEMI patients in whom routine CMR for LV thrombus evaluation could be most meaningful. Additional investigation is warranted to validate the clinical application of the score.

Funding Acknowledgement

Type of funding source: None