Implicit and explicit motor imagery ability after SCI: Moving the elbow makes the difference

Cervical spinal cord injury (SCI) causes dramatic sensorimotor deficits that restrict both activity and participation. Restoring activity and participation requires extensive upper limb rehabilitation focusing elbow and wrist movements, which can include motor imagery. Yet, it remains unclear whether MI ability is impaired or spared after SCI. We investigated implicit and explicit MI ability in individuals with C6 or C7 SCI (SCIC6 and SCIC7 groups), as well as in age- and gender-matched controls without SCI. Inspired by previous studies, implicit MI evaluations involved hand laterality judgments, hand orientation judgments (HOJT) and hand-object interaction judgments. Explicit MI evaluations involved mental chronometry assessments of physically possible or impossible movements due to the paralysis of upper limb muscles in both groups of participants with SCI. HOJT was the paradigm in which implicit MI ability profiles differed the most between groups, particularly in the SCIC6 group who had impaired elbow movements in the horizontal plane. MI ability profiles were similar between groups for explicit MI evaluations, but reflected task familiarity with higher durations in the case of unfamiliar movements in controls or attempt to perform movements which were no longer possible in persons with SCI. Present results, obtained from a homogeneous population of individuals with SCI, suggest that people with long-term SCI rely on embodied cognitive motor strategies, similar to controls. Differences found in behavioral response pattern during implicit MI mirrored the actual motor deficit, particularly during tasks that involved internal representations of affected body parts.

Anodal transcranial direct current stimulation does not enhance the effects of motor imagery training of a sequential finger-tapping task in young adults

When applied over the primary motor cortex (M1), anodal transcranial direct current stimulation (a-tDCS) could enhance the effects of a single motor imagery training (MIt) session on the learning of a sequential finger-tapping task (SFTT). This study aimed to investigate the effect of a-tDCS on the learning of an SFTT during multiple MIt sessions. Two groups of 16 healthy young adults participated in three consecutive MIt sessions over 3 days, followed by a retention test 1 week later. They received active or sham a-tDCS during a MIt session in which they mentally rehearsed an eight-item complex finger sequence with their left hand. Before and after each session, and during the retention test, they physically repeated the sequence as quickly and accurately as possible. Both groups (i) improved their performance during the first two sessions, showing online learning; (ii) stabilised the level they reached during all training sessions, reflecting offline consolidation; and (iii) maintained their performance level one week later, showing retention. However, no significant difference was found between the groups, regardless of the MSL stage. These results emphasise the importance of performing several MIt sessions to maximise performance gains, but they do not support the additional effects of a-tDCS.

Learning functional human anatomy with a new interactive three-dimensional digital tool

Human anatomy requires understanding spatial relationships among anatomical structures and is often perceived as difficult to learn by students. To overcome this concern, several digital tools exist with some strengths and limitations among which the lack of interactivity especially for complex functional anatomy learning. In this way, a new interactive three-dimensional tool called Antepulsio was designed. Antepulsio was assessed by comparing three groups of first year kinesiology students to test whether it is likely to favor functional anatomy learning during three training sessions spread over a week. The experiment was conducted during a real academic course. Laterality judgment, 3D spatial abilities and working memory abilities from all participants were previously collected to create three homogeneous groups: the active group (n = 17, 17.76 ± 0.56 years) interacted with Antepulsio, the passive group (n = 18, 17.89 ± 0.83 years) watched videos of Antepulsio while the control group (n = 15, 18.07 ± 0.80 years) performed a neutral activity unrelated to anatomy. Anatomy knowledge was also assessed during pretest, posttest, and retention test (8 weeks after the posttest). The most significant outcome of this study revealed that in case of better working visual memory, the active group outperformed the passive group between pretest and retention test (p < 0.01). In other words, Antepulsio tool is efficient only for students with high visuospatial working memory. These selective benefits of Antepulsio are discussed in terms of cognitive load, training duration and the necessary period of familiarization with the tool.

Inter-Task Transfer of Prism Adaptation through Motor Imagery

Prism adaptation (PA) is a useful method to investigate short-term sensorimotor plasticity. Following active exposure to prisms, individuals show consistent after-effects, probing that they have adapted to the perturbation. Whether after-effects are transferable to another task or remain specific to the task performed under exposure, represents a crucial interest to understand the adaptive processes at work. Motor imagery (MI, i.e., the mental representation of an action without any concomitant execution) offers an original opportunity to investigate the role of cognitive aspects of motor command preparation disregarding actual sensory and motor information related to its execution. The aim of the study was to test whether prism adaptation through MI led to transferable after-effects. Forty-four healthy volunteers were exposed to a rightward prismatic deviation while performing actual (Active group) versus imagined (MI group) pointing movements, or while being inactive (inactive group). Upon prisms removal, in the MI group, only participants with the highest MI abilities (MI+ group) showed consistent after-effects on pointing and, crucially, a significant transfer to throwing. This was not observed in participants with lower MI abilities and in the inactive group. However, a direct comparison of pointing after-effects and transfer to throwing between MI+ and the control inactive group did not show any significant difference. Although this interpretation requires caution, these findings suggest that exposure to intersensory conflict might be responsible for sensory realignment during prism adaptation which could be transferred to another task. This study paves the way for further investigations into MI's potential to develop robust sensorimotor adaptation.

Anodal tDCS does not enhance the learning of the sequential finger-tapping task by motor imagery practice in healthy older adults

Background

Motor imagery practice (MIP) and anodal transcranial direct current stimulation (a-tDCS) are innovative methods with independent positive influence on motor sequence learning (MSL) in older adults.

Objective

The present study investigated the effect of MIP combined with a-tDCS over the primary motor cortex (M1) on the learning of a finger tapping sequence of the non-dominant hand in healthy older adults.

Methods

Thirty participants participated in this double-blind sham-controlled study. They performed three MIP sessions, one session per day over three consecutive days and a retention test 1 week after the last training session. During training / MIP, participants had to mentally rehearse an 8-element finger tapping sequence with their left hand, concomitantly to either real (a-tDCS group) or sham stimulation (sham-tDCS group). Before and after MIP, as well as during the retention test, participants had to physically perform the same sequence as fast and accurately as possible.

Results

Our main results showed that both groups (i) improved their performance during the first two training sessions, reflecting acquisition/on-line performance gains, (ii) stabilized their performance from one training day to another, reflecting off-line consolidation; as well as after 7 days without practice, reflecting retention, (iii) for all stages of MSL, there was no significant difference between the sham-tDCS and a-tDCS groups.

Conclusion

This study highlights the usefulness of MIP in motor sequence learning for older adults. However, 1.5 mA a-tDCS did not enhance the beneficial effects of MIP, which adds to the inconsistency of results found in tDCS studies. Future work is needed to further explore the best conditions of use of tDCS to improve motor sequence learning with MIP.

Assessment of absolute coronary flow and microvascular resistance reserve in patients with severe aortic stenosis

Introduction

The development of left ventricular hypertrophy in patients with severe aortic stenosis (AS) is accompanied by adaptive coronary flow regulation, both in epicardial and microvascular compartment, which ultimately lead to a chronic ischemic insult even in the absence of obstructive coronary artery disease. Intracoronary continuous thermodilution of saline through a dedicated infusion catheter is a novel tool that allows to measure absolute coronary flow and microvascular resistance at rest and during hyperemia and to calculate both coronary flow reserve (CFR) and Microvascular Resistance Reserve (MRR)

Purpose

We aimed to assess absolute coronary flow, microvascular resistance, CFR and MRR in patients with AS, by continuous intracoronary thermodilution, comparing these hemodynamic findings with a propensity-score matched contemporary cohort of patients without AS.

Methods

Absolute coronary blood flow and microvascular resistance were measured by continuous thermodilution in 29 patients with AS and compared to 15 controls matched for age, gender, diabetes mellitus and functional severity of epicardial coronary lesions. Myocardial work, total myocardial mass and LAD-specific mass were quantified by echocardiography and cardiac-CT.

Results

Patients with AS presented a significantly positive LV remodeling with lower global longitudinal strain and higher global work index compared to controls (p&lt;0.02). Total LV myocardial mass and LAD-specific myocardial mass were significantly higher in patients with AS. Compared to matched controls, absolute resting flow in the LAD was significantly higher in the AS cohort (86 [66–107] ml/min vs 68 [52–75] ml/min, p=0.036), resulting, in lower CFR (2.30±0.69 vs 2.89±0.77, p=0.005) and MRR (2.73±0.74 vs 3.53±0.95, p=0.005) in the AS cohort compared to controls (Figure 1). No differences were found in hyperemic flow and resting and hyperemic resistances. Interestingly, hyperemic myocardial perfusion (calculated as the ratio between the absolute coronary flow in the LAD and the mass subtended by the vessel, expressed in mL/min/g), but not resting, was significantly lower in the AS group (1.9 [1.5–2.5] ml/min/g vs 2.3 [2–3.1] ml/min/g p=0.036).

Conclusions

In patients with severe aortic stenosis and non-obstructive coronary artery disease, with the progression of LVH, the compensatory mechanism of increased resting flow maintains an adequate perfusion at rest, but not during hyperemia (Figure 2). As consequence, both CFR and MRR are significantly impaired.

Funding Acknowledgement

Type of funding sources: None.

Repeatability of bolus and continuous thermodilution for assessing coronary microvasculatory function

Introduction

The bolus thermodilution-derived index of microcirculatory resistance (IMR) has emerged over years as the standard of reference to invasively define coronary microvascular dysfunction (CMD). However, the technique still presents some limitations, mainly related to the fact that manual injection of saline bolus accounts for some variance in the measurements. Continuous intracoronary thermodilution has been recently introduced as a tool to directly quantify absolute coronary flow and microvascular resistance both at rest and during hyperemia and has shown to be safe and operator independent. Microvascular resistance reserve (MRR), derived from continuous thermodilution, has been validated as novel index specific for microcirculation and independent from myocardial mass.

Purpose

To compare head-to-head the intra-observer repeatability of bolus and continuous thermodilution for assessing microvascular function.

Methods

Patients undergoing coronary angiography in the absence of obstructive coronary artery disease were prospectively enrolled. Bolus and continuous intracoronary thermodilution measurements were performed in duplicates in the left anterior descending artery (LAD). Patients were randomly assigned in a 1:1 ratio to undergo first bolus thermodilution or first continuous thermodilution assessment.

Results

A total of 102 patients were enrolled. Average FFR was 0.86±0.06. Coronary Flow Reserve (CFR) calculated with continuous thermodilution (CFRthermo) was significantly lower than bolus thermodilution-derived CFR (CFRbolus) (2.63±0.65 and 3.29±1.17, respectively, p&lt;0.001). CFRthermo showed a lower variability and a higher agreement than CFRbolus (variability 12.74±10.41% vs 31.26±24.85%, respectively, p&lt;0.001; ICC= 0.78 (0.70–0.85) and 0.48 (0.32–0.62), respectively, p&lt;0.001, Figure 1). Both MRR and IMR showed a good agreement (ICC 0.81 (0.74–0.87) and 0.80 (0.71–0.86)) but the variability of the MRR was significantly lower (12.44±10.06% vs 24.24±19.27, respectively, p&lt;0.001, Figure 1). Reproducibility data of all indices derived from duplicated measurements of bolus and continuous thermodilution are reported in Table 2.

Conclusion

Continuous intracoronary thermodilution has a higher repeatability than bolus thermodilution in the assessment of CMD.

Funding Acknowledgement

Type of funding sources: None.

Impact of aortic regurgitation on long-term outcomes in heart failure with preserved ejection fraction

Background

Aortic Regurgitation (AR) may aggravate the clinical course in patients with heart failure and preserved ejection fraction (HFpEF) by increasing filling pressures and triggering LV remodelling.

Objective

To assess AR's prevalence and long-term prognostic implications in patients with HFpEF.

Methods

The study population consisted of 458 consecutive patients (age 77.5±9.2 y, 57.9% females) hospitalized with de novo or worsened HFpEF. Patients with more than moderate aortic and/or mitral valve disease were excluded. Data on cardiovascular death, HF re-hospitalization and their composite (MACE) were collected.

Results

Out of 309 (67.5%) patients with any AR, 156 (34.0%) and 153 (33.5%) had mild-AR and moderate-AR, respectively. The remaining 149 (32.5%) individuals had no-AR. Patients with versus without AR were significantly older with larger LV and LA volumes and a higher prevalence of diastolic dysfunction (all p&lt;0.05). During a median follow-up of 33±25 months, a total of 114 patients (24.9%) died from cardiovascular causes, 126 patients (27.5%) were re-hospitalized for HF, while 272 (59.4%) had the composite endpoint (MACE). In multivariable Cox regression analysis, any AR emerged as an only independent predictor of MACE (HR=1.90, 95% CI 1.26–2.87, p=0.002). Mild-AR and Moderate AR increased the risk of MACE by 77% and 92%, respectively, compared to the No-AR (Figure).

Conclusions

In patients with HFpEF, mild-to-moderate AR is highly prevalent, and it seems to identify individuals with worse long-term outcomes. This suggests that even mild AR should be considered a high-risk prognostic marker in patients with HFpEF.

Funding Acknowledgement

Type of funding sources: None.

Saline-induced coronary hyperemia with continuous intracoronary thermodilution is mediated by intravascular hemolysis

Objectives

To test whether local hemolysis is a potential mechanism of saline-induced coronary hyperemia.

Background

Absolute coronary flow can be measured by intracoronary continuous thermodilution of saline through the lateral side holes of a dedicated infusion cathete. A saline infusion rate at 15–20 mL/min induces an immediate, steady-state, maximal microvascular vasodilation. The mechanism of this hyperemic response remains unclear.

Methods

Twelve patients undergoing left and right catheterization were included. The left coronary artery and the coronary sinus were selectively cannulated. Absolute resting and hyperemic coronary flow were measured by continuous intracoronary thermodilution. Arterial and venous samples were collected from the coronary artery and the coronary sinus in five phases: baseline (BL); resting flow measurement (Rest, saline infusion at 10 mL/min); hyperemia (Hyperemia,saline infusion at 20 mL/min); post-hyperemia (Post-Hyperemia, two minutes after the cessation of saline infusion); and control phase (Control, during infusion of saline through the guide catheter at 30 mL/min).

Results

Hemolysis was visually detected only in the centrifugated venous blood samples collected during the Hyperemia phase. As compared to Rest, during Hyperemia both LDH (131.50±21.89 U/dL [Rest] and 258.33±57.40 U/dL [Hyperemia], p&lt;0.001) and plasma free hemoglobin (PFHb, 4.92±3.82 mg/dL [Rest] and 108.42±46.58 mg/dL [Hyperemia], p&lt;0.001) significantly increased in the coronary sinus. The percentage of hemolysis was significantly higher during the Hyperemia phase (0.04±0.02% [Rest] vs 0.89±0.34% [Hyperemia], p&lt;0.001).

Conclusions

Saline-induced hyperemia through a dedicated intracoronary infusion catheter is associated with hemolysis. Vasodilatory compounds released locally, like ATP, are likely ultimately responsible for localized microvascular vasodilation.

Funding Acknowledgement

Type of funding sources: None.

Improvement in angina pectoris after percutaneous coronary interventions in focal and diffuse coronary artery disease

Objective

To investigate the effect of PCI on patient-reported outcomes in focal and diffuse coronary artery disease (CAD) as defined by the pullback pressure gradient (PPG).

Background

Improvements in fractional flow reserve (FFR) following PCI are associated with freedom from angina. CAD patterns influence the FFR change after stenting. Therefore, CAD patterns might be essential to assess the likelihood of PCI success in terms of angina relief.

Methods

This is a sub-analysis of the TARGET-FFR randomized clinical trial (NCT03259815). The 7-item Seattle Angina Questionnaire (SAQ-7) and EuroQol five-level EQ-5D questionnaire (EQ-5D-5L) were administered at baseline and three months after PCI. The PPG index was calculated from manual pre-PCI FFR pullbacks and the median PPG value was used to define focal and diffuse CAD.

Results

103 patients (51 with focal and 52 with diffuse disease) were analyzed. There were no differences in baseline characteristics between patients with focal and diffuse CAD. Patients with focal disease had larger increases in FFR with PCI than those with diffuse disease (0.30±0.14 units vs 0.19±0.12 units, p&lt;0.001). Patients who underwent PCI to focal CAD had significantly higher SAQ-7 summary scores at follow-up compared to those with diffuse CAD (87.1±20.3 vs. 75.6±24.4, mean difference 11.5 [95% CI 2.8 to 20.3], p=0.01). Following PCI, residual angina was present in 39.8% of all patients but was significantly lower among those with treated focal CAD (27.5% vs 51.9%, p-value=0.020).

Conclusion

Persistent angina after PCI was almost twice as common in patients with diffuse CAD as defined by the pre-PCI PPG. Patients with focal disease reported greater improvement in angina and quality of life with PCI. The likelihood of successful angina relief from PCI can be predicted by the baseline pattern of CAD.

Funding Acknowledgement

Type of funding sources: None.

Microvascular dysfunction in patients with diabetes mellitus: assessment of absolute coronary flow and microvascular resistance reserve

Background

Coronary microvascular dysfunction (CMD) is an early feature of diabetic cardiomyopathy, which usually precedes the onset of systolic and diastolic dysfunction (DDF). Continuous intracoronary thermodilution allows an accurate and reproducible assessment of absolute coronary blood flow and microvascular resistance thus allowing the evaluation of coronary flow reserve (CFR) and Microvascular Resistance Reserve (MRR), a novel index specific for microvascular function, which is independent from the myocardial mass. In the present study we compared absolute coronary flow and resistance, CFR and MRR assessed by continuous intracoronary thermodilution in diabetic versus non-diabetic patients. Left atrial reservoir strain (LASr), an early marker of DDF was compared between the two groups.

Methods

In this observational retrospective study, 108 patients with suspected angina and non-obstructive coronary artery disease (NOCAD) consecutively undergoing elective coronary angiography (CAG) from September 2018 to June 2021 were enrolled. The invasive functional assessment of microvascular function was performed in the left anterior descending artery (LAD) with intracoronary continuous thermodilution. Patients were classified according to the presence of DM. Absolute resting and hyperemic coronary flow (in mL/min) and resistance (in WU) were compared between the two cohorts. FFR was measured to assess coronary epicardial lesions, while CFR and MRR were calculated to assess microvascular function. LAS, assessed by speckle tracking echocardiography, was used to detect early myocardial structural changes potentially associated with microvascular dysfunction.

Results

The median FFR value was 0.83 [0.79–0.87] without any significant difference between the two groups. Absolute resting and hyperemic flow in the left anterior descending coronary were similar between diabetic and non-diabetic patients. Similarly, resting and hyperemic resistances did not change significantly between the two groups. In the DM cohort the CFR and MRR were significantly lower compared to the control group (CFR=2.4±0.6 and 2.9±0.8; MRR=2.8±0.9 and 3.5±1 for diabetic and non-diabetic patients respectively, [p&lt;0.05 for both], Figure 1 and 2). Likewise, diabetic patients had a significantly lower reservoir, contractile and conductive LAS (all p&lt;0.05).

Conclusions

Compared with non-diabetic patients, CFR and MRR were lower in patients with DM and non-obstructive epicardial coronary arteries, while both resting and hyperemic coronary flow and resistance were similar. LASr was lower in diabetic patients, confirming the presence of a subclinical DDF associated to the microcirculatory impairment. Continuous intracoronary thermodilution-derived indexes provide a reliable and operator-independent assessment of coronary macro- and microvasculature and might potentially facilitate widespread clinical adoption of invasive physiologic assessment of suspected microvascular disease.

Funding Acknowledgement

Type of funding sources: None.

POS1165 ASSOCIATION OF LDHD RARE VARIANTS WITH EARLY-ONSET GOUT IN TWO FAMILIES WITH AN ADDITIONAL ASSOCIATION OF RHBG VARIANT IN ONE

Background

Elevated lactate is known to favor urine urate reabsorption by the URAT1 urate/anion exchanger. Autosomal recessive gout caused by pathogenic variant in the LDHD gene encoding for D-lactate deshydrogenase has been recently identified in a large consanguineous Bedouin-Israeli kindred (1).

Objectives

We report here on two families in whom early-onset gout was linked to other variants leading to deficient D-LDH enzymes.

Methods

Studies of the two families were approved by appropriate Ethics committees. Whole exome sequencing (WES) was used to identify the genetic cause of familial gout. Dosages of D-lactate were performed on immediately frozen serum and urine samples by ELISA, using a D-lactate colorimetric assay kit (Abcam ab83429).

Results

Family 1 was Melanesian, living in the Lifou island of New Caledonia. The two index patients were two sisters who developed gout at the age of 13 and 16 years respectively. When seen at the ages of 25 and 27 years, they both had severe gout with frequent polyarticular flares, and multiple tophi and destructive arthropathies in the earliest age of onset one. WES, performed on the 2 affected sisters, their non-consanguine parents, and an unaffected brother, showed that the 2 affected sisters carried homozygous rare variant in DLDH gene (NM_153486.3: c.206 C>T; rs1035398551). This variant was at heterozygote level in both parents and absent in the unaffected brother. It was considered as probably damaging according to in silico prediction software. No association with any other gene was found.

The c.206C>T variant in LDHD was searched by Sanger sequencing method in 13 other extended family members. One 23 year-old brother of the two diseased sisters with atypical MTP flares, high uricemia and double contours at US examination of his MTPs, carried the c.206 C>T variant at the homozygous level. Three other heterozygous patients were found; two of whom were male with late-onset gout, the third one being a non-menopausal female with no gout. No variant carrier was found in the other 9 genotyped family members. The 3 homozygous patients for the c.206 C>T variant had very high hyperuricemia (range 738-834 was searched by Sanger sequencing method in 13 other extended family members. One 23 year-old brother of the two diseased sisters with atypical MTP flares, high uricemia and double contours at US examination of had very low or no D-lactate in plasma and urine. L-lactate blood and urine levels were normal in all subjects.

Family 2 was Vietnamese, living in a remote area of central Vietnam. The two affected children suffered from an extremely severe, destructive gout, which started at the age of 21 years in a daughter and at the age of 9 in her youngest brother, who had developed for the last 3 years, dysarthria, night shakes, memory loss, urine incontinence and an inability to read and count and died at the age of 34, a few months after being seen by us. WES was performed in the two probands, their father and mother (who denied consanguinity), and an unaffected brother. An undescribed variant in LDHD (NM_153486.3: c.1363dupG) was identified in homozygous level in the 2 juvenile gout patients and at the heterozygous level in their 2 parents and unaffected brother. This variant led to a frameshift followed by a stop codon p.(AlaGly432fsTer58). In addition, the two juvenile gout patients were homozygous for an undescribed frameshift (NR_046115.1: c.1064dup) variant of the RHBG gene encoding for a Rhesus Blood Group family ammonium transporter. The two parents carried the heterozygous variant which was not identified in the non-gout brother.

Conclusion

We report on 2 families in whom autosomal recessive juvenile gout was due to rare or undescribed, damaging LDHD gene variants. In addition, we observed in the Vietnamese family, an additional non-described frameshift homozygous variant in RHBG, the pathophysiological role of which deserves to be investigated.

References

[1]Drabkin M et al. Hyperuricemia and gout caused by missense mutation in D-lactate dehydrogenase. J Clin Invest. 2019;129:5163-5168

Disclosure of Interests

Thomas Bardin Consultant of: leo Pharma, Yves-Marie Ducrot: None declared, Quang Nguyen: None declared, Emmanuel Letavernier: None declared, Hang-Korng Ea: None declared, Frederic Touzain: None declared, Duc Minh Do: None declared, Julien Corot: None declared, Yan Barguil: None declared, Antoine Biron: None declared, Pascal Richette: None declared, Corinne Collet: None declared

Performance of non-invasive myocardial work to predict the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF)

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Dr. Paolisso, Dr. Esposito, Dr. Fabbricatore are supported by a research grant from the CardioPaTh PhD Program of University of Naples Federico II

Background

Non-invasive myocardial work (MW) is a validated index of left ventricular (LV) systolic performance, incorporating afterload and myocardial metabolism. The role of MW in predicting the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF) is still unknown.

Purpose

To investigate the diagnostic performance of MW to predict the first de novo HFpEF hospitalization in ambulatory individuals with preserved LVEF.

Methods

Twenty-nine patients with trans-thoracic echocardiography performed at least 6 months before the first HFpEF hospitalization were compared with 29 matched controls. MW was derived as the area of pressure-strain loop using speckle-tracking and brachial artery blood pressure. Global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE) were collected. First HFpEF hospitalization and its combination with cardiovascular death (MACE) and all-cause of death (MAE) were assessed.

Results

At baseline, future HFpEF patients showed lower GWI, GCW, GWE and higher GWW than controls (all p &lt; 0.05).  At admission versus baseline, GWE significantly decreased, and GWW increased in the HFpEF group (p &lt; 0.05), whereas no significant difference was observed in the controls over time. GWW, with a cut-off of 170 mmHg%, showed the largest AUC to predict first HFpEF hospitalization (AUC = 0.80, 95% CI 0.69–0.91, p &lt; 0.001), MACE (AUC = 0.80, 95% CI 0.66–0.90, p &lt; 0.001) and MAE (AUC = 0.79, 95% CI 0.62–0.88, p = 0.001). GWW &gt; 170 mmHg% was associated with a 4-fold increase of MACE (HR = 4.5, 95% CI 1.59–13.12, p = 0.005) and a 3-fold higher risk of MAE (HR = 2.9, 95% CI 1.24–6.6, p = 0.014).

Conclusions

In ambulatory patients with preserved LVEF and risk factors, GWW showed high accuracy to predict the first HFpEF hospitalization and its combination with mortality. The GWW routine assessment may be clinically helpful in patients with dyspnea. Abstract Figure 1: Serial changes of LARs, LV GLS  Abstract Figure 2:Kaplan–Meier survival curves fo

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

BACKGROUND

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions are associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using calcium modifying techniques such as Rotational Atherectomy (RA) or Intravascular Lithotripsy (IVL) has been advocated. Studies comparing these technologies are lacking. We aimed to compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either RA or IVL.

METHODS

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥ 0.90.

RESULTS

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65 ± 0,13 RA and 0,67 ± 0,11 IVL). After PCI, in-stent pressure gradients were significantly lower in the IVL group (0.032 ± 0.026 vs 0.043 ± 0.026 in the RA group, p = 0.024). The proportions of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p = 0.669).

CONCLUSIONS

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Stabilometric Correlates of Motor and Motor Imagery Expertise

Motor Imagery (MI) reproduces cognitive operations associated with the actual motor preparation and execution. Postural recordings during MI reflect somatic motor commands targeting peripheral effectors involved in balance control. However, how these relate to the actual motor expertise and may vary along with the MI modality remains debated. In the present experiment, two groups of expert and non-expert gymnasts underwent stabilometric assessments while performing physically and mentally a balance skill. We implemented psychometric measures of MI ability, while stabilometric variables were calculated from the center of pressure (COP) oscillations. Psychometric evaluations revealed greater MI ability in experts, specifically for the visual modality. Experts exhibited reduced surface COP oscillations in the antero-posterior axis compared to non-experts during the balance skill (14.90%, 95% CI 34.48–4.68, p &lt; 0.05). Experts further exhibited reduced length of COP displacement in the antero-posterior axis and as a function of the displacement area during visual and kinesthetic MI compared to the control condition (20.51%, 95% CI 0.99–40.03 and 21.85%, 95% CI 2.33–41.37, respectively, both p &lt; 0.05). Predictive relationships were found between the stabilometric correlates of visual MI and physical practice of the balance skill, as well as between the stabilometric correlates of kinesthetic MI and the training experience in experts. Present results provide original stabilometric insights into the relationships between MI and expertise level. While data support the incomplete inhibition of postural commands during MI, whether postural responses during MI of various modalities mirror the level of motor expertise remains unclear.

Does anodal cerebellar tDCS boost transfer of after-effects from throwing to pointing during prism adaptation?

Prism Adaptation (PA) is a useful method to study the mechanisms of sensorimotor adaptation. After-effects following adaptation to the prismatic deviation constitute the probe that adaptive mechanisms occurred, and current evidence suggests an involvement of the cerebellum at this level. Whether after-effects are transferable to another task is of great interest both for understanding the nature of sensorimotor transformations and for clinical purposes. However, the processes of transfer and their underlying neural substrates remain poorly understood. Transfer from throwing to pointing is known to occur only in individuals who had previously reached a good level of expertise in throwing (e.g., dart players), not in novices. The aim of this study was to ascertain whether anodal stimulation of the cerebellum could boost after-effects transfer from throwing to pointing in novice participants. Healthy participants received anodal or sham transcranial direction current stimulation (tDCS) of the right cerebellum during a PA procedure involving a throwing task and were tested for transfer on a pointing task. Terminal errors and kinematic parameters were in the dependent variables for statistical analyses. Results showed that active stimulation had no significant beneficial effects on error reduction or throwing after-effects. Moreover, the overall magnitude of transfer to pointing did not change. Interestingly, we found a significant effect of the stimulation on the longitudinal evolution of pointing errors and on pointing kinematic parameters during transfer assessment. These results provide new insights on the implication of the cerebellum in transfer and on the possibility to use anodal tDCS to enhance cerebellar contribution during PA in further investigations. From a network approach, we suggest that cerebellum is part of a more complex circuitry responsible for the development of transfer which is likely embracing the primary motor cortex due to its role in motor memories consolidation. This paves the way for further work entailing multiple-sites stimulation to explore the role of M1-cerebellum dynamic interplay in transfer.

Angiography vs physiology-based deferral of revascularization in patients with reduced left ventricular ejection fraction: a 10-year clinical follow-up

Background

Deferring percutaneous coronary intervention (PCI) in patients with non-ischemic coronary stenoses based on fractional flow reserve (FFR) and preserved left ventricular ejection fraction (LVEF) is associated with favorable long-term clinical outcomes. In patients with reduced LVEF, the role of reversible/residual ischemia in deferring revascularization is still debated.

Purpose

To investigate whether FFR provides additive clinical benefit compared to coronary angiography in deferring revascularization in patients with intermediate coronary stenoses and reduced LVEF.

Methods

Among 4577 coronary angiographies performed between 2002 and 2010, consecutive patients with reduced LVEF (≤50%) and at least one intermediate coronary stenosis [diameter stenosis (DS)% 40–70%] in whom revascularization was deferred based either on FFR (FFR-guided) or angiography (Angiography-guided) were screened. The primary endpoint of the study was cumulative incidence of death at 10 years.

Results

A total of 843 patients were included (209 in the FFR-guided and 634 in the Angio-guided group). Median clinical follow-up was 7.1 years (IQR 3.2–11.2 years). After 1:1 propensity score matching, baseline characteristics between the two groups were similar. All-cause death at 10 years was significantly lower in the FFR-guided compared with the Angiography-guided group (94 [45%] vs 115 [55%], HR 0.72 [95% CI 0.55–0.95], p&lt;0.05). Similarly, the incidence of major adverse cardiovascular and cerebrovascular events (MACCE, composite of all-cause death, myocardial infarction, any revascularization and stroke) was lower in the FFR guided group (125 [60%] vs 140 [67%], HR 0.77 [95% CI 0.61–0.98], p&lt;0.05).

Conclusions

In patients with reduced LVEF and associated coronary artery disease, deferring revascularization of intermediate stenoses based on FFR is associated with lower incidence of death and MACCE at 10 years.

Funding Acknowledgement

Type of funding sources: None.

Physiological and angiographic outcomes of PCI in calcified lesions after rotational atherectomy or intravascular lithotripsy

Background

Percutaneous coronary interventions (PCI) in calcified coronary artery lesions is associated with impaired stent expansion, higher rate of periprocedural complications and cardiac mortality. Lesion preparation using dedicated calcium modifying techniques such as RA or IVL has been advocated. Studies comparing these technologies are lacking.

Objectives

To compare the in-stent pressure gradient, evaluated by virtual fractional flow-reserve, in calcific lesions treated using either rotational atherectomy (RA) or intravascular lithotripsy (IVL).

Methods

Patients undergoing either RA- or IVL-assisted PCI from two European centers were included. Propensity score matching (1:2) was performed to control for potential bias. Primary outcome was post- PCI in-stent pressure gradient calculated by virtual fractional flow reserve (vFFRgrad, calculated as the difference between the vFFR at the proximal minus distal edge of the stent). Secondary outcomes included the proportion of patients with complete functional revascularization defined as of distal vFFR post PCI (vFFRpost) ≥0.90.

Results

From a cohort of 210 patients, 105 matched patients (70 RA and 35 IVL) were included. Pre-PCI vFFR did not differ between groups (0,65±0,13 RA and 0,67±0,11 IVL). After PCI, in-stent pressure gradient was significantly lower in the IVL group (0.032±0.026 vs 0.043±0.026 in the RA group, p=0.024). The proportion of vessels with functional complete revascularization was similar between the two groups (32.9% vs. 37.1% in the RA and IVL group, respectively; p=0.669)

Conclusions

Calcific lesions preparation with IVL is effective and resulted in improved in-stent pressure gradient compared to RA. Approximately one third of the patients undergoing PCI for a severely calcified lesion achieved functional revascularization with no difference between rotational RA and IVL.

Funding Acknowledgement

Type of funding sources: None. In stent gradients after RA and IVL

Baseline troponin-T is powerful predictor of mortality after coronary bifurcation stenting

Introduction

Considerable progress has been made in the treatment of coronary bifurcation stenosis. Anatomical characteristics of the lesion, however, fail to give information about the functional significance of the bifurcation stenosis. There is no study that systematically establishes the baseline functional significance of coronary stenosis and its effect on procedural and clinical outcomes.

Methods

Patients with significant angiographically bifurcation lesions defined as diameter stenosis &gt;50% in main vessel and/or side branch were included. FFR was performed in main vessel (MV) and side branch (SB) before and after percutaneous coronary intervention (PCI). If FFR was ≤0.80 the lesion was considered functionally significant, and patients underwent PCI. For the group with FFR &gt;0.80 – intervention was deferred. All patients were followed-up for vital status every 3 months. Cox regression analysis was performed to identify independent predictors of all-cause and cardiovascular death. The local ethics committee approved the study and patients signed informed consent for participation into registry.

Results

For mean follow-up of 38±18 months (median 40, IQR 23–55 months) all-cause mortality was numerically lower: 8.5% (n=7/82) in deferred group and 12.6% in stented group (n=11/76, p=0.387). The cardiac mortality was also numerically lower, but statistically not significant (9.8%, n=8/82 vs. 11.5%, n=10/88, p=0.714). On multivariate model, independent predictors were mitral regurgitation &gt;1st degree – HR=1.778 (CI 1.100–2.874, p=0.019); dyslipidemia HR=0.765 (CI 0.594–0.985, p=0.038); hemoglobin concentration – HR=0.976 (CI 0.964–0.988, p&lt;0.001); pre-PCI serum troponin ≥0.010 ng/ml – HR=2.702 (CI 1.451–5.032, p=0.002). On multivariate analysis, the following factors were identified as independent predictors of cardiac mortality: age – HR=1.035 (CI 1.009–1.062, p=0.009); diabetes – HR=1.789 (CI 1.089–2.962, p=0.024); dyslipidemia treated with statin – HR=0.667 (CI 0.515–0.863, p=0.002); LV posterior wall thickness – HR=1.230 (CI 1.062–1.424, p=0.006); mitral regurgitation more than 1st degree – HR=1.763 (CI 1.065–2.917, p=0.027); troponin pre-PCI ≥0.010 ng/ml – HR=2.498 (CI 1.228–5.081, p=0.011); true bifurcation lesion – HR=1.820 (CI 1.026–3.229, p=0.040); SBBARI score &lt;10% – HR=1.715 (CI 1.049–2.804, p-0.031).

Conclusion

Baseline high-sensitive troponin T value is a strong predictor for both all cause and cardiac mortality in patients undergoing coronary bifurcation lesion PCI.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Alexandrovska University Hospital

The effects of body position and actual execution on motor imagery of locomotor tasks in people with a lower-limb amputation

Motor imagery (MI) is usually facilitated when performed in a congruent body position to the imagined movement, as well as after actual execution (AE). A lower-limb amputation (LLA) results in important structural and functional changes in the sensorimotor system, which can alter MI. In this study, we investigated the effects of body position and AE on the temporal characteristics of MI in people with LLA. Ten participants with LLA (mean age = 59.6 ± 13.9 years, four females) and ten gender- and age-matched healthy control participants (mean age = 60.1 ± 15.4 years, four females) were included. They performed two locomotor-related tasks (a walking task and the Timed Up and Go task) while MI times were measured in different conditions (in congruent/incongruent positions and before/after AE). We showed that MI times were significantly shorter when participants imagined walking in a congruent-standing position compared to an incongruent-sitting position, and when performing MI after actual walking compared to before, in both groups. Shorter MI times in the congruent position and after AE suggest an improvement of MI’s temporal accuracy (i.e. the ability to match AE time during MI) in healthy individuals but not in the LLA group.

Non-invasive brain stimulation shows possible cerebellar contribution in transfer of prism adaptation after-effects from pointing to throwing movements

Whether sensorimotor adaptation can be generalized from one context to others represents a crucial interest in the field of neurological rehabilitation. Nonetheless, the mechanisms underlying transfer to another task remain unclear. Prism Adaptation (PA) is a useful method employed both to study short-term plasticity and for rehabilitation. Neuro-imaging and neuro-stimulation studies show that the cerebellum plays a substantial role in online control, strategic control (rapid error reduction), and realignment (after-effects) in PA. However, the contribution of the cerebellum to transfer is still unknown. The aim of this study was to test whether interfering with the activity of the cerebellum affected transfer of prism after-effects from a pointing to a throwing task. For this purpose, we delivered cathodal cerebellar transcranial Direct Current Stimulation (tDCS) to healthy participants during PA while a control group received cerebellar Sham Stimulation. We assessed longitudinal evolutions of pointing and throwing errors and pointing trajectories orientations during pre-tests, exposure and post-tests. Results revealed that participants who received active cerebellar stimulation showed (1) altered error reduction and pointing trajectories during the first trials of exposure; (2) increased magnitude but reduced robustness of pointing after-effects; and, crucially, (3) slightly altered transfer of after-effects to the throwing task. Therefore, the present study confirmed that cathodal cerebellar tDCS interferes with processes at work during PA and provides evidence for a possible contribution of the cerebellum in after-effects transfer.

A haptic laparoscopic trainer based on affine velocity analysis: engineering and preliminary results

BACKGROUND

There is a general agreement upon the importance of acquiring laparoscopic skills outside the operation room through simulation-based training. However, high-fidelity simulators are cost-prohibitive and elicit a high cognitive load, while low-fidelity simulators lack effective feedback. This paper describes a low-fidelity simulator bridging the existing gaps with affine velocity as a new assessment variable. Primary validation results are also presented.

METHODS

Psycho-motor skills and engineering key features have been considered e.g. haptic feedback and complementary assessment variables. Seventy-seven participants tested the simulator (17 expert surgeons, 12 intermediates, 28 inexperienced interns, and 20 novices). The content validity was tested with a 10-point Likert scale and the discriminative power by comparing the four groups' performance over two sessions.

RESULTS

Participants rated the simulator positively, from 7.25 to 7.72 out of 10 (mean, 7.57). Experts and intermediates performed faster with fewer errors (collisions) than inexperienced interns and novices. The affine velocity brought additional differentiations, especially between interns and novices.

CONCLUSION

This affordable haptic simulator makes it possible to learn and train laparoscopic techniques. Self-assessment of basic skills was easily performed with slight additional cost compared to low-fidelity simulators. It could be a good trade-off among the products currently used for surgeons' training.

Effect of motor imagery and actual practice on learning professional medical skills

BACKGROUND

The peripheral venous catheter is the most frequently used medical device in hospital care to administer intravenous treatment or to take blood samples by introducing a catheter into a vein. The aim of this study was to examine the effect of motor imagery associated with actual training on the learning of peripheral venous catheter insertion into a simulated venous system.

METHOD

This was a prospective monocentre study in 3rd year medical students. Forty medical students were assigned to the experimental group (n = 20) performing both real practice and motor imagery of peripheral venous catheter insertion or to the control group (n = 20) trained through real practice only. We also recruited a reference group of 20 professional nurses defining the benchmark for a target performance.

RESULTS

The experimental group learned the peripheral venous catheter insertion faster than the control group in the beginning of learning phase (p < 0.001), reaching the expected level after 4 sessions (p = .87) whereas the control group needed 5 sessions to reach the same level (p = .88). Both groups were at the same level at the end of the scheduled training.

CONCLUSIONS

Therefore, motor imagery improved professional motor skills learning, and limited the time needed to reach the expected level. Motor imagery may strengthen technical medical skill learning.

Early mandibular morphological differences in patients with FGFR2 and FGFR3-related syndromic craniosynostoses: A 3D comparative study

Syndromic craniosynostoses are defined by the premature fusion of one or more cranial and facial sutures, leading to skull vault deformation, and midfacial retrusion. More recently, mandibular shape modifications have been described in FGFR-related craniosynostoses, which represent almost 75% of the syndromic craniosynostoses. Here, further characterisation of the mandibular phenotype in FGFR-related craniosynostoses is provided in order to confirm mandibular shape modifications, as this could contribute to a better understanding of the involvement of the FGFR pathway in craniofacial development. The aim of our study was to analyse early mandibular morphology in a cohort of patients with FGFR2- (Crouzon and Apert) and FGFR3- (Muenke and Crouzonodermoskeletal) related syndromic craniosynostoses. We used a comparative geometric morphometric approach based on 3D imaging. Thirty-one anatomical landmarks and eleven curves with sliding semi-landmarks were defined to model the shape of the mandible. In total, 40 patients (12 with Crouzon, 12 with Apert, 12 with Muenke and 4 with Crouzonodermoskeletal syndromes) and 40 age and sex-matched controls were included (mean age: 13.7 months ±11.9). Mandibular shape differed significantly between controls and each patient group based on geometric morphometrics. Mandibular shape in FGFR2-craniosynostoses was characterized by open gonial angle, short ramus height, and high and prominent symphysis. Short ramus height appeared more pronounced in Apert than in Crouzon syndrome. Additionally, narrow inter-condylar and inter-gonial distances were observed in Crouzon syndrome. Mandibular shape in FGFR3-craniosynostoses was characterized by high and prominent symphysis and narrow inter-gonial distance. In addition, narrow condylar processes affected patients with Crouzonodermoskeletal syndrome. Statistical analysis of variance showed significant clustering of Apert and Crouzon, Crouzon and Muenke, and Apert and Muenke patients (p < 0.05). Our results confirm distinct mandibular shapes at early ages in FGFR2- (Crouzon and Apert syndromes) and FGFR3-related syndromic craniosynostoses (Muenke and Crouzonodermoskeletal syndromes) and reinforce the hypothesis of genotype-phenotype correspondence concerning mandibular morphology.

Quantifying coronary microvascular disease: assessing absolute microvascular resistance reserve (MRR) by continuous coronary thermodilution

Background and aim

Hyperemic absolute coronary blood flow (in mL/min) can be safely and reproducibly measured with intracoronary continuous thermodilution of saline at room temperature at an infusion rate of 20 mL/min. This study aims at assessing whether continuous thermodilution can also measure resting flow and microvascular resistance.

Methods and results

In 87 coronary arteries (58 patients) with angiographic non-significant stenoses absolute flow was assessed by continuous thermodilution of saline at infusion rates of 10 mL/min and 20 mL/min using a pressure/temperature sensored guide wire, a dedicated infusion catheter and a dedicated software. In addition, in 26 arteries, average peak velocity (APV) was measured simultaneously using an intracoronary Doppler-wire.

There was no significant difference between Pd/Pa at baseline and during saline infusion at 10 mL/min, (0.95±0.053 vs 0.94±0.054, respectively (p=0.53) and there was no significant difference in APV at baseline and during the infusion of saline at 10 mL/min (22.2±8.40 vs 23.2±8.39 cm/s, respectively, p=0.63), thus indicating presence of resting coronary blood flow during the infusion of 10 mL/min of saline.

In contrast, at an infusion rate of 20 mL/min, a significant decrease in Pd/Pa was observed compared to baseline: (0.85±0.089 vs 0.95±0.053, respectively, p&lt;0.001) and a significant increase in APV was observed (22.2±8.4 cm/s to 57.8±25.5 cm/s, respectively, p&lt;0.001). The coronary flow reserve (CFR) calculated by thermodilution and by Doppler flow velocity were similar (2.73±0.85 vs 2.72±1.07, respectively) and their individual values correlated closely (r=0.87, 95% CI 0.72–0.94, p&lt;0,001). Microvascular resistance (Rμ), defined as the distal coronary pressure divided by the absolute flow was calculated both at rest (Rμ-rest) and during hyperemia (Rμ-hyper). Microvascular Resistance Reserve (MRR), is calculated as the ratio of Rμ-rest and Rμ-hyper and showed a good correlation with the analogous Doppler-derived parameter (using the APV instead of absolute flow). Mean doppler and thermodilution derived MRR were similar (3.32±1.50 vs 3.23±1.16) and values correlated closely (r=0.91, 95% CI 0.81 - 0.96, p&lt;0.001; Bland-Altman analysis: mean bias = 0.071, limit of agreement −1.195 to 1.338).

Conclusion

Absolute coronary blood flow (in mL/min) can be measured by continuous thermodilution both at rest and during hyperemia. This allows accurate, reproducible, and operator-independent direct volumetric calculation of CFR and MRR. The latter is a quantitative metric which is specific for microvascular function and independent from myocardial mass.

Doppler and Thermodilution derived MRR

Funding Acknowledgement

Type of funding source: None

Endoscopic repair of atrial functional mitral regurgitation in heart failure: long-term effects

Introduction

In patients with heart failure and preserved ejection fraction (HFpEF), even mild atrial functional mitral regurgitation (AFMR) has been associated with poor outcome.

Objective

To describe long-term effects of endoscopic mitral valve (MV) repair on outcome in patients with HFpEF and AFMR.

Methods

The study population consisted of consecutive patients with HFpEF (LVEF ≥50%, H2FPEF score ≥5) and AFMR, who underwent isolated, minimally invasive (endoscopic), MV repair (MVRepair group) (n=131) or remained on standard of care (StanCare group) (n=139). Patients with coronary artery disease or organic MR were excluded. Patients were matched using inverse probability of treatment weighting. Primary objective was all-cause mortality or HFpEF readmissions.

Results

The median follow up was 5.03 years (IQR 2.6–7.9 years). In the MVRepair group, the perioperative, 30-day, 1- and 5-year mortality was 0, 1% and 12%, respectively. Additional 13 (10%) patients were readmitted for worsening HFpEF, while 2 (1%) individuals underwent redo MV surgery for recurrent MR. MVRepair compared with StanCare showed 21–29% (SE 6–8%) and 19–26% (SE 6–8%) absolute risk reduction of all-cause mortality and HFpEF readmissions, respectively (all p&lt;0.05). MVRepair emerged as the strongest independent predictor of all-cause mortality (HR 0.16, 95% CI 0.07–0.34, p&lt;0.001) and HFpEF readmissions (HR 0.21, 95% CI 0.09–0.51, p&lt;0.001). At 5-year follow-up, in the MVRepair group, a total of 88% were alive and 80% were alive without readmission for HFpEF.

Conclusions

Endoscopic MV repair is associated with low perioperative mortality, high long-term efficacy and appears to improve clinical outcome in patients with AFMR and HFpEF.

Mortality and readmission for HF

Funding Acknowledgement

Type of funding source: None

Thermodilution-derived resting coronary flow measurement: “a reverse dose finding study”

Background

Hyperemic absolute coronary blood flow (in mL/min) can be safely and reproducibly measured with intracoronary continuous thermodilution of saline at room temperature at an infusion rate of 20 mL/min. This study aims at assessing the best infusion rate to measure resting flow by thermodilution, i.e. low enough to avoid microvascular dilation but high enough to allow reliable thermodilution tracings

Methods and results

In 26 coronary arteries (24 patients) with angiographic non-significant stenoses, absolute flow was assessed by continuous saline thermodilution at infusion rates of 10 mL/min and 20 mL/min using a pressure/temperature sensored guide wire, a dedicated infusion catheter and a dedicated software. Average peak velocity (APV) was measured simultaneously using an intracoronary Doppler-wire. In addition, in a subgroup of 10 arteries, absolute flow and APV were also measured during saline infusion at 6 ml/min and 8 ml/min.

In 26 coronary arteries there was no significance difference in the Pd/Pa and in the APV at baseline and during the infusion of saline at 10 ml/min (Pd/Pa: 0.94±0.057 vs 0.94±0.059, p=0.82; APV: 22.2±8.40 vs 23.2±8.39 cm/s, p=0.63). In contrast, at an infusion rate of 20 mL/min, we observed a significant decrease in Pd/Pa compared to baseline (0.85±0.089 vs 0.95±0.053 vs, respectively, p&lt;0.001) and a significant increase in APV (22.2±8.4 cm/s to 57.8±25.5 cm/s, respectively, p&lt;0.001). The coronary flow reserve (CFR) evaluated by Doppler and intracoronary continuous thermodilution correlated well (r=0.87, 95% CI = 0.72–0.94, p&lt;0.001) and Bland-Altman analysis documented a mean bias of −0.003 (limit of agreement −1.05 to 1.04) thus indicating the presence of resting coronary blood flow during the infusion of 10 mL/min of saline. In 10 coronary arteries saline infusions at 6 and 8 ml/min did not produce any significant changes in the Pd/Pa and in the APV compared to baseline and both Doppler and Thermodilution derived CFR correlated well at each infusion rate (6 ml/min: r=0.71, 95% CI 0.14–0.92, p=0.02; 8ml/min: r=0.78, 95% CI=0.31–0.95, p=0.007). However, with an infusion rate of 6 mL/min, an unstable thermodilution tracing was observed. Accordingly, Bland-Altman analysis showed a significantly larger dispersion of the CFR values when 6 ml/min was used to measure resting coronary flow (as compared with 8 m/min): mean bias at 6 ml/min: −0.53, limits of agreement: −2.25 to 1.20: mean bias at 8 ml/min: 0.004, limits of agreement: −0.72 to 0.73.

Conclusion

Absolute resting coronary flow can be measured by intracoronary continuous thermodilution of saline at infusion rate of 8–10 ml/min.

Funding Acknowledgement

Type of funding source: None

Hyperemic hemodynamic characteristics of serial coronary lesions assessed by pressure pullbacks gradients (PPG) index

Introduction

The evaluation of functional significance in serial coronary lesions is crucial for achieving optimal clinical outcomes. In this setting, fractional flow reserve (FFR) measurements with pullback pressure recording can be helpful in assessing lesion functional significance.

Purpose

To describe the functional characteristics of angiography-defined serial coronary lesions using FFR-derived motorised pullback tracings, and to describe the Pullback Pressure Gradients (PPG) index - in these lesions.

Methods

Prospective, multicentre study with independent core laboratory analysis. Patients undergoing coronary angiography due to stable angina were enrolled. Serial lesions were defined angiographically as the presence of 2 or more narrowings with visual diameter stenosis &gt;50% separated at least by 3 times the reference vessel diameter in the same coronary vessel. Continuous IV adenosine-FFR measurements were obtained using a motorised device at a speed of 1 mm/s. Pullback curves were assessed to determine the presence of focal step-ups (FFR &gt;0.05 units over 20 mm). In addition, the PPGindex was computed for all vessels. PPGindex values close to 0 define functional diffuse disease whereas values close to 1 define focal disease.

Results

From a total of 159 vessels (117 patients), 25 vessels were adjudicated as presenting serial lesions (mean PPGindex 0.48±0.17, range 0.26–0.87). Two focal pressure step-ups were observed in 40% of the cases (n=10; mean PPGindex 0.59±0.17), whereas 8% of the vessels presented a progressive pressure losses (n=2; mean PPGindex 0.27±0.01). In the remaining 52% of the cases, a single pressure step-up was recorded (n=13; mean PPGindex 0.44±0.12; ANOVA p-value = 0.01). The PPGindex independently predicted the presence of two focal pressure step ups.

Conclusion

Hyperemic FFR curves in tandem stenoses revealed high prevalence of functional diffuse CAD. Two pressure step-ups occurred in less than half of the vessels. High PPG-Index identified vessels with two focal pressure drops. FFR tracings and the PPGindex provide a more objective CAD evaluation, which can lead to changes in the therapeutic approach.

Funding Acknowledgement

Type of funding source: None

Long-term outcome of minimally invasive mitral valve annuloplasty in disproportionate mitral regurgitation

Background

Hypothetical concept of disproportionate secondary mitral regurgitation (SMR) has been recently introduced to facilitate patient's selection for mitral valve intervention. However, real world data validating this concept are unavailable.

Purpose

To investigate long-term effects of minimally invasive mitral valve annuloplasty (MVA) in patients with disproportionate (dSMR) versus proportionate SMR.

Methods

The study population consisted of 44 consecutive patients (age 67±9,5 years; 64% males) on guidelines-directed therapy with advanced heart failure (HF), reduced LV ejection fraction (EF) (32±9,7%) and SMR undergoing isolated mini-invasive MVA. Patients with organic mitral regurgitation or concomitant myocardial revascularization were excluded. To assess SMR disproportionality, the PISA-derived effective regurgitant orifice area (EROA) and regurgitant volume (RV) were compared to the estimated EROA and RV by using Gorlin formula and pooled real world data.

Results

According to EROA, a total of 20 (46%) and 24 (54%) patients, respectively, had dSMR and proportionate SMR (pSMR). According to RV, a total of 17 (39%) had dSMR and 27 (61%) had pSMR. Patients with dSMR showed significantly lower prevalence of male gender and higher prevalence of diabetes mellitus than patients with pSMR (p&lt;0,001). Moreover, we observed smaller LV end-diastolic volume, larger EROA and RV (both p&lt;0,01) and higher LV EF (p=0,02) in the dSMR versus the pSMR group. Other baseline characteristics were similar. During median follow up of 4.39 y (IQR 2,2–9,96y), a total of 25 (56%) patients died from any cause while 21 (47%) individuals were readmitted for worsening HF. Patients with dSMR versus pSMR according to both EROA and RV showed significantly lower rate of HF readmissions (both p&lt;0.05) (Figure 1, 2). In Cox regression analysis combining clinical and imaging parameters, dSMR was the only independent predictor of HF readmissions (HR 0.20, 95% CI 0.07–0.60, p=0.004). In contrast, mortality was similar between dSMR and pSMR (NS) with age as the only independent predictor (HR 1,10; 95% CI 1,03–1,18, p=0,003).

Conclusions

Minimally invasive MVA is associated with significant reduction of HF readmissions in patients with dSMR versus pSMR while the mortality is similar. This suggests the importance of other parameters, i.e. age and degree of LV remodeling, to guide clinical management in SMR.

Funding Acknowledgement

Type of funding source: None

Quantification of calcium volume by coronary CT compared to OCT

Background

Coronary artery calcifications are frequently observed in patients referred for cardiac catheterization. Using OCT, the calcified volume can be determined. CT is a sensitive non-invasive tool to detect coronary artery calcifications and may be useful to guide percutaneous coronary intervention.

Purpose

The aim of the study was to investigate the accuracy of CT-derived calcium volume with OCT as a reference in patients undergoing PCI.

Methods

66 calcified plaques (32 vessels) from 31 patients undergoing OCT-guided PCI with coronary CT angiography acquired as a standard of care were included. Coronary CT angiography and OCT images were matched using fiduciary points. Calcified plaques were reconstructed in three dimensions to calculate calcium volume. A Passing-Bablok regression analysis and the Bland-Altman method were used to assess agreement between imaging modalities.

Results

27 left anterior descending arteries and 5 right coronary arteries were analyzed. Median calcium volume by CT angiography and OCT were 18.23 mm 3 [IQR 8.09, 36.48] and 10.03 mm 3 [IQR 3.6, 22.88]. The Passing-Bablok analysis showed a proportional difference without a systematic difference (Coefficient A 0.08, 95% CI: −1.37 to 1.21, Coefficient B 1.61, 95% CI: 1.45 to 1.84); with a mean difference of 9.69 mm3 (LOA −10.2 mm 3 to 29.6 mm 3). No significant differences were observed for MLA: median value for CT 2.84 mm2 [IQR 2.03, 3.74] and for OCT 2.55 mm2 [IQR 1.91, 4.43].

Conclusions

Coronary CT angiography volumetric calcium evaluation overestimates calcium volume by 60% compared to OCT. Accounting for CT overestimation may allow for appropriate interpretation of calcific burden in the non-invasive setting. Coronary CT angiography may emerge as a tool to quantify calcium burden for invasive procedural planning.

Calcium burden comparison CT vs OCT

Funding Acknowledgement

Type of funding source: None

P4661Increased levels of sST2 in patients with mitral annulus disjunction and ventricular arrhythmias

Background

Mitral annulus disjunction (MAD), a basal displacement of the mitral valve annulus, is described as a possible aetiology of sudden cardiac death. Stretch-induced fibrosis in the sub-valvular apparatus has been suggested as the substrate of arrhythmias.

Purpose

We hypothesized that the stretch related biomarker soluble Suppression of Tumorigenicity-2 (sST2) is a marker of ventricular arrhythmias in patients with MAD.

Methods

We included patients with ≥1 mm MAD on cardiac magnetic resonance imaging, and recorded left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE) suggesting papillary muscle fibrosis. Circulating levels of sST2 were assessed by blood sampling. The occurrence of ventricular arrhythmias, defined as aborted cardiac arrest, sustained or non-sustained ventricular tachycardia, was assessed retrospectively.

Results

We included 72 patients with MAD [55 (35–62) years old, 48 (67%) female], of which 22 (31%) had ventricular arrhythmias. Patients with ventricular arrhythmias had lower LVEF (60±6% vs. 63±6%, p=0.04), more prevalent papillary muscle fibrosis [14 (64%) vs. 10 (20%), p<0.001] and higher sST2 levels [31.6±10.1 ng/mL vs. 25.3±9.2 ng/mL, p=0.01] compared to those without. Combining sST2-level, LVEF and papillary muscle fibrosis optimally detected individuals with arrhythmias (area under the curve 0.82, 95% CI 0.73–0.92) and improved the risk model (p<0.05) compared to individual parameters (Figure right panel).

Conclusion

Circulating sST2 levels were higher in patients with MAD and ventricular arrhythmias compared to patients without arrhythmias. Combining sST2, LVEF and LGE may improve risk stratification in patients with MAD.

Acknowledgement/Funding

This work was supported by public grant [203489/030] from the Norwegian Research Council, Oslo, Norway. E. Scheirlynck received an ESC research grant

P1963The determinants of functional significance of coronary bifurcation lesions and its implications on clinical follow up to 48 months (insights from FIESTA registry)

Background

There is no study up-to-now to determine the rate of functionally significant coronary bifurcation lesions, which have to be intervened and what are the clinical consequences of the FFR case selection strategy.

Methods

We analyzed patients from FIESTA registry, which was continuation of FIESTA study (Ffr vs. IcEcgSTA, ClinicalTrials.gov Identifier: NCT01724957). Patients with stable angina were included (if there were other coronary stenoses they were threated first after checking by FFR for functional significance). The inclusion criterions were angiographic bifurcation lesions in a native coronary artery with diameter ≥2.5 mm and ≤4.5 mm and SB diameter ≥2.0 mm. We excluded patients with ST-segment elevation myocardial infarction, left main, hemodynamic instability and those with non-cardiac co-morbidity conditions with a life expectancy of less than one year. PCI was performed according to the current guidelines. Provisional stenting was the default strategy in all patients. Two guidewires were inserted into both distal MB and SB. Initial FFR was performed using the PrimeWire or PrimeWire Prestige (Volcano Corp., USA). For all FFR measurements, intracoronary adenosine was given in increasing doses of 60 mcg, 120 mcg, and 240 mcg. The minimum value of FFR measurements was taken for analysis. All patients received double antiplatelet therapy with ADP-antagonist and aspirin for at least 12 months.

Results

A 130 consecutive patients with coronary bifurcation stenoses were included – 57 had positive FFR<.80 in main vessel of bifurcation lesion (44% functionally significant lesions). The mean age was 67±10 years, 66% males, 96% hypertensive, 39% diabetic, 96% dyslipidemic (or on treatment with statin), 55% smokers, 22% with previous myocardial infarction, 51% with previous PCI. The residual SYNTAX score before FFR bifurcation assessment was 13±4 (FFR<.80) vs. 8±3 (FFR≥0.80), p<0.001. Univariate predictors of bifurcation FFR<.80 were: proximal (MV%DS) or distal (MB%DS) main vessel stenosis ≥85% (derived from ROC analysis with overall accuracy 77% and 72%, accordingly), lesion length, SYNTAX score, triglyceride concentration, previous MI on lateral wall and carotid artery disease. On multivariate logistic analysis only MV%DS>85% (OR=8.929, CI 2.887–27.619, p<0.001), MB%DS>85% (OR=3.831, CI 1.349–10.883, p=0.012) and SYNTAX score≥12 (OR=16.466, CI 5.225–15.889, p<0.001). At median follow-up of 26 months (IQR 17–35) the all-cause mortality was 17.5% in FFR positive bifurcations vs. 4.1% in FFR negative lesions (log-rank =.067).

Conclusions

Less than a half of angiographically significant coronary bifurcation lesions are functionally significant and require stent implantation. The functional significance was related with higher degree stenosis in main vessel and overall disease severity estimated with SYNTAX score. A trend to lower mortality was noted in group with non-significant FFRs.

1156Coronary artery bypass grafting vs. FFR-guided PCI in diabetic patients with multivessel disease

Background

In diabetic patients with multivessel coronary disease (MVD), coronary artery bypass grafting (CABG) has shown long-term benefits in mortality over percutaneous coronary revascularization (PCI). Nevertheless, the impact of fractional flow reserve (FFR)-guided PCI on clinical outcomes has never been investigated in these patients.

Purpose

To evaluate the long-term (5-year) clinical outcome of diabetic patients with MVD treated with FFR-guided PCI compared to CABG.

Methods

From February 2010 to February 2018, all diabetic patients undergoing coronary angiography in one centre (n=4622) were screened for inclusion. The inclusion criterion was presence of at least two-vessels CAD defined as with diameters stenosis ≥50%. In case of intermediate coronary stenosis (%DS 30–70%), FFR was performed at the discretion of the operator. Revascularization was performed when FFR ≤0.80. Exclusion criteria were ST-elevation myocardial infarction, prior CABG, and moderate or severe valvular heart dysfunction.

To account for confounders, we compared outcomes by calculating an adjusted Kaplan-Meier estimator using inverse probability of treatment weighting (IPTW). Propensity score variables included age, sex, smoking habit, hypertension, hyperlipidemia, insulin therapy, family history of CAD, chronic obstructive pulmonary disease (COPD), glomerular filtration rate (GFR), prior myocardial infarction, peripheral vascular disease (PVD), admission for NSTEMI, ejection fraction, number of angiographic stenotic vessels. Odds ratios were calculated using generalized linear models (GLM). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), defined as all-cause death, myocardial infarction and stroke. Secondary endpoints were the individual component of MACCE and any repeated revascularization.

Results

A total of 538 diabetic patients with MVD were included in the analysis. Among them, 317 (59%) patients underwent CABG and 221 (41%) FFR-guided PCI.

Patients treated with FFR-guided PCI had more often COPD as compared to patients in the CABG-group, but patients treated with CABG had lower GFR, more PVD, higher number of angiographic stenotic vessels (2.8±0.4 vs. 2.5±0.5; p<0.01) and higher Syntax score (20±7 vs. 14±6; p<0.01) as compared to the FFR-guided PCI group.

Clinical follow-up was obtained in 95% of the patients at a median follow-up of 5 years.

The incidence of MACCE was similar in the CABG and in the FFR-guided PCI group [27% vs. 29%; OR (95% CI) 1.05 (0.68–1.63); p=0.74]. No differences were found in the individual components of MACCE. Repeat revascularization was more frequent in the FFR-guided PCI group than in the CABG group [27% vs. 7%; OR (95% CI) 4.3 (2.35–7.9); p<0.01].

Conclusions

In diabetic patients with MVD undergoing FFR-guided PCI, no differences in major adverse events were observed at a median follow-up of 5 years compared with CABG.

279Clinical outcome after coronary bifurcation stenting: a systematic review and network meta-Analysis of PCI bifurcation techniques comprising 5572 patients

Background

The optimal PCI technique for bifurcation lesions remains a matter of debate. Several RCT have compared different bifurcation PCI techniques. Provisional stenting has been recommended as the default technique for most bifurcation lesions. However, emerging data suggests that double-kissing crush technique can be considered in true left main bifurcation lesions and has been endorsed by the European Society of Cardiology Guidelines.

Purpose

To compare the clinical outcome between different bifurcation PCI techniques.

Methods

We searched MEDLINE for randomized clinical trials (RCT) comparing PCI bifurcation techniques for coronary bifurcation lesions. Outcomes of interest were major adverse cardiovascular events (MACE) defined as the composite of cardiac death, myocardial infarction (MI) and target vessel or lesion revascularization (TVR/TLR), and the individual components of MACE. Stent thrombosis was assessed as defined by the ARC. Stratification based on left-main or distal bifurcations was performed. We evaluated the studies' risk of bias in accordance to the Cochrane Handbook for Systematic Reviews of Interventions, and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We estimated summary odds ratios (ORs) using pairwise and Bayesian network meta-analysis.

Results

We identified 263 studies and of these included 19 RCT including 5572 patients treated with 5 bifurcation PCI techniques namely provisional stenting, systematic T-stenting, crush, culotte and double-kissing crush. Median follow-up was 12 months (IQR 8 to 36). When all bifurcation lesions were combined, double-kissing crush technique reduced the occurrence of MACE (OR 0.42; CrI 0.28 to 0.61) compared to provisional stenting. This difference was driven by a reduction in TVR/TLR (OR 0.39; CrI 0.25 to 0.65). No differences were found in cardiac death, MI or stent thrombosis among analyzed PCI techniques. No differences in MACE were observed between provisional stenting, systematic T-stenting, crush. In distal bifurcations (n=17 studies, 4634 patients), double-kissing crush also showed to reduce MACE (OR 0.48; CrI 0.29 to 0.67 vs. Provisional). In left-main bifurcations (n=3 studies, 938 patients) no differences in MACE were found between PCI techniques.

Conclusions

In this network meta-analysis, PCI bifurcation techniques were similar with respect to the occurrence of cardiac death, myocardial infarction and stent thrombosis. When all coronary bifurcations were combined, an advantage of double-kissing crush was observed in terms of MACE driven by lower rate of repeated revascularization. Further studies are required to define the best PCI bifurcation technique for left main coronary artery disease.

P854Physiological patterns of coronary artery disease

Background

Randomised controlled trials have confirmed the clinical benefit of invasive functional assessment to guide clinical decision making about myocardial revascularisation in patients with stable coronary artery disease. Treatment decision is based on one FFR value which provides a vessel-level metric as a surrogate of myocardial ischaemia. Also, the distribution of epicardial conductance can be evaluated using an FFR pullback manoeuvre.

Purpose

The objective of the present study is to characterise the physiological patterns of CAD using motorised coronary pressure pullbacks during continuous hyperaemia in patients with stable coronary artery disease.

Methods

Prospective, multicentre study of patients undergoing clinically-indicated coronary angiography. A pullback device, adapted to grip the coronary pressure wire, was set at a speed of 1 mm/sec. The pattern of CAD was adjudicated by visual inspection of the FFR pullback curves as focal, diffuse, or a combination of both mechanisms. Also, a quantitative classification of the physiological pattern of CAD was performed based on (1) the functional contribution of the epicardial lesion in relation to the total vessel FFR (Δlesion FFR/Δvessel FFR) and (2) the length (mm) of epicardial coronary segments with FFR drops in relation to the total vessel length. The combination of these two ratios, namely, lesion-related pressure drops (%FFR-lesion), and the extent of functional disease, resulted in the functional outcomes index (FOI), a metric that represents the pattern of CAD (i.e. focality or diffuseness) based on coronary physiology. Agreement on CAD patterns and between observers was assessed using Fleiss' Kappa. Analysis of variance (ANOVA) was used to compared quantitative variables. Correlation between variables was assessed by the Pearson moment coefficient.

Results

One hundred and fifty-eight vessels were included; 984,813 FFR values were used to generate the FFR pullback curves. Using motorised FFR pullbacks, 34% of the vessel disease patterns (i.e. focal, diffuse or combined) were reclassified compared to conventional angiography. The mean contribution of the angiographic lesions to the distal FFR (%FFR-lesion) was 61.7±25% whereas vessel length with the physiological disease was 59.8±21% of the total vessel length. The mean FOI was 0.61±0.17, and differentiated focal from diffuse CAD in terms of %FFR-lesion (p<0.001) and physiological extent of CAD (p<0.001).

Conclusion

Coronary angiography was inaccurate to assess the patterns of CAD. The inclusion of the functional component reclassified 34% of the vessel disease patterns (i.e. focal, diffuse or combined). A new metric, the FOI, based on the functional impact of anatomical lesions and the extent of physiological disease, discriminated focal from diffuse CAD. Further clinical trials are required to evaluate the usefulness of FOI for clinical decision making and outcomes.

P855Evaluation of epicardial coronary resistance using computed tomography angiography

Background

A Fractional flow reserve (FFR) pullback allows assessing the distribution of pressure loss along the vessel. FFR derived from CT (FFRCT) provides a virtual pullback curve that may also aid in the assessment of epicardial coronary resistance in the non-invasive setting.

Purpose

The present study aims to determine the accuracy of the virtual FFRCT pullback curve using a motorized invasive FFR pullback as reference in patients with stable coronary artery disease.

Methods

This is a single centre, prospective study of patients with stable coronary artery disease in whom FFRCT was performed as standard of care for non-invasive assessment. Patients referred to coronary angiography with clinically indicated invasive FFR measurement were included. FFRCT and invasive FFR values were extracted from coronary vessels every 1 mm to generate pullback curves. Invasive FFR pullbacks were acquired using a dedicated device at a speed of 1 mm/s. The area under the pullback curve (AUPC), defined as the sum of areas under the FFR pullback curve, was compared between FFRCT and invasive FFR pullbacks. Lesions were defined based on invasive angiography. FFR gradients in lesions and non-obstructive segments were defined as the difference between FFR values at the proximal and distal edge of the segments. FFR vessel gradient was defined as the difference between the most distal FFR value and the FFR at the ostium of the vessel. Mixed effect model was used to account for the correlation of FFR values within vessels. The agreement between FFRCT and FFR gradients was assessed using the Passing Bablok regression analysis and Bland-Altman methods at the vessel, lesion and non-obstructive level.

Results

A total of 3172 matched FFRCT and FFR values were obtained in 24 vessels. The correlation coefficient between FFRCT and FFR was 0.76 (95% CI 0.75 to 0.78; p<0.001). The mean difference between the FFRCT and invasive FFR pullback values was 0.07 (LOA −0.11 to 0.24). AUPC was similar between FFRCT and invasive FFR (79.0±16.1 vs. 85.3±16.4, p=0.097); the mean slope of FFRCT pullback curve was steeper compared to invasive FFR (p<0.001). The mean difference in lesion gradient was −0.07 (LOA −0.26 to 0.13) and −0.01 (LOA −0.06 to 0.05) in non-obstructive segments. There were no systematic or proportional differences between FFRCT and FFR gradients either in lesion or non-obstructive segments); however, vessel gradients were overestimated by FFRCT with a bias of −0.12 (LOA −0.35 to 0.12) driven by a higher mean difference in lesion gradients (−0.07; 95% CI −0.26 to 0.13).

Conclusions

The evaluation of epicardial coronary resistance using coronary CT angiography with FFRCT was feasible. FFRCT pullbacks were accurate in the assessment of lesion and non-obstructive gradients. FFRCT can identify the physiological pattern of coronary artery disease in the non-invasive setting.

Associating Vehicles Automation With Drivers Functional State Assessment Systems: A Challenge for Road Safety in the Future

In the near future, vehicles will gradually gain more autonomous functionalities. Drivers' activity will be less about driving than about monitoring intelligent systems to which driving action will be delegated. Road safety, therefore, remains dependent on the human factor and we should identify the limits beyond which driver's functional state (DFS) may no longer be able to ensure safety. Depending on the level of automation, estimating the DFS may have different targets, e.g., assessing driver's situation awareness in lower levels of automation and his ability to respond to emerging hazard or assessing driver's ability to monitor the vehicle performing operational tasks in higher levels of automation. Unfitted DFS (e.g., drowsiness) may impact the driver ability respond to taking over abilities. This paper reviews the most appropriate psychophysiological indices in naturalistic driving while considering the DFS through exogenous sensors, providing the more efficient trade-off between reliability and intrusiveness. The DFS also originates from kinematic data of the vehicle, thus providing information that indirectly relates to drivers behavior. The whole data should be synchronously processed, providing a diagnosis on the DFS, and bringing it to the attention of the decision maker in real time. Next, making the information available can be permanent or intermittent (or even undelivered), and may also depend on the automation level. Such interface can include recommendations for decision support or simply give neutral instruction. Mapping of relevant psychophysiological and behavioral indicators for DFS will enable practitioners and researchers provide reliable estimates, fitted to the level of automation.