Significance and distribution of aortic valve calcium score before TAVI

Introduction

Aortic valve calcium scoring by multislice computed tomography (MSCT) is an alternative load independent assessment of aortic stenosis severity. Recent studies have further demonstrated that aortic valve calcification load is related to adverse outcomes during and after transcatheter aortic valve implantation (TAVI), however reference values in this population are uncertain. This study aimed to assess aortic valve calcium in P referred for TAVI.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2014 and 2020 in a tertiary care centre. Clinical and echocardiographic characteristics, along with MSCT-derived aortic valve calcium score were collected.

Results

A total of 467 P were included, 57% female, median age 83 (9) years (minimum 45 and maximum 95 years-old). The prevalence of hypertension, dyslipidemia and diabetes was 83%, 69% and 36%, respectively. Chronic renal failure was present in 51%, atrial fibrillation in 34% and peripheral artery disease in 14%.

Considering the 346 P with aortic valve calcification quantified by MSCT, median calcium score was 2161 (1761) AU. Age did not correlate with valvular calcification (r=0.043, p=0.422). Male gender showed significantly higher calcium score (2800 (2093) vs 1850 (1584), p<0.001) (Figs. 1 and 2).

11P had bicuspid aortic valve disease, with this population being younger (75 (16) vs 83 (8) years, p=0.001), nonetheless displaying higher aortic valve calcium load (2800 (2599) vs 2112 (1788), p=0.025). A weak but statistically significant correlation between calcium score and maximum (r=0.366, p<0.001) and mean gradients (r=0.387, p<0.001) and aortic valve area (r=−0.120, p=0.047) was demonstrated. Valvular calcification was not significantly different in P with reduced ejection fraction (<50%) (p=0.388).

Conclusion

There are significant differences in aortic valve calcium score between men and women referred for TAVI. Higher maximum and mean gradients were associated with increasing valvular calcification. Age and left ventricle ejection fraction were not related. P with bicuspid aortic valve have distinct calcification characteristics. As calcification burden may influence preprocedural planning, this parameter should be incorporated in the general work-up and reference values in this population should be known.

Funding Acknowledgement

Type of funding sources: None.

3 year outcomes of permanent pacemaker implantation after alcoholic septal ablation

Introduction

Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete hear block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear.

Objectives

This study aims to evaluate the long-term clinical outcomes in patients who implant PPM after ASA.

Methods

In a tertiary center, patients who underwent ASA were consecutively enrolled prospectively. Patients with previous PPM or implantable cardio-defibrillator were from this analysis. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and 3-year primary and secondary endpoints.

Results

Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). At 3 years after ASA procedure, the primary endpoint (composite of all-cause mortality and all-cause re-hospitalization) showed a statistical tendency to a lower event rate in the group who implanted PPM (p-value 0.097, Graphic 1). The secondary endpoint (composite of all-cause mortality and cardiac cause re-hospitalization) did not show any significant statistical difference between the two groups (p-value 0.216, Graphic 2).

Conclusions

The long-term endpoint analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to a lower rate of the endpoint composite of all-cause mortality and all cause re-hospitalizations.

Funding Acknowledgement

Type of funding sources: None.

Coronary sinus reducer device for the treatment of refractory angina therapy. A multicentric initial experience

Introduction

The coronary sinus Reducer device (CSRD) emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSRD in a real-world setting.

Methods

Twenty-six patients with refractory angina (RA), evidence of myocardial ischemia attributable to the left coronary artery unsuitable for revascularization were treated with the CSRD at two centres between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at 6-month follow-up, were a reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7) and reduction in anti-anginal therapy.

Results

Twenty-three patients had end-stage CAD without revascularization targets and 3 patients had microvascular disease without epicardial stenosis. Procedural success was achieved 23 patients, with 2 device/procedural-related complications and one anatomically-related failure to deliver the device. Ultimately 25 patients implanted the device and entered the efficacy analysis. Eighteen patients (75.0%) had at least 1 reduction in CCS class, 41.7% had at least 2 class reductions, and 16.7% became asymptomatic, with a mean reduction of CCS class of 1.3±0.2 (p=0.001) at 6-month follow-up. All SAQ-7 domains improved, namely physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction of anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010).

Conclusion

In this real-world, multicentric experience, implantation of the CSRD was associated with improvement of angina and QoL in patients with RA.

Funding Acknowledgement

Type of funding sources: None.

Transcatheter aortic valve implantation outcomes in patients with low flow low gradient aortic stenosis

Background

There are limited data about the outcomes of transcatheter aortic valve implantation (TAVI) in patients with low flow – low gradient (LF-LG) aortic stenosis (AS), but some studies suggest that these patients may have worse results.

Purpose

To compare outcomes between LF-LG AS and high gradient AS patients submitted to TAVI.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteriscs and outcomes after the procedure were collected. LF-LG AS was considered in patients with mean gradient <40mmHg, valve area <1mm2, stroke volume index <35mL/m2 and at least one other criteria of contractile reserve confirmed by stress echocardiography, with elevation of mean gradient to >40mmHg, or high aortic calcium score in angio-CT.

Results

A total of 480P (56.9% female) were included, with a mean age of 82±7 years. Patients with LF-LG AS (81P, 16.9%) had worse baseline characteriscs, with higher new euroscore (10.4% vs 6.3%, p<0.0001), and natriurec peptide B (11252 vs 3095 pg/mL, p=0.001), more frequent left ventricular ejection fraction (LVEF) <40% (33.3% vs 8.8%, p<0.0001), more coronary artery disease (58% vs 37.1%, p<0.0001), including previous myocardial infarction (28.4% vs 14.1%, p=0.002) and coronary artery bypass graft (29.6% vs 12.3%, p<0.0001). In univariable analysis, LF-LG AS was associated with worse 1 year and long-term functional class (NYHA 3–4 – 17.8% vs 3.8% p<0.0001 and 20.5% vs 6.0%, p<0.0001, respectively), 1 year mortality (21.3% vs 10.8%, p=0.012) and 1 year and long-term heart failure hospitalizations (16.6% vs 3.3%, p<0.0001 and 24.3% vs 6.3%, p<0.0001). When adjusted to the differences in baseline characteristics, in a mulvariable analysis, LF-LG AS was still associated with worse functional class at 1 year (p=0.023) and long-term (p=0.004) and with heart failure hospitalizations at 1 year and long-term (p=0.001 and p<0.0001, respectively). In a sub-analysis considering only the patients with LF-LG AS, those with LVEF <40% have the worst outcomes, with more global, intra-hospital and 30 days mortality (48.1% vs 18.5%, p=0.005; 14.8% vs 1.9%, p=0.040; 18.5% vs 1.9%, p=0.014), global cardiovascular mortality (25.9% vs 7.4%, p=0.036), worse 1 year functional class (31.8% vs 11.8%, p=0.040) and more long-term heart failure hospitalizations (40.9% vs 17.3%, p=0.031).

Conclusion

Patients with LF-LG AS have worse short and long-term outcomes, even when adjusted for baseline characteriscs differences. The sub-group of patients with LVEF <40% have the worst global outcomes.

Funding Acknowledgement

Type of funding sources: None.

Predictors of pacemaker dependency after transcatheter aortic valve replacement

Funding Acknowledgements

Type of funding sources: None.

Background

Conduction disturbances after transcatheter aortic valve replacement (TAVR) are common with a variable risk of long-term pacemaker dependency (PD), being influenced by patient- and procedure-specific factors. As pacemaker (PM) implantation is associated with potential complications, our aim was to assess predictors of PD requirement after TAVR.

Methods

Retrospective analysis of consecutive patients (P) who underwent TAVR with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. Cumulative percentage of ventricular pacing (%Vp) was determined from stored PM data. P with a PM implanted previous to TAVR were excluded. PM implantation post-TAVR was defined as a device implant performed during hospital stay in the context of TAVR or during the first month after discharge. PD was defined as a %Vp > 80% at one-year follow-up. Multivariate analysis for the prediction of PD was done using Cox regression.

Results

A total of 474 P (57% male, age 81.7±6.5 years, left ventricular ejection fraction 51.5±14.6%) were analysed. Mean follow-up was 18.7 months. Mean baseline gradient was 51.7 mmHg with a mean aortic valve area of 0.71 cm2. One hundred and four P (21.9%) required PM implantation after TAVR, with a mean %Vp of 65.3±43.4%, presenting PD in 60% of the cases at one-year follow-up. A glomerular filtration rate > 60 ml/min (OR 0.87, CI 95% 0.74-0.96, p=0.021) and mean aortic annulus perimeter (OR 0.89, CI 95% 0.80-0.98, p=0.029) were independent predictors of a PD < 5%. Arterial hypertension (OR 7.00, CI 95% 1.31-37.40, p=0.023), baseline right bundle branch block (OR 10.2, CI 95% 1.21-18.45, p=0.033), and the EUROSCORE II (OR 1.05, CI 95% 1.01-1.10, p=0.044) were predictors of PD > 80%. Baseline left bundle branch block, implantation depth and aortic valve calcium score were not predictors of PD.

Conclusion

Predictors of PD after TAVR may influence PM implantation, as well as device selection and programming. P with a higher aortic annulus perimeter and preserved kidney function may undergo a more expectant management, as PD rates are low after 1 year follow-up.

Permanent pacemaker implantation after Alcoholic Septal Ablation: long-term outcomes

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete heart block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear.

Objectives

This study aims to evaluate the long-term pacemaker dependency in patients with PPM after ASA and to assess the long-term impact of PPM in these patients.

Methods

In a tertiary center, patients who underwent ASA were retrospectively analyzed. Patients with previous PPM or implantable cardio-defibrillator were excluded. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and outcomes. In the group who implanted PPM, the long-term pacing rates were evaluated.

Results

Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding co-morbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). In the PPM group, the mean pacing rates at 1 month, 1 year and 2 years were 66.6±38.0, 50.4±44.1 and 50.8±42.5, respectively, with 2 patients (12.5%) having 1-5% pacing and none having pacing <1% at 2 years. In the group without PPM, 5 patients (6.2%) required posteriorly PPM implantation during the follow-up. There were no statistically significant differences in the two groups regarding in-hospital mortality, 1 year mortality or 1 year re-hospitalization. Despite a lower mean follow-up period in the PPM group (2.3±1.5 years versus 3.5±2.2 years, p0.05), there were no differences in the groups regarding all-cause mortality, cardiac cause mortality and cardiac cause re-hospitalization, with a statistical tendency to a lower all cause re-hospitalization in the PPM group (19% versus 43%, p0.07).

Conclusions

The registered pacing rates shows that all devices were adequately implanted. The long-term impact analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to reduce all cause re-hospitalizations.

Long-term follow-up of percutaneous balloon mitral valvuloplasty for mitral stenosis: an old but needed player

Funding Acknowledgements

Type of funding sources: None.

Background

In the era of innovative transcatheter valve interventions, percutaneous balloon mitral valvuloplasty (PBMV) remains the primary treatment option in anatomic suitable patients. 

Purpose

This study aimed to evaluate longterm follow-up (FU) of PBMV and to determine predictors of MACE. 

Methods

Between 1991 and June 2021, 202 consecutive patients underwent PBMV in a single tertiary centre. Clinical data, echocardiographic parameters, and MACE (cardiovascular mortality, need for percutaneous or surgical mitral reintervention and hospitalization for heart failure) were analysed. Predictors of MACE were determined by Cox regression analysis. 

Results

Mean age was 47.3 ± 13.6 years, 89.6% female, 47.3% patients presenting atrial fibrillation. Mean Wilkins score was 7.6 ± 1.4, 51.5% had mild or moderate mitral regurgitation and mean pulmonary artery systolic pressure (PASP) of 46.7 ± 17.1 mmHg. Mean pre MVA and mean mitral valve (MV) gradient were 1.1 ± 0.2 cm2 and 10.8 ± 5.6 mmHg, respectively.  Successful PMBV was achieved in 89.1%. 

During a mean FU of 12.0 ± 8.8 years, there were 25 deaths (12.4%) and 33.3% needed MV reintervention (6.5% underwent PBMV and 29.7% needed MV surgery). At univariate analysis, previous MV intervention [HR = 1.95 (1.02–3.72), p < 0.05],  Wilkins score [HR = 1.22 (1.01–1.47), p < 0.05],  pre mean MV gradient≥8 [HR = 0.62 (0.38–1.00), p < 0.05],  mean MV gradient after procedure [HR = 1.37 (1.19–1.58), p < 0.05] and PASP >45 mmHg [HR = 3.29 (1.13–9.55), p < 0.05] were predictors of MV reintervention. At multivariate analysis, pre mean MV gradient≥8 [HR = 0.17 (0.037–0.81), p < 0.05] and mean MV gradient after procedure were independent predictors of MV reintervention [HR = 1.74 (1.21–2.49), p < 0.05]. Wilkins score [HR = 1.29 (1.06–1.57), p < 0.05] and mean MV gradient after procedure [HR = 1.41 (1-21–1.63), p < 0.05] were independent predictors of MACE. Cumulative event-free survival at 10 and 20 years were 72.0 and 46.0%, respectively. 

Conclusions

PBMV remains a reliable and efficient therapeutic option of mitral stenosis, warranting event-free survival at 10 years in most patients selected for the procedure. Mean MV gradient after procedure was independent predictor of MV reintervention and MACE during follow-up. Abstract Figure.  Abstract Figure.

Epicardial fat volume improves prediction of adverse clinical events

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recent studies have demonstrated the potential of epicardial fat volume (EFV) to predict obstructive coronary artery disease (CAD), however its impact in clinical outcomes remains elusive.

Objectives

To assess the association between EFV and demo­graphic and morphometric data, coronary atherosclerotic burden and adverse events in a population of patients (pts) referred for coronary computed tomography angiography (CTA).

­Methods: Retrospective analysis of pts without known CAD referred for coronary CTA in a single tertiary care centre. A standardized protocol for quantification of EFV, thoracic fat volume (TFV), coronary artery calcification (CAC) and coronary angiography was performed. Endpoint was composite of cardiovascular death, nonfatal myocardial infarction and urgent hospitalization leading to revascularization at 12 months.

Results

72 pts were included, 58% male, mean age 67 ± 9 years. The prevalence of hypertension, dyslipidemia and diabetes was 75%, 82% and 24%, respectively. Median EFV was 101 (68) ml and total TFV 1504 (694) ml. EFV was directly related with age (rs= 0.42, p <0.001), male sex (135 ± 50 vs 78 ± 30, p <0.001), body mass index (rs= 0.32, p= 0.008) and TFV (rs= 0.27, p= 0.025). A positive correlation with CAC (rs= 0.47, p <0.001) and a significant association with CAD (116 ± 50 vs 90 ± 37, p= 0.029) and obstructive CAD (141 ± 60 vs 97 ± 39, p= 0.031) were demonstrated. Composite endpoint was observed in 13 pts (18%). After adjusting for all considered confounders, EFV remained an independent predictor of adverse events (OR: 1.015, 95%CI: 1.003-1.027, p= 0.041). ROC analysis of EFV (AUC 0.751, p = 0.005) allowed to estimate that EFV >124 ml had a sensibility and specificity to predict clinical outcomes of 69% and 71%, respectively.

Conclusion

EFV positively relates to coronary atherosclerotic burden. This study also advocates that EFV may improve risk stratification for clinical outcomes. Larger studies are required to evaluate these results. Abstract Figure 1

Pulmonary hypertension in mitral stenosis patients submitted to percutaneous balloon mitral valvuloplasty: an innocent bystander?

Funding Acknowledgements

Type of funding sources: None.

Background

Percutaneous balloon mitral valvuloplasty (PBMV) is the cornerstone of the treatment of rheumatic mitral stenosis (MS) in suitable patients. Pulmonary hypertension (PH) is a common coexisting finding and an indication for intervention. We sought to assess the influence of PH in PBMV immediate results and in very longterm outcome.

Methods

Between 1991 and June 2021, 202 consecutive patients underwent PBMV in a single tertiary centre. Clinical data, echocardiographic parameters, and MACE (cardiovascular mortality, need for percutaneous or surgical mitral reintervention) were analysed.

Results

Mean age was 47.3 ± 13.6 years and 89.6% were women. A previous commissurotomy or PBMV was found in 10.4% and mean Wilkins score was 7.6 ± 1.4. PH, defined as pulmonary artery systolic pressure (PASP) ≥45mmHg, was present in 32.7% of patients. A successful procedure was achieved in 89.1% of total population. Mean mitral valve (MV) gradient decreased from 13.1 to 5.0 mmHg (p < 0.001) and MV area increased from 1.1 to 1.8 cm2 (p < 0.001). A significant reduction also occurred in left atrium diameter (48.8 to 46.8 mm, p < 0.001) and PASP (50.5 to 38.5 mmHg, p < 0.001). During a mean follow-up of 12.0 ± 8.8 years, 7 cardiovascular deaths occurred (3.5%) and 33.2% of patients needed MV reintervention. Baseline PH did not impact immediate success and was not related with MACE in the follow-up. However, PH persistence after PBMV was correlated with unsuccessful procedure (p = 0.023) and with the occurrence of MACE during FU (HR 3.3, CI 95% 1.1-9.6, p = 0.028 and Kaplan-Meier analysis, log-rank 0.020).

Conclusions

PBMV in patients with MS and PH is a safe and effective intervention, achieving a significant decrease in PASP after procedure. Baseline PH was not associated with success or MACE. However, PH persistence after PBMV, correlated with worse prognosis in longterm follow up. Special attention and further investigation for this subgroup is needed. Abstract Figure.

Periprocedural and short-term stroke after transcatheter aortic valve implantation – what are the outcomes and how can we predict it

Background

Stroke is a known complication after transcatheter aortic valve implantation (TAVI). Although risk factors for its occurrence are being suggested, we still don't have clear tools to predict which patients will most probably have it and how to prevent it.

Purpose

To identify possible clinical and procedural predictors of early post-TAVI stroke.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteristics, procedural information and stroke in first 30 days after TAVIwere collected.

Results

A total of 494P (56,1% female) were included, with a mean age of 82±6 years (minimum 45 and maximum 95 years- old). The majority (98,4%) had at least one cardiovascular risk factor (83,2% hypertension, 67,6% dyslipidemia, 64% excess weight, 36,8% diabetes, 11,9% smoking). Half patients had chronic kidney disease, 34,8% atrial fibrillation, 16,4% peripheral artery disease, 15,4% porcelain aorta, and 12,3% a previous stroke. The procedure was done via transfemoral access in 460P (93,1%), subclavian artery in 16P (3,2%), transcava in 10P (2%) and transaortic in 7P (1,4%). Aortic valve pre-dilation was done in 35,6% and post-dilation in 31,2%. In the first 30 days after TAVI 19P (3,8%) had a stroke (11P with a major and 8P with a minor stroke). Patients with stroke had more hypertension (100% vs 82,4%, p=0.045), higher BMI (29 vs 27, p=0.039) and more frequently porcelain aorta (36,8% vs 15,5%, p=0,014). They also tended to have more peripheral artery disease (31,6% vs 15,7%, p=0,066). There weren't other differences in baseline characteristics between the two groups. Considering the aspects related to the procedure, post-dilation was the only predictor of events (58,8% vs 32%, p=0,021). In a multivariable analysis including clinical and procedural predictors, porcelain aorta (p=0,048, OR = 2,895) and post-dilation (p=0,042, OR = 2,844) were the independent predictors. Stroke after TAVI was associated with longer hospital stay (36 vs 15days, p<0,001) and intensive care unit stay (12 vs 3 days, p<0,001), higher intra-hospital mortality (14,8% vs 3,2%, p=0,002), global 30-day mortality (12,1% vs 3,3%, p=0,0011) and cardiovascular 30-day mortality (11,5% vs 3,4%, p=0,038).

Conclusion

Periprocedural and 30-day stroke is a relatively uncommon but potentially devastating complication after TAVI. There are clinical and procedural characteristics that are associated with a higher risk and should be considered when selecting patients for treatment and strategies to prevent events.

Funding Acknowledgement

Type of funding sources: None.

Virtual fractional flow reserve derived from coronary angiography – artery and lesion specific correlations

Introduction

Virtual Fractional flow reserve (vFFR) from standard non-hyperaemic invasive coronary angiography (ICA) has emerged as a promising non-invasive test to assess hemodynamic severity of coronary artery disease (CAD).

Purpose

To investigate the difference in vFFR analysis between vessels and specific lesions.

Methods

Retrospective analysis of consecutive patients (pts) who underwent invasive functional assessment (iFA) in a tertiary center between 2019 and 2020. vFFR was calculated using dedicated software (CAAS Workstation 8.4) based on coronary angiograms of the acquired in ≥2 different projections, by operators blinded to iFA results. Diagnostic performance of vFFR was evaluated and correlated with iFA, according to coronary vessel, vessel diameter at stenosis, diameter stenosis and area stenosis at lesion. vFFR was considered positive when <0.80. FFR <0.8 and iFR/RFR <0.90 were classified as positive according to current clinical standards.

Results

106 coronary arteries of 95 pts (78% male, mean age 67.8±9.7 years) underwent vFFR evaluation. ICA indications were chronic coronary syndrome in 63% or acute coronary syndrome (non-culprit lesion) in the remaining pts. VFFR accuracy was good (AUC 0.839 (p<0.001) and Pearson's correlation coefficient 0.533 (p<0.001) when vFFR was measured in the distal vessel segment. The correlation improved when vFFR were assessed at lesion site (r=0.631, p<0.001) or up to 1cm below the stenosis (0.610, p<0.001). Binary concordance of 89% were observed in RCA and LAD (Sensibility -S 68%, Specificity-Sp 96%, False positive -FP 3.8%, False negative - FN 31%, predictive positive value-PPV 87%, predictive negative value- PNV 89%), while in the circumflex coronary artery binary concordance were of 77% (S 50%; Sp 82%; FP 18%; FN 50%; PPV 33% and PNV 90%). Correlation between vFFR and iFA was higher in vessels ≥2mm (r=0.730, p<0.001). and in lesions in the extremes of the severity spectrum (Table 1).

Conclusion

vFFR has a moderate to high linear correlation to iFA, depending on the artery and type of lesion studied. The higher correlation was found when vFFR were measured at lesion site, in non-circumflex artery stenosis, in vessels ≥2mm and in vessels with mild or severe stenosis.

Funding Acknowledgement

Type of funding sources: None.

Urgent vs non-urgent transcatheter aortic valve implantation outcomes

Background

There are limited data about the outcomes of non-elective transcatheter aortic valve implantation (TAVI), but some studies suggest that these patients have worst results.

Purpose

To compare outcomes in patients submitted to urgent versus elective TAVI.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2018 and 2020 in a tertiary center. Baseline characteristics and outcomes after the procedure were collected. Urgent TAVIwas considered when patients were not electively admitted for the procedure but required the intervention on the current admission for medical reasons and could not be sent home without a definitive procedure.

Results

A total of 208P (55,3% female) were included, with a mean age of 82±7 years. Patients submitted to urgent TAVI (57P, 27,4%) had worse baseline characteristics, with higher EuroScore risk (10,7% vs 5,4%, p<0,001), STS score (7,3% vs 4,4%, p<0,001), and natriuretic peptide B (1350 vs 728 pg/mL, p=0,021), lower left ventricle ejection fraction (44% vs 50%, p<0,001), more diabetes (49,1% vs 33,1%, p=0,033), peripheral artery disease (22,8% vs 4,6%, p<0,001) and worse accesses (21,2% vs 5%, p=0,002). In univariable analysis, urgent TAVI was associated with higher intra-hospital mortality (14% vs 4%, p=0,01), 30-days mortality (17,5% vs 4%, p=0,001) and 30-days cardiovascular mortality (17,5% vs 3,3%, p<0,001), life- threatening bleeding (17,9% vs 4%, p=0,001), acute kidney injury (16,1% vs 4,7%, p=0,007), vascular complications (16,1 vs 4%, p=0,003) and longer hospital and intensive care unit stay (30 vs 12 days, p<0,001 and 6 vs 4 days, p=0,025 respectively), but not with post-TAVI hospital stay (12 vs 10 days, p=0,37). When adjusted to the differences in baseline characteristics, in a multivariable analysis, urgent TAVI was only associated with longer hospital stay (p<0,0001). There were no differences in outcomes between groups beyond the first 30 days after the procedure, including mortality and hospital admissions.

Conclusion

Patients submitted to urgent TAVI tend to have worse short-term outcomes, but this seems to be attributable to the worse baseline characteristics of these cases instead of the urgent nature of the procedure. Even with the adjustment for baseline differences, these patients have longer global hospital stays, but they don't have latter post-TAVI discharge.

Funding Acknowledgement

Type of funding sources: None.

Transesophageal echocardiography versus intracardiac echocardiography-guided left atrial appendage occlusion: a comparative analysis

Introduction

The left atrial appendage occlusion (LAAO) procedure is a therapeutic option for stroke prevention in patients with atrial fibrillation (AF) which have contraindication to oral anticoagulants or still develop embolic events despite therapeutic anticoagulation. Transesophageal echocardiography (TEE) has been the gold standard to guide this procedure, with the intracardiac echocardiography (ICE) emerging as an alternative because of the advantage of reducing the general anesthesia burden compared to TEE.

Objectives

This study aims to compare the safety, procedure-related parameters and outcomes between TEE-guided LAAO and ICE-guided LAAO.

Methods

In a tertiary center, patients who underwent TEE-guided LAAO and ICE-guided LAAO were compared retrospectively regarding technical success, procedure-related events, procedure-related parameters (fluoroscopy time, dose of radiation and contrast volume), 45 days-transthoracic echocardiography (TTE) and 1-year outcomes (mortality, stroke and major bleeding).

Results

88 patients underwent LAAO between 2009 and 2020 (n=43 with TEE, n=45 with ICE). Baseline characteristics were similar. Success was achieved in 95.3% (n=41) and 95.6% (n=43) of the patients in the TEE and ICE groups, respectively (OR 0.95, p=0.96). Procedure-related complications (major vascular complications, perforation, device embolization) didn't show significant differences (14.0% vs 8.9%, OR 1.66, p=0.46) in the TEE and ICE groups, respectively. Fluoroscopy time was inferior in the TEE group (29.1±13.6 vs 44.1±17.4 minutes, p=0.001), while radiation dose (2761±1555 vs 3397±2118 mGy, p=0.113) and contrast volume (220.3±104.1 vs 204.0±100.9mL, p=0.469) showed no significant differences. 45 days-TTE showed no significant differences between the TEE and ICE groups regarding peri-device leaks (14.0% vs 24.4%, p=0.212), device thrombus (2.3% vs 0%, p=0.990) and iatrogenic atrial septal defects, all mild (4.7% vs 13.3%, p=0.174). 1-year outcomes showed no significant differences regarding stroke (9.3% vs 4.4%, p=0.186), major bleeding (9.3% vs 2.2%, p=0.78) and all-cause mortality (9.3% vs 11.1%, p=0.38) between the TEE and ICE groups, respectively.

Conclusions

ICE-guided LAAO is associated with similar results, procedure-related events, procedure related-parameters (fluoroscopy time being the only exception) and 1-year outcomes, compared with TEE-guided LAAO.

Funding Acknowledgement

Type of funding sources: None.

Feasibility of virtual fractional flow reserve derived from coronary angiography and its correlation with invasive functional assessment

Introduction

Invasive functional assessment (iFA) of coronary artery disease (CAD) needs expensive devices, has potential procedure-related complications and is still underutilized. Virtual Fractional Flow Reserve (vFFR) derived from invasive coronary angiography (ICA) has the potential to overcome these limitations.

Purpose

To investigate the feasibility of vFFR analysis and its correlation with iFA (iFR, RFR or FFR).

Methods

Retrospective analysis of consecutive patients (pts) who underwent iFA in a tertiary center between 2019 and 2020. vFFR was calculated using a dedicated software (CAAS Workstation 8.4) based on standard non-hyperaemic coronary angiograms acquired in ≥2 different projections, by operators blinded to iFA results. Diagnostic performance and accuracy of vFFR were evaluated. vFFR was considered positive when <0.80. FFR <0.8 and iFR/RFR <0.90 were classified as positive according to current clinical standards.

Results

Out of 113 coronary arteries of 102 pts, vFFR was successfully analysed in 106 (94%). Reasons for vFFR analysis failure were: vessel projection overlap (48%), <2 angiographic projections (28%) and table movement while acquisition (24%). From 106 coronary arteries of 95 pts with analysable vFFR (78% male, mean age 67.8±9.7 years), 90 (85%) showed agreement with the respective iFA result. The vFFR predicted which lesions were physiologically significant and which were not with accuracy, sensitivity, specificity, positive and negative predictive values of 73%, 73%, 83%, 53%, and 92% respectively. The mean difference between vFFR and iFA were −0.0484±0.096 and Pearson's correlation coefficient was 0.533 (p<0.001). The ROC area under the curve was 0.839 (0.751–0.928, p<0.001).

Conclusion

FFR were feasible in 94% of cases analysed retrospectively. As compared to gold-standard iFA, vFFR had an overall moderate accuracy in detecting ischemia-producing lesions and a negative predictive value >90%. vFFR has the potential to substantially simplify physiological coronary lesion assessment and thus improve its current uptake.

Funding Acknowledgement

Type of funding sources: None. Bland-Altman plot between vFFR and IFA

Real world experience with coronary sinus reducer implantation for the treatment of refractory angina: a single-centre experience

Background

Coronary sinus Reducer device (CSF) implantation is a novel therapeutic option to relieve symptoms in patients with refractory angina (RA). There is limited real-world data describing its use outside of clinical trials.

Aim

To assess the safety and efficacy of this procedure in a real-world setting.

Methods

This is a report of a single centre prospective registry of consecutive patients with RA (CCS II-IV) deemed unsuitable for revascularization. Between May 2017 and August 2019, 17 patients were referred to CSF implantation. Baseline and follow-up evaluation consisted of clinical assessment, including completion of the short version of the Seattle Angina Questionnaire (SAQ-7) and CCS class evaluation and objective evaluation by transthoracic echocardiography and cardiopulmonary exercise test (CPET).

Results

A total of 13 patients (70,6±6,5 years, 76,9% male) underwent CSF implantation with a procedural success of 84.6%. No cases of periprocedural serious adverse events were reported. At 12-month follow-up, any reduction in CCS Class was achieved in 72.7% of cases, with 27.2% reducing 2 CCS classes. Baseline CCS score was reduced from 2.8±0.4 to 1.7±0.8 (p=0.009). Quality of life (QoL) was significantly improved as assessed by the improvement seen in all items of SAQ-7 (p<0.017 for all). CPET duration was significantly increased (p=0.034), but no change was noted in the remainder CPET variables. During follow-up, 3 patients suffered myocardial infarction, resulting in 1 death.

Conclusion

CSF implantation in patients with RA was safe and led to a significant reduction of the angina burden and improvement of QoL at 12-month follow-up.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of percentage of ventricular pacing in patients requiring pacemaker implantation after transcatheter aortic valve replacement

Background

Despite the continuous developments of transcatheter aortic valve implantation (TAVI), around 15% of the patients (P) who undergo this procedure require permanent pacemaker (PM). Right ventricular pacing (RVP), particularly with a cumulative percentage of ventricular pacing (CVp) above 40%, has been associated with detrimental effects on ventricular function and an increased risk of cardiovascular events in non-TAVI patients.

Aim

To evaluate the long-term prognostic significance of RVP, regarding overall mortality and the combined endpoint of overall mortality/heart failure hospitalization in P requiring a PM after TAVI.

Methods

We retrospectively examined P who underwent TAVI with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. CVp was determined from stored PM data. P with previous PM were excluded. Post-TAVI PM implantation was defined as a device implantation during hospital stay or during the first month after discharge.

Results

474P, 57% male, mean age 81.7±6.5 years with a mean left ventricular ejection fraction of 51.5±14.6% were analysed. Mean follow-up was 18.7 months. Mean STS score and mean Euroscore II were, respectively, 6.89% and 5.76%. Mean gradient was 51.67 mmHg and mean aortic valve area 0.71 cm2. After TAVI, 104P (21.9%) required PM implantation, with a mean CVp of 65.3±43.4%. Post-TAVI PM was not associated with a worse outcome - overall mortality: HR 1.13, 95% CI 0.72 – 1.78, p=0.57; combined mortality/heart failure hospitalization: HR 1.22, 95% CI 0.87 – 1.70, p=0.24. The follow-up Kaplan-Meier curves according to the need for PM post-TAVI were similar: log rank p=0.24. A CVp cut-off of 40% was not associated with any of the study endpoints - overall mortality: HR 1.72, 95% CI 0.38–7.86, p=0.48; combined mortality/heart failure hospitalization: HR 1.32, 95% CI 0.45–3.91, p=0.61. Also, a CVp cut-off of 40% did not provide an accurate risk stratification as survival free of events was similar between these P and those below this cut-off (log rank p=0.11) and in comparison, with P without PM (log rank p=0.65).

Conclusions

In P submitted to TAVI with a self-expanding valve, the need for PM implantation is common, but not associated with increased risk of total mortality or heart failure hospitalization during a 18 months follow-up period. A CVp cut-off of 40% showed poor discriminative ability regarding long-term events in this population.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular remodelling patterns after MitraClip implantation: Do ischemic patients have the same benefit?

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Percutaneous mitral valve repair has shown to prevent and even reverse adverse LV remodelling in most patients with moderate to severe mitral regurgitation (MR). This effect is, however, highly variable and may differ according to the MR etiology.

Objectives

 The aim of the present study is to evaluate cardiac remodelling patterns and clinical outcomes after MitraClip implantation (MI) in ischemic and non-ischemic patients (P).

Methods

 A standardized registry was prospectively performed between 2013 and 2019 for all P who underwent MitraClip insertion in a single terciary care centre. Transthoracic echocardiographic information was assessed at baseline and 1, 6, 12 and 18 months after MI. Student’s t-test was used to assess the procedure’s effect on several variables. Clinical outcomes were compared with the use of Fisher’s exact test or the chi-square test, as appropriate.

Results

 46 P, 61% male, mean age 65 ± 14 years. 39% had ischemic MR. Dyslipidemia was more frequent in ischemic P (52% versus 93%, p= 0.002) as well as history of smoking (32% versus 67%, p= 0.022). Atrial fibrillation was significantly associated with non-ischemic etiology (75% versus 44%, p= 0.036). MI success rate was 87% (proper placement and reduction in MR to grade 2 or less), with an average of 1.5 clips. Considering the 37 P that completed 18 months of follow-up (FU), the echocardiographic parameters at baseline were: left ventricular ejection fraction (LVEF) 36 ± 12%, LV end-diastolic dimeter (LVEDD) 68.2 ± 10.2mm, LV end-systolic diameter (LVESD) 52.2 ± 13.5mm and left atrial diameter (LAD) 53.1 ± 6.7mm; there were no significant differences between groups. After MI, a compelling difference in LVEDD was noticeable early in the first month, with significant lower dimensions in non-ischemic P (66.6 ± 11.4 versus 72.8 ± 5.4, p= 0.039). Sustained differences in LVEDD were consistent at 6, 12 and 18 months (62.4 ± 12.3 versus 73.5 ± 7.4, p= 0.025). There was also a reduction in LVESD that became apparent in the sixth month (45.5 ± 15.1 versus 55.3 ± 9.8mm, p= 0.047) and that was sustained after 18 months from MI (45.4 ± 11.7 versus 58.3± 8.9, p= 0.012). No significant differences in LVEF or LAD were noticed over time. Regarding clinical outcomes at 18 months, overall mortality (M) was 24% (9P) and 51% (19P) died or were hospitalized due to heart failure (MH).  No difference was found between groups: M (p= 0.119), MH (p= 0.091).

Conclusion

 This study reports better LV reshape effects after MI in P with non-ischemic etiology, with sustained improvement over time. However, no differences regarding mortality or hospitalization due to HF were apparent at the 18-month FU. Larger long-term studies are required to evaluate these results.

Abstract Figure. LV remodelling pattern

Prognostic impact of suspected cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)>12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull's eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2±5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57±15% and 26.6% presented EF<50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS >1 was identified in 22 P (23.4%). An EF/GLS ratio >4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4±25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p=0.002) and MACE (48.7% vs 22.2%, p=0.01). RALS>1 correlated also with all-cause mortality (31.8% vs. 12.5%, p=0.04) and with new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p=0.05). P with GLS>−14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p=0.003) and MACE (p=0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR=4.49, p=0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Funding Acknowledgement

Type of funding source: None

P1136Is there a negative impact of permanent pacemaker implantation in long-term outcomes after transcatheter aortic valve implantation?

Introduction

Transcatheter aortic valve implantation (TAVI) is an established treatment in patients (P) with aortic stenosis. Despite the continuous developments of this procedure, high-grade conduction disturbances requiring permanent pacemaker (PPM) implantation is still a major and common complication of TAVI. Furthermore, long-term chronic right ventricular pacing has been associated with negative effects on ventricular function and heart failure (HF).

Aim

  to evaluate the long-term impact of PPM after TAVI focusing on mortality and HF hospitalization.

Methods

 We retrospectively examined P who underwent TAVI with a self-expanding valve from 2009 to 2018 at our institution. All P had pre-procedural clinical evaluation, including ECG, cardiac computed tomographic angiography and transthoracic echocardiography. P with previous PPM were excluded.

Results

 265P (57% male, mean age 81.4 years, 20% with left ventricular ejection fraction <40%) were analysed. Mean STS score and mean Euroscore II were 6.33% and 7.07%, respectively. Mean transvalvular gradient was 52.78 mmHg and mean aortic valve area 0.67 cm2. Forty-seven P (17%) underwent PPM implantation during the first 30 days after TAVI. P requiring PPM had higher prevalence of diabetes mellitus, chronic renal disease, atrial fibrillation and right bundle branch block. During a mean follow-up of 20.3 months, post-TAVI PPM was associated with similar mortality rate (29.8% vs. 25.6%, HR 1.28, 95% CI 0.72-2.29, p = 0.42) and similar cardiovascular mortality (9.8% vs. 6.4%, HR 0.72, 95% CI 0.21-2.4, p = 0.59) compared to P without PPM. There were no significant differences in HF hospitalization (4.9% vs. 2.4%, p = 0.47). Kaplan-Meier curves of total mortality and cardiovascular mortality according to the need for PPM post-TAVI were similar. 

Conclusions

 In P submitted to TAVI, PPM implantation is a relatively common finding, not associated with higher risk of total mortality, cardiovascular mortality or HF hospitalization in a long-term follow-up.

1226 Prognostic impact of concomitant cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)>12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull’s eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2 ± 5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57 ± 15% and 26.6% presented EF < 50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS > 1 was identified in 22 P (23.4%). An EF/GLS ratio > 4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4 ± 25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p = 0.002), new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p = 0.05) and MACE (48.7% vs 22.2%, p = 0.01). All-cause mortality was also higher in P with RALS (31.8% vs. 12.5%, p = 0.04). P with GLS>-14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p = 0.003) and MACE (p = 0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR = 4.49, p = 0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Abstract 1226 Figure. Kaplan–Meier curves and ASPB

P1256 Salvage mitraclip implantation for postmyocardial infarction mitral regurgitation: 2 case reports

Introduction

Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR.

Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms.

Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic.

Conclusion

Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.

P1330 A rare coronary anomaly in the adult: an extremely large arteriovenous fistula

Introduction

Arteriovenous coronary fistulae are a rare coronary anomaly, which can be congenital or acquired. They can be diagnosed in older adults with heart failure symptoms, atherosclerosis or cardiac arrhythmias.

The authors report the case of an adult patient with an extremely large coronary artery fistula of the left main coronary artery (LMCA).

Clinical case

A 57-year-old caucasian male with known background of arterial hypertension, obesity, pulmonary emphysema and bronchiectasis presented to a Cardiology outpatient appointment with symptoms of congestive heart failure and new-onset atrial fibrillation.

A transthoracic echocardiogram was performed which revealed a possible coronary fistula with multiple rosary-like folds between the LMCA and the coronary sinus. Other echocardiographic findings were left ventricular and biatrial enlargement with biventricular systolic dysfunction (left ventricular ejection fraction 44%) and a GLS of -7.8% as well as mild pericardial effusion.

The patient was referred to our hospital for further diagnostic work-up and clarification of the coronary anatomy.

A cardiac computed tomography (CT) scan was done which showed ectasia and calcification of the LMCA, left anterior descending and circumflex arteries and a large caliber tortuous coronary fistula between the LMCA, the right atrium and the coronary sinus comprised of multiple folds covering from the pulmonary artery to the left atrium.

A coronary artery angiography was also performed, which confirmed the detailed anatomy and dimensions of the coronary fistula.

Follow-up magnetic resonance imaging revealed dilation of both left and right cardiac chambers with no significant shunt (QP/QS = 1)

The patient was started on heart failure medical therapy and was referred to the Cardiac Surgery Department and is currently asymptomatic awaiting for surgical correction of the coronary fistula.

Abstract P1330 Figure. CT scan: large caliber coronary fistula

P1787 Pharmacologic stress test: still an important prognostic factor? a follow-up study

Introduction

Dobutamine stress echocardiography (DSE) is an established exam for evaluation of extent and severity of coronary artery disease.

Purpose

To analyse the results and complications of DSE and identify prognostic predictors in patients (P) who underwent DSE for myocardial ischemia detection.

Methods

220P who underwent consecutive DSE from 2013 to 2017. P with significant valvular disease were excluded. Clinical data, echocardiographic parameters and data from follow up (FU) regarding all-cause mortality and MACEs were analysed. Mean age 64.8 ± 12.0 years(Y), 143 men (65%).

Results

88P (40%) had positive, 102 had negative and 30 had inconclusive DSE; complications rate of 15%. Prevalence of hypertension, diabetes mellitus (DM), dyslipidemia, prior MI, percutaneous coronary interventionc (PCI), coronary arterial bypass graft (CABG) and HF was 82.7%, 42.3%, 67.7%, 35.9%, 31.8%, 10.9% and 9.5%, respectively. Mean left ventricular endsystolic (LVSD) and enddiastolic dimensions were 33.7 ± 8.9 and 52.8 ± 7.1 mm. Mean resting wall motion score index (rWMSI) and peak (pWMSI) were 1.16 ± 0.28 and 1.24 ± 0.34. Mean resting GLS (rGLS) and peak GLS (pGLS) were -16.3 ± 4.3 and -16.6 ± 4.3. Mean no. of ischemic segments was 1.7 ± 2.4 and 16.8% had ischemia >3 segments. There was ischemia in left anterior descending (LAD) coronary in 53P and in circumflex and right coronary territories in 18 and 68P. 22.6% had more than one ischemic territory. 43P (49.4%) underwent intervention, 38 with PCI and 5 with CABG. During a mean FU of 38.8 ± 16.8 months, 47 MACEs were observed, including 32 deaths (14.5%). Positive DSE (p = 0.012), no. of ischemic segments (p = 0.019), ischemia in the LAD (p = 0.003), rGLS (p = 0.038) and pGLS (p = 0.038) were related to the occurrence of MACEs. In Cox regression analysis, age (p = 0.005), DM (p = 0.005), HF (p = 0.006), prior CABG (p = 0.015), LVSD (p = 0.026), rWMSI (p = 0.029), pWMSI (p = 0.013) and pGLS (p = 0.038) were associated with increased all-cause mortality. Kaplan–Meier survival analysis showed that survival was significantly worse for ischemia > 3 segments (log rank 0.005), ischemia of more than one territory (log rank 0.025) and pWMSI >1.5 (log rank < 0.0005). With multivariate Cox regression analysis, age >65Y (HR 4.22, p = 0.004), DM (HR 2.49,p = 0.038) and pWMSI > 1.5 (HR 9.73,p = 0.007) were independently associated with all-cause mortality.

Conclusion

In patients who underwent DSE there were some baseline and DSE-related independent predictors of long-term prognosis: age, DM and peak WMSI.

Abstract P1787 Figure. Kaplan–Meier curves

P198 Long-term outcomes after mitraclip implantation

Background

Mitraclip implantation (MI) is a well-established option for patients (P) with severe mitral regurgitation (MR) noneligible to surgery. Its impact on long term prognosis is being addressed by several recent studies.

Purpose

To identify predictors of morbidity and mortality in P undergoing MI and evaluate if the COAPT, Everest and MITRAFR exclusion criteria (EC) had any impact on the outcome of our population.

Methods

prospective study of P who underwent MI between 2013 and 2018 in one medical center. EC: COAPT: LVEF < 20%, LV end-diastolic diameter > 70mm or pulmonary artery systolic pressure > 70mmHg; Everest: LVEF < 25% or LV end-systolic diameter (LVESD)>55mm; MITRA-FR: LVEF < 15% or >40% or primary MR. An univariate analysis was performed followed by a multivariate Cox analysis to evaluate overall mortality (M), overall mortality/ heart failure hospitalization (MH) and mortality in the first year post-MI(M1). Survival analysis using Kaplan-Meier plots. p < 0.05 were considered significant.

Results

40P, 60% male, mean age 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months. 67.5% presented with MR grade IV and 75% had functional MR. Successful implantation in 97.5%, with 55% presenting mild MR post-procedure. Overall mortality was 30% (12P), mostly due to cardiovascular causes, with 9P dying in the first year (30%). There was no difference between pts with functional and primary MR: M- 33%vs20% (p = 0.6); MH– 53.3%vs30% (p = 0.5). P who met the COAPT exclusion criteria (N-22) presented an inferior 1Ysurvival (64.5%vs86.7%, p = 0.046). The overall outcome was comparable between P who matched and didn"t match Everest and MITRA-FR exclusion criteria. Basal BNP value (p = 0.037), mean preprocedural MAGGIC score (p = 0.040) and EROA (p = 0.039) were associated to M1. Multivariate Cox analysis revealed that basal BNP was an independent predictor of M (p = 0.017), whereas a higher distance in the pre-procedural 6 minute walk test (p = 0.008) and the "reduction in the MR severity and PASP" (p = 0.008) presented a protective effect. LVESD > 55mm was an independent predictor of MH (p = 0.017), but MR of grade 2 or less after procedure was protective (p = 0.006).

Conclusion

There was no M difference between P with functional and primary MR. P with COAPT exclusion criteria had worse 1Ysurvival. A higher distance in 6MWT and a reduction in MR severity and PASP were protective. An LVESD > 55 mm had a worse prognosis. Careful P selection may be crucial to improve MI"s results

Abstract P198 Figure. Kaplan-Meier Plots

P209 Mitraclip - experience of a portuguese tertiary care center - mid-term review of results

Background

Mitral regurgitation (MR) is a marker of bad prognosis in heart failure (HF) patients (pts). Mitraclip implantation (MI) leads to a clinical improvement.

Purpose

To characterize the adult population submitted to MI and evaluate its mid-term results.

Methods

Prospective analysis of 40 pts with moderate to severe MR (grades III-IV) submitted to MI between 2013 and 2018. Paired sample t-test to assess the procedure’s effect on several variables. P-values < 0.05 were considered significant.

Results

40pts, 60% male, with a mean age of 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months (M), of which 67.5% presented with grade IV MR (mean regurgitant volume - 43.5 ± 29 ml; mean EROA - 34.8 ± 13 mm2 ) and 75% with functional MR. Mean LVEF of 35%±10.3, with 55% presenting a LVEF < 35%. Mean Euroscore II of 6.0 ± 7. 27.5% had already undergone a previous cardiac surgery, in most cases CABG (63.6%). 30% had already suffered an acute coronary syndrome and 62.5% had atrial fibrillation. Mean pre-procedural peak VO2 of 14.5mL/kg/min and mean distance in the 6 minute walk test (6MWT) of 321 ± 100m. The device implantation was successful in 39 pts with a device success rate of 85% (successful implantation and reduction in MR to grade 2 or less), with 55% of pts presenting mild MR before discharge. There were immediate complications related to the procedure in 17.5% of pts, with 4pts experiencing tendinous cord rupture and 2pts leaflet tear. There were no cases of pericardial tamponade or embolic complications. Follow-up mortality of 30% (12pts), 9 deaths (D) due to cardiovascular events. 9D in the first-year post-procedure (1D within the first M), with 1 pt referred to cardiac surgery due leaflet tear and 1pt to heart transplantation. Successful MIwas associated with an improvement in NYHA functional class (3.0vs2.0, p < 0.001) and in several echocardiographic variables in the first 6M following the procedure: left ventricular (LV) end diastolic volume: 194.5mLvs168.4mL, p = 0.012; LV end systolic volume: 132.6mLvs106.7mL, p = 0.008; systolic pulmonary artery pressure: 50.5mmHgvs40.8mmHg, p = 0.013. It was also associated with a significant improvement in both 6M peak VO2 (14.4vs15.5, p = 0.028) and 6MWT distance (321.3mvs374m, p < 0.001).

Conclusion

MI is a safe procedure with a low rate of periprocedural complications. It’s associated with a functional class improvement and a significant reverse left ventricular remodeling.

P3633Should we continue to routinely revascularize patients during valve surgery in optimal medical therapy era?

Background

Optimal management of stable obstructive coronary artery disease (CAD) in patients (pts) undergoing heart valve surgery remains controversial. The aim of the present study is to evaluate the effective prognostic role of CABG in pts undergoing valve surgery who had concomitant CAD.

Methods

We conducted a retrospective multicenter survival analysis using multivariable Cox models and Kaplan-Meier curves of consecutive pts undergoing valve surgery with or without concomitant CABG between January 2015 and February 2017.

Results

From 1196 consecutive pts undergoing valvular surgery in 3 portuguese centers, 257 (21.5%) were found to have obstructive CAD (55.6% male, mean age 74±8 y.o., mean follow-up time 16±8 months, aortic valve disease 78.8%). No coronary revascularization (R) was attempted in 177 pts, complete R was achieved in 40 and R was anatomically incomplete in the remaining 40 pts. Age (75 vs 77.3 y.o.; p=0.202), multivessel disease (46.3% vs 53.8%, p=0.270), aortic valve disease (91.0% vs 92.5%, p=0.683), left ventricular ejection fraction <40% (11.8% vs 19.4%, p=0.272) were comparable between nonrevascularized and revascularized pts; SYNTAX score was low and also similar in both groups (7±12 vs 7±5, p=0.856). Left main disease (8.5% vs 17.5%, p=0.034) and EUROSCORE IIrisk score (2.3±2 vs 3.2±2, p=0.011) was higher for those with any revascularization. Non-revascularized pts had significantly lower all-cause mortality at follow up than those with any R (10.2% vs 21.2%, p=0.016). However, both in-hospital (4% vs 7.5%, p=0.230) and cardiovascular mortality (6.9% vs 7.1%, p=1.00) were similar. In a multivariate analysis, independent predictors for all-cause mortality were: any surgical R (HR 4.52, CI95% 2.09–9.78), baseline atrial fibrillation (HR 2.51, CI95% 1.07–5.90), left main disease (HR 3.153, CI95% 1.26–7.90) and peripheral artery disease (HR 2.95, CI95% 1.036–8.421). All-cause mortality for pts with obstructive CAD was higher than in pts with no CAD (13.6% vs 6.2, p<0.001). Interestingly, however, after multivariable adjustment, complete R was not found to be protective as compared to no R (HR 0.79, IC 0.31–2.06, p=0.633)

Kaplan-Meier Plots

Conclusion

Significant CAD is associated with worse outcomes in pts undergoing valve surgery. In this study, standard angiographically-guided R was not associated with improved results. Randomized controlled trials are needed to further assess risk stratification and the role of coronary R of stable CAD in this setting.

P3628Contemporary coronary artery disease prevalence in a valvular heart disease population undergoing surgery

Background

Patients undergoing heart valve surgery are routinely evaluated for the presence of Coronary Artery Disease (CAD), with the standard practice of combining valve intervention with a revascularization procedure, notably Coronary Artery Bypass Graft (CABG). Older studies suggest rates as high as 50% prevalence of CAD in this population. However, CAD prevalence, its treatment and prognostic implication has been questioned recently.

Objectives

The goal of this study is to evaluate the baseline characteristics, prevalence of CAD and treatment strategies in a contemporary population with valvular heart disease (VHD) referred for valve surgery.

Methods

In a national multicentre registry, consecutive patients, from Jan 2015 to Dec 2016, with a formal indication for heart valve surgery referred for a pre-op routine coronary angiogram were systematically analysed. Baseline characteristics, valve pathology and CAD prevalence and patterns were determined. Obstructive CAD was defined as luminal angiographic stenosis ≥70% (≥50% for left main artery). The prognostic impact of the different valve disease and CAD treatment strategies were assessed.

Results

1175 patients (mean age 72.5±10.1; male 49.2%) fulfilled the clinical or echocardiographic indication for valve surgery by European guidelines. Valvular disease prevalence was: aortic stenosis (66.7%), aortic regurgitation (6.6%), mitral stenosis (6%), mitral regurgitation (19.2%), tricuspid regurgitation (7.5%). Mean follow-up time was 29.06±18.46 months. Prevalence of comorbidities was: Diabetes Mellitus (DM) 26%, chronic obstructive pulmonary disease (COPD) 5.7% and chronic kidney disease (CKD) 23.4%. Mean Euroscore II was 2.6%. Obstructive CAD was present in 27.3% patients. Mean Syntax score was 10.2 (<22 in 88%, 23–32 in 10.2% and >33 in 1.8%). Left main artery and 3-vessel disease were found in 13.1% and 11.8% of patients with CAD, respectively. Valvular surgery was ultimately performed in 80.3%. In patients with CAD, 57.3% were revascularized. All-cause mortality rate during follow-up was 12.9%, with 7.8% from cardiovascular causes. In univariate analysis DM, COPD, CKD, NYHA class, obstructive CAD and no surgery (p<0.05) were associate with mortality on follow up. In multivariate analysis obstructive CAD (OR 2.36, 95% CI 1.53–3.65, p<0.01) and no surgery (OR 6.05, 95% CI 3.95–9.30, p<0.01) persisted as independent all-cause mortality predictors.

Conclusion

In a contemporary cohort of patients with VHD and surgical indication, CAD prevalence is lower (27.3%) than described in literature. Mortality rates were higher in patients with obstructive CAD, worse NYHA functional class and in those who never underwent surgery.

Dermal exposure to weathered MC252 crude oil results in echocardiographically identifiable systolic myocardial dysfunction in double-crested cormorants (Phalacrocorax auritus)

During the Deepwater Horizon Natural Resource Damage Assessment, gross morphologic cardiac abnormalities, including softer, more distensible musculature, were noted upon gross necropsy in hearts from laughing gulls and double-crested cormorants exposed to weathered MC252 crude oil. A species specific, echocardiographic technique was developed for antemortem evaluation of function that was used to evaluate and better characterize cardiac dysfunction. Control (n=12) and treated (n=13) cormorant groups of similar sex-ratio and ages were dermally treated with approximately 13ml of water or weathered MC252 crude oil, respectively, every 3 days for 6 dosages. This resulted in a low to moderate external exposure. Upon visualization and clinical assessment of the hearts of all test subjects, comprehensive diagnostic cardiographic measurements were taken twice, prior to oil application and after a 21day dermal oil exposure. Oil-treated birds showed a decrease in cardiac systolic function, as characterized by an increased left ventricular internal dimension-systole and left ventricular stroke volume as well as concurrent decreased left ventricular ejection fraction and left ventricular fractional shortening when compared to both control birds' and the treated birds' time zero values. These changes are indicative of a possible dilative cardiomyopathy induced by oil exposure, although further elucidation of possible collagen damage is recommended. Arrhythmias including tachycardia in two treated birds and bradycardia in all treated birds were documented, indicating further clinically significant abnormalities induced by MC252 oil that warrant further investigation. A statistically significant increase in free calcium concentration, important to muscular and neurologic function in treated birds was also noted. This study documents that weathered MC252 oil caused clinically significant cardiac dysfunction that could result in mortality and decrease recruitment.

Reprint of: CYP1A protein expression and catalytic activity in double-crested cormorants experimentally exposed to Deepwater Horizon Mississippi Canyon 252 oil

Double-crested cormorants (Phalacrocorax auritus, DCCO) were orally exposed to Deepwater Horizon Mississippi Canyon 252 (DWH) oil to investigate oil-induced toxicological impacts. Livers were collected for multiple analyses including cytochrome P4501A (CYP1A) enzymatic activity and protein expression. CYP1A enzymatic activity was measured by alkoxyresorufin O-dealkylase (AROD) assays. Activities specific to the O-dealkylation of four resorufin ethers are reported: benzyloxyresorufin O-debenzylase (BROD), ethoxyresorufin O-deethylase (EROD), methoxyresorufin O-demethylase (MROD), and pentoxyresorufin O-depentylase (PROD). CYP1A protein expression was measured by western blot analysis with a CYP1A1 mouse monoclonal antibody. In study 1, hepatic BROD, EROD, and PROD activities were significantly induced in DCCO orally exposed to 20ml/kg body weight (bw) oil as a single dose or daily for 5 days. Western blot analysis revealed hepatic CYP1A protein induction in both treatment groups. In study 2 (5ml/kg bw oil or 10ml/kg bw oil, 21day exposure), all four hepatic ARODs were significantly induced. Western blots showed an increase in hepatic CYP1A expression in both treatment groups with a significant induction in birds exposed to 10ml/kg oil. Significant correlations were detected among all 4 AROD activities in both studies and between CYP1A protein expression and both MROD and PROD activities in study 2. EROD activity was highest for both treatment groups in both studies while BROD activity had the greatest fold-induction. While PROD activity values were consistently low, the fold-induction was high, usually 2nd highest to BROD activity. The observed induced AROD profiles detected in the present studies suggest both CYP1A4/1A5 DCCO isoforms are being induced after MC252 oil ingestion. A review of the literature on avian CYP1A AROD activity levels and protein expression after exposure to CYP1A inducers highlights the need for species-specific studies to accurately evaluate avian exposure to oil.

Low level exposure to crude oil impacts avian flight performance: The Deepwater Horizon oil spill effect on migratory birds

In 2010, the Deepwater Horizon oil spill released 134 million gallons of crude oil into the Gulf of Mexico making it the largest oil spill in US history. The three month oil spill left tens of thousands of birds dead; however, the fate of tens of thousands of other migratory birds that were affected but did not immediately die is unknown. We used the homing pigeon as a surrogate species for migratory birds to investigate the effects of a single external oiling event on the flight performance of birds. Data from GPS data loggers revealed that lightly oiled pigeons took significantly longer to return home and spent more time stopped en route than unoiled birds. This suggests that migratory birds affected by the oil spill could have experienced long term flight impairment and delayed arrival to breeding, wintering, or crucial stopover sites and subsequently suffered reductions in survival and reproductive success.

Organ weights and histopathology of double-crested cormorants (Phalacrocorax auritus) dosed orally or dermally with artificially weathered Mississippi Canyon 252 crude oil

A series of toxicity tests were conducted to assess the effects of low to moderate exposure to artificially weathered Deepwater Horizon Mississippi Canyon 252 crude oil on representative avian species as part of the Natural Resource Damage Assessment. The present report summarizes effects of oral exposure (n=26) of double-crested cormorants (DCCO; Phalacrocorax auritus) to 5 or 10ml oil kg^-1 day^-1 for up to 21 days or dermal application (n=25) of 13ml oil to breast and back feathers every three days totaling 6 applications in 21 days on organ weights and histopathology. Absolute and relative kidney and liver weights were increased in birds exposed to oil. Additionally, gross and/or histopathologic lesions occurred in the kidney, heart, pancreas and thyroid. Clinically significant renal lesions in the orally dosed birds included squamous metaplasia and increased epithelial hypertrophy of the collecting ducts and renal tubules and mineralization in comparison to controls. Gross cardiac lesions including thin walls and flaccid musculature were documented in both orally and dermally dosed birds and myocardial fibrosis was found in low numbers of dermally dosed birds only. Cytoplasmic vacuolation of the exocrine pancreas was noted in orally dosed birds only. Thyroid follicular hyperplasia was increased in dermally dosed birds only possibly due to increased metabolism required to compensate damaged feather integrity and thermoregulate. Gastrointestinal ulceration was found in orally dosed birds only. There were no significant hepatic histopathologic lesions induced by either exposure route. Therefore, hepatic histopathology is likely not a good representation of oil-induced damage. Taken together, the results suggest that oral or dermal exposure of DCCOs to artificially weathered MC252 crude oil induced organ damage that could potentially affect survivability.

Reprint of: Overview of avian toxicity studies for the Deepwater Horizon Natural Resource Damage Assessment

The Oil Pollution Act of 1990 establishes liability for injuries to natural resources because of the release or threat of release of oil. Assessment of injury to natural resources resulting from an oil spill and development and implementation of a plan for the restoration, rehabilitation, replacement or acquisition of natural resources to compensate for those injuries is accomplished through the Natural Resource Damage Assessment (NRDA) process. The NRDA process began within a week of the Deepwater Horizon oil spill, which occurred on April 20, 2010. During the spill, more than 8500 dead and impaired birds representing at least 93 avian species were collected. In addition, there were more than 3500 birds observed to be visibly oiled. While information in the literature at the time helped to identify some of the effects of oil on birds, it was not sufficient to fully characterize the nature and extent of the injuries to the thousands of live oiled birds, or to quantify those injuries in terms of effects on bird viability. As a result, the US Fish and Wildlife Service proposed various assessment activities to inform NRDA injury determination and quantification analyses associated with the Deepwater Horizon oil spill, including avian toxicity studies. The goal of these studies was to evaluate the effects of oral exposure to 1-20ml of artificially weathered Mississippi Canyon 252 oil kg bw^-1 day^-1 from one to 28 days or one to five applications of oil to 20% of the bird's surface area. It was thought that these exposure levels would not result in immediate or short-term mortality but might result in physiological effects that ultimately could affect avian survival, reproduction and health. These studies included oral dosing studies, an external dosing study, metabolic and flight performance studies and field-based flight studies. Results of these studies indicated changes in hematologic endpoints including formation of Heinz bodies and changes in cell counts. There were also effects on multiple organ systems, cardiac function and oxidative status. External oiling affected flight patterns and time spent during flight tasks indicating that migration may be affected by short-term repeated exposure to oil. Feather damage also resulted in increased heat loss and energetic demands. The papers in this special issue indicate that the combined effects of oil toxicity and feather effects in avian species, even in the case of relatively light oiling, can significantly affect the overall health of birds.

Weathered MC252 crude oil-induced anemia and abnormal erythroid morphology in double-crested cormorants (Phalacrocorax auritus) with light microscopic and ultrastructural description of Heinz bodies

Injury assessment of birds following the Deepwater Horizon (DWH) oil spill in 2010 was part of the Natural Resource Damage Assessment. One reported effect was hemolytic anemia with the presence of Heinz bodies (HB) in birds, however, the role of route and magnitude of exposure to oil is unknown. The purpose of the present study was to determine if double-crested cormorants (Phalacocorax auritis; DCCO) exposed orally and dermally to artificially weathered crude oil would develop hemolytic anemia including HB and reticulocytosis. In the oral experiment, sub-adult, mixed-sex DCCOs were fed control (n = 8) or oil-injected fish with a daily target dose of 5 (n = 9) or 10 (n = 9) ml oil/kg for 21 days. Then, subadult control (n = 12) and treated (n = 13) cormorant groups of similar sex-ratio were dermally treated with approximately 13ml of water or weathered MC252 crude oil, respectively, every 3 days for 6 dosages approximating 20% surface coverage. Collected whole blood samples were analyzed by light (new methylene blue) and transmission electron microscopy. Both oral and dermal treatment with weathered DWH MC252 crude oil induced regenerative, but inadequately compensated, anemia due to hemolysis and hematochezia as indicated by decreased packed cell volume, relative increase in reticulocytes with lack of difference in corrected reticulocyte count, and morphologic evidence of oxidant damage at the ultrastructural level. Hemoglobin precipitation, HB formation, degenerate organelles, and systemic oxidant damage were documented. Heinz bodies were typically <2µm in length and smaller than in mammals. These oblong cytoplasmic inclusions were difficult to see upon routine blood smear evaluation and lacked the classic button appearance found in mammalian red blood cells. They could be found as light, homogeneous blue inclusions upon new methylene blue staining. Ultrastructurally, HB appeared as homogeneous, electron-dense structures within the cytosol and lacked membranous structure. Oxidant damage in avian red blood cells results in degenerate organelles and precipitated hemoglobin or HB with different morphology than that found in mammalian red blood cells. Ultrastructural evaluation is needed to definitively identify HB and damaged organelles to confirm oxidant damage. The best field technique based on the data in this study is assessment of PCV with storage of blood in glutaraldehyde for possible TEM analysis.

Toxic effects of orally ingested oil from the Deepwater Horizon spill on laughing gulls

The explosion of the Deepwater Horizon oil rig released, millions of gallons of oil into the environment, subsequently exposing wildlife, including numerous bird species. To determine the effects of MC252 oil to species relevant to the Gulf of Mexico, studies were done examining multiple exposure scenarios and doses. In this study, laughing gulls (Leucophaeus atricilla, LAGU) were offered fish injected with MC252 oil at target doses of 5 or 10mL/kg bw per day. Dosing continued for 27 days. Of the adult, mixed-sex LAGUs used in the present study, ten of 20 oil exposed LAGUs survived to the end of the study; a total of 10 of the oil exposed LAGUs died or were euthanized within 20 days of initiation of the study. Endpoints associated with oxidative stress, hepatic total glutathione (tGSH), oxidized glutathione (GSSG) and reduced glutathione (rGSH) significantly increased as mean dose of oil increased, while the rGSH:GSSG ratio showed a non-significant negative trend with oil dose. A significant increase in 3-methyl histidine was found in oil exposed birds when compared to controls indicative of muscle wastage and may have been associated with the gross observation of diminished structural integrity in cardiac tissue. Consistent with previous oil dosing studies in birds, significant changes in liver, spleen, and kidney weight when normalized to body weight were observed. These studies indicate that mortality in response to oil dosing is relatively common and the mortality exhibited by the gulls is consistent with previous studies examining oil toxicity. Whether survival effects in the gull study were associated with weight loss, physiologic effects of oil toxicity, or a behavioral response that led the birds to reject the dosed fish is unknown.

Testing of an oral dosing technique for double-crested cormorants, Phalacocorax auritus, laughing gulls, Leucophaeus atricilla, homing pigeons, Columba livia, and western sandpipers, Calidris mauri, with artificially weather MC252 oil

Scoping studies were designed to determine if double-crested cormorants (Phalacocorax auritus), laughing gulls (Leucophaues atricilla), homing pigeons (Columba livia) and western sandpipers (Calidris mauri) that were gavaged with a mixture of artificially weathered MC252 oil and food for either a single day or 4-5 consecutive days showed signs of oil toxicity. Where volume allowed, samples were collected for hematology, plasma protein electrophoresis, clinical chemistry and electrolytes, oxidative stress and organ weigh changes. Double-crested cormorants, laughing gulls and western sandpipers all excreted oil within 30min of dose, while pigeons regurgitated within less than one hour of dosing. There were species differences in the effectiveness of the dosing technique, with double-crested cormorants having the greatest number of responsive endpoints at the completion of the trial. Statistically significant changes in packed cell volume, white cell counts, alkaline phosphatase, alanine aminotransferase, creatine phosphokinase, gamma glutamyl transferase, uric acid, chloride, sodium, potassium, calcium, total glutathione, glutathione disulfide, reduced glutathione, spleen and liver weights were measured in double-crested cormorants. Homing pigeons had statistically significant changes in creatine phosphokinase, total glutathione, glutathione disulfide, reduced glutathione and Trolox equivalents. Laughing gulls exhibited statistically significant decreases in spleen and kidney weight, and no changes were observed in any measurement endpoints tested in western sandpipers.

Dietary intake of Deepwater Horizon oil-injected live food fish by double-crested cormorants resulted in oxidative stress

The Deepwater Horizon oil spill released 134 million gallons of crude oil into the Gulf of Mexico making it the largest oil spill in US history and exposing fish, birds, and marine mammals throughout the Gulf of Mexico to its toxicity. Fish eating waterbirds such as the double-crested cormorant (Phalacrocorax auritus) were exposed to the oil both by direct contact with the oil and orally through preening and the ingestion of contaminated fish. This study investigated the effects of orally ingestedMC252 oil-contaminated live fish food by double-crested cormorants on oxidative stress. Total, reduced, and oxidized glutathione levels, superoxide dismutase and glutathione peroxidase activities, total antioxidant capacity and lipid peroxidation were assessed in the liver tissues of control and treated cormorants. The results suggest that ingestion of the oil-contaminated fish resulted in significant increase in oxidative stress in the liver tissues of these birds. The oil-induced increase in oxidative stress could have detrimental impacts on the bird's life-history.

Changes in white cell estimates and plasma chemistry measurements following oral or external dosing of double-crested cormorants, Phalacocorax auritus, with artificially weathered MC252 oil

Scoping studies were designed whereby double-crested cormorants (Phalacocorax auritus) were dosed with artificially weathered Deepwater Horizon (DWH) oil either daily through oil injected feeder fish, or by application of oil directly to feathers every three days. Preening results in oil ingestion, and may be an effective means of orally dosing birds with toxicant to improve our understanding of the full range of physiological effects of oral oil ingestion on birds. Blood samples collected every 5-6 days were analyzed for a number of clinical endpoints including white blood cell (WBC) estimates and differential cell counts. Plasma biochemical evaluations were performed for changes associated with oil toxicity. Oral dosing and application of oil to feathers resulted in clinical signs and statistically significant changes in a number of biochemical endpoints consistent with petroleum exposure. In orally dosed birds there were statistically significant decreases in aspartate amino transferase (AST) and gamma glutamyl transferase (GGT) activities, calcium, chloride, cholesterol, glucose, and total protein concentrations, and increases in plasma urea, uric acid, and phosphorus concentrations. Plasma electrophoresis endpoints (pre-albumin, albumin, alpha-2 globulin, beta globulin, and gamma globulin concentrations and albumin: globulin ratios) were decreased in orally dosed birds. Birds with external oil had increases in urea, creatinine, uric acid, creatine kinase (CK), glutamate dehydrogenase (GLDH), phosphorus, calcium, chloride, potassium, albumin, alpha-1 globulin and alpha-2 globulin. Decreases were observed in AST, beta globulin and glucose. WBC also differed between treatments; however, this was in part driven by monocytosis present in the externally oiled birds prior to oil treatment.

Body mass change in flying homing pigeons externally exposed to Deepwater Horizon crude oil

The Deepwater Horizon oil spill contaminated thousands of miles of habitat valuable to hundreds of species of migratory and resident birds of the Gulf of Mexico. Many birds died as a direct result of the oil spill; however, the indirect effects of oil exposure on the flight ability and body condition of birds are difficult to assess in situ. This study utilizes the homing pigeon as a surrogate species for migratory birds to investigate the effect of multiple external oil exposures on the flight performance and body mass change of birds over a series of repeated flights from 136.8km flight distance. Oiled pigeons took significantly longer to return home, lost more weight during flight, and were unable to recover their weight, resulting in reduction of body weight overtime. Based on our data, migratory birds that were oiled, even partially, by the Deepwater Horizon oil spill likely took longer to complete migration and were likely in poor body condition, increasing their risk of mortality and reproductive failure.

Homing pigeons externally exposed to Deepwater Horizon crude oil change flight performance and behavior

The Deepwater Horizon oil spill was the largest in U.S. history, contaminating thousands of miles of coastal habitat and affecting the lives of many avian species. The Gulf of Mexico is a critical bird migration route area and migrants that were oiled but did not suffer mortality as a direct result of the spill faced unpredictable fates. This study utilized homing pigeons as a surrogate species for migratory birds to investigate the effects a single low level external oiling event has on the flight performance and behavior of birds flying repeated 161 km flights. Data from GPS data loggers showed that lightly oiled pigeons changed their flight paths, increased their flight durations by 2.6 fold, increased their flight distances by 28 km and subsequently decreased their route efficiencies. Oiled birds also exhibited reduced rate of weight gain between flights. Our data suggest that contaminated birds surviving the oil spill may have experienced flight impairment and reduced refueling abilities, likely reducing overall migration speed. Our findings contribute new information on how oil spills affect avian species, as the effects of oil on the flight behavior of long distance free-flying birds have not been previously described.

CYP1A protein expression and catalytic activity in double-crested cormorants experimentally exposed to deepwater Horizon Mississippi Canyon 252 oil

Double-crested cormorants (Phalacrocorax auritus, DCCO) were orally exposed to Deepwater Horizon Mississippi Canyon 252 (DWH) oil to investigate oil-induced toxicological impacts. Livers were collected for multiple analyses including cytochrome P4501A (CYP1A) enzymatic activity and protein expression. CYP1A enzymatic activity was measured by alkoxyresorufin O-dealkylase (AROD) assays. Activities specific to the O-dealkylation of four resorufin ethers are reported: benzyloxyresorufin O-debenzylase (BROD), ethoxyresorufin O-deethylase (EROD), methoxyresorufin O-demethylase (MROD), and pentoxyresorufin O-depentylase (PROD). CYP1A protein expression was measured by western blot analysis with a CYP1A1 mouse monoclonal antibody. In study 1, hepatic BROD, EROD, and PROD activities were significantly induced in DCCO orally exposed to 20ml/kg body weight (bw) oil as a single dose or daily for 5 days. Western blot analysis revealed hepatic CYP1A protein induction in both treatment groups. In study 2 (5ml/kg bw oil or 10ml/kg bw oil, 21day exposure), all four hepatic ARODs were significantly induced. Western blots showed an increase in hepatic CYP1A expression in both treatment groups with a significant induction in birds exposed to 10ml/kg oil. Significant correlations were detected among all 4 AROD activities in both studies and between CYP1A protein expression and both MROD and PROD activities in study 2. EROD activity was highest for both treatment groups in both studies while BROD activity had the greatest fold-induction. While PROD activity values were consistently low, the fold-induction was high, usually 2nd highest to BROD activity. The observed induced AROD profiles detected in the present studies suggest both CYP1A4/1A5 DCCO isoforms are being induced after MC252 oil ingestion. A review of the literature on avian CYP1A AROD activity levels and protein expression after exposure to CYP1A inducers highlights the need for species-specific studies to accurately evaluate avian exposure to oil.

Overview of avian toxicity studies for the Deepwater Horizon Natural Resource Damage Assessment

The Oil Pollution Act of 1990 establishes liability for injuries to natural resources because of the release or threat of release of oil. Assessment of injury to natural resources resulting from an oil spill and development and implementation of a plan for the restoration, rehabilitation, replacement or acquisition of natural resources to compensate for those injuries is accomplished through the Natural Resource Damage Assessment (NRDA) process. The NRDA process began within a week of the Deepwater Horizon oil spill, which occurred on April 20, 2010. During the spill, more than 8500 dead and impaired birds representing at least 93 avian species were collected. In addition, there were more than 3500 birds observed to be visibly oiled. While information in the literature at the time helped to identify some of the effects of oil on birds, it was not sufficient to fully characterize the nature and extent of the injuries to the thousands of live oiled birds, or to quantify those injuries in terms of effects on bird viability. As a result, the US Fish and Wildlife Service proposed various assessment activities to inform NRDA injury determination and quantification analyses associated with the Deepwater Horizon oil spill, including avian toxicity studies. The goal of these studies was to evaluate the effects of oral exposure to 1-20ml of artificially weathered Mississippi Canyon 252 oil kg bw^-1 day^-1 from one to 28 days or one to five applications of oil to 20% of the bird's surface area. It was thought that these exposure levels would not result in immediate or short-term mortality but might result in physiological effects that ultimately could affect avian survival, reproduction and health. These studies included oral dosing studies, an external dosing study, metabolic and flight performance studies and field-based flight studies. Results of these studies indicated changes in hematologic endpoints including formation of Heinz bodies and changes in cell counts. There were also effects on multiple organ systems, cardiac function and oxidative status. External oiling affected flight patterns and time spent during flight tasks indicating that migration may be affected by short-term repeated exposure to oil. Feather damage also resulted in increased heat loss and energetic demands. The papers in this special issue indicate that the combined effects of oil toxicity and feather effects in avian species, even in the case of relatively light oiling, can significantly affect the overall health of birds.

Timing and long-term prognosis of recurrent MI after primary angioplasty : Stent thrombosis vs. non-stent-related reinfarction

BACKGROUND

In patients recovering from an ST-segment elevation myocardial infarction (STEMI), it is not clear whether the negative impact of stent thrombosis (ST) is different from a non-stent-related recurrent myocardial infarction (NSRMI). This study sought to assess the long-term incidence and prognostic impact of recurrent myocardial infarction (MI) after percutaneous coronary intervention (PCI) for STEMI by comparing outcomes of ST versus NSRMI.

PATIENTS AND METHODS

From 2001 to 2007, 1025 patients undergoing PCI for STEMI were prospectively followed up. Patients with ST, with NSRMI, and those free from recurrent MI were compared regarding mortality and major adverse cardiac and cerebrovascular events (MACCE).

RESULTS

Recurrent MI decreased from 37 events per 1000 person/months in the first month to 3.3 events per 1000 person/months after the first year. The cumulative 5‑year incidence of ST and NSRMI was 5.27 % and 13.2 %, respectively. MACCE at 60 months after recurrence were not significantly different for patients with reinfarction but were significantly higher than for patients free from any recurrent MI (both log-rank p < 0.001). However, the cumulative all-cause death rate did not differ between the three groups (27.8 vs. 26.7 vs. 23.0 %). Compared with ST occurring in the first 30 days after PCI for STEMI, early NSRMI was associated with a significantly reduced risk for all-cause death (HR, 0.21; 95 % CI, 0.33-3.30) but this association did not persist for recurrent MIs occurring in the late (HR, 1.05; 95 % CI, 0.33-3.30) or very late follow-up periods.

CONCLUSION

Although ST was associated with a significant increase in adverse events in the early recovery period, in the long term, MACCE and all-cause mortality rates were comparable to those for NSRMI.