Clinical outcomes in patients with bicuspid aortic valves and ascending aorta dilatation equal or above 50mm

Background

Little is known about clinical outcomes in patients with bicuspid aortic valve (BAV) and ascending aortic diameters ≥50 mm where the elective surgical-indication zone begins.

Purpose

To assess incident aortic dissection (AoD), post-surgical survival and guideline implementation.

Methods

Multi-center retrospective study of BAV patients (≥18 years) with maximal root or tubular-ascending aortic diameters ≥50mm detected by transthoracic echocardiography at baseline. Ascertainment of aortic surgery, AoD and death was carried-out at their respective institutions. The primary outcome was AoD: “confirmed” AoD by surgery or death certificate, or “possible” AoD defined as sudden cardiac death of unknown cause by death certificate. Secondary outcomes were aortic surgery, post-surgical survival and guideline implementation.

Results

We included 506 consecutive BAV patients, mean age 61±14 years, 83% men, mean maximal aortic diameter 52±2 mm at baseline, ascending aorta was the most common segment ≥50mm (85%). During a median follow-up of 7.7 years, 356 (71%) underwent elective surgery (89% of class 1 patients). Early-surgery (≤6 months from baseline) occurred in 195 patients and 311 patients remained “under-surveillance”. Surgery under-surveillance (>6 months from baseline) occurred in 161/311 (52%) patients at 2.6 [IQR: 1.5–4.7] years of follow-up. Surgical mortality was 1.4%. Ten-year post-surgical survival was >90% and similar between early-surgery and surgery under-surveillance (p=0.8). Of 8 AoD events, 3 confirmed and 5 possible (all occurring in unoperated patients under-surveillance), 5 events occurred with maximal aortic baseline diameter ≥55 mm and/or >1 year without clinical follow-up; therefore, under guideline non-compliance. Incidence of confirmed plus possible aortic dissection was 0.37% per year with size 50–54mm, 1.13% per year between 55–59mm, and 10.41% per year with size ≥60mm. Aortic stenosis was associated with AoD (p=0.04) and all-cause death in unoperated patients (p=0.001).

Conclusions

Our results suggest that BAV patients can be safely followed as per guidelines after aortic diameters enter the elective surgical zone (≥50mm), with excellent post-surgical survival regardless of whether surgery is early- or under-surveillance. Appropriate guideline implementation for surgical thresholds and interval clinical follow-up could have prevented most AoD events. Valvular disease guideline should also be followed to prevent AoD and improve survival in these patients.

Funding Acknowledgement

Type of funding sources: None.

Clinical implications of the morphological features of left ventricular intracavitary thrombi after anterior ST elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular thrombi (LVT) after an anterior ST elevation myocardial infarction (STEMI) are usually classified as protruding or laminar according to their morphological characteristics. However, it is unknown whether this morphology has any clinical implication.

Purpose

Determine prognostic between laminar or protruding LVT in the community of anterior STEMI.

Methods

An observational cohort study on patients with LVT after anterior STEMI detected by echocardiography between 2008 and 2019 was conducted. Laminar LVT was defined as those protruding <5mm inside the cavity.

Results

Of 1.215 anterior STEMI patients, 121 (10%) cases presented LVT: 86 (71%) were protruding and 35 (29%) laminar. Mean follow-up was 323 ± 116 days. No differences in baseline clinical and echocardiographic characteristics were detected between both groups. However, protruding LVT patients were more frequently treated with triple therapy (71% vs 40%; p < 0.001). Laminar LVT patients presented a lower stroke rate (3% vs 16%; P = 0.042) and embolism-related rate (3% vs 19%; p = 0.024) than protruding LVT cases (see Figure). Laminar LVT was associated with lower embolism-related events during follow-up independently than left ventricular ejection fraction (LVEF) and age (OR = 0.11; 95% CI,0.12-0.94; p = 0.045). No differences were observed in laminar LVT patients in embolism-related events during follow-up between those treated with or without triple therapy (7% vs 0%; p = 0.400).

Conclusions

Laminar LVT after anterior STEMI presented a lower rate of embolism-related complications during follow-up compared with protruding LVT regardless of LVEF, age and even with a lower rate of triple therapy.

Abstract Figure.

Clinical implications of the morphological features of left ventricular intracavitary thrombi after anterior ST elevation myocardial infarction

Background

Left ventricular thrombi (LVT) after an anterior ST elevation myocardial infarction (STEMI) are usually classified as protruding or laminar according to their morphological characteristics. However, it is unknown whether this morphology has any clinical implication.

Purpose

Determine prognostic between laminar or protruding LVT in the community of anterior STEMI.

Methods

An observational cohort study on patients with LVT after anterior STEMI detected by echocardiography between 2008 and 2019 was conducted. Laminar LVT was defined as those protruding <5mm inside the cavity.

Results

Of 1.215 anterior STEMI patients, 121 (10%) cases presented a LVT: 86 (71%) were protruding and 35 (29%) laminar. Mean follow-up was 323±116 days. No differences in baseline clinical and echocardiographic characteristics were detected between laminar or protruding LVT groups. However, protruding LVT patients were more frequently treated with triple therapy (71% vs 40%; p<0.001). Laminar LVT patients presented a lower stroke rate (3% vs 16%; P=0.042) and embolism-related rate (3% vs 19%; p=0.024) than protruding LVT cases. Kaplan-Meier analysis demonstrated significant differences in embolism-related event rate between the 2 groups (p=0.003) during the follow-up period. Laminar LVT was associated with lower embolism-related events during follow-up independently than left ventricular ejection fraction (LVEF) and age (HR=0.17; 95% CI,0.10–0.29; p<0.001). No differences were observed in laminar LVT patients in embolism-related events during follow-up between those treated with or without triple therapy (7% vs 0%; p=0.400).

Conclusions

Laminar LVT after anterior STEMI presented a lower rate of embolism-related complications during follow-up compared with protruding LVT regardless of LVEF, age and even with a lower rate of triple therapy.

Figure 1. Kaplan-Meier curve showing cumulative probability of embolism-related event rate after anterior STEMI according to LVT morphology at 1 year.

Funding Acknowledgement

Type of funding source: None

P754 Severe aortic stenosis with preserved ejection prognostic differences according to flow status and gradient fraction: a Spanish multicentre study

Background and objectives

Low-flow low-gradient (LFLG) aortic stenosis portends bad prognosis in different series. The objective of this study was to evaluate the evolution of this entity in our country.

Methods

We included 1394 consecutive patients evaluated between 2008-2016 with severe AS (AVA <1 cm²) and ejection fraction> 50% from 14 Spanish centres. The results (aortic valve intervention and mortality) were compared using the Kaplan-Meier survival analysis.

Results

Three groups based on gradient and flow status were established (high gradient: HG, normal flow under gradient: NFLG, low gradient low flow: LFLG). No significant demographic or clinical differences between groups were observed. After a follow-up of 61.52 months (IQR 43.5-86.5), 551 (73.8%) HG, 268 (35.4%) with NFLG and 81 (57.9%) LFLG received intervention, with a later surgery/TAVI indication in the LFLG group compared with HG group (p = 0.001) (Figure 1). The analysis of the Kaplan-Meier mortality curves showed no significant differences.

Conclusions

Patients with LFLG aortic stenosis with normal ejection fraction received less and later aortic valve intervention than the HG group with no significant differences in mortality.

Abstract P754 Figure. Time to surgery

P917 Additional value of atrial parameters evaluated by echocardiography on the scales of cardioembolic risk in atrial fibrillation

Background

Atrial morphological parameters may influence the presence of atrial thrombus, a factor strongly associated with cardiac thromboembolism, independently of those included in the CHA2DS2-VASc risk estimation scale in patients with a history of atrial fibrillation (AF). The aim of our study was to evaluate this possible association by transthoracic echocardiography (TTE).

Methods

Prospective multicenter study including 401 patients with a history of AF, in which a TTE and a transesophageal echocardiogram (TEE) were performed for evaluation of atrial thrombus between 2016-2019. The parameters included in the CHA2DS2-VASc scale, the heart rhythm at the time of the study and the anticoagulant treatment performed, as well as the atrial morphological parameters were collected.

Results

Twenty-three patients (6%) presented with atrial thrombus in TEE. The left atrial area (28 ± 6cm2 vs 33 ± 6cm2; p < 0.001), the presence of AF during the study (83% vs 17%; p = 0.002) and CHA2DS2-VASc (1.7 ± 1.5cm2 vs 3.0 ± 1.3cm2; p < 0.001) were associated with the presence of atrial thrombus. The left atrial area was a diagnostic predictor of atrial thrombus (area under the curve = 73%; p = 0.001): a value >30cm2 presented a sensitivity of 79% and a specificity of 70% to detect its presence. Logistic regression analysis, including heart rhythm during the study and anticoagulant treatment, showed that CHA2DS2-VASc (OR = 1.5; CI95%=1.1-1.9; p = 0.003) and left atrial area >30cm2 (OR = 5.2;CI 95% =1.7-16.0; p = 0.004) were independent predictors of atrial thrombus presence.

Conclusions

The left atrial area is associated with the presence of atrial thrombus in patients with a history of AF independently of the CHA2DS2-VASc scale, heart rhythm during the study, and anticoagulant treatment. This parameter should be evaluated to be included in the cardioembolic risk scales.

P1760 Cardiac prognosis of patients with subaortic membrane according to their morphology

INTRODUCTION

Subaortic membrane is an entity which evolves during adulthood and can associate cardiac complications. Different morphologies have been described, although it is unknown if their prognosis varies according to these patterns. The aim of this study was to evaluate the cardiac prognosis of patients with subaortic membrane according to their morphological characteristics in adulthood.

METHODS

Forty-five patients diagnosed with subaortic membrane by imaging techniques were consecutively included (March 1999-August 2018). Three morphologies were described: fibromuscular ridge (FR), crescent-shaped (CS) and filamentous-shaped (FS). Cardiac complications were defined as mortality due to heart failure and/or necessity of aortic valve surgery and/or membrane resection.

RESULTS

Twenty-six cases (58%) had FR, 16 (35%) had CS and 3 (7%) presented FS (7%) (Fig.1). No differences were found in basal clinical parameters between groups. FR type was associated with the presence of dynamic gradient in baseline study (27% vs 0%, p = 0.014), but there were no differences in left ventricular ejection fraction (68 ± 8% vs 64 ± 8%; p = 0.092), nor in maximum thickness of basal interventricular septum (12.1 ± 3.9mm vs 11.7 ± 4.1mm, p = 0.699), nor in the presence of moderate/severe aortic stenosis (15% vs 11%, p > 0.999) with the other morphologies. During follow-up (mean ± SD= 5.8 ± 4.4years) 15 (33%) patients presented cardiac complications (2 deaths due to heart failure and 12 valvular interventions and/or membrane resection). FR type patients presented a higher cardiac complication rate (50% vs 11%, p = 0.006) and greater necessity of open-heart surgery (46% vs 11%, p = 0.011) than the other groups during follow-up.

CONCLUSIONS

FR type is associated with a higher rate of cardiac complications during follow-up than other subaortic membrane morphologies. Dynamic gradient associated to this pattern could be the basis of a possible pathophysiological mechanism related to the worst prognosis of these patients.

Figure 1. Different morphologies of subaortic membranes. (A) Fibromuscular ridge type; (B) Crescent-shaped type; (C) Filamentous-shaped type. aL: anterior leaflet of mitral valve ; Ao: aorta; LA: left atrium; LV: left ventricle; RV: right ventricle.

Abstract P1760 Figure.

P661 Relationship between streptococcal infective endocarditis and preneoplastic colorectal lesions

Background

Colorectal cancer is associated with infective endocarditis (IE), due to specific gut pathogens like streptococcus Gallolyticus that use the tumor presence as a point of blood entry. However, the association between streptococcal IE and pre-cancerous lesions such as dysplastic adenomas is unknown.

Objectives

To determine the association with pre-neoplastic colorectal lesions and streptococcal IE.

Methods

Two hundred eighty consecutive patients with IE were included in a protocol of clinical, microbiological and imaging follow-up, between January 2008 and December 2018. Precancerous lesions were divided as high and low-grade dysplasia based on World Health Organization criteria. Colorectal cancer was defined as the presence of malignant cell beyond the muscularis mucosa.

Results

A colonoscopy was performed in 81 patients (29%) and 26 of them (32%) presented colorectal lesions: 10 (38%) colorectal cancer and 16 (62%) precancerous lesions (12% high degree (n = 2); 88% low degree (n = 14)). Both, colorectal cancer (20% vs 11%; p = 0.02) and preneoplastic lesions (44% vs 8%; p < 0.001) were associated with higher incidence of streptococcus Gallolyticus IE (Figure 1). Additionally, the subgroup of precancerous lesions with low degree also showed this association (43% vs 9%; p = 0.001).

Conclusions

Precancerous colorectal lesions are also associated with streptococcus Gallolyticus IE, even low-grade lesions. Hence, it is necessary to rule out occult neoplastic and preneoplastic colorectal lesions with colonoscopy in these patients.

Figure 1: Relationship between S. Gallolyticus IE and colorectal lesions.

a Statistical significance between colorectal cancer and S. Gallolyticus IE.

b Statistical significance between preneoplastic colorectal lesions and S. Gallolyticus IE.

Abstract P661 Figure.

P367 Cardioprotective effect of angiotensin converting enzyme inhibitors and beta-blockers in the primary prevention of cardiotoxicity: systematic review and meta-analysis of randomised studies

Funding Acknowledgements

none

OnBehalf

none

Background

Chemotherapy cardiotoxicity is a serious complication in breast and haematological malignancies. However, its primary prevention with angiotensin converting enzyme inhibitors (ACEI)/angiotensin II receptor antagonists (ARB) and/or beta-blockers (BB) medication has discrepant results. The aim of our study was to establish whether primary prevention using these treatments prevents cardiotoxicity and whether any of them is superior to the others.

Methods

A systematic review and meta-analysis was performed following a search of EMBASE, MEDLINE and PsycINFO from January 2005 to April 2019 of all randomised studies evaluating primary prevention of cardiotoxicity by chemotherapy with any of these treatments. Cardiotoxicity was defined as the drop of the left ventricular ejection fraction below 50% or greater than 10% and/or clinical heart failure during the first year of follow-up.

Results

Nine randomised studies with 913 participants in which chemotherapy was performed were included: 337 (37%) received BB, 152 (17%) received ACEI/ARB, 45 (5%) received BB + ACEI and 379 (41%) were controls. One hundred and eight cases (12%) developed cardiotoxicity (follow-up range: 1-12 months). Patients receiving cardioprotective treatment had a lower risk of developing cardiotoxicity than controls (RR = 0.381, IC95%, 0.160-0.911, P = 0.030, I2 = 63.2%; Fig.1). The subgroup analysis showed a non-significant tendency for both treatments to have a cardioprotective effect (BB: RR = 0.477; IC95%, 0.178-1.275; P = 0.140; I2 = 57.3%) / ACEI/ARB: RR = 0.283; IC95%, 0.027-2.982; P = 0.293; I2 = 79.0%). There was no difference between both treatments in those studies comparing them (RR = 0.743, CI95%, 0.325-1.698, P = 0.481, I2 = 0.0%). The estimated number of patients to be treated to avoid one case of cardiotoxicity was 10 patients.

Conclusions

Primary prevention with BB and/or ACEI/ARB reduces cardiotoxicity by chemotherapy during the first year in breast and haematological malignancies. For every 10 patients treated, one case of cardiotoxicity could be avoided.

Figure 1. Cases treated with BB and/or ACEI/ARB versus control group without treatment of the different randomised studies comparing the number of patients who developed cardiotoxicity during the first year.

Abstract P367 Figure 1

P2763Clinical prognosis of pure right-sided infective endocarditis without association to cardiac devices or intravenous drug abuse

Background

Pure right-sided infective endocarditis (RSIE) without association with cardiac devices or intravenous drug users (IVDUs) is an entity with unclear predisposing factors and prognosis.

Purpose

To evaluate predisposing factors and prognosis of pure RSIE compared tothose associated to cardiac devices or IVDUs.

Methods

280 consecutive patients with endocarditis were included retrospectively in a protocol of clinical and imaging follow-up. Endocarditis-related event was defined as endocarditis mortality or open-surgery requirement. Besides, a review and meta-analysis of the literature between january 2000 and december 2018 were performed.

Results

Fifty-two (19%) patients presented RSIE: 20 of them (39%) were pure RSIE. Intravascular catheters carriers (25% vs 3%; p=0.026) and congenital heart diseases (20% vs 0%; p=0.018) were associated to pure RSIE. These patients demonstrated the worst clinical prognosis, with the highest in-hospital mortality (25% vs 3%; p=0.026) and endocarditis-related event rate (45% vs 6%; p=0.001), being pure RSIE independently associated with in-hospital endocarditis-related events (OR=8.40; 95% CI, 1.13–62.68; p=0.038). Four studies, including ours, with 315 participants diagnosed of RSIE were evaluated in meta-analysis: 94 individuals (30%) presented pure RSIE.This group demonstrated a higher in-hospital mortality than those with cardiac devices or IVDUs (RR=2.854; 95% CI, 1.640–4.965; P<0.001; I2=0.0%; Figure 1).

Figure 1. RSIE and in-hospital mortality based on groups: cases with pure RSIE versus those with cardiac devices or IVDUs.

Conclusions

Pure RSIE is the worst prognosis group among RSIE with the highest endocarditis-related event rate and in-hospital mortality. This growing group should stake out the benign impression and recommendations given to RSIE among IE patients.

3328Relationship between streptococcal infective endocarditis and pre-neoplastic colorectal lesions

Background

Colorectal cancer is associated with infective endocarditis (IE), due to specific gut pathogens like streptococcus Gallolyticus that use the tumor presence as a point of blood entry. However, the association between streptococcal IE and pre-cancerous lesions such as dysplastic adenomas is unknown.

Objectives

To determine the association with pre-neoplastic colorectal lesions and streptococcal IE.

Methods

Two hundred eighty consecutive patients with IE were included retrospectively in a protocol of clinical, microbiological and imaging follow-up, between January 2008 and December 2018. Pre-cancerous lesions were divided as high and low-grade dysplasia based on World Health Organization criteria. Colorectal cancer was defined as the presence of malignant cell beyond the muscularis mucosa.

Results

Fifty patients (18%) presented neoplastic or pre-neoplastic lesions, and 26 of them (52%) were colorectal: 10 (38%) colorectal cancer and 16 (62%) precancerous lesions (12% high degree (n=2); 88% low degree (n=14)). Both, colorectal cancer (20% vs 5%; p=0.03) and pre-neoplastic lesions (44% vs 3%; p<0.05) were associated with higher incidence of streptococcus Gallolyticus IE (Figure 1). Additionally, 42% (n=11) of colorectal lesions were diagnosed in the IE event. No significant differences were found about cardiac surgery and in-hospital mortality in these patients.

Figure 1. Relationship between S. Gallolyticus IE and colorectal lesions. (a) Statistical significance between colorectal cancer and S. Gallolyticus IE. (b) Statistical significance between pre-neoplastic colorectal lesions and S. Gallolyticus IE.

Conclusions

Pre-cancerous colorectal lesions are also associated with streptococcus Gallolyticus IE, even low-grade lesions. Hence, it is necessary to rule out occult neoplastic and also pre-neoplastic colorectal lesions with colonoscopy in these patients.

Mucinous adenocarcinoma on perianal fistula. A rising entity?

INTRODUCTION

Mucinous adenocarcinoma on perianal fistula is a rare entity; it could be underdiagnosed because it behaves often as a regular perianal fistula.

MATERIALS AND METHODS

We have recently treated four cases in our unit. We present them and review the literature, emphasizing on clinical characteristic and therapeutic options. The four patients were male with a mean age of 64. Three of them were classified as locally advances cases and therefore treated with neoadjuvant therapy.

RESULTS

All of them underwent laparoscopic abdominoperineal escisión. Surgical specimens are described and clinical characteristic specified. Review of the literature shows that this disease has a very high potential risk of local recurrence and we must be aggressive with the resection. Sometimes plastic surgery is needed to reconstruct the perianal wound.

CONCLUSIONS

Mucinous adenocarcinoma associated with anal fistula is a rare disease. Neoadjuvant chemoradiotherapy followed by an adequate abdominoperineal excision may result in favourable outcomes.

Comparing CTVs for permanent prostate brachytherapy

BACKGROUND AND PURPOSE

To delineate the clinical target volume (CTV) in low dose rate (LDR) brachytherapy for prostate cancer, American Brachytherapy Society (ABS) recommends a CTV = prostate. ESTRO advocates a CTV = prostate + 3 mm excluding rectum and many authors use and recommend other different CTVs. This study aims to: (1) evaluate the appropriateness of these recommendations and (2) test the applicability of seed distributions on the different CTVs and contrast the dosimetric differences.

MATERIALS AND METHODS

Ninety-eight patients treated with (125)I seeds (dose 145 Gy; CTV = prostate) were studied. We established for every patient: (1) risk of extraprostatic extension (EPE), (2) adequacy of original plan to an extended CTV with 3 mm-margin (3) a new planning and seed distribution for this CTV and (4) comparison of dosimetry of both plans.

RESULTS

Mean risk of EPE was 28.46 %. Original plan, when applied to the extended CTV, resulted in unsatisfactory dosimetry. A plan was generated for the 98 extended CTVs meeting all dosimetric specifications.

CONCLUSIONS

The risk of EPE is high enough to consider a 3 mm-margin around prostate necessary for all cases. A CTV = prostate + 3 mm except rectum as ESTRO recommends is feasible and would adjust planning to the most probable extension of the tumor.

Prediction of oral appliance treatment outcome in obstructive sleep apnoea syndrome: a preliminary study

OBJECTIVE

Predictors of treatment outcome of oral appliances (OAs) in patients with obstructive sleep apnoea syndrome (OSAS) are not known. There is a pressing need for simple, clinically useful tools to predict treatment outcome. This study aimed to identify predictors of successful OA therapy for OSAS, including evaluation of pharyngeal morphology, which can be measured during routine examination by an otorhinolaryngologist.

METHODOLOGY

This was a prospective study of 26 OSAS patients treated with OAs. A favourable outcome was obtained in 14 patients (responders) but not in 12 patients (nonresponders). The baseline patient characteristics and polysomnography and rhinopharyngeal findings were analysed.

RESULTS

Body mass index (BMI) was significantly lower in responders versus nonresponders (23.6 ± 2.8 vs. 27.9 ± 4.7 kg/m2; p < 0.05). Pharyngeal morphology, age, sex and nasal resistance did not differ between the groups. Multiple regression analysis showed that BMI was a significant predictor of improvement in the apnoea/hypopnoea index after OA treatment (p < 0.05).

CONCLUSION

Here we demonstrated that BMI is a favourable predictor of OA treatment outcome in OSAS patients. Among the OSAS patients, responders had wider retroglossal spaces than nonresponders.

Benefits of intrahospital exercise training after pediatric bone marrow transplantation

The purpose of this study was to determine if an eight-week intrahospital supervised, conditioning program improves functional capacity and quality of life (QOL) in children (4 boys, 4 girls) (mean [SD] age: 10.9 [2.8] years [range: 8-16]) who have undergone bone marrow transplantation (BMT) for leukemia treatment within the last 12 months. A group of 8 age and gender-matched healthy children served as controls. The experimental group performed 3 weekly sessions of resistance and aerobic training inside an intra-hospital gymnasium. A significant combined effect of group and time (p < 0.05) was observed for muscle functional capacity (Timed Up and Down Stairs [TUDS] test) and peak oxygen uptake (V.O(2peak)), i.e., with BMT children showing greater improvements than controls (V.O(2peak) at pre- and post-training of 25.9 (8.2) and 31.1 (7.6) mL/kg/min in diseased children). Muscle strength (6 RM test for bench and leg press and seated row) also improved after training (p < 0.05) in the BMT group. Concerning QOL, a significant combined effect of group and time (p < 0.05) was also observed for children's self-report of comfort and resilience and for parents' report of their children's satisfaction and achievement. In summary, children who have received BMT experience physical and overall health benefits after a relatively short-term (8 weeks) supervised exercise training program.