Immunohistochemical Findings of Lens Capsules Obtained from Dead Bag Syndrome Patients

PURPOSE

To investigate the extracellular matrix and cellular components in lens capsules extracted from patients with dead bag syndrome (DBS) through immunohistochemistry.

SETTING

Department of Ophthalmology, Wakayama Medical University School of Medicine and Department of Ophthalmology and Visual Sciences, John A. Moran Eye Center, University of Utah.

DESIGN

Immunohistochemical experimental study.

METHODS

Nine capsular bag specimens from DBS cases, as well as 2 control specimens from late-postoperative in-the-bag intraocular lens dislocation cases related to previous vitrectomy, pseudoexfoliation, and blunt trauma were included. They were processed for histopathology; unstained sections were obtained from each one, and analyzed by immunohistochemistry targeting collagen type IV, laminin, vimentin, collagen type I and fibronectin.

RESULTS

Immunohistochemistry in DBS showed lens capsule stained for basement membrane components. The outer part of the anterior capsule that was split from the inner part was more markedly stained for type IV collagen as compared with the posterior part. Faint staining for fibrous posterior capsular opacification (PCO) components, e. g., collagen type I and fibronectin, was detected in limited areas, but the major portion of the capsule was free from these components. Small spotty vimentin-positive materials, suggesting the presence of cell debris, was also detected in limited samples.

CONCLUSION

Small amounts of fibrotic PCO components were detected in capsules extracted from patients with DBS, but their major parts were free from PCO components. Current findings suggest small amounts of lens epithelial cells were present after surgery and secreted fibrous components before undergoing cell death process.

Clinical Outcomes of Carbon-Ion Radiotherapy for Large-Sized (≥4cm) Hepatocellular Carcinoma

PURPOSE/OBJECTIVE(S)

Radical treatment options for bulky unresectable locally advanced hepatocellular carcinoma (HCC) are limited. The purpose of this study is to evaluate the safety and efficacy of carbon-ion radiotherapy (C-ion RT) for bulky (≥4cm) locally advanced HCC.

MATERIALS/METHODS

We performed a retrospective cohort study of patients with bulky (≥4cm) locally advanced HCC treated by C-ion RT between April 2000 and March 2020 in our institution. The eligibility criteria for this study were: (1) the treatment protocols of 45.0-48.0 Gy/2 fractions or 52.8-60.0 Gy/4 fractions, which proven the safety and efficacy in the past clinical trials; (2) Tumors within 3 intrahepatic lesions and with a maximum tumor diameter of 4 cm or greater; (3) N0M0 status; (4) an Eastern Cooperative Oncology Group performance status of 0 to 2; (5) controllable ascites; (6) Child-Pugh grade was A or B. Overall survival (OS), progression-free survival (PFS), and local control rate (LC) were calculated by the Kaplan-Meier method, and Cox regression analysis was used for multivariate analysis. Adverse events were evaluated by CTCAE ver. 5.0. JMP® 12 (SAS Institute Inc., Cary, NC, USA) was used for all analyses. We defined p < 0.05 as statistically significant.

RESULTS

A total of 187 patients met the criteria and were evaluated. The median patient age was 73 years (range, 37-90), and 139 of 187 patients were male. Child-Pugh grade was A in 163 patients and B in 24. Modified albumin-bilirubin (mALBI) grade was 1 in 96 patients, 2a in 50, and 2b in 41. The number of HCV-related HCC cases was in 80, HBV in 32 and non-B and non-C in 75. In 51 patients, identification of vascular invasion to the first-order branch of the portal vein and/or major hepatic vein was confirmed. The median maximum tumor diameter was 5.1 cm (4.0-13.5 cm). In 76 patients, C-ion RT were treated for recurrence. With a median follow-up period of 25.9 months (range, 1.1-215.1), 2-year overall survival, progression-free survival and local control rates were 68.3% (95% confidence interval [CI], 64.7-72.0%), 39.0% (95% CI, 35.2 - 42.8%) and 86.7% (95% CI, 84.7 - 89.7%), respectively. Late adverse events were observed in 3 patients (1.6%) with Grade 3 liver dysfunction and in 3 patients (1.6%) with Grade 3 skin disorders, but there were no cases of Grade 4 or higher. Multivariate analysis of prognostic factors for overall survival revealed that mALBI grade in 2b(HR:3.13, 1.97-4.78, p<0.0001), tumor status in recurrent treatment (HR:1.50, 1.02-2.21, p = 0.039), the number of tumors in 2 or more (HR:2.16, 1.01-2.17, p = 0.045), and maximum tumor diameter in larger than 6 cm (HR:2.34, 1.50-3.61, p = 0.0001) were the predominant prognostic factors, while age, presence of vascular invasion, AFP and DCP were not.

CONCLUSION

The safety and efficacy of C-ion RT for bulky (≥4cm) locally advanced HCC was demonstrated. These results suggested that C-ion RT may be a new treatment option for locally advanced bulky HCC with no curative treatment options.

Long-Term Clinical Outcome of Carbon Ion Radio Therapy for Hepatocellular Carcinoma in the Caudate Lobe

PURPOSE/OBJECTIVE(S)

Surgical resection is the first-line treatment for hepatocellular carcinoma in the caudate lobe (caudate HCC), but it is often difficult due to the tumor's location. In addition, radiofrequency ablation and transcatheter arterial chemoembolization are also difficult for the same reason. This study aimed to evaluate the safety and efficacy of carbon-ion radiation therapy (C-ion RT) for caudate HCC.

MATERIALS/METHODS

We performed a retrospective cohort study of patients with hepatocellular carcinoma treated by C-ion RT between April 2000 and March 2020 in our institution. The eligibility criteria for this study were: (1) located mainly in the caudate lobe (2) the treatment protocols of 45.0-48.0 Gy/2 fractions or 52.8-60.0 Gy/4 fractions, which proved the safety and efficacy in the past clinical trials; (3) N0M0 status; (4) an Eastern Cooperative Oncology Group performance status (PS) of 0 to 2; (5) controllable ascites. The prescribed dose (Gy) used in this study is relative biological effectiveness (RBE) weighted dose. Overall survival (OS), progression-free survival (PFS), and local control rate (LC) were calculated by the Kaplan-Meier method. Adverse events were evaluated by NCI-CTCAE ver. 5.0. SPSS software version 27.0 (IBM Inc.) was used for all analyses. We defined p-value < 0.05 as statistically significant.

RESULTS

A total of 25 patients met the criteria and were evaluated. The median patient age was 73 years (range 58-89), and 21 of 25 patients were male. The number of patients with PS 0 was 22, PS 1 was 1, and PS 2 was 2. The number of HBV-related HCC cases was in 8, HCV-related HCC cases was in 11, and non-B and non-C cases was in 6. The median maximum tumor diameter was 3.0 cm (1.1-4.8 cm). In 6 patients, identification of vascular invasion to the main trunk of the portal vein and/or major hepatic vein was confirmed. The Child-Pugh (CP) grade was A in 21 patients and B in 4. The modified albumin-bilirubin (mALBI) grade 1 is in 17 patients, 2a in 4, 2b in 4. Prescribed doses were 45 Gy / 2 fr in 3 cases, 48 Gy / 2 fr in 12 cases, 52.8 Gy / 4 fr in 7 cases, and 60 Gy / 4 fr in 3 cases. With a median follow-up period of 43.6 months (range 0.3-85.0), 3-year OS, PFS, and LC were 74% (95% confidence interval [CI], 54.8-93.8%), 32% (95% CI, 11.8-51.4%), and 93% (95% CI, 79.4-106%), respectively. All patients had no Grade 2 or higher adverse events during the observation period.

CONCLUSION

The safety and efficacy of C-ion RT for caudate HCC were demonstrated. These results suggested that C-ion RT may be a promising treatment option for patients with caudate HCC.

Impaired healing in an incision wound in corneal stroma in a lumican-null mouse

PURPOSE

We investigated healing pattern of an incisional wound in corneal stroma of lumican-null (KO) mice.

METHODS

C57BL/6 mice (wild-type, WT) and lumican-null (knockout, KO) mice were used. A linear full-thickness incision was produced in one cornea of each mouse. After intervals of healing, the corneas were processed for the following analyses. Histology was employed to measure the distance between each edge of the disrupted Descemet's membrane at the center of the cornea. Immunohistochemistry and real-time RT-PCR were employed to evaluate the expression of wound healing-related components in the tissue. Cultured ocular fibroblasts were obtained from cornea and sclera of WT and KO postnatal day 1 pups. The cells were subjected to examination for cell proliferation and expression of wound healing-related gene products. In vitro gel contraction assay was used to asses cell contractile activity of WT and KO cells.

RESULTS

At day 5 of incision, the distance between the disrupted Descemet's membrane was larger in a KO mouse as compared with a WT mouse. Myofibroblast appearance in the wound was suppressed by the loss of lumican. The loss of lumican downregulated TGFβ1's effects on mRNA expression of α-smooth muscle actin and collagen Ia1 in cultured ocular fibroblasts. Cell proliferation rate increased in injured stroma, which was further supported by in vitro datum of cell proliferation augmentation by the loss of lumican. Loss of lumican suppressed cell-mediated gel contraction.

CONCLUSION

Loss of lumican perturbs the healing of penetrating incision in mouse corneal stroma in association with suppression of myofibroblast generation.

Antithrombotic monotherapy for stable coronary artery disease and atrial fibrillation patients with and without prior coronary artery revascularization: Insights from the AFIRE trial

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation under a contract with Bayer Yakuhin

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial demonstrated that rivaroxaban monotherapy was noninferior to combination therapy with rivaroxaban plus a single antiplatelet therapy regarding efficacy and superior for safety endpoints in patients with atrial fibrillation and stable coronary artery disease including patients not requiring revascularization [prior percutaneous coronary intervention (PCI) or bypass grafting (CABG)].

Purpose

The aim of this post-hoc subgroup analysis was to investigate the efficacy and safety of rivaroxaban monotherapy compared to combination therapy in patients with and without prior revascularization.

Methods

Among 2,215 patients included in the modified intention-to-treat analysis in the AFIRE trial, 1445 patients (65.2%) had undergone previous PCI alone, and 252 (11.4%) had undergone previous CABG. The remaining 518 patients (23.4%) was categorized as a group without prior revascularization and then compared with a group with prior revascularization (PCI or CABG). The primary efficacy end point was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, or death from any cause. The primary safety end point was major bleeding, according to the criteria of the International Society on Thrombosis and Hemostasis.

Results

In 1697 patients with prior revascularization, efficacy and safety endpoints of rivaroxaban monotherapy were superior to combination therapy (efficacy: HR 0.62, 95%CI 0.45-0.85, p=0.003; safety: HR 0.62, 95%CI 0.39-0.98, p=0.040), whereas there were no significant differences in efficacy and safety endpoints among 518 patients without prior revascularization (efficacy: HR 1.19, 95%CI 0.67-2.11, p=0.553; safety: HR 0.47, 95%CI 0.18-1.26, p=0.125). There was a borderline interaction of efficacy endpoint (P for interaction=0.055) by randomized treatment assignment (Figure 1 and Figure 2). Compared with combination therapy, the safety benefit of rivaroxaban monotherapy on any bleeding was significant in patients without prior revascularization (HR 0.59, 95%CI 0.38-0.93, p=0.022).

Conclusions

In patients with prior PCI or CABG, rivaroxaban monotherapy resulted in more favorable safety and efficacy outcomes than combination therapy. There was a borderline interaction for primary efficacy outcome between prior revascularization and anti-thrombotic therapy.

Loss of TRPV4 Cation Channel Inhibition of Macrophage Infiltration and Neovascularization in a Mouse Cornea

Corneal injury-associated inflammation could induce inward-growing neovascularization from the periphery of the tissue. Such neovascularization could cause stromal opacification and curvature disturbance, and both potentially impair visual function. In this study, we determined the effects of the loss of transient receptor potential vanilloid 4 (TRPV4) expression on the development of neovascularization in the corneal stroma in mice by producing a cauterization injury in the central area of the cornea. New vessels were immunohistochemically labeled with anti-TRPV4 antibodies. TRPV4 gene knockout suppressed the growth of such CD31-labeled neovascularization in association with the suppression of infiltration of macrophages and tissue messenger RNA expression of the vascular endothelial cell growth factor A level. Treatment of cultured vascular endothelial cells with supplementation of HC-067047 (0.1 μM, 1 μM, or 10 μM), a TRPV4 antagonist, attenuated the formation of a tube-like structure with sulforaphane (15 μM, for positive control) that modeled the new vessel formation. Therefore, the TRPV4 signal is involved in injury-induced macrophagic inflammation and neovascularization activity by vascular endothelial cells in a mouse corneal stroma. TRPV4 could be a therapeutic target to prevent unfavorable postinjury neovascularization in the cornea.

Atezolizumab plus bevacizumab versus lenvatinib or sorafenib in non-viral unresectable hepatocellular carcinoma: an international propensity score matching analysis

BACKGROUND

A growing body of evidence suggests that non-viral hepatocellular carcinoma (HCC) might benefit less from immunotherapy.

MATERIALS AND METHODS

We carried out a retrospective analysis of prospectively collected data from consecutive patients with non-viral advanced HCC, treated with atezolizumab plus bevacizumab, lenvatinib, or sorafenib, in 36 centers in 4 countries (Italy, Japan, Republic of Korea, and UK). The primary endpoint was overall survival (OS) with atezolizumab plus bevacizumab versus lenvatinib. Secondary endpoints were progression-free survival (PFS) with atezolizumab plus bevacizumab versus lenvatinib, and OS and PFS with atezolizumab plus bevacizumab versus sorafenib. For the primary and secondary endpoints, we carried out the analysis on the whole population first, and then we divided the cohort into two groups: non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH) population and non-NAFLD/NASH population.

RESULTS

One hundred and ninety patients received atezolizumab plus bevacizumab, 569 patients received lenvatinib, and 210 patients received sorafenib. In the whole population, multivariate analysis showed that treatment with lenvatinib was associated with a longer OS [hazard ratio (HR) 0.65; 95% confidence interval (CI) 0.44-0.95; P = 0.0268] and PFS (HR 0.67; 95% CI 0.51-0.86; P = 0.002) compared to atezolizumab plus bevacizumab. In the NAFLD/NASH population, multivariate analysis confirmed that lenvatinib treatment was associated with a longer OS (HR 0.46; 95% CI 0.26-0.84; P = 0.0110) and PFS (HR 0.55; 95% CI 0.38-0.82; P = 0.031) compared to atezolizumab plus bevacizumab. In the subgroup of non-NAFLD/NASH patients, no difference in OS or PFS was observed between patients treated with lenvatinib and those treated with atezolizumab plus bevacizumab. All these results were confirmed following propensity score matching analysis. By comparing patients receiving atezolizumab plus bevacizumab versus sorafenib, no statistically significant difference in survival was observed.

CONCLUSIONS

The present analysis conducted on a large number of advanced non-viral HCC patients showed for the first time that treatment with lenvatinib is associated with a significant survival benefit compared to atezolizumab plus bevacizumab, in particular in patients with NAFLD/NASH-related HCC.

Effect of rivaroxaban monotherapy vs. combination with anti-platelet therapy in patients with atrial fibrillation and stable coronary artery disease across different body mass index categories

Background

The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial showed both noninferiority for efficacy and superiority for safety endpoints of rivaroxaban monotherapy compared to rivaroxaban plus antiplatelet therapy (combination therapy) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, no accumulating evidence regarding efficacy and safety of these fixed-dose direct oral anticoagulant therapy was available in underweight and obese patients.

Purpose

The aim of this post-hoc analysis of the AFIRE trial was to evaluate outcomes of rivaroxaban monotherapy (vs. combination therapy) in patients with AF and stable CAD across body mass index (BMI) categories.

Methods

Patients were categorized into groups 1 (underweight: BMI of &lt;18.5 kg/m2), 2 (normal: BMI of 18.5 to &lt;25 kg/m2), 3 (overweight: BMI of 25 to &lt;30 kg/m2), and 4 (obesity: BMI of ≥30 kg/m2). Efficacy (a composite of all-cause death, myocardial infarction, unstable angina requiring revascularization, stroke, or systemic embolism) and safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria) were compared between rivaroxaban monotherapy and combination therapy across BMI categories.

Results

We analyzed 2,054 patients with a median age of 75.0 (interquartile range [IQR], 69 to 80)) years old and CHA2DS2-VASc of 4 (IQR, 3 to 5). Group 1 through 4 included 72 (3.5%), 1,158 (56.4%), 680 (33.1%), 144 (7.0%) patients and 62.3%, 52.3%, 36.2%, and 30.3% were received reduced dose of rivaroxaban, respectively. Although the sample sizes for group 1 and 4 were limited, monotherapy was superior to combination therapy for efficacy in group 2 (hazard ratio [HR], 0.64; 95% CI, 0.44 to 0.95) and safety in group 3 (HR, 0.25; 95% CI, 0.10 to 0.62), whereas a significant difference in the endpoints was not observed in the other BMI categories. Impact of monotherapy on endpoints did not have a significant interaction in BMI.

Conclusions

Rivaroxaban monotherapy had similar effect on prognosis across all BMI categories in patients with AF and stable CAD.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd

Early vascular responses to abluminal biodegradable polymer-coated versus circumferential durable polymer-coated newer-generation drug-eluting stents in humans: a pathologic study

Background

Recent clinical trials are testing strategies for short (1–3 months) dual antiplatelet therapy (DAPT) following newer-generation drug-eluting stent (DES) placement. However, the safety of short DAPT regimens is not supported by biological evidence in humans.

Purpose

We sought to evaluate early pathologic responses to newer-generation DES by comparing abluminal biodegradable polymer-coated DES (BP-DES) with circumferential durable polymer-coated DES (DP-DES) in human autopsy cases.

Methods

The study included a total of 37 coronary lesions with thin strut newer-generation DES (DP-DES=23 [XIENCE=18, Resolute Integrity=5] and BP-DES=14 [SYNERGY=9, Ultimaster=5]) with duration of implantation &lt;90 days in 25 autopsy cases. The process of stent healing was precisely evaluated for every single strut in association with underlying tissue characteristics. The degree of strut coverage was defined as follows: grade 0 (bare struts), grade 1 (struts covered with thrombus, fibrin, or other tissues or cells without endothelium), grade 2 (struts covered with single-layered endothelium without underlying smooth muscle cell layers), and grade 3 (struts covered with endothelium and underlying smooth muscle cell layers) (Figure 1).

Results

Duration of implantation was similar in lesions with DP-DES and those with BP-DES (median=20 vs. 17 days). A total of 1986 struts (DP-DES=1261, BP-DES=725) were pathologically analyzed. Focal grade 2 coverage was observed as early as 5 days after the implantation in both stents. Multilevel mixed-effects ordered logistic regression model demonstrated that BP-DES exhibited greater strut coverage compared with DP-DES (odds ratio; 3.50, 95% CI; 1.31–9.41, P=0.013), which remained significant after adjustment for duration of implantation and underlying tissue characteristics (odds ratio; 2.64, 95% CI; 1.04–6.68, P=0.040). The time course of vessel healing assessed as predictive probability of strut coverage (grade 0–3) stratified by duration of implantation is shown in Figure 2. Predictive probability of grade 2 and 3 coverage was comparably limited at 30 days (DP-DES=17.7% vs. BP-DES=29.0%) and increased at 90 days (DP-DES=76.1% vs. BP-DES=85.9%). Both stents showed few inflammation and similar degree of fibrin deposition.

Conclusions

The current first pathologic study on early biological responses to newer-generation DES in humans demonstrated that single-layered endothelial coverage begins in days following the stent placement, and abluminal BP-DES potentially exhibit faster strut coverage with smooth muscle cell infiltration than circumferential DP-DES. Nevertheless, vessel healing remains suboptimal at 30 days in both DP- and BP-DES, which progresses with time to become substantial at 90 days. Our results suggest that very short duration of DAPT for 1 month should be applied with caution, taking into account the trade-off between bleeding and thrombotic risks.

Funding Acknowledgement

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

Prognostic impact of plasma level of NT-pro BNP in patients with microvascular angina – a report from the international cohort study by COVADIS

Aims

Although the importance of microvascular angina (MVA) has been emerging, prognostic biomarkers for MVA remain to be developed. We thus aimed to examine whether plasma level of N-terminal prohormone of brain natriuretic peptide (NT-pro BNP) could predict the prognosis of MVA patients.

Methods

In the international prospective cohort study of MVA patients by the Coronary Vasomotor Disorders International Study (COVADIS) group, we evaluated the association between plasma level of NT-pro BNP and the incidence of major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization due to heart failure or unstable angina.

Results

We examined a total of 226 MVA patients (M/F 66/160, 61.9±10.2 [SD] years) with both plasma NT-pro BNP levels and echocardiographic data in the COVADIS study. Plasma NT-pro BNP level was elevated (median 94 pg/ml, IQR 45–190) while mean LVEF (69.2±10.9%) and E/e' (10.7±5.2) were almost normal. During follow-up period of a median of 365 days (IQR 365–482), 29 MACEs occurred. ROC curve analysis identified plasma NT-pro BNP level of 78 pg/ml as the optimal cut-off value. Multivariable logistic regression analysis revealed that plasma NT-pro BNP level ≥78 pg/ml significantly correlated with the incidence of MACE (odds ratio (OR) [95% confidence interval (CI)] 3.11 [1.14–8.49], P=0.03). When divided into 2 groups by NT-pro BNP 78 pg/ml, the Kaplan-Meier survival analysis showed a significantly worse prognosis in the group with NT-pro BNP ≥78 (log lank, P=0.03) (Figure).

Conclusions

These results indicate that plasma NT-pro BNP level is a novel prognostic biomarker for MVA patients.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Japan Heart Foundation

Delayed regression of laser-induced choroidal neovascularization in TNFα-null mice

We investigated the effects of lacking TNFα on the development and regression of Argon-laser-induced choroidal neovascularization (CNV) in mice. We lasered ocular fundus for induction of CNV in both wild-type (WT) and TNFα-null (KO) mice. Fluorescence angiography was performed to examine the size of CNV lesions. Gene expression pattern of wound healing-related components was examined. The effects of exogenous TNFα on apoptosis of human retinal microvascular endothelial cells (HRMECs) and on the tube-like structure of the cells were investigated in vitro. The results showed that Argon-laser irradiation-induced CNV was significantly larger in KO mice than WT mice on Day 21, but not at other timepoints. Lacking TNFα increased neutrophil population in the lesion. The distribution of cleaved caspase3-labelled apoptotic cells was more frequently observed in the laser-irradiated tissue in a WT mouse as compared with a KO mouse. Exogenous TNFα induced apoptosis of HRMECs and accelerated regression of tube-like structure of HRMECs in cell culture. Taken together, TNFα gene knockout delays the regression of laser-induced CNV in mice. The mechanism underlying the phenotype might include the augmentation of neutrophil population in the treated tissue and attenuation of vascular endothelial cell apoptosis.

Anomaly of cornea and ocular adnexa in spinster homolog 2 (Spns2) knockout mice

Spinster 2 (Spns2) is a transporter that pumps sphingosine-1-phosphate (S1P), a bioactive lipid mediator synthesized in the cytoplasm, out of cells into the inter cellular space. S1P is a signal that modulates cellular behavior during embryonic development, inflammation and tissue repair, etc. A Spns2-null (KO) mouse is born with failure of eyelid closure (eyelid-open-at birth; EOB) and develop corneal fibrosis in adulthood. It remains elusive whether corneal lesion is caused by exposure to keratitis (lagophthalmos) of EOB phenotype or the loss of Spns2 directly perturbs the corneal tissue morphogenesis and intra-eyelid structures. Therefore, we investigated differences between the cornea and ocular adnexa morphogenesis in KO and wild-type (WT) embryos and adults as well. The loss of Spns2 perturbs cornea morphogenesis during embryonic development as early as E16.5 besides EOB phenotype. Histology showed that the corneal stroma was thinner with less extracellular matrix accumulation, e.g., collagen and keratocan in the KO mouse. Epithelial stratification, expression of keratin 12 and formation of desmosomes and hemidesmosomes were also perturbed in these KO corneas. Lacking Spns2 impaired morphogenesis of the Meibomian glands and of orbicularis oculi muscles. KO glands were labeled for ELOVL4 and PPARγ and were Oil-Red O-positive, suggesting KO acinar cells possessed functionality as the glands. This is the first report on the roles of Spns2 in corneal and Meibomian gland morphogenesis. Corneal tissue destruction in an adult KO mouse might be due to not only lagophthalmos but also to an impaired morphogenesis of cornea, Meibomian glands, and orbicularis oculi muscle.

POS0472 AGONISTIC STIMULATION OF GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AMELIORATED INFLAMMATORY MYOPATHIES THROUGH SUPPRESSING MUSCLE FIBER NECROPTOSIS

Background

While glucocorticoids (GC) are the cornerstone of the treatment for polymyositis (PM), GC-induced myopathy is inevitable, which further deteriorates muscle weakness. Therefore, novel therapeutic strategy that not only suppresses muscle inflammation but also improves muscle strength is awaited. We recently found that injured muscle fibers in PM undergo FASLG-mediated necroptosis1, a form of regulated cell death accompanied with release of pro-inflammatory mediators such as HMGB1, which contributes to accelerate muscle inflammation and muscle weakness. We also showed that inhibition of necroptosis or HMGB1 ameliorated the muscle weakness and muscle inflammation1 in C protein-induced myositis (CIM), a murine model of PM. Glucagon-like peptide-1 receptor (GLP-1R) agonists, which have been developed as an anti-diabetic therapy, have pleiotropic actions including anti-inflammatory effects2, suppression of muscle wasting3, and inhibition of cell death4. Accordingly, we hypothesized that GLP-1R agonists have beneficial effects on PM to recover muscle strength and to suppress muscle inflammation.

Objectives

The aims of this study are to examine the role of GLP-1R in PM and the effect of a GLP-1R agonist on in vivo and in vitro models of PM.

Methods

Muscle specimens of PM patients and CIM were examined with immunofluorescence staining for the expression of GLP-1R. The effect of PF1801, a GLP-1R agonist, on CIM was examined in monotherapy or in combination with prednisolone (PSL). As an in vitro model of PM, C2C12-derived myotubes were treated with FAS ligand (FASLG) to induce necroptosis. The levels of HMGB1, TNF-α, and IL-6 in the serum of CIM and in the culture supernatant of the in vitro model were measured by ELISA. The effect of PF1801 on the myotube necroptosis was examined using time lapse imaging 5 and its effect on the activation of AMP-activated protein kinase (AMPK), the expression of PGAM5, and ubiquitination of PGAM5 was assessed with immunoblotting. The levels of reactive oxygen species (ROS) in the myotubes were analyzed with CellROX assay. The effect of PF1801 on the expression of antioxidant molecules in the myotubes was analyzed with quantitative real-time PCR.

Results

GLP-1R was expressed on the inflamed muscle fibers of PM and CIM. The treatment with PF1801 in monotherapy or in combination with PSL suppressed CIM-induced muscle weakness and the muscle weight loss as well as the severity of histological myositis while the monotherapy with PSL did not suppress muscle weakness and muscle weight loss. PF1801 decreased the levels of inflammatory mediators such as HMGB1, TNF-α, and IL-6 in the serum of CIM. In vitro, PF1801 inhibited FASLG-induced myotube necroptosis and decreased the levels of HMGB1, TNF-α, and IL-6 in the supernatant. PF1801 activated AMPK and decreased the levels of PGAM5, which was crucial for FASLG-induced necroptosis of the myotubes. The inhibitory effect of PF1801 on myotube necroptosis was cancelled by compound C, an AMPK-kinase inhibitor, or MG132, a proteasome inhibitor, suggesting that PF1801 promoted ubiquitin-proteasome-mediated PGAM5 degradation through the activation of AMPK. Furthermore, PF1801 suppressed FASLG-induced reactive oxygen species (ROS) accumulation in myotubes, which was also crucial for the execution of necroptosis, thorough up-regulating the antioxidant molecules such as Nfe2l2, Hmox1, Gclm, and Nqo1.

Conclusion

GLP-1R agonist could be a novel therapy for PM that restores muscle strength as well as suppresses muscle inflammation through inhibiting muscle fiber necroptosis.

References

[1]Kamiya M, et al. Nat Commun. 2022;13:166

[2]Du X, et al. Int Immunopharmacol. 2019;75:105732.

[3]Hong Y, et al. J Cachexia Sarcopenia Muscle. 2019;10:903–918.

[4]Younce CW, et al. Am J Physiol - Cell Physiol. 2013;304:508–518.

[5]Kamiya M, et al. Rheumatology (Oxford). 2020; 59:224-232

Acknowledgements

We thank Katsuko Yamasaki for the histological analysis.

Disclosure of Interests

Mari Kamiya Speakers bureau: Pfizer and Ono Pharmaceutical, Grant/research support from: GlaxoSmithKline, Fumitaka Mizoguchi Speakers bureau: AbbVie, Asahi Kasei Pharma, Bristol-Myers Squibb, Chugai Pharmaceutical, Eizai, Eli Lilly and Company, Glaxo Smith Kline, Ono Pharmaceutical, and Pfizer., Consultant of: Asahi Kasei Pharma and ImmunoForge., Grant/research support from: AbbVie, Astellas Pharma, Bristol-Myers Squibb, Chugai Pharmaceutical, Daiichi Sankyo Company, Eisai, Eli Lilly and Company, ImmunoForge, Japan Blood Products Organization, Mitsubishi Tanabe Pharma, Novartis Pharma Japan, Ono Pharmaceutical, Otsuka Pharmaceutical Factory, Pfizer, Sanofi, Takeda Pharmaceutical Company and Teijin, Hirokazu Sasaki: None declared, Natsuka Umezawa: None declared, Shinsuke Yasuda Speakers bureau: Abbvie, Asahi Kasei Pharma, Chugai Pharmaceutical, Eisai, Eli Lilly, GlaxoSmithKline, Mitsubishi Tanabe Pharma, Ono pharmaceutical, and Pfizer., Consultant of: ImmunoForge, Grant/research support from: Abbvie, Asahi Kasei Pharma, Chugai Pharmaceutical, CSL Behring, Eisai, ImmunoForge, Mitsubishi Tanabe Pharma, and Ono pharmaceutical.

POS0197 SARS-CoV-2 INFECTION CAUSED THROMBOSIS IN THE LUPUS MODEL WITH ANTIPHOSPHOLIPID ANTIBODY, WHEREAS COVID-19 ASSOCIATED THROMBOSIS WAS IRRELEVANT IN PATIENTS WITH POSITIVE ANTIPHOSPHOLIPID ANTIBODY

Background

Thrombosis is a unique complication in coronavirus disease 2019 (COVID-19). We have reported that elevated ferritin and D-dimer on admission were the risk factors of thromboses by analyzing the patients sequentially admitted to our hospital due to COVID-19 (1). However, we have not analyzed thrombotic complications in the view of the antiphospholipid antibodies (aPLs), which are frequently detected in the COVID-19 patients.

Objectives

To elucidate the thrombogenic effects of aPLs in COVID-19, we analyzed the development of thrombosis in three lupus models after SARS-CoV-2 infection. Additionally, we evaluated the association of thrombotic events and the serum profile of aPLs in Japanese patients with COVID-19.

Methods

Three animal models of lupus (MRL-lpr/lpr, NZBxNZW F1 and NZW×BXSB F1) were evaluated in this study. NZW×BXSB F1 was also considered as a model of antiphospholipid syndrome (APS) since aPLs were detected with a high titer (2). Experimental SARS-CoV-2 infection was induced using mouse-passaged virus strain (3). The incidence of thromboses in the lungs and kidneys were identified by evaluating H&E staining and PTAH staining of paraffin-embedded sections. We have experienced 44 thrombotic events in 34 out of 594 patients admitted to our institute. As a non-thrombotic COVID-19, 68 patients were selected to make a 1 to 2 matched-pair based on the propensity score. In total 102 patients, seven types of aPLs (anti-cardiolipin (CL) IgG/IgM, anti-β2GP1 IgG/IgA/IgM, and anti-phosphatidyl serine/prothrombin complex (PS/PT) IgG/IgM) were measured using specific ELISA kits. The patients’ clinical characteristics and serological profile of aPLs were further evaluated.

Results

We identified the development of thromboses in the lungs or kidneys in 6 out of 12 (50%) NZW×BXSB F1 mice after the SARS-CoV-2 infection, whereas no thrombosis was observed in non-infected mice. Further, there was no thrombosis in the other lupus models (0%) after the infection. These findings might suggest the pathogenic role of aPLs under the SARS-CoV-2 infection.

Among our COVID-19 patients, 39 out of 102 (38%) were tested positive for one or more aPLs. The positive ratios of any aPLs were statistically indifferent between the patients with or without thrombosis; anti-CL IgG (8.8% vs 5.9%)/IgM (0% vs 5.9%), anti-β2GP1 IgG (21% vs 12%)/IgA (8.8% vs 15%)/IgM (0% vs 1.5%), and anti-PS/PT IgG (0% vs 2.9%)/IgM (12% vs 13%), respectively. In addition, their titers were relatively lower than those observed in APS patients. The patients’ characteristics and the prognosis of COVID-19 were comparable regardless of the detection of any aPLs. These findings suggested that COVID-19 associated aPLs were irrelevant to thrombotic complications.

Conclusion

Thromboses were induced after the infection of SARS-CoV-2 only in the APS model. However, aPLs detected in COVID-19 patients have little impact on the development of thrombosis. SARS-CoV-2 infection might have a high risk of thrombosis, especially in APS patients, as shown in the case report (4). The discrepancy of its thrombogenic effects of aPLs might be explained by the low titer of the antibody or the diversity of antibody epitope. Further analyses are required to clarify the mechanisms of aPLs production and the development of thrombosis in COVID-19.

References

[1]Oba S, et al. Arterial and Venous Thrombosis Complicated in COVID-19: A Retrospective Single-Center Analysis in Japan. Front Cardiovasc Med. 2021 Nov 19;8:767074.

[2]Hashimoto Y, et al. Anticardiolipin antibodies in NZW x BXSB F1 mice. A model of antiphospholipid syndrome. J Immunol. 1992 Aug 1;149(3):1063-8.

[3]Iwata-Yoshikawa N, et al. A lethal mouse model for evaluating vaccine-associated enhanced respiratory disease during SARS-CoV-2 infection. Sci Adv. 2022 Jan 7;8(1):eabh3827.

[4]Chidharla A, et al. A Case Report of COVID-Associated Catastrophic Antiphospholipid Syndrome Successfully Treated with Eculizumab. J Blood Med. 2021 Oct 30;12:929-933.

Disclosure of Interests

Seiya Oba: None declared, Tadashi Hosoya Speakers bureau: Janssen Pharmaceutical K.K.

Daiichi Sankyo Company, limited

Asahi Kasei Corporation

Ono pharmaceuticals

Eisai

Eli Lilly, Daisuke Kawata: None declared, Wenshi Lee: None declared, Mari Kamiya: None declared, Yoji Komiya: None declared, Hideyuki Iwai: None declared, Yuko Nukui: None declared, Shuji Tohda: None declared, Shinsuke Yasuda Speakers bureau: Abbvie,

Asahi Kasei Pharma,

Chugai Pharmaceutical,

Eisai, Eli Lilly,

GlaxoSmithKline,

Mitsubishi Tanabe Pharma,

Ono pharmaceutical,

Pfizer., Consultant of: ImmunoForge, Grant/research support from: Abbvie,

Asahi Kasei Pharma,

Chugai Pharmaceutical,

CSL Behring,

Eisai,

ImmunoForge,

Mitsubishi Tanabe Pharma,

Ono pharmaceutical

Contribution of the human cytochrome P450 2C subfamily to the metabolism of and the interactions with endogenous compounds including steroid hormones

The objectives of this study were as follows: 1) to compare the metabolic activities of endogenous compounds and their effects on dopamine formation and hydroxylation of steroid hormones, mediated by human cytochrome P450 (CYP), including CYP2C9.1 and CYP2C19, as well as the variants CYP2C9.2 (Arg144Cys) and CYP2C9.3 (Ile359Leu); and 2) to assess the effects of steroid hormones on the activities of CYP2C9.1, CYP2C9.2, and CYP2C19 to estimate the contribution of the CYP2C subfamily to metabolism and drug-drug interactions of endogenous compounds. Dopamine formation from p -tyramine and 6β- and 21- (for progesterone) hydroxylation of testosterone, cortisol, and progesterone by CYP2C9 variants, CYP2C19, CYP2D6, and CYP3A4 were determined using HPLC. The effects of steroid hormones such as testosterone, cortisol, and progesterone on tolbutamide methyl hydroxylation mediated by CYP2C subfamily members were investigated. Only CYP2D6 catalyzed dopamine formation. The 6β-hydroxylation activities of testosterone, cortisol, and progesterone catalyzed by CYP2C9 variants and CYP2D6 were less than 5% of those by CYP3A4. Although cortisol did not inhibit tolbutamide methyl hydroxylation catalyzed by CYP2C9.1, CYP2C9.2, or CYP2C19 and testosterone did not inhibit CYP2C19 activity, the reactions catalyzed by CY2C9.1 and CYP2C9.2 were inhibited by testosterone. The inhibition of progesterone by CYP2C19 was stronger than that by CYP2C9.1 and CYP2C9.2. CYP2C9.1 and CYP2C19 noncompetitively and competitively inhibited tolbutamide methyl hydroxylation with inhibition constants of 43.2 μM and 1.03 μM, respectively. Clinical interactions among endogenous compounds would vary within the CYP2C subfamily, although the contribution of the CYP2C subfamily may be of minor importance for dopamine formation and the detoxification (6β-hydroxylation) of endogenous steroid hormones.

Nonalcoholic steatohepatitis in hepatocarcinoma: new insights about its prognostic role in patients treated with lenvatinib

BACKGROUND

Hepatocellular carcinoma (HCC) treatment remains a big challenge in the field of oncology. The liver disease (viral or not viral) underlying HCC turned out to be crucial in determining the biologic behavior of the tumor, including its response to treatment. The aim of this analysis was to investigate the role of the etiology of the underlying liver disease in survival outcomes.

PATIENTS AND METHODS

We conducted a multicenter retrospective study on a large cohort of patients treated with lenvatinib as first-line therapy for advanced HCC from both Eastern and Western institutions. Univariate and multivariate analyses were performed.

RESULTS

Among the 1232 lenvatinib-treated HCC patients, 453 (36.8%) were hepatitis C virus positive, 268 hepatitis B virus positive (21.8%), 236 nonalcoholic steatohepatitis (NASH) correlate (19.2%) and 275 had other etiologies (22.3%). The median progression-free survival (mPFS) was 6.2 months [95% confidence interval (CI) 5.9-6.7 months] and the median overall survival (mOS) was 15.8 months (95% CI 14.9-17.2 months). In the univariate analysis for OS NASH-HCC was associated with longer mOS [22.2 versus 15.1 months; hazard ratio (HR) 0.69; 95% CI 0.56-0.85; P = 0.0006]. In the univariate analysis for PFS NASH-HCC was associated with longer mPFS (7.5 versus 6.5 months; HR 0.84; 95% CI 0.71-0.99; P = 0.0436). The multivariate analysis confirmed NASH-HCC (HR 0.64; 95% CI 0.48-0.86; P = 0.0028) as an independent prognostic factor for OS, along with albumin-bilirubin (ALBI) grade, extrahepatic spread, neutrophil-to-lymphocyte ratio, portal vein thrombosis, Eastern Cooperative Oncology Group (ECOG) performance status and alpha-fetoprotein. An interaction test was performed between sorafenib and lenvatinib cohorts and the results highlighted the positive predictive role of NASH in favor of the lenvatinib arm (P = 0.0047).

CONCLUSION

NASH has been identified as an independent prognostic factor in a large cohort of patients with advanced HCC treated with lenvatinib, thereby suggesting the role of the etiology in the selection of patients for tyrosine kinase treatment. If validated, this result could provide new insights useful to improve the management of these patients.

Predictive value of QRS duration normalized to left ventricular volume for responding to cardiac resynchronization therapy in patients with mid-QRS duration enrolled in the multicenter registry

Background

For cardiac resynchronization therapy (CRT), patients with chronic heart failure (HF) and wide (&gt;150msec) QRS duration (QRSd) received class I/A indication. However, its beneficial effect seemed to be limited for those with mid- (120–150msec) QRSd. Recent studies demonstrated that QRSd normalized to left ventricular end-diastolic volume (QRSd/ LVEDV) improved prediction of clinical outcome in patients with CRT. Therefore, we sought to investigate predictive value of QRSd/LVEDV for responding to CRT in patients with mid-QRSd.

Methods

This was retrospective multi-center observational cohort study. A total 506 consecutive patients who underwent CRT implantation in Tohoku University Hospital and National Cerebral and Cardiovascular Center were evaluated. Exclusion criteria were QRSd less than 120ms, upgrade procedures from other implanted non-CRT devices and bradycardia requiring pacing. We evaluated clinical variables, data of electrocardiogram and transthoracic echocardiography at baseline and 6 months after CRT implantation. Primary endpoint was a HF hospitalization after CRT implantation. Distribution of free from HF hospitalization during follow-up was calculated using Kaplan-Meier curves, and the effects of covariate on the time to endpoint were investigated using a Cox proportional hazards model.

Results

After 199 patients were excluded based on exclusion criterion, remaining 307 patients were included for the analysis. Mean age was 62±14 [SD] years, and 238 (77%) were male. Mean LVEF and LVEDV were 25±9% and 234±82ml, respectively, and 24% of patients had ischemic etiology of HF. During the median 948 days of follow-up, CRT patients with mid QRSd (n=126; 136±10msec), as compared with those with wide QRSd (n=181; 174±17msec), tended to have higher incidence of HF hospitalization (Wilcoxon p=0.03). Multivariate analysis showed that QRSd and QRSd/LVEDV were significant predictors for HF hospitalization in CRT patients with mid QRSd, and cut-off values (137msec of QRSd and 0.65 of QRSd/LVEDV), which was calculated by receiver operative curve analysis, was used for risk stratification. QRSd&lt;137msec was significant negative predictors for HF hospitalization (p=0.005), and Mid-QRSd patients with QRSd≥137msec demonstrated equivalent clinical outcome with those with wide QRSd. Moreover, patients with QRSd/LVEDV≥0.65 tended to have lower incidence of HF hospitalization as compared with those without it among patients with QRSd&lt;137msec (n=64, Figure).

Conclusion

The present study demonstrates that QRSd normalized to left ventricular end-diastolic volume (QRSd/ LVEDV) could be clinical value in predicting outcome in CRT patients with mid-QRSd. These findings indicate normalized QRSd reflects myocardial conduction properties and contribute to risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Aspirin vs. P2Y12 inhibitors with anticoagulation therapy for atrial fibrillation: insights from the AFIRE trial

Background

Patients with coronary artery disease (CAD) and atrial fibrillation (AF) can be treated with multiple antithrombotic therapies including antiplatelets and oral anticoagulants; however, this has the potential to increase bleeding risk.

Purpose

This sub-analysis aimed to evaluate the efficacy and safety of P2Y12 inhibitors and aspirin in patients also receiving oral anticoagulant therapy.

Methods

We evaluated patients from the Atrial Fibrillation and Ischemic Events with Rivaroxaban in Patients with Stable Coronary Artery Disease (AFIRE) trial who received combination therapy (rivaroxaban plus a single antiplatelet agent). The choice of antiplatelets was left to the physician's discretion. The primary efficacy endpoint was a composite of stroke, systemic embolism, myocardial infarction, unstable angina requiring revascularization, and death from any cause. The primary safety endpoint was major bleeding according to the International Society on Thrombosis and Haemostasis criteria.

Results

A total of 1,075 patients were included (P2Y12 inhibitor group, n=297; aspirin group, n=778). Approximately 60% of patients were administered proton pump inhibitors (PPIs), and there was no significant difference in PPI use in the P2Y12 inhibitor and aspirin groups. Regarding the primary efficacy endpoint, there was no significant difference between the P2Y12 inhibitor and aspirin groups (hazard ratio, 1.31; 95% confidence interval, 0.88–1.94; p=0.178). Likewise, the primary safety endpoint was not different between the groups (hazard ratio, 0.79; 95% confidence interval, 0.43–1.47; p=0.456). In the detailed subgroup analysis, there were no differences in the efficacy and safety endpoints.

Conclusions

There were no significant differences between P2Y12 inhibitors and aspirin in cardiovascular events in patients with AF and stable CAD taking rivaroxaban in the chronic phase.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd. Summary of this study

Comparison of coronary atherosclerotic features in response to achieving LDL-C &lt;55 mg/dl between non-diabetic and diabetic patients: insights from the REASSURE-NIRS registry

Introduction

Current ESC guideline recommends achieving LDL-C &lt;1.4 mmol/l in very high-risk subjects. Despite fabvourable anti-atherosclerotic effects of lowering LDL-C, its efficacy is diminished in type 2 diabetic patients. Whether response of coronary atheroma to on-treatment LDL-C &lt;1.4 mmol/l differs in diabetic and non-diabetic subjects has not been elucidated yet.

Methods

The REASSURE-NIRS registry is an on-going multi-center registry to enroll CAD subjects receiving PCI under the guidance of near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS: DualProTM, Nipro, Tokyo, Japan) imaging. Culprit lesions in 557 CAD patients who already received a statin were evaluated by NIRS/IVUS. Maximum 4-mm-lipid-core burden-index (maxLCBI4mm) and plaque calcification grade at culprit sites were measured. Calcification grade at each 1-mm cross-sectional image was defined as follows: calcium arc 0° = 0, 0–90° = 1, 90–180° = 2, 180–270° = 3, 270–360° = 4. MaxLCBI4mm and the averaged calcification grade were compared in diabetic and non-diabetic subjects stratified according to on-treatment LDL-C level, respectively.

Result

The proportion of diabetic (n=293, HbA1c; 6.9±0.9%) and non-diabetic patients (n=264) with on-treatment LDL-C &lt;1.4 mmol/l was 8.54 and 16.67%, respectivey (p=0.01). In non-diabetic patients, achieving LDL-C &lt;1.4mmol/L was associated with a lower maxLCBI4mm, whereas, in diabetic patients, maxLCBI4mm was numerically smaller under achieving LDL-C &lt;1.4 mmol/l, but this comparison did not meet statistical significance (Figure 1). Furthermore, a greater degree of calcification grade in non-diabetic patients was observed in association with on-treatment LDL-C level (Figure 2). However, plaque calcification at diabetic coronary atheroma was not necessarily induced under achieving stricter LDL-C goal. Subgroup analysis demonstrated that diabetic patients with body mass index ≥25 (odds ratio = 0.15; 95% CI: 0.18–1.19, p=0.04), estimated glomerular filtration rate &lt;60 (mL/min/1.73m2) (odds ratio = 0.31; 95% CI: 0.10–0.90, p=0.03) and non-insulin use (odds ratio = 0.36; 95% CI: 0.14–0.87, p=0.02) benefit from achieving LDL-C &lt;1.4 mmol/l.

Conclusion

Achieving LDL-C &lt;1.4 mmol/l was associated with more stabilized atheroma in non-diabetic patients with CAD, whereas these favourable effects were not observed in diabetic subjects. Our findings suggest the potential need to modify additional atherogenic risks for stabilizing diabetic coronary atheroma under achieving LDL-C &lt;1.4 mmol/l.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

Acute myocardial infarction in a patient with uncorrected tetralogy of Fallot accompanied by coronary artery ectasia: A case report

A 63-year-old male with a medical history of uncorrected tetralogy of Fallot (TOF) presented to our hospital due to acute myocardial infarction (AMI). Emergency coronary angiography (CAG) was performed and it showed a severe thrombotic stenosis in the middle right coronary artery (RCA) and total thrombotic occlusion of the posterior descending branch of the RCA. Subsequently, percutaneous coronary artery intervention (PCI) under the guidance of intravascular ultrasound (IVUS) was performed. He was discharged on the 14th day in stable condition. Nine months after the PCI procedure, coronary computed tomography angiography was performed for follow-up, which revealed tetralogy of Fallot and complete resolution of the thrombus and ectasic coronary artery without stenosis. When he was 70 years old, he was transferred to our hospital because of recurrent AMI. As emergency CAG showed total thrombotic occlusion of the middle RCA, IVUS-guided PCI was performed. We experienced a very rare case of AMI in an adult patient with uncorrected TOF accompanied by coronary artery ectasia (CAE). To the best of our knowledge, this is the first case of AMI in an adult patient with uncorrected TOF accompanied by CAE. <Learning objective: Previous studies have reported that erythrocytosis of cyanotic heart disease and coronary artery ectasia (CAE) increase the risk of acute myocardial infarction (AMI) due to coronary thrombosis. In this report, we describe a very rare AMI case in an adult patient with uncorrected tetralogy of Fallot with CAE. Erythrocytosis of　cyanotic heart disease and CAE can synergistically increase the risk of coronary thrombosis and anticoagulation therapy would be effective to prevent recurrent AMI.>.

Loss of sphingosine 1-phosphate receptor 3 gene function impairs injury-induced stromal angiogenesis in mouse cornea

Sphingosine 1-phosphate (S1P) is a bioactive sphingolipid generated through sphingosine kinase1 (SPK1)-mediated phosphorylation of sphingosine. We show here that injury-induced S1P upregulation increases corneal neovascularization through stimulating S1PR3, a cognate receptor. since this response was suppressed in S1PR3-knockout mice. Furthermore, Cayman10444, a selective S1PR3 inhibitor, reduced this response in WT mice. Such reductions in neovascularization were associated with reduced vascular endothelial growth factor A (VEGF-A) mRNA expression levels in WT TKE2 corneal epithelial cells and macrophages treated with CAY10444 as well as macrophages isolated from S1PR3 KO mice. S1P increased tube-like vessel formation in human vascular endothelial cells (HUVEC) and human retinal microvascular endothelial cells (HRMECs) cells expressing S1PR3. In S1PR3 KO mice, TGFβ1-induced increases in αSMA gene expression levels were suppressed relative to those in the WT counterparts. In S1PR3 deficient macrophages, VEGF-A expression levels were lower than in WT macrophages. Transforming growth factor β1(TGFβ1) upregulated SPK1 expression levels in ocular fibroblasts and TKE2 corneal epithelial cells. CAY10444 blocked S1P-induced increases in VEGF-A mRNA expression levels in TKE2 corneal epithelial cells. Endogenous S1P signaling upregulated VEGF-A and VE-cadherin mRNA expression levels in HUVEC. Unlike in TKE2 cells, SIS3 failed to block TGFβ1-induced VEGF-A upregulation in ocular fibroblasts. Taken together, these results indicate that injury-induced TGFβ1 upregulation increases S1P generation through increases in SPK1 activity. The rise in S1P formation stimulates the S1PR3-linked signaling pathway, which in turn increases VEGF-A expression levels and angiogenesis in mouse corneas.

Candida guilliermondii-induced chorioretinitis in a patient with eating disorder

Candidemia is a life-threatening fungal infection among patients undergoing long-term intravenous catheterization, hematopoietic stem cell transplantation, or immunosuppressive therapy, as well as patients with severe immunodeficiency or cancer. Endophthalmitis is a rare but severe form of ocular inflammation caused by infection of the intraocular cavity, which can lead to irreversible visual loss if not treated properly and promptly. The initial manifestation typically involves chorioretinitis, which requires early diagnosis and appropriate treatment. Candida guilliermondii is a non-Candida albicans yeast species; its frequency of detection in Japan has increased in recent years, and many drug-resistant and less-chorioretinitis-related strains are known. Here, we describe a 17-year-old girl with an eating disorder who exhibited chorioretinitis because of catheter-related bloodstream infection (CRBSI) caused by C. guilliermondii. The patient was hospitalized with severe weight loss, and she was presumed to develop candidemia because of immunosuppression during central parenteral nutrition therapy with a peripherally inserted central catheter. After onset of CRBSI, the catheter was immediately removed. Antifungal therapy was modified following fundus examination, fungal species confirmation, and drug sensitivity confirmation; thus, the patient recovered without long-term complications. To the best of our knowledge, this is the first report of C. guilliermondii-induced chorioretinitis in a patient with an eating disorder. Prolonged malnutrition and immunosuppression during nutritional therapy create a risk of candidemia in patients with eating disorders. After the onset of CRBSI, early administration and appropriate use of antifungal agents, with respect to specific ocular complications, are important for reduction of both mortality and ocular complications.

Successful percutaneous removal of dislodged ring-marker of optical coherence tomography catheter using the twisted wire technique with a guide-extension catheter: A case report

An 81-year-old male with diabetes and hypertension was admitted to our hospital due to chest pain on exertion. Coronary angiography revealed a severe stenosis at the middle of right coronary artery (RCA). We performed percutaneous coronary intervention under the guidance of optical coherence tomography (OCT) to the lesion in the middle RCA. After balloon dilations, a drug-eluting stent was deployed to the lesion. Then, OCT examination was performed. At that time, fluoroscopy revealed a foreign body over the 0.014-inch guidewire in the distal RCA, which was the ring-marker of OCT catheter. As RCA blood flow was well preserved, percutaneous removal of the dislodged ring-marker was immediately attempted. At first, we tried to remove the dislodged ring-marker with the guide-extension catheter trapping technique. However, it failed and advanced balloon catheter made the dislodged ring-marker migrate more distally. Therefore, we tried the twisted wire technique with the guide-extension catheter and finally the dislodged ring-marker was removed with it. To the best of our knowledge, this is the first case report of a successful percutaneous removal of a dislodged ring-marker of OCT catheter using the twisted wire technique with a guide-extension catheter. <Learning objective: Although intravascular foreign bodies during percutaneous coronary intervention (PCI) are very rare, it is one of the challenging complications. In this case, we experienced the dislodgement of ring-marker of optical coherence tomography catheter which was removed by twisted wire technique with a guide-extension catheter. The twisted wire technique with a guide-extension catheter can be a useful approach for percutaneous removal of foreign bodies, when other percutaneous retrieval techniques are unsuitable.>.

Effect of eicosapentaenoic acid/docosahexaenoic acid on coronary high-intensity plaques detected with non-contrast T1-weighted imaging: subgroup analysis of the AQUAMARINE EPA/DHA study

Background

In the recent the Reduction of Cardiovascular Events with EPA-Intervention Trial (REDUCE-IT), statin therapy plus high-dose eicosapentaenoic acid (EPA) significantly reduced the risk of cardiovascular death in patients with coronary artery disease (CAD) with elevated triglyceride (TG) levels. An epidemiologic study has shown that increasing the intake of long-chain n-3 polyunsaturated fatty acids, especially EPA and docosahexaenoic acid (DHA), are associated with a lower risk of fatal CAD. However, the anti-atherosclerotic effect of high-dose EPA/DHA has not be clarified.

We reported that coronary high-intensity plaques (HIPs) detected with non-contrast T1-weighted imaging (T1WI) on cardiac magnetic resonance (CMR), which can be uniquely quantitative assessed using the plaque-to-myocardium signal intensity ratio (PMR) of ≥1.4, are significantly associated with future coronary events. Moreover, we demonstrated that intensive statin therapy reduces the PMR of coronary HIPs by 19% but is unlikely to completely resolve HIP (PMR&lt;1.0).

In the AQUAMARINE EPA/DHA study, our goal was to assess the anti-atherogenic effect of EPA/DHA in an exploratory manner by examining the change in PMR of coronary HIPs after 12 months of EPA/DHA therapy in patients with CAD on statin therapy.

Methods

This study was designed as a single-center, triple-arm, parallel-group, randomized controlled, open-label, superiority trial examining the effect of 12 months of additional EPA/DHA therapy on coronary HIPs in patients with CAD who receiving statin therapy. Eligible subjects are randomly assigned to the 2 g/day EPA/DHA group (n=26), the 4 g/day group (n=23), or the no EPA/DHA (statin-only) group (n=24) between May 2014 and December 2017. The PMR was defined as the signal intensity of the coronary plaque divided by that of nearby left ventricular myocardium. The primary endpoint is the change in PMR after EPA/DHA treatment.

Results

These 3 groups were well matched at baseline, with no statistically significant differences in age, male sex, conventional coronary risk factors, TG level, medications, and PMR. Figure 1 shows subgroup analysis of patients with high triglyceride levels (&gt;150mg/dl). In the patient-based analysis (A), 12 months of EPA/DHA therapy significantly reduced the PMR of primary lesions. In the segment-based analysis (B), additional reduction of PMR was observed in the high-dose EPA/DHA group compared with the no EPA/DHA treatment group.

Discussion

The present study of patients with high triglyceride levels demonstrated that EPA/DHA had a dose-dependent anti-atherosclerotic effect. This finding may provide additional information of EPA/DHA for lowering the residual risk in patients with CAD on statin therapy.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Takeda Pharmaceutical Co., Ltd.

Characterization of thromboembolic and bleeding risks in cancer patients with acute myocardial infarction under the use of guideline-recommended dual-antiplatelet therapy

Background

Atherosclerotic cardiovascular disease including acute myocardial infarction (AMI) has become one of major co-existing diseases in cancer patients due to their improved survival rate. Current guideline recommends dual-antiplatelet therapy (DAPT) in patients with AMI. Given that the presence of cancer elevates not only coagulability but bleeding risks, these substrate may further worsen cardiovascular outcomes and bleeding risks in cancer subjects with AMI receiving DAPT.

Methods

We retrospectively analyzed 712 AMI patients treated by primary PCI with drug-eluting stent and DAPT between 2007 and 2017. The diagnosis of cancer was determined through medical record review. Clinical characteristics, thromboembolic (=all-cause death+non-fatal MI+stroke) and bleeding events were compared in AMI subjects with vs. without cancer.

Results

Cancer was identified in 11.1% (=79/712) of study subjects. Of these, around 40% of them had gastrointestinal cancer (=35/79), followed by lung cancer (=5/79) and breast cancer (=8/79). Cancer patients were more likely to be older (77±7 v. 69±13 years, p&lt;0.001) with a history of Af (25 v. 10%, p&lt;0.001), CKD (eGFR&lt;60: 60 v. 42%, p=0.002), anemia (hemoglobin: 12.8±1.8 v. 13.9±1.8 g/dl, p&lt;0.001). Under anti-thrombotic (DAPT=86%, triple-antiplatelet therapy=14%) and optimal medical therapies (ACE-I=90%, beta-blocker=76%, statin=96%), more frequent occurrence of thromboembolic events was observed in patients with cancer (34.2 v. 12.6%, p=0.004, Picture). Furthermore, the presence of cancer was associated with more than four times greater risk of bleeding events compared to non-cancer subjects (18.9 v. 4.3%, p&lt;0.001, Picture). In particular, the frequency of both major (10.1 vs. 3.3%, p=0.003) and minor (8.9 vs. 0.9%, p&lt;0.001) bleeding events was significantly higher in patients with cancer. In multivariate analysis, cancer independently predicted bleeding events (Table).

Conclusions

Under the use of guideline recommended DAPT, the concomitance of cancer in AMI subjects was a predictor for thromboembolic as well as bleeding events. In particular, the relationship between cancer and bleeding was significant. These observations underscore the appropriate selection and duration of anti-thrombotic agents in AMI subjects with cancer.

Cardiac/Bleeding Events in AMI Subjects

Funding Acknowledgement

Type of funding source: None

Influence of caffeine intake on intravenous adenosine-induced fractional flow reserve

Background

This study evaluated whether caffeine abstention is required before fractional flow reserve (FFR) measurement by intravenous adenosine triphosphate (ATP) administration in Japanese patients.

Methods and results

This study was a subanalysis of a previously published study and a total of 208 intermediate lesions that underwent FFR measurements were enrolled for this analysis. Hyperemia was induced by continuous intravenous ATP infusion at 150μg/kg/min (IVATP150) and 210μg/kg/min (IVATP210), and by intracoronary administration of nicorandil 2mg (ICNIC2mg) as a reference standard. The degree of change in the FFR value both after IVATP150 and after IVATP210, as compared with the FFR value after ICNIC2mg was similar between the caffeine and non-caffeine groups (−0.04±0.05 vs. −0.04±0.07, and 0.00±0.02 vs. 0.01±0.02, respectively). In patients who consumed caffeine before the FFR measurement, the degree of FFR change was independent of the time interval (&lt;12 hours, 12–24 hours, and 24–48 hours) between caffeine intake and catheterization both after IVATP150 and ICNIC2mg and after IVATP210 and ICNIC2mg.

Conclusion

When compared with the FFR value after ICNIC2mg, the degree of change in the FFR value both after IVATP150 and after IVATP210 remained similar regardless of caffeine intake. Strict caffeine abstention before intravenous ATP-induced FFR measurement may not be required in clinical practice.

Funding Acknowledgement

Type of funding source: None

Muse cells, endogenous reparative pluripotent stem cells, are mobilized into the peripheral blood after percutaneous coronary intervention in patients with coronary artery disease

Background

Multilineage-differentiating stress enduring (Muse) cells, endogenous reparative pluripotent stem cells, are defined as stage-specific embryonic antigen 3+ (SSEA3+) and CD105+ double-positive cells. We previously reported that intravenously injected Muse cells home to the damaged heart and differentiate into cardiomyocytes and vessels, and reduce the infarct size and improve cardiac function in a rabbit model of acute myocardial infarction (AMI) (Circ Res 2018), and that endogenous Muse cells are mobilized into the peripheral blood in the acute phase of patients with AMI, which improve left ventricular (LV) function and attenuate LV remodeling in the chronic phase at 6 months (Circ J 2018). However, whether Muse cells are mobilized into the peripheral blood after percutaneous coronary intervention (PCI) in patients with coronary artery disease.

Methods

Muse cells in the peripheral blood was measured by fluorescence-activated cell sorting (FACS) as SSEA3+ and CD105+ double-positive cells in patients with coronary artery disease with 75% coronary stenosis who underwent PCI (n=18) with a mean age of 73.0±7.2 (14 male and 4 female). Blood samples were collected from the antecubital vein in patients with coronary artery disease before, and 1 and 24 h after PCI. Since the majority of Muse cells were detected in the monocyte area and few Muse cells if any were detected in the lymphocyte area, we counted the Muse cells in the monocyte area by FACS. The number of Muse cells was expressed as cells per 100 μL of blood, as follows: absolute number of Muse cells (/100 μL) = white blood cells (/100 μL) × monocytes (%) × SSEA3+/CD105+ double-positive cells (%).

Results

Typical case of SSEA3+/CD105+ double-positive Muse cells measured by FACS shows that majority of Muse cells exist in the monocyte area (Fig, 1-A). The number of Muse cells in the peripheral blood was significantly greater (p&lt;0.05) at 1 h (58.6±23.8 /100 μL) or 24 h after PCI (69.7±43.1/100 μL) as compared with that before PCI (46.3±19.0/100 μL) (Fig. 1-B).

Conclusion

Muse cells, endogenous pluripotent stem cells, are mobilized into the peripheral circulating blood 1 h and 24 h after PCI in patients with coronary artery disease. Mobilized Muse cells after PCI might be contributing to repair the damaged coronary artery.

Figure 1

Funding Acknowledgement

Type of funding source: None

Beneficial effects of balloon pulmonary angioplasty on clinical outcomes in patients with residual pulmonary hypertension after pulmonary endarterectomy

Background

Although pulmonary endarterectomy (PEA) is an established surgical treatment for chronic thromboembolic pulmonary hypertension (CTEPH), a part of patients after PEA show residual pulmonary hypertension, leading to limited exercise capacity. Recently, several studies have indicated that balloon pulmonary angioplasty (BPA) improves hemodynamics, exercise capacity and prognosis in inoperable CTEPH patients. However, the effects of BPA in patients with residual pulmonary hypertension after PEA remain to be elucidated.

Aim

In the present study, we investigated comprehensive efficacy of BPA on hemodynamics, exercise capacity and right ventricular function in those with residual pulmonary hypertension after PEA.

Methods

From October 2010 to February 2019, 227 patients with CTEPH underwent PEA in our institution. Right heart catheterization after PEA (median follow up period from PEA to right heart catheterization 39 [10.5, 90] months) showed that 55 patients showed residual PH (mean pulmonary artery pressure (mPAP)≥25mmHg), and 38 of them referred to BPA (mean age 57 years old, male 8 (21%)) due to residual symptoms. In 29 out of 38 patients (76%) who completed BPA and underwent follow-up right heart catheterization, we examined hemodynamics, exercise capacity and right ventricular function before and after BPA. Follow-up examination was performed 3 months after last BPA session.

Results

In this study population (N=29), PEA significantly improved mPAP (47±7 to 38±10 mmHg), pulmonary vascular resistance (PVR, 14.6±4.6 to 9.2±4.6 WU) and right ventricular ejection fraction measured by magnetic resonance imaging (26.6±11.3 to 38.4±6.8%) (Figure). Median period from PEA to first BPA procedure was 42 [13.5, 94] months. Total session number during study period was 160 sessions, and mean session number of BPA was 5.5±1.5 per patient. Follow-up study revealed that BPA additionally improved mPAP (38±10 to 27±8 mmHg) and PVR (9.2±4.6 to 5.1±2.2 WU) (Figure). Similarly, 6-minute walk distance (393±125 to 452±125 m) and peak VO2 (16.4±3.8 to 18.1±4.6 ml/min/kg, p&lt;0.05) were increased, and WHO functional class also significantly improved by BPA (I/II/III/IV, 0/21/8/ 0 to 1/27/1/0, p&lt;0.01). In addition, right ventricular ejection fraction (38.4±6.8 to 44.2±7.1%) was increased after BPA (Figure). There were no procedure-related deaths and major lung injuries requiring oral intubation during study period. 3-year survival in patients after BPA was 100% (median follow-up period after last BPA session, 32 [18, 46] months).

Conclusion

In CTEPH patients with residual pulmonary hypertension after PEA, additional BPA significantly improved hemodynamics, right ventricular function, exercise capacity and residual symptoms without severe complications, leading to good prognosis. These results suggest that combination therapy of PEA and BPA could be an effective therapeutic option for post PEA patients with residual symptoms and exercise limitation.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic differences between atrial functional mitral regurgitation and ventricular functional mitral regurgitation

Introduction

Atrial functional mitral regurgitation (A-FMR) has been under-recognized until recently as a cause of FMR, and the prognostic difference between A-FMR and ventricular FMR (V-FMR) has not been fully elucidated. As there has been different mechanisms of FMR suggested in A-FMR and V-FMR, we hypothesized that prognosis and prognostic predictors of A-FMR may differ from those of V-FMR.

Purpose

To investigate the prognosis and prognostic predictors of A-FMR in comparison with V-FMR.

Methods

Among 1312 consecutive patients with grade 3+ (moderate to severe) or 4+ (severe) MR, 378 consecutive FMR patients were identified by excluding patients with degenerative MR, previous cardiac surgery, or concomitant aortic valve disease and/or mitral stenosis. FMR with ejection fraction (EF) &lt;40% or FMR due to regional wall motion abnormalities with leaflet tethering were classified as V-FMR (N=288), and FMR due to left atrial (LA) and/or annular dilatation with preserved or mid-range EF (≥40%) were classified as A-FMR (N=90). All-cause death and heart failure hospitalization were analyzed as cardiovascular (CV) events in this study. Surgical or percutaneous mitral valve intervention without CV events was handled as not reaching an endpoint and these cases were censored.

Results

A-FMR were significantly older (76 [69–82] vs. 70 [58–77] years), higher rates of female (64 vs. 35%) and atrial fibrillation (88 vs. 42%), and lower B-type natriuretic peptide (BNP) values (169 [101–318] vs. 447 [213–952] pg/ml) compared to V-FMR (all P&lt;0.05). On echocardiography, LV end-diastolic and end-systolic dimensions (52 [48–57] vs. 64 [58–72] mm, 34 [31–37] vs. 55 [48–64] mm), respectively) were smaller, and EF (55 [50–60] vs. 28 [19–35] %) and LA volume (99 [73–137] vs. 73 [57–91] ml/m2) were larger in A-FMR (all P&lt;0.05). Effective regurgitant orifice area (32 [26–40] vs. 31 [24–45] mm2) and regurgitant volume (50±15 vs. 52±16 ml) were similar (both n.s.). During a median follow up of 1407 days, 206 (54%) patients developed CV events. Kaplan-Meier analysis revealed that V-FMR had a significantly higher rates of CV events compared to A-FMR (Figure) with adjusted hazard ratio (HR) of 1.762 [1.168–2.660], P=0.007 after adjusted for variables including age, sex, New York Heart Association functional class, previous heart failure hospitalization, estimated glomerular filtration rate (eGFR) and BNP. Further, stepwise multivariate analysis showed that independent prognostic predictors of A-FMR were LA volume and eGFR, while those for V-FMR were LA volume, age, and LV end-systolic dimension.

Conclusions

A-FMR had relatively better prognosis compared to V-FMR, and there were different prognostic predictors between A-FMR and V-FMR. Our results suggest that different treatment strategies need to be considered between A-FMR and V-FMR.

The Kaplan-Meier life table

Funding Acknowledgement

Type of funding source: None

Recurrences of disease activity in patients with cardiac sarcoidosis under corticosteroid therapy: prevalence, clinical background and prognosis

Background

Corticosteroid therapy (CTx) has been widely accepted as first-line therapy for cardiac sarcoidosis (CS), but there are very limited data regarding recurrence of disease activity of CS. We retrospectively investigated the prevalence, patient characteristics and prognostic significance in patients with recurrences of CS.

Methods

We identified 102 consecutive patients who were clinically diagnosed CS (admission: 2012 and 2019) and whose disease activity was diminished clinically at least once. Recurrence of CS was defined as detection of increased uptake of 18F-fluoro-2-deoxyglucose or gallium-67 in the follow-up examination. Composite adverse events (events) were defined as all-cause of death or hospitalization for heart failure. Echocardiographic and laboratory data before initiation of CTx were obtained.

Results

During the follow-up term (median: 4.9 years), the recurrences of CS occurred in 28 patients at 30 months (median) after the initiation of CTx. In patients with recurrence, left ventricular (LV) ejection fraction before initiation of CTx was lower than in those without recurrences (median: 31% vs. 39%, p&lt;0.05). After the detection of CS recurrences, 17 patients were treated with only increases of PSL and remaining 11 patients were treated with adding other immunosuppressive therapies to CTx. The univariate analysis demonstrated that there were no parameters in echocardiographic and laboratory examinations to predict the recurrences of CS. The results of univariate analysis for event occurrences (n=12) are shown in the Table. Additionally, the Kaplan-Meier analysis showed that there were no differences in event free survival rate in the patients with and without CS recurrences (Figure).

Conclusion

This study showed that the recurrences of disease activity were observed in a substantial number of patients with CS even under the CTx. All patients received intensification of CTx or additional immunosuppressive therapy, and LV systolic function, rather than the recurrence itself, was associated with clinical outcomes in this study.

Kaplan-Meier analysis for events

Funding Acknowledgement

Type of funding source: None

Characterization of plaque features exhibiting physiological mismatch between fractional flow reserve and resting index: near-infrared spectroscopy imaging analysis

Background

In addition to fractional flow reserve (FFR), resting indexes (RI) have been shown as another physiological measure to evaluate myocardial ischemia. Despite the clinical usefulness of RI without the use of intravenous vasodilatory agent, discrepancy between FFR and RI infrequently occurs. Whether this physiological mismatch is derived by specific plaque feature remains unknown.

Purpose

To characterize coronary plaques associated with coronary physiological mismatch.

Methods

We analyzed 59 coronary arteries (LAD/RCA/LCX=49/4/6) with FFR≤0.80 in 57 stable CAD subjects receiving PCI. Following measurement of FFR and RI, culprit lesion was evaluated by near-infrared spectroscopy and intravascular ultrasound (NIRS/IVUS). The analyzed vessels were stratified according to FFR and RI values: FFR≤0.75+RI&gt;0.89 (n=6: physiological mismatch), FFR&gt;0.75+RI&gt;0.89 (n=6), FFR≤0.75+RI≤0.89 (n=33) and FFR&gt;0.75+RI≤0.89 (n=14).

Results

The median values of percent diameter stenosis, FFR and RI were 51%, 0.75 and 0.87, respectively. Physiological mismatch was observed in 10.1% (=6/59) of analyzed vessels. On IVUS imaging, maximum percent plaque area was greater than 70% in all groups (p=0.29). Furthermore, there were no significant differences in angiographic and IVUS-derived minimum lumen area across 4 groups (Table). However, culprit lesions exhibiting physiological mismatch contained a substantially larger amount of lipid plaque, reflected by a higher maximum 4-mm lipid-core burned index (maxLCBI4mm: p=0.04) on NIRS imaging (Table). Multivariate analysis demonstrated maxLCBI4mm as the only plaque feature associated with physiological mismatch (odds ratio=1.010, 95% CI: 1.001–1.019, p=0.02).

Conclusion

Plaque feature associated with coronary physiological mismatch was the extent of lipidic materials but not the quantity of coronary atheroma. Since the accumulation of lipidic plaque component is caused by endothelial dysfunction, this vascular substrate could impair baseline vasomotion, thereby causing a lower FFR despite preserved RI value. Evaluation of lipidic burden may be a potential option to avoid unnecessary deferral of revascularization in subjects with normal RI value.

maxLCBI4mm in each group

Funding Acknowledgement

Type of funding source: None

Sex differences in door-to-balloon time and long-term adverse events after percutaneous coronary intervention for acute coronary syndrome: a sub-study from the Prospective JAMIR study

Background

Shortening of onset to admission time (OAT) and door-to-balloon time (DBT) is associated with lower adverse cardiac event after primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Bleeding event also results in poor outcome in patients with AMI after primary PCI. Little is known about sex differences in DBT and ischemic, bleeding events after AMI.

Purpose

This study aimed to assess the sex differences of OAT, DTB and adverse cardiac event, incident of bleeding event after primary PCI in patients with AMI.

Methods

The Japan AMI Registry (JAMIR) is a multicenter, nationwide, prospective registry enrolling patients with AMI from 50 institutes between December 2015 and May 2017. Primary endpoints of this study were ischemic event (composite of cardiovascular death, myocardial infarction and ischemic stroke) and bleeding event (BARC type 3 or 5,).Median follow-up period was 12 months.

Results

A total of 3,411 patients were enrolled at first. Among them, 329 patients without treated with PCI and 199 patients missing OAT time were excluded from this study. A total 2883 patients of men (n=2240, 77.7%) and women (n=643, 22.3%) were enrolled. OAT and DBT of women were significantly longer than that of men (OAT: 130min, interquartile range 62–300 min vs. 155 min, interquartile range 69–350 min, p=0.040, DBT: 67 min, interquartile range 50–95 min vs. 75 min, interquartile range 53–120 min, p&lt;0.001). There was no significant difference in ischemic events between men and women (7.1% vs. 7.5%, log-rank p=0.741, Figure 1). Multivariate Cox regression analysis showed female sex was significantly associated with lower ischemic event (hazard ratio 0.57; 95% confidence interval 0.38–0.85; p=0.007). Bleeding event of women was significantly higher than that of men (BARC type 3 or 5: 3.8% vs. 7.8%, p&lt;0.001, Figure 2).

Conclusion

The real-world database of the JAMIR showed that the female sex was significant factor for the delay in primary percutaneous coronary intervention and high incident of bleeding, however, ischemic event was lower than that of male sex. Sex difference appears to be associated with ischemic and bleeding event after acute myocardial infarction.

Funding Acknowledgement

Type of funding source: None

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Figure 1

Funding Acknowledgement

Type of funding source: None

SAT0116 COMPARISON OF THE EFFICACY OF ABATACEPT ON ELDERLY AND YOUNG PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

The widespread use of biologic agents has greatly improved the prognosis of rheumatoid arthritis (RA). On the other hand, elderly patients with RA are relatively increasing. Although achieving low disease activity is a goal for those elderly patients as well as young patients, the efficacy of tumor necrosis factor inhibitors were reported to be equally or slightly less effective in elderly patients than in young patients. There is a lack of evidence for the efficacy of abatacept (ABT) in elderly patients.

Objectives:

In this study, we aimed to clarify the efficacy of ABT in elderly and young patients with RA compared to csDMARDs.

Methods:

This is a multicenter, open-label, prospective, observational study. All patients with RA enrolled this study are refractory to csDMARDs and have not received any biologics. Either ABT or csDMARDs was administered at the discretion of physicians to elderly (65 years and older) and young (20-64 years) patients (ABT-elderly, ABT-young, control (CTL)-elderly, and CTL-young groups). Comparison was made between 4 groups of patients. The primary study endpoint was a good response by EULAR response criteria at week 24 after administration. The research procedure has been approved by the ethics committee of Toho University School of Medicine (Approval number: A17112).

Results:

A total of 219 patients, 127 in the ABT group and 92 in the CTL group, were enrolled in this study. The majority of patients were women (82.7%) with a mean age (±SD) of 64.9±13.6 years (74.5±5.9 years in the elderly group and 52.4±10.1 years in the young group). The ABT group had higher disease activity, higher HAQ, and higher steroid use rates and dosage than the CTL group. These were also observed in the elderly group. In the young group, although the ABT group had higher disease activity and higher HAQ than the CTL group, no difference was observed in steroid use rates and dosage. The ABT group more frequently achieved a good response by EULAR response criteria compared to the CTL group at week 24 (58.8% and 27.2%, respectively, p<0.0001). The ABT group also showed higher efficacy than the CTL group in the elderly and young groups with a good response. Regarding the improvement in DAS28-ESR and DAS28-CRP, the ABT group was also superior to the CTL group. There was no difference on efficacy between elderly and young patients from the ABT groups.

Based on propensity score matching for disease activity at baseline, 61 matched pairs of patients treated with ABT or csDMARDs were statistically extracted. Although there was no significant difference in the rate of patients with a good response by EULAR response criteria between the ABT and the CTL groups, the ABT group showed significantly better response than the CTL group in the elderly. Furthermore, the ABT group was superior to the CTL group in improvement in both DAS28-ESR and DAS28-CRP, and similar results were obtained in the elderly. However, there was no significant difference between the ABT group and the CTL group in the young. In addition, elderly patients had significant improvement in DAS28-ESR compared with young patients in the ABT group.

Conclusion:

Treatment with ABT showed higher efficacy compared with CTL, particularly in elderly patients with RA.

References:

[1]Harigai M, et al. Mod Rheumatol. 2019;29:747.

[2]Sugihara T, Harigai M. Drugs Aging. 2016;33:97.

Disclosure of Interests:

Sei Muraoka Consultant of: Asahikasei Pharma Corp., Speakers bureau: Ono Pharmaceutical Co., Ltd., Eisai Co., Ltd., Asahikasei Pharma Corp., and Astellas Pharma Inc., Zento Yamada: None declared, Wataru Hirose: None declared, Hajime Kono: None declared, Shinsuke Yasuda Speakers bureau: Bristol Myers Squibb, Chugai Pharmaceutical Co., Tanabe Mitsubishi Parma Co., and GlaxoSmith Kline, Toshihiro Nanki Grant/research support from: Chugai Pharmaceutical Co., Eisai Co., Ltd., Teijin Pharma Ltd., Eli Lilly Japan K.K., Bristol-Myers K.K., Ono Pharmaceutical Co., Ltd., Novartis Pharma K.K., Asahikasei Pharma Corp., Mitsubishi-Tanabe Pharma Co., Astellas Pharma Inc., Ayumi Pharmaceutical Co., Pfizer Japan Inc., Daiichi Sankyo Co., Ltd., Shionogi & Co., Ltd., Sanofi K.K., Nippon Kayaku Co., Ltd., Yutoku Pharmaceutical Ind. Co., Ltd., UCB Japan Co. Ltd., Nihon Pharmaceutical Co., Ltd., and Bayer Yakuhin, Ltd., Consultant of: UCB Japan Co., Ltd., Eisai Co., Ltd., and Chugai Pharmaceutical Co., Speakers bureau: Mitsubishi-Tanabe Pharma Co., Chugai Pharmaceutical Co., Eisai Co., Ltd., Astellas Pharma Inc., Janssen Pharmaceutical K.K., Ayumi Pharmaceutical Co., Pfizer Japan Inc., Asahikasei Pharma Corp., Sanofi K.K., Novartis Pharma K.K., Eli Lilly Japan K.K., Nippon Kayaku Co., Ltd., Teijin Pharma Ltd., Takeda Pharmaceutical Co., Nippon Boehringer Ingelheim Co., Ltd., and AbbVie GK.

A Case of Repeating Transient Increase in Intraocular Pressure by Instability of an Intraocular Lens Implanted in the Capsular Bag

We observed repeated episodes of rapid increases in intraocular pressure (IOP) considered to be caused by an in-the-bag intraocular lens (IOL) instability in a patient with an implanted IOL. As acute glaucoma attack-like increase in IOP was noted in the left eye on November 8, she was admitted to Wakayama Medical University Hospital. The findings at the first examination included an IOP of 62 mm Hg, instability of a PMMA one-piece IOL, shallow anterior chamber, narrow angle, moderate mydriasis, and loss of pupillary light reaction in the left avitreous eye. On November 15, a 6-mm Hg increase in IOP was observed during 60-min dark room prone provocative testing. After the first examination, the patient perceived pain and reduced visual acuity of the left eye and emergently consulted our hospital twice. Despite miosis, normalization of the anterior chamber depth and IOP with widening of the angle were achieved by resting in the supine position. These episodes were thought to be caused by instability and anterior shift of the IOL. On January 17, 2018, suture fixation of the in-the-bag IOL was performed. The IOL was fixed by transscleral suturing of the bilateral supporting parts to the sclera. Recurrence of sudden ophthalmalgia, instability of the in-the-bag IOL, and an increase in IOP have not been observed for 1 year after surgical treatment. Instability of an in-the-bag IOL caused repeated acute angle-closure glaucoma-like attacks. The situation was well treated by suturing and fixing the haptics of IOL to the sclera.

P177 Left atrial strain in patients with cardiac amyloidosis. Relationship to left atrial amyloid deposition focusing on prognosis

Background

 In cardiac amyloidosis (CA), the left atrium (LA) is frequently infiltrated by the amyloid fibrils. It is currently known that LA strain is a marker of LA function and prognosis in many cardiac diseases, however its significance in CA remains unknown. 

Purpose

 Our aim was to investigate correlation between LA strain measured by Cardiovascular Magnetic Resonance (CMR) and amyloid deposit in LA, and also evaluate the LA strain on the prognostic significance. 

Methods and results

 Of 74 consecutive patients with biopsy-proven CA, we analyzed 42 patients (age 72 ± 10 years; 76 % males) with contrast-enhanced CMR, and examined LA late gadolinium enhancement (LGE) and CMR derived LA strain using feature tracking method. Of the 42 patients, 29 patients (69 %) was transthyretin cardiac amyloidosis (ATTR-CA) in the majority. We divided these 42 patients into two groups according to the CMR measured peak atrial longitudinal strain (PALS) (&gt; = or &lt; median); high-strain (&gt; = 6.67 %, n = 21) and low-strain (＜ 6.67 %, n = 21) and compared the patient’s characteristics, blood test data, echocardiography and CMR parameters. There were no significant differences between two groups in these parameters but in the extent of LA-LGE (54 % vs 80 %, p = 0.008). The PALS correlated with the extent of LA-LGE (ρ= 0.50, p = 0.001). In multivariate analysis including LVEF, E/e’ and BNP, LA-LGE was an independent determinant of PALS. During three-year follow up, the LA strain significantly related to heart failure hospitalization in the ATTR-CA patients (p = 0.036)(Figure). 

Conclusions

 In CA patients, CMR measured LA longitudinal strain correlates with the LA-LGE. It also provides useful information for poor prognosis of patients with ATTR-CA.

Abstract P177 Figure. Heart failure hospitalization in ATTR-CA

Factor Xa inhibitors for preventing recurrent thrombosis in patients with antiphospholipid syndrome: a longitudinal cohort study

OBJECTIVE

The objective of this study was to clarify the efficacy and safety of factor Xa inhibitors for antiphospholipid syndrome patients in real world utilization.

METHODS

This is a retrospective cohort study comprised of all consecutive patients with antiphospholipid syndrome in our department over a period of 28 years. Patients treated with factor Xa inhibitors were extracted from the cohort. As a control group, patients treated with warfarin were selected from the same cohort with matched age, gender, coexistence of systemic lupus erythematosus, and the presence of antiplatelet therapy, after which we used a propensity score for each of the risk factors as an additional covariate in multivariate Cox proportional hazard regression. The primary endpoint was set as thrombotic and hemorrhagic event-free survival for five years.

RESULTS

Among 206 patients with antiphospholipid syndrome, 18 had a history of anti-Xa therapy (five rivaroxaban, 12 edoxaban, one apixaban). Fourteen out of 18 patients on anti-Xa therapy had switched to factor Xa inhibitors from warfarin. Event-free survival was significantly shorter during anti-Xa therapy than that during warfarin therapy (hazard ratio: 12.1, 95% confidence interval: 1.73-248, p = 0.01) ( Figure 1(a) ). Similarly, event-free survival in patients treated with factor Xa inhibitors was significantly shorter compared with controls (hazard ratio: 4.62, 95% confidence interval: 1.54-13.6, p = 0.0075). In the multivariate Cox proportional hazard model, event-free survival in patients with anti-Xa therapy remained significantly shorter (hazard ratio: 11.9, 95% confidence interval: 2.93-56.0, p = 0.0005).

CONCLUSIONS

Factor Xa inhibitors may not be recommended for antiphospholipid syndrome.

P5635Predictive ability of lipdic burden for FFR-derived physiological measures: insights from near-infrared spectroscopy imaging analysis

Background

Fractional flow reserve (FFR) has enabled to physiologically assess the myocardial ischemia of coronary artery with intermediate stenosis. Mechanistically, not only the severity of coronary stenosis but also the extent of maximal vasodilatation within the entire coronary artery potentially affects this physiological measure. Since the accumulation of lipidic materials within vessel wall increases vascular stiffness via inducing endothelial dysfunction, the presence of lipidic atheroma burden may affect physiological measures.

Purpose

To investigate the association of FFR with lipidic coronary atheroma by near-infrared spectroscopy/intravascular ultrasound (NIRS/IVUS) imaging, which quantitatively visualize lipidic burden in vivo.

Methods

We analyzed 61 coronary arteries (LAD/RCA/LCX=52/5/4) with FFR≤0.80 in 59 stable coronary artery disease subjects receiving PCI. Following FFR measurement, NIRS/IVUS imaging was conducted to evaluate the extent of atheroma burden (maximum percent plaque area=max%PA) and lipidic materials (lipid core burden index within the entire vessel=LCBIvessel). The analyzed vessels were stratified according to FFR: definite FFR group (FFR≤0.74, n=34) and gray-zone FFR group (0.75≤FFR≤0.80, n=27).

Results

NIRS/IVUS imaging analysis (analyzed longitudinal length=77±7mm) was more likely to exhibit a significantly higher LCBIvessel and a larger max%PA in the definite FFR group (Table). Of note, FFR was significantly correlated to LCBIvessel (ρ=-0.299, p=0.02), but not max%PA (ρ=-0.255, p=0.07). Multivariate analysis demonstrated that an independent determinant of FFR≤0.74 was LCBIvessel [odds ratio (OR)=1.016, 95% confidential interval (CI)=1.002–1.031, p=0.02], but not max%PA [OR=1.084, 95% CI=0.994–1.182, p=0.07]. Area under the receiver-operating characteristic curve analysis elucidated that the addition of LCBIvessel to angiography- and IVUS-derived measures resulted in a significant improvement for detecting FFR≤0.74 (picture).

Definite FFR Group (FFR≤0.74, n=34) Gray-zone FFR Group (0.75≤FFR≤0.80, n=27) p value Fractional flow reserve (FFR) 0.68±0.05 0.78±0.02 <0.01 Percent diameter stenosis (%) 56.2±13.1 51.9±7.8 0.16 Maximum percent plaque area (max%PA, %) 84.3±6.9 79.9±7.2 0.01 Lipid core burden index within the entire vessel (LCBIvessel) 102.0±60.2 65.6±51.6 0.01

ROC analysis for detecting FFR≦0.74

Conclusion

The propagation of lipidic burden associates with the physiological measures. The present findings indicate the possibility that vessel characteristics or instability may have influence for causing ischemia on the coronary artery.

P3615The number of coronary risk factors and mortality in patients with acute myocardial infarction from Japanese nation-wide real-world database

Background

Hypertension, diabetes, dyslipidemia and smoking are so-called coronary risk factors for coronary heart disease, which were established by extensive epidemiological research. However, in Japanese patients with acute myocardial infarction (AMI), the impact of number of coronary risk factors on in-hospital morality has not been elucidated.

Methods

The Japan Acute Myocardial Infarction Registry (JAMIR) is a nationwide real-world database integrated form 10 regional registries. We examined the association between number of coronary risk factors and in-hospital mortality from this JAMIR registry.

Results

The data were obtained from total of 20462 AMI patients (mean age, 68.8±13.3 years old; 15281 men, 5181 women). Figure 1 shows the prevalence of each coronary risk factors stratified by sex and decade. The prevalence of hypertension became higher with the advanced age while the prevalence of smoking became lower with the advanced age. Prevalence of diabetes and dyslipidemia were highest in middle age. Majority (76.9%) of the patients with AMI had at least 1 of these coronary risk factors and, 23.1% had none of them. Overall, except women under 50, number of coronary risk factor was relatively less in older age (Figure 2). In-hospital mortality by sex and decades was shown in figure 3. In-hospital mortality rates were 10.7%, 10.5%, 7.2%, 5.0% and 4.5% with 0, 1, 2, 3 and 4 risk factors, respectively (Figure 4A). After adjusting age and sex, there was an inverse association between the number of coronary risk factors and in-hospital mortality (adjusted odds ratio [1.68; 95% CI, 1.20–2.35] among individuals with 0 vs. 4 risk factors, Figure 4B).

Conclusion

In the present study of Japanese patients with AMI, who received modern medical treatment, in-hospital mortality was inversely related to the number of coronary risk factors.

Acknowledgement/Funding

Grant-in-Aid for Scientific Research

P938Extensive formation of atherosclerotic cardiovascular disease in subjects with severe familial hypercholesterolemia defined by the international atherosclerosis society criteria

Introduction

The International Atherosclerosis Society (IAS) has proposed “severe familial hypercholesterolemia (FH)” as a FH phenotype with the highest cardiovascular risk. Coronary artery disease (CAD) represents a major atherosclerotic change in FH patients. Given their higher LDL-C level and atherogenic clinical features, more extensive formation of atherosclerosis cardiovascular disease including not only CAD but stroke/peripheral artery disease (PAD) may more frequently occur in severe FH.

Methods

481 clinically-diagnosed heterozygous FH subjects were analyzed. Severe FH was defined as untreated LDL-C>10.3 mmol/l, LDL-C>8.0 mmol/l+ 1 high-risk feature, LDL-C>4.9 mmol/l + 2 high-risk features or presence of clinical ASCVD according to IAS proposed statement. Cardiac (cardiac death and ACS) and non-cardiac (stroke and peripheral artery disease) events were compared in severe and non-severe FH subjects.

Results

Severe FH was identified in 50.1% of study subjects. They exhibit increased levels of LDL-C and Lipoprotein (a) with a higher frequency of LDLR mutation. Furthermore, a proportion of %LDL-C reduction>50% was greater in severe FH under more lipid-lowering therapy (Table). However, during the observational period (median=6.3 years), severe FH was associated with a 5.9-fold (95% CI, 2.05–25.2; p=0.004) and 5.8-fold (95% CI, 2.02–24.7; p=0.004) greater likelihood of experiencing cardiac-death/ACS and stroke/PAD, respectively (picture). Multivariate analysis demonstrated severe FH as an independent predictor of both cardiac-death/ACS (hazard ratio=3.39, 95% CI=1.12–14.7, p=0.02) and stroke/PAD (hazard ratio=3.38, 95% CI=1.16–14.3, p=0.02) events.

Clinical characteristics of severe FH Non-severe FH Severe FH P-value Baseline LDL-C (mmol/l) 5.3±1.5 6.6±2.0 <0.0001 Lp(a) (mg/dl) 15 [8–28] 21 [10–49] <0.0001 LDLR mutation (%) 49.6% 58.9% 0.00398 On-treatment LDL-C (mmol) 133 [106–165] 135 [103–169] 0.9856 %LDL-C reduction>50% 21.3% 49.8% <0.0001 High-intensity statin (%) 13.3% 42.3% <0.0001 PCSK9 inhibitor (%) 6.3% 21.2% <0.0001

Clinical outcome

Conclusions

Severe FH subjects exhibit substantial atherosclerotic risks for coronary, carotid and peripheral arteries despite lipid lowering therapy. Our finding underscore the screening of systemic arteries and the adoption of further stringent lipid management in severe FH patients.

P5655Efficacy of new-generation atrial antitachycardia pacing for atrial tachyarrhythmias in patients with left ventricular dysfunction

Background

The progression to persistent atrial fibrillation (AF) is associated with a worse clinical outcome in patients with previous atrial tachyarrhythmias. New-generation atrial antitachycardia pacing (ATP) (Reactive ATP) reduced the progression to persistent AF in patients with pacemaker and preserved left ventricular (LV) function. However, little is known about the efficacy of Reactive ATP in patients with cardiac implantable electronic devices (CIED) and LV dysfunction.

Purpose

We aimed to investigate the efficacy of Reactive ATP for atrial tachyarrhythmias in patients with LV dysfunction (LV ejection fraction [LVEF] <40%).

Methods

This study included 423 patients with CIED and previous atrial tachyarrthythmias. Reactive ATP was programmed in 284 patients (ATP group) and 139 were implanted with a dual-chamber device without ATP function (control group). The differences in the success rate of ATP and incidence of progression to persistent AF (≥7 days) between the ATP and control groups were evaluated in 108 patients with LVEF <40% (reduced LVEF) and 315 with LVEF ≥40% (preserved LVEF). Patients with persistent AF were excluded from this study.

Results

During 710±337 days of follow-up period, 16 patients (15%) with reduced LVEF and 51 (16%) with preserved LVEF progressed to persistent AF (p=0.88). The mean ATP success rate was lower in patients with reduced LVEF than in those with preserved LVEF, although not statistically significant (reduced LVEF: 27.2±19.4% and preserved LVEF: 35.1±29.2%, p=0.12). The incidence of progression to persistent AF was significantly lower in the ATP group than in the control group both in patients with reduced and preserved LVEF (log-rank, reduced LVEF: p=0.0070 and preserved LVEF: p<0.0001) (Figure). Multivariate analysis showed that use of Reactive ATP and smaller left atrium were associated with lower incidences of persistent AF, while LVEF was not predictive of progression to persistent AF (Reactive ATP: hazard ratio [HR] 0.28, 95% confidence interval [CI] 0.17–0.46, p<0.0001, left atrium diameter: HR 1.03, 95% CI 1.00–1.07, p=0.030).

Figure 1

Conclusions

Reactive ATP was effective in preventing AF progression in patients with LV dysfunction.

P5551Comparison of prognostic predictors of heart failure admission and progression to end-stage in hypertrophic cardiomyopathy

Background

Heart failure (HF) is a common complication within the clinical spectrum of hypertrophic cardiomyopathy (HCM). HCM-related HF is recognized to be multifactorial, including outflow obstruction, diastolic dysfunction, or progression to end-stage; however, prognostic predictors of HF events are not fully understood. We sought to investigate predictors for various HF outcomes in HCM.

Methods

We studied 289 consecutive HCM patients with EF≥50%. Patients with outflow obstruction (peak pressure gradient ≥30mmHg) were defined as obstructive HCM. HF events assessed in this study were 1) HF admission and 2) progression to end-stage (EF<50%).

Results

The mean age was 63±16 years, 53% male, EF 61±5%, NYHA class 1.8±0.7, and 39% obstructive. During a median follow up of 5.2 [3.7–7.0] years, 48 HF admission and 19 progression to end-stage were observed. Only 8/48 (17%) patients with HF admission had progressed to end-stage; while 11/19 (58%) patients with progression to end-stage remained free from HF admission. Univariate Cox regression hazard analysis showed different prognostic predictors between HF admission and progression to end-stage (Table). Multivariate Cox regression hazard analysis showed atrial fibrillation was an independent predictor of HF admission (adjusted HR 2.711 [1.094–7.389], P=0.031); while LV end-systolic dimension was an independent predictor of progression to end-stage (adjusted HR 1.114 [1.018–1.229], P=0.025).

Cox hazard analysis for predicting event HF admission Progression to end-stage HR (95% CI) P value HR (95% CI) P value Age, 1 year 1.042 (1.017–1.071) <0.001 1.002 (0.975–1.035) 0.89 Male sex 1.052 (0.595–1.882) 0.86 2.853 (1.034–10.02) 0.043 Atrial fibrillation 3.247 (1.809–6.608) <0.001 1.434 (0.570–3.559) 0.44 Non-obstructive 0.850 (0.481–1.531) 0.58 5.439 (1.558–34.30) 0.005 LV end-diastolic dimension, 1mm 1.027 (0.981–1.077) 0.25 1.120 (1.035–1.218) 0.005 LV end-systolic dimension, 1mm 1.059 (1.008–1.110) 0.023 1.167 (1.080–1.258) <0.001 EF, 1% 0.974 (0.926–1.032) 0.36 0.894 (0.825–0.980) 0.018 LA volume, 1ml/m2 1.012 (1.001–1.020) 0.044 1.006 (0.978–1.023) 0.64 Transmitral E wave, 1m/s 1.013 (1.002–1.024) 0.025 1.006 (0.987–1.023) 0.50 Transmitral DcT, 1msec 0.999 (0.995–1.003) 0.59 0.985 (0.974–0.994) <0.001 E/e', 1.0 1.062 (1.012–1.109) 0.015 1.089 (1.010–1.164) 0.027

Conclusions

Different prognostic predictors were found for HF admission and progression to end-stage, suggesting the difficulty and multifactorial nature of HCM-related HF.

P1932Predictors of DAPT use in patients beyond 1 year post myocardial infarction: Insights from the TIGRIS observational study

Background

International guidelines vary in their recommendations for dual antiplatelet therapy (DAPT) use beyond 1 year post-myocardial infarction (MI).

Purpose

To identify predictors of DAPT use in patients ≥1 year post-MI prior to the publication of the DAPT score and the 2017 European Society of Cardiology (ESC) guidelines for DAPT in coronary artery disease.

Methods

TIGRIS (NCT01866904) was a prospective, multi-center (369 centers in 25 countries), observational study of patients 1 to 3 years post-MI between June 2013 and November 2014. We performed a multivariable logistic regression analysis to identify independent predictors of DAPT use at 396 days post-MI (365 + 31 days overrun period to allow intended DAPT discontinuation at 1 year). Patients on oral anticoagulation were excluded.

Results

Of 8464 patients enrolled (mean age 66 years, women 24%, ST-elevation MI 53%), 40% were on DAPT at 396 days post-MI (Figure). In the subset of patients on DAPT at 396 days post-MI, aspirin was combined with clopidogrel in 84%, prasugrel in 12%, and other antiplatelet agents in 4%. DAPT use at 396 days post-MI was independently associated with geographic region, age, PCI for the index MI, and a history of multivessel disease or angina (Table). Several variables included in the DAPT score and ESC guideline recommendations (diabetes, second prior MI, hypertension, peripheral artery disease, heart failure, smoking, and renal insufficiency) were not independent predictors of DAPT use at 396 days.

Independent predictors of DAPT @396 days Variable at enrolment Patients Odds ratio (95% CI) P-value Region: Europe 3813 Reference group 0.01 North America 923 1.65 (0.56, 4.86) Latin America 1084 2.55 (1.19, 5.47) Asia and Australia 2644 3.01 (1.42, 6.36) Age <65 years 3274 1.15 (1.04, 1.28) 0.005 PCI for index MI 6925 2.08 (1.82, 2.38) <0.0001 Multi-vessel disease 5598 1.37 (1.24, 1.52) <0.0001 History of angina 829 1.46 (1.24, 1.71) <0.0001

DAPT use at 396 days post-MI by region

Conclusion

During the study period, DAPT use ≥1 year post-MI was prevalent and appeared to be influenced by regional practices. Further research is needed to determine whether the DAPT score and the 2017 ESC guidelines for dual antiplatelet therapy have changed long-term DAPT use practices.

Acknowledgement/Funding

AstraZeneca AB, Södertälje, Sweden

P1561An elevated risk of heart failure and stroke events in octogenarian Japanese patients with acute myocardial infarction who received percutaneous coronary intervention

Background

The proportion of the octogenarian population is expanding especially in Eastern society. Due to the clustering of risk factors, acute myocardial infarction (AMI) represents a major cardiovascular complication in octogenarian subjects. This suggests the need to further optimize their therapeutic management to prevent future cardiac events after AMI. However, analysis of clinical characteristics and cardiovascular outcomes in octogenarian subjects with AMI who received the current established medical therapies is limited.

Purpose

To investigate clinical features and prognosis in octogenarian AMI subjects treated with percutaneous coronary intervention (PCI).

Methods

We analyzed 1547 AMI subjects underwent PCI between 2007 and 2017. Baseline characteristics and the occurrence of composite major adverse cardiovascular events (cardiac death, non-fatal MI, revascularization, heart failure and stroke) were compared in octogenarian and non-octogenarian subjects.

Results

22.0% (340/1547) of study subjects was octogenarian. They were more likely to have chronic kidney disease (CKD) and a lower level of LDL-C on admission (Table). Moreover, a higher prevalence of severer Killip class and LVEF <30% were observed in octogenarians (Table). However, they were not optimally treated with the established medical therapies at discharge (Table). During the observational period (median=3.1 years), the composite of cardiovascular events more frequently occurred in octogenarian subjects. Of note, they exhibited a 2.15-fold and 3.01-fold increased risk for heart failure and stroke events, respectively (Figure).

Table 1 Non-Octogenarian (n=1207) Octogenarian (n=340) P-value CKD* (%) 33.8 63.2 <0.0001 LVEF <30% (%) 5.7 10.3 0.02 Killip class 1.33±0.03 1.55±0.05 <0.0001 LDL-C (mmol/L) 3.20±0.03 2.80±0.05 <0.0001 Statin (%) 86.3 78.2 0.0006 Beta-blocker (%) 74.0 65.8 0.005 ACE-I/ARB (%) 87.3 76.6 <0.0001 DAPT (%) 86.0 88.6 0.42 *CKD is defined as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2.

Figure 1

Conclusions

Octogenarian subjects with AMI were high-risk group associated with heart failure and stroke events. Their distinct clinical backgrounds may affect the adoption of optimal medical therapies, potentially resulting in worse cardiovascular outcomes. Further intensified management should be applied to octogenarian subjects with AMI.

P5502Comparison of clinical characteristics and prognosis between non-octogenarians and octogenarians with cardiac troponin positive acute myocardial infarction

Background

Cardiac troponin (cTn) is the preferred biomarker for the diagnosis of acute myocardial infarction (AMI). Octogenarians who presented cTn positive AMI are not usually recruited in clinical trials. Therefore, their clinical characteristics and prognosis are rarely investigated.

Objective

To study the characteristics and prognosis in octogenarians who presented cTn positive AMI.

Methods and results

The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective and multicenter registry. A total of 3,283 consecutive AMI patients who were diagnosed by cTn-based criteria were included. The patients were divided into non-octogenarians (n=2,593) and octogenarians (n=690). Compared with non- octogenarians, octogenarians showed significantly lower incidence of diabetes mellitus (37.6% and 31.9%, p=0.006) and dyslipidemia (53.6% and 45.6%, p<0.001), and significantly higher incidence of hypertension (64.1% and 75.3%, p<0.001) and chronic kidney disease (38.7% and 68.7%, p<0.001). Octogenarians showed significantly longer onset to door time (p<0.001) and longer door to device time (p<0.001). Though, compared with non-octogenarians, octogenarians showed lower peak CK (2,506 and 1,926, p<0.001), LVEF was significantly lower in octogenarians (54.6% and 52.6%, p=0.005). The presentation of AMI was different between the two group. The incidence of ST-segment elevation MI (STEMI) was 70.7% in non-octogenarians and 62.0% in octogenarians. Non-STEMI with CK elevation and without CK elevation were 16.2% and 13.1% in non- octogenarians, and 20.9% and 17.1% in octogenarians. In-hospital mortality was higher in octogenarians (4.7% and 13.2%, P<0.001). Especially, octogenarians with STEMI and non-STEMI with CK elevation showed the highest in-hospital mortality. And octogenarians without CK elevation showed similar in hospital mortality with non-octogenarians with STEMI (Figure).

Conclusions

J-MINUET showed the poor prognosis of octogenarians who were diagnosed as AMI based on cTn.

Acknowledgement/Funding

None

P915Clinical characteristics, natural history and predictors of disease progression in patients with degenerative mitral stenosis

Background

Mitral annular calcification (MAC) is a common echocardiographic finding and an increasingly recognized cause of degenerative mitral stenosis (DMS). However, little is known about the natural history and predictors of disease progression of DMS, especially compared with rheumatic mitral stenosis (RMS).

Purpose

To compare the clinical characteristics and disease progression among patients with DMS and those with RMS, and to investigate the determinants of disease progression in DMS patients.

Methods

We retrospectively reviewed consecutive MS patients with a trans-mitral mean gradient ≥2 mmHg who underwent echocardiography at our institution between January 2014 and December 2017. We selected patients who had an initial and follow-up echocardiography with a ≥3-month interval and without prior and interim mitral valve intervention. DMS was defined as MS with MAC with normal or minimally reduced leaflet motion without tips restriction. RMS was defined as MS with tip restriction, thickening and restriction of leaflet mainly. We defined MAC severity as mild (focal), moderate (marked density >1/3 but <1/2 of the mitral annulus) and severe (marked density involving >1/2 of the mitral annulus) based on previous reports. We calculated disease progression from the annual increase rate of trans-mitral mean gradient. First, we compared the backgrounds and disease progression between DMS group and RMS group. Second, we investigated the predictors of disease progression in DMS group.

Results

We enrolled 111 patients (64 in DMS group and 47 in RMS group) with a mean follow-up period of 2.1 years. Patients in DMS group were significantly older (79±9 vs. 70±10 years; P<0.01), had higher prevalence of hypertension (P<0.01) and coronary artery disease (P=0.02), and had higher plasma BNP level (P<0.01) than those in RMS group. Baseline trans-mitral mean gradient was slightly lower in DMS group than in RMS group (3.9±1.9 vs. 4.7±1.8 mmHg; P=0.02). There were wide variations among individuals in progression rate (range: 0 to 3.5 mmHg/year in DMS group and 0 to 5.8 mmHg/year in RMS group, respectively), and the progression rate was comparable between DMS group and RMS group (0.49±0.79 vs. 0.61±1.37 mmHg/year; P=0.59). In DMS group, higher prevalence of dyslipidemia (P=0.01) and lower baseline trans-mitral mean gradient (P<0.01) were significantly associated with disease progression even after adjustment for age and sex. Unexpectedly, there was no significant difference in the disease progression regardless of the MAC severity among DMS group (Picture).

MAC severity and disease progression

Conclusions

Progression in DMS group is highly variable, but generally slow as that in RMS group. Initial mean gradient was inversely associated with disease progression in DMS group. Furthermore, baseline MAC severity did not correlate with the progression, suggesting the importance of follow-up echocardiography in spite of the MAC severity and initial mean gradient.