Venomous snakes of medical importance in the Brazilian state of Rio de Janeiro: habitat and taxonomy against ophidism

Snakebite envenoming is a major global health problem that kills or disables half a million people in the world's poorest countries. Identifying the biting snake and its habitat use is key to understanding snakebite eco-epidemiology and optimizing its clinical management. To prevent and combat the neglected snakebite disease, we characterize the morphology, geographic distribution, habitat use, and snakebites of medically important venomous snakes in the state of Rio de Janeiro (Brazil). Despite Philodryas spp. not being considered of medical importance by the Brazilian Ministry of Health, we also explore their data once the bites may require medical intervention, may cause death, and their consequences are underestimated. Methods: We assessed taxonomy and geographic data from specimens housed in scientific collections, the literature, and the Notifiable Diseases Information System. Our data revealed fragility in the morphological characters recommended to distinguish Bothrops jararaca from B. jararacussu, identify the subspecies of Crotalus durissus and distinguish the species of Philodryas. To help identify these species, we present an identification key to the venomous snake species from Rio de Janeiro based on the morphological data collected. We record the genera Bothrops and Micrurus in all mesoregions of the state. Here, we provide the first record of C. durissus in the Serrana region, supporting the hypothesis of geographic expansion of the species in the state. The crotalic antivenom must not be missing in Médio Paraíba, Centro-Sul Fluminense, and Serrana, where the rattlesnake C. durissus occurs. Bothrops bilineatus and Lachesis muta have historical records presented for the first time herein. However, these species are likely endangered or extinct in the state. There were 7,483 snakebites reported between 2001 and 2019, with an annual average of 393.8 cases. The Bothrops genus is responsible for the majority of accidents. The highest number of cases occurred in the Serrana region, the largest pole of family agriculture in Rio de Janeiro. We improve the identification of venomous snake species, better delimit their distribution, and update the number of cases of snakebites, thus providing greater precision in the attention to this problem in Rio de Janeiro. We emphasize the importance of clinical studies to test using bothropic-crotalic antivenom and heparin in all mesoregions to treat B. jararacussu envenomation; and mechanical ventilation, atropine, and anticholinesterases in the emergency health centers in the Metropolitana and Norte Fluminense regions due to the occurrence of the coral M. lemniscatus in these areas.

A method for the quantitative and reversible trapping of sulfidic gases from headspaces and its application to the study of wine reductive off-odors

Some relevant food systems release tiny amounts of sulfidic gases, whose measurement is difficult because of their inherent instability. The present paper demonstrates that Cu(I) solutions trap quantitatively and stabilize sulfidic gases. Once trapped, the gases remain stable for weeks at 4 °C and at least 8 days at 75 °C. Trapped gases can be quantitatively released with tris(2-carboxyethyl) phosphine (TCEP) and brine dilution and then determined by GC. Trapping solutions, placed in 20-mL opened vials housed in 100 mL hermetically-sealed flasks containing wine in anoxia, have been used to monitor the release of sulfidic gases by wines, revealing that at 50 °C, up to 400 μg/L of H₂S and 58 μg/L of MeSH can be released in 68 days, and 3-5 times more at 75 °C in 28 days. The possibility to differentiate between released and accumulated amounts provides key clues to understanding the fate of sulfidic gases in wine and other food systems.

Cardiac myxoma embolic events: characterization and predictors

Introduction

Myxomas are the most common heart tumors. Although, myxomas are often diagnosed incidentally in asymptomatic patients, they are frequently associated with embolic events, becoming an important cause of morbidity and mortality. Whether some myxomas' characteristics predict more embolic risk is not well established.

Objectives

This analysis aims to describe the clinical and echocardiographic data in a long cohort of patients with cardiac myxomas and to establish potential predictors of embolic events int these patients.

Methods

Between 1990 and 2021, 88 patients were diagnosed with cardiac myxoma. 84 were included in this analysis. Baseline characteristics, echocardiographic findings and embolic events were noted retrospectively. A binary logistic regression analysis using SPSS statistics software, version 25.0 was performed to establish possible embolic predictors.

Results

84 patients (mean age 63.1±12.9 years old, 75% female) with cardiac myxoma (sporadic type in 100%) were analyzed (table 1). The majority were located in the left atrium (88.1%, n=74), followed by right atrium (10.7%, n=9) and right ventricle (1.2%, n=1). The average dimension (longer axis) was 36.8±17.4mm. 9.6% of the patients (n=8) had Atrial Fibrillation (AF) rhythm. 22.6% of the patients (n=19) experienced embolic events, the majority to the central nervous system (19.0%, n=6), followed by peripheric/limbs (2.4%, n=2), renal (1.2%, n=1) and coronary (1.2%, n=1). The presence of irregular borders (papillary, bosselated) was the only parameter independently associated with increased risk of embolic events, by 6 times (OR 6.78, 95% confidence interval of 2.14–21.51, p-value 0.001). Neither the presence of AF, myxoma dimensions, presence of calcifications, pediculated insertion, myxoma mobility or heterogeneous aspect predicted embolic events with statistical significance (table 2).

Conclusions

Cardiac myxomas are frequently associated with embolic events (22.6% in our population), posing an important cause of morbidity and mortality in these patients. Besides the presence of irregular borders, the other myxoma's characteristics did not consistently predict the occurrence of embolic events. This data supports the well-recognized fact that all cardiac myxomas have the potential to embolic events, and therefore, should be excised, although those with very irregular borders are at much higher risk of embolization.

Funding Acknowledgement

Type of funding sources: None.

Left atrial vorticity is independently associated with embolic brain infarcts and represents a promising imaging biomarker of cardioembolism in sinus rhythm and atrial fibrillation

Background

Atrial fibrillation (AF) is associated with embolic stroke, but risk scores such as CHA2DS2-VASc perform only modestly (C statistics 0.6–0.7). Meanwhile, up to 25% of embolic strokes in patients without AF have no identifiable cause, and occult left atrial (LA) thromboembolism may be a relevant mechanism in such cases.

Purpose

We hypothesised that imaging of left atrial blood flow could improve embolic risk prediction in patients with and without AF. We used 4D flow magnetic resonance imaging (MRI) to identify a biomarker that is: (a) independently associated with embolic brain infarction by brain MRI, (b) able to stratify blood flow characteristics both during AF and in sinus rhythm (SR), and (c) reproducible.

Methods

We recruited 3 patient cohorts to respectively address each aim. Firstly, to assess the association between LA flow parameters and embolic brain infarcts, we recruited cohort A, consisting of 134 patients (41% female; age 70±9 years) with a history of ischaemic stroke (N=44) or no history of stroke but with CHA2DS2VASc score ≥1 (N=90). Next, the sensitivity of 4D flow parameters to rhythm change was assessed in cohort B: 37 patients with persistent AF studied before and after cardioversion, whose results were compared with those of 23 healthy controls in SR [CHA2DS2-VASc = 0.0 (0.0–0.0)]. Finally, scan-rescan coefficients of variation (CV) and interval-scan CV at 30 days were determined in Cohort C (86 subjects; 64 in SR, 22 in AF). Brain MRI was used to identify large non-cortical or cortical brain infarcts (LNCCI) – i.e. infarcts likely to be embolic in origin.

Results

At least one LNCCI was present in 39 of 134 patients in cohort A. Lower LA vorticity was significantly associated with higher risk of prevalent LNCCIs (Figure 1), after adjustment for AF, age, and CHA2DS2VASc score [OR=2.10 (95% CI 1.12–3.92) per SD, P=0.02]. This association remained significant after further adjustment for other cardiac parameters (all P<0.05, Figure 1). By contrast, there was no significant association between peak velocity and LNCCIs (P=0.21).

LA vorticity was sensitive to rhythm change, improving significantly in patients in cohort B in SR at ≥4 weeks after cardioversion (CV) of persistent AF (Figure 2A, paired P<0.001 vs pre-CV), but remained impaired compared to healthy controls (Figure 2B, P<0.01).

Finally, reproducibility studies in cohort C showed that LA vorticity had a same-day scan-rescan CV of 7% without significant differences between SR and AF subjects (P>0.05), and also showed no significant temporal variability on interval scanning (P>0.05).

Conclusions

LA vorticity is reproducible, sensitive to changes in heart rhythm, and independently associated with embolic brain infarcts, suggesting a promising imaging biomarker of cardioembolism in SR and AF. LA blood flow imaging could improve stroke prediction and the personalisation of decisions about anticoagulation, regardless of heart rhythm.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Oxford BRC, BHF

Outcomes in pregnant women with valvular heart disease from sub Saharan Africa transferred to a developed nation. A distinct care model

Background

Pregnant women with valvular heart disease (VHD) in African countries still bear a disproportionate burden of maternal morbidity and mortality, due to the reduced accessibility to health care and the scarcity of skilled professionals. It is unclear if outcomes would be improved by care-delivery model changes.

Purpose

We performed a clinical audit of African pregnant women with VHD who were transferred for their care from five countries to our cardio-obstetrics unit, during a twenty-year period, through a memorandum of agreement of international cooperation.

Methods

A retrospective analysis of 81 pregnancies (P) in 45 African women with VHD (median age 24, IQR 22–29 years) from 2001 to 2020. The main outcome measures were major maternal complications and perinatal outcome.

Results

History of rheumatic heart disease was determined in 74.1% of the P. Most women were in NHYA I or II before P (79.0%), 43.2% had previous cardiac medication and 60.5% were anticoagulated (33.3% with acenocoumarol and 27.2% with warfarin). 59.3% of P had at least one valvular prosthesis, including 38 mechanical prosthetic valve (MPV) and 10 biological valves. 22.2% had prior surgical or percutaneous VHD correction, excluding prosthesis implantation. At baseline, impaired left ventricular ejection fraction was found in 12.3%. Previous arrhythmic event, stroke or infectious endocarditis were found in 12.3%, 8.6% and 6.2% of P, respectively.

During P, deterioration in NYHA functional class occurred in 42.0% and 9.9% required initiation or intensified cardiac medication. For MPV, 51% maintained a vitamin K antagonist, 15.7% used LMWH from 6 to 12th weeks and 9.8% used LMWH throughout P. Valve thrombosis occurred in 4 women (4.9% of P), with one maternal death in a patient with double MPV.

Hemorrhagic complications happened in 8.6% of P, all anticoagulated, in immediate postpartum or puerperal period. The 81 P resulted in 56 live births (69.1%), with a medium birth weight of 3026±471g. Delivery by caesarean section was performed in 28.3% of newborns. The incidence of miscarriage was 23.5% and fetal malformations occurred in 14.8%, with warfarin embryopathy in 4 cases. In univariate analysis, the presence of valvular protheses (p=0.001), and anticoagulation (p=0.001) were related to unsuccessful P. In multivariate analysis, VKA therapy was the unique independent predictor of unsuccessful P (p=0.048).

Conclusion

With the multidisciplinary care provided, pregnancy was relatively well tolerated and successful for women transferred from sub–Saharan Africa. However, the presence of a valvular prothesis is associated with unsuccessful pregnancy even in a developed nation. Efforts other than the implantation of a MPV should be pursued vigorously in sub Saharan Africa.

Funding Acknowledgement

Type of funding sources: None.

Cardiac myxomas: characteristics and outcomes in a tertiary center

Introduction

Cardiac myxoma (CM) is the most common primary cardiac tumour. It can manifest in a variety of clinical presentations or it can be asymptomatic and, ultimately, be detected with image techniques. The only successful treatment of these tumours is surgical excision, with low complications and recurrence rate.

Objectives

This analysis aims to describe the clinical forms of presentation and echocardiographic characteristics of cardiac myxomas, establish myxoma features associated with obstructive symptons, as well as describe the postoperative outcome and long-term recurrence in a tertiary center.

Methods

Between 1990 and 2021, 88 patients were diagnosed with cardiac myxoma. 84 were included in this analysis. Baseline characteristics, clinical presentation, echocardiographic findings and outcomes were noted retrospectively. A binary logistic regression analysis using SPSS statistics software, version 25.0 was performed to establish myxoma features associated with atrioventricular valves obstruction.

Results

Mean age was 63±12 years old, 75% female. All CM were sporadic. The majority of the patients (52.4%, n=44) were asymptomatic, embolic events were present in 22.9% of the patients (n=19), with the most common site being central nervous system (19.0%, n=16) and constitutional symptoms in 16.7% (n=14), the most frequent fatigue (11.9%, n=10). Atrial fibrilation was present in 9.6% of the patients (n=8). The majority of the myxomas were located in the left atrium (88.1%), followed by right atrium (10.7%) and right ventricle (1.2%). Mean myxoma dimension was 36.8±17.4mm (longer axis), with heterogeneous aspect in 63.1%, presence of calcification in 11.9%, pediculated insertion in 40.5%, mobility in 70.2% and irregular borders in 52.4%. Moderate or severe ventricular inflow obstruction was present in 13.1% (n=11), 13.6% with mitral obstruction in the left atrial myxomas and 11.1% with tricuspid obstruction in the right atrial myxomas. CM longer axis 40–59mm and superior to 60mm were independently associated with obstruction (OR 5.1, 95% CI 1.4–18.4, p0.014 and OR 11.5, 95% CI 2.9–45.4, p0.001, respectively). No other morphologic features were associated with mitral or tricuspid obstruction. All but 3 patients had the myxoma surgically removed because of advanced age and comorbidities (96.4% surgical rate). There was no in-hospital or 1 year mortality in these patients. During the follow-up period, 3.6% patients had recurrence of the myxoma, with a men period of 5 years after the first surgery (one, two and twelve years), all of them re-submitted to surgical excision.

Conclusion

Despite being asymptomatic in the majority of the patients and often diagnosed incidentally, cardiac myxomas are frequent source of morbidity and mortality due to embolic events, obstructive and constitutional symptoms. Surgery is the treatment of choice for cardiac myxomas and in most cases it is curative, with low complications and low recurrence rate.

Funding Acknowledgement

Type of funding sources: None.

3 year outcomes of permanent pacemaker implantation after alcoholic septal ablation

Introduction

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Funding Acknowledgement

Type of funding sources: None.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

Lemierre's syndrome: case report of "the forgotten disease" in current COVID-19 pandemic

Lemierre's syndrome refers to infectious thrombophlebitis of the internal jugular vein developed as complication of an oropharyngeal infection. It is a rare syndrome, affecting otherwise healthy young adults, which may lead to sepsis complicated by septic embolization. Although there is a characteristic clinical picture, many modern physicians are unaware of this syndrome, leading it to be termed 'the forgotten disease'. The authors report a case of late diagnosis due to initial suspicion of COVID-19 and highlight the pitfalls on its diagnosis.

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

Funding Acknowledgements

Type of funding sources: None.

Introduction

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

Objectives

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

Methods

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

Results

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

Conclusions

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

Ecocardiographic comprehensive evaluation of OHCM patients treated with percutaneous ASA

Funding Acknowledgements

Type of funding sources: None.

Introduction

Alcohol septal ablation (ASA) has been widely accepted as an alternative to surgical myectomy in patients with symptomatic obstructive hypertrophic cardiomyopathy (OHCM) despite optimal medical treatment.

The aim of this study was to analyse the effect of ASA on anatomical and functional features analysed by echocardiography, as well as its clinical impact. We further evaluated the safety of procedure.

Methods and results

Retrospective analysis of consecutive patients submitted to ASA (2009 – 2019) in a single tertiary centre. A dedicated echocardiogram was performed at 3 and 6 months after procedure. Echocardiographic primary endpoint was a > 50% reduction in left ventricular outflow tract (LVOT) gradient (the definition used for successful procedure). Echocardiographic secondary endpoint was improvement in mitral regurgitation. Clinical primary endpoint was defined as a combined endpoint of cardiac death or hospitalization during follow-up (FU).

110 patients were included, 66.4% women, mean age 65.1 ± 12.2 years. Functional class NHYA class III/IV, angina CCS class II/III and syncope were present in 87.3%, 52.7% and 10.0%, respectively.

Baseline LVOT gradients at rest and at Valsalva manoeuvre were 93.6 ± 39.8 mmHg and 118.9 ± 44.2 mmHg. Maximum septal thickness was 21.0 ± 3.3 mm, 24.5% had moderate mitral regurgitation and 52.7% showed systolic anterior motion of mitral valve.

During hospitalization for ASA, peak creatine kinase after procedure was 1306 ± 816 U/l. 17 (17.1%) patients required permanent PM due to induction of permanent complete heart block. There was one case of inferior myocardial infarction and one case of cardiac tamponade. 

Echocardiographic primary endpoint was achieved by 83.6% of patients. At 3 and 6-months follow up, LVOT gradients was significantly decreased in successful comparing with unsuccessful procedure group (24.6 ± 23.9 vs 82.0 ± 28.7 mmHg, p = 0.003 and 31.8 ± 34.5 vs 68.6 ± 27.8 mmHg, p = 0.027, respectively). There was no difference in baseline clinical or echocardiographic parameters between both groups. Regarding the echocardiographic secondary endpoint, among patients with moderate mitral regurgitation, 80% improved to mild regurgitation. A significant reduction in basal septal thickness was achieved in most patients, from 21.0 ± 3.3mm to 16.4 ± 2.7 mm after ASA (p = 0.001). 

During mean FU of 3.4 ± 2.1 years, clinical primary endpoint occurred in 25.5%, mainly in unsuccessful procedure group (50.0% vs 20.7%, p = 0.013). Reintervention was performed for recurrence of symptoms in 14 (12.7%) patients, surgical myectomy in 3 (3.6%) and repeated ASA in 10 (9.1%). 

Conclusion

ASA allows a significant reduction in LVOT gradient and improvement of mitral regurgitation in the majority of patients with OHCM. Systematic and comprehensive echocardiographic evaluation assumes a paramount importance for the evaluation of procedural success. Abstract Figure.

Evaluation of RV-arterial coupling in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

The ratio of echocardiography-derived tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP) - TAPSE/PASP ratio - is a noninvasive measure of RV-arterial coupling. TAPSE/PASP ratio is a potent independent predictor of prognosis in heart failure and pulmonary arterial hypertension, with a prognostic cutoff value of 0.36 mm/mmHg.

Objective

To assess the prognostic impact of TAPSE/PASP ratio in a population of advanced HF patients.

Methods

Prospective evaluation of adult patients with advanced HFrEF referred to our Institution for evaluation with HF team and possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 2 years for the primary endpoint of cardiac death and HT. Echocardiographically determined TAPSE/PASP ratio was used to assess RV-arterial coupling and a survival analysis was performed to evaluate the prognostic impact of the suggested cutoff of 0.36 mm/mmHg.

Results

A total of 450 Heart Failure with Reduced Ejection Fraction (HFrEF) patients with a mean age of 56 ± 12 years, of which 80% are male, and with a mean LVEF of 29 ± 4%, mean TAPSE of 19 ± 3 mm and PASP of 38 ± 11mmHg. The mean TAPSE/PASP was 0.80 ± 0.28. Fifty-four patients (12%) met the primary endpoint. Patients with RV-arterial uncoupling (TAPSE/PASP < 0.36 mm/mmHg) were more likely to have a non-ischaemic etiology for HF (66.7% vs 40%, p = 0.047), had a lower prevalence of diabetes (53.3% vs 77.9%, p = 0.041), a higher prevalence of moderate-to-severe mitral regurgitation (33.3% vs 13.0%, p = 0.035), a lower LVEF (26.2 ± 6.1 vs 29.9 ± 5.9, p = 0.038), a higher prevalence of RV dysfunction (73.3% vs 26.7%, p < 0.001) and worse cardiopulmonary fitness (pVO2: 12.7 ± 5.1 vs 15.8 ± 6.0 ml/kg/min, p = 0.047; VE/VCO2 slope: 49.5 ± 17.2 vs 37.6 ± 9.7, p < 0.001; cardiorespiratory optimal point: 36.9 ± 11.3 vs 29.0 ± 6.4, p < 0.001). More patients in the group of TAPSE/PASP < 0.36 mm/mmHg met the primary endpoint (33.3% vs 9.6%, p = 0.034) and more patients underwent urgent HT (13.3% vs 1.4%, p = 0.44). RV-arterial coupling was associated with a lower survival free of events during follow-up (log-rank p = 0.010).

Conclusion

RV-arterial coupling predicts a worse prognosis in advanced HF patients, with those below a cutoff of 0.36 mm/mmHg having lower survival. This variable may improve risk stratification in this setting. Abstract Figure.

Assessment of myocardial work: a promising tool in obstructive and nonobstructive hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Myocardial work is a novel dynamic non-invasive method for assessing myocardial deformation providing incremental information to left ventricular ejection fraction (LVEF) and strain imaging. The aim of this study was to assess left ventricular myocardial work in hypertrophic cardiomyopathy (HCM) and compare patients with obstructive HCM (oHCM) and nonobstructive HCM (nHCM).

Methods

Prospective assessment of HCM patients’ myocardial strain parameters with 2D speckle-tracking echocardiography, stratified according to LV segments (basal, midcavity and apical regions). Results were compared between oHCM and nHCM patients.

Results

83 patients with HCM, 60% male, 33% oHCM (with a LVOT gradient of 89 ± 60 mmHg). There was no significant difference between groups in mean age (56 ± 13 years vs. 55 ± 15 years, p = 0.719), LV mass index (186 ± 75 g/m2 vs. 158 ± 65 g/m2, p = 0.103), maximum wall thickness (21 ± 4 mm vs. 19 ± 5 mm, p = 0.425) or left ventricular ejection fraction (LVEF) (68 ± 8% vs. 67 ± 11%, p = 0.584).

Regarding global work index (GWI) there was no significant difference between oHCM and nHCM (1206 ± 431 mmHg% vs. 1384 ± 437 mmHg%, p = 0.090), although oHCM patients had a significantly inferior GWI in the basal (921 ± 383 mmHg% vs. 1364 ± 419 mmHg%, p < 0.001) and midcavity (1049 ± 456 mmHg% vs. 1288 ± 492 mmHg%, p = 0.038) segments (Figure 1). No significant difference was noted in the apical segments (1680 ± 653 mmHg% vs. 1519 ± 770 mmHg%, p = 0.335). Myocardial work index in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.242, p = 0.032) and maximum provoked LVOT gradient (r=-0.291, p = 0.010). Furthermore, patients with septal hypertrophy pattern showed significantly impaired basal myocardial work index compared with apical hypertrophy patients (1090 ± 428 mmHg% vs 1537 ± 389 mmHg%, p < 0.001).

Global constructive work (GCW) (1443 ± 449 mmHg% vs. 1604 ± 426 mmHg%, p = 0.123) and global wasted work (GWW) (197 ± 140 mmHg% vs. 154 ± 107 mmHg%, p = 0.137) were not significantly different between groups.

Global work efficiency (GWE) was significantly reduced in oHCM patients vs. nHCM (84.1 ± 7% vs. 88.3 ± 7.3%, p = 0.017), particularly in the basal (80.2 ± 11.2% vs. 88.3±.7.2%, p = 0.033) and midcavity segments (85.4 ± 9.2% vs. 90.0 ± 8.5%, p = 0.044) (Figure 2). No significant difference was noted in the apical segments (88.2 ± 9.9% vs. 87.0 ± 12%, p = 0.679). Myocardial work efficiency in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.389, p = 0.002) and maximum provoked LVOT gradient (r=-0.446, p < 0.001). Moreover, patients with septal hypertrophy pattern showed significantly reduced basal myocardial work efficiency versus apical hypertrophy patients (83 ± 9% vs 92 ± 3%, p < 0.001).

Conclusion

Myocardial work is a promising tool to evaluate myocardial function in patients with oHCM and nHCM. oHCM patients had a significantly inferior GWI and GWE particularly in the basal and midcavity segments versus nHCM patients. Abstract Figure 1: Myocardial Work Index  Abstract Figure 2: Myocardial Work Efficiency

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

Funding Acknowledgements

Type of funding sources: None.

Background

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

Purpose

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

Methods

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

Results

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

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

Conclusions

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

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

Funding Acknowledgements

Type of funding sources: None.

Background

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

Methods

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

Results

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

Conclusions

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

Non-vitamin K antagonist oral anticoagulants in adult congenital heart disease: a single-center study

Introduction

Adults with congenital heart disease (ACHD) are at an increased risk for thromboembolic events and atrial arrhythmias are common in this population. Non-vitamin K anatagonist oral anticoagulants (NOACs) prescription is increasing, however data on efficacy and safety in ACHD is unclear, particularly in patients (P) with complex CHD. The aim of the study was to review the use of NOACs in various types of ACHD and assess its safety and efficacy.

Methods

Evaluation of consecutive ACHD P started on NOAC therapy from 2014 to 2020. P were followed-up for bleeding or thromboembolic events and mortality. CHA2DS2-VASc and HASBLED scores were calculated and risk factors for bleeding were identified.

Results

93 ACHD P were included, mean age 52±15 years, 58% female, 44% with complex CHD (3.2% with Fontan circulation), with diagnosis of: 22.2% atrial septal defect, 20% tetralogy of Fallot, 11.1% transposition of the great arteries, 10% Ebstein's anomaly, 8.9% ventricular septal defect, 7.8% pulmonary stenosis, 5.6% ductus arteriosus, 4.4% AV septal defect, 3.4% univentricular heart, 3.4% coarctation of aorta, 2.2% supra-aortic stenosis and 1% with Uhl disease.

Most P were anticoagulated with rivaroxaban (43%), followed by edoxaban (24%), apixaban (20%), and dabigatran (13%). The indications for anticoagulation were: atrial arrhythmias (81%), pulmonary embolism (PE) (6.3%), atrial thrombi (4.3%), thromboprophylaxis in Fontan circulation (3.2%), deep vein thrombosis (3.2%) and stroke (2%). 66% of P had a CHA2DS2-VASc score ≥2 and 82% HASBLED score ≤2.

In a mean follow-up of 41±21 months (400.4 patient-years), there were embolic events in 2P (1 splenic infarction and 1 PE) albeit both were in the context of oral anticoagulation interruption. The cardiovascular mortality was 2% and allcause mortality 5%, however with no relation to thrombosis or bleeding events.

6 P (6.5%) suffered a minor and 3 P (3.2%) suffered a major bleeding, a median time of 12 (IQR 15) months after starting NOAC therapy. The annual risk for bleeding was 2.2%/patient/year. P with bleeding events showed no significant difference regarding age (55±16 vs 52±15 years, p=0.587), gender (13% female vs 5.1% male, p=0.295) or CHD type (p=0.582). 8.6% of P required dose reduction, mostly for bleeding (3.2%) or renal impairment (2.2%).

Renal disease was a strong risk factor for major bleeding (HR 14.6 [95% CI 1.23–73.6], p=0.033 and multivariate analysis showed that an increased HASBLED score was an independent predictor of minor (adjusted HR 3.44 [95% CI 1.13–10.52], p=0.030) and major (adjusted HR 5.29 [95% CI 1.14–24.45], p=0.033) bleeding complications.

Conclusion

Anticoagulation with NOACs is a safe and effective option for selected ACHD P, although bleeding complications were not negligible, particularly in P with renal disease. Larger scale research studies are required, especially regarding complex CHD such as P with Fontan circulation.

Funding Acknowledgement

Type of funding sources: None.

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

Introduction

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

Quantification of epicardial fat with cardiac CT and association with cardiovascular risk factors and obstructive coronary disease

Introduction

Recent studies advocate epicardial fat (EF) as a biologically active organ that influence coronary atherosclerosis development through endocrine and paracrine pathways. We aim to study the relations between EF, thoracic adipose tissue (TAT), cardiovascular risk factors (CRF) and obstructive coronary disease (OCD).

Methods

Retrospective analysis of patients (pts) referred to 64-multislice cardiac computed tomography (CT) in one center. The authors underwent a standardized protocol for quantification of EAT, TAT (subcutaneous and visceral), abdominal visceral fat, coronary calcium score and angiography.

Results

Total of 178 pts: male 99 (56%), mean age 65.9±12.9 years. Indications for performing CT were coronary disease (76%), valvular heart disease (15%), atrial fibrillation (6%) and congenital heart disease (2%). Regarding CRF, EF was only significant higher in patients with diabetes (115±60 vs 95±47, p=0.018), in male gender (114±60 vs 91±42, p=0.04) and was linear correlated with age (p=0.004). The authors also found that EF volume is significant higher in patients with typical angina (p=0.02) and with coronary atherosclerosis: non-obstructive (p=0.0049) and OCD (p=0.001) – Graphic 1. ROC analysis of EF (AUC 0.659, p=0.0039) and EF/TAT relation (AUC 0.704, p=0.003) allowed to estimate that EF>100 ml and EF/TAT >0.06 had a sensibility to predict OCD of 53% and 58%, respectively, and specificity of 66% and 60%. We did not find a correlation between EF, EF/TAT or TAT and coronary calcium score.

Conclusion

EF is higher in patients with diabetes and coronary atherosclerosis. EF and EF/TAT relation had moderate sensibility and specificity to predict OCD, irrespective of calcium score. EF and EF/TAT are promising atherosclerotic markers that could be routinely use in the near future.

Funding Acknowledgement

Type of funding sources: None.

Malignant cardiac tumors: a single-centre 25-year review

Background

Primary cardiac tumors are extremely rare and are usually diagnosed late due to the nonspecific symptoms. Surgery is the main treatment option, and despite chemotherapy, the prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome. The aim of this study was to review patients (P) with malignant cardiac tumors that were diagnosed by transthoracic echocardiogram (TTE) or transoesophageal echocardiogram (TOE) in a tertiary center between 1995 and 2020.

Methods

Retrospective analysis of clinical data, echocardiographic assessment of tumor location and morphology, histology results and survival outcomes.

Results

A total of 44 malignant cardiac tumors were diagnosed: 12 primary tumors (A) and 32 metastatic tumors (B). A: Regarding primary cardiac tumors, the most common types were angiosarcomas (6), undifferentiated pleomorphic sarcomas (2), fibrosarcomas (2), myxofibrosarcoma (1) and primary cardiac lymphoma (1). The mean age of P at time of diagnosis was 43±15 years, 50% male. The most frequent presentation was heart failure symptoms (50%) followed by arrhythmias (20%). 1 P presented with pruritus and polyarthralgias. On TTE, the most prevalent tumor location was in the right-heart chambers (70%) – mostly the right atrium (50%), with mean dimensions of 40±18x27±11 mm. 85% of P had preserved biventricular systolic function and there was severe pericardial effusion in 38%. The most frequent metastatic involvement at diagnosis was pulmonary (33%) and hepatic (33%). 50% of P were submitted to tumor resection and 40% to chemotherapy. Regarding angiosarcomas, the most common immunohistochemical markers were vimentin, CD31 and CD34. The authors found a mortality rate of 10P (83%) in P with primary cardiac tumors, with a median time to mortality of 5.5 (IQR 2–10) months (Figure 1), in a median follow-up of 6.2 (IQR 2.5–15) months (minimum of 20 days and maximum of 19 years). In the latter case, the P was submitted to heart transplantation after diagnosis of a fibrosarcoma and is still alive and well.

B: Regarding secondary cardiac invasion, there was a diagnosis of the following primary tumor sites: 12 lung carcinomas, 7 thymomas, 4 lymphomas, 3 hepatocellular carcinomas, 2 bladder carcinomas, 1 parathyroid carcinoma, 1 soft tissue sarcoma, 1 uterine sarcoma and 1 melanoma. The mean age of P was 57±19 years, 57% male. On TTE/TOE the authors found a right-sided chambers predominance (12 P, 38%) vs left-sided chambers in (8 P, 25%), with pericardial metastasis also present in 13 P (41%). Cardiac tamponade occurred in 6P (19%). The mortality rate was 75% (24P), with a median time to mortality of 1.1 (IQR 0.6–3.8) months (minimum of 7 days, maximum of 44 months), in a median follow-up of 2.3 (IQR 0.8–14) months.

Conclusion

Cardiac malignant tumors generally present in a late stage with a dismal prognosis. When possible, heart transplantation can be an option with a favourable outcome.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier analysis

A 3D-TTE left atrial function study in cardio-oncology patients

Introduction

Transthoracic Doppler echocardiography (TTE) remains the standard imaging method to evaluate cancer therapeutics-related cardiac dysfunction (CTRCD). 3D-TTE with strain analysis is a novel technique, proved useful for earlier detection of left ventricular (LV) function impairment. However, diastolic and left atrial (LA) function impact is less studied.

Purpose

To assess LA volumetric and LA strain (LAS) features by 3D-TTE in cardio-oncology patients.

Methods

A prospective study of female breast cancer patients (P) submitted to therapy (TH) who underwent serial monitoring by 2D and 3D-TTE. Standard 2D, 3D-TTE and LAS parameters were evaluated, including longitudinal (LALS) and circumferential strain (LACS) during conduit (cd), contraction (ct) and reservoir (r) phases. P were evaluated at T0, T1 and T2 (before, ≥6 and ≥12 months after starting TH). CTRCD was defined as an absolute decrease in 2D LVEF >10% to a value <54% or a relative decrease in 2D GLS >15%, according to literature. P with previous cancer treatment, coronary artery disease, significant valvular disease, and atrial arrhythmias were excluded.

Results

98 P (mean age 54.6±12.0 years-old), mostly treated with anthracyclines (78.6%, cumulative dose 268.2±77.6mg/m2), anti-HER (70.4%) and radiotherapy (80.6%) were included. 2D LV and LA volumes had a significantly raise from baseline to T1 (2D LVEDV 82.2±18.8 vs 91.9±18.8 mL, p=0.019 and LA 43.3±12.9 vs 49.8±13.3 mL, p=0.005). 2D and 3D LVEF were significantly reduced during TH, however remaining within the limits of normality. 2D GLS was also impaired at T1 (−19.9±2.6% vs −18.6±3.1%, p=0.009). During a mean follow-up of 14.1±8.1months, 31 P (31.6%) developed CTRCD. 3D LV and LA volumes also globally increased at T1 comparing to baseline with partially recovery at T2. Maximum LA volume was significantly higher at T1 (39.1±9.3 vs 43.6±10.6 ml, p=0.024). 3D LA ejection fraction (T0 53.7±9.7%, T1 53.4±8.6%, T2 49.9±8.6%, pT0-T2=0.039) and LAS values tended to progressively worse during TH. LA dilation (vol>34ml/m2) at baseline was correlated to dysfunction in contraction phase at T1 (LACSct −19.6±8.6 vs −17.3±4.6%, p=0.024). LACSr has substantially decreased from baseline to T2 (31.4±11.6 vs 27.0±10.4%, p=0.05). In univariate analysis, delta LALSr (T1-T0) was a predictor of CTRCD (mean −5.2% vs 1.9%, p=0.05).

Conclusion

CTRCD was frequent during the earlier phase of breast cancer treatment. LA function was also affected, mirroring LV volumetric and functional changes. Diastolic dysfunction, assessed through LA reservoir strain, was impaired in association with CTRCD. 3D-TTE usefulness in the surveillance and monitoring of CTRCD goes beyond systolic LV function assessment, allowing a detailed LA function analysis.

Funding Acknowledgement

Type of funding sources: None.

Familial hypercholesterolemia in acute coronary syndrome patients: underdiagnosis in female and in young patients

Introduction

Familial hypercholesterolemia (FH) is often underdiagnosed, particularly in female patients (P), even during hospital admission for acute coronary syndromes (ACS). The aim of this study was to apply the Dutch Lipid Clinic Network (DLCN) Criteria in P admitted for ACS and evaluate gender and age differences.

Methods

Prospective evaluation of P with ACS admitted to a tertiary center from 2005 to 2019. Data including family history and laboratory tests was analysed for the application of the DLCN criteria and results were stratified according to ACS subtype, gender and age groups (20–39, 40–59, 60–79 and ≥80 years [y]). P were followed up for 30 days for hospitalization, recurring ACS and mortality.

Results

3811 P were evaluated, mean age 63±13 years, 28% female and mean LDL cholesterol of 125±43 mg/dL. The admission diagnosis was unstable angina (UA) in 5%, non-ST-segment elevation myocardial infarction (NSTEMI) in 27% and ST-segment elevation MI (STEMI) in 68%.

Applying the DLCN criteria, 3089 P (81%) had a score of <3 (unlikely FH), 675P (17.7%) a score of 3 to 5 (possible FH), 41P (1.1%) a score of 6 to 8 (probable FH) and 1P (0.03%) a score of >8 (definite FH). Stratifying according to ACS type: among UA, 31P (16%) had possible FH and 4P (2.1%) had probable FH. Among NSTEMI, 145P (14.2%) had possible FH, 9P (0.9%) probable FH and 1P (0.03%) definite FH. Finally, among STEMI P, 497P (19.1%) had possible FH and 28P (1.1%) probable FH. Regarding female P, 158P (14.7%) had possible FH and 16 P (1.5%) probable FH. Among male P, 517P (18.9%) had possible FH and 25P (0.9%) probable FH (p=0.016 for interaction).

According to age groups, among P aged 20–39 y (136P), 61P (44.9%) had possible FH and 6P (4.4%) had probable FH. Concerning P aged 40–59 y (1766P), 575P (32.6%) had possible FH, 31 P (1.8%) probable FH and 1P (0.1%) definite FH. With regard to P aged 60–80 y (2122P), 80P (3.8%) had possible FH and 4P (0.2%) probable FH. Among P aged ≥80 y (1837P), only 9P (0.5%) had possible FH and no P had probable FH.

In a 30-day follow-up, there was an hospitalization rate of 3.5% (134P) and recurring ACS in 1.7% (65P), while the all-cause mortality was 2% (78P) and cardiovascular (CV) death was 1.3% (49P). Female P had a significantly lower hospitalization rate (1.8% vs 3.2%, p=0.003) as well as fewer recurring ACS (0.6% vs 1.7%, p=0.001). There was no significant gender difference regarding all-cause mortality (female 1.7% vs 1.5%, p=0.552) or CV death (0.8% vs 1.1%, p=0.323). The DLCN criteria score was significantly correlated with admission for recurring ACS (OR 1.19 [95% CI 1.04–1.36], p=0.04).

Conclusion

Application of the DLCN criteria in female P admitted for ACS revealed 158P (14.7%) with possible FH and 16P (1.5%) with probable FH. Regarding younger ACS P (20–39y), 44.9% had criteria for possible FH and 4.4% for probable FH, prompting us to do not overlook these P subgroups in daily practice and routinely assess the likelihood of FH.

Funding Acknowledgement

Type of funding sources: None.

Fetal and maternal outcomes in patients with tetralogy of Fallot

Introduction

Women with tetralogy of Fallot (TOF) have an increased risk of adverse cardiac and neonatal events during pregnancy. The aim was to assess fetal and maternal outcomes in patients (pts) with uncorrected and corrected TOF.

Methods

Retrospective analysis of cardiological and obstetric data in women with TOF followed at our institution. Pregnancy and neonatal outcomes were compared in patients (pts) submitted to corrective surgery vs pts with no previous intervention and in pts with or without cyanosis.

Results

51 women (median age 27 years; median number of previous interventions of 2), 22% with cyanosis, who experienced 126 pregnancies resulting in 73 live births A previous corrective surgery was found in 78% (40 pts), while 4% (2 pts) had previous palliative surgery and 18% (9 pts) no previous procedure. We found that women that were not submitted to previous intervention had a significant higher incidence of preterm birth (56% vs 17.5%, p=0.029), spontaneous abortion (56% vs 10%, p=0.006) and stillbirth (22% vs 0%). No difference was found for obstetric complications between groups. Cyanotic pts also demonstrated higher incidence of low birth weight (LBW) (36% vs 7.5%, p=0.031), preterm birth (54% vs 17.5%, p=0.021), spontaneous abortion (55% vs 10%, p=0.004) and stillbirth (18% vs 0%). There were no cardiac complications during pregnancy nor evident deterioration on cardiac status. Congenital heart disease was reported in 2 infants (3% of live births).

Conclusions

Pregnancy is well tolerated in pts with TOF. In our population, even in uncorrected TOF and in pts with cyanosis, there were no cardiac complications during pregnancy, although those pts had worse fetal outcomes. An explanation for the low incidence of cardiac events may be less severe forms of the disease, allowing survival into adulthood without intervention.

Funding Acknowledgement

Type of funding sources: None.

Left ventricular noncompaction: the importance of identifying high-risk patients within the scope of left ventricular hypertrabeculation

Introduction

Prominent left ventricular (LV) trabeculation is frequently encountered, however LV noncompaction (LVNC) criteria are not always fulfilled. The clinical and prognostic significance of these findings remains unclear.

Objectives

To characterize the patients (P) with echocardiographic suspicion of LVNC and to assess clinical outcomes.

Methods

Retrospective single-centre study that included all echocardiograms between January 2018 and June 2020 perceiving LV hypertrabeculation. The cohort underwent diagnostic assessment for LVNC by Chin and Jenni criteria. Baseline characteristics were evaluated. Composite endpoint of cardiovascular death, heart failure (HF) hospitalization, ventricular arrythmias (VA) and nonfatal stroke was considered.

Results

51P, 75% male, mean age 50±18 years. 35P (69%) had associated heart conditions, of which 57% had other known cardiomyopathy (mainly dilated cardiomyopathy), 14% congenital, 26% ischemic and 3% valvular heart disease. 2P were in postpartum period and 1P was an athlete. Family history of cardiomyopathy was present in 8P (16%). 12P underwent genetic testing, with TTN and MYH7 mutations being the most frequently detected. Prior clinical HF was reported in 53%, previous stroke in 14%, and non-sustained and sustained VA in 24% and 4%, respectively. Mean NYHA classification was 1.8±0.7, with 31% being asymptomatic.

The prevalence of LVNC by Chin criteria was 31% and by Jenni criteria was 55%. 32P (63%) met at least one LVNC criteria. This group was younger (45±18 vs 59±15, p=0.004), had higher NT-proBNP levels (3644±2819 vs 389±640, p=0.048) and QRS fragmentation (59% vs 21%, p=0.027). Significantly higher LV end-diastolic volume (84 (41) vs 64 (28)ml/m2, p=0.008) and end-systolic volume (51 (37) vs 35 (20)ml/m2, p=0.004), along with lower LV ejection fraction (39±12 vs 49±13%, p=0.009) and global longitudinal strain (−11±5 vs −17±4%, p=0.003) were noticed. P who met LVNC criteria also had higher number of affected LV segments (6.4±1.8 vs 4.2±1.6, p<0.001).

Over a mean follow-up of 18±9 months, the incidence of composite endpoint was 35%. Univariate Cox analysis showed a significant association between the presence of LVNC criteria and adverse outcomes (HR: 5.108, 95% CI: 1.682–11.236, p=0.030) (Fig. 1).

Conclusion

LV hypertrabeculation can be encountered in a variety of clinical scenarios and often overlaps with other heart diseases. P satisfying criteria for LVNC had more impairment in LV performance and worse clinical outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1

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

Introduction

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Funding Acknowledgement

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

Pregnancy outcomes in women with severe congenital heart disease – a specialized centre experience

Introduction

Progress in pediatric cardiology and cardiac surgery has dramatically raised the number of women with severe complex congenital heart disease (SC-CHD) that reach reproductive age. Pregnancy (P) in this group of women has an increased risk of adverse cardiac and neonatal events and its predictive factors are not fully defined. Our purpose was to assess the experience of our center regarding P and neonatal outcomes in women with SC-CHD.

Methods

Retrospective analysis of obstetric data in women with CHD followed at our institution. P and neonatal outcomes were evaluated regarding patients presenting SC-CHD and mild and moderate complexity CHD (MMC-CHD), according to ESC guidelines CHD complexity classification.

Results

The study enrolled 680 women with CHD (median age, 27.2 years) who experienced 1262 pregnancies, resulting in 998 live births. A previous corrective procedure was found in 334 women (49.1%). CHD complexity was considered mild, moderate and severe in 263 (38.7%), 359 (52.8%) and 58 (8.5%), respectively. SC-CHD included 38 women with cyanotic CHD and 18 with pulmonary vascular disease. The most common heart defect in SC-CHD pts was cyanotic tetralogy of Fallot (19.0%), followed by dextro-transposition of the great arteries with atrial switch /palliative procedure (13.8%) – Figure 1.

Pts with SC-CHD had successful deliveries in 56.1% comparing with 82.1% in MMC-CHD. Women with SC-CHD had significantly higher incidence of preterm birth (24.6% vs 7.4%, p<0.001), spontaneous abortion (26.3% vs 12.3%, p=0.004) and neonatal mortality (10.3% vs 2.3%) comparing with MMC-CHD. Low birth weight was also extremely more frequent in the SC-CHD group (44.7% vs 8.5%, p<0.001). No difference was found relating to the presence of CHD in infants from SC-CHD mothers compared to off-spring from MMC-CHD (8.4 vs 5.3%, p=0.407). Cesarian deliveries had similar rates independently of increased CHD complexity (34.2% vs 32.1%). Overall, pregnancy was quite well tolerated, although cardiac complications were more common in SC-CHD P (0.4% vs 4.3%, p 0.013). Only one maternal death was registered, during 1st trimester, in a woman with a large unrepaired ventricular septal defect and cyanosis.

Conclusion

Severe complex CHD remains a challenging condition for pregnancy with increased maternal and neonatal morbimortality. This emphasizes the importance of extensive prepregnancy counselling and centralization of care to address specific risks and requirements of the condition.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Severe CHD

Impaired myocardial energetics limits cardiac functional reserve and leads to exercise-induced pulmonary congestion in heart failure with preserved ejection fraction

Background

Abnormal cardiac mitochondrial function and energetics may be a unifying feature in the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Transient pulmonary congestion during exercise is emerging as an important determinant of reduced exercise capacity and symptoms in patients with HFpEF.

Purpose

We sought to determine if impaired myocardial energetics limits cardiac exercise reserve and leads to exercise-induced pulmonary congestion in HFpEF.

Methods

42 patients across the spectrum of diastolic dysfunction and HFpEF (controls n=10; type 2 diabetes (T2DM) n=9; HFpEF n=14; severe diastolic dysfunction due to cardiac amyloid n=9) (Fig. 1a) underwent assessment of cardiac energetics (myocardial phosphocreatine to adenosine triphosphate ratio, PCr/ATP) and function using cardiovascular magnetic resonance (CMR) imaging and echocardiography, and lung-water using a novel pulmonary proton-density MR sequence. Studies were performed at rest and during exercise (20W for 6 minutes) using a CMR-ergometer.

Results

Paralleling the stepwise decline in diastolic function across the groups (E/e' ratio, p<0.0001) was an increase in NT-pro BNP (p<0.0001, Fig. 1b) and reduction in PCr/ATP (control 2.00 [1.86,2.15], T2DM 1.71 [1.61,1.91], HFpEF 1.66 [1.44,1.89], amyloid 1.30 [1.16,1.53], p<0.0001, Fig. 1c). During exercise, there was progressive blunting of left ventricular (LV) diastolic filling (p<0.0001) (Fig. 2a-b), left atrial (LA) dilatation (p<0.0001), failure of RVEF augmentation (p=0.003), RV-PA uncoupling (RV stroke volume to end-systolic volume (SV/ESV) ratio, p=0.0002), and right atrial (RA) dilatation (p<0.0001) across the groups (Fig. 2b). LV diastolic filling (r 0.41, p=0.008), LA dilatation (r −0.35, p=0.03), RVEF augmentation (r 0.46, p=0.003), RV-PA uncoupling (r 0.36, p=0.02), and RA dilatation (r −0.68, p<0.001) during exercise were strongly linked with impaired myocardial energetics (Fig. 2b).

The novel pulmonary proton-density sequence provided images that scaled linearly with water content (validated using a water-doped sponge phantom; r 0.98, p<0.0001), and revealed a progressive increase in lung water signal/pulmonary congestion (Fig. 2c) post-exercise (p<0.0001) across the groups (controls: +0.25% [−1.8, 3.1], p=0.82; T2DM: +0.8% [−1.7, 1.9], p=0.82; HFpEF: +4.4% [0.5, 6.4], p=0.002; amyloid: +6.4% [3.3, 10.0], p=0.004). Pulmonary congestion was associated with impaired LV diastolic filling (r −0.32, p=0.04), RV-PA uncoupling (r −0.39, p=0.01) and RA dilatation (r 0.4, p=0.01) during exercise, and impaired myocardial energetics (r −0.36, p=0.02).

Conclusion

A gradient of myocardial energetic deficit exists across the spectrum of HFpEF. This energetic deficit is related to markedly abnormal cardiac exercise responses, which leads to transient pulmonary congestion. The findings support an energetic basis for impaired cardiac reserve and exercise-induced pulmonary congestion in HFpEF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Baseline clinical and CMR parametersExercise cardiopulmonary parameters

The impact of the cardiac rehabilitation program in patients with mid-range heart failure (40-50%) in improving cardio respiratory predictors

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Universitário Lisboa Central

Methods

We studied 30 patients (P) with ejection fraction (EF) 40-50%, in a number of 198 P that participated in cardiac rehabilitation program (CRP). Of these P, 24 (80%) male and 6 (20%) female, 20 P were diagnosed myocardial infarction with ST-segment elevation, 2 P myocardial infarction non ST and 8 P with myocardial hypertrophy non ischemic. Of these P 30% were diabetics, 56% hypertension, 70% dyslipidemia, 36% smokers previous to CRP and body mass index 26,3 medium.

All P were submitted to previous echocardiogram, cardiopulmonary exercise testing (CET) and a rehabilitation program minimum 4 sessions and maximum 52 sessions. At the end of the total sessions the echocardiogram and CET were repeated.

Results

Of the 30 P that participated in CRP only 20 completed the program, while the other 10 P dropped out because of social and economic problems. Of the P that completed the CRP, 70% got better on EF, 80% improved VE/VCO2 slope < 33 therefore are classified VC-II in ventilatory classification (VC), 5% VE/VCO2 slope > 40  VC-III classification, and 15% maintained the initial classification.  50% of the P increased at least one level metabolic equivalent of task (MET) from the first CET. Only 3 of the 20 patients came, once, to the hospital after the CRP with heart failure, and one died but did not fulfill the program.

Conclusion

Patients with mid-range heart failure submitted to a CRP can improve cardiorespiratory predictors, leading to a better quality of life. However, it is important to find solutions to minimize the causes that make patients to give up CRP.

Low-fluoro workflows and impact in radiation exposure in the electrophysiology lab

Funding Acknowledgements

Type of funding sources: None.

Background

 During electrophysiology (EP) procedures, fluoroscopy imaging is employed to visualise catheters position in real-time. However, ionizing radiation is a health hazard to both the patient and operator. In recent years, the use of electroanatomical mapping systems and operator adoption of low-fluoro workflows has allowed a reduction of radiation exposure. The aim of this study was to assess the evolution of fluoroscopy time (FT) in EP procedures, using conventional technique or an electroanatomical mapping system (EMS).

Methods

A retrospective analysis of consecutive EP procedures performed at a tertiary centre between September 2018 and October 2020 was conducted. The procedures were divided in 3 tertiles according to date (T1, T2 and T3), with T3 corresponding to the most recent interventions. Procedural duration, FT, use of EMS, radiofrequency time (RT), acute ablation success and procedural complications were examined.

Results

A total of 615 procedures were analysed: atrioventricular node reentry tachycardia (AVNRT) – n = 144, accessory pathways (AP) – n = 83, typical atrial flutter – n = 106, atrial fibrillation (AF) ablation with radiofrequency (RF) – n = 61, AF ablation with cryoballoon – n = 92, ablation of ventricular arrhythmias – n = 53, and 75 miscellaneous procedures (including atrioventricular node ablation, left atrial flutter ablation and cardioneuroablation). Mean age was 54.6 ± 18.2 years with 59.4% male sex patients. An EMS was used in 75% of the procedures, without significant differences between tertiles. A progressive reduction in median FT was observed over the tertiles (T1 6.3 min, interquartile range [IQR] 2.9-13.6; T2 5.4 min, IQR 2.1-12.0, and T3 3.1 min, IQR 1.2-7.2, Figure 1), and a statistical significant difference was found when comparing T1 to T3 (p < 0.001) and T2 to T3 (p < 0.001). The decrease in FT was observed throughout the study period for all different EP procedures (Figure 2). The number of procedures with zero fluoroscopy had gradually increased (T1 6.1%, T2 8.5% and T3 14.1%; T1 vs. T3 p <0.01). Younger patients (<20 years) were submitted to low fluoroscopy doses with a significant decrease over tertiles (T1 1.2 min, IQR 0.0-4.3; T2 0.9 min, IQR 0.0-2.5; T3 0.0, IQR 0.0-2.2, T1 vs.T3 p < 0.001). No significant difference in procedural duration, RT, acute procedural success or complication rate were noted between tertiles.

Conclusion

Reduction in radiation exposure can be achieved without compromising duration, safety and effectiveness of the procedure.  The commitment of operators to reduce radiation exposure using 3D mapping technology can lead to a significant decrease in the use of fluoroscopy. Abstract Figure. Fluoroscopic time analysis

Late gadolinium enhancement as a predictor of arrhythmias in patients with hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of arrhythmias and sudden cardiac death (SCD). The Late gadolinium enhancement (LGE) in cardiovascular magnetic resonance (CMR) has been associated with the occurrence of arrhythmic events.

Purpose

The aim was to analyze the association between LGE burden and location and arrhythmic events in HCM patients (P).

Methods

Retrospective analysis of P with HCM in a single tertiary center. Baseline clinical, echocardiographic and CMR characteristics were collected. On follow up arrhythmias (ventricular fibrillation (VF), sustained ventricular tachycardia (SVT), non-sustained ventricular tachycardia (NSVT), paroxysmal supraventricular tachycardia (PSVT), atrial fibrillation (AF) and atrial flutter (AFL)) were identified. LGE on CMR was compared between patients with and without arrhythmias.

Results

61P (59% male) were included, with a mean age of 58 ± 2 years. The HCM risk-SCD score was 3.35 ± 0.28%. On echocardiography mean left ventricle ejection fraction was 62.16 ± 1.36% and maximum wall thickness 20.59 ± 0.596mm. 31.1% had systolic anterior movement of mitral valve and 26.7% had left ventricle outflow tract obstruction. LGE was present in 88.5% P with a median number of 5 ± 7 segments involved. Interventricular septum (IVS) was involved in 78.7% P, anterior wall

in 57.4%, inferior wall in 54.1%, lateral wall in 52.5%, posterior wall in 9.8%, basal segments in 62.3%, median segments in 68.9% and apical segments in 63.9%. On follow up 3.3%P died, 45.8% had hospitalizations (22,2% because of an arrhythmia) and 75% had arrhythmias (1.6% VF, 6.6% SVT, 50% NSVT, 9.8% PSVT, 37.7% AF and 6.6% AFL). The number of segments with LGE correlated with arrhythmias (p = 0.05 for arrhythmias, p = 0.03 for SVT, p = 0.008 for NSVT and p = 0.042 for PSVT). A cut off of 5 segments involved was a good predictor of arrhythmias (p = 0.002), NSVT (p= 0.006), PSVT (p = 0.024) and AF (p = 0.0029). For SVT the best cut off was 9 (p = 0.003). Considering the LGE location, we found an association between the segments involved and the occurrence of different arrhythmias (table 1).

Conclusion

Supraventricular and ventricular Arrhythmias are frequent in patients with HCM, with the most frequents being NSVT and AF. The LGE burden (>5 segments) and location (median inferior IVS, median anterior IVS, median anterior wall, basal anterior IVS, apical anterior wall, median inferior wall, apical anterior wall and basal inferior IVS) were correlated with arrhythmic events. Abstract Figure.

Insights on the role of acetaldehyde and other aldehydes in the odour and tactile nasal perception of red wine

Wine models with or without a dearomatised and lyophilized red wine extract containing a young red aroma base (control) plus one vector with one or several aroma compounds (unsaturated-aldehydes, saturated-aldehydes, benzaldehyde, isoamyl-alcohol, methoxypyrazines and (Z)-1,5-octadien-3-one) were prepared. Models were spiked with increasing amounts of acetaldehyde whose headspace concentrations were controlled. Odour and nasal chemesthesic properties were assessed by a trained sensory panel. Results confirm the contribution of the different players, notably isoamyl-alcohol, (Z)-1,5-octadien-3-one, benzaldehyde and methoxypyrazines, to wine aroma and tactile nasal characteristics and demonstrate that acetaldehyde levels play an outstanding role in their modulation. At low levels, it can play positive roles in some specific aromatic contexts, while at higher levels, enhance the negative effects associated to the generic presence of other aldehydes (saturated, unsaturated and Strecker aldehydes) by enhancing "green vegetable" notes and "itching" character and the "burning" effects linked to high levels of isoamyl alcohol.

Myocardial work brings a new insight into left ventricule remodelling in cardiooncology patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Serial echocardiographic assessment of 2D left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) is the gold standard screening method for cancer therapeutics-related cardiac dysfunction (CTRCD). Non-invasive left ventricular (LV) pressure-strain loop (PSL) provides a novel method of quantifying myocardial work (MW) with potential advantages, as it incorporates measurements of myocardial deformation and LV pressure.

Purpose

To evaluate the impact of cardiotoxic treatments in MW indices.

Methods

Prospective study of female breast cancer patients (P) submitted to therapy (TH) who underwent serial monitoring by 2D, 3D transthoracic echocardiography (TTE) and concomitant blood pressure assessment. P were evaluated at T0, T1 and T2 (before, ≥6 and ≥12 months after starting TH). PSL analysis allowed the calculation of the following indices: Global Work Index (GWI), Global Constructive Work (GCW), Global Work Waste (GWW) and Global Work Efficiency (GWE). CTRCD was defined as an absolute decrease in 2D LVEF > 10% to a value < 54% or a relative decrease in 2D GLS > 15%, according to literature. 

Results

122 patients (mean age 54.7 ± 12.0 years), mostly treated with anthracyclines (77.0%, cumulative dose 268.6 ± 71.8mg/m2), anti-HER (75.4%) and radiotherapy (77.0%) were included. 2D and 3D LVEF were significantly reduced during TH, however remaining within the limits of normality (2D LVEF T0-T1 64.2 ±7.6 vs 61.1 ± 8.2%, p = 0.006 and 3D LVEF T0-T1 60.2 ± 6.7 vs 56.9 ±6.3%, p = 0.022). 2D GLS was also more impaired at T1 (-19.8 ± 2.7% vs -18.5 ± 3.0%, p = 0.003).

All MW indices were significantly reduced at T1 compared to baseline (GWI 1756.9 ± 319.2 vs 1614.3 ± 338.5mmHg%, p = 0.005; GCW 2105.6 ± 352.0 vs 1970.5 ± 376.2 mmHg%, p = 0.015; GWW 121.1 ± 66.6 vs 161.1 ± 84.1 mmHg%, p = 0.001; GWE 93.5 ± 3.1 vs 91.1 ± 4.5%, p = 0.001). Between T1 and T2 no statistical difference was found but a partial recovery of parameters was observed when comparing T2 to T0 (GWI (T2) 1650.6 ± 357.5 mmHg%, p = 0.035; GCW (T2) 2013.3 ± 379.3 mmHg%, p = 0.086; GWW (T2) 148.0 ± 85.0 mmHg%, p = 0.02 and GWE (T2) 92.0 ± 4.7%, p = 0.012). 

During a mean follow-up of 14.9 ± 9.3 months, 36 patients (29.5%) developed CTRCD.  P presenting CTRCD revealed a significant decrease in GWI and GWE at T1 comparing with women without CTRCD (GWI 1.8 ± 21.6 vs -14.2 ± 18.5%, p = 0.004 and GWE -1.0 ±3.0 vs -3.6 ±3.9%, p = 0.005). GWW had a substantially increase at T1 in P with cardiotoxicity (27.6 ± 76.3% vs 64.1 ± 68.0%, p = 0.051).

Conclusion

Left ventricular systolic function study with MW showed a reduction in cardiac performance with a peak at 6 months from the start of chemotherapy and partial recovery after term. Assessment of myocardial deformation parameters, namely MW, proved to be a useful tool for a better characterisation of cardiac remodelling, and could enhance patient selection for cardioprotective therapeutics.

Abstract Figure. TTE parameters

Liquid Chromatography-Mass Spectrometry-Based Metabolomics for Understanding the Compositional Changes Induced by Oxidative or Anoxic Storage of Red Wines

The aim of this work was to study the physicochemical changes of eight red wines stored under conditions differing in O₂ exposure and temperature and time under anoxia. The methods used to analyze the wines included the measurement of volatile sulfur compounds, color, tannin (T) polymerization, and liquid chromatography-mass spectrometry untargeted metabolomic fingerprint. After 3 months, the color of the oxidized samples evolved 4-5 times more intensively than in wines stored under anoxia. The major metabolomic differences between oxidative and anoxic conditions were linked to reactions of acetaldehyde (favored in oxidative) and SO₂ (favored in anoxia). In the presence of oxygen, the C-4 carbocation of flavanols delivered ethyl-linked tannin-anthocyanin (T-A) and tannin-tannin (T-T) adducts, pyranoanthocyanins, and sulfonated indoles, while under reduction, the C-4 carbocation delivered direct linked T-A adducts, rearranged T-T adducts, and sulfonated tannins. Some of these last reactions could be related to the accumulation of reduced species, eventually ending with reductive off-odors.

Predictors of atrial fibrillation occurrence in patients with hypertrophic cardiomyopathy

Introduction

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of dysrhythmias, especially atrial fibrillation (AF).

Purpose

The aim of this study was to evaluate the incidence of AF in HCM patients (P) and to determine predictors of AF.

Methods

Retrospective analysis of HCM P at a single tertiary center. Baseline clinical, echocardiographic and cardiovascular magnetic resonance (CMR) characteristics were collected. On follow up AF was identified by electrocardiogram and/or 24 hours Holter monitoring.

Results

61P (59% male) were included, with a mean age of 58±2 years. 27.9% had angina (all of them CCS 2), 34.4% were in NYHA II and 14.8% in NYHA III, 8.2% had syncope and 39.3% had palpitations. A family history of sudden cardiac death (SCD) or cardiomyopathy was present in 40.4% of the cases. The mean HCM risk SCD score was 3.35±0.28%. On echocardiography left atrium (LA) diameter was 44.86±0.87mm, LA volume (LAvol) was 89.97±5.39mL (indexed LAvol 46.05±2.55mL/m2), interventricular septum (IVS) was 16.83±0.663mm, left ventricle (LV) mass was 290.94±13.897g and maximum wall thickness (MWT) was 20.59±0.596mm. 77% P had LA enlargement. 88.5%P had late gadolinium enhancement (LGE) in CMR with a median number of 5±7 segments involved. AF developed in 23P (37.7%), with a mean age of 58±3 years. Predictors of AF development were NYHA III (p=0.007), risk score (p=0.007), LA diameter (p=0.007), LAvol (p=0.005) and indexed LAvol (p=0.002), MWT (p=0.0015), LGE in more than 5 segments (p=0.029) and LGE in the inferior basal and inferior median IVS (p=0.033 and p=0.042). The only independent predictor was LAvol (p=0.0012), with an area under the curve of 0.755 and a cut off of 85.9mL being the best predictor (p=0.004). Combining LAvol >85.9mL with LGE involving >5 segments and LAvol >85.9mL with LGE in inferior basal IVS (IBIVS) a statistically significant difference between groups was achieved (p=0.009 in the combined predictor LAvol + LGE >5 segments and p=0.002 in the combined predictor LAvol + LGE in IBIVS) (figure 1 and figure 2). In a multivariable analysis including these 2 combined predictors and LAvol alone the only independent predictor was the combination of LAvol + IBIVS involvement.

Conclusion

AF is frequent in patients with HCM and develops in younger ages than in general population. NYHA III, risk score, LA diameter, LAvol, MWT, LGE >5 segments and LGE in IBIVS and in IMIVS were predictors of AF, with LAvol being the independent predictor. The combination of LAvol with LGE >5 segments and LAvol with LGE in IBIVS presented stronger predictor value comparing with these characteristics alone.

Funding Acknowledgement

Type of funding source: None

Pregnancy outcomes in women with mechanical heart valves

Background

Mechanical heart valves (MHV) and their absolute need for adequate anticoagulation poses a challenge for pregnancy, either due to warfarin fetotoxicity or an increased risk of maternal thromboembolism. This represents a unique patient (P) group where data is scarce and maternal and fetal risks and benefits must be carefully weighed.

Purpose

To assess maternal and perinatal outcomes in women with MHV on different anticoagulant regimens and compare them with patients with other types of valvular heart disease (VHD).

Methods

A retrospective analysis of 131 pregnancies in 83 women with VHD (mean age 26.5±5.6 years) was carried out in a tertiary referral centre from 2000 to 2019. 92 pregnancies with VHD, including 11 with biological prosthetic valves, and 39 pregnancies in 22 P with MHV were identified. The main outcome measures were major maternal complications and perinatal outcome.

Results

MHV implanted were in mitral position (89.7%), aortic (2.6%), or both (7.7%). History of rheumatic heart disease was identified in 16 P (72.7%) and a congenital etiology was present in 2 P (9.1%). 9 P (40.9%) were on warfarine and 13 P (59.1%) on acenocumarol. Regarding anticoagulation strategy, 21 P (65.6%) remained on oral anticoagulation and 10 P (31.3%) had been switched to some form of heparin during part or the entire pregnancy. Mechanical valve thrombosis complicated pregnancy in 4 patients (10.2%), all cases on heparin, and resulted in maternal death in 1 P. MHV P had more hemorrhagic complications (15.4 vs 2.2%, p=0.004) requiring transfusion or surgical revision. MHV P tended to experience more NHYA class worsening demanding initiation or intensification of cardiac medication (17.9 vs 5.4%, p=0.023). Also in the MHV group there was a higher incidence of miscarriage (46.2 vs 12.0%, p≤0.0005), comprising spontaneous abortion (31.6 vs 7.6%, p<0.0005) and fetal malformations (18.4 vs 5.4%, p=0.028), including warfarin embryopathy (10.3 vs 1.1%, p=0.012). The live birth rate was higher in women on heparin compared with those on warfarin (85.9 vs 79.2%, p=0.002). The presence of multivalve disease (p=0.04), mechanical protheses (p<0.001), ACO (p<0.001) and previous impaired LVEF (p=0.02) were related to miscarriage. In multivariate analysis, ACO was the unique independent predictor of unsuccessful pregnancy (p=0.01). Only 29% of the patients with an MHV had a pregnancy free of serious adverse events compared with other types of VHD (81.5%, p<0.0005).

Conclusions

MHV remains a challenging condition for pregnancy with only 29% chance of experiencing an uncomplicated pregnancy with a live birth. The increased morbimortality warrant extensive prepregnancy counseling with prosthesis type discussion,centralization of care and further larger studies to come up with evidence-based recommendations.

Funding Acknowledgement

Type of funding source: None

Role of tilt-table testing in syncope diagnosis and management: analysis of patients referred to a syncope unit

Introduction

Head-up tilt-testing (HUT) enables the reproduction of reflex syncope in a laboratory setting. Despite being used to confirm the diagnosis of this syncope, there is some concerns regarding the best protocol to use and recent studies with implantable loop recorders have called the value of HUT into question.

Aim

To characterize the population undergoing HUT according to the modified Italian protocol, type of response to HUT and subsequent management at our center in the last 4 years.

Methods

Retrospective analysis of consecutive P who underwent HUT between 2015 and 2018. Descriptive analysis of patients (P) demographics and medical history, indication for HUT, type of response to HUT and management.

Results

A total of 419P (55.1% female) were included with a mean age of 62 years. The majority (n=302, 72.1%) had comorbidities (structural heart disease – 55%, cardiac dysrhythmias – 57.6%, hypertension – 48.3%, diabetes – 15.6%, depression – 15.9%, cerebrovascular disease –10.6%) or was under medication (n=220, 52.5%) with a potential hypotensive or bradycardic effect (44.1% ACEI/ARA, 29.1% beta-blocker, 27.7% diuretic, 23.6% antidepressant, 22.7% calcium channel blocker, 19.1% benzodiazepines). Syncope/presyncope episodes accounted for 56.1% of the HUT, with falls and disequilibrium accounting for 52%. In 21 cases (5%) suspected dysautonomia or other non-specified reasons were the indication for HUT. HUT were ordered according to the guidelines in 136P (84.6% – indication level I, 3.6% – level IIa, 11.8% – level IIb). HUT was positive in 292P (69.7%) – 77.1% after nitroglycerin administration (vasodepressor – 170P, cardioinhibitory – 53P, mixed – 62P and dysautonomic – 7P). Cardioinhibitory (CI) response predominated in the younger, and vasodepressor in the older P. Of the P with CI response, 41.5% had asystole (median of 41.4s, minimum 7.5s, maximum 115s). All P were instructed in the need to avoid triggering factors and perform counterpressure maneuvers. A pacemaker was implanted in 24P (5.7% of all population, due to long sinus pauses and asystole). Twenty-four P (5.7%) completed a tilt training program.

Conclusion

Most of the HUT were requested for syncope/presyncope, frequently according to the guidelines. There was a high rate of positive tests, with a predominance of vasodepressive response, particularly in the elderly.

Funding Acknowledgement

Type of funding source: None

Performance of the padit score in patients undergoing transvenous lead extraction

Background

The PADIT trial identified 5 independent predictors of cardiac implantable electronic device (CIED) infection (prior procedure, age, chronic kidney disease, immunosuppression and type of procedure) and developed a novel infection risk score.

Aim

To assess whether the PADIT score (PS) could predict CIED reinfection and adverse events in patients (pts) submitted to transvenous lead extraction (LE) using the Pisa Technique (PT) due to CIED infection.

Methods

We conducted a single-centre prospective study of consecutive procedures (P) of LE using the PT between February 2013 and October 2019. Demographic, clinical, microbiological, device/ procedure related variables, morbidity and mortality data were retrieved during follow-up (FUP). An univariate analysis was performed to evaluate the ability of the PS to predict CIED reinfection (Re), procedural complications (C), all-cause hospital mortality (M), all-cause mortality/ hospitalization during first year of follow-up (MH1) and cardiovascular mortality (CM).

Results

A total 171 Ps including 159 pts, of which 80.7% (130 pts)were due to CIED infection: 55.1% due to pocket site infection, 18.8% to occult bacteremia with probable CIED infection and 26.1% due to both pocket site and systemic infection, with 44% of pts presenting with valvular/ lead vegetation (mean age - 70.3Y, 77.7% male, mean LVEF of 49.6%). The Rs rate was 93.1% and the clinical success rate was 99.2%. There were no deaths related to the procedure. During a mean FUP of 33 months, 11 pts had to undergo a new P, 5 of them due to pocket reinfection. The mortality rate was 24.2% (37 pts), with 8 pts dying during hospital stay, and 19 pts during the first year post-P. The mean PS was 2.9±2.5 (min- 0, max- 10). A higher PS value was associated with Re (HR - 1,43, CI95% 1.09–1.87, p=0.011), CM (HR - 1,39, CI95% 1.06–1.85, p=0.018) and MH1 (OR - 1,19, CI95% 1.03–1.38, p=0.021). There was no association between the PS and the rate of clinical success of the procedure (2.9% vs 4.5%, p=0.395), procedural complications (2.9% vs 3.3%, p=0.656) and M (4.0% vs 2.8%, p=0.192). Interestingly, a higher PS was not associated with a higher use of an antibacterial envelope during device reimplantation (3.5% vs 2.9%, p=0.371).

Conclusion

The PADIT score revealed a high predictive power for reinfection, all-cause mortality/ hospitalization during first year of follow-up and cardiovascular mortality in pts submitted to LE using the PT for CIED infection.

Funding Acknowledgement

Type of funding source: None

Insights from microRNAs into the pathophysiology of coronary and multiterritorial atherosclerosis

Introduction

The mechanisms underlying the different phenotypic presentations of atherosclerosis are still poorly understood. MicroRNAs regulate genetic expression at the post-transcriptional level and each has specific biological functions. MicroRNAs could therefore be useful for understanding the epigenetic drivers for development of isolated coronary atherosclerosis and more extensive disease (coronary and extra-coronary). We evaluated if the expression profile of circulating microRNAs was associated with coronary and multiterritorial atherosclerosis.

Methods

We prospectively recruited three groups of age- and sex-matched participants, with: 1) no coronary atherosclerosis (calcium score=0, no soft plaques in coronary angioCT scan), neither carotid or inferior limbs atherosclerosis (controls); 2) isolated obstructive coronary artery disease (CAD) (≥50% for the left main, ≥70% for other epicardial vessels) (isolated CAD group); 3) obstructive disease of the coronary, inferior limbs and carotid arterial beds (multi-territorial disease group). Obstructive atherosclerosis of carotid and inferior limbs arteries (≥50% stenosis by Doppler or angioCT imaging) was assessed in all participants. Acute atherosclerotic events or coronary revascularization within 12 months, heart failure, infections, malignancy and severe renal dysfunction were exclusion criteria. Six microRNAs with diverse mechanisms of action were selected (mir-21, miR-27b, miR-29a, miR-126, miR-146, miR-218) and measurements of their circulating levels were performed in a blinded fashion, using RT-PCR SYBR Green.

Results

Twenty four patients were included, including 8 patients in each group. Mean age was 61±9 years, and 83% were male. In patients with atherosclerosis, classical cardiovascular risk factors were globally more prevalent. The expression of miR-146 and miR-218, both of which regulate endothelial function, was significantly decreased in the isolated CAD group compared to controls (Figure; data are expressed as median [IQR]). There was a further decrease in the expression of both microRNAs in patients with multiterritorial atherosclerosis compared to patients with isolated CAD. The expression of other microRNAs did not differ. Smoking was associated with the presence of isolated CAD and multiterritorial atherosclerosis (14% vs 30% vs 56% of smokers across groups, p=0.002), and with a decreased expression of miR-218 (1.6 [0.02–83] fold vs 0.1 [0.001–0.7] fold, p=0.023).

Conclusions

The expression of the endothelial regulators miR-146 and miR-218 was decreased in patients with isolated CAD compared to controls, and even more hampered in patients with multiterritorial atherosclerosis. Higher degrees of endothelial dysfunction may therefore contribute to a more diffuse atherosclerotic presentation through miR-146 and miR-218. Atherogenesis related to smoking may be partially mediated by miR-218.

Funding Acknowledgement

Type of funding source: None

New onset atrial fibrillation after percutaneous Patent Foramen Ovale closure: how serious is this problem?

Background

Percutaneous Patent Foramen Ovale (pPFO) closure benefits for secondary prevention after cardio-embolic stroke have recently been proved. With the increasing number of cases and procedures, a concern with new onset atrial fibrillation (NOAF) has been raised.

Purpose

To evaluate long-term outcome regarding NOAF rate and to identify its predictors and clinical impact, in a real population submitted to pPFO closure.

Methods

From 2000 to 2017, consecutive patients (P) submitted to pPFO closure in a tertiary centre were prospectively enrolled. The primary endpoint was NOAF rate and secondary endpoints were all-cause, neurologic and cardiac mortality rates and recurrent ischemic events. Previous and follow-up electrocardiographic, echocardiographic and 24-hour heart rhythm monitoring data were analysed. Follow-up was performed through medical visits, medical charts consultation and a phone call based system, in order to assess clinical status, on-going treatment and events.

Results

496 patients were submitted to pPFO. Immediate success was achieved in 98.8% and 9.1% presented a residual shunt on the 1st year TEE. Mean age was 45.0±11.2 years-old with 50.2% of males. The prevalence of hypertension, hypercholesterolemia and atrial septum aneurysm (ASA) was 25.7%, 45.0% and 46.3%, respectively. Pre-procedural mean left atrial (LA) diameter was 36.0±5.3 mm. FU data was available for 490 (98.6%), for a mean FU time of 7.41±3.51 years. 34 P (6.9%) presented ischemic events recurrence (26 strokes and 8 TIA). The primary endpoint was observed in 21 P (4.3%) during the FU period.

Median time to 1st AF episode since PFO closure was 5.90±5.53 years. 11 P (52.3%) initiated oral anticoagulation. In univariate analysis, age (44.6±11.3 vs 51.8±6.0 years, p=0.005) and hypertension (24.7% vs 47.6%, p=0.019) were predictors of NOAF in this population. In multivariated analysis, only age remained a predictor of NOAF (OR 1.05 (1.007–1.101), p=0.025). LA pre pPFO closure dimensions, ASA, device type or size and the presence of residual shunt in TEE were not determinants of AF occurrence. The incidence of NOAF was associated with the need for hospitalization due to cardiac causes (19% vs 3.2%, p=0.001) and a trend towards higher rate of recurrent stroke (4.9% vs 14.3%, p=0.06).

Conclusion

Despite being a highly successful and safe procedure in most patients, pPFO closure was associated with a non-negligenciable rate of NOAF during long-term follow-up. NOAF predictors were related with classical cardiovascular risk factors, such as age and hypertension. None of the procedure or device features were associated with NOAF. Yet, a clinical impact was attributed to NOAF, with more hospitalizations and a trend towards ischemic events recurrence.

As young patients submitted to pPFO closure grow older, prevention strategies to diagnose and treat NOAF should be endeavoured.

Funding Acknowledgement

Type of funding source: None

Innate immunity is linked to the severity of stable coronary artery disease through sCD40L pathway

Introduction

Soluble CD40 ligand (sCD40L) activates different cell types involved in innate immunity, including macrophages and platelets. The influence of innate immunity, particularly of sCD40L pathway, on stable coronary artery disease (SCAD) expression is not fully understood. We evaluated if sCD40L expression is related to the presence of SCAD and to its clinical and anatomical severity.

Methods

We prospectively recruited two groups of age- and sex-matched participants: 1) without coronary artery disease (CAD) (calcium score=0, no soft plaques on coronary angioCT scan) (controls); and 2) with stable obstructive CAD (≥50% for the left main, ≥70% for other epicardial vessels, on invasive coronary angiography). Acute atherosclerotic events or coronary artery bypass grafting (CABG) within 12 months, previous percutaneous coronary intervention, heart failure, infection, malignancy and severe renal dysfunction were exclusion criteria. Clinical, laboratorial and anatomical data were prospectively collected. Serum was stored at −80°C and measurements were performed in a blinded fashion, by ELISA (sCD40L Human Quantikine).

Results

Sixty-three participants were included: 14 controls and 49 patients with SCAD. In SCAD patients, classical cardiovascular risk factors were globally more prevalent and the serum levels of sCD40L (5553±3356 vs 3099±644 ng/mL, p<0.001), leucocytes counts (7.6±1.8 vs 6.4±1.7x109/L, p=0.010), neutrophils counts (4.4±1.5 vs 3.5±1.5x109/L, p=0.010) and neutrophils/lymphocytes ratio (2.4±1.1 vs 1.9±0.7, p=0.019) were significantly higher, while c-reactive protein (CRP) levels did not differ, compared to controls. sCD40L levels were positively correlated with leucocytes (r=0.36) and neutrophils (r=0.28) counts (all p<0.05), but not with CRP. Clinically, sCD40L levels were associated (ANOVA p<0.001) and positively correlated (Pearson r=0.54, p<0.001) with angina severity (Fig. 1A). Anatomically, patients with a higher number of significant coronary artery lesions presented higher sCD40L levels (Fig. 1B); sCD40L levels were positively correlated with the number of: diseased vessels (r=0.33), significant coronary artery lesions (r=0.31), and all coronary artery lesions (r=0.33) (all p<0.05), without correlation with the Gensini score. Linear regression analysis considering clinical and laboratorial data revealed that sCD40L was an independent predictor of CAD severity, as assessed by the number of significant lesions (model: sCD40L β 0.28, 95% CI 0.03–0.34; hypertension β 1.1, 95% CI 0.97–3.64). Among SCAD patients, those with previous CABG (n=15) had lower sCD40L levels than patients waiting for revascularization (n=34) (3317±1680 vs 6793±3631 ng/mL, p<0.001).

Conclusions

Increased expression of sCD40L was associated with the presence of SCAD, with angina severity and with CAD severity, while previous revascularization was associated with decreased sCD40L levels.

Funding Acknowledgement

Type of funding source: None

Prognostic value of the cardiorespiratory optimal point during submaximal exercise testing

Background

Peak oxygen consumption (pVO2) is a key parameter in assessing the prognosis of heart failure with reduced ejection fraction (HFrEF) patients (pts). However, it is a less reliable parameter when the cardiopulmonary exercise test (CPET) is not maximal. It is crucial to identify the submaximal exercise variables with the best prognostic power (PP), in order to improve the management of pts that cannot attain a maximal CPET.

Purpose

The aim of this study was to evaluate and compare the PP of several exercise parameters in submaximal CPET for risk stratification in pts with HFrEF.

Methods

Prospective evaluation of adult pts with HFrEF submitted to CPET in a tertiary center. A submaximal CPET was defined by a respiratory exchange ratio (RER) ≤1.10. Pts were followed up for at least 1 year for the primary endpoint of cardiac death and urgent heart transplantation/ ventricular assist device implantation. Several CPET parameters were analyzed as potential predictors of the combined endpoint and their PP (area under the curve - AUC) was compared to that of pVO2, using the Hanley and McNeil test.

Results

CPET was performed in 487 HF pts, of which 317 (66%) performed a submaximal CPET. Pts averaged 57±12 years of age, 77% were male, 45.7% had ischemic cardiomyopathy, with a mean LVEF of 30.4±7.6%, a mean heart failure survival score of 8.6±1.1. The mean pVO2 was 17.1±5.5 ml/kg/min and the mean RER 1.01±0.08. During a mean follow-up (FU) time of 11±1 months, 18 pts (6%) met the primary endpoint. Cardiorespiratory optimal point (OP - VE/VO2) had the highest AUC value (0.915, p=0.001), followed by the partial pressure of end-tidal CO2 at the anaerobic threshold - PETCO2L (0.814, p<0.001). pVO2 presented an AUC of 0.730 (p=0.001). OP≥31 and PETCO2L ≤37mmHg had a sensitivity of 100 and 76.9% and a specificity of 71.1 and 67%, respectively, for the primary outcome. OP presented a significantly higher PP than pVO2 (p=0.048), whether PETCO2L didn't achieve any statistical significance (p=0.164). Pts with anOP≥31 presented a significantly lower survival free of HT during FU (log rank p=0.002).

Conclusion

OP had the highest PP for HF events of all parameters analyzed for a submaximal CPET. This parameter can help stratify the HF pts physiologically unable to reach a peak level of exercise.

Funding Acknowledgement

Type of funding source: None

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

Background

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

Purpose

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

Methods

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

Results

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

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

Conclusions

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

Funding Acknowledgement

Type of funding source: None

New onset atrial fibrillation after dual chamber pacemaker implantation: long term predictors

Background

Preserving atrioventricular synchrony has been accepted as a significant advantage of atrial and dual-chamber (DDD) pacing. However, little is known about the incidence of atrial fibrillation (AF) after DDD implantation and its prognostic predictors in long term.

Purpose

To determine the incidence of new AF episodes and to identify risk factors and prognostic predictors for new-onset AF and all-cause mortality after implantation of dual-chamber pacemakers.

Population and methods

713 consecutive patients (P) who underwent colocation of DDD pacemaker, due to AV block (AVB) or sinus node disease (SND), with no prior history of AF, from 2011 to 2015. Through periodic PM interrogation, occurrence of AF (“automatic mode switch” episodes with documented AF), switch to ventricular pacing (VVIR), pacing site (apical or septal) and cumulative right ventricular (RV) pacing % were analysed.

Results

Follow-up data was available for 669 patients (93.8%) for a mean follow-up (FU) time of 47.8±22.7 months. Mean age was 72.9±10.8 years with 60.1% male. New occurrence of AF was observed in 345 P (51.6%) during the FU period; 45.7% of them were consequently anticoagulated (59.0% with NOACs). Median time to 1st AF episode since implantation was 21.6 months and in 50.9% of the cases it lasted ≥1h. In univariate analysis, 1st AF episode lasting more than 1 hour and existence of at least one episode longer than 24 hours were directly related to switch to VVIR (p<0.0005; p<0.0005; p<0.0005) as well as prescription of anticoagulation (p=0.001; p=0.011; p<0.0005).

Compared to non-AF P, those with AF were older (74.0±9.9 vs. 71.8±11.7 years; p=0.008), had higher prevalence of SND (50.0% vs 40.20%; p=0.015), had superior % of RV pacing (65.9±39.3% vs. 58.3±44.3%; p=0.021) and more frequently had RV apical pacing (70.1% vs 57.3%; p=0.001). The prevalence of hypertension, diabetes mellitus and dyslipidemia were similar in the two groups. With multivariable Cox-regression, age (HR 1.02; p=0.017), SND (HR 1.49; p=0.010), admission for HF (HR 1.55; p=0.012) and % RV pacing (HR 1.01; p=0.003) were significantly associated with the incidence of FA. Predictors of all-cause mortality in Cox regression were the occurrence of AF in 1st of FU (HR 1.67; p=0.018) and % RV pacing (HR 1.01; p=0.043).

Conclusions

New onset AF is a frequent finding after DDD pacemaker implantation and is associated with all-cause mortality in long term. Age, admission for heart failure, sinus node disease and % of RV pacing were independent predictors for AF during follow-up.

Funding Acknowledgement

Type of funding source: None

Correlation of static knee angle in kinematic and radiographic in medial knee osteoarthritis

Introduction The hip-knee-ankle (HKA) angle measured on a full-length weight bearing X-ray made in standing position is considered the gold standard to measure the knee static alignment. However, this method requires special equipment, involves significant radiation exposure and generates extra costs. The 3D motion capture can assess knee angles in a reliable and accurate way.

Objectives This study aimed to analyse the correlation between the HKA angle achieved in full-length X-ray and the in static knee kinematic analysis in patients with medial knee osteoarthritis (OA).

Methodology A descriptive study was design. Anterior-posterior full-limb radiographs were obtained using standard procedures in the same hospital. The HKA angle was measure by an experimental orthopaedic doctor. The kinematics were obtained using Visual3D software after 3D motion capture in two static positions: static comfortable position (Static-1) and a static standard position (Static-2). Kinematic data were filtered (6 Hz) and expressed in degrees (°). The knee joint was created by the distance between the distal end of the thigh and the proximal end of the shank. The angles lower than 180° were considered as varus alignment and those higher than 180° valgus alignment.

Results This study includes 36 patients (22 females; mean age 61,6 ± 8,4; weight 75,8 ± 12,7 kg, and height 161 ± 9,2 cm) with diagnosed medial knee OA Kellgren/Lawrence grade 2 (16 patients) or 3. The patients presented a mean of HKA of 176,2° ± 3,2 in X-ray; 182,1° ± 6,0 in Static-1 and 180,0° ± 5,6 in Static-2. A significant correlation was found between HKA angle and Static-1 (r = 0,525; p = 0,001) and between HKA angle and Static-2 (r = 0,556; p = 0,000).

Conclusion A moderate but significant correlation was found between X-ray and two measure of 3D motion capture in frontal knee angle. Clinically, 3D analysis may help health care professionals in a more practical way to identify the joint angles.

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

Background

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

Purpose

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

Methods

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

Results

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

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

Conclusions

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

Abstract 1226 Figure. Kaplan–Meier curves and ASPB

P715 When "wait and see" is the best option: a case report of a spontaneous coronary artery dissection

Introduction

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and is now being identified more frequently, in part because of increased awareness.

Case report

We present the case of a 63-year-old female, without cardiovascular risk factors or relevant past medical history. She complained of atypical chest pain in the last year. The patient was admitted due to acute chest pain at rest, hemodynamically stable, with unremarkable physical examination, including absence of heart failure signs. The EKG revealed a dynamic ST depression in leads V4-V6. The peak of high sensitivity troponin I was 13744pg/mL (ULN< 15.6) and CK 874U/l (ULN <168). The echocardiogram showed preserved left ventricular ejection fraction and hypokinesia of mid-apical segments of anterior wall. Considering the diagnosis of NSTEMI the patient underwent coronary angiography that revealed luminal narrowing of 70% in left main artery, 70% in proximal anterior descending artery (LAD) and 99% in first obtuse marginal. Given the absence of cardiovascular risk factors, the smooth angiographic appearance of coronary lesions and absence of calcium, we suspected of spontaneous dissection or vasculitis. Considering the absence of angina revascularization was delayed. A first coronary angio-CT confirmed the luminal narrowing and suggested a spontaneous dissection. Two weeks later the coronariography and the angio-CT were repeated with a significant improvement, showing only intermediate stenosis of proximal LAD. The additional imaging study revealed a 45mm ascending aortic dilation and a left primitive carotid stenosis without other vascular territory alterations, excluding fibromuscular dysplasia. The auto-immune study was unremarkable. With all these results it was assumed the diagnosis of a spontaneous coronary artery dissection and the patient was discharged asymptomatic under single antiplatelet therapy and Rivaroxaban. Three months later a new coronary angio-CT showed no significant coronary artery stenosis and the patient was asymptomatic.

Discussion and conclusion

The recognition of spontaneous coronary artery dissection is essential to the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in these patients are suboptimal and conservative management is probably the best option.

Abstract P715 Figure. angio-CT