Ovarian hemangioma: A rare encounter

Ovarian hemangioma, though rare and asymptomatic, can mimic malignant ovarian tumors, thus it is necessary for comprehensive histopathological and immunohistochemical evaluation for accurate diagnosis and appropriate management.

Reproducibility of semi-quantitative assessment of aortic valve calcification and valve motion on echocardiography: a small-scale study

BACKGROUND

Aortic stenosis (AS) is the most common degenerative valve disease in high income countries. While hemodynamic metrics are commonly used to assess severity of stenosis, they are impacted by loading conditions and stroke volume and are often discordant. Anatomic valve assessments such as aortic valve calcification (AVC) and valve motion (VM) during transthoracic echocardiography (TTE) can offer clues to disease severity. The reliability of these semi-quantitatively assessed anatomic imaging parameters is unknown.

METHODS

This is a retrospective study of semi-quantitative assessment of AVC and valve VM on TTE. TTEs representing a range of AS severities were identified. The degree of calcification of the aortic valve and the degree of restricted VM were assessed in standard fashion. AVC scores and valve motion were assessed by readers with varied training levels blinded to the severity of AS. Correlation and inter-reader reliability between readers were assessed.

RESULTS

420 assessments (210 each for AVC and VM) were collected for 35 TTEs. Correlation of AVC for imaging trainees (fellows and students, respectively), ranged from 0.49 (95% CI 0.18-0.70) to 0.62 (95% CI 0.36-0.79) and 0.58 (95% CI 0.30-0.76) to 0.54 (95% CI 0.25-0.74) for VM. Correlation of anatomic assessments between echocardiographer-assigned AVC grades was r = 0.76 (95% CI 0.57-0.87)). The correlation between echocardiographer-assigned assessment of VM was r = 0.73 (95% CI 0.53-0.86), p < 0.00001 for both. For echocardiographer AVC assessment, weighted kappa was 0.52 (0.32-0.72), valve motion weighted kappa was 0.60 (0.42-0.78).

CONCLUSION

There was good inter-reader correlation between TTE-based semi-quantitative assessment of AVC and VM when assessed by board certified echocardiographers. There was modest inter-reader reliability of semi-quantitative assessments of AVC and VM between board certified echocardiographers. Inter-reader correlation and reliability between imaging trainees was lower. More reliable methods to assess TTE based anatomic assessments are needed in order to accurately track disease progression.

CLINICAL TRIAL NUMBER

STUDY00003100.

Reducing Salivary Toxicity with Adaptive Radiotherapy (ReSTART): A Randomized Controlled Trial Comparing Conventional IMRT to Adaptive IMRT in Head and Neck Squamous Cell Carcinomas

BACKGROUND

The utility of Adaptive Radiotherapy (ART) in Head and Neck Squamous Cell Carcinoma (HNSCC) remains to be ascertained. While multiple retrospective and single-arm prospective studies have demonstrated its efficacy in decreasing parotid doses and reducing xerostomia, adequate randomized evidence is lacking.

METHODS AND ANALYSIS

ReSTART (Reducing Salivary Toxicity with Adaptive Radiotherapy) is an ongoing phase III randomized trial of patients with previously untreated, locally advanced HNSCC of the oropharynx, larynx, and hypopharynx. Patients are randomized in a 1:1 ratio to the standard Intensity Modulated Radiotherapy (IMRT) arm {Planning Target Volume (PTV) margin 5 mm} vs. Adaptive Radiotherapy arm (standard IMRT with a PTV margin 3 mm, two planned adaptive planning at 10th and 20th fractions). The stratification factors include the primary site and nodal stage. The RT dose prescribed is 66Gy in 30 fractions for high-risk PTV and 54Gy in 30 fractions for low-risk PTV over six weeks, along with concurrent chemotherapy. The primary endpoint is to compare salivary toxicity between arms using salivary scintigraphy 12 months' post-radiation. To detect a 25% improvement in the primary endpoint at 12 months in the ART arm with a two-sided 5% alpha value and a power of 80% (and 10% attrition ratio), a sample size of 130 patients is required (65 patients in each arm). The secondary endpoints include acute and late toxicities, locoregional control, disease-free survival, overall survival, quality of life, and xerostomia scores between the two arms.

DISCUSSION

The ReSTART trial aims to answer an important question in Radiation Therapy for HNSCC, particularly in a resource-limited setting. The uniqueness of this trial, compared to other ongoing randomized trials, includes the PTV margins and the xerostomia assessment by scintigraphy at 12 months as the primary endpoint.

Reducing the environmental impact of rice production in subtropical India by minimising reactive nitrogen loss

The future of reactive nitrogen (N) for subtropical lowland rice to be characterised under diverse N-management to develop adequate sustainable practices. It is a challenge to increase the efficiency of N use in lowland rice, as N can be lost in various ways, e.g., through nitrous oxide (N2O) or dinitrogen (N2) emissions, ammonia (NH3) volatilization and nitrate (NO3-) leaching. A field study was carried out in the subsequent wet (2021) and dry (2022) seasons to assess the impacts of different N management strategies on yield, N use efficiency and different N losses in a double-cropped rice system. Seven different N-management practices including application of chemical fertilisers, liquid organic fertiliser, nitrification inhibitors, organic nutrient management and integrated nutrient management (INM) were studied. The application of soil test-based neem-coated urea (NCU) during the wet season resulted in the highest economic yield, while integrated nutrient management showed the highest economic yield during the dry season. Total N losses by volatilization of NH3, N2O loss and leaching were 0.06-4.73, 0.32-2.14 and 0.25-1.93 kg ha-1, corresponding to 0.06-5.84%, 0.11-2.20% and 0.09-1.81% of total applied N, respectively. The total N-uptake in grain and straw was highest in INM (87-89% over control) followed by the soil test-based NCU (77-82% over control). In comparison, recovery efficiency of N was maximum from application of NCU + dicyandiamide during both the seasons. The N footprint of paddy rice ranged 0.46-2.01 kg N-eq. t-1 during both seasons under various N management. Ammonia volatilization was the process responsible for the largest N loss, followed by N2O emissions, and NO3- leaching in these subtropical lowland rice fields. After ranking the different N management practices on a scale of 1-7, soil test-based NCU was considered the best N management approach in the wet year 2021, while INM scored the best in the dry year 2022.

Soil quality assessment of lowland rice soil of eastern India: Implications of rice husk biochar application

The role of biochar in improving the soil properties of problem soils is well known, but its long term impact on lowland rice soil is not well recognized. The soil quality indicators of biochar applied lowland rice soil are not widely reported. We developed soil quality index (SQI) of a biochar applied lowland rice soil based on 17 soil properties (indicators). Field experimentation consisted of six treatments such as 0.5, 1, 2, 4, 8 and 10 t ha^-1 of rice husk derived biochar (RHB) along with control. An overall SQI was calculated encompassing the indicators using multivariate statistics (principal component analysis) and non-linear scoring functions after generation of minimum data set (MDS). Sequential application of RHB improved the SQI by 4.85% and 16.02% with application of 0.5 t ha^-1 and 10 t ha^-1 RHB, respectively, over the recommended dose of fertilizer (control). PCA-screening revealed that total organic carbon (C_tot), zinc (Zn), pH and bulk density (BD) were the main soil quality indicators for MDS with 27.79%, 26.61%, 23.67% and 14.47% contributions, respectively. Apart from C_tot, Zn is one of the major contributors to SQI and RHB application can potentially be an effective agronomic practice to improve Zn status in lowland rice soil. The overall SQI was significantly influenced by RHB application even at 0.5 t ha^-1. The present study highlights that application of RHB improves the soil quality even in fertile, well managed, lowland rice soil.

Biomedical waste plastic: bacteria, disinfection and recycling technologies-a comprehensive review

Plastic recycling reduces the wastage of potentially useful materials as well as the consumption of virgin materials, thereby lowering the energy consumption, air pollution by incineration, soil and water pollution by landfilling. Plastics used in the biomedical sector have played a significant role. Reducing the transmission of the virus while protecting the human life in particular the frontline workers. Enormous volumes of plastics in biomedical waste have been observed during the outbreak of the pandemic COVID-19. This has resulted from the extensive use of personal protective equipment such as masks, gloves, face shields, bottles, sanitizers, gowns, and other medical plastics which has created challenges to the existing waste management system in the developing countries. The current review focuses on the biomedical waste and its classification, disinfection, and recycling technology of different types of plastics waste generated in the sector and their corresponding approaches toward end-of-life option and value addition. This review provides a broader overview of the process to reduce the volume of plastics from biomedical waste directly entering the landfill while providing a knowledge step toward the conversion of "waste" to "wealth." An average of 25% of the recyclable plastics are present in biomedical waste. All the processes discussed in this article accounts for cleaner techniques and a sustainable approach to the treatment of biomedical waste.

Graphical abstract

Multi-criteria assessment to screen climate smart rice establishment techniques in coastal rice production system of India

Introduction

Conventional rice production techniques are less economical and more vulnerable to sustainable utilization of farm resources as well as significantly contributed GHGs to atmosphere.

Methods

In order to assess the best rice production system for coastal areas, six rice production techniques were evaluated, including SRI-AWD (system of rice intensification with alternate wetting and drying (AWD)), DSR-CF (direct seeded rice with continuous flooding (CF)), DSR-AWD (direct seeded rice with AWD), TPR-CF (transplanted rice with CF), TPR-AWD (transplanted rice with AWD), and FPR-CF (farmer practice with CF). The performance of these technologies was assessed using indicators such as rice productivity, energy balance, GWP (global warming potential), soil health indicators, and profitability. Finally, using these indicators, a climate smartness index (CSI) was calculated.

Results and discussion

Rice grown with SRI-AWD method had 54.8 % higher CSI over FPR-CF, and also give 24.5 to 28.3% higher CSI for DSR and TPR as well. There evaluations based on the climate smartness index can provide cleaner and more sustainable rice production and can be used as guiding principle for policy makers.

Function Preservation With Brachytherapy: Reviving the Art. Improving Quality of Life With Brachytherapy for Urological Malignancies

Brachytherapy for localised prostate, muscle-invasive bladder and penile cancer is well established, providing high tumour dose delivery and minimising normal tissue doses compared with external beam techniques. In prostate cancer, the main impact on quality of life relates to diminished sexual function and irritative or obstructive urinary symptoms, which are seen up to 15 years after treatment. Significant changes in bowel function are rare. Compared with radical prostatectomy or external beam radiotherapy, irritative or obstructive urinary symptoms are more prominent, whereas incontinence is less than after radical prostatectomy and bowel changes are less than after external beam radiotherapy. For muscle-invasive bladder cancer, when compared with radical cystectomy, although no difference is seen for urinary symptoms or fatigue, role and social functioning scores are higher and there is better post-treatment sexual function in both men and women. Compared with surgical treatment for penile cancer, brachytherapy results in better erectile function scores than after glansectomy and partial penectomy and high quality of life scores, with good satisfaction ratings for cosmetic appearance.

P-795 Comparison of intra-ovarian platelet rich plasma versus autologous bone marrow derived stem cell instillation in women with diminished ovarian reserve for ovarian rejuvenation

Study question

To compare role of intra-ovarian platelet rich plasma (PRP) versus marrow derived stem cell (SC) instillation for improvement in ovarian reserve (AFC, AMH and FSH)

Summary answer

Both PRP and SC therapy improves the ovarian reserve however, response to PRP is superior to SC post intervention

What is known already

With increasing incidence of females with diminished ovarian reserve (DOR), posing a serious challenge in terms of limited treatment options for these couples. Clinicians are trying to find effective strategies besides oocyte donation or adoption Of late, novel ovarian rejuvenation approaches has been investigated which are currently available for research purposes only. Multiple studies are evaluating effect of intra-ovarian PRP or autologous SC instillation, the results are encouraging as they are showing improvement in ovarian reserve thus bringing a paradigm shift in treatment options. None of the published studies so far have compared PRP versus SC in DOR population.

Study design, size, duration

A prospective comparative study was conducted at Division of Reproductive Medicine of a tertiary care institute. 72 infertile females (20-39 years) with poor ovarian reserve (AMH &lt;1.2 ng /ml; AFC&lt;5) were enrolled in the study between January 2020 to December 2021. The two comparative groups underwent either intra-ovarian PRP instillation (n = 42) or autologous SC transplantation (n = 30).

Participants/materials, setting, methods

After the two groups were matched (PRP vs SC) for baseline characteristics (Age, AMH, AFC, FSH, Estradiol), 30 subjects in each group were compared for change in serum FSH/AMH/Estradiol levels, AFC, right and left ovarian volume at 1st month and 3rd month post intervention from the baseline. This was also compared between the two groups using Student t-test. The cost and procedural pain measured using Visual analog scale (VAS) were also compared between the groups.

Main results and the role of chance

After matching for baseline characteristics, significant ∼ 1.8/2 and ∼1.5/1.6 fold increase in AFC at 1st/3rd month post intervention (p&lt;0.001) was observed after PRP instillation and SC transplantation respectively. This significant improvement was observed more in PRP group than SC group at 3rd month post intervention (7.07 vs 5.60, p=0.02), while no significant difference existed at 1st month of follow up. However, there was no significant improvement in serum FSH, AMH and Estradiol levels (p0.05) from the baseline at 1st and 3rd month post intervention in both the groups. Similarly, there was no significant difference between the two groups in serum FSH level (7.98 IU/ml vs 9.62 IU/ml, p=0.062; 8.26 IU/ml vs 9.50 IU/ml, p=0.15), AMH level (1.62 ng/ml vs 1.02 ng/ml, p=0.27; 1.35 ng/ml vs 0.95 ng/ml, p=0.24), Estradiol level (49.12 pg/ml vs 56.48 pg/ml p=0.443; 54.7 pg/ml vs 61.12 pg/ml, p=0.44), right ovarian volume (3.13 cm3 vs 2.49 cm3, p=0.06; 3.37 cm3 vs 2.74 cm3,p=0.063) and left ovarian volume (2.98 cm3 vs 2.47 cm3, p=0.102; 2.87 cm3 vs 2.34 cm3,p=0.103) at 1st and 3rd month post intervention respectively. PRP was more cost-effective and associated with less pain (32.5 mm vs 28.13 mm, p=0.02), and better patient compliance.

Limitations, reasons for caution

This was a comparative study and the participants were not randomized but were matched for the baseline characteristics. Also due to impact of Covid-19 causing intermittent pause in nonessential facilities like IVF services, a smaller sample size could be enrolled and also clinical outcomes could not be evaluated

Wider implications of the findings

This study, although comparative, for the first time highlights the beneficial role of PRP over SC, thus can establish superiority of PRP as minimally invasive, economical, patient friendly and a recommended therapy for ovarian rejuvenation and folliculogenesis, providing the DOR females an opportunity to produce their own offspring.

Trial registration number

CTRI/2020/01/022726

P94 LOWER RATE OF MAJOR BLEEDING IN HIGH–RISK PATIENTS UNDERGOING LEFT ATRIAL APPENDAGE OCCLUSION: A PROPENSITY MATCHED COMPARISON WITH DIRECT ORAL ANTICOAGULATION

Background

Stroke prophylaxis in very high risk (CHA2DS2–VASc ≥ 5) patients with atrial fibrillation (AF) is one of the major challenges faced by physicians. Specifically, initiating direct oral anticoagulants (DOACs) in these patients poses a therapeutic conundrum due to the concomitant high risk of bleeding. Left atrial appendage occlusion (LAAO) might be a potential alternative for thromboembolic (TE) prevention; however, there are no studies comparing these two strategies in very high–risk patients.

Objective

To evaluate the efficacy of LAAO versus DOACs in AF patients at very high TE risk.

Methods

Data were extracted from two prospective databases including 1053 Watchman and 1328 DOAC patients. Watchman patients with a CHA2DS2–VASc ≥ 5 accounted for 26.3% (n = 277). In order to attenuate the imbalance in covariates, a 1:1 propensity score matching technique was used (co–variates: age, sex, CHA2DS2–VASc and HAS–BLED scores). This method resulted in 554 matched patients (277 patients per group; mean age: 79±7y; 57.4% F; CHA2DS2–VASc: 5.8±0.9). The primary endpoint was a composite of cardiovascular (CV) death, TE events (Stroke/TIA/peripheral embolism) and clinically significant bleeding. The annual TE and major bleeding risks were estimated based on the CHA2DS2–VASc score and compared with the annualized observed risk.

Results

After a mean follow–up of 26±7 months, total events were 55 (9.4 event rates per 100 patient–years) in LAAO group vs. 78 (14.9 event rates per 100 patient–years) in DOAC group. DOACs had a significantly higher risk of the primary endpoint (hazard ratio [HR]: 1.30; 95% confidence interval [CI]: 1.08 to 1.56; p = 0.03). TE events (HR: 1.15; 95% CI: 0.84 to 1.57; p = 0.63) and CV death (HR: 1.13; 95% CI: 0.84 to 1.54; p = 0.63) did not differ between groups. Major bleeding events were significantly lower in LAAO patients (HR: 0.75; 95% CI: 0.51 to 0.82; p = 0.04). The unadjusted estimated risk of TE events was 12.3% with LAAO and 12.4% with DOACs. The annualized incidence of TE was 3.2% with LAAO and 4.1% with DOACs, which led to a risk reduction of 74% and 67%, respectively.

Conclusion

In a large cohort of AF patients at very high TE risk (CHA2DS2–VASc ≥ 5), LAAO showed similar stroke prevention but a significantly lower risk of major bleeding than DOACs during a &gt; 2year follow–up.

C32 TRANSCATHETER LEAK OCCLUSION WITH ENDOVASCULAR COILS FOLLOWING LEFT ATRIAL APPENDAGE CLOSURE: PROCEDURAL SUCCESS AND OUTCOMES BEFORE AND AFTER LEAK CLOSURE

Background

Whether residual peri–device leaks after left atrial appendage occlusion (LAAO) portend a higher risk of thromboembolism (TE), it is still a matter of debate.

Objectives

We report the TE risk in patients with incomplete LAA closure before and after leak closure with endovascular coils.

Methods

One hundred twenty–four Watchman patients with a significant (≥3mm) leak (mean age: 74 ± 9 years; 66.9% males; CHA2DS2–VASc: 4.4 ± 1.7; HAS–BLED: 3.1 ± 1) underwent LAA leak coiling. The expected annual TE risk was estimated based on the patients’ CHA2DS2–VASc and compared with the annualized incidence observed before and after coiling (Fig.1B).

Results

The time between LAAO and leak coiling was 8±6 months [83 patients–year (PY)]; before leak closure, 6 (4.8%) patients had a TE event (annualized rate: 7.2%). Coil deployment was successful in all cases [median n. of coils deployed: 5 (IQR: 2–10)]. Procedure time was 79 ± 40 min; the mean volume of iodinated contrast medium used was 80 ± 43mL. The overall complication rate was 2.4% (1 pericardial tamponade, 2 pericardial effusion). Follow–up TEE after 61±14 days revealed complete LAA sealing or a negligible leak in 117 cases (94.4%); the remaining 7 patients had a moderate leak. During 14±6 months post–coiling (145 PY), 1 (0.8%) patient suffered from stroke. The incidence of TE events was significantly lower after leak closure than before coiling (0.8% vs 4.8%; log–rank p = 0.02; Fig.1A). The annualized TE rates were 7.2% before and 0.7% after leak closure (Fig. 1A). According to the expected rate estimated from the patients’ CHA2DS2–VASc (9.8%), LAAO with and without significant leaks yielded to a risk reduction of 26.5% and 92.9% (Fig. 1B).

Conclusions

Transcatheter leak occlusion via endovascular coils was safe. LAA closure led to a significant reduction in TE events.

P4 LEFT ATRIAL APPENDAGE ANATOMICAL CHANGES FOLLOWING RADIOFREQUENCY–BASED OSTIAL ISOLATION

Background

Left atrial appendage (LAA) electrical isolation (ei) may be achieved via radiofrequency (RF) energy applications at the level of the appendage ostium targeting the sites of earliest activation recorded by a mapping catheter. Notably, RF has long been used in vascular, orthopedic, and aesthetic surgery to promote thermal–induced collagen matrix contraction, fibrosis, and tissue retraction. LAA anatomical changes associated to RF–induced tissue retraction have never been reported.

Objective

To quantify the anatomical changes of the LAA ostium following RF–based LAAei.

Methods

Thirty–four consecutive patients requiring AF ablation with LAAei underwent transesophageal echocardiography (TEE) within 7 days before (baseline TEE) and &gt;6 months after (follow–up TEE) ablation. The diameter of LAA orifice and landing zone were measured at 4 different views (0°, 45°, 90°, 135°). Measurements were performed by two independent reviewers blinded to the patient’s identity.

Results

Among 34 AF patients (68±7yrs, 73.5% males), the LAA morphology was classified as chicken wing in 15 (44%) patients, windsock in 10 (29%), cactus in 6 (18%), and cauliflower in 3 (9%). At baseline TEE, the mean maximum and mean minimum ostial diameters were 25±4mm and 22±4mm, respectively. The mean maximum and mean minimum diameters of the landing zone were 26±4mm and 23±3mm, respectively. On average, LAAei was achieved after 16±7 minutes of RF at a power of 45–47W. Follow–up TEE was performed 257±148 days after LAAei. The median LAA contraction velocity was 0.1 m/s (IQR: 0.04–0.18) and was significantly impaired in all patients. At follow–up TEE, the mean maximum and mean minimum ostial diameters were 19±4mm and 17±3mm, respectively. The mean maximum and mean minimum diameters of the landing zone were 20±4mm and 18±4mm, respectively. The mean relative reduction of the ostium and the landing zone were –24.4% and –22.5%, respectively. Box–Whisker plots of the maximum and minimum ostial diameters before and after LAAei are reported in Fig. 1.

Conclusion

RF led to a &gt; 20% reduction of the diameters of the ostium and the landing zone. These changes may have important implications for a successful percutaneous occlusion procedure and justify a staged approach of isolation and occlusion.

COMPARATIVE STUDY OF CONCURRENT CHEMORADIATION USING PACLITAXEL IN TWO HISTOPATHOLOGICAL SUBTYPES (SQUAMOUS CELL CARCINOMA/ADENOCARCINOMA) OF UNRESECTABLE NON-SMALL CELL LUNG CANCER

Background. Lung cancer is still a global burden and with rising population and increasing life expectancy the incidence of lung cancer is still on the rise. Objective. To compare the treatment response and toxicity of weekly paclitaxel in locally advanced unresectable non-small cell lung cancer (NSCLC), when administered concurrently with external beam radiation to the chest in two different histopathological types – adenocarcinoma and squamous cell carcinoma. Methods. A prospective randomised control trial was conducted in 60 NSCLC patients who were divided into two arms; adenocarcinoma and squamous cell carcinoma arm. All patients were treated with chemoradiation with concurrent paclitaxel 60 mg/m2. Data were evaluated with SPSS version 21.0 for windows with p-value <0.05. Results. Haematological toxicity was the most common side effects evident from the third week of chemotherapy. At the end of 1 month of treatment, two (6.7%) patients had complete response in Arm A and one (3.3%) patient had complete response in Arm B. One (3.3%) patient had disease progression in Arm A and two patients progressed in Arm B. At 7 months post treatment three (10%) patients had complete response in both Arm A and Arm B. Four (13.3%) patients had disease progression in Arm A and ten (33.4%) patients progressed in Arm B. Conclusions. Paclitaxel can be used as an alternative chemotherapeutic agent to the standard cisplatin. However, further studies with larger sample size are required to confirm the findings.

Measurement of Differential Branching Fractions of Inclusive B→X_{u}ℓ^{+}ν_{ℓ} Decays

The first measurements of differential branching fractions of inclusive semileptonic B→X_{u}ℓ^{+}ν_{ℓ} decays are performed using the full Belle data set of 711  fb^{-1} of integrated luminosity at the ϒ(4S) resonance and for ℓ=e, μ. With the availability of these measurements, new avenues for future shape-function model-independent determinations of the Cabibbo-Kobayashi-Maskawa matrix element |V_{ub}| can be pursued to gain new insights in the existing tension with respect to exclusive determinations. The differential branching fractions are reported as a function of the lepton energy, the four-momentum-transfer squared, light-cone momenta, the hadronic mass, and the hadronic mass squared. They are obtained by subtracting the backgrounds from semileptonic B→X_{c}ℓ^{+}ν_{ℓ} decays and other processes, and corrected for resolution and acceptance effects.

Optimal ablation targets during second catheter ablation in patients with persistent AF

Introduction

Pulmonary vein isolation (PVI) is the cornerstone of ablative therapy in atrial fibrillation (AF). However, the one-year success rate after single ablation procedure is known to be up to 60%, necessitating repeat procedures in many.

Purpose

We evaluated the impact of different ablation strategies on procedural success at the second ablation in patients with persistent AF (PerAF).

Methods

Consecutive PerAF patients scheduled to undergo their second ablation were screened and only those that have received PVI plus isolation of left atrial posterior wall (PWI) and superior vena cava (SVC) at the first procedure (n=1390), were included in the analysis. At the second ablation, all reconnected structures were ablated. Additionally, based on operators' decision, non-PV triggers were targeted for ablation.

Patients were classified into two groups based on the ablation strategy: group 1: Re-isolation of reconnected PVs, PW, SVC and group 2: additional ablation of non-PV triggers (from inter-atrial septum, coronary sinus (CS), left atrial appendage (LAA) and crista terminalis). Arrhythmia-monitoring was performed quarterly for 1 year and biannually afterwards. Ablation success was assessed off-antiarrhythmic drugs (AAD).

Results

Of the 1390 patients included in the analysis, 698 were in group 1 and 692 were in group 2.

In group 1, reconnected PV, PW and SVC were re-isolated in 98 (14%), 311 (44.5%) and 173 (24.8%) respectively. In 131 (18.7%) patients, in the absence of any reconnection, CS was empirically isolated.

In group 2, PV, PW and SVC were re-isolated in 83 (12%), 270 (39%) and 113 (16.3%) patients respectively. Additionally, non-PV triggers were ablated in 505 (73%) and empirical isolation of LAA and CS in the absence of detectable triggers and PV reconnection was performed in 187 (27%).

At 2 years of follow-up, 425 (61%) and 602 (87%) from group 1 and 2 were arrhythmia-free off-AAD (p&lt;0.001).

Conclusion

Including non-PV triggers as targets for ablation at the repeat procedure was associated with significantly higher success rate in persistent AF.

Funding Acknowledgement

Type of funding sources: None.

Long-term outcome of endocardial-only versus combined endocardial-epicardial homogenization of the scar for treatment of ventricular tachycardia in patients with ischemic cardiomyopathy

Introduction

We investigated the ablation success of scar homogenization with combined (epicardial + endocardial) versus endocardial-only approach for ventricular tachycardia (VT) in patients with ischemic cardiomyopathy (ICM) at 5 years of follow-up.

Method

Consecutive ICM patients undergoing VT ablation at our center were classified into group 1: endocardial scar homogenization and group 2: endocardial +epicardial scar homogenization. Patients with previous open heart surgery were excluded.

All patients underwent bipolar substrate mapping with standard scar settings defined as normal tissue &gt;1.5 mV and severe scar &lt;0.5 mV. Non-inducibility of monomorphic VT was the procedural endpoint in both groups. Patients were followed up twice a year for 5 years with implantable device interrogations.

Results

A total of 361 (Group 1: 291 and group 2: 70) patients were included in the study (mean age: 67 years, male: 88.4%).

At 5 years, significantly higher number of patients from group 2 remained arrhythmia-free (figure 1). Of those patients, 87 (45%) and 51 (89%) from group 1 and 2 respectively were off-anti-arrhythmic drugs (AAD) (p&lt;0.001). After adjusting for age, gender, hypertension, diabetes, and obstructive sleep apnea, scar homogenization using endo-epicardial approach was associated with 51% less recurrence compared to the endocardial ablation strategy (Hazard Ratio: 0.49, 95% CI: 0.27–0.89, p: 0.02).

Conclusion

In this series of patients with ischemic cardiomyopathy and VT, endo-epicardial scar homogenization was associated with a lower need for AAD and a significantly lower recurrence rate at 5-years of follow-up compared to the endocardial ablation alone.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Linear increase in the number of non-pulmonary vein triggers from paroxysmal to persistent and long-standing persistent AF in patients undergoing repeat procedure after successful isolation of pulmona

Introduction

This study evaluated the prevalent triggers responsible for recurrence following successful PVI in different types of atrial fibrillation (AF).

Methods

Consecutive AF patients undergoing repeat catheter ablation with permanently isolated PV were included in the analysis. High-dose isoproterenol challenge (20- 30μg/min for 15–20min) was used to confirm PV reconnection and identify non-PV triggers.

Circular mapping catheter (CMC) was used to map the site of origin of significant ectopic activity by comparing the activation sequence of the sinus beat with that of the ectopic beat. For the coronary sinus (CS), ablation catheter was positioned at the level of the mitral valve annulus, parallel to the one positioned in the CS. Left atrial appendage (LAA) firing was detected by placing the CMC in the left superior PV and thus recording far-field potentials from the LAA.

Results

This prospective study included 1850 AF patients undergoing repeat AF ablation (Table 1), of which 573 (31%) had received one and the remaining 1277 patients had received 2 earlier ablations. Permanent PVI was confirmed with isoproterenol challenge.

Table 1 shows the distribution of non-PV triggers. A linear increase in the number of non-PV triggers was observed from PAF to PerAF to LSPAF. Significantly higher number of LSPAF patients had detectable non-PV triggers compared to PerAF and PAF cases.

Conclusion

We observed a linear increase in the number of non-PV triggers in PAF to PerAF and LSPAF patients experiencing recurrence with successful isolation of PVs. As non-PV triggers are often not targeted by operators, this could be the underlying mechanism for more frequent recurrences in non-paroxysmal AF.

Funding Acknowledgement

Type of funding sources: None. Table 1

Benefits of early intervention with catheter ablation in patients with atrial fibrillation

Background

Radiofrequency catheter ablation, a widely recognized therapeutic option for atrial fibrillation (AF) has limited success rate as it is influenced by several factors including duration of AF.

Purpose

We evaluated the ablation success in AF patients intervened early versus late in the disease course.

Methods

Consecutive AF patients undergoing their first catheter ablation in 2015–16 at our center were included in the analysis. Patients were classified into two groups based on the time to ablation after AF diagnosis; 1) early: ≤12 months and 2) late: &gt;12 months.

All received PV isolation plus isolation of posterior wall and superior vena cava. Additionally, in non-paroxysmal AF cases, non-PV triggers were identified with isoproterenol-challenge and ablated. Patients were prospectively followed up for 3 years with regular rhythm monitoring.

Results

A total of 752 and 1248 patients were included in the “early” and “late” group respectively. Baseline characteristics of the study population is provided in Table 1 A. At 4 years of follow-up, overall success rate off-antiarrhythmic drugs was significantly higher in the “early” group (65.4% vs 57%, p&lt;0.001). After stratification by AF type, “early” group was still associated with significantly higher success rate compared to the “late” group (Table 1B).

Conclusion

In this large series with standardized ablation strategy, early intervention with catheter ablation was associated with higher success rate in all AF types.

Funding Acknowledgement

Type of funding sources: None. Table 1

Recovery of conduction following high power short duration approach in radiofrequency catheter ablation for atrial fibrillation: a single-center experience

Introduction

High-power short-duration (HPSD) ablation is currently being adopted by many as the preferred procedural technique in atrial fibrillation (AF). However, the optimal duration of energy delivery to successfully create a durable lesion is not clear yet.

Purpose

We evaluated the association of electrical reconnection with lesion-duration in HPSD ablation.

Methods

Consecutive AF patients undergoing repeat procedure after a prior HPSD ablation with or without isolation of left atrial appendage (LAA) and coronary sinus (CS) were included in this analysis. HPSD ablation was defined as ablation with maximum temperature setting at 420C and power delivery at 45 W for 10–15 sec (5 seconds in the CS area and posterior wall near the esophagus). In some patients a mechanical esophageal deviation tool was used to deflect the esophagus away from the ablation site.

Results

A total of 2249 AF patients (with LAA and CS isolation: 1451; without LAA and CS isolation: 798) receiving redo ablation after a prior HPSD procedure were included in the analysis. At the prior procedure with the HPSD approach, mean duration of ablation was significantly shorter in the area facing the esophagus compared to elsewhere (5.2±1.5 vs 12.5±1.7 seconds, p&lt;0.001). Application duration was reduced to &lt;10 sec to avoid overheating and steam pops in 1221 (84%) patients receiving LAA and CS isolation.

At the redo, recovery of conduction was noted in the CS (592, 40.8%), LAA (493, 34%), and PV and left atrial posterior wall (LAPW) (310, 13.8%). Of the 310 patients with LAPW reconnection, 91% (n=282) had the conduction recovered in the area facing the esophagus.

In 73 patients, esophageal displacement device was used during the prior HPSD ablation. Average duration of ablation lesions in LAPW among those 73 patients was 9.2±2 seconds. PV-LAPW reconnection was observed in 3/73 (4.1%) patients.

Conclusion

HPSD ablation with lesion duration of &lt;10 sec was associated with conduction recovery in the LAA, CS and the LAPW area facing esophagus.

Funding Acknowledgement

Type of funding sources: None.