β-Sheet Richness of the Circulating Tumor-Derived Extracellular Vesicles for Noninvasive Pancreatic Cancer Screening

Tumor-derived extracellular vesicles (EVs) are under intensive study for their potential as noninvasive diagnosis biomarkers. Most EV-based cancer diagnostic assays trace supernumerary of a single cancer-associated marker or marker signatures. These types of biomarker assays are either subtype-specific or vulnerable to be masked by high background signals. In this study, we introduce using the β-sheet richness (BR) of the tumor-derived EVs as an effective way to discriminate EVs originating from malignant and nonmalignant cells, where EV contents are evaluated as a collective attribute rather than single factors. Circular dichroism, Fourier transform infrared spectroscopy, fluorescence staining assays, and a de novo workflow combining proteomics, bioinformatics, and protein folding simulations were employed to validate the collective attribute at both cellular and EV levels. Based on the BR of the tumorous EVs, we integrated immunoprecipitation and fluorescence labeling targeting the circulating tumor-derived EVs in serum and developed the process into a clinical assay, named EvIPThT. The assay can distinguish patients with and without malignant disease in a pilot cohort, with weak correlations to prognosis biomarkers, suggesting the potential for a cancer screening panel with existing prognostic biomarkers to improve overall performance.

Freeform hyperspectral imager design in a CubeSat format

A freeform pushbroom hyperspectral imager design was investigated as a combination of a freeform reflective triplet imager and a freeform reflective triplet spectrometer used in double-pass. The design operates at about F/2 with a 15-degree cross-track field-of-view and a 30 mm entrance pupil diameter. The design process led to achieving a small volume of less than 2 liters that fits comfortably within a 3U CubeSat geometry, exemplifying the compactness of this hyperspectral imager. We report the freeform sag departures and maximum slopes of the freeform surfaces, as well as the manufacturing tolerances together with an evaluation of the system stray light, all of which highlight the feasibility of a design in this class to be manufactured. This design uniquely positions itself on the landscape of compact hyperspectral imagers.

Smooth muscle cell specific ablation of CXCL12 downregulates endothelial CXCR7 leading to defective coronary arteries and cardiac hypertrophy

Aims

The chemokine CXCL12 plays a fundamental role in cardiovascular development, cell trafficking, and myocardial repair. Human genome-wide association studies even have identified novel loci downstream of the CXCL12 gene locus associated with coronary artery disease and myocardial infarction. Nevertheless, cell and tissue specific effects of CXCL12 are barely understood. Since we detected high expression of CXCL12 in smooth muscle (SM) cells, we generated a SM22-alpha-Cre driven mouse model to ablate CXCL12 (SM-CXCL12−/−).

Methods and results

SM-CXCL12−/− mice revealed high embryonic lethality (50%) with developmental defects, including aberrant topology of coronary arteries. Postnatally, SM-CXCL12−/− mice developed severe cardiac hypertrophy associated with fibrosis, apoptotic cell death, impaired heart function, and severe coronary vascular defects characterized by thinned and dilated arteries. Transcriptome analyses showed specific upregulation of pathways associated with hypertrophic cardiomyopathy, collagen protein network, heart-related proteoglycans, and downregulation of the M2 macrophage modulators. CXCL12 mutants showed endothelial downregulation of the CXCL12 co-receptor CXCR7. Treatment of SM-CXCL12−/− mice with the CXCR7 agonist TC14012 attenuated cardiac hypertrophy associated with increased pERK signaling.

Conclusion

Our data suggest a critical role of smooth muscle-specific CXCL12 in arterial development, vessel maturation, and cardiac hypertrophy. Pharmacological stimulation of CXCR7 might be a promising target to attenuate adverse hypertrophic remodeling.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): FWF-Austria

C-reactive protein velocity predicts microvascular pathology after acute ST-elevation myocardial infarction

Background

The role of C-reactive protein velocity (CRPv) as an early and sensitive marker of an excessive inflammatory response in the setting of acute ST-elevation myocardial infarction (STEMI) is only poorly understood.

Purpose

The aim of this study was to investigate, in patients with STEMI treated with primary percutaneous coronary intervention (PCI), the association of CRPv with microvascular infarct pathology.

Methods

This prospective cohort study included a total of 316 patients with STEMI undergoing PCI. CRPv was defined as the difference between CRP 24±8h and CRP at hospital admission, divided by the time (in h) that have passed during the two examinations. The association of biomarker levels with cardiac magnetic resonance (CMR)-determined microvascular obstruction (MVO) was evaluated. CMR was performed at a median of 3 [interquartile range 2–4] days after PCI.

Results

After adjustment for cardiac troponin T (cTnT), culprit lesion location and TIMI-flow post-PCI, CRPv (odds ratio 3.36, 95% confidence interval (CI) 1.72–6.57; p<0.001) remained significantly associated with the occurrence of MVO. CRPv (area under the curve [AUC] 0.76, 95% CI 0.71–0.81; p<0.001) was a better predictor for MVO compared to 24h CRP (AUC difference: 0.03, p=0.002). The addition of CRPv to peak cTnT resulted in a higher AUC for MVO prediction than peak cTnT alone (AUC 0.86, 95% CI 0.82–0.90; p<0.001 vs. AUC 0.84, 95% CI 0.79–0.88; p<0.001. AUC difference: 0.02, p=0.042).

Conclusions

In patients with STEMI treated with primary PCI, CRPv was associated with microvascular infarct pathology with a predictive value incremental to cTnT, suggesting CRPv as an early and sensitive biomarker for more severe infarct pathology and outcome.

Funding Acknowledgement

Type of funding sources: None. ROC analysis for the prediction of MVO.CRPv (median) and clinical outcome.

Glycaemic status and reperfusion injury in patients with ST-segment elevation myocardial infarction

Background

Failed myocardial tissue reperfusion due to microvascular injury despite successful culprit lesion percutaneous coronary intervention (PCI) is associated with poor clinical outcome in patients with ST-elevation myocardial infarction (STEMI). A possible influence of dysglycaemia on myocardial reperfusion injury is unclear.

Objectives

To investigate the association between glycaemic status and microvascular injury determined by magnetic resonance imaging in STEMI patients.

Methods

This prospective observational cohort study included 260 consecutive STEMI patients undergoing primary PCI between 2016 and 2019. Peripheral venous blood samples for glucose and HbA1c measurements were drawn on admission. Primary microvascular injury endpoint was defined as presence of intramyocardial haemorrhage (IMH) assessed by cardiac magnetic resonance T2* mapping at 4 (interquartile range [IQR]:2–5) days after PCI.

Results

HbA1c (odds ratio [OR]: 1.73 [95% CI: 1.24–2.40]; p=0.001), pre-diagnosis of diabetes (OR: 2.63 [95% CI: 1.18–5.90]; p=0.02) and glucose concentration (OR: 1.01 [95% CI: 1.00–1.01]; p=0.01) significantly predicted IMH, which was present in 90 (35%) patients. Of these three parameters, only HbA1c remained significantly associated with IMH (OR: 2.12 [95% CI: 1.12–3.99]; p=0.02) after adjusting for total ischemic time, culprit lesion location, pre- and post-interventional TIMI flow and peak biomarker concentrations (troponin, N-terminal pro-B-type natriuretic peptide and C-reactive protein). The rate of IMH was 24% in patients with HbA1c <5.7%, 43% in patients with HbA1c ≥5.7 to 6.4% and 59% in patients with HbA1c ≥6.5% (p<0.001).

Conclusions

In STEMI patients undergoing primary PCI, admission HbA1c was independently associated with reperfusion injury as determined by IMH. These findings suggest that IMH could represent the underlying pathophysiological link between dysglycaemia and adverse outcomes following STEMI.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): FWF - Austrian Science Fund; ÖKG - Austrian Society of Cardiology Figure 1. This figure illustrates the relation between HbA1c and IMH by two patient examples successfully treated with PCI (intervention with stent implantation schematically shown on the very left side). The first patient (upper line), representing the patient group with HbA1c <5.7% (associated IMH risk 24%), showed an anterior wall STEMI without IMH (T2* mapping on the very right, corresponding schematic picture of the infarct area without IMH next on the left). The second patient (lower line), representing the patients with HbA1c ≥5.7% (associated IMH risk 47%), showed an anterior wall STEMI with large IMH (arrows point to the hypo-intense core on the T2* mapping image and to the corresponding dark-red area in the schematic illustration). The zoomed view of one microvessel indicates the complex pathophysiology of IMH (including endothelial destruction, embolisation of thrombotic material and inflammation). (Created with BioRender)

Evolution of myocardial tissue injury over a decade after ST-elevation myocardial infarction: a cardiac magnetic resonance study

Background

In patients with first ST-elevation myocardial infarction (STEMI), the evolution of myocardial tissue injury parameters over a decade as assessed by cardiac magnetic resonance (CMR) has not yet been described.

Purpose

This study examined long-term myocardial tissue injury dynamics in STEMI patients treated with primary percutaneous coronary intervention (PCI), as well as its association with patient characteristics.

Methods

A total of 104 patients with STEMI were included in this observational study. Sequential late gadolinium enhanced CMR studies (after 3 days [interquartile ranges (IQR) 2–4], 4 months [IQR 4–5] and 9 years [IQR 8–10]) were conducted to assess left ventricular (LV) dimensions and function, infarct size and microvascular obstruction (MVO). T2* mapping was added at 9 year scan to assess the presence of persistent iron within the infarct core.

Results

Infarct size decreased progressively from 13% of LV myocardial mass [IQR 7–21] to 10.2% [IQR 5.2–16.1] to 8% [IQR 2.4–12.3] (p<0.001), with an average reduction rate of 6.4% ± 3.4 per year. Relative reduction of infarct size from baseline to 9y follow-up was 43% [IQR 18–66], 21% [IQR 3–42] during the first 4m and 33% [IQR 8–54] between 4m and 9y after STEMI. Decrease of infarct size was associated with greater baseline infarct size (p<0.004) and extent of MVO (p=0.01). MVO was present in 60% (60/104) of patients at baseline, but in none of the follow-up examinations. Sixteen patients had persistent iron within the infarct core at 9 year CMR. Clinical and imaging associates of persistent iron included younger age at study inclusion (p=0.036), higher peak hs troponin T (p<0.001), higher peak creatine kinase (p<0.001) and higher peak CRP (p=0.036) as well as greater infarct size at any occasion (all p<0.001) and greater MVO (p<0.001). Patients with persistent iron showed less relative infarct size regression (51% [IQR 41–79] versus 46% [IQR 32–54], p=0.009).

Conclusion

In patients with STEMI, the evolution of infarct size is a dynamic process that extends well beyond the first few months after the acute event. MVO vanishes in the first few weeks after the index event in all patients. However, persistence of iron within the infarct core occurs up to a decade after reperfused STEMI, reflecting its irreversibility and is associated with the initial infarct severity and worse infarct healing.

Funding Acknowledgement

Type of funding sources: None. Central Illustration.Evolution of STEMI over a decade.

Aortic stenosis reexpanded – a novel approach to determine aortic valve area with phase contrast cardiovascular magnetic resonance imaging

Background

Transthoracic echocardiography (TTE) has become the diagnostic standard for evaluating aortic stenosis (AS) severity, mainly because of its advantages in comparison to the gold standard of cardiac catheterization. However, its inaccuracies in determining stroke volume (SV) and consequentially computing aortic valve area (AVA) call for a more precise and dependable method. Phase contrast cardiovascular magnetic resonance imaging (PC-CMR) is an aspiring tool to push these boundaries.

Purpose

The aim of this study was to validate a novel and simple approach based on PC-CMR against the invasive and echocardiographic determination of SV and AVA in patients with moderate and severe AS.

Methods

A total of 50 patients with moderate or severe AS underwent TTE, cardiac catheterization and CMR; AVA by PC-CMR was determined via plotting momentary flow across the valve against momentary flow velocity. SV via CMR was measured directly via PC-CMR and volumetrically using cine images. Invasive SV and AVA were determined via Fick principle and Gorlin formula, respectively. TTE yielded SV and AVA using the continuity equation. Finally, gradients were calculated via the modified Bernoulli equation.

Results

SV by PC-CMR showed a strong correlation with cine-CMR with no significant bias (r: 0.730, p<0.001; SV by PC-CMR: 85±31ml; SV by cine-CMR: 85±19ml, p=0.829). Peak gradients determined by PC-CMR were 65±29mmHg and correlated inversely with AVA by PC-CMR (r: −0.371; p=0.008). Mean AVA during the whole systolic phase showed a moderate correlation (r: 0.544, p<0.001) to invasive AVA with a small bias (AVA by CMR: 0.78±0.25cm2 versus invasive AVA: 0.70±0.23cm2, bias: 0.08cm2, p=0.017). Inter-methodical correlation and bias of AVA as measured by TTE and invasive AVA (AVA by TTE: 0.81±0.23cm2, r: 0.580, p<0.001, bias 0.11cm2, p<0.001) were similar to AVA by PC-CMR and invasive AVA.

Conclusion

PC-CMR provides a great option to yield reliable and solid SV values in patients with moderate and severe AS. Furthermore, continuous determination of flow volumes and flow velocities is able to determine AVA in these patients in an easy and reproducible manner. Our novel approach shines a light on the diagnostic potential of PC-CMR for non-invasive AS grading, especially in cases where echocardiography reaches its limits and where clinical findings appear inconclusive.

Funding Acknowledgement

Type of funding sources: None. Central IllustrationCine (l,r) and PC-CMR (m) images in AS

Determinants and prognostic relevance of aortic stiffness in patients with recent ST-elevation myocardial infarction

Background

The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood. We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI.

Methods

We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (PPCI). Aortic pulse wave velocity (PWV), a direct measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 (interquartile range [IQR] 12–31) months. Cox regressionand logistic regression analysis were performed to explore predictors of PWV and MACCE.

Results

Median aortic PWV was 6.6 m/s (IQR 5.6–8.3m/s). In multivariable analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI], 1.08–1.14, p<0.001) and hypertension (OR 2.45, 95% CI, 1.53–3.91, p<0.001) were independently associated with increased PWV. Sex, diabetes, smoking status, dyslipidemia, and obesity were not significantly associated with PWV in adjusted analysis (all p>0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis (hazard ratio [HR] 2.45, 95% CI 1.19–5.04, p=0.014).

Conclusion

In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome post-STEMI, suggesting it as a relevant therapeutic target in this population.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Austrian Science Fund (FWF)Austrian Society of Cardiology Figure 1. Biorender.com

Epidemiology, comorbidities, and healthcare utilization of patients with chronic urticaria in Germany

BACKGROUND

Comprehensive data on the epidemiology and comorbidities of chronic urticaria (CU) in Germany are either limited, or not contemporary.

OBJECTIVES

To investigate the epidemiology of CU, overall comorbidities and healthcare resource utilized by patients with CU in Germany, using an anonymized statutory health insurance (SHI) database.

METHODS

Anonymized SHI claims research database of the Institute for Applied Health Research, Berlin [InGef] (01 January 2015-30 September 2018) was used to analyse insured individuals with a confirmed diagnosis of CU (ICD-10-GM codes). Twelve-month diagnosed prevalence and incidence, comorbidities (vs. atopic dermatitis and psoriasis), and healthcare utilization by patients with CU were investigated.

RESULTS

Of 4 693 772 individuals of all ages listed in the database, 3 538 540 were observable during 2017. Overall, 17 524 patients (˜0.5%) were diagnosed with CU; chronic spontaneous urticaria (CSU: 71.2%), chronic inducible urticaria (CIndU: 19.7%), CSU+CIndU (9.1%). Females, vs. males, had higher diagnosed prevalence (0.62% vs. 0.37%) and diagnosed incidence (0.18% vs. 0.11%) of CU among all patients. Patients most frequently visited general practitioners (41.3% of total visits). Hypertensive diseases (43.5%), lipoprotein metabolism disorders (32.1%) and affective disorders (26.0%) were the most frequently reported comorbidities of special interest. Rates of most comorbidities of special interests were similar to atopic dermatitis and psoriasis patients, and all higher vs. overall population. More than half (54.1%) of all CU patients were not prescribed any treatment. Second-generation H₁ -antihistamines were the most commonly prescribed medication for adult (17.9%) and paediatric (27.9%) patients. Patients with CIndU (paediatric, 15.5%; adult, 7.8%) were more often hospitalized versus patients with CSU (paediatric, 9.9%; adult, 4.6%).

CONCLUSIONS

In Germany, prevalence of CU along with multiple comorbidities may pose increased burden on the healthcare system. Awareness of adhering to treatment guidelines, and aiming for complete control of urticaria, needs to be driven and may improve outcomes.

[Terbinafine-resistant dermatophytoses and onychomycosis due to Trichophyton rubrum]

BACKGROUND

In recent years, therapy-refractory courses of dermatophytoses have increasingly become the focus of attention. The most frequent pathogens are Trichophyton (T.) rubrum and T. mentagrophytes. In addition to local therapy, first-line treatment includes terbinafine, an allylamine antifungal agent that acts by inhibiting squalene epoxidase and thus interfering with ergosterol synthesis. In refractory cases, terbinafine resistance due to point mutation in the squalene epoxidase gene has been frequently detected.

OBJECTIVES

The aim is to present specific aspects in the epidemiology of dermatophytoses with terbinafine resistance and to illustrate them on the basis of four patient cases including diagnostic procedures.

MATERIALS AND METHODS

A review of handbook knowledge, a selective literature search, and a review of four patient cases were performed.

RESULTS

Detection of the terbinafine resistance was performed by in vitro testing using the breakpoint method as well as sequencing of the Trichophyton isolate and detection of the point mutation with amino acid substitution at position L393F or F397L of squalene epoxidase.

CONCLUSION

In refractory and recurrent dermatophytoses, terbinafine resistance should be considered, especially in T. mentagrophytes and T. rubrum, and in vitro resistance testing of the dermatophyte and point mutation analysis of squalene epoxidase (SQLE) should be performed. Therapeutically, intermittent administration of itraconazole in combination with antifungal local therapy is recommended. Nevertheless, a recurrent course is to be expected and long-term therapy with itraconazole is usually necessary.

Roadmap for the unobscured three-mirror freeform design space

In rotationally symmetric lens design, there are rule-of-thumb boundaries on field-of-view and aperture for well-known design forms that provide valuable information to the designer prior to starting a design. In the design space of unobscured three-mirror imagers, freeform optics have been shown to provide a significant benefit over conventional surface shapes, but the degree to which they improve the performance for any given combination of field-of-view, entrance pupil diameter, and F-number remains unknown. Thus, designers of these systems are not afforded any pre-design information to inform their specification decisions. Here, we designed over 200 systems to establish a first-of-its-kind roadmap of specification ranges over which an unobscured three-mirror imager using freeform surfaces can achieve diffraction-limited performance in the visible spectrum. The scalability of the findings to the infrared regions of the spectrum is also addressed.

Patch test informed consent form: position statement by European Academy of Dermatology and Venereology Task Force on Contact Dermatitis

BACKGROUND

To our knowledge, an international consensus is lacking regarding the development of an adequate informed consent form for a patch test (PT) and the information that should be included in such document.

OBJECTIVES

The aim of the study was to reach a consensus on the specific points that need to be addressed in a PT consent form.

METHODS

A Delphi survey, comprising 2 rounds and 1 final discussion, was used to gather and analyse data, which was conducted over the Internet. Each statement that reached a consensus with the respondents (9 expert dermatologists from Europe) was defined as a median consensus score (MED) of ≥7 and agreement among panelists as an interquartile range (IQR) of ≤3. All study participants were members of the EADV task force on contact dermatitis.

RESULTS

The expert panel addressed several topics that should be included in an informed consent form for a PT: introduction, preparation for PT, testing procedure, allowed activities, adverse events and additional authorizations.

CONCLUSIONS

Our results assess recommendations regarding points to be contained in an informed consent form for a PR. Future actions towards standardization and harmonization of this specific consent form are needed.

Feasibility and effectiveness of a multidimensional post-discharge disease management programme for heart failure patients in clinical practice: the HerzMobil Tirol programme

AIMS

It remains unclear whether transitional care management outside of a clinical trial setting provides benefits for patients with acute heart failure (AHF) after hospitalization. We evaluated the feasibility and effectiveness of a multidimensional post-discharge disease management programme using a telemedical monitoring system incorporated in a comprehensive network of heart failure nurses, resident physicians, and secondary and tertiary referral centres (HerzMobil Tirol, HMT), METHODS AND RESULTS: The non-randomized study included 508 AHF patients that were managed in HMT (n = 251) or contemporaneously in usual care (UC, n = 257) after discharge from hospital from 2016 to 2019. Groups were retrospectively matched for age and sex. The primary endpoint was time to HF readmission and all-cause mortality within 6 months. Multivariable Cox proportional hazard models were used to assess the effectiveness. The primary endpoint occurred in 48 patients (19.1%) in HMT and 89 (34.6%) in UC. Compared with UC, management by HMT was associated with a 46%-reduction in the primary endpoint (adjusted HR 0.54; 95% CI 0.37-0.77; P < 0.001). Subgroup analyses revealed consistent effectiveness. The composite of recurrent HF hospitalization and death within 6 months per 100 patient-years was 64.2 in HMT and 108.2 in UC (adjusted HR 0.41; 95% CI 0.29-0.55; P < 0.001 with death considered as a competing risk). After 1 year, 25 (10%) patients died in HMT compared with 66 (25.7%) in UC (HR 0.38; 95% CI 0.23-0.61, P < 0.001).

CONCLUSIONS

A multidimensional post-discharge disease management programme, comprising a telemedical monitoring system incorporated in a comprehensive network of specialized heart failure nurses and resident physicians, is feasible and effective in clinical practice.

Invasive validation of a novel approach to determine aortic valve area with phase-contrast cardiac magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology

Background. Echocardiography is considered the standard method for screening and diagnosing aortic valve stenosis. However, inaccuracies in the determination of stroke-volumes by the continuity equation might particularly make the evaluation of patients with low-flow states difficult. Phase-contrast cardiac magnetic resonance (PC-CMR) is a promising tool in overcoming these limitations by the simultaneous determination of flow volumes and velocities across the stenotic valve.

Purpose

The aim of this study is to validate a novel approach based on PC-CMR against the invasive determination of the aortic valve area (AVA).

Methods. PC-CMR was performed in 50 patients with moderate or severe AS (n = 52; age 72 years [interquartile range (IQR) 66 - 78], 38% of patients with low-flow states). All of them were referred to invasive evaluation of aortic stenosis by cardiac catheterization. Additionally, transthoracic echocardiography (TTE) was performed. Aortic valve area (AVA) was determined by PC-CMR (AVAPC-CMR) via plotting momentary flow across the valve against momentary flow velocity. AVAPC-CMR at different time points over the entire cardiac cycle was compared to invasively determined AVA, calculated according to the Gorlin-formula. Stroke volumes (SV) were determined by the Fick-principle, pressure gradients according to the modified Bernoulli-equation.

Results. Mean AVA during the whole systolic phase showed a good correlation (r: 0.544, p &lt; 0.001) with invasive AVA with a small bias (AVACMR: 0.78 cm², IQR: [0.60-0.96] versus AVAINVASIVE: 0.70 cm², IQR: [0.52-0.87], bias: 0.08 cm², p = 0.017). Intermethodical correlation and bias of AVA as measured by TTE (AVATTE) and AVAINVASIVE were similar to AVAPC-CMR (AVATTE: 0.81 cm²; IQR: [0.64-0.96] versus AVAINVASIVE: 0.70 cm², IQR: [0.52-0.87] r: 0.580, p &lt; 0.001, bias 0.11 cm², p &lt; 0.001). SV by PC-CMR showed a good correlation with Cine-CMR with no significant bias (r: 0.730, p &lt; 0.001; SVPC-CMR: 86 ± 31 ml; SVCine: 85 ± 19 ml). Maximum gradients determined by PC‑CMR were 65 ± 2 9mmHg and showed a good inverse correlation with AVAPC-CMR (r: ‑0.371; p = 0.008).

Conclusion. PC-CMR with continuous determination of flow volumes and flow velocities is able to determine AVA in patients with severe aortic stenosis with a tendency to overestimate AVA compared to invasively determined AVA.

Evolution of myocardial tissue injury over a decade after ST-elevation myocardial infarction: a cardiac magnetic resonance study

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Society of Cardiology

Background

In patients with first ST-elevation myocardial infarction (STEMI), the evolution of myocardial tissue injury parameters over a decade as assessed by cardiac magnetic resonance (CMR) has not yet been described.

Purpose

This study examined long-term myocardial tissue injury dynamics in STEMI patients treated with primary percutaneous coronary intervention (PCI), as well as its association with patient characteristics.

Methods

A total of 104 patients with STEMI were included in this observational study. Sequential late gadolinium enhanced CMR studies (after 3 days [interquartile ranges (IQR) 2-4], 4 months [IQR 4-5] and 9 years [IQR 8-10]) were conducted to assess left ventricular (LV) dimensions and function, infarct size and microvascular obstruction (MVO). T2* mapping was added at 9 year scan to assess the presence of persistent iron within the infarct core.

Results

Infarct size decreased progressively from 13% of LV myocardial mass [IQR 7-21] to 10.2% [IQR 5.2-16.1] to 8% [IQR 2.4-12.3] (p &lt; 0.001), with an average reduction rate of 6.4% ± 3.4 per year. Relative reduction of infarct size from baseline to 9y follow-up was 43% [IQR 18-66], 21% [IQR 3-42] during the first 4m and 33% [IQR 8-54] between 4m and 9y after STEMI. Decrease of infarct size was associated with greater baseline infarct size (p &lt; 0.004) and extent of MVO (p = 0.01). MVO was present in 60% (60/104) of patients at baseline, but in none of the follow-up examinations. Sixteen patients had persistent iron within the infarct core at 9 year CMR. Clinical and imaging associates of persistent iron included younger age at study inclusion (p = 0.036), higher peak hs troponin T (p &lt; 0.001), higher peak creatine kinase (p &lt; 0.001) and higher peak CRP (p = 0.036) as well as greater infarct size at any occasion (all p &lt; 0.001) and greater MVO (p &lt; 0.001). Patients with persistent iron showed less relative infarct size regression (51% [IQR 41-79] versus 46% [IQR 32-54], p = 0.009).

Conclusion

In patients with STEMI, the evolution of infarct size is a dynamic process that extends well beyond the first few months after the acute event. MVO vanishes in the first few weeks after the index event in all patients. However, persistence of iron within the infarct core occurs up to a decade after reperfused STEMI, reflecting its irreversibility and is associated with the initial infarct severity and worse infarct healing.

Peanut-induced anaphylaxis in children and adolescents: Data from the European Anaphylaxis Registry

BACKGROUND

Peanut allergy has a rising prevalence in high-income countries, affecting 0.5%-1.4% of children. This study aimed to better understand peanut anaphylaxis in comparison to anaphylaxis to other food triggers in European children and adolescents.

METHODS

Data was sourced from the European Anaphylaxis Registry via an online questionnaire, after in-depth review of food-induced anaphylaxis cases in a tertiary paediatric allergy centre.

RESULTS

3514 cases of food anaphylaxis were reported between July 2007 - March 2018, 56% in patients younger than 18 years. Peanut anaphylaxis was recorded in 459 children and adolescents (85% of all peanut anaphylaxis cases). Previous reactions (42% vs. 38%; p = .001), asthma comorbidity (47% vs. 35%; p < .001), relevant cofactors (29% vs. 22%; p = .004) and biphasic reactions (10% vs. 4%; p = .001) were more commonly reported in peanut anaphylaxis. Most cases were labelled as severe anaphylaxis (Ring&Messmer grade III 65% vs. 56% and grade IV 1.1% vs. 0.9%; p = .001). Self-administration of intramuscular adrenaline was low (17% vs. 15%), professional adrenaline administration was higher in non-peanut food anaphylaxis (34% vs. 26%; p = .003). Hospitalization was higher for peanut anaphylaxis (67% vs. 54%; p = .004).

CONCLUSIONS

The European Anaphylaxis Registry data confirmed peanut as one of the major causes of severe, potentially life-threatening allergic reactions in European children, with some characteristic features e.g., presence of asthma comorbidity and increased rate of biphasic reactions. Usage of intramuscular adrenaline as first-line treatment is low and needs to be improved. The Registry, designed as the largest database on anaphylaxis, allows continuous assessment of this condition.

Metaform optics: Bridging nanophotonics and freeform optics

The demand for high-resolution optical systems with a compact form factor, such as augmented reality displays, sensors, and mobile cameras, requires creating new optical component architectures. Advances in the design and fabrication of freeform optics and metasurfaces make them potential solutions to address the previous needs. Here, we introduce the concept of a metaform-an optical surface that integrates the combined benefits of a freeform optic and a metasurface into a single optical component. We experimentally realized a miniature imager using a metaform mirror. The mirror is fabricated via an enhanced electron beam lithography process on a freeform substrate. The design degrees of freedom enabled by a metaform will support a new generation of optical systems.

Validation of a simple ECG score for infarct size estimation in patients with first-time ST-elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Austrian Science Fund

Background

The magnitude of myocardial damage after acute ST-elevation myocardial infarction (STEMI) is a crucial prognostic determinant. Cardiac magnetic resonance (CMR) imaging offers a precise infarct severity assessment after STEMI; however, limited to restricted availability in daily clinical routine. Recently, a simple ECG score (DETERMINE score) was developed for infarct size (IS) estimation in STEMI patients with prior infarction. We sought to validate this score in patients with first-time STEMI for the assessment of myocardial injury visualized by CMR.

Methods

In this validation study, 423 revascularized first-time STEMI patients (median age 56, 17% women) were included. ECG was conducted at discharge for evaluation of the DETERMINE and Selvester score. CMR imaging was performed at a median of 3 days for the assessment of infarct characteristics (IS and microvascular obstruction [MVO]).

Results

Median DETERMINE score of the overall cohort was 8 points (interquartile range: 5-11). Patients presenting with a score &gt; 8 points had more often anterior infarct localization (64% vs. 29%, p &lt; 0.001) and higher peak hs-TnT levels (6957 ng/l vs. 3117 ng/l, p &lt; 0.001). In linear and binary multivariable logistic regression analysis, the DETERMINE score remained as independent associate of IS (odds ratio [OR]: 1.09, 95% confidence interval [CI] 1.00 to 1.18, p = 0.047) and MVO (OR: 1.09, 95% CI 1.02 to 1.16, p = 0.016), after adjustment for Selvester score and peak hs-cTnT.

Conclusions

In survivors of first-time STEMI, the DETERMINE score provides an easy and inexpensive tool for suitable IS estimation. Moreover, the DETERMINE score showed significant and independent association with MVO. Thus, this simple ECG score might help identify patients at high risk of large infarct burden who might benefit from more aggressive treatment strategies.

Cardiac magnetic resonance derived global longitudinal strain outperforms established functional parameters in prognostication after ST-elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Although left ventricular ejection fraction (LVEF) is recommended for left ventricular (LV) systolic function assessment and risk stratification of patients with ST-elevation myocardial infarction (STEMI), its prognostic value is limited. Other measures of LV function such as global longitudinal strain (GLS) and mitral annular plane systolic excursion (MAPSE) might provide additional prognostic information post-STEMI. However, comprehensive investigations comparing these parameters in terms of prediction of hard clinical events following STEMI are lacking so far.

Purpose

We aimed to investigate the comparative prognostic value of LVEF, MAPSE and GLS by cardiac magnetic resonance (CMR) imaging in acute STEMI patients.

Methods

This observational study included 407 consecutive acute STEMI patients treated with primary percutaneous coronary intervention (PCI). Comprehensive CMR investigations were performed 3 [interquartile range (IQR): 2-4] days after PCI to determine LVEF, GLS and MAPSE as well as myocardial infarct characteristics. Primary endpoint was the occurrence of MACE defined as composite of death, re-infarction and congestive heart failure.

Results

During a follow-up of 21 [IQR: 12-50] months, 40 (10%) patients experienced MACE. Patients with MACE showed significantly lower LVEF (49% vs. 53%, p = 0.005) and MAPSE (7.9 mm vs. 9.1 mm, p = 0.001), as well as higher GLS values (-10.2% vs. -12.3 %, p &lt; 0.001). GLS showed the highest prognostic value with an area under the curve (AUC) of 0.71 (95% CI 0.63-0.79; p &lt; 0.001) compared to MAPSE (AUC: 0.67, 95% CI 0.58-0.75; p = 0.001) and LVEF (AUC: 0.64, 95% CI 0.54-0.73; p = 0.005). After multivariable analysis, GLS emerged as independent predictor of MACE (HR: 1.22, 95% CI 1.11-1.35; p &lt; 0.001). Of note, GLS remained associated with MACE (p &lt; 0.001) even after adjustment for infarct size and microvascular obstruction.

Conclusion

CMR-derived GLS emerged as strong and independent predictor of MACE after acute STEMI with additive prognostic validity to LVEF and parameters of myocardial damage.

Determinants and prognostic relevance of aortic stiffness in patients with recent ST-elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

The association between aortic stiffness, cardiovascular risk factors and prognosis in patients with recent ST-elevation myocardial infarction (STEMI) is poorly understood.

Purpose

We analyzed the relationship between cardiovascular risk factors and arterial stiffening and assessed its prognostic significance in patients with recent STEMI.

Methods

We prospectively enrolled 408 consecutive patients who sustained a first STEMI and underwent primary percutaneous coronary intervention (pPCI). Aortic pulse wave velocity (PWV), a direct measure of aortic stiffness, was determined by the transit-time method using velocity-encoded, phase-contrast cardiac magnetic resonance imaging. Patient characteristics were acquired at baseline and major adverse cardiac and cerebrovascular events (MACCE) were assessed at 13 (interquartile range [IQR] 12–31) months. Cox regression- and logistic regression analysis were performed to explore predictors of PWV and MACCE.

Results

Median aortic PWV was 6.6 m/s (IQR 5.6–8.3m/s). In multivariable analysis, age (odds ratio [OR] 1.10, 95% confidence interval [CI], 1.08–1.14, p &lt; 0.001) and hypertension (OR 2.45, 95% CI, 1.53–3.91, p &lt; 0.001) were independently associated with higher PWV. Gender, diabetes, smoking status, dyslipidemia, and obesity were not significantly associated with PWV in adjusted analysis (all p &gt; 0.05). High PWV significantly and independently predicted occurrence of MACCE in adjusted analysis (hazard ratio [HR] 2.45, 95% CI 1.19–5.04, p = 0.014).

Conclusion

In patients with recent STEMI, the impact of classical cardiovascular risk factors on aortic stiffness is mainly dependent on age and increased blood pressure. Increased aortic stiffness is associated with adverse clinical outcome, suggesting it as a relevant therapeutic target in this population.