Electrocardiographic imaging a valid tool or an inaccurate toy?

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Learning Health

Background and aim

Electrocardiographic imaging (ECGI) is capable of performing an activation map with a single beat. However, previous studies using the epicardial-only system, have suggested a bad accuracy for the assessment of the epicardial breakthrough. Recent systems using endo-epicardial analysis have shown promising results. The aim of this study was to assess the accuracy and reproducibility of two endo-epicardial ECGI systems using different cardiac sources one based on the extracellular-potential, and the other on the equivalent double layer model, respectively the AMYCARD (EP Solutions SA, Switzerland) and VIVO (Catheter Precision, NJ USA) systems.

Methods

We studied 11 consecutive patients referred for ablation of frequent idiopathic premature ventricular contractions at our center that had an ECGI performed using both systems on the same day. The AMYCARD system uses a dense array of body-surface electrocardiograms with up to 224 leads and VIVO uses just the 12-leads ECG. Both systems use a patient-specific heart torso geometry obtained with a CT-scan or cardiac magnetic resonance. The localisation of the PVCs based on ECGI was done using a segmental model with 22 segments on the left ventricle, to include the classical 17 segment model plus the aortic cusps and the papillary muscles, and 12 segments on the right ventricle including 4 on the right ventricular outflow tract (RVOT): (anterior, lateral, right septum and left septum). A perfect match was defined as a predicted location within the same anatomic segment, whereas a near match as a predicted location within the same segment or a contiguous one.

Results

The median (Q1-Q3) number of leads used for the AMYCARD was 131 (118-144). Seven patients underwent ablation and in 4 ablation is pending. The predicted locations and the ablation site are depicted on the Table. We found a perfect match between both systems in 73% (Figure) and near match in 91% of cases. In patients that underwent ablation the systems localised the site of origin of the PVCs within the same segment or the contiguous segment in all patients with VIVO and in six out of seven with AMYCARD.

Conclusions

ECGI is an accurate diagnostic tool with reproducible results regardless the cardiac source used for analysis.

A cardiac magnetic resonance myocardial strain patterns analysis in left bundle branch block

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recently, a classification with four types of septal longitudinal strain patterns was described using a speckle tracking based strain analysis in echocardiography suggesting pathophysiological continuum of LBBB-induced LV remodeling. Little data exist on feature tracking cardiac magnetic resonance (FT-CMR) in LBBB patients, and whether such patterns could be reproduced in CMR is not established yet.

Purpose

In this study, we aimed to: 1) Assess and reproduce the new strain patterns classification by CMR and 2) Evaluate its association with LV remodeling and myocardial scar in a LBBB cohort.

Methods

Single center registry which included LBBB patients with septal flash (SF) referred to CMR to assess the structural cause of LV dysfunction. LBBB was defined according to Strauss criteria as strict LBBB, non-strict LBBB or nonspecific LV conduction delay.

A semi-automated FT-CMR was used to quantify myocardial strain and detect the four septal longitudinal and radial strain patterns, according to the recent classification (LBBB-1 through LBBB-4) – Figure. Extent of SF was visually scored as mild, moderate, or prominent.

Results

A total of 115 patients were included (mean age 66±11 years; 57% men; 38% with ischemic heart disease). Median duration of QRS was 150± 26ms and majority of the patients (n=90, 78%) were classified as strict LBBB.

In longitudinal strain analyses LBBB-1 was observed in 23 (20%), LBBB-2 in 37 (32.1%), LBBB-3 in 25 (21.7%), and LBBB-4 in 30 (26%) patients. Patients at higher LBBB stages (longitudinal or radial pattern) had more prominent septal flash, greater LV volumes, lower LV ejection fraction and lower absolute global longitudinal, circumferential and radial strain values compared with patients in less advanced stages (p < 0.05 for all) - table.

There was no difference between patterns in clinical characteristics, ischemic etiology, QRS duration and time delay between septal and lateral LV wall.

Late gadolinium enhancement (LGE) was found in 63 patients (54.8%), with a septal location in 34 (29.6%) patients, lateral in 4 (3.5%) patients, septal and lateral in 11 (9.6%) patients. Furthermore, no difference was found for LGE presence, distribution or location between the four strain patterns.

Conclusions

Among patients with LBBB, our study found a good association between longitudinal and radial strain patterns with the degree of LV remodeling and LV dysfunction by FT-CMR analysis. Additionally, myocardial fibrosis didn’t seem to interfere with the staged LBBB classification.

Late gadolinium enhancement is a strong predictor of life threatening arrhythmias in patients with non-ischemic dilated cardiomyopathy undergoing ICD implantation for primary prevention of sudden card

Funding Acknowledgements

Type of funding sources: None.

Background

The usefulness of implantable cardioverter defibrillators (ICD) for primary prevention of arrhythmic sudden cardiac death (SCD) in patients with non-ischemic dilated cardiomyopathy (DCM) has been questioned. Efforts to improve risk stratification have included scores such as the ‘MADIT-ICD benefit score’, and the use of late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR).

The purpose of this study was to evaluate the potential usefulness of these two tools to assess the risk of life-threatening arrhythmias in patients with non-ischemic DCM undergoing ICD implantation for primary prevention of SCD.

Methods

We conducted a single-center retrospective study of consecutive patients who underwent contrast-enhanced CMR before ICD implantation for primary prevention of SCD. Patients with ischemic cardiomyopathy were used as reference. Patients with non-dilated cardiomyopathies were excluded.

The arrhythmic component of the MADIT-ICD benefit score (VT/VF score) was calculated for each patient, and considered high if ≥ 7, as recommended.

The primary endpoint was the occurrence of SCD or life-threatening arrhythmias (VF or VT >200 bpm). Follow-up was performed by device interrogation in all patients except those who suffered SCD.

Results

A total of 151 patients (93 ischemic, mean age 62±13 years, 75% male) with mean left ventricular ejection fraction (LVEF) of 27±8% were included. Overall, 72% (n=67) ischemic and 45% (n=26) non-ischemic patients had scores ≥ 7 and were considered high-risk. LGE was present in all patients with ischemic cardiomyopathy, and in 76% (n=44) of patients with non-ischemic DCM.

During a median follow-up of 21 (8-38) months, 21 patients (13.9%, 11 ischemic and 10 non-ischemic) met the primary endpoint.

Overall, the event-free survival of non-ischemic patients was similar to that of ischemic patients (log rank p=0.269) – Fig 1A. In patients with non-ischemic DCM, there were 7 arrhythmic events (26.9%) in those with MADIT-ICD VT/VF scores ≥7, and 3 events (9.4%) in those with scores <7 (log rank p= 0.104) – Fig 1B.

In the same population, there were 10 arrhythmic events (23%) in patients with LGE, but no events in patients without LGE (log rank p=0.036) – Fig 1C.

LVEF was similar in patients with and without arrhythmic events (26±8% vs. 27±7%, p=0.717), and in those with and without LGE (26±7% vs. 28±9%, p=0.342).

Conclusion

The presence of LGE is a strong predictor of life threatening arrhythmias in patients in non-ischemic DCM undergoing ICD implantation for primary prevention, seemingly outperforming the clinical MADIT-ICD benefit score.

The peri-infarct gray zone of myocardial fibrosis is a better predictor of ventricular arrhythmias than dense core fibrosis in patients with previous myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Current sudden cardiac death (SCD) risk stratification relies heavily on left ventricular ejection fraction (LVEF), but markers to refine risk assessment are needed. Dense core fibrosis (DCF) and peri-infarct "gray zone" of myocardial fibrosis (GZF) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) have been proposed as potential arrhythmogenic substrates. The aim of our study was to determine whether DCF and GZF could predict the occurrence of ventricular arrhythmias in patients with previous myocardial infarction.

Methods

We performed a single centre retrospective study enrolling consecutive patients with previous myocardial infarction undergoing CMR before implantable cardioverter-defibrillator (ICD) implantation. Areas of LGE were subdivided into "core" DCF and "peri-infarct" GZF zones based on signal intensity (>5 SD, and 2-5 SD above the mean of reference myocardium, respectively).

The primary endpoint was a composite of sudden arrhythmic death, appropriate ICD shock, ventricular fibrillation (VF), or sustained ventricular tachycardia (VT) as detected by the device.

Results

A total of 88 patients (median age 61 years [IQR 54-73], 84% male, median LVEF 30% [IQR 23-36%], 14% secondary prevention) were included. During a median follow-up of 23 months [IQR 9-38], 13 patients reached the primary endpoint (10 appropriate ICD shock, 2 sustained VT or VF, and 1 sudden arrhythmic death). Patients who attained the primary endpoint had similar DCF (30.4g ± 14.7 vs. 28.0g ± 15.3; P = 0.601) but a greater amount of GZF (18.1g ± 9.6 vs. 11.9g ± 6.7; P = 0.005). On univariate analysis, GZF was associated with the composite endpoint (HR: 1.09 per gram; 95%CI: 1.02-1.15; P = 0.006), whereas DCF was not (HR: 1.01 per gram; 95%CI: 0.98-1.05; P = 0.571). After adjustment for LVEF, GZF remained independently associated with the primary endpoint (adjusted HR: 1.06 per gram; 95% CI: 1.01-1.12; P = 0.035). Decision tree analysis identified 11.9g of GZF as the best cut-off to predict life-threatening arrhythmic events. The primary endpoint occurred in 11 out of the 35 patients (31.4%) with GZF ≥11.9g, but in only 2 of the 53 patients (3.8%) with GZF <11.9g – Figure.

Conclusions

The extent of peri-infarct GZF seems to be a better predictor of ventricular arrhythmias than DCF. This parameter may be useful to identify a subgroup of patients with previous myocardial infarction at increased risk of life-threatening arrhythmic events.

Assessment of activation duration across the right ventricular outflow tract in patients with premature ventricular contractions using noninvasive electrocardiographic mapping: a validation study

Funding Acknowledgements

Type of funding sources: Private hospital(s). Main funding source(s): Learning Health

Introduction

Previous studies have reported that wavefront propagation speed across the right ventricular outflow tract (RVOT) can distinguish premature ventricular contractions (PVCs) with a RVOT origin from PVCs with a left ventricular outflow tract (LVOT) origin.

Aim

Validate the non-invasive electrocardiographic mapping (ECGI) for assessment of RVOT activation duration (AD) during PVCs and assess its value as a predictor of the origin of the PVCs.

Methods

We studied 18 consecutive patients, 8 males, median age 55 (35-63) years that underwent ablation of frequent (> 10.000 per 24 h) idiopathic PVCs with inferior axis, that had and an ECGI performed before ablation and the RVOT mapped in PVC. The ECGI was performed with the Amycard system, and invasive mapping was performed with the Carto or Ensite system. Isochronal activation maps of the RVOT in PVC were obtained with the activation direction method (ADM) of the ECGI, and with the Carto and Ensite systems. Total RVOT AD was measured as the time interval between the earliest and the latest activated region. Agreement between the two methods was performed using a Bland-Altman plot and linear regression . The cutoff value of AD to predict PVC origin was calculated with ROC curve.

Results

PVCs originated from the RVOT in 11 (61%) patients. The median (Q1-Q3) RVOT AD measured with ECGI was 54 (39-68) ms and with invasive map 57 (36-70) ms. The agreement between both methods was good with an R2 of 0.747, p<0.0001. Figure displays the Bland-Altman plot (panel A), the linear regression plot (panel B). and two examples of the ECGI isochronal map (panel C). The AD was significantly higher in PVCs from the RVOT vs LVOT, both with ECGI and Carto, respectively 62 (58-73) vs 37 (33-40) ms, p<0.0001 and 68 (60-75) vs 34 (30-40) ms, p<0.0001. The cutoff value of 43 ms for AD measured with ECGI, predicted the origin of the PVCs with a sensitivity and specificity of 100%.

Conclusions

We found good agreement between ECGI and Carto. The AD obtained with ECGI was accurate to predict the origin of the PVCs.

Prognostic significance of peak atrial longitudinal strain in patients with functional mitral regurgitation

Funding Acknowledgements

Type of funding sources: None.

Background

Chronic mitral regurgitation has been shown to promote left atrial (LA) dysfunction and remodeling. However, the significance of LA dysfunction in this setting has not been fully investigated. The aim of our study was to assess the prognostic impact of peak atrial longitudinal strain (PALS), a surrogate of LA function, in a cohort of patients with LV systolic dysfunction and functional mitral regurgitation (FMR).

Methods

Patients with at least mild FMR and reduced LVEF (< 50%) under optimized medical therapy who underwent transthoracic echocardiography between 2010 and 2018 were retrospectively identified at a single-centre. FMR grading was undertaken according to the new 2021 valvular guidelines. PALS was assessed by 2D speckle tracking in apical 4-chamber view (as per EACVI current recommendations). Cox proportional hazards regression was applied for univariable and multivariable analysis to investigate the association between clinical and echocardiographic parameters, namely PALS, and all-cause mortality.

Results

A total of 307 patients (median age 70 years, 77% male) were included. Median LVEF was 35% (IQR: 27 – 40%) and median mitral regurgitant volume was 25mL (IQR: 14 – 34mL). According to the new ESC 2021 valvular guidelines, 32 patients had severe FMR (10%). During a median follow-up of 3.5 years (IQR 1.4 – 6.6), 148 patients died. Median PALS was 14% (IQR 8 – 20%). The unadjusted mortality incidence per 100 persons-years increased with progressively lower values of PALS (figure 1). On ROC curve analysis, the best PALS cut-off value associated with mortality was < 15%. Kaplan-Meier survival curves according to FMR severity and PALS > or < 15% are depicted in figure 2. PALS remained independently associated with all-cause mortality on multivariable analysis (adjusted hazard ratio [aHR]: 0.94; 95%CI: 0.90 – 0.98; p = 0.004) even after adjustment for several (n = 14) clinical and echocardiographic confounders.

Conclusion

In a cohort of patients with reduced LVEF and functional mitral regurgitation, peak atrial longitudinal strain was associated with all-cause mortality. Abstract Figure 1  Abstract Figure 2

3D printed FBG based sensor for vital signal monitoring – Influence of the infill printing parameters

The fused deposition modelling technique has been used in the production of strain sensors in which fibre Bragg gratings (FBGs) are encapsulated during the 3D printing process. This paper reports the study of the influence of the FBG position and the material filling, in this case a flexible polymer material, on the sensors’ sensitivity and overall performance. In addition, this study preliminarily evaluated the ability of the strain sensor to monitor (heart rate) HR and (respiratory rate) RR as a wearable on the wrist and as a non-intrusive solution on the back of an office chair.

Migration and season explain tick prevalence in Brazilian birds

Neotropical birds are mostly parasitized by immature ticks and act as reservoir hosts of tick-borne pathogens of medical and veterinary interest. Hence, determining the factors that enable ticks to encounter these highly mobile hosts and increase the potential for tick dispersal throughout migratory flyways are important for understanding tick-borne disease transmission. We used 9682 individual birds from 572 species surveyed across Brazil and Bayesian models to disentangle possible avian host traits and climatic drivers of infestation probabilities, accounting for avian host phylogenetic relationships and spatiotemporal factors that may influence tick prevalence. Our models revealed that the probability of an individual bird being infested with tick larvae and nymphs was lower in partial migrant hosts and during the wet season. Notably, infestation probability increased in areas with a higher proportion of partial migrant birds. Other avian ecological traits known to influence tick prevalence (foraging habitat and body mass) and environmental condition that might constrain tick abundance (annual precipitation and minimum temperature) did not explain infestation probability. Our findings suggest that migratory flyways harbouring a greater abundance of migrant bird hosts also harbour a higher prevalence of immature ticks with potential to enhance the local transmission of tick-borne pathogens and spread across regions.

COVID-19 in a pediatric cohort—retrospective review of chest computer tomography findings

Background

Radiological features of the novel 2019 coronavirus disease (COVID-19) have been mainly described in adults. Available literature states that imaging findings in children are similar but less pronounced. The aim of this study is to describe and illustrate the chest computer tomography (CT) features of pediatric COVID-19.

Results

This retrospective study was based on the review of all the chest CTs performed in pediatric patients with confirmed COVID-19 disease between March 8th and May 26th 2020 (n = 24). The presence of comorbidities and coinfection was assessed, as well as timing of CT examination in relation to the onset of symptoms. CT findings were categorized as typical, indeterminate, atypical, and negative for COVID-19 according to International Expert Consensus Statement on Chest Imaging in Pediatric COVID-19 Patient Management. This study found that CT findings were abnormal in 17 (71%) patients, with 5 (21%), 9 (38%), and 3 (13%) patients considered to have typical, indeterminate, and atypical findings, respectively. The most common CT patterns were multiple ground-glass opacities (58%), followed by consolidations (50%). Six patients showed predominantly peripheral distribution of parenchymal abnormalities. A halo sign was identified in 3 patients and a perilobular pattern was identified in one of the cases with typical findings.

Conclusions

Chest CT findings in children infected with SARS-CoV-2 can be subtle or absent. Besides recognizing typical findings, radiologists should be able to identify features that favor different or concomitant diagnosis.

Prevalence of cognitive impairment before treatments for prostate cancer

Background/Objective

Up to 30% of patients with cancer may present cognitive impairment (CI) before treatment but data are scarce regarding prostate cancer (PCa). We aim to estimate the prevalence of CI in patients with PCa, before cancer treatment.

Methods

Between February 2018 and April 2021, the NEON-PC cohort included 609 patients with a recent PCa diagnosis to be treated at Instituto Português de Oncologia do Porto. Previous history of chemotherapy, radiotherapy, androgen deprivation therapy, and neurologic or psychyatric conditions impairing cognitive performance were exclusion criteria. The Montreal Cognitive Assessment (MoCA) was used to assess cognitive performance before any treatment for PCa. Participants with a MoCA at least 1.5 SD below age- and education-specific norms were considered to have probable cognitive impairment (PCI) and were proposed for a comprehensive neuropsychological (NP) assessment. Participants scoring <2.0 SD age-corrected norms in at least one cognitive test, or < 1.5 SD age-corrected norms in ≥ 2 cognitive tests were classified as having CI. Data from the population-based cohort EPIPorto (n = 351 men, evaluated in 2013-2015) were used for comparison.

Results/Discussion

Prevalence of PCI was 17.4% in the EPIPorto and 15.1% in the NEON-PC cohort (age- and education-adjusted OR = 1.02,95% confidence interval: 0.70,1.50). NP assessment was performed in 65 patients with PCa: 38.5% had normal cognitive function; 7.7% had a light deficit (<1.0 SD of age-corrected norms in ≥ 1 cognitive tasks); and 53.9% had CI.

Conclusions

PCI was as frequent in patients recently diagnosed with PCa as in the general population. Prevalence of CI was lower than in previous reports, which may be explained by differences in the assessment and definition of CI and of the type of cancer.

Funding

POCI-01-0145FEDER-032358;PTDC/SAU-EPI/32358/2017;UIDB/4750/2020; SFRH/BD/119390/2016

Key messages

Patients with prostate cancer and the general population had similar odds of having a score below normative values in the MoCA. Differences in the prevalence of CI between this study and others suggest that the type of cancer may affect patients’ cognitive performance differently, which deserves further confirmation.

Gender (in)equality in the labor market: a case study of Environmental Health Officers

 

The female gender has been discriminated, as it is considered inferior, in relation to the male. In the health sector, although the proportion of women has increased, the occupational segregation still persist. The mortality rate reduction, is largely due to the unrecognized contribution of women. Segregation manifests itself in a variety of ways, ranging from a limited set of opportunities to wage disparities. It's paradox since, even in “mostly female” jobs, like Environmental Health (EH), the minority of men usually have an “escalator”, reaching leadership quickly. This abstract addresses the gaps in the challenges of gender inequality in EH, since the fact that women are a health driver is been ignored. We seek to know the attitudes and opinions of the Environmental Health Officers (EHO), about: identity centralities; discrimination in society, profession and organization. This study is observational, descriptive, cross-sectional and level of knowledge II. The target population comprises by EHO (women and men). The sample design adopted was non-probabilistic and technical for convenience. The information was collected through a digital questionnaire. On average, men presented a more conservative view, compared to the female, associating women to mother's role and housewives, revealing a certain conservatism. There was, therefore, a prevalence of gender stereotypes. A correlation was found, about the organizational discrimination, since who revelead a minor difference between genders, were also those who presented a lower index of stereotypes. In other words, an organization that provides a life balance, leads its workers to desconstruct social and professional stereotypes. In conclusion, a gender diagnosis is essential to identify asymmetries and to start the change. This study identifies and analyzes inequalities in the EH area. Most of the results found follow the literature and are relevant to define future strategies.

Key messages

Global health organizations are starting to recognize the importance of gender challenges as a way to achieve universal health coverage which facilitates a new narrative. Recent data from the International Labor Organization estimate that gender pay gaps in the health sector are higher compared to other sectors, although women hold a large number of health jobs.

Androgen deprivation therapy and cognitive decline in the NEON-PC study

Background/Objective

Androgen deprivation therapy (ADT) has been associated with cognitive decline, but results have been heterogenous. We describe changes in cognitive performance in patients with prostate cancer (PCa), according to treatment with ADT, during the 1st year after PCa diagnosis.

Methods

Between February 2018 and March 2021, 348 patients with PCa treated at the Instituto Português de Oncologia do Porto were evaluated with the Montreal Cognitive Assessment (MoCA), before treatment and after one year (1y). ADT was used in 183 participants, and 165 were treated without ADT (total prostatectomy, radiotherapy, brachytherapy, active surveillance). Cognitive decline was defined as the decrease in MoCA from baseline to the 1y-evaluation below 1.5SD of the distribution of the MoCA variation in the whole cohort. Participants scoring below age- and education-based normative reference values in MoCA were considered to have probable cognitive impairment (PCI). Multivariate logistic regression was used to estimate age- and education-adjusted OR (aOR) of the association between ADT and cognitive decline/incident PCI.

Results/Discussion

PCI was observed in 12.4% of the patients at baseline. Mean MoCA scores increased from baseline to the 1y-evaluation (22.4 vs. 22.9, p = 0.001), and 51.2% of PCI cases at baseline had normal MoCA scores at 1y. Cognitive decline was most frequent in the ADT group (9.3% vs. 3.6%, p = 0.034), although the aOR was 2.44 (95%CI:0.89-6.71). The 1yr cumulative incidence of PCI was 10.4% (95%CI:6.2%-16.2%) in the ADT-group and 2.8% (95%CI:0.8-%-7.1%) in the non-ADT group [aOR=3.15 (95%CI:0.97-10.25)].

Conclusions

ADT was associated with a decrease in the cognitive performance of PCa patients during the 1st year after diagnosis. The completion of the 1y-evaluation in the whole cohort (n = 600) is needed to confirm these preliminary results.

Funding

POCI-01-0145FEDER-032358;PTDC/SAU-EPI/32358/2017; UIDB/4750/2020;SFRH/BD/119390/2016

Key messages

Half of the cases with cognitive impairment at baseline improved at one-year. Patients treated with ADT seem to be affected by cognitive decline more frequently.

Catheter ablation supported by extracorporeal membrane oxygenation -last resort treatment of arrhythmic storm?

Introduction

Arrhythmic storm (AS) is associated with high mortality, even with best medical care and hemodynamic support. If medical therapeutic failure, electrophysiological mapping and ablation are potential lifesaving therapies. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and can be used as a salvage intervention in patients with cardiogenic shock. Considering the seriousness of AS and the technical complexity involved, catheter ablation supported by VA-ECMO is infrequently performed. We sought to assess the safety and effectiveness of emergent catheter ablation procedures performed in patients on VA-ECMO at our hospital.

Methods

Retrospective study of all ventricular tachycardia (VT) catheter ablation procedures performed with VA-ECMO support at a tertiary centre between 2016 and 2020. Follow-up data was obtained from review of electronical records.

Results

Five patients underwent 6 emergent VT ablation procedures due to AS. The median age was 62 years (range, 52) and 4 patients were men. Three patients had VT at admission, while 2 were admitted with an acute coronary syndrome and developed VT during the hospitalization. Four patients had ischemic heart disease, though only 1 had previous history of VT; the remaining patient presented no structural heart disease. Median left ventricle ejection fraction was 11% (range 30).

All patients had incomplete response to amiodarone, lidocaine or overdrive pacing, before being proposed to catheter ablation. Four patients were on ECMO support before ablation, while 1 was cannulated during the procedure due to hemodynamic instability. Ablation was performed using a retrograde approach in 3 patients, and combined retrograde and transeptal access in 2; one patient had epicardial ablation after unsuccessful endovascular approach. Three patients had left ventricle substrate ablation and the remaining 2 of the right ventricle. No major complications were seen directly related to the procedures.

The median length of stay in intensive care unit was 22 days (range 41 days). Weaning of VA-ECMO was accomplished in all patients. Two patient died during the same hospitalization (one due to uncontrolled arrhythmic events). At a median 23 months (range 31) of follow-up of the surviving patients, two had recurrence of VT but no one had return of AS.

Conclusion

In our sample VT ablation on VA-ECMO support was a safe procedure, with no immediate complications. However, as reported in the literature, a high mortality rate was observed both in-hospital and during follow-up, mostly related to advanced structural heart disease. Also, considerable VT recurrence rates were seen, but with no re-hospitalization. Our experience shows that catheter ablation is a life-saving procedure in otherwise uncontrollable AS and allowed absolute success in weaning VA-ECMO.

Funding Acknowledgement

Type of funding sources: None.

Validation of a novel framework defining the acceptable standard of care for heart failure with reduced ejection fraction

Background

In heart failure with reduced ejection fraction (HFrEF), uptitration of neurohormonal antagonists to trial-proven doses shown to reduce mortality is challenging and seldomly achieved in clinical practice. A major reason for underdosing of these agents is the lack of a clear description of what constitutes an acceptable standard of care in HFrEF. To address this limitation, a novel framework for describing the physician adherence to evidence-based treatment was recently proposed. The aim of our study was to evaluate and validate the proposed framework in a real-world population of patients with HFrEF.

Methods

A cohort of patients with HFrEF, defined as left ventricular ejection fraction (LVEF) <40%, under treatment with neurohormonal antagonists for at least 3 months were retrospectively identified at a tertiary hospital's Heart Failure Clinic. Demographic, clinical, echocardiographic and treatment data were assessed. Patients were divided in three strata for each neurohormonal antagonist, according to the proposed framework: Status I – patients receiving target doses or the highest tolerated dose; Status II – use of subtarget doses for reasons unrelated to clinically important intolerance; and Status III – not receiving the drug at any dose. The prognostic value of each strata was assessed for all-cause mortality.

Results

A total of 408 patients (mean age 68±12 years, 78% male, 63% ischemic etiology) were included. The median LVEF was 31% (IQR 25–36) and most patients were in NYHA class II or III [210 (51.5%) and 163 (40%), respectively]. Medical therapy is described in Table 1. During a median follow-up of 3.3 years (IQR 1.4–5.6), 210 patients died. On univariable analysis, achieving Status I of beta-blocker (BB) therapy (HR: 0.50; 95% CI: 0.32–0.81; P=0.004) or ACEi/ARB (HR: 0.56; 95% CI: 0.36–0.86; P=0.012) was associated with reduced all-cause mortality. The mortality of patients in Status II of BB or ACEi/ARB was similar to the mortality of those not receiving the drug (HR for BB: 0.90; 95% CI: 0.53–1.52; P=0.69 and HR for ACEi/ARB: 0.71; 95% CI: 0.42–1.18; P=0.182) – figure 1. Achieving Status I of BB remained independently associated with reduced mortality after adjustment for several clinical and echocardiographic confounders (n=13) (adjusted HR: 0.59; 95% CI: 0.35–0.98; P=0.041).

Conclusions

In this real-world population of patients with HFrEF, the vast majority of patients were in Status I of BB and ACEi/ARB therapy. Achieving Status I of BB therapy seems to be associated with reduced mortality, even after adjustment for several markers of disease severity, highlighting the need for uptitration of medical therapy to maximal tolerated doses according to trial-proven regimens.

Funding Acknowledgement

Type of funding sources: None.

Anomalous origin of the right coronary artery with interarterial course: red flag or innocent bystander?

Aims

Anomalous origin of the right coronary artery from the opposite sinus (right-ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomography angiography (CCTA) has led to increasing recognition of this condition, even among healthy individuals. Our study sought to examine the prevalence, anatomical characteristics and outcomes of right-ACAOS with IAC in patients undergoing CCTA for suspected coronary artery disease (CAD).

Methods and results

We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital from January 2012 to December 2020. Right-ACAOS with IAC patients were analyzed for cardiac symptoms and long-term occurrence of first MACE (SCD, non-fatal myocardial infarction (MI) or revascularization of the anomalous vessel). CCTAs were reviewed for anatomical high-risk features and concomitant CAD. Among 10928 patients referred for CCTA, 28 patients with right-ACAOS with IAC were identified. Mean age was 55±17 years, 64% were male and 11 (39.3%) presented with stable cardiac symptoms. Most patients had at least one high risk anatomical feature. During follow-up, there were no CV deaths or aborted SCD episodes and only 1 patient underwent surgical revascularization of the anomalous vessel.

Conclusion

Right-ACAOS with IAC is an uncommon finding (prevalence of 0.26%). In a contemporary population of predominantly asymptomatic patients who survived this condition well into adulthood, most patients were managed conservatively with a low event rate. Additional studies are needed to support medical follow-up as the preferred option in this setting.

Funding Acknowledgement

Type of funding sources: None.

Incorporating coronary calcification into pretest assessment of the likelihood of coronary artery disease: validation and recalibration of a new diagnostic tool

Background

A new clinical tool was recently proposed to improve the estimation of pre-test probability of obstructive coronary artery disease (CAD) by incorporating coronary artery calcium score (CACS) with clinical risk factors. This new model (Clinical+CACS) showed improved prediction when compared to the method recommended by the 2019 ESC guidelines on chronic coronary syndromes, but was never tested or adjusted for use in our population. The aim of this study was to assess the performance of this new method in a Portuguese cohort of symptomatic patients referred for coronary computed tomography angiography (CCTA), and to recalibrate it if necessary.

Methods

We conducted a two-center cross-sectional study assessing symptomatic patients who underwent CCTA for suspected CAD. Key exclusion criteria were age <30 years, known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. The Clinical+CACS prediction model was assessed for discrimination and calibration. A logistical recalibration of the model was conducted in a random sample of 50% of the patients and subsequently validated in the other half.

Results

A total of 1910 patients (mean age 60±11 years, 60% women) were included in the analysis. Symptom characteristics were: 39% non-anginal chest pain, 30% atypical angina, 19% dyspnea and 12% typical angina. The observed prevalence of obstructive CAD was 12.9% (n=247). Patients with obstructive CAD were more often male, were significantly older, had higher prevalence of typical angina and cardiovascular risk factors, and higher CACS values. The new Clinical+CACS tool showed greater discriminative power than the ESC 2019 prediction model, with a C-statistic of 0.83 (CI 95% 0.81–0.86) versus 0.67 (CI 95% 0.64–0.71), respectively (p-value for comparison <0.001). Before recalibration, the Clinical+CACS model underestimated the likelihood of CAD in our population across all quartiles of pretest probability (mean relative underestimation of 49%), which was subsequently corrected by the recalibration procedure - Figure.

Conclusions

In a Portuguese cohort of symptomatic patients undergoing CCTA for suspected CAD, the new Clinical+CACS model showed better discrimination power than the 2019 ESC method. The underestimation of the Clinical+CACS model was corrected by recalibrating it for our population. This new tool might prove useful for guiding decisions on the need for further testing.

Funding Acknowledgement

Type of funding sources: None.