P1353Echocardiographic predictor of sick sinus syndrome following catheter ablation of persistent atrial fibrillation

Funding Acknowledgements

Abbott Medical Japan, Medtronic Japan, Boston Scientific Japan, Biotronic Japan, Japan Life Line

Background / Introduction

Although sick sinus syndrome(SSS) can be associated with atrial fibrillation(AF), predictive factors of SSS following catheter ablation(CA) of persistent atrial fibrillation(perAF) are not well known.

Purpose

We investigated echocardiographic parameters to predict occurrence of SSS after restoration of sinus rhythm by CA for perAF patients.

Methods

Ninety-eight consecutive perAF patients from June 2014 to May 2018 treated with CA were retrospectively reviewed. Twelve patients(12%, SSS group) developed SSS after successful CA and 86 patients(88%, non-SSS group) did not. Baseline characteristics, blood exam, and echocardiographic findings(RA area size, LA area size, EF, etc) before AF CA were analyzed using Student’s t test, Mann-Whitney test, Chi-square test and Univariate analysis. Multivariate logistic analysis was then performed using those parameters. The atrial area size was calculated from 4 chamber view at the atrial end- systole.

Results

The multivariate analysis for predictive factors of SSS is shown in the table. Right atrium(RA) area could predict SSS(17.3 ± 4.8cm2 vs. 14.7 ± 3.6cm2, odds ratio 1.468; 95% confidence interval 1.088 to 1.981, p = 0.012). Gender (female) was also an independent predictor(4/12 (33%) vs. 8/86 (9%), odds ratio 39.832; 95% confidence interval 2.589 to 612.938, p = 0.008). The other echocardiographical findings(LA area size, EF, etc), baseline characteristics and blood exam results were not related to SSS after successful CA of perAF patients.

Conclusions

The large RA area size and gender (female) could predict SSS in perAF patients after restoration of sinus rhythm by successful CA. We may need to inform possible SSS after CA to female patients with a large RA before CA.

Multivariate Logistic analysis Total(N = 98) SSS group (N = 12) Non SSS group (N = 86) Odds ratio 95% CI P-value Age 64(58-69) 68(60-72) 63(57-69) 1.032 0.929-1.145 0.560 Gender/Female 12(12%) 4(33%) 8(9%) 39.832 2.589-612.938 0.008 CKD 27(28%) 6(50%) 21(24%) 1.264 0.179-8.945 0.814 BNP 91(53-180) 206(167-304) 82(48-169) 1.003 0.993-1.012 0.609 RDW 45.1 ± 3.9 46.4 ± 4.8 44.9 ± 3.8 1.242 0.971-1.588 0.085 RA area 15.1 ± 3.8 17.3 ± 4.8 14.7 ± 3.6 1.468 1.088-1.981 0.012 LA area 24.2(17.0-24.9) 24.4(17.7-26.3) 24.1(16.8-24.4) 0.967 0.803-1.165 0.726 Right atrium area and gender were the independent predictor of SSS in persistent atrial fibrillation patients after restoration of sinus rhythm

P943The impact of diabetes on patients with frail after endovascular treatments: from I-PAD registry

Background

Diabetes mellitus (DM) is known to be one of the risks of arteriosclerosis. However, it is still unknown whether DM is a risk factor also in secondary prevention of frail patients after endovascular treatments (EVT)

Purpose

To investigate impact of diabetes on patients with frail after EVT.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed EVT were enrolled in I-PAD registry. We could conduct follow up survey 361 patients (446 lesions) and divided into 2 groups; with diabetes (185 patients, 226 lesions) or without diabetes (176 patients, 220 lesions) and analyzed. And among them,we selected 96 patients with frail and divided into 2 groups; with diabetes (49 patients, 70 lesions) or without diabetes (46 patients, 58 lesions) and analyzed. We defined frail patients as the patients with Clinical Frailty Scale 5 (mild frail) or higher. The primary end point was all-cause-death and major adverse limb events (MALE: TLR, TVR, major amputations) at 1 year.

Result

At 1 years in the patients group with diabetes, overall survival and freedom from MALE were significantly lower (81.7% vs 95.8% P<0.0001; 80.0% vs 94.6%, P<0.0001) than the group without diabetes.Among the patients with frail, between the patients group with diabetes and the group without, there is no significant differences in overall survival and freedom from MALE (88.2% vs 88.9% P=0.83; 80.7% vs 84.1%, P=0.55) at 5 years.

Conclusion

The prognosis of patients with diabetes after EVT was worse than the patient without. On the other hand, the prognosis of frail patients with diabetes after EVT was no difference with the frail patient without diabetes in this study.

P942Impact of left ventricular ejection fraction in patients with critical limb ischemia: from I-PAD registry

Introduction

In patients with critical limb ischemia (CLI) it is known that malnutrition, low BMI, inflammation and so on are prognostic factors. But, it is unclear whether left ventricular ejection fraction (LVEF) affects prognosis of CLI patients. So we investigated that LVEF affects prognosis of CLI patients.

Methods

From July 2015 to July 2016, 371 consecutive peripheral artery disease patients who performed endovascular treatment (EVT) were enrolled in I-PAD registry. 179 of them were patients with CLI. We could conduct follow up survey about 126 (age 75.5±11.1, men 63.5%) and divided two groups according to their LVEF (group with LVEF≤40%, n=13, group without LVEF≤40%, n=113). The primary end point was major adverse limb events (MALE: TLR, TVR, major amputations) and secondary end point was all-cause death.

Results

The median follow-up period was 11.5±6.7 months. The 18 months MALE rate was significant higher in the group with low LVEF than group without low LVEF (76.9% vs 37.2% p<0.05). The 18months all-cause death tended to be higher in the group with low LVEF, however there was not statistical significance in the two groups (53.8% vs 24.8% p=0.09).

Conclusion

LVEF was associated with MALE in patients with CLI.

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

Background

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

Methods

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

Results

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

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

Conclusions

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

P1957Impact of fraility on the super elderly patients with peripheral artery disease

Background

The current consensus is that frail patients have high risks of mortality. However, it remains unclear whether frailty is associated with mortality risks in super-elderly patients with peripheral artery disease (PAD).

Methods

The I-PAD registry was a prospective multicenter observational study involving 12 institutions in Nagano prefecture in Japan. From July 2015 to July 2016, the I-PAD registry enrolled 371 consecutive PAD patients who had undergone endovascular therapy (EVT). Among them, we selected and analysed 109 PAD patients who were >80 years old when they had undergone EVT and divided them into two groups: those with frailty (Clinical Frailty Scale≥5, n=47) and those without frailty (Clinical Frailty Scale≤4, n=62). The primary endpoints were overall survival and major adverse limb events (MALE), defined as a composite of all-cause death, major amputation and revascularization.

Results

The median follow-up period was 1.58±0.3 years. Overall, 109 patients with a mean age of 84.8±4.0 years, of whom 63.3% were men, were included. Overall survival and freedom from MALE were significantly lower among patients with frailty than among those without frailty (60.5% vs. 91.6%, P<0.001; 51.4% vs. 87.5%, P<0.001; respectively).

Conclusion

The prognosis of super-elderly patients with frailty is worse than that of patients without frailty.

P936Impact of left ventricular ejection fraction in patients with peripheral artery disease: from I-PAD registry

Introduction

In patients with peripheral artery disease (PAD) it is known that CVD is one of prognostic factors. But, it is unclear whether left ventricular ejection fraction (LVEF) affects prognosis of PAD patients. So we investigated that LVEF affects prognosis of PAD patients.

Methods

From July 2015 to July 2016, 371 consecutive PAD patients who performed endovascular treatment (EVT) were enrolled in I-PAD registry. We could conduct follow up survey about 337 (age 73.8±9.6, men 72.4%) patients and divided two groups according to their LVEF (group with LVEF≤40%, n=18, group without LVEF≤40%, n=319). The primary end point was major adverse limb events (MALE: TLR, TVR, major amputations) and secondary end point was all-cause death.

Results

The median follow-up period was 13.6±5.7 months. The 18 months MALE and all-cause death rate were significantly higher in the group with low LVEF than group without low LVEF (61.1% vs 21.6% p<0.001, 44.4% vs 11.6% p<0.001).

Conclusion

LVEF was significantly associated with MALE and all-cause death in patients with PAD.

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

Background

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

Purpose

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

Methods

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

Results

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

MAC severity and disease progression

Conclusions

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

ETV2-TET1/TET2 Complexes Induce Endothelial Cell-Specific Robo4 Expression via Promoter Demethylation

Although transcription factors regulating endothelial cell (EC)-specific gene expression have been identified, it is not known how those factors induce EC-specificity. We previously reported that DNA hypomethylation of the proximal promoter elicits EC-specific expression of Roundabout4 (Robo4). However, the mechanisms establishing EC-specific hypomethylation of the Robo4 promoter remain unknown. In this study, we demonstrated that the hypermethylated Robo4 proximal promoter is demethylated as human iPS cells differentiate into endothelial cells. Reporter assays demonstrated that ETV2, an ETS family transcription factor, bound to ETS motifs in the proximal promoter and activated Robo4 expression. Immunoprecipitation demonstrated direct interaction between ETV2 and methylcytosine-converting enzymes TET1 and TET2. Adenoviral expression of ETV2-TET1/TET2 complexes demethylated the Robo4 promoter and induced Robo4 expression in non-ECs. In summary, we propose a novel regulatory model of EC-specific gene expression via promoter demethylation induced by ETV2-TET1/TET2 complexes during endothelial differentiation.

Birth order and paediatric allergic disease: A nationwide longitudinal survey

BACKGROUND

Environmental factors seem to be related to the incidence of allergic disease. Children with a later birth order are often exposed to environments, where pathogens and endotoxins can be found, and thus have a higher risk of developing infectious diseases. Therefore, birth order is regarded as an indicator that reflects post-natal environment. However, longitudinal studies are limited on this subject. This study sought to elucidate the relationships between birth order and allergic disease.

METHODS

From a nationwide longitudinal study that followed children born in 2001 (n = 47 015), we selected doctors' visits for 3 types of allergic disease-bronchial asthma, food allergy and atopic dermatitis-from infancy to 12 years of age and conducted binomial log-linear regression analysis to evaluate the associations between birth order and these diseases. We adjusted for the child and parental factors and estimated risk ratio (RR) and 95% confidence interval (CI) for each outcome.

RESULTS

The associations between birth order and bronchial asthma were diverse; later birth order increased the risk in early childhood, but decreased the risks during school age. For example, the adjusted RR comparing third-born or higher and first-born children was 1.19 (95% CI, 1.05-1.35) between 30 and 42 months of age, but was 0.76 (95% CI, 0.65-0.89) between 10 and 11 years. Later birth order was generally protective for food allergy but increased the risk of atopic dermatitis.

CONCLUSION

The influence of birth order depended on the type of allergic disease and the childhood period. Childhood is unique in terms of physical and immunological development, and the immune response to the post-natal environment in childhood appears to be heterogeneous.

Role of extracellular vesicles in the interaction between epithelial and mesenchymal cells during oviductal ciliogenesis

Extracellular vesicles (EVs) have been shown to transport miRNA, mRNA and protein, suggesting that they are new communication mediators. Diffusible mesenchymal factors determine the fate of Műllerian epithelial cells into oviductal ciliated cells. In the present study, we investigated whether EVs mediate the communication in the epithelial-mesenchymal interaction during oviductal ciliogenesis. EVs were isolated from cells of oviductal mesenchymal cell line (S1 cells) and characterized by TEM and expression of exosomal marker CD81. CD81 protein was also detected in oviductal mesenchyme, suggesting that CD81-expressing exosomes may be secreted from oviductal mesenchyme, as well as S1 cells. β-actin, Gapdh and Vimentin mRNAs and miRNAs were detected in the exosomes. mRNA in S1 cells was able to be transported into cells of Műllerian epithelial cell line (E1 cells) via the exosomes. The effects of exosomes derived from S1 cells on ciliogenesis of E1 cells were analyzed by in vitro models. Culture with exosomes increased the number of ciliated cells in E1 cells. These results suggest that exosomes derived from mesenchymal cells modulate the oviductal ciliogenesis and open new avenues for developmental study of EVs.