The effect of implantable cardioverter defibrillator in patients with cardiac resynchronizational therapy and diabetes mellitus

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): (NKFIA; NVKP_16-1-2016-0017 National Heart Program).

Background

Heart failure (HF) and diabetes mellitus (DM) are common causes of death on their own, but the coexistance of these two diseases are especially fatal. 1 In DM, sudden cardiac death (SCD) is more common than in non-DM patients, however in many cases, implantable cardioverter defibrillator (ICD) could not prevent SCD. 2

Purpose

Our aim is to decide which device warrant higher life expectancy, cardiac resynchronizational therapy with or without defibrillator.

Methods

We examined retrospectively 2525 CRT implanted patients, with a mean follow-up time of 4.6 years. Implantaions were based on the current guidelines. The primary endpoint was all-cause mortality, while our composite end-point were all-cause mortality and heart failure hospitalization.

Results

In our population, 928 people (36%) had diabetes. We did not find statistical differences between age (68 vs. 68 years; p<0.099), gender (26% women, 23% women; p<0.08) LVEF (28% vs. 29% p<0.1425), incidence of atrial fibrillation (37% vs. 38%; p<0.76), implantation of an ICD (53% vs. 54%; p<0.847), NT-proBNP median levels (2939 pg/ml vs. 2778 pg/ml; p<0.35), and NYHA I (0,5% vs. 0,5%; p<0.898), and NYHA IV stadium (11% vs. 11%; p<0,82). However DM patients had higher BMI (28 kg/m2 vs. 26 kg/m2; p<0.001), lower eGFR levels (57 ml/min/1,73m2 vs. 60 ml/min/1,73m2; p<0.011) higher prevalence of hypertonia (82% vs. 66%; p<0.001), NYHA III stadium (39% vs. 33%; p<0,0008), ischemic etiology (56% vs. 44%; p<0.001), previous acute myocardial infartion (42,9% vs. 36%; p<0.001), a percutan coronaria intervention (35% vs. 25%; p<0.001) compared to non-DM patients. Those patients with DM showed a 25% higher risk of all-cause mortality (HR 1.25; 95% CI 1.12-1.40; p‹0.01) then non-DM patientes, also observable after adjusting for relevant clinical covariates such as age, gender, atrial fibrillation and the addition of an ICD (HR 1.17; 95% CI 1.06-1.31; p‹0.01).

Conclusions

Adding an ICD for CRT patients with diabetes reduces the risk of all-cause mortality significantly by 32% (HR 0,68; CI 0,56-0,82; p‹0.001) during the first six years but diminished on longer follow-up time (HR 0,95; CI 0,80-1,12; p=0,54).

Impact of morphine use on mortality in STEMI patients treated with primary PCI – results from a new registry

Background

Opioids decrease the effect of P2Y12 receptor inhibitors in vitro and observational reports suggest that morphine use may be associated with larger infarct size. Our research group showed previously, using a prospective single-centre registry, that periprocedural morphine use may have no impact on long-term mortality in STEMI patients treated with primary PCI and clopidogrel.

Purpose

We aimed to study this in vitro interaction on clinical outcomes in patients who were predominantly treated with the novel P2Y12 inhibitors prasugrel or ticagrelor, according to the current guidelines.

Methods

From May 2020 through February 2021, we collected demographic, anamnestic, procedural and laboratory data of 297 consecutive STEMI cases who were treated with primary PCI at our tertiary centre. Of them 126 patients (42.4%) received IV morphine during the periprocedural period. Outcome measure was time to all-cause mortality. The median follow-up time was 147 days (IQR 71–242 days), with 39 events. To adjust for confounding, a 1:1 propensity score-matching analysis (PSM) was performed using 186 cases. Absolute difference in survival was analysed using Kaplan-Meier survival curves and the logrank test, whereas the relative change was assessed by univariable Cox regression.

Results

An adequate balance on baseline covariates was achieved by the propensity score-matching. Kaplan-Meier analysis showed no statistically significant difference in all-cause mortality of the treatment groups neither in the original nor in the propensity score-matched population (p=0.220 and 0.762 respectively). In the matched population we found no difference in survival as the HR (Morphine/No Morphine) was 0.88 (95% confidence interval [CI]: 0.39–2.00), p=0.76.

Conclusion

Our preliminary data suggest that morphine may have no impact on mortality in STEMI patients treated with primary PCI and medical therapy according to the current guidelines including novel P2Y12 antagonists.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The research was supported by the Ministry of Innovation and Technology NRDI Office within the framework of the Artificial Intelligence National Laboratory Program. Kaplan-Meier curves: Original populationKaplan-Meier curves: PSM population

The role of feature-tracking strain analysis in the differentiation of cardiac amyloidosis from hypertrophic cardiomyopathy

 

Cardiac magnetic resonance (CMR) examinations have an essential role in the differentiation of cardiac involvement of amyloidosis (CA) from hypertrophic cardiomyopathy (HCM). The CMR diagnosis is traditionally based on morphologic features and the pattern of late gadolinium enhancement (LGE). However, in patients contraindicated for contrast agent administration, the diagnosis can be challenging. Novel CMR techniques, including strain analysis, can help in the differentiation of these patients.

The aim of our study was to investigate the differential diagnostic and prognostic importance of feature-tracking strain analysis in patients with left ventricular hypertrophy caused by CA or HCM.

We investigated 89 HCM patients (48 males; 50±18 years) and 46 CA patients (29 males; 64±10 years) who underwent CMR examination. The left ventricular ejection fraction (LVEF), volumes (end-diastolic volume: LVEDV, end-systolic volume: LVESV, stroke volume: LVSV), mass (LVM), and the amount of LGE were quantified. Global longitudinal (GLS), circumferential (GCS) and radial (GRS) LV strain parameters, and basal, midventricular, and apical LS and CS were measured. The apex-to-base regional LS and CS ratios were calculated. The all-cause mortality of the patients was analyzed. The characteristics of groups were compared with an independent t-test or Mann-Whitney test, as appropriate. ROC curve analysis was performed to analyze the diagnostic accuracy of a parameter and to identify optimal cutoff values. The prognostic value of CMR parameters was assessed with Cox proportional hazard regression analyses. Survival probability was analyzed with Kaplan-Meier curves and compared by the log-rank test.

CA patients had significantly lower LVEF (51±11 vs. 63±8%; p<0.0001), lower LVSVi (43±12 vs. 54±12 ml/m2; p<0.0001), higher LVMi (94±24 vs. 79±24 g/m2; p<0.001), higher amount of LGE (29±15 vs. 8±8%; p<0.0001), and more impaired global and regional strain values (GRS: 55±22 vs. 93±29%; GCS: −33±10 vs. −42±8%; GLS: −18±4 vs. −25±6%; basal CS: −26±9 vs. −39±7%; basal LS: −15±4 vs. −22±6%; p<0.0001) than HCM patients. The apex-to-base CS and LS ratios were higher in CA patients, suggestive of apical sparing (1.71±0.68 vs. 1.29±0.33; p<0.0001; 1.88±0.76 vs. 1.57±0.62; p<0.05; respectively). In the differentiation of CA and HCM, LGE, basal CS, basal LS, GRS, and GLS had the highest diagnostic accuracies (AUCs: 0.911, 0.866, 0.848, 0.859, 0.849). During the mean 2.1±2.0 years of follow-up, three HCM patients (3.4%) and 29 CA patients (63%) died (p<0.0001). The significant independent predictors of mortality were a diagnosis of CA, LVSVi and basal LS.

Our results show that CMR-based strain analysis might be a useful method for differentiating cardiac involvement of amyloidosis from HCM. Furthermore, this technique provides additional information for the assessment of prognosis in this patient population.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Research, Development and Innovation Office of Hungary; Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging programmes of the Semmelweis University

In-hospital and mid-term outcome after complex endovascular aortic repair with fenestrated and branched stent-grafts

Objective

The aim of the study is to evaluate in-hospital and mid-term outcome after complex endovascular aortic repair with fenestrated and branched stent-grafts (fEVAR / bEVAR).

Methods

This is a single-center retrospective analysis from a prospectively collected database of all patients treated electively with fEVAR or bEVAR for para/suprarenal (PAA) and thoraco-abdominal aortic aneurysm (TAAA) between September 2010 and June 2019. In-hospital and mid-term mortality, major adverse events and re-interventions were assessed.

Results

Fifty-one patient (84% male) with a mean age of 74±7 years were analysed. Eighteen patients (35%) had TAAA, four patients (8%) suprarenal, and 29 patients (57%) pararenal aortic aneurysms. Mean aneurysm diameter was 64±8 mm. Thirty-eight patients (75%) underwent fEVAR and 13 patients (25%) bEVAR. A total of 157 target vessels were incorporated: 22 celiac trunks (CT), 40 superior mesenteric arteries (SMA), 92 renal arteries (RA), two separate hepatic arteries and one splenic artery. No in-hospital death or stroke was recorded. One patient suffered from early postoperative paraplegia and did not recover and one had paraparesis after 38 days and recovered completely. Six patients (12%) with patent renal arteries experienced acute postoperative kidney injury; one required temporary dialysis. Five in-hospital re-interventions were stent-graft related (four bridging stents angioplasty and one iliac leg extension) and seven re-interventions were not stent-graft related.

Mean follow-up was 19±17 months. Eleven patients (22%) died during follow-up: nine were not aortic-related and two were unknown. The Kaplan-Meier estimated survival rates at 1 and 2 years were 81% and 77%, respectively. Five renal stents (5%, 5/92) occluded during follow-up: three were successfully recanalized and two remained occluded. Ten stents (three CT, five SMA, and two RA stents required relining after 13±16 months postoperatively, resulting with estimated primary assisted patency at 2 years of 100%, 100%, 93%, and 95% for the CT, SMA, right RA and left RA, respectively.

Conclusion

Complex endovascular aortic repair with fEVAR / bEVAR for PAA and TAAA is safe with very low early mortality and morbidity. In-stent stenosis/occlusions occurred within the first two years. However, primary assisted patency was high. A surveillance program to detect potential stent-graft related complications is mandatory.

Impact of morphine use on mortality in STEMI patients treated with primary PCI - preliminary data from a new registry

Funding Acknowledgements

Type of funding sources: None.

Background

Opioids decrease the effect of P2Y12 receptor inhibitors in vitro and observational reports suggest that morphine use is associated with larger infarct size. Our research group presented previously, using a prospective single-center registry, that periprocedural morphine use may have no impact on long-term mortality in STEMI patients treated with primary PCI and clopidogrel.

Purpose

Our purpose is to check this interaction using a new registry of patients treated according to the current guidelines, including novel antiplatelet agents.

Methods

From May until November 2020, we collected 196 STEMI patients treated with primary PCI. 88 (44.9%) of them got morphine during the prehospital and periprocedural care. Baseline demographic, anamnestic, procedural, and laboratory data were collected. Survival data were analysed using Kaplan-Meier survival curves and the log-rank test. To adjust for confounding, a 1:1 propensity score-matching analysis was performed using 114 cases.

Results

An adequate balance on baseline covariates was achieved during propensity score-matching. Kaplan-Meier analysis showed no difference in 30-days mortality of the patients treated with or without morphine neither in the original nor in the propensity score-matched population (p = 0.094 and p = 0.309, respectively).

Conclusion

Our preliminary data suggest that morphine may have no impact on mortality in STEMI patients treated with primary PCI and medical therapy according to the current guidelines including novel P2Y12 antagonists.

Abstract Figure. Kaplan-Meier curves

Tissue characteristics of the athlete"s heart: differentiation of physiological and pathological hypertrophy using parametric T1 and T2 mapping

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Fund of Hungary

Background

Intensive physical exercise leads to structural and functional cardiac adaptation termed athlete’s heart. Cardiac magnetic resonance (CMR) has an important role in the differentiation of physiological adaptation and pathological conditions. Beside the precise measurement of the ventricular volumes, mass, and function, it provides tissue specific information. Recently, native T1 mapping technique has been applied as a non-contrast method to detect myocardial fibrosis. Previous studies suggested that native T1 mapping can identify myocardial pathology before other CMR imaging techniques. T2 mapping values are elevated in case of myocardial edema.

Purpose

The aim of our study was to investigate the differences in CMR characteristics especially the native T1 and T2 mapping values of highly trained healthy athletes, healthy controls and patients with hypertrophic cardiomyopathy (HCM).

Methods

A total of 43 healthy athletes (water polo, swimming, football, 22 ± 8 training hours/week), 27 non-athlete healthy control and 25 HCM patients were involved in the study. Our inclusion criteria were: age >18 years,  in the athlete group >7 training hours per week . We evaluated the left ventricular (LV) end-systolic, end-diastolic (EDVi) and stroke volume (SVi) index, mass index (LVMi), ejection fraction (EF) and maximal end-diastolic wall thickness (EDWT). In a basal short axis slice the native T1 and T2 mapping values were evaluated.

Results

Athletes had significantly higher LV volumes compared to the control and HCM group (LVEDVi 114 ± 13 vs. 86 ± 11; 84 ± 15  ml/m2, LVSVi 64 ± 7 vs. 51 ± 7; 54 ± 10 ml/m2, respectively, p < 0.0001). HCM patients had the highest LVMi (72 ± 14 g/m2) and EDWT (18 ± 4 mm) compared to athletes and controls, athletes had higher LVMi (60 ± 11 vs. 42 ± 8 g/m2) and EDWT (10 ± 2 vs. 8 ± 1 mm) compared to the controls (p < 0.001). The native T1 mapping values differed significantly in the three groups, athletes had the lowest, HCM patients had the highest T1 values (athletes: 956 ± 19 ms, controls: 971 ± 20 ms, HCM patients: 993 ± 39 ms; p < 0.0001). There was no difference in the T2 mapping values between athletes and controls (44 ± 2 vs. 43 ± 2 ms), HCM patients had higher T2 values (45 ± 2 ms) compared to the other two groups (p < 0.01).

Conclusion

Intensive and regular training may lead to tissue specific changes of the myocardium. T1 and T2 mapping are potentially useful tools for differentiating between athlete"s heart and patients with hypertrophic cardiomyopathy.

Abstract Figure. T1 mapping in HCM and athlete

Diagnostic and prognostic impact of cardiac magnetic resonance, including scar quantification and strain imaging in patients with malignant ventricular arrhythmias and nonobstructed coronary arteries

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, National Research, Development and Innovation Office

Background

In case of malignant ventricular arrhythmias (VA) and nonobstructed coronary arteries, the differential diagnosis of the  underlying diseases is still challenging, due to the board spectrum of possible causes. Cardiac magnetic resonance (CMR) provides functional, morphological and tissue specific information, including necrotic and scar-tissue. 

Aims

  We aimed to assess the diagnostic and prognostic implications of CMR parameters including global strain values and myocardial scar in patients after ventricular fibrillation (VF) or sustained ventricular tachycardia (SVT) and nonobstructed coronary arteries.

Methods

Between 2011 and 2019, 99 patients (42 ±17 years, 54 male) presenting with VF or SVT and nonobstructed coronary arteries, who underwent CMR examination before secondary prevention implantable cardioverter defibrillator (ICD) implantation were included in our study. Post-processing included feature-tracking strain analysis and left ventricular (LV) scar quantification. Patients were followed for the combined endpoint of all-cause-mortality and appropriate ICD therapy.

Results

CMR examination proved structural myocardial disease in 72%: dilated (n = 21), arrhythmogenic (n = 11), hypertrophic cardiomyopathy (n = 7) and other cardiomyopathies (n = 3). We found LGE patterns showing chronic myocardial infarction (n = 4), suggesting chronic myocarditis (n = 4) and aspecific nonischemic scar formation (n = 14). In 7 cases aspecific structural alterations without scar formation were detected. Overall, myocardial scar was found in 52%, with an average extent of 12 ± 8% of the LV myocardium. The CMR examination changed the clinical diagnosis in 55% of the patients.  During a median follow-up at 2 years, 6 patients died and 42 experienced appropriate ICD therapy. We found an association between cardiac events and the presence of structural abnormality and myocardial scar (logrank: 4,553, p < 0.05 and 8.375, p <0.01).  On Cox proportional-hazards modell LV ejection fraction, LV stroke volume index, the presence of structural abnormality, the presence and extent of  myocardial scar, global LV strain parameters including longitudinal and circumferential strain, and a global left ventricular dssynchrony parameter (mechanical dispersion) were univariate predictors of the combined endpoint of all-cause-mortality and appropriate ICD therapy(p < 0.05). 

Conclusion

CMR performed in patients after malignant VA and nonobstructed coronary arteries not only establishes the diagnosis in a high proportion of patients, but may also provide additional prognostic factors. This may indicate that CMR could play a complementary role in the risk stratification in this patient population.

Abstract Figure.

Economic evaluation of adjuvant trastuzumab emtansine in patients with HER2-positive early breast cancer and residual invasive disease after neoadjuvant taxane and trastuzumab-based treatment in Canada

Background

In the katherine trial, adjuvant trastuzumab emtansine [T-DM1, Kadcyla (Genentech, South San Francisco, CA, U.S.A.)], compared with trastuzumab, significantly reduced the risk of recurrence or death by 50% (unstratified hazard ratio: 0.50; 95% confidence interval: 0.39 to 0.64; p < 0.0001) in patients with her2-positive early breast cancer (ebc) and residual invasive disease after neoadjuvant systemic treatment. A cost-utility evaluation, with probabilistic analyses, was conducted to examine the incremental cost per quality-adjusted life-year (qaly) gained associated with T-DM1 relative to trastuzumab, given the higher per-cycle cost of T-DM1.

Methods

A Markov model comprising a number of health states was used to examine clinical and economic outcomes over a lifetime horizon from the Canadian public payer perspective. Patients entered the model in the invasive disease-free survival (idfs) state, where they received either T-DM1 or trastuzumab. Transition probabilities between the health states were derived from the katherine trial, Canadian life tables, and published literature from other relevant clinical trials (emilia, cleopatra, and M77001). Resource use, costs, and utilities were derived from katherine, other clinical trials, published literature, provincial fee schedules, and clinical expert opinion. Sensitivity analyses were conducted for key assumptions and model parameters.

Results

Compared with trastuzumab, adjuvant T-DM1 was associated with a cost savings of $8,300 per patient and a 2.16 incremental qaly gain; thus T-DM1 dominated trastuzumab. Scenario analyses yielded similar results, with T-DM1 dominating trastuzumab or producing highly favourable incremental cost-utility ratios of less than $10,000 per qaly.

Conclusions

Adjuvant T-DM1 monotherapy is a cost-effective strategy compared with trastuzumab alone in the treatment of patients with her2-positive ebc and residual invasive disease after neoadjuvant systemic treatment.

Structural and functional cardiac changes after transplantation: experiences of the first year of the prospective Heart-TIming CMR substudy

Background

In case of heart transplantation (HTX) the heart is affected by several factors e.g. ischaemia/reperfusion, denervation, immunosuppression. During the adaptation, the heart may show marked temporal changes in terms of myocardial mechanics, function and tissue characteristics. To better understand cardiac temporal characteristics after orthotopic bicaval HTX we started the prospective Heart-TIming (Transplantation Imaging) trial in January 2018.

Purpose

In our CMR substudy we aimed to evaluate the physiological structural and functional left and right ventricular characteristics and their temporal changes after HTX using cardiac magnetic resonance.

Methods

As part of the study HTX patients underwent CMR at one, three, six and twelve months after HTX (n=49; 53±11y, 39 male). Cine images, T2-weighted, native T1 and T2 mapping, late gadolinium enhancement (LGE) and adenosine stress perfusion (at 1 and 12 month) images were acquired. In order to describe physiological characteristics of the transplanted heart we excluded pts with significant coronary artery disease, ischaemic scar, ≥Grade II allograft rejection from this present study (n=9). We evaluated the left (LV) and right ventricular (RV) ejection fractions (EF), volumes, masses (M) and the global LV strain values: longitudinal (GLS), circumferential (GCS) strain and the standard deviation (SD) of the peak longitudinal strain (LS) and the mechanical dispersion. In a basal short axis slice the native T1 and T2 mapping values were evaluated. We compared baseline CMR parameters to age and gender matched healthy controls (n=20; 48±10y, 16 male), and analyzed the temporal changes after HTX.

Results

Comparing the HTX patients' CMR parameters at one month with normal controls, HTX patients had lower end-diastolic volumes (LVEDVi: 74±15 vs 89±13 ml/m2; RVEDVi: 72±16 vs 89±15 ml/m2 p&lt;0.05), stroke volumes (LVSVi: 45±7 vs 55±8 ml/m2, RVSVi: 43±8 vs 54±8 ml/m2, p&lt;0.0001), higher LVMi (63±2 vs 55±3 g/m2, p&lt;0.05), increased SD of peak LS (14±2 vs 10±2, p&lt;0.0001) and more pronounced mechanical dispersion (18±5 vs 12±4, p&lt;0.0001). The native T1 mapping values were significantly higher in HTX pts (1007±40 vs 975±24 ms, p&lt;0,01). Examining temporal changes in HTX pts we found a decrease in LVMi (66±14 vs 59±10 g/m2, p&lt;0.01) already at three months. At 12 months LVMi decreased further, less negative GLS (−25±4 vs −20±4, p&lt;0.01) and GCS (−38±7 vs −34±4, p&lt;0.05), and lower SD of the peak LS (14±2 vs 11±2, p&lt;0.01) were measured.

Conclusions

Understanding the temporal changes of cardiac mechanics, function and tissue characteristics, furthermore the establishment of physiological values may help in the early, noninvasive identification of pathological changes in HTX pts.

Tissue specific information in HTX pts

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. Supported by the ÚNKP-18-3-IV New National Excellence Program of Human Capacities.

Safety and efficacy of different arterial pressure bandages following percutaneous coronary interventions from radial access: preliminary data of the RAD-PRESS trial

Background

The overwhelming majority of diagnostic coronary angiographies and percutaneous coronary interventions (PCIs) are performed via radial access as recommended by the current European revascularization guidelines. Using dedicated pressure bandages for the radial access site in high-volume centres can be a significant part of the budget of catheterization laboratories, therefore we developed a cost-effective pressure bandage utilizing wrapped empty glass vials of intravenous medications. Furthermore, compression time of the radial puncture site following PCI is a predictor of radial artery occlusion, therefore shortening the period of compression to as short as possible is feasible.

Purpose

Our aim was to validate efficacy and safety of our cost-effective pressure bandage by comparing it to two dedicated devices, as well as reducing length of compression to as short as possible.

Methods

We designed the RAD-PRESS trial, major inclusion criteria of which were first puncture of a radial artery with a diameter greater than 1.8mm, PCI performed as per guidelines utilizing a 6 French guiding catheter and age below 80 years. Patients were then randomized to receive one of three pressure bandages: the glass vial, Seal-One or the gold standard TR-band. Release of pressure was performed as fast as possible in 10-minute steps, and guided by pulse oximetry. Hematoma formation was thoroughly checked for all patients and categorized using the Easy scale. Radial artery patency was investigated by ultrasound 24 hours after final removal of the bandage. The data of 40 patients of every group was analysed.

Results

Population characteristics were similar among the groups. Length of compression time (126±10, 142±11 and 144±11 mins for Vial, Seal-One and TR-band, respectively, p&gt;0.05), hematoma formation (Easy Grade 1 in 17.5%, 15.0% and 10.0%, Easy Grade 2 in 5.0%, 7.5% and 7.5% for Vial, Seal-One and TR-band, respectively, all p&gt;0.05) were not significantly different among the groups. Radial artery occlusion occurred in only 2 patients (Vial and TR-Band groups), accounting for 1.7% of the cases.

Conclusions

The cost-effective wrapped vial strategy to compress the radial puncture site was comparable to both Seal-One and the gold standard TR-band regarding safety and efficacy. Furthermore, compression time could be safely shortened to approximately 2.5 hours.

Funding Acknowledgement

Type of funding source: None

The diagnostic value of cardiac magnetic resonance in athletes with suspected structural myocardial diseases

Introduction

Sudden cardiac death (SCD) is the leading cause of death in athletes occurring usually during intensive training. Cardiac magnetic resonance (CMR) is a reliable technique to assess ventricular volumes and function. Furthermore, it provides tissue-specific information and has a crucial role in detecting structural myocardial diseases.

Aim

We aimed to investigate the prevalence of myocardial structural heart diseases and the etiology of sudden cardiac death in highly trained athletes and their outcome during follow-up.

Method

We examined athletes (training ≥6 hours/week) who underwent CMR due to suspected structural myocardial disease at Semmelweis University Heart and Vascular Center between 2009 and 2019. Cine movie images and late gadolinium enhanced (LGE) images were performed. Athletes with structural myocardial alterations were followed for the endpoint of all-cause-mortality.

Results

CMR was performed on a total of 338 athletes (280 male, 24±11 age). The indications for CMR were as follows: aborted sudden cardiac death/sustained ventricular tachycardia (SVT) (4%), ECG alterations (36%), echocardiographic alterations (32%), positive family history of SCD or cardiomyopathies (CMP) (3%), and patients' complaints, e.g. palpitation, syncope, dyspnoea, chest complaints (25%). CMR confirmed structural myocardial disease in 82 athletes with the following distribution: 20 hypertrophic (HCM), 10 arrhythmogenic (AC), 8 dilated (DCM), and 7 non-compact (NCCMP) CMP. The CMR images of three patients indicated Fabry disease. We found post-myocardial infarction scars in 7 cases, and atypical non-ischemic scars in 28 athletes. Besides pathological conditions, we identified minor alterations in 58 patients (51 male, 25±12 age) such as: increased trabeculation, nonspecific LGE in left ventricular insertion point and myocardial crypts. Among athletes examined after aborted sudden cardiac death or SVT we found structural heart disease in 11 males and one female: AC (n=7), HCM (n=1), NCCMP (n=1) and atypical non-ischemic scars (n=3, in two patients the localisation was lateral subepicardial) were diagnosed. During the median follow up of five years one patient died in whom CMR showed lateral scar formation and only mildly reduced left ventricular ejection fraction (50%).

Conclusions

The most common structural alteration was non-ischaemic scar, the most common CMP was HCM, and the leading cause of sudden cardiac death or SVT in our competitive athletes was AC and lateral subepicardial scar formation.

LGE pattern in various cardiomyopathies

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Cardiac magnetic resonance features of acute myocarditis presenting as acute coronary syndrome

Background

Clinical presentation of myocarditis varies, one specific form of myocarditis appears with the clinical signs of acute coronary syndrome (ACS). Cardiac magnetic resonance (CMR) is an important method for assessing ventricular function and morphology, additionally provides accurate tissue specific and functional information of the heart.

Aims

Our aim was to investigate the characteristics, and prognosis of myocarditis presenting with ACS symptoms.

Methods

113 patients with the clinical signs of ACS but nonobstructed coronary arteries in whom the CMR revealed acute myocarditis were included in our study. CMR was performed in acute phase and at 3–6-month follow-up. Left ventricular (LV) volumes, mass and strain parameters expressing myocardial deformity were determined. Additional images were taken to represent tissue specific information. Relationships between laboratory and CMR parameters were investigated. Parameters predicting changes in LV ejection fraction (LVEF) were analyzed by logistic regression.

Results

A total of 113 patients with myocarditis (98 males, 31±11 years) underwent acute and follow-up CMR. Sixty two patients reported fever or infection before the beginning of their complaints, most commonly gastroenteritis (33%) and pharyngitis (32%). The creatinine kinase MB value measured in the acute phase showed positive correlation with the extent of necrosis, and the global longitudinal- and circumferential strain. The extent of the LV necrosis showed negative correlation with LVEF and positive correlation with global circumferential strain (GCS) (p&lt;0.05). On the control CMR examination LVEF and all global strain values improved, fibrosis persisted in 82% of cases but shrank (15±11 vs 5±4 g) and LV mass decreased (p&lt;0.01) compared to the acute phase. Compared to the acute phase, 21% of the patients had lower LVEF on the follow-up CMR. Lower initial LVEF, worse acute GCS, and greater LV necrosis were independent predictors of LVEF reduction in the logistic regression model. During a median follow-up of 6-years of patients treated at our clinic (n=39) no patient suffered cardiac death, heart failure, or documented ventricular arrhythmia but 21% of them had recurrent myocarditis.

Conclusion

Myocarditis mimicking ACS affects predominantly young men and shows functional improvement and good prognosis on follow-up, but it may reoccur in some cases. The reduction of LV function on control CMR may be predicted by worse initial LVEF, GCS, and a larger LV scar.

Strain, LGE in acute phase and follow-up

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

Diagnostic impact of early cardiac magnetic resonance imaging in patients with the working diagnosis of MINOCA. Does the final diagnosis affect patients outcome?

Introduction

The diagnostic value of cardiac magnetic resonance (CMR) imaging has been suggested in determination of the cause in patients with the working diagnosis of Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA). According to the current STEMI Guideline CMR is considered to have the best diagnostic performance, when CMR timing is within its optimal ≤2 weeks.

Aims

The aim of our study was to assess the diagnostic value of early (1–7 days) CMR examination in patients with signs of troponin positive acute coronary syndrome (ACS) but with nonobstructive coronary arteries. We also aimed to investigate how early CMR changes the provisional diagnosis. We investigated the mortality in each patient group.

Methods

273 consecutive patients (43±16 years, 64% male) with working diagnosis of MINOCA underwent CMR examination following coronary angiography in a mean length of time of 2.5 days between 2009–2020. Cine movie, T2-weighted and late gadolinium enhanced images (LGE) were performed. Left ventricular end-diastolic and end-systolic volumes (LVESVi), ejection fraction (LVEF), mass (LVM) and myocardial necrosis were evaluated. We analysed the risk factors and laboratory values of our patients. Patients were followed for all-cause mortality.

Results

CMR examination established a definitive diagnosis in 86% of the cases: acute myocardial infarction (MI) in 65 patients (47% male), acute myocarditis in 142 patients (87% male), Tako-Tsubo syndrome (TTS) in 27 woman, myocardial contusion in one case. The diagnosis of four patients remained inconclusive after CMR and in 34 pts (50% male) there was no CMR abnormality. CMR changed the provisional diagnosis in 53% of the patients. LVEF was lower, LVESVi was elevated in TTS patients compared to MI and myocarditis (LVEF: 43±9.5 vs 56±7.7 vs 54±6.7%; LVESVi: 52±12.8 vs 38±13.2 vs 42±9.1 ml/m2 p&lt;0.001). Myocarditis patients were younger (myocarditis: 34±10 vs MI 47±14.8 vs TTS 66±10.7 years; p&lt;0.001) and lower percentage had hypercholesterolaemia (myocarditis:18.8 vs MI: 40 vs TTS:54.5%, p&lt;0.01) or hypertension (myocarditis: 20 vs MI: 49 vs TTS: 60%, p&lt;0.001). Laboratory values showed significant elevation of hsTroponin and CKMB of MI and myocarditis patients compared to other groups (p&lt;0.05), but there was no difference between these two groups. During the median follow-up of 3-years 13 patients died. Mortality rate in deaths per patient-year was as follows: MI 2.6 vs Myocarditis 0.4 vs TTS 7.4%. We found a strong association between CMR diagnosis and mortality (logrank 22.3 p&lt;0.001).

Conclusion

Our study demonstrates the diagnostic value of early CMR in patients with the working diagnosis of MINOCA. It established a definite diagnosis in 86% of our patients and changed the provisional diagnosis in 53%. According to our results there is an association between CMR diagnosis and mortality.

Myocarditis, MI, TakoTsubo syndrome

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. This project was supported by a grant from the National Research, Development and Innovation Office (NKFIH) of Hungary (K 120277).

TRIACCESS study: randomized comparison between radial, femoral and transpedal access for for percutanous supertfitial femoral artery angioplasty

Background

Traditional access for the treatment of femoral artery lesions is the femoral artery (FA) approach, but radial (RA) and pedal access (PA) is an alternative access site. The aim of the study was to compare the success rate, complication rate of different access sites for the treatment of superfitial artery stenosis in a randomized study

Methods

180 consecutive patients were randomized in a prospective study to treat symptomatic superficial femoral stenosis, via RA, FA and PA. Primary endpoint: technical success, rate of major and minor access site complications. Secondary endpoints: major adverse events (MAE), procedural factors, cross-over rate, and duration of hospitalization.

Results

Technical success was achieved in 96.6%, 100% and 100% patients in RA, FA and PA group (p=ns). Secondary access site was used in 30%, 3.3% and 30% in the RA, FA and PA access group (p&lt;0.01). Stent implantation was done in the femoral artery in 26.6%, 58.3% and 71.6% cases in RA, FA and PA group (p&lt;0.01). CTO recanalization was performed in 34/36 (100%), 30/30 (100%) and 45/45 (100%) cases successfully in RA, FA and PA group (p=ns). Contrast consumption, fluoroscopy and procedure time was not statistically different, but the X Ray dose was significantly lower in PA than in the RA and FA access group (63.1 vs 162 vs 153 Dyn). The cumulative rate of access site complications in the RA, FA and PA group was 3.3% (0% major and 3.3% minor), 15% (3.3% major and 11.6% minor) and 3.3% (0% major and 3.3% minor) (p&lt;0.01), respectively. The cumulative incidence of MAE's at 6 months in the RA, FA and PA group was 8.3% vs 13.3% and 18.3%. (p&lt;0.05)

Conclusion

Femoral artery intervention can be safely and effectively performed using radial, femoral and pedal access, but radial and pedal access is associated with less access site complication rate. Pedal access is associated with less X Ray dose than radial and femoral access.

Funding Acknowledgement

Type of funding source: None

A Latin American and Spanish pediatric gastroenterology group's understanding of cow's milk protein allergy diagnosis and treatment: Results of a survey by the Food Allergy Working Group of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición Pediátrica

INTRODUCTION

There are discrepancies in the diagnosis and management of cow's milk protein allergy (CMPA) in Spain and Latin America. The aim of the present study was to find out how Spanish and Latin American pediatric gastroenterologists diagnose and treat CMPA.

MATERIAL AND METHODS

Pediatric gastroenterologists, members of the Sociedad Latinoamericana de Gastroenterología, Hepatología y Nutrición, were invited to fill out a structured survey, the results of which were then compared with the 2012 and 2014 diagnosis and treatment guidelines, respectively.

RESULTS

The survey results showed that 17% of the participants follow the diagnostic recommendations based on the published consensus and guidelines. To diagnose non-IgE-mediated CMPA, 15% of the participants utilize IgE-specific skin prick tests, 22% use IgE-specific blood tests, and 45% employ oral food challenges. To diagnose IgE-mediated CMPA the percentages for the same diagnostic methods were 57, 83 and 22%, respectively. Once diagnosis is confirmed, 98% of the participants provide dietary recommendations. In children that are not breastfed, 89% of the participants prescribe an initial extensively hydrolyzed formula, 9% an amino acid formula, 1% a soy formula, and 1% a hydrolyzed rice formula. In patients with IgE-mediated CMPA, 34% of the participants carry out an oral challenge once treatment is completed, 39% according to symptom severity, and 27% in relation to IgE-specific testing.

CONCLUSION

CMPA management is diverse and there is poor adherence to the clinical practice guidelines.

P577Effect of adding an implantable cardioverter defibrillator on long-term survival in non-ischemic CRT patients stratified by Goldenberg risk score

Background

There are limited and incomprehensive long-term data on the effects of adding an implantable cardioverter defibrillator (ICD) to cardiac resynchronization therapy (CRT) in patients with non-ischemic heart failure. 

Purpose

We compared the long-term all-cause mortality and relative risk reduction in mortality of non-ischemic patients after CRT-P vs. CRT-D implantation stratified by their Goldenberg risk score.

Methods

In our retrospective registry, data of 1196 non-ischemic patients who underwent CRT implantation between 2000 to 2018 were collected. Goldenberg sudden cardiac risk score was calculated by the presence of atrial fibrillation, NYHA class &gt; 2, age &gt; 70 years, blood urea nitrogen &gt; 26mg/dl and QRS width. 

Results

In our registry from 1196 CRT implanted patients with non-ischemic heart failure, 716 patients had all the required data to calculate the Goldenberg score. From this cohort 379 (53%) had CRT-P and 337 (47%) CRT-D implantation. The mean value of the Goldenberg score was 2.7 in the total cohort, while a significantly higher score was found in the CRT-P group (CRT-P 2.9 ± 1.1 vs. CRT-D 2.5 ± 1.1 p &lt; 0.001). During the median follow-up time of 4.9 years, 345 (48%) patients reached the primary endpoint, 220 patients (64%) with CRT-P and 125 patients (36%) with CRT-D. After comparing patients by low (≤3) and high (&gt;3) Goldenberg score, we found that CRT-D patients with lower risk score showed mortality benefit compared to CRT-P (HR 0.69; 95%, CI 0.53-0.89; p = 0.001). In the contrary there was no apparent mortality benefit in CRT-D patients compared to CRT-P when high Goldenberg score subgroup was analyzed (HR 0.99; 95%, CI 0.67-1.45; p = 0.95).

Conclusions

In non-ischemic heart failure patients, Goldenberg sudden cardiac risk score can be also applied. In CRT-D patients those with less co-morbidities and lower (≤3) Goldenberg risk score showed mortality benefit compared to CRT-P patients, while among patients with higher score (&gt;3) adding an ICD had no additional effect on all-cause mortality.

Cows selected for divergent mastitis susceptibility display a differential liver transcriptome profile after experimental Staphylococcus aureus mammary gland inoculation

Infection and inflammation of the mammary gland, and especially prevention of mastitis, are still major challenges for the dairy industry. Different approaches have been tried to reduce the incidence of mastitis. Genetic selection of cows with lower susceptibility to mastitis promises sustainable success in this regard. Bos taurus autosome (BTA) 18, particularly the region between 43 and 59 Mb, harbors quantitative trait loci (QTL) for somatic cell score, a surrogate trait for mastitis susceptibility. Scrutinizing the molecular bases hereof, we challenged udders from half-sib heifers having inherited either favorable paternal haplotypes for somatic cell score (Q) or unfavorable haplotypes (q) with the Staphylococcus aureus pathogen. RNA sequencing was used for an in-depth analysis of challenge-related alterations in the hepatic transcriptome. Liver exerts highly relevant immune functions aside from being the key metabolic organ. Hence, a holistic approach focusing on the liver enabled us to identify challenge-related and genotype-dependent differentially expressed genes and underlying regulatory networks. In response to the S. aureus challenge, we found that heifers with Q haplotypes displayed more activated immune genes and pathways after S. aureus challenge compared with their q half-sibs. Furthermore, we found a significant enrichment of differentially expressed loci in the genomic target region on BTA18, suggesting the existence of a regionally acting regulatory element with effects on a variety of genes in this region.

Study of Two-Photon Exchange via the Beam Transverse Single Spin Asymmetry in Electron-Proton Elastic Scattering at Forward Angles over a Wide Energy Range

We report on a new measurement of the beam transverse single spin asymmetry in electron-proton elastic scattering, A_{⊥}^{ep}, at five beam energies from 315.1 to 1508.4 MeV and at a scattering angle of 30°<θ<40°. The covered Q^{2} values are 0.032, 0.057, 0.082, 0.218, 0.613 (GeV/c)^{2}. The measurement clearly indicates significant inelastic contributions to the two-photon-exchange (TPE) amplitude in the low-Q^{2} kinematic region. No theoretical calculation is able to reproduce our result. Comparison with a calculation based on unitarity, which only takes into account elastic and πN inelastic intermediate states, suggests that there are other inelastic intermediate states such as ππN, KΛ, and ηN. Covering a wide energy range, our new high-precision data provide a benchmark to study those intermediate states.

A genome-wide significant association on chromosome 15 for congenital entropion in Swiss White Alpine sheep

Entropion is a known congenital disorder in sheep presumed to be heritable but no causative genetic variant has been reported. Affected lambs show a variable inward rolling of the lower eyelids leading to blindness in severe cases. In Switzerland, the Swiss White Alpine (SWA) breed showed a significantly higher prevalence for entropion than other breeds. A GWAS using 150 SWA sheep (90 affected lambs and 60 controls), based on 600k SNP data, revealed a genome-wide significant signal on chromosome 15. The 0.2 Mb associated region contains functional candidate genes, SMTNL1 and CTNND1. Pathogenic variants in human CTNND1 cause blepharocheilodontic syndrome 2, a rare disorder including eyelid anomalies, and SMTNL1 regulates contraction and relaxation of skeletal and smooth muscle. WGS of a single entropion-affected lamb revealed two private missense variants in SMTNL1 and CTNND1. Subsequent genotyping of both variants in 231 phenotyped SWA sheep was performed. The SMTNL1 variant p.(Asp452Asn) affects an evolutionary conserved residue within an important domain and represents a rare allele, which occurred also in controls. The p.(Glu943Lys) variant in CTNND1 represents a common variant unlikely to cause entropion as the mutant allele occurred more frequently in non-affected sheep. Therefore, we propose that these protein-changing variants are unlikely to explain the phenotype. Additionally, WGS of three further disconcordant pairs of full siblings was carried out but revealed no obvious causative variant. Finally, we conclude that entropion represents a more complex disease caused by different non-coding regulatory variants.

P345 Temporal changes of left atrial function after orthotopic heart transplantation in a single-center prospective study

Funding Acknowledgements

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

The geometry and function of the left atrium (LA) change after orthotopic heart transplantation (HTX) with bicaval technique, as the LA has a recipient part around the pulmonary veins and a donor part, and these often contract separately. Because of this altered LA function, the recognition of left ventricular diastolic dysfunction can be challenging. The standard echocardiographic diastolic parameters are often in abnormal range in HTX patients despite of normal left ventricular diastolic function.

The aim of our prospective study was to investigate the LA volumes and function and their temporal changes after HTX using cardiac magnetic resonance (CMR).

To better understand the cardiac characteristics of HTX patients, we started a prospective trial in January 2018. CMR was performed at one, three and six months after HTX. Left atrial contour detection was performed in 2- and 4-chamber views. Patients who had ≥Grade II allograft rejection before the CMR examination, were excluded (n = 2). In the remaining HTX patients (n = 21) and in a control group (n = 21) LA ejection fraction (EF), BSA-corrected maximum and minimum LA volume (Vi), stroke volume (SVi) were evaluated using bi-plane mode. LA global longitudinal strain (GLS) was defined with CMR based deformation imaging, called feature tracking.

HTX patients had significantly higher LA volumes (maxLAVi 71 ± 22 vs. 47 ± 6 ml/m2, minLAVi 53 ± 22 vs. 18 ± 5 ml/m2) lower LASVi (19 ± 7 vs. 29 ± 4 ml/m2), LAEF (27 ± 10 vs. 62 ± 8%) and LA-GLS (8 ± 3 vs. 39 ± 10%) compared to the control group (p &lt; 0.0001).

Analysing the temporal changes in HTX patients, we found an increase in the LAEF (26 ± 8 vs. 30 ± 5%) and LA-GLS (8 ± 3 vs. 11 ± 3%) at three months (p &lt; 0.05), there was no significant difference between the LA parameters at three and six months.

Better understanding of the changes of left atrial function after HTX could help us to recognise pathological conditions.

Abstract P345 Figure. Strain analysis of the left atrium

1642 Mitral annulus disjunction, a rare form of focal arrhythmogenic cardiomyopathy

Funding Acknowledgements

Project no. NVKP_16-1-2016-0017 has been implemented with the support provided from the National Research, Development and Innovation Fund of Hungary

The rate of sudden cardiac death in mitral valve prolapse (MVP) patients is roughly twice that observed in the general population. Arrhythmogenic bileaflet MVP syndrome has been recently described and mitral annulus disjunction (MAD) has been found associated with papillary muscle fibrosis and ventricular arrhythmias even without severe mitral regurgitation. An underlying primary structural myocardial disease might be expected and the non-invasive imaging techniques are playing an increasingly important role in the detection of myocardial fibrosis as a focal arrhythmogenic substrate. Standard 2D-, 3D- and speckle tracking echocardiography and cardiac MRI can help to differentiate between the benign and malignant forms of MVP.

A 52-year-old man with a history of hypertension was referred for evaluation of frequent palpitations and presyncope. Ambulatory Holter monitoring showed paroxysmal atrial fibrillation and non-sustained ventricular tachycardias. Dilated left ventricle (LVEDD: 65mm, LVESD: 45 mm) and left atrium (LAVi: 52mL/m2), moderately reduced left ventricular (LV) systolic function (LVEF: 42%), and reduced LV global longitudinal strain (GLS: -13.5%) with severely decreased segmental longitudinal strain in the basal inferolateral segment were measured by transthoracic echocardiography. The diastolic function was preserved, however Pickelhaube sign was noticed in the lateral mitral annulus TDI curves. MAD (17 mm) and curling motion of the inferolateral basal segment of the left ventricle was observed. Transesophageal echocardiography showed bileaflet mitral valve prolapse with the involvement of all the six scallops (mitral valve prolapse volume: 10.2 mL). Severe mitral regurgitation (3D vena contracta area: 1cm2) and extremely dilated and dyskinetic mitral annulus (diameters: 55x72x12 mm, area: 34 cm2) was measured by 3D echocardiography. MRI showed transmural late gadolinium enhancement in the underlying myocardium of both papillary muscles and midmyocardial enhancement in the basal inferior, inferolateral and anteroseptal LV segments. During electrophysiology study ventricular fibrillation was easily induced and ICD was placed for primary prevention of sudden cardiac death. The patient was referred to the heart surgeon for mitral valve replacement.

This case highlights the importance of early recognition of MAD and arrhythmogenic MVP syndrome using novel non-invasive imaging techniques. The presence of MAD, the curling motion of the inferolateral basal LV segment, the Pickelhaube sign, the decreased LVEF and GLS, the characteristic segmental longitudinal strain pattern and the presence of late enhancement in the papillary muscles and the surrounding myocardium could be warning signs of the malignant form of MVP.

Abstract 1642 Figure. CMR images of arrhythmogenic MAD