4291Six-month outcomes from the multicenter, prospective study with the novel PASCAL transcatheter valve repair system for patients with mitral regurgitation in the CLASP study

Background

Severe mitral regurgitation may lead to an impaired prognosis if left untreated. Transcatheter treatment options have emerged as an alternative to surgery and an adjunct to medical therapy. We report the six-month results of the PASCAL transcatheter valve repair system in treating patients with mitral regurgitation enrolled in the multicenter, prospective, single arm CLASP study.

Methods

The PASCAL Transcatheter Valve Repair System is a leaflet repair therapy that uses clasps and paddles to place a woven Nitinol spacer between the native valve leaflets to fill the regurgitant orifice via a transseptal approach. Eligible patients had clinically significant MR despite optimal medical therapy and were deemed candidates for transcatheter mitral repair by the local Heart Team. Safety, performance, and clinical outcomes were prospectively assessed at baseline, discharge, 30 days, and 6 months post-procedure. All major adverse events (MAE) were adjudicated by an independent clinical events committee and echocardiographic images were assessed by a core lab. The MAE rate was the primary safety endpoint, defined as the composite of cardiovascular mortality, stroke, MI, new need for renal replacement therapy, severe bleeding, and re-intervention for study device-related complications.

Results

Between June 2017 and September 2018, 62 patients were enrolled at 14 sites worldwide for transcatheter mitral valve reconstruction using the PASCAL system. The mean age was 76.5 years (62.9% male). All patients had MR grade ≥3+, with 59% functional, 34% degenerative, and 7% mixed etiology, and 51.6% of patients were in NYHA Class III/IV. Successful implantation of the PASCAL device was achieved in 95% of patients. At discharge, 95% of patients had MR grade ≤2+ with 81% grade ≤1+. There was one cardiovascular mortality and the MAE rate was 4.8%. At 30-day follow-up, paired analyses shows that 98% of patients had MR grade ≤2+ with 81% grade ≤1+ and 88% were in NYHA Class I/II (p<0.0001). The 6MWD improved by 38.9 m (p=0.0015) and was accompanied by average improvements in KCCQ and EQ5D scores by 14.1 points (p<0.0001) and 8.3 points (p=0.0028), respectively. The six-month data will be available for presentation.

Conclusions

In this early device experience, the PASCAL transcatheter valve repair system showed an acceptable safety profile and performed as intended in treating patients with mitral regurgitation. The PASCAL device resulted in significant MR grade reduction, which was associated with clinically and statistically significant improvements in functional status, exercise capacity, and quality of life. Continued follow-up is warranted to validate these initial promising results.

Acknowledgement/Funding

Edwards Lifesciences

P6134Understanding non-attendance to an inner city tertiary centre heart failure clinic: a pilot project

Background

Tackling health inequalities is a priority in heart failure (HF). We do not fully understand why some patients do not attend their hospital HF clinic appointments. Currently when a patient DNAs (does not attend) they are offered a repeat appointment often months later or are discharged from the service with a request to the primary care physician to re-refer. Non-attendance represents a missed opportunity to improve patients' health.

Purpose

The purpose of this pilot was to look at the demographics and patient factors that contribute to non-attendance. The aim is to understand and personalise our DNA policy to reduce health inequality, improve outcomes, and reduce inefficiencies in our service.

Methods

The last consecutive 45 patients who DNAd HF clinic were identified and for each, a patient who did attend the same clinic date (Attender), was chosen at random (random.org). The demographics were obtained (age, ethnicity, contact details) and medical notes reviewed (LVEF%, co-morbidities). The patient address was scored for its Index of Multiple Deprivation (IMD) – a UK government dataset measuring relative deprivation by ranking 32,844 neighbourhoods nationally using 37 indicators across 7 domains of deprivation where neighbourhood 1 is the most deprived nationally. Patients were phoned up to three times to establish the patient's mode, duration and cost of their last journey to clinic and, for those patients who DNAd, to ascertain the reason for non-attendance.

Results

Demographic and medical history was obtained for all patients. It was not possible to contact 2/45 of the Attenders, and 13/45 of the DNA patients. There was no significant difference in age, gender, number of comorbidities, LVEF%, travel time, or travel cost between DNAs and attenders. The mean one-way journey time was 53.4 mins (range 15–210 mins) and the mean return journey cost was GBP ≤10.95 (range ≤0–≤80). Common reasons for non-attendance were not receiving appointment details, forgetting appointments, being unwell on the day and difficulties with travel. The IMD score for the patients who DNAd was significantly lower confirming these patients lived in more deprived areas (9436±5863 vs. 15414±7801, p<0.001) with 71% of DNA patient's addresses in the bottom third most deprived neighbourhoods nationally.

Figure 1

Conclusions

There was a significant difference in deprivation score between patients who attended and DNAd their clinics. In addition, we found that all patients were travelling up to an hour each way to attend clinic, and that the cost of travel may be a barrier to attendance, even in a healthcare system that is free at the point of delivery. Despite calling three times, we were unable to speak to 29% of patients who DNAd and 4% of the patients who attended their appointments. Work is ongoing to reduce our DNA rates and personalise our response in this deprived population, with the aim of improving engagement and health inequality.

A mixed methods process evaluation of a print-based intervention supported by internet tools to improve physical activity in UK cancer survivors

OBJECTIVE

A waiting list randomised control trial has shown the Move More Pack, a print-based intervention supported by Internet tools, to improve physical activity levels in cancer survivors; however, one-third of them do not improve from the intervention. The objective of this process evaluation is to understand intervention use, the mechanisms of impact, the perceived benefits and the contextual factors influencing these, identifying for whom it is a useful resource.

METHODS

The process evaluation used mixed methods, based on guidance from the UK Medical Research Council, including 181 questionnaire responses on intervention use and physical activity improvement over 12 weeks, 56 open-text responses and 17 semistructured interviews.

RESULTS

The Move More Pack was suggested to be most useful when delivered towards the start of the cancer journey to those with a positive attitude to fight cancer but with a low level of physical activity, capitalising on a teachable moment. It was suggested that healthcare professionals could support the effective distribution of the Move More Pack. The intervention's printed components were more popular and well used than the Internet tools. Use of the printed intervention components was positively correlated with physical activity improvement but use of the Internet tools was not. Women were more likely to use the intervention's printed components than men. Cancer survivors using the intervention reflected that they had increased confidence and motivation for physical activity and other lifestyle behaviours.

CONCLUSION

The Move More Pack should be offered by healthcare professionals, during cancer treatment, when health is salient, to those with a positive attitude to fight cancer but with low levels of physical activity. Use of the intervention's printed components is more likely to improve physical activity than the Internet tools, and the components are more likely to be used by women. The use of Internet tools to support physical activity improvement in cancer survivors requires further investigation.

A randomised control trial and cost-consequence analysis to examine the effects of a print-based intervention supported by internet tools on the physical activity of UK cancer survivors

OBJECTIVE

The objective of this study was to evaluate the effectiveness of a print-based intervention supported by Internet tools at improving physical activity in cancer survivors compared with a standard letter recommendation. Prediagnosis physical activity and self-efficacy were hypothesised to predict physical activity improvement.

STUDY DESIGN

Waiting list randomised control trial and cost-consequence analysis.

METHODS

Adult cancer survivors who could become physically active without prior medical approval were randomised to receive either a print-based intervention supported by Internet tools (intervention, n = 104) or a standard letter recommendation (control, n = 103). Physical activity was assessed at 12 weeks with maintenance assessed at 24 weeks in the intervention arm. The number needed to treat was calculated, and a cost-consequence analysis completed.

RESULTS

Participants in receipt of a print-based intervention supported by Internet tools improved their physical activity by 36.9% over 12 weeks compared with 9.1% in the control arm. Physical activity was maintained at 24 weeks in the intervention arm. A total of 6.29 cancer survivors needed to receive the intervention for one cancer survivor to improve their physical activity over a standard letter recommendation. Intervention delivery cost £8.19 per person. Prediagnosis physical activity and self-efficacy did not predict physical activity improvement.

CONCLUSION

A print-based intervention supported by Internet tools offers a promising low-cost means to intervene to improve physical activity in cancer survivors. The study was registered with the International Standard Randomised Controlled Trials Number registry (registration number: 66418871), and ethical approval was received from the University of Surrey (reference: UEC/2017/023/FHMS).

Comparison of ammonia emissions related to nitrogen use efficiency of livestock production in Europe

The increasing global demand for food and the environmental effects of reactive nitrogen losses in the food production chain, increase the need for efficient use of nitrogen (N). Of N harvested in agricultural plant products, 80% is used to feed livestock. Because the largest atmospheric loss of reactive nitrogen from livestock production systems is ammonia (NH₃), the focus of this paper is on N lost as NH₃ during the production of animal protein. The focus of this paper is to understand the key factors explaining differences in Nitrogen Use Efficiency (NUE) of animal production among various European countries. Therefore we developed a conceptual framework to describe the NUE defined as the amount of animal-protein N per N in feed and NH₃-N losses in the production of milk, beef, pork, chicken meat and eggs in The Netherlands, Switzerland, United Kingdom, Germany, Austria and Denmark. The framework describes how manure management and animal-related parameters (feed, metabolism) relate to NH₃ emissions and NUE. The results showed that the animal product with the lowest NUE had the largest NH₃ emissions and vice versa, which agrees with the reciprocal relationship between NUE and NH₃ within the conceptual framework. Across animal products for the countries considered, about 20% of the N in feed is lost as NH₃. The significant smallest proportion (12%) of NH₃-N per unit of Nfeed is from chicken production. The proportions for other products are 17%, 19%, 20% and 22% for milk, pork, eggs and beef respectively. These differences were not significantly different due to the differences among countries. For all countries, NUE was lowest for beef and highest for chicken. The production of 1 kg N in beef required about 5 kg N in feed, of which 1 kg N was lost as NH₃-N. For the production of 1 kg N in chicken meat, 2 kg N in feed was required and 0.2 kg was lost as NH₃. The production of 1 kg N in milk required 4 kg N in feed with 0.6 kg NH₃-N loss, the same as pork and eggs, but those needed 3 and 3.5 kg N in feed per kg N in product respectively. Except for beef, the differences among these European countries were mainly caused by differences in manure management practices and their emission factors, rather than by animal-related factors including feed and digestibility influencing the excreted amount of ammoniacal N (TAN). For beef, both aspects caused important differences. Based on the results, we encourage the expression of N losses as per N in feed or per N in product, in addition to per animal place, when comparing production efficiency and NUE. We consider that disaggregating emission factors into a diet/animal effect and a manure management effect would improve the basis for comparing national NH₃ emission inventories.

Cerebral Blood Flow and Marrow Diffusion Alterations in Children with Sickle Cell Anemia after Bone Marrow Transplantation and Transfusion

BACKGROUND AND PURPOSE

Hematopoietic marrow hyperplasia and hyperperfusion are compensatory mechanisms in sickle cell anemia. We have observed marrow diffusion and arterial spin-labeling perfusion changes in sickle cell anemia following bone marrow transplantation. We aimed to compare arterial spin-labeling perfusion and marrow diffusion/ADC values in patients with sickle cell anemia before and after bone marrow transplantation or transfusion.

MATERIALS AND METHODS

We reviewed brain MRIs from patients with sickle cell anemia obtained during 6 consecutive years at a children's hospital. Quantitative marrow diffusion values were procured from the occipital and sphenoid bones. Pseudocontinuous arterial spin-labeling perfusion values (milliliters/100 g of tissue/min) of MCA, anterior cerebral artery, and posterior cerebral artery territories were determined. Territorial CBF, whole-brain average CBF, and marrow ADC values were compared for changes before and after either bone marrow transplantation or transfusion. Bone marrow transplantation and transfusion groups were compared. Two-tailed paired and unpaired Student t tests were used; P < .05 was considered significant.

RESULTS

Fifty-three examinations from 17 patients with bone marrow transplantation and 29 examinations from 9 patients with transfusion were included. ADC values significantly increased in the sphenoid and occipital marrow following bone marrow transplantation in contrast to patients with transfusion (P > .83). Whole-brain mean CBF significantly decreased following bone marrow transplantation (77.39 ± 13.78 to 60.39 ± 13.62 ml/100 g tissue/min; P < .001), without significant change thereafter. CBF did not significantly change following the first (81.11 ± 12.23 to 80.25 ± 8.27 ml/100 g tissue/min; P = .47) or subsequent transfusions. There was no significant difference in mean CBF between groups before intervention (P = .22).

CONCLUSIONS

Improved CBF and marrow diffusion eventuate following bone marrow transplantation in children with sickle cell anemia in contrast to transfusion therapy.

A novel device for preoperative skin preparation to reduce the risk of injury and surgical site infection during lower limb surgery

Surgical site infection (SSI) continues to be a feared complication of surgery but especially orthopaedic surgery where a superficial SSI has been estimated to add nine days to the hospital stay and an average of £2500 to the cost. Despite the efficacy of all skin preparation agents being maximal at around 10 minutes no current system, apart from the double prep method attributed to Sir John Charnley, allows adequate control of bacteria. Current techniques of skin preparation require lifting of the limb with an associated risk of injury to theatre operatives. In order to provide for longer duration of contact, potentially better antisepsis and to remove the dangers inherent in lifting the limb we developed a novel system for limb antisepsis prior to surgery. To demonstrate efficacy we performed a single blind randomised controlled trial powered to demonstrate non-inferiority. We demonstrated a significant benefit of the device in terms of bactericidal effect. Whilst only recently entering full production, we would recommend the system as a significant improvement over current techniques of limb antisepsis.

The impact of hoist sling fabrics on interface pressure whilst sitting in healthy volunteers and wheelchair users: A comparative study

AIM OF THE STUDY

To evaluate the effect of three sling fabrics on gluteal interface pressure whilst sitting in a population of wheelchair users and to compare these to data previously collected in a pilot study with a healthy population.

MATERIALS AND METHODS

A repeated measures experimental design was used with 32 adult wheelchair users (15 women, 17 men). Healthy population pilot study consisted of 61 participants (51 women, 10 men) recruited from staff and students at The University of Salford.

METHODS

Gluteal pressures at six pressure zones were recorded using the X-sensor PX100 pressure sensor at 30 s intervals for 10 min. Data were collected in 4 conditions with participants seated in a standardised chair, followed by the chair with slings made of three different fabrics.

RESULTS

The spacer fabric reduced the mean gluteal pressure more effectively than slipfit and polyester (p = 0.014 and p = 0.01 respectively, 95%CI) and reduced peak pressure at the left ischial tuberosity and coccyx when compared to the slipfit (p = 0.003 and p = 0.005) with the wheelchair users. When comparing data with the pilot study, the mean gluteal pressure and peak pressures at the ischial tuberosities and coccyx were significantly higher in the wheelchair user group (p < 0.005).

CONCLUSION

The fabric identified as the most effective in reducing mean and peak pressures in both groups was the spacer fabric, suggesting that a spacer fabric sling is more likely to reduce the risk of pressure ulcer development. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.