Advanced cancer is also a heart failure syndrome: a hypothesis

We present the hypothesis that advanced stage cancer is also a heart failure syndrome. It can develop independently of or in addition to cardiotoxic effects of anti-cancer therapies. This includes an increased risk of ventricular arrhythmias. We suggest the pathophysiologic link for these developments includes generalized muscle wasting (i.e. sarcopenia) due to tissue homeostasis changes leading to cardiac wasting associated cardiomyopathy. Cardiac wasting with thinning of the ventricular wall increases ventricular wall stress, even in the absence of ventricular dilatation. In addition, arrhythmias may be facilitated by cellular wasting processes affecting structure and function of electrical cells and conduction pathways. We submit that in some patients with advanced cancer (but not terminal cancer), heart failure therapy or defibrillators may be relevant treatment options. The key points in selecting patients for such therapies may be the predicted life expectancy, quality of life at intervention time, symptomatic burden, and consequences for further anti-cancer therapies. The cause of death in advanced cancer is difficult to ascertain and consensus on event definitions in cancer is not established yet. Clinical investigations on this are called for. Broader ethical considerations must be taken into account when aiming to target cardiovascular problems in cancer patients. We suggest that focused attention to evaluating cardiac wasting and arrhythmias in cancer will herald a further evolution in the rapidly expanding field of cardio-oncology.

Advanced cancer is also a heart failure syndrome: a hypothesis

We present the hypothesis that advanced stage cancer is also a heart failure syndrome. It can develop independently of or in addition to cardiotoxic effects of anti-cancer therapies. This includes an increased risk of ventricular arrhythmias. We suggest the pathophysiologic link for these developments includes generalized muscle wasting (i.e. sarcopenia) due to tissue homeostasis changes leading to cardiac wasting associated cardiomyopathy. Cardiac wasting with thinning of the ventricular wall increases ventricular wall stress, even in the absence of ventricular dilatation. In addition, arrhythmias may be facilitated by cellular wasting processes affecting structure and function of electrical cells and conduction pathways. We submit that in some patients with advanced cancer (but not terminal cancer), heart failure therapy or defibrillators may be relevant treatment options. The key points in selecting patients for such therapies may be the predicted life expectancy, quality of life at intervention time, symptomatic burden, and consequences for further anti-cancer therapies. The cause of death in advanced cancer is difficult to ascertain and consensus on event definitions in cancer is not established yet. Clinical investigations on this are called for. Broader ethical considerations must be taken into account when aiming to target cardiovascular problems in cancer patients. We suggest that focused attention to evaluating cardiac wasting and arrhythmias in cancer will herald a further evolution in the rapidly expanding field of cardio-oncology.

Monitoring of QTc interval in patients with COVID-19. First experience with a portable EKG-recording device

Funding Acknowledgements

Type of funding sources: None.

Introduction

Off-label use of drugs with potential for QT interval prolongation was common in COVID-19 patients. We tested a portable EKG recording device to measure and monitor corrected QT (QTc) intervals in a cohort of COVID-19 patients treated with azithromycin, hydroxychloroquine, lopinavir/ritonavir, or combinations of these drugs.

Methods and results

Sixty-nine patients hospitalized with pneumonia and confirmed SARS-CoV 2 infection were included in an observational single-centre study. Six-lead EKG recordings were obtained using a KardiaMobile6L® at physicians’ discretion. In a subgroup of 16 patients with early discharge, a device was provided for at-home daily monitoring. Significant QTc interval prolongation was observed in patients taking a combination of 2 or 3 drugs (426 ± 33 vs 408 ± 33 ms, p = 0,002; and 435 ± 30 vs 394 ± 31 ms, p = 0,001, respectively). The use of the device prompted a change in the treatment of 9 patients (13%) because of prolongation of QTc interval and anticoagulation was started in one patient because of atrial fibrillation diagnosis. In the subgroup of patients with daily recording, QTc interval prolongation peaked at day 2 ± 1,8, with a shorter final QT interval than that recorded before drug initiation (350,0 ± 31,4 vs 381,0 ± 21,2; p = 0,019), pointing to a possible role of the disease itself in QT interval modification.

To assess the consistency of measurements of QTc interval, a random sample of 120 EKG recordings were analyzed by two different physicians. Inter-operator intraclass correlation coefficient was 0,702, 95% CI (0,578-0,789).

Conclusions

Portable EKG-recording device was useful for QTc interval monitoring in COVID-19 patients receiving drugs with QTc prolonging potential, allowing physicians to adapt management. Significant QT prolongation was observed in these patients.

Stabilization of unstable reentrant atrial tachycardias via fractionated continuous electrical activity ablation (CHAOS study)

Funding Acknowledgements

Type of funding sources: None.

Background. Unstable reentrant atrial tachycardias (ATs) (i.e. those with frequent circuit modification or conversion to atrial fibrillation) are challenging to ablate. 

Purpose. We have tested a strategy to convert unstable reentrant ATs into mappable stable ATs based on the detection and ablation of rotors.

Methods. From May 2017 to December 2019, we included all consecutive patients scheduled for ablation of reentrant AT, excluding CTI-dependent atrial flutter, in which the tachycardia circuit was unstable. Operators subjectively identified rotors as sites with fractionated continuous (or quasi-continuous) electrical signals on 1-2 adjacent bipoles of conventional high-density mapping catheters, without dedicated software (Figure, A). Focal ablation of these sites was performed in order to stabilize the AT or convert it into sinus rhythm. In patients without rotors or failed rotor ablation, sites with spatiotemporal dispersion (i.e. all the cycle length comprised within the mapping catheter) plus non-continuous fractionation on single bipoles were targeted (Figure, B). Procedural success was defined as the successful ablation of all inducible ATs, without need of cardioversion, final sinus rhythm and non-inducibility. Follow-up included visits with ECG and 24h Holter-ECG at 3, 6 and 12 months.

Results. From May 2017 to December 2019, 97 patients were scheduled for reentrant AT ablation, excluding CTI-dependent atrial flutter. Of these, 18 patients (18.6%; 72.1 ± 8.9 years of age, 9 females) presented unstable circuits and were included. 9 patients (50%) had structural cardiomyopathy, 11 patients (61%) prior atrial arrhythmias ablations, and 4 patients (22%) previous cardiac surgery. 13 patients (72%) had detectable rotors (26 rotors; median 2 [1–3] rotors per patient); focal ablation achieved conversion into stable AT or sinus rhythm in 12 (92%). In the other patient, and the 5 patients without detectable rotors, 17 sites with spatiotemporal dispersion were detected and focally ablated, with success to achieve arrhythmia stabilization in 5 patients (83%). Globally, and excluding one patient with spontaneous AT stabilization, ablation success to stabilize the AT was achieved in 16/17 patients (94.1%). Procedural success was achieved in 16/18 patients (88.9%). Rate of one-year freedom from atrial arrhythmias was 66.7%. In the 9 patients with stable ATs ablated during the same period, procedural success (92.4%) and one-year freedom from atrial arrhythmias (65.8%) were similar (Figure, C).

Conclusion. Most unstable reentrant ATs show detectable rotors, identified as sites with single-bipole fractionated quasi-continuous signals, or spatiotemporal dispersion plus non-continuous fractionation. Ablation of these sites is highly effective to stabilize the AT or convert it into sinus rhythm. Abstract FIGURE

Acute coronary syndrome in COVID-19 patients. Clinical features, severity and outcomes. Results from Spanish multicenter registry Car-COVID19

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Fundación del Corazón

Introduction

COVID19 has spread uncontrollably all over the world through this 2020 year. As a new entity, we did not know the potential cardiovascular manifestations of this infectious disease. This national registry was created to describe the cardiac affection and its severity.

Methods and results

A multicenter registry was conducted, including 28 centers in Spain. Patients with COVID19 diagnosis presenting an acute cardiovascular event between March 1st and May 30th were included. Eighty-two patients were included. Of them, 49 (76,6%) presented with acute coronary syndrome; the rest were diagnosed of acute myocarditis or stress cardiomyopathy. The majority of cases were STEMI (n = 31), while the remaining 35,4% presented as NSTEMI. 29 patients (61,7%) underwent emergent percutaneous coronary intervention (PCI) (Figure 1). Anterior (n = 18) and inferior (n = 16) were the most frequent locations. Coronary angiogram showed total occlusion in 20 patients (55,6%); while 7 patients presented with non-obstructive coronary arteries. PCI was done in 31 patients.

Eight patients (17,8%) developed Killip III-IV myocardial infarction. A total of 10 patients required endotracheal intubation and vasoactive agent were needed in 11 patients; none required IABP or ECMO. In-hospital mortality rate was 26,2%.

Conclusions

Patients with COVID19 may present with acute coronary syndromes. This entity has a poor prognosis, with noteworthy mortality.

Table 1. Baseline characteristics.

	n (%)
Age	69,0[63,0-76,5]
Sex (female)	9 (19,1%)
Hypertension	28 (57,1%)
Dyslipidemia	25 (51,0%)
Diabetes mellitus	11 (22,4%)
Chronic coronary disease	10 (20,4%)
Previous PCI	10 (20,4%)
Previous CABG	0
Previous AAS	15 (30,6%)
Smoking	10 (20,4%)

PCI percutaneous coronary intervention; CABG: coronary artery bypass graft; AAS: aspirin.

Abstract Figure 1.

Acute myocarditis in COVID19 patients. Clinical features, severity and outcomes. Results from Spanish multicenter registry Car-COVID19

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Fundacion del Corazon

Introduction

COVID19 has emerged as a new disease, spreading around the world, leading to a complete lockdown. It is known that other infectious diseases can affect the heart inducing myocarditis. As a new entity, it was unknown if SARS-COV2 could provoke that cardiovascular manifestation. This national registry was created to describe COVID19 cardiac affection and its severity.

Methods and results

A multicenter registry was conducted, including 28 centers in Spain. Patients with COVID19 diagnosis presenting an acute cardiovascular event between March 1st and May 30th were included. Eighty-two patients were included. Of them, 9 (14,1%, excluding missing data) presented with acute myocarditis; the rest were diagnosed of acute myocardial infarction or stress cardiomyopathy. Baseline characteristics of these patients are summarised in Table 1. The 83,3% of patients with myocarditis presented with heart failure and 25% simulating an acute coronary syndrome.

According to severity, 5 patients (62,5%) were admitted in the Intensive Care Unit, requiring orotracheal intubation 4 patients (57,1%). Left ventricle was affected in 66,7% of patients, whereas the remaining 33,3% presented biventricular failure. Mean left ventricle ejection fraction was 46% [30,0%-52%]. One patient developed refractory cardiogenic shock requiring implantation of both intra-aortic balloon pump and VA- ECMO. Three patients died during hospitalization.

Cardiac magnetic resonance was conducted in 2 patients (28,6%), showing oedema and subepicardial enhacement in postero-lateral segments. Cardiac biopsy was performed in one patient showing significant lymphoid infiltration and intersticial oedema.

Conclusions

Patients with COVID 19 who develop acute myocarditis usually present with heart failure secondary to ventricular failure. This entity has a bad prognosis with high in-hospital mortality rate.

Table 1. Baseline characteristics.

	n (%)
Age	65,0[47,0-77,0]
Sex (female)	3 (42,9%)
Hypertension	3 (42,9%)
Dyslipidemia	3 (42,9%)
Diabetes mellitus	2 (28,6%)
Chronic coronary disease	1 (14,3%)
Previous stroke	1 (14,3%)
Cancer	1 (14,3%)

P726 Cardiac amyloidosis: unmasking the simulator

Introduction

A non-invasive diagnosis of cardiac amyloidosis is a challenge, especially in cases of atypical phenotypic presentation. Differential diagnosis includes hypertrophic cardiomyopathy (HCM), hypertensive cardiomyopathy, and other infiltrative disorders. Multimodality imaging is essential to make a final diagnosis.

Case

We present the case of a 65 years old woman, with a personal history of resistant arterial hypertension and mild hypertensive cardiomyopathy. She was diagnosed 6 years earlier with multiple myeloma, treated with chemotherapy and allogeneic hematopoietic stem cell transplant, presenting with several relapses and in a stable situation at the moment of our first consult. The patient was referred for heart failure in context of acquired community pneumonia one month earlier.

Transthoracic echocardiography showed severe asymmetric left ventricle (LV) hypertrophy (Image A), systolic anterior motion of the mitral valve and diastolic dysfunction suggestive of HCM, not present in the previous examination. Strain imaging of the LV showed a typical amyloid infiltration pattern, with lower longitudinal strain values in the base compared to the apical segments (Image D). Further characterization of the myocardial tissue established the diagnosis along with performing a cardiac magnetic nuclear imaging (MRI). It showed the presence of inferior septum severe LV hypertrophy along with extensive patchy late gadolinium enhancement (LGE) of the lateral wall involving the endocardium (Image C), with normal LV contractility. There was no pleural effusion, but a small pericardial effusion was seen (Image B). With the suspicion of infiltrative heart disease, probably amyloid with an atypical LGE pattern, an oral mucosal biopsy was performed confirming amyloid diagnosis (Images E1,E2). Heart failure treatment was continued, but clinical evolution was poor with the deceasement of the patient 3 years after diagnosis.

Discussion

This case represents an example of the variety of imaging patterns we can see in cardiac amyloidosis. Despite the classical pattern of cardiac amyloidosis, with concentric LV hypertrophy, up to 8% of cases may present with asymmetrical LV hypertrophy, mimicking HCM. LGE extension and pattern can shows this variability as well: global transmural or subendocardial LGE is the most common, but focal patterns (up to 6% of cases) are described. The complexity of the diagnosis in these cases require a clinical and multimodality image approach.

Abstract P726 Figure. Images of the case

P816 Right Ventricular assessment using Advanced Cardiac Imaging in Mid-Range patients: Keys to detect the risk

Background

Patients with mid-range ejection fraction heart failure (HFmrEF) are a new category defined in actual guidelines. The aim of this study was to establish the prognostic value of several parameters obtained by Cardiac Magnetic Resonance (CMR) and Transthoracic Echocardiography (TTE) in patients with HFmrEF.

Methods

Thirty patients, defined as HFmrEF by TTE and CMR, were included between 2012-2018. Patients with structural heart disease different from Left Ventricular (LV) dysfunction were excluded. Cine sequences in CMR (SSFP) were used to obtain atrial and ventricular volumes and mass. Myocardial fibrosis was quantified by late gadolinium enhancement. TTE was used to obtain anatomical and functional parameters as LV and Right Ventricular (RV) ejection-fraction, LV and RV global longitudinal strain, and RV free-wall longitudinal strain.

The primary endpoint was the combination of all-cause death or heart failure admission. The median follow-up was 1.9 (0.5-3.3) years.

Results

Mean age was 59.3 ± 12.4 years, and 67.9% patients were male. The aetiology of LV dysfunction was mainly ischemic (n = 16, 53.3%). Results are shown in Table1. Patients who presented the primary endpoint had a lower RV ejection-fraction by CMR and a lower absolute value of RV free-wall longitudinal strain by TTE(Figure 1).

Conclusions

In HFmrEF patients, worse RV function (by CMR and TTE-Speckle Tracking) may be associated with a worse prognosis. Larger studies are needed to confirm this hypothesis.

Table1 All-cause death or HF admission (n = 5; 16.7%) No all-cause death of HF admission (n = 25; 83.3%) p iRVEDV (ml/m2) by CMR 65.5 ± 13.5 66.2 ± 12.3 0.906 iRVESV (ml/m2) by CMR 30.4 ± 7.5 24.4 ± 6.2 0.065 iLVEDV (ml/m2) by CMR 85.8 ± 23.7 98 ± 19.5 0.225 iLVESV (ml/m2) by CMR 47.8 ± 15.3 54.9 ± 11.7 0.246 Indexed LA Volume (ml/m2) by CMR 42.8 (36.5 - 49) 48.4 (42 - 63.5) 0.386 LVEF (%) by CMR 44.9 ± 3.3 44 ± 2.6 0.506 RVEF (%) by CMR 52.2 ± 7.2 61.7 ± 7.2 0.012 RV-FAC (%) by TTE 43.4 ± 4.4 44.7 ±7.5 0.378 TAPSE by TTE 2.1 ± 0.3 2.5 ± 0.1 0.032 LV Longitudinal Global Strain by TTE -14.3 ± 3.3 -15.5 ± 4.9 0.663 RV Longitudinal Global Strain by TTE -11.3 (-13.2 - -7.0) -19.5 (-23.7 - -10) 0.089 RV Free-Wall Longitudinal Strain by TTE -11.5 (-14.2 - -8.2) -20 (-26 - -13.7) 0.043 HF: Heart Failure; CMR: Cardio Magnetic Resonance; LV: Left Ventricle; RV: Right Ventricle; iRVEDV: Indexed RV End-Diastolic Volume; iRVESV: Indexed RV End-Systolic Volume; iLVEDV: Indexed LV End-Diastolic Volume; iLVESV: Indexed LV End-Systolic Volume; LA: Left Atrium; LVEF: LV Ejection Fraction; RVEF: RV Ejection Fraction; RV-FAC: RV Fractional Area Change; TAPSE: Tricuspid Annular Plane Systolic Excursion

Abstract P816 Figure 1

P906 Are all severe Tricuspid Regurgitation the same?

Introduction

Tricuspid regurgitation (TR) importance is growing in the last years. Its presence is associated with a worse prognosis. A new severity classification has been published, adding massive and torrential to the classical TR classification. However, both clinical profile of the patients as well as right chambers morphologic and functional changes have not been described compared to the severe TR patients.

Methods

Consecutive patients undergoing an echocardiographic study in 9 Spanish hospitals within a three-month period with at least moderate TR were prospectively included. All studies with severe TR were selected for analysis. TR assessment was performed as recommended by the European Association of Cardiovascular Imaging. TR severity grades was performed according to Hanh & Zamorano new published classification. Two cohorts were made: patients with severe TR and patients with massive or torrential TR.

Results

A total of 644 patients with severe or bigger TR were analysed. Severe TR was present in 540 (84%), massive was present in 83 (13%) and torrential in 21 (3%) Baseline characteristics of the study population are shown in table 1.

No differences were found in NYHA class or atrial fibrillation incidence between groups. Pacemaker was more frequent in massive/torrential group (30% vs 19%; 0,014).

Patients with massive/torrential TR presented worst RV remodelling data:

-RV was dilated (RV telediastolic basal diameter >42mm) in 84.2% of patients with massive/torrential TR vs 57% of patients with severe TR (p < 0.001).

-Right atrium was bigger in patients with massive/torrential TR (21 ± 0.8 cm2/m2 vs 17.2 ± 0,3 cm2/m2; p < 0.001)

-Tricuspid annulus diameter was bigger between massive/torrential TR patients (26.7 ± 0.6 cm/m2 vs 23.6 ± 0.3 cm/m2; p > 0.001).

No significant differences in prevalence of RV function (TAPSE < 17 mm) were noted 39% vs 33%, p = 0,273.

Conclusions

In this large multicentre cohort of patients, the presence of massive/torrential TR seems to be associated with a differential RV and RA remodelling, reflecting the greater volume overload seen in these patients. Further studies are needed to define prognosis implication of our findings and its role in clinical decision making.

Table 1 Variable Severe (n = 540) Massive/Torrential (n = 104) Body mass index 26,6 (±0,3) 26.4(±0,6) 0.350 Woman 336 (62%) 69 (66%) 0.438 Atrial firilation 298(55%) 61(59%) 0.514 Age (years) 76,5 (±0,5) 77,5(±1,1) 0.209

39 Overview of tricuspid regurgitation (tr). new classification of tr. when severe tr is too severe?

Introduction

Tricuspid regurgitation (TR) importance is growing in the last years. Its presence is associated with a worse prognosis. A new severity classification has been published, adding massive and torrential to the classical TR classification. However, it is not know how many of the patients classified as severe TR, corresponds to the new Torrential or massive classification that for sure will lead to different treatment strategies. Also few published studies have addressed the aetiologies, mechanisms and severity in large cohorts.

Purpose

To evaluate the burden of TR in a large cohort of patients referred for an echocardiography.

Methods

Prospective study where consecutive patients undergoing an echocardiographic study in 10 Spanish hospitals within a three-month period were included. All studies with at least moderate TR were selected for analysis. The evaluation was conduced according to the usual practice of the laboratory. TR assessment was performed as recommended by the European Association of Cardiovascular Imaging. TR was quantified according to Hanh & Zamorano new published classification.

Results

A total of 35088 consecutive echocardiographic studies were performed in the participant hospitals during the recruitment period. TR of at least moderate degree was detected in 2124 studies (6,05%). Mean age was 77,1 years and 62.8% were women.

Mitral or aortic valvulopthy was the most common cause, present in almost half of cases (48.4%). The second cause of TR was idiopathic with 22.2% of cases. Primary TR was found in 7.2% of patients, the most frequent aetiology in these group was cardiac implantable devices with 4.2% of total of TR. Aetiology and severity according to the new classification can be seen in the figures

Atrial fibrillation was present in 47.6% of cases. 56.4% of patients had symptoms at the time of the study (NYHA≥2 at the time of study).

Right ventricle (RV) was dilated (telediastolic basal diameter >42mm) in 39.4% of patients). RV function was impared (TAPSE <17mm) in 30.6% of patients.

Conclusions

In these larger multicentre study, significant TR may is present in up to 6% of the echocardiographic studies and is often symptomatic[m1] . 4,91% of patients had a massive or torrential grade. Most TR are secondary to mitral or aortic valvulopathy. Idiopathic TR has taken the second place.

Abstract 39 Figure. Severity and aetiology of TR

P727 Unexpected ventricular aneurysm: further ischemic aetiology

Introduction

Ventricular aneurysm is an infrequent complication of myocardial infarction. In absence of an ischemic event, alternative aetiologies include: thoracic trauma, hypertrophic cardiomyopathy, myocarditis, Chagas disease, cardiac sarcoidosis or arrythmogenic cardiomyopathy. In the absence of any of the previous, congenital aneurysm diagnosis is made.

Case

We present the case of 57-year-old man referred to cardiology department because a new onset of atrial fibrillation with left bundle branch block. Past medical history included high blood pressure and dyslipidaemia without any history or smoking, alcohol consumption or any other toxic abuse. No chest pain, shortness of breath or other significant symptoms were reported. Physical examination was unremarkable except for an arrhythmic pulse at 85-90 bpm.

Echocardiogram showed moderate dilated left ventricle with mild-moderate LV dysfunction (EF 40% ) with a septal aneurysm of 2.4x1cm (Picture A). A coronary CT was performed that ruled out coronary heart disease and confirmed the presence of the septal aneurysm (Picture B). To better characterize this image, a cardiac magnetic resonance (CMR) was performed. Moderate dilated LV with significant dysfunction (EF 31%) was reported. A septal aneurysm of 13 x 22 x 33 mm composed of a 2.8 m thin wall of true myocardial tissue was documented (picture C and D-late gadolinium enhance). No myocardial delayed enhancement was detected in any area of the LV. Moreover, no signs of myocardial non compaction, arrythmogenic cardiomyopathy, hypertrophic cardiomyopathy or myocarditis were seen. Chagas serology as well as sarcoidosis diagnosis work up were negative. Patient denied any thoracic traumatism. Congenital aneurysm diagnosis was finally established.

Electrical cardioversion was performed after 1 month of correct oral anticoagulation and heart failure treatment was started. Case was presented in the Heart Team session and a conservative management was decided based on asymptomatic status and absence of ventricular arrhythmias. After 3 years of clinical follow up, the patients is in good status, asymptomatic and in sinus rhythm. Discussion: Congenital ventricular aneurysm is a rare cardiac malformation that arises during the fourth embryonic week. Most frequently, left ventricular aneurysms are found in the apex and the perivalvular area, being the septal location an atypical one. Most patients are asymptomatic but when symptoms occur, they are mostly related to the presence of ventricular arrhythmias. Aneurysm rupture incidence is variable, ranging from 3.7% to 12 % according to the different series. For this reason, surgery is recommended in symptomatic patients. However, management of asymptomatic patients is not clear since prognosis studies are lacking.

Abstract P727 Figure. A.Echo B.-CT C.-CMR. D.-CMR gadolinium

CIBER-CLAP (CIBERCV Cardioprotection Large Animal Platform): A multicenter preclinical network for testing reproducibility in cardiovascular interventions

Despite many cardioprotective interventions have shown to protect the heart against ischemia/reperfusion injury in the experimental setting, only few of them have succeeded in translating their findings into positive proof-of-concept clinical trials. Controversial and inconsistent experimental and clinical evidence supports the urgency of a disruptive paradigm shift for testing cardioprotective therapies. There is a need to evaluate experimental reproducibility before stepping into the clinical arena. The CIBERCV (acronym for Spanish network-center for cardiovascular biomedical research) has set up the "Cardioprotection Large Animal Platform" (CIBER-CLAP) to perform experimental studies testing the efficacy and reproducibility of promising cardioprotective interventions based on a pre-specified design and protocols, randomization, blinding assessment and other robust methodological features. Our first randomized, control-group, open-label blinded endpoint experimental trial assessing local ischemic preconditioning (IPC) in a pig model of acute myocardial infarction (n = 87) will be carried out in three separate sets of experiments performed in parallel by three laboratories. Each set aims to assess: (A) CMR-based outcomes; (B) histopathological-based outcomes; and (C) protein-based outcomes. Three core labs will assess outcomes in a blinded fashion (CMR imaging, histopathology and proteomics) and 2 methodological core labs will conduct the randomization and statistical analysis.

P3853Mortality of surgical redo aortic valve replacement versus transcatheter aortic valve-in-valve implantation in patients with degenerated aortic bioprosthesis: a meta-analysis

Background

Transcatheter valve-in-valve (tVIV) implantation for degenerated aortic bioprosthesis has become an alternative to surgical aortic valve replacement (sAVR) in the past few years. However, some concerns have been raised regarding to the long-term safety and efficacy of tVIV. The objective was to compare the clinical and echocardiographic outcomes of tVIV implantation with redo cAVR.

Methods

After an extensive search of PubMed we included 7 observational studies (3 used propensity score matching) comparing tVIV versus sAVR in 762 patients The primary endpoint was all-cause mortality determined from the longest available survival data. Other outcomes of interest were stroke, permanent pacemaker implantation, paravalvular leak, hospital stay and postoperative aortic valve gradient. The review was conducted according to the MOOSE recomendations. Der Simonian and Laird random effects model was used to estimate summary measures and their 95% CI.

Results

Patients in the tVIV group were significantly older (78 vs 73 y.o.) and had a higher baseline risk compared to those in the re-sAVR group (Euroscore 19.7 vs 14.3). There was no statistical difference in procedural or 30-day mortality 5.4% vs 5.3% in tVIV and sAVR, respectively (RR 0.98, 95% CI 0.54–1.80; p=0.96], and long-term mortality (from 6 month to 5 years) 18.7% versus 16.5% (RR 1.13, 95% CI 0.80–1.60; P=0.50). The risk of stroke was similar (1.5% in tVIV vs 2.4% in sAVR, p=0.47). tVIV was associated with a significantly lower rate of permanent pacemaker implantations 6.9% vs 12.1% (RR 0.58, 95% CI 0.36–0.94; P=0.03) and shorter hospital length stay (7 days vs 12 days, p=0.02). However, echocardiographic postoperative aortic valve gradients were lower in sAVR group than in tVIV (RR 1.83, 95% CI 0.75–2.91, p<0.001).

30-day and long-term mortality

Conclusion

This meta-analysis suggests that patients with aortic degenerated bioprosthesis treated with tVIV have similar 30-day and long-term mortality with lower need of permanent pacemaker and length stay than sAVR. Thus tVIV is a valid alternative to standard surgical treatment.

P1551A genetic risk score predicts recurrent events after myocardial infarction in young adults

Background

To evaluate whether a genetic risk score (GRS) improves the prediction of recurrent events in young non-diabetic patients presenting with an acute myocardial infarction and identifies a more aggressive form of atherosclerosis in this population.

Methods and results

We performed a prospective study including 81 consecutive non-diabetic patients aged below 55 y.o. presenting with an acute myocardial infarction (48±6 y.o., 89% male). A comprehensive study including serum biomarkers, genetic testing and cardiac CT was performed. We studied the association of a GRS composed of 11 genetic variants with a primary composite end-point (all-cause mortality, recurrent acute coronary syndrome, and cardiac re-hospitalisation). After a median follow-up of 4.1 (3.5 - 4.4) years 24 recurrent events were documented. A significantly higher prevalence of 9 out of 11 risk alleles was noted compared with general population. The GRS was significantly associated with recurrent events, especially when baseline LDL-cholesterol levels were elevated. Compared with the low-risk GRS category, the multivariate-adjusted hazard ratio for recurrent events for the intermediate-risk GRS category was 10.2 (95% CI 1.1–100.3, p=0.04) and for the high-risk GRS was 20.7 (2.4–181.0, p=0.006) when LDL-C ≥2.8 mmol/L. Inclusion of the GRS improved the C statistic (ΔC statistic =0.086), the continuous Net Reclassification Index (30%) and the Integrated Discrimination Improvement (0.05) compared with a multivariate clinical risk model. Cardiac CT detected coronary calcified atherosclerosis and numerous plaques but it had a limited value for prediction of recurrences. No association was observed between extracellular matrix metabolism biomarkers and GRS or recurrent events in this population.

Cox regression analysis between GRS terciles and LDL-C Univariate analysis Multivariate analysis* HR (95% CI) p-value HR (95% CI) p-value* Low GRS 1 1 Intermediate GRS 2.0 (0.7–5.8) 0.21 LDL-C≤110 mg/dL (≤2.8 mmol/L) 1.0 (0.3–4.0) >110 mg/dL (>2.8 mmol/L) 10.2 (1.1–100.3) 0.04 High GRS 3.0 (1.0–9.2) 0.05 LDL-C≤110 mg/dL (≤2.8 mmol/L) 0.3 (0.1–1.9) >110 mg/dL (>2.8 mmol/L) 20.7 (2.4–181.0) 0.006 *Multivariate model adjusted for GRACE risk score and LDL-C and interaction. There was a strong interaction between GRS terciles and LDL-C (p<0.01).

Recurrent events based on genetic risk

Conclusions

A multilocus genetic risk score identified non-diabetic young patients at increased risk for recurrent events after a myocardial infarction. The significance of LDL-cholesterol in relation to genetic predisposition for recurrences merits further evaluation.

Acknowledgement/Funding

Instituto de Salud Carlos III (PI12/0564, PI14/01152 and PI15/00667), the CIBERCV and the Spanish Society of Cardiology (2015/CC)

P3370Prevalence of right ventricular dysfunction according to different parameters: basal and one year after transcatheter aortic valve implantation

Background

Right ventricle (RV) is not often specifically studied in patients with severe aortic stenosis (AS). It's difficult to find the correct tool to assess RV function with echocardiographic parameters, and the percentage of patients with dysfunction may vary depending on the parameter that we use.

The aim of the study was to evaluate the prevalence of RV dysfunction basal and one year after transcatheter aortic valve implantation (TAVI), according to different parameters.

Methods

Consecutive patients with severe AS undergoing TAVI from January 2016 to July 2017 were included. RV anatomical and functional parameters were analyzed according to ESC and ASE guidelines. RV dysfunction was assessed using tricuspid annular plane systolic excursion (TAPSE) <17 mm, fractional area change <35%, systolic movement of the RV lateral wall by tissue Doppler imaging (RV-S'TDI) <9.5 cm/s, global longitudinal (RV-GLS) and free wall strain (RV-FWS) using as cutting point [20]. Pre procedure echo, immediate post procedure and 1 year echo were analyzed. Statistical analysis was performed using SSPS version 22.

Results

The final study population consisted of 78 patients (115 patients were included, 37 were excluded due to suboptimal acoustic window for RV anatomical and functional evaluation), mean age 83.73±6.31 year-old, 38.2% females. We analyzed the percentages of RV dysfunction according to the different parameters evaluated before and in the control one year after. They are shown in Figure 1.

Prevalence of RV dysfunction

Conclusions

The presence of RV dysfunction in patients with severe AS is higher than expected Our data suggest that RV function improve one year after TAVI, in terms of a reduction in the number of patients with dysfunction. The assessment of RV function is difficult, and there is no agreement on what tools are more accurate and useful. RV strain seems to be the most sensible parameter to assess RV function in patients with AS undergoing TAVI. Impact of these measurements in patients management needs further evaluation.

P675Current status of anticoagulation in patients with breast cancer and atrial fibrillation

Aims

Balance between embolic and bleeding risk is challenging in patients with cancer. There is a lack of specific recommendations for the use of antithrombotic therapy in oncologic patients with atrial fibrillation (AF). We compared the embolic and bleeding risk, the preventive management and the incidence of events between patients with and without cancer. We further evaluated the effectiveness and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) within patients with cancer.

Methods

The AMBER-AF registry is an observational multicentre study that analysed patients with non-valvular AF treated in Oncology and Cardiology Departments in Spain. 1237 female patients with AF were enrolled: 637 with breast cancer and 599 without cancer. Mean follow-up was 3.1 years.

Results

Both groups were similar in age, CHA2DS2-VASc and HASB-LED scores. Lack of guidelines recommended therapies was more frequent among patients with cancer. Compared with patients without cancer, adjusted rates of stroke (hazard ratio [95% confidence interval]) in cancer patients were higher (1.56 [1.04–2.35]), whereas bleeding rates remained similar (1.25 [0.95–1.64]). Within the group of patients with cancer, the use of DOACs vs VKAs did not entail differences in the adjusted rates of stroke (0.91 [0.42–1.99]) or severe bleedings (1.53 [0.93–2.53]).

Follow-up events

Conclusions

Antithrombotic management of AF frequently differs in patients with breast cancer. While breast cancer is associated with a higher risk of incident stroke, bleeding events remained similar. Patients with cancer treated with DOACs experienced similar rates of stroke and bleeding as those with VKAs.