Impact of Covid-19 infection in high-risk coronary patients

Background

Methods

Results

Conclusions

Venous thromboembolism in non-critically ill patients with COVID-19 infection

Background

Systemic coagulation activation and thrombotic complications are frequent among critically ill patients with COVID-19. Limited data are available in non-intensive care unit (ICU) patients.

Purpose

To determine the incidence, risk factors and prognosis of venous thromboembolism (VTE) in non-ICU COVID-19 patients.

Methods

We studied consecutive COVID-19 patients admitted to general ward at Strasbourg Hospital, France (25.02.2020–19.04.2020). The primary outcome was any VTE complication. The secondary outcome was the composite of death or transfer to ICU.

Results

Among the 289 patients included (62.2 ± 17.0 years, 59.2% male), VTE occurred in 49 (17.0%). Padua prediction score for VTE was similar between VTE and non-VTE patients. VTE imaging tests were performed in 100 (34.6%) patients and VTE diagnosed in median 7 (3–11) days after admission. On-admission, time from symptom onset to admission (OR 1.07, CI 95% [1.00–1.16], P = 0.045), Improve score (OR 1.37, [1.02–1.83], P = 0.032), leukocyte count (OR 1.16, [1.06–1.27], P = 0.001) and lack of thromboprophylaxis (OR 27.85, CI 95% [9.35–82.95], P < 0.001) were independent predictors of VTE. The incidence of the composite of death or ICU transfer was 31.0% and more frequent among patients with VTE (47.9% vs. 27.9%, P = 0.01). Fever (OR 5.37, CI 95% [1.44–19.97], P = 0.012), VTE (OR 3.44, CI 95% [1.63–7.25], P = 0.001), lymphopenia (OR 0.32, 95% CI [0.15–0.71]; P = 0.005) and extent of COVID-19 evaluated by chest CT severity (OR 1.56, 95% CI [1.12–2.16]; P = 0.007) were independently associated with in-hospital death or transfer to ICU (Table 1, Fig. 1).

Conclusions

The 17.0% incidence of VTE in non-ICU patients with COVID-19 was associated with worse outcomes. Given the high incidence of VTE in ward patients, there is an urgent need to investigate the optimal anticoagulation regimen.

[Locally Advanced Breast Cancer Successfully Treated with Abemaciclib and Fulvestrant-A Case Report]

A 78-year-old woman visited our hospital for a tumor in her left breast with discharge. The 10 cm tumor had ulceration and foul smell. Scirrhous breast carcinoma was diagnosed based on core-needle biopsy findings. Chest and abdominal computed tomography( CT) revealed the tumor invading the pectoralis major muscle and a large number of swollen lymph nodes from the left axilla to the subclavian region, but no distant metastases. After 6 months of locally advanced breast cancer treatment with abemaciclib and fulvestrant, ulceration improved. CT revealed that the tumor and lymph nodes tended to shrink. Left mastectomy with axillary lymph node dissection and combined resection of pectoralis major muscle was performed. Postoperative pathological histology revealed ypT2, ypN0, ypM0, ypStage ⅡA. Subsequently, abemaciclib plus fulvestrant therapy was continued as an adjuvant therapy. The patient has survived without recurrence 6 months after the operation. We report a case of locally advanced breast cancer in which abemaciclib and fulvestrant were effective.

P2Y12 inhibition by clopidogrel increases adverse clinical outcomes in patients undergoing transcatheter aortic valve replacement

Introduction

Current recommendations support short-term dual antiplatelet therapy (DAPT) for patients undergoing transcatheter aortic valve replacement (TAVR) despite no relevant study exploring the extent of platelet inhibition by clopidogrel.

Purpose

To assess whether P2Y12 inhibition by clopidogrel as evaluated by vasodilator-stimulated phosphoprotein flow cytometry test (VASP-FCT) impacts 1-year clinical outcomes in patients undergoing TAVR.

Methods

Patients were included in a prospective registry between February 2010 and May 2019. VASP-FCT was assessed 24h after the procedure. Responder to clopidogrel was defined by a platelet reactivity index ≤50%.

Results

Of 640 patients who underwent TAVR with preprocedural clopidogrel therapy, we enrolled 491 patients for whom VASP data were available. Responders were identified in 22% (n=110) of patients and low responders were 78% (n=381) of patients. Low body mass index, active cancer, and clopidogrel on admission were found to be independent predictors of responder. Mean transaortic pressure gradient was lower in the responder group at 1-month post-TAVR (9.9±4.4 mmHg vs. 11.2±5.8 mmHg, p=0.03) but was similar at 1-year (11.5±6.2 mmHg vs. 11.9±7.4 mmHg, p=0.74). By multivariate Cox regression analysis, patients responding to clopidogrel (hazard ratio [HR]: 2.19; 95% confidence interval [CI]: 1.04 to 3.64; p=0.04), prior PCI (HR: 2.12; 95% CI: 1.07 to 4.37; p=0.03), and mean transaortic pressure gradient at baseline (HR: 0.07; 95% CI: 0.01 to 0.70; p=0.02) were identified as independent predictors of 1-year adverse clinical outcomes, including all-cause death, myocardial infarction, stroke, and heart failure hospitalization.

Conclusions

Appropriate P2Y12 inhibition by clopidogrel is a major determinant of adverse clinical events after TAVR. In sum, the present data challenges the need of DAPT as a standard therapy during TAVR.

Figure 1

Funding Acknowledgement

Type of funding source: None

Residual inflammation is a major determinant of myocardial recovery and cardiovascular outcome in takotsubo patients

Background

Recent insights have emphasized the importance of myocardial and systemic inflammation in Takotsubo Syndrome (TTS).

Objective

In a large registry of unselected patients, we sought to evaluate whether residual high inflammatory response (RHIR) could impact cardiovascular outcome after TTS.

Methods

Patients with TTS were retrospectively included between 2008 and 2018 in three general hospitals. 385 patients with TTS were split into three subgroups, according to tertiles of C-reactive protein (CRP) levels at discharge (CRP&lt;5.2 mg/l, CRP range 5.2 to 19 mg/l, and CRP&gt;19 mg/L). The primary endpoint was the impact of RHIR, defined as CRP&gt;19 mg/L at discharge, on cardiac death or hospitalization for heart failure.

Results

Follow-up was obtained in 382 patients (99%) after a median of 747 days. RHIR patients were more likely to have a history of cancer or a physical trigger. Left ventricular ejection fraction (LVEF) at admission and at discharge were comparable between groups. By contrast, RHIR was associated with lower LVEF at follow-up (61.7 vs. 60.7 vs. 57.9%; p=0.004) and increased cardiac late mortality (0% vs. 0% vs. 10%; p=0.001). By multivariate Cox regression analysis, RHIR was an independent predictor of cardiac death or hospitalization for heart failure (hazard ratio: 1.97; 95% confidence interval: 1.11 to 3.49; p=0.02).

Conclusions

RHIR was associated with impaired LVEF recovery and was evidenced as an independent factor of cardiovascular events. All together these findings underline RHIR patients as a high-risk subgroup, to target in future clinical trials with specific therapies to attenuate RHIR.

Main results

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): GERCA (Groupe pour l'Enseignement, la prévention et la Recherche Cardiovasculaire en Alsace)

Empagliflozin treatment does not affect the hypertensive response to Ang II administration to rats but decreases oxidative stress in the arterial wall, and endothelial and cardiac dysfunction

Background

Selective sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown cardiovascular protection in type 2 diabetes patients with established cardiovascular disease independently of glycemic control. Angiotensin II (Ang II) and H2O2 have been shown to be strong inducers of the expression of SGLT2 and 1 in endothelial cells promoting oxidative stress and endothelial dysfunction.

Purpose

This study examined the cardiovascular protective effect of empagliflozin (empa) in a normoglycemic experimental model of hypertension in the rat.

Methods

Male Wistar rats received empa (30 mg/kg/day) provided in the diet for 5 weeks. After 1 week, rats underwent sham surgery (sham rats) or surgery with implantation of an osmotic mini-pump infusing Ang II (0.4 mg/kg/d) for 4 weeks. Systolic blood pressure (SBP) was assessed by sphygmomanometry, the cardiac function using echocardiography, the expression level of target proteins by immunofluorescence staining, and the level of oxidative stress using dihydroethidium staining.

Results

Angiotensin II administration increased systolic blood pressure from about 130 to 180 mmHg, which was not affected by the empa treatment. The 4-week Ang II treatment did not significantly affect the systolic cardiac function (cardiac output, left ventricle ejection fraction) but impaired the diastolic function as indicated by a reduced E' and IVRT values, and an increased E/E' value. The Ang II treatment increased significantly the heart and right ventricle weight whereas the left ventricle + septum weight was slightly but not significantly increased. No such functional and structural changes were observed in the Ang II + empa treatment group. An increased immunofluorescence eNOS signal in the endothelium, and a higher level of ROS throughout the aorta wall were observed in the Ang II-treated group, both of which were significantly reduced in the empa + Ang II-treated group. In the Ang II-treated group, the high level of oxidative stress in the aorta was significantly reduced by the AT1 receptor antagonist losartan, the NADPH oxidase inhibitor VAS-2871, the eNOS inhibitor NG-nitro-L-arginine and also to a greater extent by the selective SGLT2 inhibitor empa compared to the dual SGLT1/2 inhibitor sotagliflozin.

Conclusion(s)

The present findings indicate that although the empa treatment did not affect the hypertensive response of rats to Ang II, the SGLT2 inhibitor prevented the deleterious impact of Ang II on the diastolic cardiac function and remodeling, and the upregulation of eNOS expression and oxidative stress in the aorta wall. Thus, these findings highlight the protective potential of empa on the cardiovascular system in a normoglycemic hypertensive experimental model.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boehringer Ingelheim Pharma GmbH & Co KG (Biberach an der Riss, Germany)

Effect of air pollution on acute heart failure hospitalization differ across specific heart failure populations

Introduction

Several report showed the association between ambient air pollution including particular matter under 2.5um (PM2.5) and increasing rate of hospitalization for heart failure. However, these report analyzed mainly cross-sectional, epidemiological data, thus the reports regarding association between vulnerability to PM2.5 and specific populations in acute heart failure (AHF) were scarce.

Purpose

1. To analyze the association between air pollution and rate of hospitalization for AHF

2. To analyze whether the vulnerability to air pollution differ between specific populations in AHF. Methods

A case-cross over analysis was conducted to 4980 consecutive patients registered for multicenter acute heart failure registry in 2017 in our city Japan. This registry enrolled patients transferred to cardiovascular care unit (80 institutions) via emergency medical services across our city area. Logistic regression analysis were conducted to estimate percentage changes in the rate of acute heart failure hospitalization associated with per 1μg/m3 PM2.5 concentration increase. We also conducted subgroup analysis for patients stratified by age, gender, comorbidities, left ventricular ejection fraction, and clinical scenario.

Results

An increase in 1 μg/m3 PM2.5 concentration corresponded to 2.9% (95% CI 1.2–4.6%) increase in AHF hospitalization. Patients with age younger than 75, without prior heart failure hospitalization, without history of hypertension, without anemia, and with reduced ejection fraction were more susceptible to increase in PM2.5 concentration (Figure).

Conclusions

Increase in PM2.5 concentration was associated with increased rate of AHF hospitalization. Effect of PM2.5 may differ across specific AHF subpopulations.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Tokyo Metropolitan Government

Predictive impact of PVL assessments on clinical outcomes in patients undergoing TAVR

Introduction

Paravalvular leakage (PVL) following transcatheter aortic valve replacement (TAVR) is associated with greater mortality. In clinical practice, determining PVL severity after TAVR remains challenging and often requires multiparametric assessment.

Purpose

This study sought to evaluate the respective value of various modalities of PVL assessments, including transthoracic echocardiography (TTE), cine-angiography, aortic regurgitation index (ARI), and closure time with adenosine diphosphate (CT-ADP), in the prediction of adverse clinical outcomes.

Methods

We included 1044 patients from our prospective TAVR registry between February 2010 and May 2019. Major adverse cardiac and cerebrovascular events (MACCE) was defined as a composite of all-cause death, myocardial infarction, stroke, and heart failure hospitalization within 1-year. Established cutoff values of ARI (&lt;25) and CT-ADP (&gt;180 sec) were used to assess the presence of PVL after TAVR.

Results

Moderate to severe PVL occurred in 14.2% and 5.2% of patients as measured by TTE and angiography. The rate of patients with ARI &lt;25 and CT-ADP &gt;180 sec were 36.5% and 24.9%, respectively. Among the four modalities, PVL evaluated by angiography predicted poorer clinical outcomes (Log rank test; p=0.001), whereas TTE, ARI &lt;25, and CT-ADP &gt;180 sec were not associated with 1-year MACCE. By multivariate Cox regression analysis, moderate to severe PVL by angiography was an independent predictor of 1-year MACCE (hazard ratio: 1.96; 95% confidence interval: 1.22–3.00; p=0.007).

Conclusions

Paravalvular leakage measured by angiography was evidenced as the most meaningful modality in the prediction of adverse clinical outcomes. Future multicenter studies are warranted to ensure these findings in the current TAVR era.

Figure 1

Funding Acknowledgement

Type of funding source: None

Incomplete recovery of takotsubo cardiomyopathy is a major determinant of cardiovascular mortality

Introduction

Although there is an apparent rapid and spontaneous recovery of left ventricular ejection fraction (LVEF) in patients with takotsubo cardiomyopathy, recent studies have demonstrated the long-lasting functional impairment in those patients.

Purpose

We sought to evaluate the predictors of incomplete recovery in chronic phase and its impact on cardiovascular mortality after takotsubo cardiomyopathy.

Methods

Patients with takotsubo cardiomyopathy between 2008 and 2018 were retrospectively enrolled in three different institutions. Takotsubo cardiomyopathy was diagnosed according to the European Society of Cardiology Heart Failure Association criteria. After exclusion of in-hospital deaths, 407 patients were split into 2 subgroups according whether their LVEF were &gt;50% (recovery group; n=333), or ≤50% (incomplete recovery group; n=74) at follow-up. The primary endpoint was the impact of incomplete recovery on cardiovascular mortality.

Results

Patients with incomplete recovery were more likely to be male, to have dementia, pacemaker, and supraventricular arrhythmia. C-reactive protein (CRP) levels on admission, at peak, and at discharge were significantly higher in patients with incomplete recovery. By multivariate logistic regression analysis, lower EF at discharge (odds ratio [OR]: 0.91; 95% confidence interval [CI]: 0.88 to 0.95; p&lt;0.001) and higher CRP levels (OR: 5.56; 95% CI: 1.86 to 16.61; p&lt;0.001) were independent predictors of incomplete recovery at follow-up. The cumulative event-free survival rate according to cardiovascular death was significantly lower in the incomplete recovery group (p&lt;0.001; log-rank test).

Conclusions

We demonstrate that incomplete recovery after takotsubo cardiomyopathy is characterized by a residual systemic inflammation and an increased cardiac mortality at follow-up. Altogether, our findings underline patients with persistent inflammation as a high-risk subgroup, to target in future clinical trials with specific therapies to attenuate inflammation.

Funding Acknowledgement

Type of funding source: None

Randomized clinical trial of pancreaticogastrostomy versus pancreaticojejunostomy regarding incidence of delayed gastric emptying after pancreaticoduodenectomy

PURPOSE

Delayed gastric emptying (DGE) is an important postoperative complication after pancreaticoduodenectomy (PD), and its incidence may be associated with the utilized surgical procedures. Compared with pancreaticojejunostomy (PJ) after PD, it may be speculated that pancreaticogastrostomy (PG) is a risk factor for DGE, because it needs an anastomosis of the remnant pancreas to the back wall of the stomach. This study aimed to compare PG and PJ with regard to the incidence of DGE after PD.

METHODS

We performed a prospective open-label randomized clinical trial (RCT) including patients undergoing elective pancreaticoduodenectomy, who were randomly assigned PG or PJ the day before surgery. The primary endpoint was incidence of DGE.

RESULTS

The study included 60 patients (30 PG, 30 PJ), of whom seven were deemed unresectable, one was enucleated, and one was switched from PJ to PG during surgery according to the surgeon's decision. Thus, modified intention-to-treat analyses were performed in 27 PG patients and 26 PJ patients. DGE occurred in three patients in the PG group and six patients in the PJ group, which did not constitute a significant between-group difference (P = 0.42). In the PG group, two cases were ISGPS grade A DGE and one was grade C. In the PJ group, one case was grade A, two grade B, and three grade C. The two groups also did not significantly differ in the incidence of other morbidities or postoperative hospital stay.

CONCLUSIONS

Post-PD DGE incidences were similar after PG and PJ.

Relations between anterior disc displacement and maxillomandibular morphology in skeletal anterior open bite with changes to the mandibular condyle

In this study we investigated the relation between anterior disc displacement (ADD) and maxillomandibular morphology in skeletal anterior open bite with changes to the mandibular condyle. Thirty female patients (60 joints) with both conditions were evaluated. Magnetic resonance imaging of the temporomandibular joint (TMJ) was used to diagnose both ADD and changes to the mandibular condyle (erosion, osteophyte, and deformity). The relations among ADD, changes to the mandibular condyle, and maxillomandibular morphology were examined statistically. Changes to the mandibular condyle had a higher score than sym anterior open bite, the deviated side in asymmetric anterior open bite, and the non-deviated side. The score for disc displacement on the non-deviated side was lower than both the sym side and the deviated side. Unilateral changes to the mandibular condyle and unilateral disc displacement were not apparent in sym anterior open bite, but a unilateral non-displaced disc was seen only on the asymmetric side. Mandibular condylar changes were significantly more common on the deviated, than on the non-deviated, side. The SNB angle was significantly smaller, and the ANB, GZN, and SN-mandibular plane angles were significantly larger in sym anterior open bite. Overjet, ANB angle, GZN angle, and SN-MP angle were significantly larger, and the SNB angle was significantly smaller, in the presence of ADD without reduction and mandibular condylar deformity. We conclude that the prevalence of ADD without reduction and changes to the mandibular condyle were related to mandibular asymmetry and mandibular morphology in anterior open bite. This retrospective study suggests that ADD without reduction and mandibular condylar bone changes may be related to the progression of skeletal class II open bite and mandibular asymmetry in cases of skeletal open bite.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

[A Case of Advanced Rectal Cancer with the Metastatic Abdominal Aortic Bifurcation Lymph Node Performed by Laparoscopic Surgery after Chemotherapy]

A 63-year-old underwent examination for constipation and was found to have an unresectable advanced rectal cancer. Metastatic abdominal aortic bifurcation lymph node and lung metastasis were suspected upon CT(cT3N3M1a[PUL1], cStage Ⅳa), and chemotherapy was administered(CapeOX plus Bmab). After 4 courses of chemotherapy, the size of the primary tumor and the lymph nodes decreased(PR). We performed laparoscopic rectum resection and abdominal aortic bifurcation lymph node. The pathological diagnosis indicated partial response(residual cancer cells)(Grade 1a). After 4 courses of chemotherapy(CapeOX), we performed pulmonary partial resection for metastatic lung cancer. This case suggests that laparoscopic resection of rectum after chemotherapy with CapeOX plus Bmab for locally advanced rectal cancer is a potential- ly effective procedure.

P1802 Prevalence and prognostic significance of pulmonary artery aneurysms in patients with pulmonary artery hypertension

Background

Pulmonary artery aneurysm (PAA) occurs in some patients with pulmonary arterial hypertension (PAH) and can be accompanied by various complications.

Objective

The aim of the this study is to evaluate the characteristics of cardiac dysfunction and the prognostic impact of PAA by analysing the outcome of patients with PAH complicated by PAA.

Methods

We performed echocardiography and right-heart catheterization in 130 PAH patients. We measured the maximum dimensions of the main pulmonary artery (MPA) trunk. We evaluated the right ventricular (RV) function and the five-year prognosis of patients with PAA.

Results

The maximum MPA trunk diameter of &gt;40 mm by echocardiography was defined as PAA. PAA appeared in 32 of the 130 PAH patients (24.6%: Group PAA), other 98 patients were defined as Group non-PAA. Systolic pulmonary artery pressure (76 ±18 vs. 61 ± 21 mmHg, P = 0.0008) and mean right atrial pressure (10.0 ± 8.1 vs. 5.4 ± 3.8 mmHg, P &lt; 0.0001) were significantly higher in Group PAA than in Group non-PAA. RV end-diastolic area index was significantly larger (37.3 ± 8.8 vs. 32.3 ± 7.8 mmHg, P = 0.0048), and RV fractional area change (32 ± 8 vs. 36 ± 9 %, P = 0.0176) and RV longitudinal strain amplitude (-16 ±5 vs. -20 ± 6, P = 0.0017) were significantly lower in Group PAA than those in Group non-PAA. During the five-year follow-up period, 20 patients (15%) died. The five-year mortality rate was significantly higher in Group PAA compared to Group non-PAA (30% vs. 10%, P = 0.007).

Conclusion

In PAH patients with PAA, RV dysfunction was more severe and the prognosis was poor. Assessment of PAA can be a useful index for the extraction of high-risk PAH patients.