Multimodality Imaging in the Evaluation of Ascending Aortic Pseudoaneurysms to Guide Complex Surgical Management

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Treatment of an AAP is surgical.

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The CorMatrix patch can lead to degradation and pseudoaneurysm formation.

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Use of multimodality imaging is key to evaluate, diagnose, and guide operation.

Outcome of Flow-Gradient Patterns of Aortic Stenosis After Aortic Valve Replacement

Background:

Although aortic valve replacement is associated with a major benefit in high-gradient (HG) severe aortic stenosis (AS), the results in low-gradient (LG, mean gradient <40 mm Hg) AS are conflicting. LG severe AS may be subdivided in classical low-flow (left ventricular ejection fraction <50%) and LG (CLF-LG); paradoxical low-flow (left ventricular ejection fraction ≥50% but stroke volume index <35 mL/m 2 ) and LG; and normal-flow (left ventricular ejection fraction ≥50% and stroke volume index ≥35 mL/m 2 ) and LG. The primary objective is to determine in the PARTNER 2 trial (The Placement of Aortic Transcatheter Valves) and registry the outcomes after aortic valve replacement of the 4 flow-gradient groups.

Methods:

A total of 3511 patients from the PARTNER 2 Cohort A randomized trial (n=1910) and SAPIEN 3 registry (n=1601) were included. The flow-gradient pattern was determined at baseline transthoracic echocardiography and classified as follows: (1) HG; (2) CLF-LG; (3) paradoxical low-flow-LG; and (4) normal-flow-LG. The primary end point for this analysis was the composite of (1) death; (2) rehospitalization for heart failure symptoms and valve prosthesis complication; or (3) stroke.

Results:

The distribution was HG, 2229 patients (63.5%); CLF-LG, 689 patients (19.6%); paradoxical low-flow-LG, 247 patients (7.0%); and normal-flow-LG, 346 patients (9.9%). The 2-year rate of primary end point was higher in CLF-LG (38.8%) versus HG: 31.8% ( P =0.002) and normal-flow-LG: 32.1% ( P =0.05) but was not statistically different from paradoxical low-flow-LG: 33.6% ( P =0.18). There was no significant difference in the 2-year rates of clinical events between transcatheter aortic valve replacement versus surgical aortic valve replacement in the whole cohort and within each flow-gradient group.

Conclusions:

The LG AS pattern was highly prevalent (36.5%) in the PARTNER 2 trial and registry. CLF-LG was the most common pattern of LG AS and was associated with higher rates of death, rehospitalization, or stroke at 2 years compared with the HG group. Clinical outcomes were as good in the LG AS groups with preserved left ventricular ejection fraction compared with the HG group.

Plant Bioactive Molecules Reduces Endoplasmic Reticulum Stress in Liver and Adipose Tissue of Obese Mice

Objectives

To determine if diferent plant bioactive compounds can ammelirate endoplasmic reticulum stress markers in liver and adipose tissue of obese mice and mice administered with a low dose of tunicamicin.

Methods

C57BL6 mice were fed a control diet (7% fat) or a high-fat diet (21% fat) with and without genistein or resveratrol supplementation (0.1%) for 12 weeks. Pharmacologic ER stress was induced in mice fed the control diet by an ip injection of a low dose of tunicamycin and euthanized 8 or 24 h after tunicamycin administration. Adipose tissues and liver were harvested to determine the abundance of ER stress markers by western blot and real time PCR.

Results

Genistein and resveratrol reduced the abundance of phospho JNK and phospho PERK in liver and subcutaneous adipose tissue of obese mice and lean mice administered with tunicamycin. Both polyphenols increased the mRNA abundance of XBP1s and BiP and reduced that of CHOP in both organs. These changes in proten phosphorylation and gene expression were accompanied with reduced hepatic steatosis and adipocyte hypertrophy.

Conclusions

The supplementation with plant polyphenols such as genistein or resveratrol reduced ER stress markers in liver and adipose tissue of obese mice and lean mice administerd with tunicamycin.

Funding Sources

This work is supported by a grant from CONACYT, Mexico to ITV Grant No. A1-S-41,077.

SAT-388 Dry Cough as Only Sign of a Parathyroid Adenoma Producer of PTH

BACKGROUND: The parathyroid adenoma producing an excess of PTH is characterized by hypercalcemia, asthenia, physical weakness and renal lithiasis. This clinical case is presented only with a dry (non-productive) cough sign of long duration.CASE: 51-year-old female born in Padre Las Casas, D.R. presenting with chief complain of dry cough for about four years. Clinical findings: (03/13/2019) Height 62”, Weight 142 lbs, Temperature 36.2 Celsius, BP 90/60 mmHg, RR 16 rpm, HR 60 bpm, on her neck no adenopathies or thyroid changes. Occasional coughing. A sonographic evaluation of the neck (04/09/2019) reveals a solid, heterogeneous nodular image of 0.7 cm x 0.5 cm in the left lobe of the Thyroid (Fig. 1) which by FNAB (04/10/2019) showed a benign adenomatoid node with cystic changes (Bethesda II) (Fig. 2). TEST: (03/20/2019) anti-TG 0.10 IU/mL (NV -115), anti-TPO 9.00 IU/mL (NV -34), TG 9.41 (NV -78 ng/mL), TSH 0.34 μIU/mL (VN 0.27-4.20), free T3 2.05 pg/mL (NV 2.04-4.40), total T3 0.74 ng/mL (NV 0.83-2.00), total T4 8.46 μg/dL (NV 5.1-14.1), free T4 1.61 ng/dL (NV 0.93-1.71) Calcium 10.4 mg/dL (NV 8.1-10.4), Phosphorus 2.6 mg/dL (NV 2.5-4.5), PTH-Intact 157 pg/mL (NV 14.5-87.1) Thyroid-Parathyroid scintigraphy (Sestamibi-Technetium 99mTc04: 15 mCi) (04/23/2019) shows lower left Parathyroid Adenoma (Fig. 3). She undergoes surgery (05/23/2019) removing the left thyroid lobe and left inferior parathyroid gland whose pathology shows chronic nodular colloid goiter, with areas of hemorrhage. Parathyroid adenoma of main cells (Fig. 4-5). Post-surgical TEST (06/24/2019) PTH-intact 69.0 pg/mL (NV 14.5-87.1), Calcium 8.6 mg/dL (NV 8.1-10.4), Phosphorus 2.7 mg/dL (NV 2.5-4.5), anti-TG 10.0 IU/mL (NV &lt;115), anti-TPO 9.00 IU/mL (NV &lt;34), TG 8.92 ng/mL (NV &lt;78), total T3 0.68 ng/mL (NV 0.83-2.00), free T3 1.95 pg/mL (NV 2.04-4.40), total T4 6.40 μg/dL (NV 5.1-14.1), free T4 1.02 ng/dL (NV 0.93-1.71). Post-surgical clinical evaluation (06/21/2019) Weight 142 lbs, Temperature 36.5 Celsius, BP 110/70 mmHg, RR 16 rpm, HR 60 bpm. Patient has not shown signs of coughing. Last TESTS (10/20/2019) Calcium 9.40 mg/dL, Phosphorus 3.10 mg/dL, PTH-intact 24.40 pg/mL, TG 11.90 ng/mL, total T4 6.80 μg/dL, free T4 1.23 ng/dL, total T3 0.88 ng/mL, free T3 2.66 pg/mL, anti-TPO 11.14 IU/mL, anti-TG 10 IU/mL. CONCLUSIONS: Lower left (benign) parathyroid adenoma whose clinical manifestations are not common. Dry (non-productive) cough is not known as a manifestation of elevated PTH-intact. Calcium and Phosphorus levels in normal values. In addition, histological alterations of the left thyroid lobe of benign character with few manifestations of hormonal alterations and normal antibodies. It is of crucial clinical importance to observe and document more cases with similar presentation in order to identify the possible causes of cough with an elevated PTH manifestation.

HIV self-tests for men who have sex with men, accessed via a digital vending machine: a qualitative study of acceptability

As the number of people living with undiagnosed HIV infection in the UK declines, innovative ways to access those least engaged with services are needed. This study explores the attitudes of men who have sex with men (MSM) towards using HIV self-testing (HIVST) kits distributed via a vending machine in a sauna (a licenced sex-on-premise venue). Twenty-three MSM attending the sauna were recruited to take part in semi-structured qualitative interviews. The participants were overwhelmingly positive about the HIVST vending machine. They identified convenience and flexibility as major benefits to testing in this way. The sauna was felt to be an appropriate location for the intervention. Limitations identified included the potential to reduce screening for other sexually transmitted infections and the inappropriate use of HIVST kits as a tool for risk-assessment prior to condomless sex, with a poor understanding of the window period. The implications of receiving a positive result without immediate access to support were also a concern. HIVST vending machines are an acceptable, innovative way to encourage HIV testing. Providers need to ensure this intervention is supported by adequate information regarding the limitations of the test and how to access comprehensive services to avoid any unintended negative effects.

207 Editing of prostaglandin E2 gene receptors EP2 and EP4 by CRISPR/Cas9 technology in equine adipose mesenchymal stem cells

Prostaglandin E2 (PGE2) is an important mediator of cellular responses, playing a key role in limiting inflammation. PGE2 acts distinctly through one of four EP receptors. In MSCs, it PGE2 stimulation of EP2 and EP4 receptors triggers processes such as migration, self-renewal, survival, and proliferation, and their activation is involved in homing. PGE2 has been proposed as a key factor of MSC immunomodulation. The CRISPR-Cas9 system has been adapted successfully to edit the genome of animals. Loss of EP2 and EP4 receptors in equine adipose mesenchymal stem cells (eAT-MSC) could help us understand their role in cell migration, homing, and self-renewal capacities. Here, we aimed to edit these receptors in eAT-MSC to test their function. The eAT-MSC were obtained from three Chilean breed horses and cultured in Dulbecco's modified Eagle's medium-high glucose with 10% fetal bovine serum. Guide RNAs (sgRNA) for CRISPR-Cas 9 editing were designed based on EP2 and EP4 DNA sequences. The sgRNA and PAM sequence targeting exon 1 of the equine genes (EP2-sgRNA: TGGTGCTGGCTTCGTACGCG; PAM:CGG and EP4-sgRNA: GGAGACGACCTTCTACACGT;PAM:TGG) were cloned into linearized LentiCRISPRv2GFP vector (#82416; Addgene). The lentiviral vector plus helping packaging plasmids was co-transfected into HEK293FT cells. The produced viral particles were harvested and transduced into eAT-MSC. After 48h, cells were sorted and green fluorescent protein (GFP)-positive cells were expanded to obtain individual clones. Genomic DNA was extracted for PCR amplification, and the frequency of site directed-mutation was assessed by T7 endonuclease assay. Because of the high background (e.g. excessive banding) produced by the T7E1 assay, the PCR products were cloned into a pUC57 vector, and sequenced. Quantitative PCR and immunocytochemistry staining examined expression of EP2 and EP4. The statistical analyses were performed using GraphPad Prism 6 (GraphPad Inc.) with unpaired t-test; P-values&lt;0.05 were considered statistically significant. Transduction efficiency of eAT-MSC/EP2ko and eAT-MSC/EP4ko was 31 and 38%, respectively. A total of 15 clones for each lineage obtained from a single cell culture were subjected to T7EI assay to identify the frequency of mutation. Eight eAT-MSC/EP2ko and 7 eAT-MSC/EP4ko clones showed mutations; DNA sequencing confirmed mutations in 3 eAT-MSC/EP2ko clones and 3 eAT-MSC/EP4ko clones. Immunostaining with specific anti-EP2 and anti-EP4 antibodies showed diminished expression of the particular receptors in the knockout cells. Decreased expression was quantitatively confirmed by quantitative PCR analysis, showing downregulation of PTGER2 (4.3-fold) and PTGER4 (2.7-fold) in the edited clones compared with eAT-MSC naïve cells (P&lt;0.05). This CRISPR/Cas9 design allows the possibility of using these mutant cell lines as a model system to elucidate the role of EP2 and EP4 in cell migration, homing, and self-renewal. Research was supported by FONDECYT 3170390 to ACFM, Ministry of Education, Chile.

Endoscopic duodenal mucosal resurfacing improves glycaemic and hepatic indices in type 2 diabetes: 6-month multicentre results

Insulin resistance is a core pathophysiological defect underscoring type 2 diabetes mellitus (T2DM) and non-alcoholic fatty liver disease (NAFLD). Both conditions improve with duodenal exclusion surgery. Duodenal mucosal resurfacing (DMR) is an endoscopic intervention developed to treat metabolic disease which has been shown to improve glycaemia in patients with poorly controlled T2DM. Herein, we aimed to further analyse the effects of DMR on hepatic and metabolic parameters in this patient cohort.

Methods

Eighty-five patients with T2DM who received endoscopic DMR treatment were enrolled from 5 centres and followed up for 6 months. We assessed safety in all patients. Efficacy was evaluated in patients who received at least 9 cm of duodenal ablation (n = 67). Endpoints included HbA1c, fasting plasma glucose, weight and aminotransferase levels. Metabolomic analysis was conducted in a subgroup (n = 14). Data were analysed using paired t test or ANOVA for repeated measures with Bonferroni correction and correction for initial weight loss if applicable.

Results

The DMR procedure was completed with no intraprocedural complications in the entire cohort. HbA1c was lower 6 months after DMR than at baseline (7.9 ± 0.2% vs. 9.0 ± 0.2% [mean ± SE], p ≪0.001). Fasting plasma glucose was also significantly lower 6 months after DMR compared to baseline (161 ± 7 mg/dl vs. 189 ± 6 mg/dl, p = 0.005). Body weight decreased slightly. At 6 months, alanine aminotransferase had decreased from 41 ± 3 IU/L to 29 ± 2 IU/L (p ≪0.001) and aspartate aminotransferase had decreased from 30 ± 2 IU/L to 23 ± 1 IU/L (p ≪0.001). Metabolomic analysis demonstrated that DMR had key lipid-lowering, insulin-sensitizing and anti-inflammatory effects, as well as increasing antioxidant capacity. Mean FIB-4 was also markedly decreased.

Conclusion

Hydrothermal ablation of the duodenum by DMR elicits a beneficial metabolic response in patients with T2DM. DMR also improves hepatic indices, potentially through an insulin-sensitizing mechanism. These encouraging data deserve further evaluation in randomized controlled trials.

Lay summary

Hydrothermal duodenal mucosal resurfacing (DMR) is an endoscopic technique designed to treat metabolic disease through ablation of the duodenal mucosa. DMR is a safe procedure which improves glycaemia and hepatic indices in patients with type 2 diabetes mellitus. DMR is an insulin-sensitizing intervention which can be complementary to lifestyle intervention approaches and pharmacological treatments aimed at preserving the pancreas and liver from failure. DMR is a potential therapeutic solution for patients with type 2 diabetes and fatty liver disease.

P6471Pronostic impact of significant valvular disease in long-term survivors of out-of-hospital-cardiac arrest

Background

There is scarce evidence about the prevalence and clinical relevance of moderate to severe valvular heart disease (VHD) in survivors of out of hospital cardiac arrest (OHCA).

Purpose

To determine whether VHD influence prognosis of OHCA survivors.

Methods

All consecutive patients admitted to the Acute Cardiac Care Unit after OHCA and surviving until hospital discharge were included. All patients received targeted-temperature management according to our local protocol. Univariate and multivariate Cox-proportional hazard models were employed.

Results

A total of 201 patients were included in the analysis. Mean age was 57.6±14.2 years and 168 (83.6%) were male. Eighteen patients (9.0%) had moderate or severe VHD during index admission (Table 1). Patients with VHD were less frequently of male sex, [11 (61.1%) vs 157 (85.8%), p=0.014], experienced less acute coronary syndrome-related arrhytmias [2 (11.1%) vs 85 (46.5%), p=0.005], and had a lower pH at hospital admission (6.9±1.6 vs 7.2±0.15, p=0.008). During a median follow-up of 40.3 (18.9–69.1) months, patients with VHD showed higher mortality [7 (38.9%) vs 28 (15.3%), p=0.004] and more heart failure-related admissions [7 (38.9%) vs 15 (8.2%), p<0.001]. Only five patients received surgical or percutaneous treatment for VHD during follow-up, with no deaths in this subgroup. Moderate or severe VHD proved to be an independent predictor of global cardiovascular events and specifically heart failure episodes (Figure 1).

Table1 Variable With valvular disease Without valvular disease p value Age, mean±DS, years 63.5±13.2 57.0±14.1 0.066 Hypertension, n (%) 12 (66.7) 95 (51.9) 0.231 Diabetes, n (%) 5 (27.8) 24 (13.1) 0.149 Dyslipidaemia, n (%) 7 (38.9) 79 (43.2) 0.726 Smokin habit, n (%) 4 (22.2) 90 (49.2) 0.045 Witnessed cardiac arrest, n (%) 18 (100) 175 (95.6) 1.000 Time from CA to ROSC, mean±DS, minute 19.1±7.5 21.2±13.1 0.506 Shockable rhythm, n (%) 13 (72.2) 163 (89.1) 0.055 LVEF at hospital discharge (%) 42.8±12.1 46.9±14.6 0.254

Figure 1

Conclusion

The presence of significant VHD in survivors after OHCA is a predictor of poor outcomes. Specific management of VHD may be specially relevant in this high-risk patients and guideline-oriented therapy, including surgery and percutaneous intervention should be encouraged when indicated.

P5349Platelet/lymphocyte ratio as an inflammatory marker and predictor of short-term neurological outcomes in survivors after cardiac arrest

Background

Platelet/lymphocyte ratio (PLR), an inflammatory marker associated with poor outcomes in different clinical situations, may play a role in the proinflammatory state triggered during hypoxic-ischemic brain injury secondary to cardiac arrest.

Purpose

To study PLR dynamics and its relationship with neurologic outcomes in survivors after CA treated with target-temperature-management (TTM).

Methods

Observational retrospective study from a prospective database of survivors of in-hospital and out-of-hospital CA admitted to our Acute Cardiac Care Unit between August 2006 to December 2018. All patients received TTM according to our local protocol.

Results

A total of 466 patients were included. Mean age was 62.7±14.4 years and 102 (21.9%) were women. Baseline characteristics are shown in Table 1. 430 (92.2%) of CA were witnessed, 312 (67.0%) had ventricular fibrillation as initial cardiac rhythm. Among them, 236 (51.1%) survived until hospital discharge and 208 (45.1%) presented favorable neurological outcomes (a score 1 or 2 on cerebral performance category (CPC)). The mean value of PLR at admission and during targeted temperature was 100.4±5.2 and 224.5±7.3 respectively (mean difference 123.1±7.1, p<0.0001). This increase in PLR was significantly higher among patients with worse neurological outcomes (CPC 3–5, mean DPLR 138.2±5.5) at 3 months compared with survivors with CPC 1–2 (mean DPLR 108.2±6.3, p=0.0348 for paired comparison between both groups).

Table 1 Hypertension, n (%) 235 (54.9) Diabetes, n (%) 113 (26.4) Dyslipidaemia, n (%) 171 (40.0) Smocking habit, n (%) 208 (48.5) Time to ROSC mean ± SD, min 26.6±18.6 Mean arterial pressure at HA mean±DS, mmHg 81.3±22.1 pH at HA mean ± SD 7.18±0.16 Lactic at HA mean ± SD 6.37±4.42 ROSC: return of spontaneus circulation; HA: hospital admission.

Conclusion

Our findings reflect the impact of inflammation in neurological outcomes after OHCA treated with TTM. Major increases of PLR constitute a novel marker of poor prognosis during early assessment of OHCA patients.

Duodenal mucosal resurfacing: proof-of-concept, procedural development, and initial implementation in the clinical setting

BACKGROUND AND AIMS

We aimed to develop duodenal mucosal resurfacing (DMR), a minimally invasive upper endoscopic hydrothermal ablation procedure, to treat insulin-resistant metabolic diseases.

METHODS

We completed a sham-controlled, rodent proof-of-concept study and longitudinal safety study in pigs to demonstrate feasibility to test DMR in humans. Subsequently, the DMR procedure was implemented in an open-label first-in-human (FIH) study of safety and efficacy in patients with type 2 diabetes (T2D).

RESULTS

In rats, duodenal abrasion reduced hyperglycemia by 59 mg/dL on average, compared with no change from baseline in the sham treatment arm (P < .05). In pigs, the balloon catheter successfully and safely delivered hydrothermal ablation to the duodenal mucosa and superficial submucosa. Complete mucosal healing was demonstrated by week 6. In the FIH study, hydrothermal ablation was successfully administered with no evidence of perforation, pancreatitis, or hemorrhage. Duodenal biopsy specimens obtained 3 months postprocedure demonstrated full mucosal regrowth. No inflammation was observed, and there was minimal-to-mild collagen banding deposition observed in a proportion of ablation site biopsy specimens with no evidence of fibrotic scarring. Glycemic and hepatic measures improved through 6 months of follow-up.

CONCLUSIONS

DMR shows potential as an endoscopic intervention that improves glycemic and hepatic parameters in patients with T2D. Further mechanistic and clinical studies are underway to further explore DMR as a treatment for metabolic disease.

Outcomes of patients with severe tricuspid regurgitation and congestive heart failure

Objectives

A substantial number of patients with severe tricuspid regurgitation (TR) and congestive heart failure (CHF) are medically managed without undergoing corrective surgery. We sought to assess the characteristics and outcomes of CHF patients who underwent tricuspid valve surgery (TVS), compared with those who did not.

Methods

Retrospective observational study involving 2556 consecutive patients with severe TR from the Cleveland Clinic Echocardiographic Database. Cardiac transplant patients or those without CHF were excluded. Survival difference between patients who were medically managed versus those who underwent TVS was compared using Kaplan-Meier survival curves. Multivariate analysis was performed to identify variables associated with poor outcomes.

Results

Among a total of 534 patients with severe TR and CHF, only 55 (10.3%) patients underwent TVS. Among the non-surgical patients (n=479), 30% (n=143) had an identifiable indication for TVS. At 38 months, patients who underwent TVS had better survival than those who were medically managed (62% vs 35%; p<0.001). On multivariate analysis, advancing age (HR: 1.23; 95% CI 1.12 to 1.35 per 10-year increase in age), moderate (HR: 1.39; 95% CI 1.01 to 1.90) and severe (HR: 2; 95% CI 1.40 to 2.80) right ventricular dysfunction were associated with higher mortality. TVS was associated with lower mortality (HR: 0.44; 95% CI 0.27 to 0.71).

Conclusion

Although corrective TVS is associated with better outcomes in patients with severe TR and CHF, a substantial number of them continue to be medically managed. However, since the reasons for patients not being referred to surgery could not be ascertained, further randomised studies are needed to validate our findings before clinicians can consider surgical referral for these patients.

CD32-RNA Co-localizes with HIV-RNA in CD3+ Cells Found within Gut Tissues from Viremic and ART-Suppressed Individuals

BACKGROUND

Identifying biomarkers for cells harboring replication-competent HIV is a major research priority. Recently, there have been mixed reports addressing the possibility that CD32-expressing T cells are enriched for HIV. There is growing evidence that CD32 expression increases with cellular activation that may be related to, but not necessarily specific for, infection with HIV. However, the relationship of CD32 expression to HIV-infection in subtypes of tissue-resident leukocytes is unclear.

METHODS

First, we used duplex chromogenic in situ hybridization to identify cells actively transcribing RNA for both CD32 and HIV on human gut tissues. Then we performed multiplexed immunofluorescence and in situ hybridization (mIFISH) on sections from the same tissues to determine the phenotype of individual cells co-expressing HIV-RNA and CD32-RNA.

RESULTS

HIV-RNA+ cells were more abundant in tissues from viremic individuals than in those receiving suppressive anti-retroviral therapy (ART). However, staining by both methods indicated that a higher proportion of HIV-RNA+ cells co-expressed CD32-RNA in ART-suppressed individuals than in those with viremia. The majority of HIV-RNA+ cells were CD3+.

CONCLUSIONS

Our data suggest that the transcription of CD32-RNA is correlated with HIV transcriptional activity in CD3+ cells found within human gut tissue. Whether or not up-regulation of CD32-RNA is a direct result of HIV transcription or more global T-cell activation remains unclear.