Prognosis implications of quantified mitral regurgitation stratified by left atrial function in HFrEF population

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

The debate about the independent prognostic responsibility of functional mitral regurgitation (FMR) is still in turmoil. Growing findings about the predictive role of left atrial (LA) function are emerging in several scenarios.

PURPOSE

This study aims to define FMR linkage to cardiovascular (CV) outcomes and the interplay with LA function in a prospective cohort of consecutive heart failure patients with reduced ejection fraction (HFrEF).

METHODS

286 consecutive outpatients with chronic HFrEF were enrolled. FMR was quantified by effective regurgitant orifice area (EROA). Global peak atrial longitudinal strain (PALS) was measured by speckle tracking echocardiography (STE). The primary endpoint was defined as a composite of congestive HF hospitalization and CV death.

RESULTS

The majority (81%) of patients were men (mean age: 67 ± 11 years, mean LVEF: 32 ± 6%). The median global PALS was 17.7% ranging from 2.7% to 49.2%. FMR was quantifiable in 240 (84%) patients. During a median follow-up period of 6.4 (IQR 3.9-7.7) years, the primary endpoint occurred in 88 (31%) patients (35 HF admissions, and 53 deaths). EROA showed independent prediction for the primary endpoint (HR 1.30 [1.05-1.57], P = 0.01). The spline modeling of the risk by EROA values showed an excess event risk starting at about the EROA value of 0.1 cm2 (Figure 1). There was a remarkable graded association between the EROA strata, even if tested per 0.1 cm2 increase, and the risk of congestive HF hospitalization and CV death (P = 0.0004). Any FMR grade presenting with reduced LA function (PALS < 14%) was associated with dismal outcome (event rate of 63 ± 10% for EROA exceeding 0.3 cm2 and 49 ± 6% for EROA ≥0.1 cm2 at 5 years). Conversely, the presence of EROA ≥0.1 in the context of preserved global PALS showed a better outcome (Figure 2).

CONCLUSIONS

Our results refine the independent association between FMR and CV outcome among HFrEF outpatients. The risk of CV events starts at a low EROA value, reaching a severe level above the threshold of 0.3 cm2. Within a moderate EROA range, the LA function mitigates the clinical consequences of the mitral regurgitation, providing measurable proof of the interplay between the regurgitation and the LA compliance. Abstract Figure 1  Abstract Figure 2

An evidence map and synthesis review with meta-analysis on the risk of incisional hernia in colorectal surgery with standard closure

PURPOSE

To assess the incidence of incisional hernia (IH) across various type of incisions in colorectal surgery (CS) creating a map of evidence to define research trends, gaps and areas of future interest.

METHODS

Systematic review of PubMed and Scopus from 2010 onwards. Studies included both open (OS) and laparoscopic (LS). The primary outcome was incidence of IH 12 months after index procedure, secondary outcomes were the study features and their influence on reported proportion of IH. Random effects models were used to calculate pooled proportions. Meta-regression models were performed to explore heterogeneity.

RESULTS

Ninetyone studies were included reporting 6473 IH. The pooled proportions of IH for OS were 0.35 (95% CI 0.27-0.44) I² 0% in midline laparotomies and 0.02 (95% CI 0.00-0.07), I² 52% for off-midline. In case of LS the pooled proportion of IH for midline extraction sites were 0.10 (95% CI 0.07-0.16), I² 58% and 0.04 (95% CI 0.03-0.06), I² 86% in case of off-midline. In Port-site IH was 0.02 (95% CI 0.01-0.04), I² 82%, and for single incision surgery (SILS) of 0.06-95% CI 0.02-0.15, I² 81%. In case of stoma reversal sites was 0.20 (95% CI 0.16-0.24).

CONCLUSION

Midline laparotomies and stoma reversal sites are at high risk for IH and should be considered in research of preventive strategies of closure. After laparoscopic approach IH happens mainly by extraction sites incisions specially midline and also represent an important area of analysis.

Astonishing response to Cetuximab in metastatic nasopharyn- geal carcinoma: a case report

Abstract

Nasopharyngeal carcinoma, one of the most common head and neck cancers in Southeast Asia, is uncommon in Western countries and it is frequently diagnosed in advanced stage. Chemotherapy given with radiation therapy, followed by more chemotherapy, is the standard of care of stage IV nasopharyngeal carcinoma but Cetuximab, an epidermal growth factor (EGFR) inhibitor, is now making its way in the treatment of locoregionally advanced nasopharyngeal carcinoma. We report a case of 58 years old patient with metastatic nasopharyngeal carcinoma with an astonishing response to Cetuximab. At the time of writing, the patient is still in treatment with Cetuximab with excellent disease control.

SARS-CoV-2 antibody dynamics and transmission from community-wide serological testing in the Italian municipality of Vo'

In February and March 2020, two mass swab testing campaigns were conducted in Vo', Italy. In May 2020, we tested 86% of the Vo' population with three immuno-assays detecting antibodies against the spike and nucleocapsid antigens, a neutralisation assay and Polymerase Chain Reaction (PCR). Subjects testing positive to PCR in February/March or a serological assay in May were tested again in November. Here we report on the results of the analysis of the May and November surveys. We estimate a seroprevalence of 3.5% (95% Credible Interval (CrI): 2.8-4.3%) in May. In November, 98.8% (95% Confidence Interval (CI): 93.7-100.0%) of sera which tested positive in May still reacted against at least one antigen; 18.6% (95% CI: 11.0-28.5%) showed an increase of antibody or neutralisation reactivity from May. Analysis of the serostatus of the members of 1,118 households indicates a 26.0% (95% CrI: 17.2-36.9%) Susceptible-Infectious Transmission Probability. Contact tracing had limited impact on epidemic suppression.

Impact of channels identification and ablation in ventricular tachycardia patients through high-density mapping: preliminary experience from an Italian registry

Funding Acknowledgements

Type of funding sources: None.

Background

Ventricular tachycardia (VT) ablation techniques in ischemic cardiomyopathy have evolved during the recent years. However, the long-term success rate remains disappointing. A technique based on channel identification and ablation through a novel automated algorithm may limit the extent of ablation needed and possibly lead to higher successful rate.

Purpose

To report preliminary data on feasibility and safety of a channel identification approach and to characterize late potentials (LPs) features using an ultra-high density mapping system with a novel analysis tool in ischemic VT procedures.

Methods

Consecutive patients (pts) indicated for ischemic VT ablation were enrolled in the CHARISMA study. A complete map of the left ventricle was performed prior and after ablation through the Rhythmia mapping system. For our purpose channels were defined as any signal activity bounded by anatomic and functional barriers and characterized through a novel map analysis tool (Lumipoint-LM-) that automatically identifies fragmented late potentials (LPs) and continuous activation was used on the whole ventricular substrate. Procedural endpoint was the elimination of all identified conducting channels (CCs) by ablation at the CC entrance and exit followed by abolition of any residual LPs inside the CC. The ablation endpoint was noninducibility.

Results

A total of 18 channels were identified through LM from 14 pts: 71.4% of the pts had 1 CC, 28.6% had 2 CCs. In the majority of the cases LPs where identified only inside CCs (57.1%), whereas in 6 cases (42.9%) LPs were present both inside and outside. The mean conduction time inside CCs was 50.3 ± 30ms, the mean CC length was 32.6 ± 17mm and the conduction velocity was 0.8 ± 0.5 mm/ms. LPs covered a mean area of 7.0 ± 5mm2 (ratio between LPs area and CCs’ area = 52.4 ± 33.7%). At voltage map analysis 1 CC was present in 78.6% of the cases (2 CCs in 21.4%). LPs were identified only inside CCs in 42.9% of the cases, both inside and outside in 50% and only outside in 7.1%. Healthy tissue (voltage level≥0.5mV) was prevalent (61.2 ± 13.8%), followed by intermediate voltage areas (0.5-0.05mV; 37.5 ± 13.7%) and very low voltage areas (<0.05mV; 1.2 ± 2%). LPs were found mostly at intermediate voltage areas (54.1 ± 31.7% of the covered area; 39.1 ± 28.4% at healthy tissue and 6.8 ± 17.8% at very low voltage areas). Agreement in CCs identification between advanced analysis through LM and voltage map was fair (9/14 with complete agreement). In 3 cases voltage map overestimated LPs areas, in 2 cases failed to fully identify LPs. All CCs’ entrance and exit were successfully ablated and abolition of any residual LPs inside the CC was achieved in all pts. No complication occurred. Noninducibility was achieved in all the cases.

Conclusions

In our preliminary experience, a new channel identification approach through the advanced Lumipoint algorithm seems to be safe, feasible and effective at least in the acute setting of ischemic VT ablation.

Minimal fluoroscopic approaches and factors associated with radiation dose when high-definition mapping is used for supraventricular tachycardia ablation: insight from the CHARISMA registry

Funding Acknowledgements

Type of funding sources: None.

Background

Limited data exist on factors associated with radiation exposure during ablation procedures when a high definition mapping technology is used.

Purpose

To report factors associated with radiation exposure and data on feasibility and safety of a minimal fluoroscopic approach using the Rhythmia mapping system in supraventricular tachycardia (SVT) ablation procedures.

Methods

Consecutive patients indicated for arrhythmia ablation were enrolled in the CHARISMA study at 12 centers. We included in this analysis consecutive right-side procedures performed through a minimal fluoroscopy approach with the Rhythmia mapping system were analyzed. A 3D geometry of chambers of interest was reconstructed on the basis of the electroanatomic information taken from the mapping system. Fluoroscopy was used only if deemed necessary. The effective dose (ED) was calculated using accepted formula. For our purpose high dose exposure was defined as an ED greater than the median value of ED of the population exposed to radiation.

Results

This analysis included 325 patients (mean age = 56 ± 17 years, 57% male) undergoing SVT procedures (152 AVNRT, 116 AFL, 41 AP and 16 AT). During the study, 27481 seconds of fluoroscopy was used (84.6 ± 224 seconds per procedure), resulting in a mean equivalent ED of 1.1 ± 3.7 mSv per patient. The mean reconstructed RA volume was 99 ± 54 ml in a mean mapping time of 12.2 ± 7 min. The mean number of radiofrequency ablations (RFC) to terminate each arrhythmia was 9.4 ± 9 (mean RFC delivery time equal to 6.7 ± 6 min). 192 procedures (59.1%) were completed without any use of fluoroscopy; during the remaining 133 procedures (39.9%), 206.6 ± 313.4 seconds of fluoroscopy was used (median ED = 1.2 mSv). In a minority of the cases (n = 25, 7.7%) the fluoroscopy time was higher than 5 minutes (median ED = 6.5 mSv), whereas radiologic exposure time greater than 1 minute occurred in ninety cases (27.7%, median ED = 2.1 mSv). On multivariate logistic analysis adjusted for baseline confounders the RFC application time (OR = 1.0014, 95%CI: 1.0007 to 1.0022; p = 0.0001) was independently associated to an ED greater than 1.2 mSv, whereas female gender had an inverse association (0.54, 0.29 to 0.98; p = 0.0435). Acute success was reached in 97.8% of the cases. During a mean of 290.7 ± 169.6 days follow-up, no major adverse events related to the procedure were reported. Overall, the recurrence rate of the primary arrhythmia during follow-up was 2.5%.

Conclusions

In our experience, arrhythmias ablation through minimal fluoroscopy approach with the use of a novel ablation technology is safe, feasible, and effective in common right atrial arrhythmias. High-dose exposure occurred in a very limited number of cases, without any reduction of the safety and acute and long-term effectiveness profile.

Preparation, properties, and applications of magnetic hematite microparticles

Hematite microparticles are becoming increasingly important components in the soft matter field. The remarkable combination of magnetic and photocatalytic properties that characterize them, coupled with the variety of uniform and monodisperse shapes that they can be synthesized in, makes them a one of a kind colloidal model system. Thanks to these properties, hematite microparticles have been recently applied in several important soft matter applications, spanning from novel colloidal building blocks for self-assembly to necessary tools to investigate and understand fundamental problems. In this review article we provide a detailed overview of the traditional methods available for the preparation of hematite microparticles of different shapes, devoting special attention on some of the most common hiccups that could hider a successful synthesis. We furthermore review the particles' most important physico-chemical properties and their most relevant applications in the soft matter field.

Review: Chestnut and quebracho tannins in pig nutrition: the effects on performance and intestinal health

Natural extracts are frequently adopted as a valuable alternative to antibiotics in intensive animal farming. Their diverse bioactive constituents such as phytosterols, glucosinolates, carotenoids and polyphenols have shown antioxidant, anti-inflammatory and antibacterial effects. Tannins are the largest class of polyphenol compounds of plant extracts, which can be classified into two hydrolysable or condensed subgroups. Poultry and swine nutrition are the most important sectors in which tannins have been used, firstly adopting tannin-rich feedstuffs and more recently, using tannin extracts from different plants. Several commercial products are available containing tannins extracted from the European chestnut tree (Castanea sativa Mill.) and the American quebracho (Schinopsis spp.). Tannins extracted from these plants have been applied on intensive swine farms due to their ability to improve animal performance and health. These positive and prominent effects are frequently associated with the antinutritional effects in reducing feed palatability, digestibility and protein utilization of feed. Some criticisms and contrasting results regarding pig performance and intestinal health have been reported. This paper provides an overview of the effects of chestnut and quebracho tannins on growth performance and intestinal health of pigs in order to clarify the appropriate dosage and response in the various physiological stages.

Minimal fluoroscopy approach in current clinical practice with a novel ablation technology for supraventricular tachycardia: a large multicenter experience from an Italian registry

Background

Electrophysiological studies and ablation procedures expose both physicians and patients to a large amount of radiation. Most of 3-D mapping systems provide improved tracking of catheters, possibly allowing relevant reductions in radiation exposure. No data exists on the ability of the Rhythmia mapping system to minimize fluoroscopy time and dose.

Purpose

To report preliminary data on feasibility and safety of a minimal fluoroscopic approach using the Rhythmia mapping system in supraventricular tachycardia (SVT) procedures.

Methods

Consecutive patients indicated for arrhythmia ablation were enrolled in the CHARISMA study at 12 centers. For our purpose consecutive right-side procedures performed through a minimal fluoroscopy approach with the Rhythmia mapping system were analyzed. A 3D geometry of chambers of interest was reconstructed on the basis of the electroanatomic information taken from the mapping system. Fluoroscopy was used only if deemed necessary.

Results

This analysis included 266 patients (mean age = 57±17 years, 57% male) undergoing SVT procedures (120 AVNRT, 91 AFL, 32 AP, 11 AT and 12 other right atrial procedures). In all cases, diagnostic EP and ablation catheters were positioned using a low fluoroscopic electroanatomic guided approach. The mean fluoroscopy time needed for each procedure was 55±128 s. The median reconstructed RA volume was 92 [63–131] ml in a median mapping time of 11 [7–17] min. The median number of radiofrequency ablations to terminate each arrhythmia was 6 [3–12] (total RF delivery time of 291 [180–505] s). Sixty-five percent of the procedures (n=174) were completed with less than 10 s of fluoroscopy. Low fluoroscopy approach with less than 10 s (minimal fluoroscopy approach) was most frequently obtained in case of AVNRT (91, 76%) compared to other arrhythmias' ablation (83, 57%, p=0.001) Achievement of a minimal fluoroscopic approach was not affected by operator's experience (65% vs 66%, p=1.00, respectively within physician with more or less of 10 years of active practice), whereas it was affected by presence of a fellow in training during the procedure (72% without fellow vs 26% with fellow, p<0.0001). A 100% rate of acute success was observed, and no procedure-related complications occurred. At multivariate logistic regression analysis adjusted for baseline confounders, both the total number of RF ablations (OR: 0.93 (95% CI:0.88 to 0.96; p=0.0053) and the presence of a fellow in training during the procedure (OR: 0.29; 95% CI: 0.1 to 0.87; p=0.0278) had an inverse association to the achievement of a minimal fluoroscopic approach.

Conclusions

In our preliminary experience, arrhythmias' ablation through minimal fluoroscopy approach with the use of a novel ablation technology seems to be safe, feasible, and effective in common right atrial arrhythmias. Use of fluoroscopy can be dramatically reduced in most cases, without any reduction of the safety and acute effectiveness profile.

Funding Acknowledgement

Type of funding source: None

Caveolin1 and YAP drive mechanically induced mesothelial to mesenchymal transition and fibrosis

Despite their emerging relevance to fully understand disease pathogenesis, we have as yet a poor understanding as to how biomechanical signals are integrated with specific biochemical pathways to determine cell behaviour. Mesothelial-to-mesenchymal transition (MMT) markers colocalized with TGF-β1-dependent signaling and yes-associated protein (YAP) activation across biopsies from different pathologies exhibiting peritoneal fibrosis, supporting mechanotransduction as a central driving component of these class of fibrotic lesions and its crosstalk with specific signaling pathways. Transcriptome and proteome profiling of the response of mesothelial cells (MCs) to linear cyclic stretch revealed molecular changes compatible with bona fide MMT, which (i) overlapped with established YAP target gene subsets, and were largely dependent on endogenous TGF-β1 signaling. Importantly, TGF-β1 blockade blunts the transcriptional upregulation of these gene signatures, but not the mechanical activation and nuclear translocation of YAP per se. We studied the role therein of caveolin-1 (CAV1), a plasma membrane mechanotransducer. Exposure of CAV1-deficient MCs to cyclic stretch led to a robust upregulation of MMT-related gene programs, which was blunted upon TGF-β1 inhibition. Conversely, CAV1 depletion enhanced both TGF-β1 and TGFBRI expression, whereas its re-expression blunted mechanical stretching-induced MMT. CAV1 genetic deficiency exacerbated MMT and adhesion formation in an experimental murine model of peritoneal ischaemic buttons. Taken together, these results support that CAV1-YAP/TAZ fine-tune the fibrotic response through the modulation of MMT, onto which TGF-β1-dependent signaling coordinately converges. Our findings reveal a cooperation between biomechanical and biochemical signals in the triggering of MMT, representing a novel potential opportunity to intervene mechanically induced disorders coursing with peritoneal fibrosis, such as post-surgical adhesions.

Suppression of a SARS-CoV-2 outbreak in the Italian municipality of Vo'

On 21 February 2020, a resident of the municipality of Vo', a small town near Padua (Italy), died of pneumonia due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection¹. This was the first coronavirus disease 19 (COVID-19)-related death detected in Italy since the detection of SARS-CoV-2 in the Chinese city of Wuhan, Hubei province². In response, the regional authorities imposed the lockdown of the whole municipality for 14 days³. Here we collected information on the demography, clinical presentation, hospitalization, contact network and the presence of SARS-CoV-2 infection in nasopharyngeal swabs for 85.9% and 71.5% of the population of Vo' at two consecutive time points. From the first survey, which was conducted around the time the town lockdown started, we found a prevalence of infection of 2.6% (95% confidence interval (CI): 2.1-3.3%). From the second survey, which was conducted at the end of the lockdown, we found a prevalence of 1.2% (95% CI: 0.8-1.8%). Notably, 42.5% (95% CI: 31.5-54.6%) of the confirmed SARS-CoV-2 infections detected across the two surveys were asymptomatic (that is, did not have symptoms at the time of swab testing and did not develop symptoms afterwards). The mean serial interval was 7.2 days (95% CI: 5.9-9.6). We found no statistically significant difference in the viral load of symptomatic versus asymptomatic infections (P = 0.62 and 0.74 for E and RdRp genes, respectively, exact Wilcoxon-Mann-Whitney test). This study sheds light on the frequency of asymptomatic SARS-CoV-2 infection, their infectivity (as measured by the viral load) and provides insights into its transmission dynamics and the efficacy of the implemented control measures.