Prognostic impact of the presence and management of coronary artery disease in patients undergoing TAVI

Introduction

Approximately half of transcatheter aortic valve implantaton (TAVI) candidates have coronary artery disease (CAD). Controversial results have been reported regarding the effect of the presence/severity of CAD and its management on clinical outcomes post-TAVI.

Aim

To describe the presence, extension, severityand management of CAD pre-TAVIand to evaluate its impact on 2-yearmortality in areal world all comers population.

Methods and population

Single centre retrospective analysis from a prospectively collected institutional registry (VCROSS) including 517 patients that underwent TAVI for severe aortic stenosis between January 2009 and December 2018. Patients who underwent pre TAVI CA in the context of ACS or at other institution were excluded n=138. Ultimately 380 entered the analysis. Obstructive CAD was defined as stenosis >50% in in major epicardial vessels (>2.5 mm). The total number of major epicardial with obstructive CAD was reported as was assessed the number of those left untreated. Univariate analysis was performed to assess 1) differences between patients with or without CAD and between those with significant CAD who have or have not undergone PCI, 2) variables associated with 2-year mortality. Binary logistic regression was performed to identify independent predictors of 2-year mortality including the presence of significant CAD and the type of management.

Results

A total of 380 patients were included, 55.3% male with an average age of 83YO (±6.3), mean Euroscore II of 4.35. 76 had previous coronary artery bypassgrafting (CABG) and 136 had previous PCI (43 had both). 55 patients (14.4%) presented with normal coronary arteries, 120 (31.6%) with non-obstructive CAD and 205 (54%) with obstructive CAD. Out of the latter, 112 (29.5%) underwent PCI. Statistically significant differences were found between obstructive CAD vs non-obstructive patients in terms of age, previous history of ICP and CABG. In the subgroup population with obstructive CAD, no statistically significant differences was found in the PCI vs non PCI group, apart from previous history of ICP and CABG – Figure 1. Diabetes mellitus, previous history of percutaneous coronary intervention (PCI) and reduced ejection fraction (rEF – defined has <50% echocardiographically) had a negative prognosticimpact in the 2 year mortality of the 380 patients. 2-year mortality was 14,5% (55 patients).The presence and management of CAD pre TAVI had no impact in 2-year mortality, when accounting for the differences in previous ICP history, CABG, age, and rEF.

Conclusion

The presence and type of management of obstructive CAD in this real world all comers registry did not impact the prognosis at 2 years.

Funding Acknowledgement

Type of funding sources: None.

Gold(iii) bis(dithiolene) complexes: from molecular conductors to prospective anticancer, antimicrobial and antiplasmodial agents

The anticancer, antimicrobial and antiplasmodial activities of six gold(iii) bis(dithiolene) complexes were studied. Complexes 1-6 showed relevant anticancer properties against A2780/A2780cisR ovarian cancer cells (IC50 values of 0.08-2 μM), also being able to overcome cisplatin resistance in A2780cisR cells. Complex 1 also exhibited significant antimicrobial activity against Staphylococcus aureus (minimum inhibitory concentration (MIC) values of 12.1 ± 3.9 μg mL-1) and both Candida glabrata and Candida albicans (MICs of 9.7 ± 2.7 and 19.9 ± 2.4 μg mL-1, respectively). In addition, all complexes displayed antiplasmodial activity against the Plasmodium berghei parasite liver stages, even exhibiting better results than the ones obtained using primaquine, an anti-malarial drug. Mechanistic studies support the idea that thioredoxin reductase, but not DNA, is a possible target of these complexes. Complex 1 is stable under biological conditions, which would be important if this compound is ever to be considered as a drug. Overall, the results obtained evidenced the promising biological activity of complex 1, which might have potential as a novel anticancer, antimicrobial and antiplasmodial agent to be used as an alternative to current therapeutics.

P–569 Woman with CYP19A1 TC/CC genotype have increased susceptibility to infertility development, independently of the cause

Study question

Is TC/CC genotype of codon 39 at CYP19A1 gene associated with the development of female infertility?

Summary answer

Yes, CYP19A1 codon 39 TC/CC genotype is associated with increased susceptibility to infertility development in women, regardless of associated cause.

What is known already

Aromatase protein is responsible for the aromatization of androgens into estrogens. This protein that catalyzes the final step in biosynthesis of estrogens is encoded by the gene CYP19A1. The CYP19A1 gene is located on chromosome 15q21.1. It is a member of the cytochrome P450 superfamily which are monooxygenases that catalyze many reactions involved in steroidogenesis. TC/CC genotype of codon 39 at CYP19A1 gene results in an increase of aromatase activity and thus affect the hormone levels which can lead to the development of various diseases, including infertility.

Study design, size, duration

A case-control study was designed to investigate the association of CYP19A1 gene polymorphism with female infertility. Case subjects, 201 women with infertility established as women under 39 years of age, that failed to establish a clinical pregnancy after 12 months of regular, unprotected sexual intercourse. 161 fertile female controls, with no previous history of infertility, no previous history of gynecological pathologies compatible with infertility, and no history of IVF treatments, were selected.

Participants/materials, setting, methods

Blood was collected by venous puncture and genomic DNA was extracted. CYP19A1 genotyping was performed by polymerase chain reaction-based methods with confronting two-pair primers. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated by unconditional logistic regression.

Main results and the role of chance

Significant statistical association of the TC/CC genotype combined with endometriosis risk was found, with reference to TT genotype (OR 4.554; 95% CI 2.209–9.386; p < 0.001). We also found an increased risk of developing polycystic ovary syndrome (PCOS) associated with TC/CC genotype (OR 5.317; 95% CI 2.767–10.215; p < 0.001). We also observed an increased prevalence of premature ovarian failure associated with TC/CC genotype (OR 3.376; 95% CI 1.672–6.815; p = 0.001) and verified an increased prevalence of tubal pathology in carriers of TC/CC genotype (OR 3.231; 95% CI 1.653–6.314; p = 0.001). Finally, a strong association of TC/CC genotype with female infertility, regardless of the cause was found (OR 4.232; 95% CI 2.710–6.609; p < 0.001). In conclusion, TC/CC genotype is associated with increased susceptibility to infertility development in women.

Limitations, reasons for caution

The sample size may eventually be considered small, despite the strong significance found.

Wider implications of the findings: There are not many studies in this area and the few existing exhibit disparate results. The association of TC/CC genotype with endometriosis was observed in a few studies, but some disagree. This difference could be attributed to the notable heterogeneity across the different studies.

Trial registration number

Not applicable

Patients undergoing invasive coronary angiography after a positive single-photon emission computed tomography or a positive stress cardiac magnetic resonance - What to expect at the cath lab

Funding Acknowledgements

Type of funding sources: None.

Background

 Randomized controlled trials comparing stress cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) suggest similar diagnostic accuracy for detecting obstructive coronary artery disease (CAD). However, there are few data on whether or not this remains true in routine clinical practice.

The aim of this study was to assess the clinical and angiographic characteristics of patients undergoing invasive coronary angiography (ICA) after a positive stress CMR or positive SPECT, and to compare their positive predictive value with published results from the CE-MARC trial.

Methods

In this retrospective tertiary-center analysis, we included 429 patients (mean age 67 ± 10 years, 28% women, 42% diabetic) undergoing ICA between January 2016 and December 2020, after a positive stress CMR or positive SPECT. Regarding stress test, an adenosine protocol was performed in all stress CMR and in 76.4% (n = 272) of stress SPECT. 

Stress test results, including ischemia location and severity, were classified as reported by their primary readers. Patients with missing data on key variables, and those in whom microvascular disease was considered likely in the original stress test report were excluded. Obstructive CAD was defined as any coronary artery stenosis ≥ 50% in a vessel compatible with the ischemic territory on stress testing.

Results

Out of the total 429 patients, 356 (83%) were referred after a positive SPECT, and 73 (17%) after a positive stress CMR. Patients did not differ regarding age, cardiovascular risk factors, previous revascularization or left ventricular dysfunction, but patients with SPECT were more frequently male (p = 0.046). Overall, 320 patients (75%) had obstructive CAD on ICA. The prevalence of obstructive CAD was similar in patients with positive SPECT vs. positive stress CMR (76.1% vs. 80.8%, respectively, p = 0.385). There were also no significant differences in the prevalence of left main or 3-vessel disease (9.0% vs. 9.6%, p = 0.871, and 19.7% vs. 23.3% p = 0.483, respectively). Revascularization was performed or planned in 59.3% of patients in the SPECT group, and 52.1% of those in the stress CMR group (p = 0.255). The positive predictive values of both techniques were similar to those reported in the CE-MARC trial (Figure), and would increase to 88.1% and 89.4% for SPECT and stress CMR, respectively, if patients reported as having only mild ischemia were excluded.

Conclusion

In this tertiary center analysis, stress CMR and SPECT showed similar positive predictive values, comparable to those reported in the CE-MARC trial.

Metformin combined with insulin in women with gestational diabetes mellitus: a propensity score-matched study

AIM

Metformin use in gestational diabetes (GDM) is a common practice. Although its use in combination with insulin might be advantageous, it was never formally tested. We studied whether combined treatment was associated with better obstetric or neonatal outcomes compared to insulin alone.

METHODS

This is a retrospective study, using the Portuguese National Registry of GDM (2012-2017), of women treated with insulin ± metformin. Primary endpoints were obstetric and neonatal complications. Secondary endpoints were gestational weight gain (GWG) and insulin dose. A propensity score-matched analysis was performed to balance the distribution of age, BMI, insulin treatment duration, HbA1c, first trimester diagnosis of GDM and previous GDM or macrosomia. Women treated with metformin plus insulin and insulin only were then compared.

RESULTS

A total of 4034 women were treated with insulin or insulin plus metformin (10.2%). After propensity score matching, we studied two groups of 386 patients. Obstetric and neonatal complications were similar. Women treated with metformin plus insulin had 201 (52.1%) obstetric complications versus 184 (47.7%) in insulin-only group, p = 0.22; and 112 (29.0%) neonatal complications versus 96 (24.9%), p = 0.19. Patients treated with metformin plus insulin had similar GWG, excessive weight gain and insulin dose compared to the insulin-only group.

CONCLUSIONS

Women with GDM treated with insulin plus metformin had similar obstetric and neonatal complications, weight gained and insulin dose compared to those only treated with insulin.

First psychotic episode as first manifestation of lyme disease: Case report

Introduction

Lyme disease (LD) is caused by the spirochete Borrelia burgdorferi (Bb) and has been reported to be associated with various psychiatric presentations.

Objectives

To report a case with LD and to highlight the importance of differential diagnosis in a first psychotic episode.

Methods

Case report and non-systematic review of the literature.

Results

A woman aged 31 was admitted to the psychiatric department, after a car accident with a mortal victim, due to a first psychotic episode with visual hallucinations, disorientation in time and space, persecutory and grandiosity delusions. She had a personal psychiatric history of obsessive-compulsive disorder and no previous admission to an inpatient Unit. On psychotropic drugs the condition failed to improve, and subsequently neurological symptoms developed. EEG abnormalities prompted a lumbar puncture. In the CSF a strong plasma cell reaction with atypical cells was observed. The enzyme immunoassay for Borrelia burgdorferi was positive and after treatment with penicillin the psychiatric and neurological signs and symptoms remitted. Screening assessment followed by a thorough history, comprehensive psychiatric clinical exam, review of systems, mental status exam, neurological exam and physical exam relevant to the patient’s complaints and findings with clinical judgment, pattern recognition and knowledgeable interpretation of laboratory findings facilitates diagnosis. Psychotropics and antibiotics may help improve functioning and prevent further disease progression.

Conclusions

LD is relatively rare, but awareness of the association between LD and neuropsychiatric presentations can improve understanding of the causes of mental illness and result in more effective prevention, diagnosis and treatment.

Disclosure

No significant relationships.

Attention deficit hyperactivity disorder in adulthood and the heritability of this condition

Introduction

Attention Deficit Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder characterized by inattention and/or hyperactivity-impulsivity resulting from the interaction of genetic and environmental risk factors. Family studies shows that persistent ADHD is very familial.

Objectives

We aim to review the literature on this condition and its heritability and describe the implications that a possible misdiagnosis can have during life.

Methods

Bibliography review was performed using the databases PubMed and Cochrane, using the following keywords: “ADHD”; “Adults”; “Heretability”; “Family” and “Rater effect”.

Results

Childhood ADHD persists into adolescence and adulthood substantially, identified in some studies, as going up to 78%. The prevalence of ADHD in children and adults is between 2.5% and 5% worldwide. Family studies have shown that children of adults with ADHD are at higher risk of having ADHD. Some large-scale twin studies of adult ADHD, used self-report assessments of ADHD symptoms and estimated the heritability of this condition to be between 30 to 40%, which differs from other studies that analyse parents and teachers responses and estimates heritability to be between 60 and 90%.

Conclusions

Since there is a direct influence of the evaluators in estimating the extent of ADHD heritability, future studies need to clarify and describe in detail all the related characteristics of the raters. Although ADHD is widely studied, there is still a lot to learn about its etiology. The diagnosis of ADHD is clinical and complex and must be considered both in childhood and adolescence and in adulthood, with special emphasis on the family antecedents.

Disclosure

No significant relationships.

Lithium in severe affective disorders: Balancing safety with efficacy

Introduction

Lithium has been one of the oldest substances used in psychiatric treatments and remains the first-line treatment for prevention of manic and depressive episodes of bipolar disorder (BD), but it has also a wide spectrum of side-effects.

Objectives

The goal is to review efficacy, and clinical use of lithium, such as its side effects, and its benefit-to-risk ratio.

Methods

Non-systematic literature review based on scientific databases such as PubMed.

Results

The first modern use of lithium was for the treatment of mania. Lithium has also proven useful in major depression, particularly for augmentation of antidepressants, for aggressive behavior and it has a specific antisuicide effect. Lithium’s prophylactic and antisuicidal effects are most unique. However, the use of lithium became problematic due to the serious toxicity since lithium also a narrow therapeutic index, with therapeutic levels between 0.6 and 1.5 mEq/L.

Conclusions

Awareness of the benefits and risks of lithium is essential for the use of this lifesaving agent. Lithium levels must be carefully monitored and lithium dosage adjusted as necessary.

Disclosure

No significant relationships.

Calcium score of the aortic valve as a predictor of aortic stenosis severity

Funding Acknowledgements

Type of funding sources: None.

Background

The calcium score of the aortic valve (CaScAoV) is now recommended as a supporting tool to assist in the grading of aortic stenosis (AS) severity when echocardiographic assessment is inconclusive. However, the proposed CaScAoV cut-offs for considering severe AS "unlikely", "likely", or "very likely" have never been validated in Portuguese cohorts.

Aim

The purpose of this study was to assess the performance of the proposed CaScAoV cut-offs in identifying patients with severe aortic stenosis.

Methods

A total of 513 consecutive patients (median age 83 years [IQR 79–87], 38% males) evaluated at a single-centre TAVI-programme between Jan/2016 and Nov/2019 were retrospectively identified. Only patients with an ECG-gated cardiac computed tomography (CT) and a transthoracic echocardiography performed within a 6-month time-frame were included. Main exclusion criteria were left ventricular ejection fraction < 50%, indexed stroke volume < 35 ml/m2, previous valve surgery and

bicuspid aortic disease. CaScAoV was measured according to the Agatston method (Agatston units – AU). As previously reported, the likelihood of aortic stenosis as assessed by CT was categorized as: "very likely" (>3000 AU for men, >1600 AU for women); "likely" (>2000 AU for men, >1200 AU for women) ; or unlikely (<1600 AU for men, <800 AU for women). Diagnostic tests performance measures were calculated for each category. Separate analyses were performed for each gender.

Results

Severe AS (mean gradient ≥ 40 mmHg) was present in 422 patients (overall 82.3%: 83.1% in females and 80.8% in males), with a median transvalvular gradient of 49 mmHg (IQR 42 – 60).

Overall, the discriminative ability of the CaScAoV to distinguish severe from non-severe AS was higher in men when compared with women (c-statistic 0.86 [95%CI 0.80 – 0.93] vs. 0.72 [95%CI 0.64 – 0.80], p for comparison < 0.001). In males, the "very likely" cut-off had a sensitivity of 71% (95%CI 63 – 78%), a specificity of 81% (95%CI 65 – 92%), a positive predictive value (PPV) of 94% (95%CI 89 – 97%) and a negative predictive value (NPV) of 40% (95%CI 33 – 46%) for the diagnosis of severe AS. Conversely, in women the sensitivity was 75% (95%CI 69 – 80%), specificity was 57% (95%CI 43 – 71%), PPV was 90% (95%CI 86 – 92%) and NPV was 32% (95%CI 25 – 39%).

On the other end of the spectrum, the "unlikely" cut-off showed poor performance in dismissing severe AS, particularly in females – NPV of 43% (95%CI 25-63%) in women vs. 83% (95%CI 63-93%) in men.

Conclusion

In our population, the discriminative power of CaScAoV for identifying patients with severe AS was lower than in previously published cohorts, particularly in females. While very high CaScAoV is strongly supportive of severe AS, caution should be employed when interpreting low CaScAoV values in women, since the recommended cut-off value does not allow the safe exclusion of severe aortic stenosis.

Abstract Figure. Waterfall chart of individuals CaScAoV

Patterns of revascularization in stable ischemic heart disease in the pre-ISCHEMIA era

Introduction

New evidence on the role of myocardial revascularization in stable ischemic heart disease (SIHD), recently presented, showed that revascularization guided by the presence of moderate-to severe ischemia relieves angina more effectively than optimal medical therapy (OMT), without a significant benefit in hard clinical endpoints.

Aim

To assess the representativeness of the ISCHEMIA trial in a real-world population and compare management strategies between patients who fulfill the eligibility criteria of the trial (Group 1, G1) and those who do not (Group 2, G2).

Methods and population

Single centre retrospective analysis including all consecutive patients referred to coronary angiography (CA) for SIHD from January 2018 to December 2019. Patients were stratified in two groups (G1 and G2) according to the ISCHEMIA trial inclusion and exclusion criteria. G1 was compared with G2 and with a subset of G2 with obstructive coronary artery disease (CAD), defined as ≥70% luminal stenosis in at least one coronary artery or >50% for the left main.

Results

A total of 1020 patients underwent CA, of whom only 124 (12.2%) would have been eligible for the ISCHEMIA trial (G1). Overall, there were no significant differences in baseline characteristics between the two groups. G1 patients had more extensive and severe disease, presenting more frequently with proximal left anterior descending (LAD) involvement (26.6% vs 10.4%; p<0.001), two vessel disease without proximal LAD stenosis (23.4% vs 10.3%; p<0.001) and three vessel disease (18.5% vs 5.9%; p<0.001). These patients had higher rates of revascularization, both CABG (25.8% vs 10.8%, p<0.001) and PCI (56.5% vs 39.5%, p<0.001). However, when comparing G1 with the subset of G2 patients with obstructive CAD, G1 patients had higher rates of CABG (26.8% vs 17.8%, p=0.034) but there were no differences on the rates of PCI (58.0% vs 56.9%, p=0.916).

Conclusions

Patients included in the ISCHEMIA trial are underrepresented in a real-world population of SIHD patients referred to coronary angiography. PCI rates were similar among patients with at least one significant coronary artery stenosis, regardless of previous evidence or severity of ischemia. Our findings underline the need for further refinement in criteria for revascularization in SIHD.

Funding Acknowledgement

Type of funding source: None

External validation of a new staging system for severe aortic stenosis in a Portuguese cohort

Background

Recently, a new staging system for severe aortic stenosis (AS) based upon the extent of extra-aortic-valve cardiac damage has been developed (Genereux et al. Eur Heart J 2017). The present study aimed to: 1) determine the prevalence of the different stages of extra-aortic valvular cardiac damage and its impact on prognosis in a real-world Portuguese cohort and; 2) evaluate the distribution of aortic valve calcium score (AV-CaSc) and its prognostic value.

Methods

Consecutive patients evaluated at a single-centre TAVI-programme between Nov/2015 and Nov/2018 were retrospective selected. The extent of extra-aortic valve cardiac damage was defined by echocardiography as stage 0 (no cardiac damage), stage 1 (left ventricular damage), stage 2 (mitral valve or left atrial damage), stage 3 (tricuspid valve or pulmonary artery vasculature damage) or stage 4 (right ventricular damage). AV-CaSc was estimated routinely at CT-angiography as per TAVI-programme protocol. The primary endpoint was 1-year all-cause mortality after CT-angiography. Survival analysis (Cox-regression hazards model and Kaplan-Meier) was performed. To account for the effect of aortic valve replacement (AVR), this variable entered the Cox-regression model as a time-dependent covariate.

Results

A total of 443 patients (mean age 82±7 years, 44% men, median euroSCORE II 4% [IQR 2.4–5.8]) were identified. After Heart Team discussion, 79% (n=349) underwent AVR (TAVI=307; surgical valve repair=42); 9% (n=42) await intervention; 6% (n=25) remain under medical treatment; 4% (n=19) died during the period of evaluation; and 2% (n=8) underwent palliative aortic balloon valvuloplasty.

According to the proposed classification, the distribution of patients from stages 0 through 4 was: 0.2% (n=1), 7.5% (n=34), 67.8% (n=306), 14% (n=63), and 10.4% (n=47). Additionally, for each increasing stage of cardiac damage, the burden of AV-CaSc was higher (from stage 1 through 4: 1776 [IQR 1217–2448]; 2448 [1796–3442]; 2448 [1832–3622]; 2960 [1936–4878] units; p for trend = 0.002).

All-cause mortality at 1-year was 14% (n=63). Mortality increased alongside with increasing extent of cardiac damage (from stage 0 through 4: 0% [n=0], 6% [n=2], 12% [n=36], 20% [n=12], and 30% [n=13]) – Fig. Multivariable analysis revealed chronic renal disease (HR 1.37 per stage [1.15–1.64], p<0.001), AV-CaSc (HR 1.02 per 100 units [1.01–1.03], p=0.007), AVR (HR 0.46 [0.26–0.81], p=0.007) and stage of cardiac damage (HR 1.54 per stage [1.15–2.05], p=0.004) as independent predictors of 1-year mortality.

Conclusion

In a real-world Portuguese cohort of severe AS patients, the extent of cardiac damage was associated with 1-year mortality. AV- CaSc grants additional prognostic information to this classification. Incorporation of this staging system into patient evaluation may be useful in the risk assessment of severe AS.

Survival analysis

Funding Acknowledgement

Type of funding source: None

Predicting pacemaker implantation after TAVR with procedural CT

Background and aim

The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve replacement (TAVR). Calcium distribution in the aortic-valvular complex (AVC) and, more recently, membranous septum (MS) length seem to be surrogate markers for conduction abnormalities after specific last generation balloon and self-expandable expandable valves. We sough to evaluate whether such pre-procedural association remains across the entire device spectrum.

Methods

Single-centre prospective study of 239 consecutive patients (140 women, median age of 84) with severe symptomatic aortic stenosis patients who underwent ECG-gated contrast-enhanced multi-detector computed tomography (MSCT) before TAVR since Jun/2017. Exclusion criteria were those with previous PPMI, previous bioprothesis, congenital bicuspid valve, and poor imaging quality. The J-score with an 850-Hounsfield unit threshold was used to detect areas of calcium in the region of interest. AVC was characterized by leaflet sector and region, using 3mensio Valves software 7.0 TM. An independent team retrospectively measured MS length blindly by determining the thinnest part of the interventricular septum in the coronal view in the better-defined systolic phase (usually at 40% of the R-R interval, Figure). Device selection (75.8% self-expandable devices, 20.1% balloon expandable, 3.1% other) and positioning were performed according to the operator criteria. Final implant depth was assessed based on the pre-release angiogram or final aortography.

Results

Mortality at 30-days was 1.3% and PPMI occurred in 43 patients (18%). Median MS length was 9.59mm (IQR: 3.11mm). After multivariable logistic regression analysis, MS length emerged as the single significant protective predictor for PPMI (OR: 0.14; 95% 95% CI: 0.05–0.42; p<0.001), independently of the device used (p<0.001). MS length showed strong discriminatory ability for PPMI (c-statistic 0.93; 95% CI 0.88–0.99). Sensitivity/specificity decision plots yielded an MS length of 6.9 mm as the optimal cut-off point for predicting the need for PPMI with a positive and negative predictive value of 91% and 93%, respectively (Figure). There wasn't any calcium accumulation within a specific region of AVC that independently predicted the outcome.

Conclusion

In our experience, a short membranous septum was strongly and independently associated with new permanent pacemaker implantation, regardless of the device type.

Our findings suggest that this simple measure should be routinely made to help device selection and implantation technique.

Funding Acknowledgement

Type of funding source: None

Downstream testing after an halted coronary CT angiography due to high coronary artery calcium score

Background and aim

In many centers, coronary artery calcium score (CACS) is performed immediately before coronary CT angiography (CCTA) in order to exclude heavy calcification that could hamper test performance. When high CACS values are found, CCTA is usually aborted and other tests suggested. However, there are no recommendations on which test to pursue, and little data on their diagnostic yield in this setting. The aim of this study was to assess the type and results of downstream testing among patients whose CCTA study was halted due to high CACS.

Methods

Single-centre retrospective study of consecutive patients undergoing CCTA for suspected obstructive coronary artery disease (CAD). A CACS threshold of >400 was generally used to cancel CCTA. Downstream testing and its results were assessed using electronic medical records. A group of consecutive patients with CACS <400 who underwent CCTA was used for comparison.

Results

Of the 795 patients who performed CCTA for suspected CAD, 86 (10.8%), had their test halted due to high CACS (57 men, mean age 71±11 years). In this subgroup, the median pre-test probability for CAD was 27% (interquartile range 25) and the median CACS was 983 (interquartile range 930). Compared to patients who underwent CCTA, those who saw their tests cancelled were older, more frequently male, and had higher prevalence of cardiovascular risk factors and higher pre-test probability for CAD.

Patient's downstream testing is illustrated in Figure. From the 86 patients enrolled, 12 are currently waiting for downstream tests and were excluded from further analysis. Overall, 35 patients ended up performing invasive coronary angiography (ICA, 47.3%) of whom 19 (54.3%) had significant CAD. Among those who underwent non-invasive testing (N=19, 25.7%), 10 (52.6%) had significant ischemia and 4 (21%) underwent additional testing with ICA. In 24 patients (32.4%), no downstream testing was pursued. Finally, 17 (22.3%) patients underwent coronary revascularization, either percutaneous (N=10, 13.5%) or surgical (N=7, 10.8%).

Conclusion

Invasive coronary angiography is the most frequently used downstream test when CCTA is halted due to high CACS values, and shows significant CAD in roughly half of the cases. Considering the high prevalence of significant CAD, direct referral for ICA (with the possibility of invasive functional testing) seems a reasonable approach.

Funding Acknowledgement

Type of funding source: None

Ramp lesions: a systematic review of MRI diagnostic accuracy and treatment efficacy

Purpose

We conducted a systematic review of the published literature to assess the accuracy of Magnetic Resonance Imaging (MRI) in establishing the presence of ramp lesions (RLs) in Anterior Cruciate Ligament (ACL) deficient knees and the clinical efficacy of the surgical repair of RLs.

Methods

A comprehensive search of the MEDLINE, Web of Science and Scopus databases was performed according to PRISMA guidelines. Studies assessing MRI diagnostic accuracy for RLs or the clinical effect of RL repair in participants with ACL injuries were included. Diagnostic accuracy measures were pooled and plotted in forest plots. Preoperative and at last follow-up treatment efficacy outcome measures were extracted and plotted in forest plots, for graphical comprehension.

Results

Sixteen studies met the criteria and were included. The diagnostic analysis showed a pooled sensitivity, specificity, positive and negative likelihood ratios of 65.1% (95% CI, 59.73 to 70.42), 91.6% (95% CI, 89.14 to 94.05), 2.91 (95% CI, 2.38–3.55) and 0.53 (95% CI, 0.44–0.64), respectively, with high heterogeneity (I² above 80%) for all measures. Treatment analysis showed improved Lysholm Knee Score, IKDC score and laxity difference between the knees in all studies after meniscal suture repair. A separate analysis showed no differences between repair of smaller, stable, RLs with meniscal sutures and repair with abrasion and trephination only.

Conclusion

Although the results present considerable heterogeneity, MRI seems to demonstrate moderate accuracy in the diagnosis of RLs in patients with ACL tear and the surgical repair of RLs can be associated with improved overall outcomes.

Performance, carcass yield, and meat quality of broilers supplemented with organic or inorganic zinc

ABSTRACT A total of 640 one-day-old Cobb broiler chicks, half male and half female, were reared up to 49 days of age. A completely randomized 2 × 4 factorial design was used. Experimental treatments consisted of four levels of organic zinc supplementation and one control (inorganic zinc supplementation) and two levels of sex (female and male), with four replicates of 16 birds per experimental plot. Animal performance, carcass and cut yields, and meat quality were evaluated. Feed intake increased with zinc supplementation. Broilers that received the lowest level of organic zinc showed better feed conversion than those fed an equivalent level of inorganic zinc. Increased levels of organic zinc reduced the abdominal fat content in females but impaired the oxidative stability of meat. The results showed that male broilers have better performance, carcass yield, and meat quality than females and that organic zinc improves broiler feed conversion and reduces abdominal fat but increases lipid oxidation in meat.

4181Prognosis of patients with mid-range left ventricular ejection fraction treated with PCI: insight from the global leaders study

Background

Heart failure with mid-range ejection fraction (left ventricular ejection fraction between 40 to 49%) was introduced in the 2016 European Society of Cardiology guidelines for heart failure. The prognosis of the mid-range of left ventricular ejection fraction (LVEF) was less well assessed in patients treated with percutaneous coronary intervention (PCI).

Purpose

We aimed to assess the 2-year outcomes of patients with mid-range ejection fraction (LVEF between 40 to 49%) after PCI compared with reduced LVEF (<40%) and preserved LVEF (≥50) in the GLOBAL LEADERS study.

Methods

The GLOBAL LEADERS study was a multicenter, randomized trial comparing the efficacy and safety of two antiplatelet strategies in all-comers patients undergoing PCI with biolimus-A9 eluting stent.

Patients with available information of LVEF were eligible in the present analysis. Patients were classified according to their LVEF into three groups; preserved (LVEF ≥50), mid-range (LVEF 40–49%) and reduced (LVEF <40%) left ventricular ejection fraction. Clinical outcomes at 2 years after PCI were compared among three groups in the multivariable Cox regression analysis.

The primary outcome of present study was all-cause mortality at 2 years after PCI. The secondary outcomes were patient-oriented composite endpoint (POCE). Individual components of the composite endpoint, definite or probable stent thrombosis and bleeding academic research consortium (BARC) type 3 or 5 were also reported.

Results

Out of 15968 patients included in the GLOBAL LEADERS study, information of LVEF was available in 15008 patients (93.99%); 12,128 patients (80.81%) were in the group of preserved LVEF, 1,737 patients (11.57%) were in the mid-range LVEF group and 1,143 patients (7.62%) were in the reduced LVEF group.

The risk of all-cause mortality and POCE at 2 years were significantly different among the three groups. In an adjusted model, compared with the group of preserved LVEF, the hazard ratio for the all-cause mortality at 2 years rose from 1.89 (95% CI, 1.46–2.45) to 3.72 (95% CI, 2.95–4.70) in the group of mid-range and reduced LVEF respectively. Similar rises were observed for the POCE at 2 years from 1.27 (95% CI, 1.11–1.44) in the group of mid-range LVEF to 1.63 (95% CI, 1.42–1.87) in the group of reduced LVEF.

The risk of stroke, myocardial infarction, and definite or probable stent thrombosis in patients with mid-range LVEF was not different from patients with reduced LVEF (see figure). A similar risk of revascularization was observed among the three groups.

Outcomes among three LVEF categories

Conclusion

Patients with mid-range LVEF undergoing PCI had a different prognosis from patients with reduced LVEF and preserved LVEF in term of survival and composite ischemic endpoints at 2 years.

P4737Complete surgical revascularization: the impact of the different definitions on mortality

Introduction

The concept of complete revascularization arises from the early stages on coronary artery bypass grafting (CABG). There are several different definitions applied across the literature, promoting a difficult comparison between studies. Despite the established importance of complete revascularization, there is no agreement which definition has the most impact on mortality.

Objectives

Evaluate the impact of the different definitions of complete surgical revascularization in late mortality.

Methods

Single center retrospective study of all consecutive patients submitted to isolated CABG with previous myocardial viability assessment (myocardial perfusion scintigraphy) from 2011 to 2016. Exclusion criteria: emergent procedures and previous cardiac surgery. The primary end-point was follow-up mortality (n=20). The population of study was162 patients with 22,2% female gender and a mean age of 66 years. The follow-up was complete in 98,8%, median time of 4,1 (IQR 3,0–5,5) years.

The completeness of revascularization was classified in all patients according to four different definitions (n=162 for each definition): Numerical (the number of stenotic vessels must equal the number of distal anastomoses applied); Functional (all ischemic myocardial territories are reperfused; areas of old infarction with no viable myocardium are not required to be reperfused); Anatomical Conditional (all stenotic main-branch vessels are revascularized) and Anatomical Unconditional (all stenotic vessels are revascularized, irrespective of size and territory supplied).

For each definition, statistical analysis was performed using the Kaplan-Meier method with log rank test and Cox proportional analysis (EuroSCORE II and revascularization definition).

Results

On univariate analysis, there was no significant statistical association between each definition of complete revascularization and follow-up mortality: numerical (p=0,694); anatomical unconditional (p=0,294); but a trend was found on functional (p=0,063) and anatomical conditional (p=0,084).

On multivariate analysis, incomplete functional revascularization increased the risk of follow-up mortality in 2,89 folds and anatomical conditional in 3,28 folds (Figure 1). The other definitions were not statistically associated with late mortality.

Conclusion

According to this study, complete functional and anatomical conditional revascularization definitions are determinants of follow-up mortality in a multivariate model including EuroScore II. The revascularization of all stenotic main-branch vessels (anatomical conditional) seems to have the highest impact, fact that we should be taken in consideration on daily work.

P4575UA and NSTEMI in the era of high-sensitivity Troponin: impact on patient risk profile and management

Aim

High-sensitivity troponin assays (HST) entered the clinical arena to facilitate exclusion of ACS in the emergency department (ER) in patients presenting with chest pain. Due to its higher sensitivity there is the potential for an overestimation of the diagnosis of NSTEMI, and possibly ACS overall. We assessed the impact of HST in the classification of ACS (NSTEMI vs UA) and its ability to predict obstructive coronary disease (CAD), in a population of pts referred to coronary angiography (ICA).

Methods

Retrospective analysis of 1844 pts with suspected NSTEMI or UA referred for ICA from a single ER between Feb 2013 and Nov 2018. Standard Troponin-I was used until Feb 2016 and HST thereafter. The characteristics of UA and NSTEMI pts before and after the introduction of HST were compared. Multivariate binary logistic regression models were used to access the association of different troponin assays with CAD (>50% for LM and >70% for the remaining). Sensitivity, specificity, NPV and PPV for angiographic CAD were also determined.

Results

The relative proportion of patients with UA and NSTEMI was similar between study periods: 31% vs 29% and 69% vs 71%, respectively (p=0.3). Clinical and angiographic characteristics did not differ in UA pts before and after the use of HST. NSTEMI patients in the HST era were less frequently women (39% vs 32%, p=0.026), had higher creatinine (0.93 IQR 0.75–1.3 vs 1.0 IQR 0.82–1.38), higher number of lesions (2 IQR 1–4 vs 3 IQR 1–4) and a lower rate of normal coronary arteries (10.5% vs 3.9%, p<0.001). The prevalence of significant CAD in this population, before and after HST, was 65% and 73%, respectively (p=0.001). However, when clinically relevant characteristics and judgement were accounted for, both standard troponin (OR 0.99, 95% CI 0.99–1.01) and HST (1.0, 95% CI 1.0–1.0) were poor predictors of significant CAD. Sensitivity was 69% vs 72%, specificity 30% vs 30%, PPV 65% vs 73% and NNP 34% vs 28%, respectively. Finally, rates of percutaneous intervention did not differ between the two periods (30% vs 33.5%, p=0.157), nor between ACS types within each period.

CAD/PCI in ACS within each period

Conclusion

The introduction of HST did not result in an increase of the diagnosis of NSTEM vs UA, suggesting that clinical judgment remains an important determinant of the diagnosis of ACS. Also there was no evidence of an increase in PCI rates, despite worse CAD severity in NSTEMI patients.

P3633Should we continue to routinely revascularize patients during valve surgery in optimal medical therapy era?

Background

Optimal management of stable obstructive coronary artery disease (CAD) in patients (pts) undergoing heart valve surgery remains controversial. The aim of the present study is to evaluate the effective prognostic role of CABG in pts undergoing valve surgery who had concomitant CAD.

Methods

We conducted a retrospective multicenter survival analysis using multivariable Cox models and Kaplan-Meier curves of consecutive pts undergoing valve surgery with or without concomitant CABG between January 2015 and February 2017.

Results

From 1196 consecutive pts undergoing valvular surgery in 3 portuguese centers, 257 (21.5%) were found to have obstructive CAD (55.6% male, mean age 74±8 y.o., mean follow-up time 16±8 months, aortic valve disease 78.8%). No coronary revascularization (R) was attempted in 177 pts, complete R was achieved in 40 and R was anatomically incomplete in the remaining 40 pts. Age (75 vs 77.3 y.o.; p=0.202), multivessel disease (46.3% vs 53.8%, p=0.270), aortic valve disease (91.0% vs 92.5%, p=0.683), left ventricular ejection fraction <40% (11.8% vs 19.4%, p=0.272) were comparable between nonrevascularized and revascularized pts; SYNTAX score was low and also similar in both groups (7±12 vs 7±5, p=0.856). Left main disease (8.5% vs 17.5%, p=0.034) and EUROSCORE IIrisk score (2.3±2 vs 3.2±2, p=0.011) was higher for those with any revascularization. Non-revascularized pts had significantly lower all-cause mortality at follow up than those with any R (10.2% vs 21.2%, p=0.016). However, both in-hospital (4% vs 7.5%, p=0.230) and cardiovascular mortality (6.9% vs 7.1%, p=1.00) were similar. In a multivariate analysis, independent predictors for all-cause mortality were: any surgical R (HR 4.52, CI95% 2.09–9.78), baseline atrial fibrillation (HR 2.51, CI95% 1.07–5.90), left main disease (HR 3.153, CI95% 1.26–7.90) and peripheral artery disease (HR 2.95, CI95% 1.036–8.421). All-cause mortality for pts with obstructive CAD was higher than in pts with no CAD (13.6% vs 6.2, p<0.001). Interestingly, however, after multivariable adjustment, complete R was not found to be protective as compared to no R (HR 0.79, IC 0.31–2.06, p=0.633)

Kaplan-Meier Plots

Conclusion

Significant CAD is associated with worse outcomes in pts undergoing valve surgery. In this study, standard angiographically-guided R was not associated with improved results. Randomized controlled trials are needed to further assess risk stratification and the role of coronary R of stable CAD in this setting.

P3628Contemporary coronary artery disease prevalence in a valvular heart disease population undergoing surgery

Background

Patients undergoing heart valve surgery are routinely evaluated for the presence of Coronary Artery Disease (CAD), with the standard practice of combining valve intervention with a revascularization procedure, notably Coronary Artery Bypass Graft (CABG). Older studies suggest rates as high as 50% prevalence of CAD in this population. However, CAD prevalence, its treatment and prognostic implication has been questioned recently.

Objectives

The goal of this study is to evaluate the baseline characteristics, prevalence of CAD and treatment strategies in a contemporary population with valvular heart disease (VHD) referred for valve surgery.

Methods

In a national multicentre registry, consecutive patients, from Jan 2015 to Dec 2016, with a formal indication for heart valve surgery referred for a pre-op routine coronary angiogram were systematically analysed. Baseline characteristics, valve pathology and CAD prevalence and patterns were determined. Obstructive CAD was defined as luminal angiographic stenosis ≥70% (≥50% for left main artery). The prognostic impact of the different valve disease and CAD treatment strategies were assessed.

Results

1175 patients (mean age 72.5±10.1; male 49.2%) fulfilled the clinical or echocardiographic indication for valve surgery by European guidelines. Valvular disease prevalence was: aortic stenosis (66.7%), aortic regurgitation (6.6%), mitral stenosis (6%), mitral regurgitation (19.2%), tricuspid regurgitation (7.5%). Mean follow-up time was 29.06±18.46 months. Prevalence of comorbidities was: Diabetes Mellitus (DM) 26%, chronic obstructive pulmonary disease (COPD) 5.7% and chronic kidney disease (CKD) 23.4%. Mean Euroscore II was 2.6%. Obstructive CAD was present in 27.3% patients. Mean Syntax score was 10.2 (<22 in 88%, 23–32 in 10.2% and >33 in 1.8%). Left main artery and 3-vessel disease were found in 13.1% and 11.8% of patients with CAD, respectively. Valvular surgery was ultimately performed in 80.3%. In patients with CAD, 57.3% were revascularized. All-cause mortality rate during follow-up was 12.9%, with 7.8% from cardiovascular causes. In univariate analysis DM, COPD, CKD, NYHA class, obstructive CAD and no surgery (p<0.05) were associate with mortality on follow up. In multivariate analysis obstructive CAD (OR 2.36, 95% CI 1.53–3.65, p<0.01) and no surgery (OR 6.05, 95% CI 3.95–9.30, p<0.01) persisted as independent all-cause mortality predictors.

Conclusion

In a contemporary cohort of patients with VHD and surgical indication, CAD prevalence is lower (27.3%) than described in literature. Mortality rates were higher in patients with obstructive CAD, worse NYHA functional class and in those who never underwent surgery.

P6508Percutaneous versus surgical paravalvular leak: a ten-year tertiary centre experience

Aims

Paravalvular leak (PVL) presents an incidence ranging from 2–17%. Open heart surgery is considered the standard treatment and there is no consensus regarding the role of percutaneous closure of non-endocarditis PVL.

Methods

Single-centre retrospective study including consecutive patients that had their PVL closed percutaneously or by surgery, after heart team agreement, between 2007 and 2018. The primary goal was to assess mortality and rehospitalizations. The secondary goals were: a) the technical success, defined as reduction in regurgitation [≥1 degree] and b) clinic and laboratorial improvement.

Results

Forty-eight patients were included (mean age of 66±13 years, 56% male), 12 submitted to percutaneous closure and 36 to surgery (74 vs 65 years, p=0,026, respectively), with similar gender distribution. 56% had an aortic PVL, with the remainder having a mitral leak, with no difference between groups. The indications were heart failure in 91% and haemolytic anaemia in 42%. A combination of both indications and NYHA heart failure functional class ≥ III were higher in percutaneous group. The severity of leak was comparable in both groups.

Patients treated percutaneously had a significant higher rate of atrial fibrillation (92% vs 42%), COPD (33% vs 3%), peripheral artery disease (58% vs 22%) and higher EuroScore II (13,1% [7,1 - 19,0 CI 95%] vs 4,1 [2,9 - 6,5 CI 95%], p=0,003).

There was no significant difference between groups with respect to all- cause mortality at 6 months, and to cardiovascular (CV) mortality and CV rehospitalization at 1-year follow-up. The technical success was lower in percutaneous group, but clinic and laboratorial results did not differ (table).

Primary and secondary [(a) tecnical success (b) clinical and laboratorial improvements] endpoints of percutaneous vs surgery paravalvular leak closure Percutaneous PVL closure Surgical PVL Closure p-value Mortality @ 6 M 17% 25% p=1.000 CV Mortality @ 12 M 25% 31% p=1.000 Rehospitalization @ 12 M 18% 21% p=0.694 Technical success (a) 75% 97% p=0.043 NYHA improvement (b) 70% 71% p=0.171 Hb improvement (b) mean Δ: 1.2±1.1 g/dl mean Δ: 1.3±2.5 g/dl p=0.737 LDH reduction (b) mean Δ: −682±828 U/L mean Δ: −473±1215 U/L p=0.577

Conclusions

In this high-risk population, clinical and laboratorial improvement was achieved by both methods. The percutaneous technique seems more appropriate for patients with higher risk, despite a lower technical success in the reduction of the severity of the leak.