Non-vitamin K antagonist oral anticoagulants in adult congenital heart disease: a single-center study

Introduction

Adults with congenital heart disease (ACHD) are at an increased risk for thromboembolic events and atrial arrhythmias are common in this population. Non-vitamin K anatagonist oral anticoagulants (NOACs) prescription is increasing, however data on efficacy and safety in ACHD is unclear, particularly in patients (P) with complex CHD. The aim of the study was to review the use of NOACs in various types of ACHD and assess its safety and efficacy.

Methods

Evaluation of consecutive ACHD P started on NOAC therapy from 2014 to 2020. P were followed-up for bleeding or thromboembolic events and mortality. CHA2DS2-VASc and HASBLED scores were calculated and risk factors for bleeding were identified.

Results

93 ACHD P were included, mean age 52±15 years, 58% female, 44% with complex CHD (3.2% with Fontan circulation), with diagnosis of: 22.2% atrial septal defect, 20% tetralogy of Fallot, 11.1% transposition of the great arteries, 10% Ebstein's anomaly, 8.9% ventricular septal defect, 7.8% pulmonary stenosis, 5.6% ductus arteriosus, 4.4% AV septal defect, 3.4% univentricular heart, 3.4% coarctation of aorta, 2.2% supra-aortic stenosis and 1% with Uhl disease.

Most P were anticoagulated with rivaroxaban (43%), followed by edoxaban (24%), apixaban (20%), and dabigatran (13%). The indications for anticoagulation were: atrial arrhythmias (81%), pulmonary embolism (PE) (6.3%), atrial thrombi (4.3%), thromboprophylaxis in Fontan circulation (3.2%), deep vein thrombosis (3.2%) and stroke (2%). 66% of P had a CHA2DS2-VASc score ≥2 and 82% HASBLED score ≤2.

In a mean follow-up of 41±21 months (400.4 patient-years), there were embolic events in 2P (1 splenic infarction and 1 PE) albeit both were in the context of oral anticoagulation interruption. The cardiovascular mortality was 2% and allcause mortality 5%, however with no relation to thrombosis or bleeding events.

6 P (6.5%) suffered a minor and 3 P (3.2%) suffered a major bleeding, a median time of 12 (IQR 15) months after starting NOAC therapy. The annual risk for bleeding was 2.2%/patient/year. P with bleeding events showed no significant difference regarding age (55±16 vs 52±15 years, p=0.587), gender (13% female vs 5.1% male, p=0.295) or CHD type (p=0.582). 8.6% of P required dose reduction, mostly for bleeding (3.2%) or renal impairment (2.2%).

Renal disease was a strong risk factor for major bleeding (HR 14.6 [95% CI 1.23–73.6], p=0.033 and multivariate analysis showed that an increased HASBLED score was an independent predictor of minor (adjusted HR 3.44 [95% CI 1.13–10.52], p=0.030) and major (adjusted HR 5.29 [95% CI 1.14–24.45], p=0.033) bleeding complications.

Conclusion

Anticoagulation with NOACs is a safe and effective option for selected ACHD P, although bleeding complications were not negligible, particularly in P with renal disease. Larger scale research studies are required, especially regarding complex CHD such as P with Fontan circulation.

Funding Acknowledgement

Type of funding sources: None.

Left atrial strain imaging and integrated backscatter: predictors of recurrence in patients with paroxysmal, persistent and long-standing persistent atrial fibrillation undergoing catheter ablation

Introduction

Left atrial (LA) strain imaging by echocardiography (TTE) is a promising tool in the evaluation of LA mechanical function. The aim of this study was to compare LA longitudinal strain and integrated backscatter (IBS) between paroxysmal (PAF), persistent (PersAF) and long-standing persistent AF (LsAF) and evaluate its association with AF recurrence post-index catheter ablation.

Methods

Analysis of consecutive patients (P) with symptomatic PAF and PersAF who underwent index AF catheter ablation and had performed TTE in our centre prior to AF ablation. LA reservoir phase longitudinal strain (LASr) and strain rate was assessed by 2D speckle-tracking at baseline. LA volume index (LAVi) and IBS were analysed. AF recurrence was documented with 12-lead ECG, 24h Holter monitoring, external loop recorder or pacemaker analysis in a 12-month follow-up period.

Results

78 P, 69% PAF vs 31% PersAF (46% LsAF), 65% male, 40% with structural heart disease, who underwent pulmonary vein isolation were studied (cryoballoon ablation in 53% and radiofrequency ablation in 47%). P with PersAF had a higher LAVi (46±15 mL/m2 vs 36±13 mL/m2 p=0.004), particularly LsAF P (55±17 mL/m2) and impaired LASr (9.2±4.9% vs 23.9±9.3%, p<0.001) (especially LsAF 5.61±3.08% vs 12.20±4.04%, p<0.001) as well as strain rate (0.58±0.25 s–1 vs 1.08±0.40 s–1, p<0.001). There was no significant difference between groups regarding IBS (116.6±36.1 dB vs 106.6±21.5 dB, p=0.134), including LsAF (128.8±21.5 dB vs 102.1±45.1 dB, p=0.071). During follow-up there was a 28% (22P) AF recurrence rate, higher in PersAF (50% vs PAF 20%, adjusted HR 3.44 [95% CI 1.44–7.69], p=0.005), particularly in LsAF (72% vs 31%, adjusted HR 3.24 [95% CI 0.98–10.9], p=0.048). P with AF recurrence showed significantly impaired baseline LASr both in PersAF (6.44±3.26% vs 11.93±4.79%, p=0.003), as well as PAF (13.86±5.65% vs 26.29±8.47%, p<0.001). LsAF P with AF recurrence demonstrated a considerably impaired LASr (4.99±2.93% vs 9.34±1.40%, p=0.006) vs PersAF. Multivariate analysis showed that impaired baseline LASr was an independent predictor of AF recurrence both in PersAF (adjusted HR 0.82 [95% CI 0.68–0.98], p=0.028) and PAF (adjusted HR 0.78 [95% CI 0.68–0.88], p<0.001). Kaplan-Meier analysis (Fig. 1) showed that both PAF and PersAF P with baseline LASr below the 18% cut-off had a significantly higher rate of AF recurrence, with earlier recurrence in PersAF. PAF P with AF recurrence had a higher baseline IBS (109.3±22.1 dB vs 94.7±14 dB, p=0.016) vs non-recurring P, in contrast to PersAF P (117.8±31.1 dB vs 115.4±42.1 dB, p=0.876), however IBS was not a significant predictor of AF recurrence in PAF (HR 1.03 [95% CI 0.99–1.07], p=0.060) or PersAF.

Conclusion

P with PersAF (and particularly LsAF) showed significantly impaired LASr, and PAF P with AF recurrence had superior baseline IBS vs non-recurring P. Reduced baseline LASr was an independent predictor of AF recurrence both in PAF and in PersAF P.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Malignant cardiac tumors: a single-centre 25-year review

Background

Primary cardiac tumors are extremely rare and are usually diagnosed late due to the nonspecific symptoms. Surgery is the main treatment option, and despite chemotherapy, the prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome. The aim of this study was to review patients (P) with malignant cardiac tumors that were diagnosed by transthoracic echocardiogram (TTE) or transoesophageal echocardiogram (TOE) in a tertiary center between 1995 and 2020.

Methods

Retrospective analysis of clinical data, echocardiographic assessment of tumor location and morphology, histology results and survival outcomes.

Results

A total of 44 malignant cardiac tumors were diagnosed: 12 primary tumors (A) and 32 metastatic tumors (B). A: Regarding primary cardiac tumors, the most common types were angiosarcomas (6), undifferentiated pleomorphic sarcomas (2), fibrosarcomas (2), myxofibrosarcoma (1) and primary cardiac lymphoma (1). The mean age of P at time of diagnosis was 43±15 years, 50% male. The most frequent presentation was heart failure symptoms (50%) followed by arrhythmias (20%). 1 P presented with pruritus and polyarthralgias. On TTE, the most prevalent tumor location was in the right-heart chambers (70%) – mostly the right atrium (50%), with mean dimensions of 40±18x27±11 mm. 85% of P had preserved biventricular systolic function and there was severe pericardial effusion in 38%. The most frequent metastatic involvement at diagnosis was pulmonary (33%) and hepatic (33%). 50% of P were submitted to tumor resection and 40% to chemotherapy. Regarding angiosarcomas, the most common immunohistochemical markers were vimentin, CD31 and CD34. The authors found a mortality rate of 10P (83%) in P with primary cardiac tumors, with a median time to mortality of 5.5 (IQR 2–10) months (Figure 1), in a median follow-up of 6.2 (IQR 2.5–15) months (minimum of 20 days and maximum of 19 years). In the latter case, the P was submitted to heart transplantation after diagnosis of a fibrosarcoma and is still alive and well.

B: Regarding secondary cardiac invasion, there was a diagnosis of the following primary tumor sites: 12 lung carcinomas, 7 thymomas, 4 lymphomas, 3 hepatocellular carcinomas, 2 bladder carcinomas, 1 parathyroid carcinoma, 1 soft tissue sarcoma, 1 uterine sarcoma and 1 melanoma. The mean age of P was 57±19 years, 57% male. On TTE/TOE the authors found a right-sided chambers predominance (12 P, 38%) vs left-sided chambers in (8 P, 25%), with pericardial metastasis also present in 13 P (41%). Cardiac tamponade occurred in 6P (19%). The mortality rate was 75% (24P), with a median time to mortality of 1.1 (IQR 0.6–3.8) months (minimum of 7 days, maximum of 44 months), in a median follow-up of 2.3 (IQR 0.8–14) months.

Conclusion

Cardiac malignant tumors generally present in a late stage with a dismal prognosis. When possible, heart transplantation can be an option with a favourable outcome.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier analysis

Familial hypercholesterolemia in acute coronary syndrome patients: underdiagnosis in female and in young patients

Introduction

Familial hypercholesterolemia (FH) is often underdiagnosed, particularly in female patients (P), even during hospital admission for acute coronary syndromes (ACS). The aim of this study was to apply the Dutch Lipid Clinic Network (DLCN) Criteria in P admitted for ACS and evaluate gender and age differences.

Methods

Prospective evaluation of P with ACS admitted to a tertiary center from 2005 to 2019. Data including family history and laboratory tests was analysed for the application of the DLCN criteria and results were stratified according to ACS subtype, gender and age groups (20–39, 40–59, 60–79 and ≥80 years [y]). P were followed up for 30 days for hospitalization, recurring ACS and mortality.

Results

3811 P were evaluated, mean age 63±13 years, 28% female and mean LDL cholesterol of 125±43 mg/dL. The admission diagnosis was unstable angina (UA) in 5%, non-ST-segment elevation myocardial infarction (NSTEMI) in 27% and ST-segment elevation MI (STEMI) in 68%.

Applying the DLCN criteria, 3089 P (81%) had a score of <3 (unlikely FH), 675P (17.7%) a score of 3 to 5 (possible FH), 41P (1.1%) a score of 6 to 8 (probable FH) and 1P (0.03%) a score of >8 (definite FH). Stratifying according to ACS type: among UA, 31P (16%) had possible FH and 4P (2.1%) had probable FH. Among NSTEMI, 145P (14.2%) had possible FH, 9P (0.9%) probable FH and 1P (0.03%) definite FH. Finally, among STEMI P, 497P (19.1%) had possible FH and 28P (1.1%) probable FH. Regarding female P, 158P (14.7%) had possible FH and 16 P (1.5%) probable FH. Among male P, 517P (18.9%) had possible FH and 25P (0.9%) probable FH (p=0.016 for interaction).

According to age groups, among P aged 20–39 y (136P), 61P (44.9%) had possible FH and 6P (4.4%) had probable FH. Concerning P aged 40–59 y (1766P), 575P (32.6%) had possible FH, 31 P (1.8%) probable FH and 1P (0.1%) definite FH. With regard to P aged 60–80 y (2122P), 80P (3.8%) had possible FH and 4P (0.2%) probable FH. Among P aged ≥80 y (1837P), only 9P (0.5%) had possible FH and no P had probable FH.

In a 30-day follow-up, there was an hospitalization rate of 3.5% (134P) and recurring ACS in 1.7% (65P), while the all-cause mortality was 2% (78P) and cardiovascular (CV) death was 1.3% (49P). Female P had a significantly lower hospitalization rate (1.8% vs 3.2%, p=0.003) as well as fewer recurring ACS (0.6% vs 1.7%, p=0.001). There was no significant gender difference regarding all-cause mortality (female 1.7% vs 1.5%, p=0.552) or CV death (0.8% vs 1.1%, p=0.323). The DLCN criteria score was significantly correlated with admission for recurring ACS (OR 1.19 [95% CI 1.04–1.36], p=0.04).

Conclusion

Application of the DLCN criteria in female P admitted for ACS revealed 158P (14.7%) with possible FH and 16P (1.5%) with probable FH. Regarding younger ACS P (20–39y), 44.9% had criteria for possible FH and 4.4% for probable FH, prompting us to do not overlook these P subgroups in daily practice and routinely assess the likelihood of FH.

Funding Acknowledgement

Type of funding sources: None.

Acute myocardial infarction at an early age – importance of acute chest pain fast track in patient management

Background

Acute coronary syndrome (ACS) has a higher incidence in middle-aged and elderly patients but 2% to 6% of ACS cases occur in people younger than 45 years of age (Y). Younger patients have different clinical characteristics when compared to older patients. Acute chest pain fast track led to a reduction in the time required for the diagnosis of acute coronary syndromes, particularly those with ST segment elevation (STEMI).

Aim

This study aims to assess the differences in risk factors and clinical characteristics between young and older ACS patients. Besides that, we try to determine if the benefits of acute chest pain fast track have extended to this younger population.

Material and methods

Retrospective observational study carried out through the analysis of the clinical process. Clinical data were collected from ACS patients under 45Y from 2010 to 2019 and from ACS patients over 45Y from 2010 to 2012. Statistical analysis was made using R software and RStudio.

Results

This study included 93 patients with ACS under 45Y and 172 patients with ACS over 45Y. A total of 265 patients were included. The male gender was predominant in both groups but with a higher prevalence in the younger ones (88% vs 73%, p<0,005). The prevalence of hypertension was higher in older ACS patients but the younger ones had more overweight (39.8% vs 17.4%, p<0,001), smoking history (84.9% vs 38.4%, p<0,001) and family history of sudden death (25.8% vs 5.8%, p<0,01). Diabetes had no statistical difference. Dyslipidemia as previous known risk factor had no statistical difference but LDL was higher in patients with less than 45Y (147.2 vs 120.7 mg/dL, p<0,001). STEMI were tendentially more prevalent in patients under 45Y (55.9% vs 44.8%, p 0.09). The anterior wall was the most frequently involved in both groups (52% vs 63%, p 0.28), followed by the inferior wall (42% vs 36%). Accordantly, anterior descending artery was the artery most frequently involved in both groups (44.1% vs 48.3%), followed by right coronary artery (24.7 vs 26.7%). STEMI patients under 45Y were submitted to an emergent coronary angiography in 89% of cases and STEMI patients over than 45Y were submitted in 70.1% of cases. Particularly for patients under 45Y, all STEMI patients were submitted to an emergent coronary angiography after 2014, which emphasis the importance of acute chest pain fast track in the emergency room. Finally, ACS patients under 45Y were less submitted to percutaneous coronary angiography compared to patients over 45Y (15.1% vs 4.7%, p<0,001).

Conclusions

Cardiovascular risk factors differ accordingly the age of ACS patients. Younger patients had more overweight and smoking history. They probably have alternative pathophysiologic mechanisms that explain differences in percutaneous coronary angiography. Acute chest pain fast track had an important role reducing morbimortality related to ACS by reducing the time until STEMI diagnose.

Funding Acknowledgement

Type of funding sources: None.

Sutureless bioprosthesis as an alternative to conventional aortic valve replacement surgery

Background

Aortic valve stenosis is the most common adult valve disease in industrialized countries. The ageing population and the rising in comorbidities have urged the development of safer alternatives to the current gold standard surgical treatment. Sutureless bioprosthesis have shown promising results, especially in technically difficult procedures and as more and more patients need concomitant surgeries.

Purpose

Assess clinical and haemodynamic performance, safety and durability of the sutureless bioprosthesis implanted in patients with aortic valve disease, over a period of 5 years, both in isolated aortic valve replacement surgeries as well as in concomitant procedures.

Methods

Single centre retrospective longitudinal cohort study collected data of all adult patients with aortic valve disease who underwent valve replacement with a sutureless bioprosthesis between February 2015 and October 2020. Of the 196 patients analysed (mean age 77.20±5.08 years; 45.40% were female; mean logistic EuroSCORE 2.91±2.20%), the majority had aortic stenosis. To assess the comparative risk of adding concomitant procedures, patients were divided into two groups and compared: one comprised patients who underwent isolated valve implantation (n=132) and the other patients who had concomitant coronary artery bypass graftings (n=49). 15 patients had other heterogeneous concomitant procedures and were therefore not considered in this comparison.

Results

Overall mean cross-clamp and cardiopulmonary bypass times were 45.50±19.04 and 36.50±11.40 minutes, respectively. 4 valves were reimplanted due to misplacement. Mean transvalvular gradients were 7.82±3.62 mmHg. Mean ICU and total hospital stay were 3.32±3.20 and 7.70±5.82 days, respectively. Procedural success was 99%, as two explantations occurred. Pacemaker implantation occurred in 12.8% of patients, atrial fibrillation de novo in 21.9% and renal replacement support was necessary in 3.1%. Early mortality was 0.51%. We report no structural valve deterioration, strokes or endocarditis and one successfully treated valve thrombosis. By comparison, patients with concomitant procedures had worse left ventricular function (40.8 vs 79.5%; p=0.030), longer aortic clamping (43.33±11.60 vs 27.30±8.10 minutes; p<0.001) and cardiopulmonary bypass times (59.98±17.60 vs 37.45±11.30 minutes; p<0.001), as expected. ICU stay after surgery was also longer (3.96±3.20 vs 2.80±2.70 days; p=0.016). Apart from this, there were no other significant differences in postoperative complications and survival, even up to 5 years.

Conclusion

Our study confirms the excellent clinical and haemodynamic performance and safety of a truly sutureless aortic valve, even up to the 5-year follow-up. These results were consistent both in isolated and concomitant interventions, solidifying this device as a viable treatment of isolated aortic valve disease, and now also in patients needing concomitant procedures.

Funding Acknowledgement

Type of funding sources: None.

The impact of the cardiac rehabilitation program in patients with mid-range heart failure (40-50%) in improving cardio respiratory predictors

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Universitário Lisboa Central

Methods

We studied 30 patients (P) with ejection fraction (EF) 40-50%, in a number of 198 P that participated in cardiac rehabilitation program (CRP). Of these P, 24 (80%) male and 6 (20%) female, 20 P were diagnosed myocardial infarction with ST-segment elevation, 2 P myocardial infarction non ST and 8 P with myocardial hypertrophy non ischemic. Of these P 30% were diabetics, 56% hypertension, 70% dyslipidemia, 36% smokers previous to CRP and body mass index 26,3 medium.

All P were submitted to previous echocardiogram, cardiopulmonary exercise testing (CET) and a rehabilitation program minimum 4 sessions and maximum 52 sessions. At the end of the total sessions the echocardiogram and CET were repeated.

Results

Of the 30 P that participated in CRP only 20 completed the program, while the other 10 P dropped out because of social and economic problems. Of the P that completed the CRP, 70% got better on EF, 80% improved VE/VCO2 slope < 33 therefore are classified VC-II in ventilatory classification (VC), 5% VE/VCO2 slope > 40  VC-III classification, and 15% maintained the initial classification.  50% of the P increased at least one level metabolic equivalent of task (MET) from the first CET. Only 3 of the 20 patients came, once, to the hospital after the CRP with heart failure, and one died but did not fulfill the program.

Conclusion

Patients with mid-range heart failure submitted to a CRP can improve cardiorespiratory predictors, leading to a better quality of life. However, it is important to find solutions to minimize the causes that make patients to give up CRP.

POS1113 ANTIRESORPTIVE THERAPY AFTER TERIPARATIDE DISCONTINUATION – WHEN IS THE BEST TIME TO STARTING IT?

Background:

Treatment with teriparatide (TPTD) is associated with reduction of fracture risk in patients with severe osteoporosis. This drug can only be used for up to 2 years. After that a treatment course with antiresorptives should be considered, in order to prevent the rebound of bone turnover observed after TPTD discontinuation. In this regard, interest in sequential osteoporosis therapy has grown in recent years but the ideal timing for starting another treatment after TPTD is not well established.

Objectives:

The aim of this study is to assess if the timing of onset of antiresorptive therapy after TPTD discontinuation has implications in total hip bone mineral density (BMD) and in fracture risk.

Methods:

We performed a retrospective cohort study that included patients with severe osteoporosis treated with TPTD 20mcg/day for 24 months and followed for at least 2 more years in the rheumatology department of a tertiary university hospital. For analysis, demographic and clinical data and results of dual-energy X-ray absorptiometry (DXA) after cessation of teriparatide were used. For comparison between groups Mann-Whitney U test was used.

Results:

Fifty-five patients with osteoporosis, with a median age of 68 (32-85) years, were included. Forty-nine patients were female (89.1%). Nineteen patients (34.5%) had primary osteoporosis and 36 (65.5%) glucocorticoid-induced osteoporosis. The median time for initiating antiresorptive treatment was 7 (0-35) months after cessation of TPTD. Forty-three patients (78.2%) started a bisphosphonate, 6 denosumab (10.9%) and 6 patients did not receive any other treatment. The most prescribed bisphosphonate was zoledronate (69.8%). All patients received calcium and vitamin D supplementation. After completion of TPTD regimen 8 patients experienced at least one fragility fracture (14.5%). At follow-up, 37 (67.3%) of patients underwent DXA on average 30.0±15.4 months after starting antiresorptive agents. The median total hip BMD in patients who started antiresorptive therapy in the first 12 months (inclusive) after cessation of TPTD regime was 0,738 (0.587-0.993) g/cm2 and the median total hip BMD of patients who started therapy after one year of discontinuation of TPTD was 0.683 (0.390-0.813) g/cm2. This difference is marginally significant (p=0.067). The median time in starting antiresorptive treatment is higher in patients with new fragility fractures after TPTD than in patients without new fractures however this difference was not statistically significant (10.0 [2-35] vs 6.0 [0-35] months; p=0.393, respectively).

Conclusion:

Although this study is unable to show that anti-resorptive treatment should be started in the first year after discontinuation of TPTD, it is promising since the difference between the medians in the total hip BMD values obtained until one year and after one year are marginally significant. These results can be linked to the small sample size and highlight the need for further studies in this area.

References:

[1]Napoli N, Langdahl BL, Ljunggren Ö, Lespessailles E, Kapetanos G, Kocjan T, Nikolic T, Eiken P, Petto H, Moll T, Lindh E, Marin F. Effects of Teriparatide in Patients with Osteoporosis in Clinical Practice: 42-Month Results During and After Discontinuation of Treatment from the European Extended Forsteo® Observational Study (ExFOS). Calcif Tissue Int. 2018 Oct;103(4):359-371. doi: 10.1007/s00223-018-0437-x. Epub 2018 Jun 16. PMID: 29909449; PMCID: PMC6153867.

Disclosure of Interests:

None declared.

Left atrial strain imaging evaluation: a strong predictor of atrial fibrillation recurrence after single-procedure catheter ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Identification of predictors of arrhythmia recurrence after catheter ablation of atrial fibrillation (AF) is a clinically relevant issue. Transthoracic echocardiography (TTE) is a readily accessible exam that can be useful in estimating left atrial (LA) mechanical function. The aim of this study was to evaluate LA structure and LA strain imaging at baseline and its association with AF recurrence after an index AF catheter ablation. Methods: Analysis of patients with symptomatic paroxysmal and persistent AF who underwent a single-procedure for AF ablation between 2015 and 2019 and had performed TTE in our centre prior to AF ablation. LA parameters were assessed by 2D speckle-tracking at baseline. LA diameter index (LAVi), LA ejection fraction, LA phasic strain: reservoir (LASr), conduit (LAScd) and contraction phases (LASct), as well as integrated backscatter (IBS) values were analysed. AF recurrence was documented with 12-lead ECG, 24h Holter monitoring, external loop recorder or pacemaker analysis during a 12-month follow-up period. Results: Of a total of 106 patients, 28 patients were excluded due to poor image quality. We studied 78 patients who underwent pulmonary veins isolation (PVI) (age 59 ± 14 years, 65% male, 40% with structural heart disease, 69% paroxysmal AF) with cryoballoon ablation in 53% and radiofrequency ablation in 47%. In a 12-month follow-up there was a 28% (22 patients) AF recurrence rate. Patients with AF recurrence had a baseline significantly superior LAVi (47 ± 17 mL/m2 vs. 36 ± 12 mL/m2, adjusted HR 1.04 [95% CI 1.01-1.06], p = 0.002) and lower estimated LA ejection fraction (25 ± 19.7% vs. 45.4 ± 21%, adjusted HR 0.96 [95% CI 0.94-0.98], p = 0.001). Multivariate analysis showed that baseline LA strain parameters were independent predictors of AF recurrence, as patients with AF recurrence showed impaired LASr (9.81 ± 5.79% vs 22.94 ± 9.98%, adjusted HR 0.81 [95% CI 0.73-0.89], p < 0.001) and LAScd (-6.74 ± 4.11% vs. -11.85 ± 7%, adjusted HR 1.11 [95% CI 1.03-1.19], p = 0.004). In patients in sinus rhythm during baseline TTE, LASct also correlated with AF recurrence, as patients with recurrence also showed impaired baseline LASct (-7.49 ± 3.65% vs -13.74 ± 5.4%, adjusted HR 1.39 [95% CI 1.11-1.75], p = 0.005). LASr <18% showed a sensitivity of 86% and specificity of 70% to predict AF recurrence. Kaplan-Meier curves (figure 1) showed that patients with LASr below the 18% cut-off had a significantly higher rate of AF recurrence. Baseline IBS did not reveal significant differences in AF recurrence (111.2 ± 23.9 dB vs. 105.9 ± 33.5 dB, HR 1.007 [0.993-1.002], p = 0.349). Conclusion: Baseline LA strain imaging parameters, including reservoir phase LA strain, were demonstrated to be independent predictors of AF recurrence after PVI. A LASr <18% showed good accuracy to predict AF recurrence. Abstract Figure. Kaplan-Meier curves - time to recurrence

Late gadolinium enhancement as a predictor of arrhythmias in patients with hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of arrhythmias and sudden cardiac death (SCD). The Late gadolinium enhancement (LGE) in cardiovascular magnetic resonance (CMR) has been associated with the occurrence of arrhythmic events.

Purpose

The aim was to analyze the association between LGE burden and location and arrhythmic events in HCM patients (P).

Methods

Retrospective analysis of P with HCM in a single tertiary center. Baseline clinical, echocardiographic and CMR characteristics were collected. On follow up arrhythmias (ventricular fibrillation (VF), sustained ventricular tachycardia (SVT), non-sustained ventricular tachycardia (NSVT), paroxysmal supraventricular tachycardia (PSVT), atrial fibrillation (AF) and atrial flutter (AFL)) were identified. LGE on CMR was compared between patients with and without arrhythmias.

Results

61P (59% male) were included, with a mean age of 58 ± 2 years. The HCM risk-SCD score was 3.35 ± 0.28%. On echocardiography mean left ventricle ejection fraction was 62.16 ± 1.36% and maximum wall thickness 20.59 ± 0.596mm. 31.1% had systolic anterior movement of mitral valve and 26.7% had left ventricle outflow tract obstruction. LGE was present in 88.5% P with a median number of 5 ± 7 segments involved. Interventricular septum (IVS) was involved in 78.7% P, anterior wall

in 57.4%, inferior wall in 54.1%, lateral wall in 52.5%, posterior wall in 9.8%, basal segments in 62.3%, median segments in 68.9% and apical segments in 63.9%. On follow up 3.3%P died, 45.8% had hospitalizations (22,2% because of an arrhythmia) and 75% had arrhythmias (1.6% VF, 6.6% SVT, 50% NSVT, 9.8% PSVT, 37.7% AF and 6.6% AFL). The number of segments with LGE correlated with arrhythmias (p = 0.05 for arrhythmias, p = 0.03 for SVT, p = 0.008 for NSVT and p = 0.042 for PSVT). A cut off of 5 segments involved was a good predictor of arrhythmias (p = 0.002), NSVT (p= 0.006), PSVT (p = 0.024) and AF (p = 0.0029). For SVT the best cut off was 9 (p = 0.003). Considering the LGE location, we found an association between the segments involved and the occurrence of different arrhythmias (table 1).

Conclusion

Supraventricular and ventricular Arrhythmias are frequent in patients with HCM, with the most frequents being NSVT and AF. The LGE burden (>5 segments) and location (median inferior IVS, median anterior IVS, median anterior wall, basal anterior IVS, apical anterior wall, median inferior wall, apical anterior wall and basal inferior IVS) were correlated with arrhythmic events. Abstract Figure.

Effect of processing smoked salmon on contaminant contents

The influence of the type of smoking process (natural/liquid; hot/cold) and salt (NaCl or KCl) on the levels of polybrominated diphenyl ethers (PBDEs) and polycyclic aromatic hydrocarbons (PAHs) in smoked salmon was evaluated. One parent compound - BDE 47 - and two methoxylated forms - 2'-MeO-BDE-68 and 6-MeO-BDE-47 - were detected in all the samples. Among the 14 PAHs analysed, naphthalene was the most abundant followed by phenanthrene and fluorene. Only smoked salmon treated with NaCl presented quantifiable levels of chrysene and benzo[b]fluoranthene. Among the four smoking processes evaluated, natural smoke led to higher levels of PAHs. Risk characterization tools, such as hazard index (HI) and incremental lifetime cancer risk (ILCR), showed that the risk of both PBDEs and PAHs to human health through the consumption of smoked salmon was very low.

Cardiopulmonary exercise testing in repaired tetralogy of Fallot: a valuable tool for pulmonary regurgitation severity assessment

Funding Acknowledgements

Type of funding sources: None.

Introduction and purpose

The optimal timing for pulmonary valve replacement (PVR) in asymptomatic patients with repaired tetralogy of Fallot (TOF) and pulmonary regurgitation (PR) remains uncertain but is often guided by imaging characterization of the right ventricle. As cardiopulmonary exercise testing (CPET) performance is an accessible prognostic indicator, we assessed which CPET parameters best correlate with pulmonary regurgitation severity to potentially improve identification of high-risk patients.

Methods

A retrospective chart review was done from 2009 to 2018 on adult patients with repaired TOF who underwent maximal effort cardiopulmonary exercise testing with cycle ergometry and with concurrent pulmonary function testing. Demographics, standard measures of CPET interpretation, and major cardiovascular outcomes were collected.

Results

Cardiopulmonary exercise testing was performed in 54 adult repaired TOF patients (59% male), with a mean follow-up of 60 ± 33 months. The mean age was 34 ± 9 years. 30 patients (56%) had severe pulmonary regurgitation and 26 patients (48%) were submitted to PVR, with a 0% mortality rate. PVR was performed a mean 28 ± 7 years after TOF repair surgery. There was moderate to severe right ventricular dysfunction in 11 patients (20%). 12 patients (22%) had a hospitalization for heart failure. Arrhythmic events occurred in 9 patients (17%), mainly atrial fibrillation or atrial flutter (67%). 2 patients (4%) received an implantable cardioverter-defibrillator for secondary prevention of sudden cardiac death.

Peak VO2 consumption (pVO2) showed no statistically significant correlation with severity of pulmonary regurgitation (HR 0.26, 95% CI 0.879-1.036, p= 0.262) or PVR (HR 0.92, 95% CI 0.829-1.028, p = 0.914), while percent of predicted pVO2 significantly correlated with severity of pulmonary regurgitation (HR 0.95, 95% CI 0.918-0.993, p = 0.020) and PVR (HR 0.94, 95% CI 0.886-0.992, p = 0.025).

VE/VCO2 slope was not a significant predictor of severity of pulmonary regurgitation (HR 1.03, 95% CI 0.929-1.130, p = 0.622) or PVR (HR 1.04, 95% CI 0.952-1.128, p = 0.414) or) and neither cardiorespiratory optimal point (HR 0.94, 95% CI 0.786-1.120, p = 0.480) nor maximum end-tidal carbon dioxide pressure (PETCO2) (HR 0.93, 95% CI 0.846-1.037, p = 0.213) correlated with severity of pulmonary regurgitation or PVR.

Conclusion

Percent of predicted peak VO2 had the highest predictive power of all CPET parameters analysed in adult repaired TOF patients. Preoperative CPET could be an accessible way to identify high-risk patients earlier for PVR and should therefore be included in the routine assessment of these patients.

Effect of exercise training on amyloid-like protein aggregates among patients with heart failure

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): MG and CS were supported by a PhD FCT grant (SFRH/BD/128893/2017) and by an individual grant from CAPES [BEX 0554/14-6], respectively. This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). iBiMED is a research unit supported by the Portuguese Foundation for Science and Technology (REF: UID/BIM/04501/2020) and FEDER/Compete2020 funds).

Introduction

Amyloid-like protein aggregates play a decisive role in the pathology of heart failure. Alterations in protein homeostasis, in particular, the clearance of toxic amyloid-like aggregates are emerging therapeutic targets in cardiovascular medicine. The clinical benefits of cardiac rehabilitation and exercise training are widely accepted in heart failure; however, little is known about the potential benefit of exercise training in amyloid-like protein aggregates.

Purpose

To assess the effects of a moderate-intensity exercise training program on amyloid-like protein aggregates levels among patients with heart failure with reduced ejection fraction.

Methods

Eighteen subjects participated in the study; eight patients (age: 66.6 ± 5.9 years; FEVE: 38.4 ± 8.9%) with heart failure with reduced ejection fraction participated in a 3-month exercise training program (2 x 60 min sessions per week of moderate-intensity aerobic and resistance exercise). Ten healthy subjects (age: 68. 4 ± 3.1 years) were recruited to an age-matched reference group.  Amyloid-like protein aggregates were assessed before and after 3 months of exercise training. Clinical data, medication, anthropometrics, and cardiorespiratory fitness were also assessed. Thioflavin T (ThT) dye fluorescence was used to quantify the plasma levels of amyloid-like aggregates and the Fourier transform infrared spectroscopy (FTIR) was applied to evaluate the conformation of cross-β-sheet structures characteristic of amyloid protein aggregates.

Results

Exercise program improved cardiorespiratory fitness by 14.0 ± 17.1% (17.4 ± 3.2 to 19.7 ± 2.9 ml/kg/min) and reduced NT-proBNP levels by 16.5% (34.2) (median concentration of 632 pg/mL (720.8) to 517.5 pg/mL (707.0)) in the heart failure patients. A slight decrease of amyloid-like aggregates levels was observed in post-exercise training samples (a reduction of 3.1%); interestingly, after the exercise training program, the heart failure patients showed levels of amyloid-like aggregates similar to the reference group (1132.0 ± 114.2 vs. 1094.8 ± 132.9 a.u.). Additionally, the PLS-R multivariate analysis of the amide I region of the FTIR spectra revealed enrichment of antiparallel β-sheets (1693 cm-1) assigned to amyloid-like oligomers in the samples of heart failure patients before, but not after, the exercise program. Of note, oligomeric species, as intermediates of amyloid assembly, can contribute to the increase of amyloid burden, but also, some have been reported to be highly reactive and toxic to cells, being key elements of amyloid pathogenesis.

Conclusions

 Our preliminary results indicate that 3 months of exercise training may have significant effects on amyloid-like oligomers, and start hindering the formation of the larger ThT-positive aggregates among patients with heart failure.

Abstract Figure.

The influence of Castanea sativa Mill. flower extract on hormonally and chemically induced prostate cancer in a rat model

Prostate cancer (PCa) is one of the most common cancers in men, with a huge impact on their health. The use of Castanea sativa Mill. flowers (CFs) in beverages has been reported, through ancestral claims, as having health benefits. In vitro research has evidenced the properties of CFs, such as antitumor and antioxidant activities. This study aimed to evaluate the effects of CF extract in an animal model of PCa. Forty male Wistar Unilever rats were randomly assigned to four groups: control, induced, control + CF, and induced + CF groups. Animals from the induced groups were exposed to a multistep protocol for PCa induction. The CF extract, rich in trigalloyl-HHDP-glucoside and obtained via decoction, was administered to the CF groups in drinking water (3 mg per animal per day) for 49 weeks. Animals were sacrificed at 61 weeks of age. Regarding the effects of CFs on dorsolateral prostate tumorigenesis, no significant differences were observed between the induced and induced + CF groups. However, animals exposed to the CF extract showed fewer inflammation areas on the dorsolateral prostate lobe than those not exposed to CF. Moreover, the CF extract alleviated the hepatic oxidative stress associated with the multistep protocol, resulting in lower levels of lipid peroxidation. These results suggest that CF extract has antioxidant and anti-inflammatory properties.

Right atrial strain by speckle-tracking echocardiography as a prognostic predictor in a pulmonary hypertension cohort

Funding Acknowledgements

Type of funding sources: None.

Background

Right atrial (RA) strain is as a promising technique for assessment of RA function and several studies have suggested it is a powerful prognostic marker in pulmonary hypertension (PH) patients (pts). Our aim was to assess the prognostic power of RA strain in Pulmonary Arterial Hypertension (PAH) and Chronic Thromboembolic Pulmonary Hypertension (CTEPH) pts.

Methods

Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). Correlation between RA strain and other variables was tested with Pearson"s correlation analysis. Regression and survival analysis were performed to assess the combined endpoint of all-cause mortality or hospitalization in the first follow-up year (MH1).

Results

A total of 51 PH pts (mean age 54 ± 46 years, 33.3% male, baseline BNP of 342.4 ± 439.9pg/mL and baseline pulmonary artery systolic pressure – PASP - of 78 ± 26mmHg), of which 64.7% had PAH and 35.3% presented CTEPH. 19 ots (37.3%) met the primary endpoint. The mean RA strain was -21.9 ± -4.9%, with no significant difference between groups (-23.4% vs -17.8%, p = 0.150), however male pts had a significantly lower RA strain (-15.9% vs -25.1%, p = 0.014). There was a statistically significant (p < 0.05) correlation between RA strain and age (r = -0.287), indexed RA area (r = -0.539), index RA volume (r = -0.522) and right ventricular strain (r = -0.453). There was no correlation between RA strain and BNP value (p = 0.150), 6MWT distance (p = 0.145) or PASP (p = 0.072). RA strain was a predictor of MH1 (OR = 0.94, 95% CI: 0.894-0.998, p = 0.048). Pts who met the primary endpoint had a significantly worse RA strain (-17.0 vs -24.6%, p = 0.032). Those with a RA strain worse than -19% presented a significantly lower survival free of events during the first follow-up year (log rank p = 0.022).

Conclusion

RA strain is a powerful predictor of adverse events in a PH population and should be systematically assessed in order to improve risk stratification.

Abstract Figure.

Anti-inflammatory potential of Portuguese thermal waters

In light of Medical Hydrology, thermal waters (TW) are all-natural mineral waters that emerge inside a thermal resort and have therapeutic applications. Their beneficial effect has been empirically recognized for centuries, being indicated for symptom alleviation and/or treatment of several diseases, almost all associated with inflammation. Indeed, an anti-inflammatory effect has been attributed to many different Portuguese TW but there is no scientific validation supporting this empiric knowledge. In the present study, we aimed to investigate the anti-inflammatory properties of 14 TW pertaining to thermal centers located in the Central Region of Portugal, and grouped according to their ionic profile. Mouse macrophage cells stimulated with lipopolysaccharide (LPS), a Toll-like receptor 4 agonist, were exposed to culture medium prepared in TW. Metabolism, nitric oxide (NO) production, inducible nitric oxide synthase (iNOS) expression levels and the scavenging capacity of TW, were investigated in vitro. 11 out of 14 TW reduced NO production and/or iNOS expression, and/or scavenging activity, in macrophages exposed to LPS. The sulphated/calcic TW did not show any effect on at least one of the inflammatory parameters evaluated. Two sulphurous/bicarbonate/sodic TW and the sulphurous/chlorinated/sodic TW promoted an increase in NO production and/or iNOS expression. Our results validate, for the first time, the anti-inflammatory properties of Portuguese TW, supporting their therapeutic use in the treatment of inflammation-related diseases and promoting their putative application in cosmetic products and medical devices.

Predictors of atrial fibrillation occurrence in patients with hypertrophic cardiomyopathy

Introduction

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of dysrhythmias, especially atrial fibrillation (AF).

Purpose

The aim of this study was to evaluate the incidence of AF in HCM patients (P) and to determine predictors of AF.

Methods

Retrospective analysis of HCM P at a single tertiary center. Baseline clinical, echocardiographic and cardiovascular magnetic resonance (CMR) characteristics were collected. On follow up AF was identified by electrocardiogram and/or 24 hours Holter monitoring.

Results

61P (59% male) were included, with a mean age of 58±2 years. 27.9% had angina (all of them CCS 2), 34.4% were in NYHA II and 14.8% in NYHA III, 8.2% had syncope and 39.3% had palpitations. A family history of sudden cardiac death (SCD) or cardiomyopathy was present in 40.4% of the cases. The mean HCM risk SCD score was 3.35±0.28%. On echocardiography left atrium (LA) diameter was 44.86±0.87mm, LA volume (LAvol) was 89.97±5.39mL (indexed LAvol 46.05±2.55mL/m2), interventricular septum (IVS) was 16.83±0.663mm, left ventricle (LV) mass was 290.94±13.897g and maximum wall thickness (MWT) was 20.59±0.596mm. 77% P had LA enlargement. 88.5%P had late gadolinium enhancement (LGE) in CMR with a median number of 5±7 segments involved. AF developed in 23P (37.7%), with a mean age of 58±3 years. Predictors of AF development were NYHA III (p=0.007), risk score (p=0.007), LA diameter (p=0.007), LAvol (p=0.005) and indexed LAvol (p=0.002), MWT (p=0.0015), LGE in more than 5 segments (p=0.029) and LGE in the inferior basal and inferior median IVS (p=0.033 and p=0.042). The only independent predictor was LAvol (p=0.0012), with an area under the curve of 0.755 and a cut off of 85.9mL being the best predictor (p=0.004). Combining LAvol >85.9mL with LGE involving >5 segments and LAvol >85.9mL with LGE in inferior basal IVS (IBIVS) a statistically significant difference between groups was achieved (p=0.009 in the combined predictor LAvol + LGE >5 segments and p=0.002 in the combined predictor LAvol + LGE in IBIVS) (figure 1 and figure 2). In a multivariable analysis including these 2 combined predictors and LAvol alone the only independent predictor was the combination of LAvol + IBIVS involvement.

Conclusion

AF is frequent in patients with HCM and develops in younger ages than in general population. NYHA III, risk score, LA diameter, LAvol, MWT, LGE >5 segments and LGE in IBIVS and in IMIVS were predictors of AF, with LAvol being the independent predictor. The combination of LAvol with LGE >5 segments and LAvol with LGE in IBIVS presented stronger predictor value comparing with these characteristics alone.

Funding Acknowledgement

Type of funding source: None

Role of tilt-table testing in syncope diagnosis and management: analysis of patients referred to a syncope unit

Introduction

Head-up tilt-testing (HUT) enables the reproduction of reflex syncope in a laboratory setting. Despite being used to confirm the diagnosis of this syncope, there is some concerns regarding the best protocol to use and recent studies with implantable loop recorders have called the value of HUT into question.

Aim

To characterize the population undergoing HUT according to the modified Italian protocol, type of response to HUT and subsequent management at our center in the last 4 years.

Methods

Retrospective analysis of consecutive P who underwent HUT between 2015 and 2018. Descriptive analysis of patients (P) demographics and medical history, indication for HUT, type of response to HUT and management.

Results

A total of 419P (55.1% female) were included with a mean age of 62 years. The majority (n=302, 72.1%) had comorbidities (structural heart disease – 55%, cardiac dysrhythmias – 57.6%, hypertension – 48.3%, diabetes – 15.6%, depression – 15.9%, cerebrovascular disease –10.6%) or was under medication (n=220, 52.5%) with a potential hypotensive or bradycardic effect (44.1% ACEI/ARA, 29.1% beta-blocker, 27.7% diuretic, 23.6% antidepressant, 22.7% calcium channel blocker, 19.1% benzodiazepines). Syncope/presyncope episodes accounted for 56.1% of the HUT, with falls and disequilibrium accounting for 52%. In 21 cases (5%) suspected dysautonomia or other non-specified reasons were the indication for HUT. HUT were ordered according to the guidelines in 136P (84.6% – indication level I, 3.6% – level IIa, 11.8% – level IIb). HUT was positive in 292P (69.7%) – 77.1% after nitroglycerin administration (vasodepressor – 170P, cardioinhibitory – 53P, mixed – 62P and dysautonomic – 7P). Cardioinhibitory (CI) response predominated in the younger, and vasodepressor in the older P. Of the P with CI response, 41.5% had asystole (median of 41.4s, minimum 7.5s, maximum 115s). All P were instructed in the need to avoid triggering factors and perform counterpressure maneuvers. A pacemaker was implanted in 24P (5.7% of all population, due to long sinus pauses and asystole). Twenty-four P (5.7%) completed a tilt training program.

Conclusion

Most of the HUT were requested for syncope/presyncope, frequently according to the guidelines. There was a high rate of positive tests, with a predominance of vasodepressive response, particularly in the elderly.

Funding Acknowledgement

Type of funding source: None