Wells and Geneva decision rules to predict pulmonary embolism: can we use them in Covid-19 patients?

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Pulmonary embolism (PE) is a recognized complication of SARS-COV2 infection due to hypercoagulability. Before the COVID era, the need for computed tomography pulmonary angiography (CTPA) to rule out PE was determined by clinical probability, based on Wells and Geneva scores, in association with D-dimer measurements. However, patients with SARS-COV2 infection have a pro-thrombotic and pro-inflammatory state which may compromise the usefulness of these algorithms to select patients for CTPA. 

Purpose

 To evaluate the accuracy of the Wells and Geneva scores to predict PE in patients with SARS-COV2 infection.

Methods

 Retrospective study of consecutive outpatients with SARS-COV2 infection proved by positive PCR who underwent CTPA due to suspected PE. The Wells and Geneva scores were calculated and the area under the curve (AUC) of the receiver operating characteristic curve was measured.

Results

 We enrolled 235 patients (61% males, mean age 69.10 ± 16.69 years) and the incidence of pulmonary embolism was 15% (35 patients). In patients with PE, emboli were located mainly in segmental arteries (60%) and bilaterally (46%). Patients with PE were older (mean age 75.06 ± 2.23 vs. 68.06 ± 1.21 years, p = 0.022), and did not differ in sex or risk factors for thromboembolic diseases from the non-PE group. Patients with PE had higher D-dimer levels (median 15.41 mg/dl, IQR 1.17 – 20.00) compared to patients without PE (median 5.99 mg/dl, IQR 0.47 – 2.82, p < 0.001).

 There was no statically significant difference between the average Wells score in patients with PE and without PE (1.04 and 0.89 respectively, p = 0.733) and the AUC demonstrated that the Wells score had no discriminatory power (AUC = 0.52). Within patients with PE, 19 patients had a Wells score of zero. Regarding the Geneva score, there was also no difference between the average score in patients with and without PE (4.20 vs 3.93 respectively, p = 0.420). AUC for Geneva score was 0.54.

Clinical probability combined with D-dimer measurement had a 100% sensitivity for both Wells and Geneva scores, but a specificity of 10% and 11%, respectively. 

Conclusion

 PE diagnosis may be challenging in patients with SARS-COV2 infection since both conditions may have similar signs and symptoms and may be associated with increased D-dimers. According to our results, traditional clinical prediction scores have little discriminatory power in these patients and a higher D-dimer cut-off should be considered to better select patients for CTPA to minimize radiation exposure and contrast-related complications in COVID-19 patients.

[Radiological and functional results in high-energy tibial plate fractures]

INTRODUCTION

The tibial plateau fractures due to high-energy mechanisms are serious injuries that occur on a load bearing joint. These are difficult to approach because, also affect the bone structure of the leg, they usually have associated soft tissue injuries.

OBJECTIVE

To evaluate the radiological and functional results of high-energy tibial plateau fractures with a minimum follow-up of one year.

MATERIAL AND METHODS

Retrospective, observational and multicenter study. Analysis of radiological and functional outcomes in the treatment of high-energy tibial plateau fractures, treated by open reduction and internal fixation (ORIF) between 2014 and 2019.

RESULTS

54 fractures treated by ORIF. Follow-up one year. 98.1% consolidation in 13 weeks on average. 83.4% without alterations of the axis in the coronal plane. 74% without postoperative joint widening. Functional scores: Lysholm 82.1 average points and Oxford Knee Score (OKS) 39.5 average points.

CONCLUSION

The joint range of motion was reduced after a high-energy tibial plateau fracture, but with good functional results. The less off axis and less post-operative radiographic widening, the better results are obtained.

Anesthetic considerations in a laboring woman with systemic mastocytosis

Mastocytosis is characterized by clonal expansion of mast cells, with abnormal accumulation in different organs. Perioperatively, numerous stimuli may lead to the release of vasoactive substances by mast cells. Parturients with systemic mastocytosis pose a challenge to the anesthesiologist: on one hand, the pain and stress of labor may lead to greater mast cell activation and, on the other, the administration of drugs that may possibly trigger the release of mast cell mediators. The authors describe a case of a 34-year-old pregnant woman with systemic mastocytosis who requests labor analgesia. An epidural analgesia was performed after induction of labor, after considering anesthetic particularities. The epidural procedure, labor and delivery were uneventful. A review of systemic mastocytosis is provided and its anesthetic considerations are discussed.

Early discharge after cryoablation procedure: is it safe?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Discharge after overnight hospital stay is standard procedure in patients submitted to elective atrial fibrillation (AF) ablation. Taking into consideration the low rate of cryoablation procedure complications could the same day discharge be an option?

Purpose

To access the safety of same day discharge of patients submitted to AF cryoablation.

Methods

Single-center retrospective study of consecutive pts admitted to elective AF cryoablation in a tertiary center between February 2017 and November 2020. Patients were divided into two groups: same day discharge and next day discharge. Only patients submitted to ablation until 4 p.m. were included. Complication rates were obtained up to six months after the procedure. Complications were defined as death, pericardial tamponade, hematoma requiring evaluation and/or intervention, major bleeding requiring transfusion, hospital admission related to the procedure.

Results

One hundred fifty-four pts were included, with a mean age of 61 ± 10.9 years, 66.2% were males, 18.2% with diabetes, 65.6% with dyslipidemia, 77.9% with hypertension, 10.4% with chronic kidney disease KDIGO stage 3 or more. Median follow-up of 436 (IQ 178 – 729) days. Most of the pts had paroxysmal (73.4%) and persistent short duration AF (23.4%). Sixty-two pts (40.3%) were early discharged and there were no differences between the two groups regarding epidemiological and clinical characteristics (p = NS).

A very low rate of complications in both groups was observed, occurring in 6.5% of pts with early discharge and in 8.7% of pts in overnight stay, without statistical significance between the two groups (p = 0.61). The most frequent complications were local hematoma (5 pts, 2 in early discharged group), pericardial effusion (3 pts, all in overnight stay), femoral pseudo-aneurism (2 pts, 1 in each group) and arteriovenous fistula (1 pt in overnight stay group). The type of complications did not differ between the two groups (p = 0.51). Two pts died during the follow up, unrelated with the procedure.

In addition, no difference in success rate and arrhythmic recurrence was observed between the two groups. (p = NS)

Conclusion

Our study suggests that is safe to early discharge pts submitted to AF ablation, reducing the hospital stay length in selected pts. Larger studies are needed to confirm this data before routine implementation of this strategy.

“This is not a doctors thing, it is witchcraft” - A case report of acute psychosis concomitant to primary hyperparathyroidism

Introduction

Primary hyperparathyroidism (PHPT), usually caused by a parathyroid adenoma, is characterized by a pathologically high secretion of parathyroid hormone and consequent hypercalcemia. PHPT has a high prevalence among elderly patients and might be responsible for neuropsychiatric symptoms.

Objectives

We aim to report the rare manifestation of acute psychosis accompanying a PHPT diagnosis, and to discuss the neurobiological relationship between hyperparathyroidism, hypercalcaemia and neuropsychiatric symptoms.

Methods

We present a clinical case based on patient’s history and clinical data, along with a literature review on PHPT neuropsychiatric symptons.

Results

We present the case of a 68-year-old man diagnosed with PHPT in November 2019. He was brought up to psychiatric evaluation for the first time in May 2020 upon behavioral changes (aggressiveness and bizarre rituals). The patient described the sensation of burns scattered throughout the body since January 2020, felling anxious and frightened, sleeping poorly and progressive social isolation. He presented delusional ideas of mystical and paranoid content. No significant cognitive impairments were found. The patient’s psychosis was partially responsive to atypical antipsychotics. He’s waiting for surgery. Hypercalcaemia might manifest as mood disorders, cognitive changes and rarely as acute psychosis. Although there is not yet a clear mechanism to explain it, high calcium levels seem to cause neurotoxicity and neurotransmission dysfunction. Restoration of normal calcium levels tend to resolve neuropsychiatric symptoms, but in PHPT parathyroidectomy is usually recommended.

Conclusions

Neuropsychiatric symptoms are responsible for great disability, and demand an organic in-depth investigation. A multidisciplinary team approach must always be considered in the management of such conditions.

Clinical case of animal hoarding – characterization and management of a new disorder

Introduction

Animal hoarding is characterized by hoarding of a large number of animals without providing minimum conditions of nutrition and sanitation, accompanied by lack of insight for the behavior and by social isolation. Despite studies detecting an increasing incidence, the behavior is still poorly understood.

Objectives

To review clinical evidence on animal hoarding and to report a clinical case.

Methods

We report a clinical case based on patient’s history and clinical data, along with a review of the literature on animal hoarding. The terms “Noah syndrome” and “animal hoarding disorder” were searched on PubMed® database.

Results

We present the case of a 51-years-old woman, living alone, with higher education. His first contact with psychiatry was in August 2019 upon aggravated self-neglect and behavioral disorganization. She was living with around 40 cats, her home was extremely deteriorated. In December 2019 she was admitted to a psychiatric unit. A schizophrenia diagnosis was established and pharmacological treatment was initiated. She was discharged to a chronic psychiatric institution. Studies found out that animal hoarders are typically middle age/older women living alone in squalid conditions. Animal hoarding is characterized by a chronic course and intense emotional attachment to animals. It seems to be associated with traumatic situations, as well as mental disorders such as schizophrenia or dementia. Published data on intervention and treatment is still limited.

Conclusions

Animal hoarding phenomenon requires further investigation, regarding developmental risk factors and co-morbid mental disorders. Comprehensive approaches to clinical intervention and management strategies in animal hoarding are necessary.

Prolonged length of stay in acute psychiatric wards: A descriptive study

Introduction

The psychiatric care paradigm has shifted towards community-centered models. Yet, prolonged hospitalizations are still a reality, with debated impact at healthcare systems and patients.

Objectives

This work aims to describe prolonged hospitalizations in acute psychiatric wards through patients’ sociodemographic and clinical data.

Methods

We analyzed a national hospitalization database that contained all hospitalization episodes registered in Portuguese public hospitals from 2008 to 2015. All episodes with a primary diagnosis of mental disorder defined as ICD-9-CM codes 290.x-319.x were included. Prolonged hospitalizations were defined as having a LoS ≥ P97.5; LOS ≥180 days or LOS ≥1 year. Age, sex, lengh of stay, in-hospital mortality were analysed.

Results

The LoS ≥ P97.5(≥62 days) group comprised 3911 hospitalizations (2.3% of all psychiatric hospitalizations) and 1755 patients. The median LOS was 81 days and the mean age was 51 years. Sex was equally distributed, though a higher frequency of male patients was found on the ≥180 days (n=364) and ≥ 1 year (n=121) groups. Psychotic disorders were the main diagnosis at discharge (n= 1769, 45.2%), followed by mood disorders (n=1057, 27.0%) and dementia (n=451, 11.5%). In-hospital mortality increased in the higher LoS groups (1.1%; 4.4%; 9.1%, respectively).

Conclusions

Overall, middle aged patients with psychotic disorders represent most of the prolonged hospitalizations occurring in acute psychiatric wards. Community-based programs require further development to meet the existing needs.

Disclosure

No significant relationships.

Mitral valve prolapse: American versus European guidelines - which one is better

Funding Acknowledgements

Type of funding sources: None.

Introduction

According to the most recent recommendations of AHA, mitral valve prolapse (MVP) is defined as systolic displacement of the mitral leaflet into the left atrium (LA) of at least 2 mm from the mitral annular plane. The ESC recommendations define MVP, flail and billowing, according to the location of the leaflet tips in relation to the coaptation plan. Differences in outcomes considering these classifications are not established.

Purpose

To evaluate the differences in clinical presentation and outcomes of MVP considering AHA and ESC classifications.

Methods

Single-center retrospective study of consecutive patients with MVP (defined according to the AHA classification) documented in transthoracic echocardiogram between January 2014 and October 2019. Demographic, clinical, echocardiographic and electrocardiographic data were collected. The results were obtained using Chi-square and ANOVA tests.

Results

We included 247 patients (mean age 62.9 ± 18 years, 61% males) according to AHA classification; considering the ESC classification: 147 (59%) had prolapse, 30 (12%) flail and 67 (39%) billowing.

In comparison to patients with flail and billowing, patients with MVP had less cordae rupture (p = 0.02). Prolapse was associated with better survival (p = 0.037) and was an independent predictor of survival (OR = 0.372, CI95% [0.148-0.935], p = 0.035) Patients with flail were older in comparison to the ones with prolapse and billowing (71 ± 14 vs 63 ± 17 vs 60 ± 21 years, respectively, p = 0.022). Patients with flail were mostly men (80%, p = 0.028), with more significant mitral regurgitation (p = 0.003) and higher NYHA class (p = 0.018). They also had higher systolic pulmonary artery pressure (SPAP) (48 ± 23 vs 38 ± 18 vs 36 ± 12mmHg, p = 0.015) and higher values of LV mass and posterior wall thickness (144 ±32 vs 125 ± 44 vs 114 ± 37g/m2, p = 0.005 and 11 ± 1,5 vs 10 ± 1,7 vs 9 ± 1.9 mm, p = 0.009, respectively). Women had more billowing (p = 0.04) than prolapse and flail.

Conclusion

The ESC classification adds information to the AHA classification in what concerns to clinical presentation and prognosis of mitral valve prolapse, so both classifications should be used in daily practice.

Mitral annulus disjunction: is it a marker of ominous prognosis?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Mitral annulus disjunction (MAD) has been proposed as a contributing factor for arrythmias and mitral regurgitation in patients with mitral valve prolapse (MVP), however its clinical relevance is still under investigation.

Objective

To evaluate the frequency of MAD in MVP patients, to characterize clinically patients with MAD and assess potential markers for events.

Methods

Single-center retrospective study of consecutive patients with MVP documented in transthoracic echocardiogram between January 2014 and October 2019. MVP was defined according to the 2017 AHA recommendations; MAD was defined as a separation between mitral valve annulus and the left ventricle free wall. Demographic, clinical, echocardiographic, electrocardiographic data were collected. The results were obtained using Chi-square and Mann-Whitney tests; logistic regression was used to find predictors of events.

Results

247 patients were included (mean age 62.9 ± 18 years, 61% males), of these 23 (9.3%) had MAD (mean age 56 ± 20 years, 56.5% males). The maximum diameter of MAD was 10 ± 3mm (range 5-18). 21 patients (92.3%) had mitral regurgitation, and it was at least of moderate severity in 65.2% of patients. Most of the patients (91.3, n = 21) were in sinus rhythm (SR).

During follow-up (FUP) of 29 ± 19 months, 39% (n = 9) of the patients developed symptoms, 22% (n = 5) had atrial fibrillation (AF), 4.3% (n = 1) had acute aortic syndrome (AAS), 4.3% (n = 1) needed ICD, 22% (n = 5) were submitted to mitral valve intervention, 8.7% (n = 2) were admitted to hospital and 8.7% (n = 2) died. None of the patients presented sustained ventricular arrhythmias (SVA) as assessed in regular Holter monitoring.

These patients had more AAS and needed more ICD in FUP compared to patients without MAD (p = 0.007 and p = 0.006, respectively)

Mitral cord rupture (p = 0.04), age (p = 0.044), maximum velocity of tricuspid regurgitation (p = 0.04) and IVS thickness (p = 0.017) were associated with AF in MAD patients. in univariate analysis, interventricular septum thickness was a predictor of AF in this subgroup (OR 4.0, 95%CI 1.1-14.3, p = 0-032) The presence of SR was associated with survival (p = 0.03). There were no predictors of hospital admission or mitral intervention.

Conclusion

Patients with MAD had a relatively benign prognosis with few events during follow-up, although with more AAS and ICD in FUP. In our sample, AF was more common than SVA. Left ventricle hypertrophy was a predictor of AF and sinus rhythm was associated with survival. Larger studies with more patients and other methods of imaging are needed to confirm our results.

Are we aiming for different metabolic targets in heart failure patients?

Introduction

Metabolic control plays an important role on major cardiovascular events (MACE) prevention. The 2019 ESC guidelines on dyslipidaemia management recommend tighter LDL-cholesterol (LDL-C) control in order to prevent cardiovascular events. However, it is not yet proven that thigh control of dyslipidaemia, glycaemic levels and body mass index (BMI) in Heart Failure (HF) patients (pts) have an impact on prognosis.

Objective

To evaluate the impact of LDL-C, HbA1c and BMI values on HF pts mortality and MACE rates.

Methods

Single centre study that included consecutive pts hospitalized for acute / decompensated chronic HF in a tertiary Hospital between January 2016 to December 2018 and followed for 12 months. The impact of LDL-C, HbA1c and BMI on mortality and MACE was assessed using Cox regression and Kaplan-Meier curve, after adjustment for age, sex, functional class and ejection fraction. A safety cut-off was established when any of these variables was deemed protective using ROC curve analysis.

Results

Two hundred twenty-four patients (71.68±13.45 years, 63.8% males) were included. Eighty-four (37.5%) pts had type 2 diabetes, 39.7% had ischemic heart disease and the median left ventricular ejection fraction was 34% (IQR 25–49.5; 60.3% HFrEF; 13.8% HFmrEF; 22.3% HFpEF). The median BMI was 25.4 kg/m2 (IQR 23.1–30.5), HbA1c, 6.4% (IQR 5.6–6.8) and LDL-C, 89.5 mg/dL (IQR 64–106); 145 (64.7%) pts were medicated with statins. The overall mortality and MACE rates during follow-up were 16.1% and 21.0%, respectively. According to the CV risk classification 39.7% pts were at very high risk and 19.6% pts at high risk. On multivariate analysis HbA1c (HR 1.5 IQR 1.1–1.9; p=0.007) and female sex (HR 9.453 IQR 2.4–37.2; p=0.001) were independent predictors of mortality, whereas LDL-C (OR 1.05 IQR 1.022–1.075; p<0.001) and BMI (OR 1.23 IQR 1.075–1.404; p=0.002) were independent protective factors. LDL-C and BMI had no effect on MACE rates, although HbA1c was an independent predictor of MACE (HR 1.27 IQR 1.03–1.57; p=0.026). For high and very high-risk pts there was still a protective trend on mortality, although non-significant, for higher levels of LDL-C (OR 1.04 IQR 0.99–1.075; P=NS). Protective LDL-C cut-off were estimated for the whole population (LDL-C 88mg/dL; AUC 0.819; sn 56.6%, sp 100%) and for the high and very-high CV risk pts (LDL-C 84mg/dL; AUC 0.815; sn 59.3%; sp 100%). A BMI safety cut-off for mortality of 25.75 kg/m2 was found (AUC 0.627; sn 61.2%; sp 58.3%).

Conclusion

This study supports the theory of the obesity and LDL-C paradox in HF. Lower LDL-C and BMI increased mortality and there is no trade-off effect on MACE rates, supporting the idea that LDL-C and BMI should not be aggressively addressed in HF pts. In our cohort a cut-off level of LDL-C below 88mg/dL is associated with higher mortality. On the other hand, diabetes should be actively treated as HbA1c predicts death and MACE in HF pts.

Funding Acknowledgement

Type of funding source: None

A landslide risk index for municipal land use planning in Portugal

In Portugal landslides caused 237 fatalities and >1600 displaced people in the period 1865-2015. Spatial distribution and temporal patterns of slope instability can be related with a complex set of natural and human factors responsible for generating damages. It is essential to develop new methodologies to synthetize risk dimensions to contribute to the landslide risk management at the municipal level. This work proposed a municipal landslide risk index (LRI) considering three risk dimensions: hazard, exposure and physical vulnerability of buildings. The hazard dimension includes the landslide susceptibility performed at the national scale, the probability of weather types associated with landslides and an extreme precipitation susceptibility index. The exposure dimension considered the population density and the number of buildings, whereas the average physical vulnerability of the buildings was computed using four statistical variables from the official census: (i) construction technique and construction materials; (ii) reinforced structure; (iii) number of floors; and (iv) conservation status. Each variable includes different classes that were empirically weighted. After evaluating the three risk dimensions and the LRI, a cluster analysis was performed in order to identify the most important landslide risk drivers in each municipality. Exposure is the main driving force of LRI in the metropolitan areas of Lisbon and Porto, while the hazard is more relevant in the NW municipalities and the physical vulnerability is the major driving force in the south of the country. This methodological approach contributes to a comprehensive and synthetized knowledge about the landslide risk driving forces within the 278 Portuguese municipalities. In addition, it contributes to the diversification and context-oriented strategies of landslide risk management that still lacks in most of the national-level risk governance processes. Finally, this methodology can be generalized to other geographical contexts, improving the risk management, land use planning and the disaster risk reduction.

Assessing the implementation of population based cervical cancer screening in Amadora, Portugal

Background

Population-based cervical cancer screening (CCS) are deemed to be more cost-effective than opportunistic screening and to reduce inequalities. Implementation in Portugal has been heterogeneous, at the regional level. In Amadora healthcare cluster (Lisbon area), implementation started in April 2018 in a pilot unit and was scaled-up. We aimed to assess population-based CCS implementation in Amadora.

Methods

Population-based CCS targets women aged 30-65, and utilises liquid-based cytology with partial HPV genotyping (HPV16/18 and other high-risk HPV - hrHPV). Samples positive for other hrHPV undergo a cytology. HPV16/18+ and other hrHPV+ with ≥ASCUS (atypical squamous cells of undetermined significance) are referred to colposcopy. We assessed implementation according to key indicators extracted from our information system: geographic coverage, number of tests, positive results, positive predictive value of referral (number of cervical intraepithelial neoplasia-CIN/number colposcopies).

Results

As of 30 August 2019, CCS were in place in 4 of the 9 units, potentially covering 20904 women (48.4% of the target population). 1797 womem performed screening within the programme. Invitation for screening is currently implemented in 1 of the 4 units. Screening results were available for 1702 women, 11,1% were HPV+. From these, 26,5% were HPV 16/18+ and 86.2% positive for other hrHPV. Among the latter, 63.2% were negative for intraepithelial lesion and 36.8% were ≥ASCUS. Overall, of these 189 women, 51.3% (n = 97) were referred for colposcopy. Colposcopy results were available for 37 women, of which 13 had a CIN. PPV of referral was 35.1% (95%confidence interval: 20.7;52.6).

Conclusions

Despite being a population-based screening most tests are still opportunistic. There is still a limited number of colposcopies results but the current PPV of referral is low and requires further investigation. Implementation towards a full population-based screening in Amadora should continue.

Key messages

Implementation of a population-based cervical cancer screening in Amadora, Portugal is underway but most screening tests are still applied in an opportunistic manner. A limited number of results is avaliable to estimate positive predictive value of referral to colposcopy. Results available indicate a value of 35.1%, which requires further investigation.

Trajectories of cognitive performance over 5 years in a cohort of breast cancer patients (NEON-BC)

Purpose

Cancer-related cognitive impairment may affect 30-70% of cancer patients, either at baseline or during and after treatment. We aimed to identify trajectories of cognitive performance, from before any treatment to 5 years later, in a cohort of breast cancer (BCa) patients.

Methods

BCa women admitted to the Portuguese Institute of Oncology, Porto, were included in the NEON-BC study during 2012. They were evaluated with the Montreal Cognitive Assessment (MoCA) before any treatment, and after 1, 3 and 5 years (N = 506, 503, 475 and 466, respectively). Nlme R package was used to fit a mixed-effect model of the trends in MoCA scores over time, with age and education as fixed effect. Coefficients of this model were retrieved to calculate an age- and education-modified MoCA score (mMoCA). Mclust was used to obtain clusters of trajectories of mMoCA.

Results

Two trajectories were identified, one with higher scores and increasing over time, and the other showing a continuous decline (25.9% of the participants and 84% of the women with cognitive impairment confirmed by neuropsychological tests and clinical examination by neurologist at the 5 year follow-up). Each trajectory was split into 2, according to scoring above or below to the median value of mMoCA at baseline to account for the possibility of patients being in a declining pathway before treatment. In addition to trajectories characterized by the highest and lowest scores, respectively, relatively stable over time, two trajectories with middle-range scores were observed, one increasing over time and the other decreasing (12.7% of the participants); being older than 65 years, suffering from anxiety, depression or poor sleep after treatment were more frequent among the latter.

Conclusions

One quarter of the 5-year breast cancer survivors had a declining trajectory in cognitive performance. Anxiety, depression and sleep quality should be considered as targets for preventive or curative interventions of cognitive decline.

Key messages

Cognitive decline occurs during breast cancer care, affecting one quarter of the patients. Anxiety, depression and sleep quality should be considered as targets for preventive or curative interventions of cognitive decline.

864A modified snare technique improves left ventricular lead implant success and response rate to cardiac resynchronization therapy

Introduction

Left ventricular (LV) lead placement is often the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies.

Purpose

To evaluate the efficacy of a modified snare technique in the LV lead implantation in cases of standard technique failure and to evaluate its impact in the response rate to CRT.

Methods

A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was implemented, using a secondary coronary sinus delivery sheath introduced through the same venous puncture.  Patients were evaluated every 6 months. Efficacy was quantified by long-term surgical intervention rates. Patients were evaluated with transthoracic echocardiography before CRT implant and between 6-12 months post-implant. Patients with ejection fraction (EF) elevation ≥ 10% or LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated by the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%) with LV lead implant in a lateral vein in 94.7% of cases. Baseline clinical characteristics were similar between patients who implanted LV lead with snare vs standard technique (p = NS). The 4-year surgical intervention rate was lower with the modified snare implant technique than with the standard technique (3.2% vs. 10.2%, HR 0.26, 95% CI 0.08-0.84, p < 0.05), with a relative risk reduction of 74% and a number needed to treat to prevent one surgical intervention of 14. The intervention rate was also lower regarding LV lead implant failure or dislodgement rates (0% vs. 5.3%, p < 0.05). Major complications were similar between groups.

In addition, the response rate to CRT was higher in the modified snare technique than in the standard approach (71.1% vs 55.0%, p < 0.05). In patients who implanted the LV lead with the snare technique, EF increased from 28.1 ± 8.2% to 36.1 ± 11.1% (p < 0.05) and LV ESV decreased from 127.8 ± 64.0mL to 99.8 ± 61.1mL (p = 0.01).

The super-response rate was similar between groups (33.3% vs 27.8%, p = NS).

Conclusion

For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was effective, with significantly lower surgical intervention rates and a higher response rate to resynchronization therapy. This higher than expected response rate with the snare technique, evaluated by remodeling criteria, may be explained by the implant of LV lead in the desired target lateral vein.

Abstract Figure.

Despite mutation acquisition in hematopoietic stem cells, JMML-propagating cells are not always restricted to this compartment

Juvenile myelomonocytic leukemia (JMML) is a rare aggressive myelodysplastic/myeloproliferative neoplasm of early childhood, initiated by RAS-activating mutations. Genomic analyses have recently described JMML mutational landscape; however, the nature of JMML-propagating cells (JMML-PCs) and the clonal architecture of the disease remained until now elusive. Combining genomic (exome, RNA-seq), Colony forming assay and xenograft studies, we detect the presence of JMML-PCs that faithfully reproduce JMML features including the complex/nonlinear organization of dominant/minor clones, both at diagnosis and relapse. Further integrated analysis also reveals that although the mutations are acquired in hematopoietic stem cells, JMML-PCs are not always restricted to this compartment, highlighting the heterogeneity of the disease during the initiation steps. We show that the hematopoietic stem/progenitor cell phenotype is globally maintained in JMML despite overexpression of CD90/THY-1 in a subset of patients. This study shed new lights into the ontogeny of JMML, and the identity of JMML-PCs, and provides robust models to monitor the disease and test novel therapeutic approaches.

Defining evacuation travel times and safety areas in a debris flow hazard scenario

Debris flows are one of the most hazardous types of landslides in mountain regions. In the upper part of the Zêzere valley (Serra da Estrela, Portugal) several debris flows events occurred in the last 200 years, some of them causing loss of lives and material damages. In this work, a methodology for pedestrian evacuation modelling, in a debris flow hazard scenario, was implemented. A dynamic run-out model, developed in previous studies, was used to evaluate the debris flows velocities, thickness of the deposits and extent of the mobilized material. The buildings potentially affected by the impact of debris flows were identified and the potentially exposed population was estimated by applying a dasymetric distribution. The results lead to the conclusion that, in the study area, the elderly are those who are most exposed to debris flows. Furthermore, the time lapse between the debris flows initiation and the arrival at the buildings at risk was estimated, allowing to account for the overall number of buildings where the evacuation time takes longer than the debris flows arrival. Additionally, the safe areas within the study area were identified, and several safe public buildings with the capacity to gather a large number of persons were selected. Considering that the study area is located in a mountain region, characterized by steep slopes, the evacuation modelling was performed based on an anisotropic approach, in order to consider the influence of slope direction on travel costs. At the end, three pedestrian evacuation travel time scenarios, based on different walking speeds to accommodate residents with different ages in safer places, were compared and the results mapped. The implemented methodology is not local dependent, which allows its reproduction elsewhere.

P871 Giant left ventricular (pseudo?)aneurysm complicating anterior myocardial infarction

Introduction

Clinical approach of cardiac aneurysms and pseudoaneurysms is significantly distinct. Therefore, it is crucial to accurately differentiate these two entities, which could be a real challenge.

Case report

We describe a case of a 55-year-old woman, with hypertension and previous smoking habits. She was admitted in our Cardiology Department with the diagnosis of anterior acute myocardial infarction, and was submitted to emergent coronariography, unveiling an occlusion of the middle segment of the anterior descending artery. She underwent successful primary percutaneous coronary intervention (PCI) 1h45 after the chest pain onset. Transthoracic echocardiogram (TTE) revealed depressed left ventricle ejection fraction (LVEF 30%), with akinesia of anterior and septal walls and all apical segments. She evolved in Killip-Kimbal class 2 and was discharged clinically stable. One week later, the patient performed a control TTE that showed an apical thrombus, with a small pericardial effusion, and she initiated warfarin. Three weeks later, a reevaluation TTE demonstrated a severe increase of the left ventricle dimensions, with LVEF 32%, and a small pericardial effusion. In apical 4-chambers incidence, it was visualized a linear structure (42 mm x 5 mm) attached to the endocardial border of the anterolateral apical segment and to the apical segment of the interventricular septum, of undefined nature. The apical segments were dyskinetic and had a very thin wall, which could correspond to aneurysm versus pseudoaneurysm. To clarify these findings, the patient performed a cardiac magnetic resonance revealing a large anterior myocardial infarction complicated with extensive myocardial necrosis, severe depression of LV systolic function (LVEF 25%) and septum rupture distal to the right ventricle apex (without connecting with it), compatible with a large apical pseudoaneurysm. The clinical case was discussed in the Heart Team and it was decided to perform cardiac surgery. However, surgical findings showed integrity of septal and free walls, and she underwent an aneurysmectomy, without further complications. Histological examination confirmed the presence of a thin myocardial wall with marked fibrosis and, consequently, the diagnosis of ventricular aneurysm. She was discharged clinically stable and maintains follow-up in Cardiology consultation of our Hospital.

Conclusion

In this patient, initially admitted with an anterior myocardial infarction submitted to primary PCI, follow-up with advanced imaging modalities pointed to the diagnosis of pseudoaneurysm. Despite the preoperative diagnosis, surgical findings were compatible with a giant left ventricular aneurysm. Even with high spatial resolution exams, postoperative evaluation of tissue layers remains the gold standard for this differential diagnosis.

Abstract P871 Figure. Apical pseudoaneurysm vs aneurysm

Litter traits and rainfall reduction alter microbial litter decomposers: the evidence from three Mediterranean forests

The objective of the study was to evaluate changes in microbial communities with the predicted arrival of new species to Mediterranean forests under projected intensification of water stress conditions. For that, litter from three Mediterranean forests dominated respectively by Quercus pubescens Willd., Quercus ilex L. and Pinus halepensis Mill. were collected, and placed to their 'home' forest but also to the two other forests under natural and amplified drought conditions (i.e. rainfall reduction of 30%). Quantitative PCR showed that overall, actinobacteria and total bacteria were more abundant in Q. pubescens and Q. ilex than in P. halepensis litter. However, the abundance of both groups was dependent on the forest sites: placement of allochthonous litter to Q. pubescens and P. halepensis forests (i.e. P. halepensis and Q. pubescens, respectively) increased bacterial and fungal abundances, while no effect was observed in Q. ilex forest. P. halepensis litter in Q. pubescens and Q. ilex forests significantly reduced actinobacteria (A/F) and total bacteria (B/F) to fungi ratios. The reduction of rainfall did not influence actinobacteria and bacteria but caused an increase of fungi. As a result, a reduction of A/F ratio is expected with the plant community change towards the dominance of spreading P. halepensis under amplified drought conditions.

P1698Age shock index is a simple bedside clinical risk stratification tool in patients with non-ST-segment elevation myocardial infarction

Introduction

Shock index (SI), (heart rate (HR)/systolic blood pressure (SBP)), has been reported to predict worse outcomes in different acute settings. Two derivatives, named modified SI (MSI), defined as HR/mean BP; and Age SI, defined as SI multiplied by age, were later developed, but only the former was tested for short-term outcomes in patients with myocardial infarction (MI). We hypothesize that Age SI may demonstrate higher prognostic accuracy than SI and MSI due to the added prognostic value of age in this population.

Purpose

Compare the prognostic performance of admission age SI, MSI and SI for predicting in-hospital mortality in patients with NSTEMI.

Methods

Retrospective cohort study of consecutive patients admitted to the Cardiology department of a tertiary care hospital with the diagnosis of NSTEMI between October 2010 and September 2018. Very high-risk patients in need of emergent treatment were excluded. Of the initial cohort of 2476 patients, we excluded 5 who presented cardiac arrest before or at hospital admission, 4 with cardiogenic shock, 95 with acute pulmonary oedema, 10 with SBP <80 mmHg, 1 with HR <40bpm and 1 with HR >160bpm. The primary outcome was all-cause in-hospital mortality. The discriminatory capacity of Age SI, MSI, SI for the primary outcome was assed using the ROC-AUC and compared with the DeLong method, and the value with highest Youden-index was considered the optimal cut-off point. Calibration was assessed using the Hosmer-Lemeshow (HL) test and adjustment for confounding variables was performed using logistic regression analysis.

Results

2359 patients were included [mean age 66±13 years; 1732 (73.4%) men], of whom 40 (1.7%) died during hospitalization. Discrimination by ROC-AUC was highest for Age SI (0.78 [95% CI 0.71–0.86)], compared to MSI (0.69 [95% CI 0.61–0.78]) and SI (0.69 [95% CI 0.61–0.78)], p<0.01 for comparison. All indexes demonstrated adequate calibration (HL: Age SI 7.4; MSI 4.5; SI 6.4; p>0.5). The optimal cut-off for Age SI was 40, which was present in 684 patients (29%) and had 75% sensitivity, 72% specificity, 4.5% positive and 99.5% negative predictive value (NPV) for in-hospital mortality (4.4% vs 0.6%, p<0.001). After adjusting for covariates, an Age SI higher than 40 was associated with increased in-hospital mortality (adjusted OR 3.2, 95% IC 1.06–9.55), p=0.039).

Mortality and Age Shock Index

Conclusion

Age SI demonstrated better discriminatory capacity and equal calibration, compared to SI and MSI for in-hospital mortality. An age SI higher than 40 was associated with a 3-fold increased risk of in-hospital death. This cut-off demonstrated excellent negative predictive value (99.5%) and may allow very early risk assessment in patients with non-ST-segment elevation MI (NSTEMI), before laboratorial values are available for GRACE calculation. This may guide initial therapy and help select the most appropriate initial site of care.

P5689First intention epicardial VT ablation: what are the results?

Introduction

Ventricular tachycardia (VT) endocardial mapping and ablation may not be sufficient in several arrhythmogenic contexts, because ventricular myocardium may comprise intricate endocardial, intramural and epicardial substract. Thus, epicardial ablation has lately become a complementary and necessary tool to approach some VTs in different types of cardiomyopathies.

Purposes

To evaluate the clinical characteristics of patient most suitable for first intention epicardial VT ablation and to describe our centre experience.

Methods

Single-centre prospective study of consecutive patients (pts) undergoing isolated first intention epicardial VT mapping and ablation since August 2015. All pts had clinical assessment, electrocardiogram (ECG), echocardiogram and cardiac magnetic resonance when feasible. Pts with a previous endocardial ablation were excluded. Epicardial subxiphoid access utilizing a tuhoy needle was performed under fluoroscopic guidance. High-density mapping was performed using CARTO® V4 and EnSite PrecisionTM systems and multipolar catheters. Radiofrequency energy was applied with an irrigated-tip catheter.

Results

First intention epicardial VT ablation was attempted in 12 pts (mean age 57.6±14.6 years, 91% male). The majority had non-ischemic dilated cardiomyopathy, of unknown aetiology in 59%, hereditary dilated cardiomyopathy in 17% ethanolic origin in 8% and post-myocarditis in 8%. Right Ventricular Arrhythmogenic Cardiomyopathy was present in 1 patient. As expected, our population presented a mean ejection fraction of 29% and 11 pts (92%) had an implantable cardioverter defibrillator - ICD (55% as primary prevention, 45% as secondary prevention). All pts had experienced symptomatic VT, with all ICD carriers receiving appropriate shocks. Only 4 pts had an available 12 lead ECG of the VT, and all of them had a QS pattern in lead aVL and a slurred initial QRS complex. The majority of patients presented low voltage areas and local abnormal ventricular activities at the epicardial surface, with the exception of 2 pts in whom ablation was not performed (one non-ischemic cardiomyopathy of ethanolic aetiology and the other of unknown origin). Mean ablation application time was 68 minutes, with an average maximum power of 39.9 watts. Mean overall procedure and fluoroscopic time was 132 and 24 minutes, respectively, with no major intraprocedural complications. During a mean follow-up of 307±328 days, 3 pts died (mean 121 days after procedure), 3 had recurrent VT episodes and ICD shocks, and 2 received heart transplant.

Conclusion

In selected pts, with non-ischemic dilated cardiomyopathy and ECG with QS pattern in aVL and slurred QRS, epicardial VT mapping and ablation may be used as first approach, preventing unnecessary endocardial mapping. This procedure demonstrated to be safe.