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

Impact of diabetes mellitus on the early phase arterial healing after drug-eluting stent implantation: a multicenter coronary angioscopic study

Background

Diabetes mellitus (DM) is a strong risk factor for major cardiac and cerebrovascular events. In particular, coronary artery disease with DM is often complicated with complex lesions. Drug-eluting stents (DES) are mainly used for these lesions, and dual-antiplatelet therapy (DAPT) has been used to prevent stent thrombosis. Early arterial healing after DES implantation may enable short DAPT strategy. However, the impact of DM on the arterial healing in the early phase has not been elucidated to date.

Purpose

We evaluated the arterial healing in the early phase after DES implantation using coronary angioscopy (CAS) and compared the findings between DM and non-DM patients.

Methods

This study was a multicenter retrospective observational study. We analyzed CAS findings of 337 lesions from 270 patients which were evaluated 3 to 5 months after DES implantation. Patients were divided into two groups: DM (149 lesions in 118 patients) versus non-DM groups (188 lesions in 152 patients). We assessed neointimal coverage (NIC) grades (maximum, minimum and dominant), thrombus adhesion and maximum yellow color of plaque underneath the stent. NIC was graded as follows: grade 0, stent struts were not covered; grade 1, stent struts were covered by thin layer; grade 2, stent struts were buried under neointima. Yellow color was graded as follows: grade 0, white; grade 1, light yellow; grade 2, yellow; grade 3, intensive yellow.

Results

Minimum NIC coverage grade was lower in DM group than in non-DM group (P=0.002, Figure), while maximum and dominant NIC coverage grades were similar between them (P=0.94 and P=0.59, respectively). Thrombus adhesion (44.3% versus 38.8%, P=0.32) and maximum yellow color grade (P=0.78) were also similar between DM and non-DM groups. Even after the adjustment by the confounding factors such as follow-up duration and primary disease of acute coronary syndrome, DM was an independent factor predicting grade 0 of minimum NIC (odds ratio [OR] 1.83 [95% confidence interval 1.11–3.03], P=0.019).

Conclusion

DM patients showed less covered struts than non-DM patients 3 to 5 months after DES implantation, suggesting that the recent ultra-short DAPT strategy might not be easily applicable to DM patients.

Minimum neointimal coverage grade

Funding Acknowledgement

Type of funding source: None

Prognostic impact of suspected cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)>12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull's eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2±5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57±15% and 26.6% presented EF<50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS >1 was identified in 22 P (23.4%). An EF/GLS ratio >4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4±25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p=0.002) and MACE (48.7% vs 22.2%, p=0.01). RALS>1 correlated also with all-cause mortality (31.8% vs. 12.5%, p=0.04) and with new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p=0.05). P with GLS>−14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p=0.003) and MACE (p=0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR=4.49, p=0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Funding Acknowledgement

Type of funding source: None

New onset atrial fibrillation after dual chamber pacemaker implantation: long term predictors

Background

Preserving atrioventricular synchrony has been accepted as a significant advantage of atrial and dual-chamber (DDD) pacing. However, little is known about the incidence of atrial fibrillation (AF) after DDD implantation and its prognostic predictors in long term.

Purpose

To determine the incidence of new AF episodes and to identify risk factors and prognostic predictors for new-onset AF and all-cause mortality after implantation of dual-chamber pacemakers.

Population and methods

713 consecutive patients (P) who underwent colocation of DDD pacemaker, due to AV block (AVB) or sinus node disease (SND), with no prior history of AF, from 2011 to 2015. Through periodic PM interrogation, occurrence of AF (“automatic mode switch” episodes with documented AF), switch to ventricular pacing (VVIR), pacing site (apical or septal) and cumulative right ventricular (RV) pacing % were analysed.

Results

Follow-up data was available for 669 patients (93.8%) for a mean follow-up (FU) time of 47.8±22.7 months. Mean age was 72.9±10.8 years with 60.1% male. New occurrence of AF was observed in 345 P (51.6%) during the FU period; 45.7% of them were consequently anticoagulated (59.0% with NOACs). Median time to 1st AF episode since implantation was 21.6 months and in 50.9% of the cases it lasted ≥1h. In univariate analysis, 1st AF episode lasting more than 1 hour and existence of at least one episode longer than 24 hours were directly related to switch to VVIR (p<0.0005; p<0.0005; p<0.0005) as well as prescription of anticoagulation (p=0.001; p=0.011; p<0.0005).

Compared to non-AF P, those with AF were older (74.0±9.9 vs. 71.8±11.7 years; p=0.008), had higher prevalence of SND (50.0% vs 40.20%; p=0.015), had superior % of RV pacing (65.9±39.3% vs. 58.3±44.3%; p=0.021) and more frequently had RV apical pacing (70.1% vs 57.3%; p=0.001). The prevalence of hypertension, diabetes mellitus and dyslipidemia were similar in the two groups. With multivariable Cox-regression, age (HR 1.02; p=0.017), SND (HR 1.49; p=0.010), admission for HF (HR 1.55; p=0.012) and % RV pacing (HR 1.01; p=0.003) were significantly associated with the incidence of FA. Predictors of all-cause mortality in Cox regression were the occurrence of AF in 1st of FU (HR 1.67; p=0.018) and % RV pacing (HR 1.01; p=0.043).

Conclusions

New onset AF is a frequent finding after DDD pacemaker implantation and is associated with all-cause mortality in long term. Age, admission for heart failure, sinus node disease and % of RV pacing were independent predictors for AF during follow-up.

Funding Acknowledgement

Type of funding source: None

Exciton Dynamics in Droplet Epitaxial Quantum Dots Grown on (311)A-Oriented Substrates

Droplet epitaxy allows the efficient fabrication of a plethora of 3D, III–V-based nanostructures on different crystalline orientations. Quantum dots grown on a (311)A-oriented surface are obtained with record surface density, with or without a wetting layer. These are appealing features for quantum dot lasing, thanks to the large density of quantum emitters and a truly 3D lateral confinement. However, the intimate photophysics of this class of nanostructures has not yet been investigated. Here, we address the main optical and electronic properties of s-shell excitons in individual quantum dots grown on (311)A substrates with photoluminescence spectroscopy experiments. We show the presence of neutral exciton and biexciton as well as positive and negative charged excitons. We investigate the origins of spectral broadening, identifying them in spectral diffusion at low temperature and phonon interaction at higher temperature, the presence of fine interactions between electron and hole spin, and a relevant heavy-hole/light-hole mixing. We interpret the level filling with a simple Poissonian model reproducing the power excitation dependence of the s-shell excitons. These results are relevant for the further improvement of this class of quantum emitters and their exploitation as single-photon sources for low-density samples as well as for efficient lasers for high-density samples.

Angle-resolved reflection spectra of Dirac cones in triangular-lattice photonic crystal slabs

The dispersion relation and the angle-resolved reflection spectra of triangular-lattice photonic crystal slabs of the C_6v symmetry were examined by the finite element method. The Dirac-cone dispersion relation on the Γ point of the reciprocal space was confirmed. The reflection spectra showed unique selection rules that agreed with the analytical calculation by the k · p perturbation theory. The distortion of the liner dispersion relation of the Dirac cones due to diffraction loss was also reproduced well by the numerical calculation, while we found distortion-free Dirac cones materialized with E₂-symmetric modes.

Strain relaxation in InAs heteroepitaxy on lattice-mismatched substrates

Strain relaxation processes in InAs heteroepitaxy have been studied. While InAs grows in a layer-by-layer mode on lattice-mismatched substrates of GaAs(111)A, Si(111), and GaSb(111)A, the strain relaxation process strongly depends on the lattice mismatch. The density of threading defects in the InAs film increases with lattice mismatch. We found that the peak width in x-ray diffraction is insensitive to the defect density, but critically depends on the residual lattice strain in InAs films.

Mid-IR Dirac-cone dispersion relation materialized in SOI photonic crystal slabs

We materialized the isotropic Dirac-cone dispersion relation in the mid-infrared range by fabricating photonic crystal slabs of the C_4v symmetry in SOI (silicon-on-insulator) wafers by electron beam lithography. The dispersion relation was examined by the angle-resolved reflection spectra with our home-made high-resolution apparatus, which showed a good agreement with the dispersion relation and the reflection spectra calculated by the finite element method. The reflection spectra also agreed with the selection rules derived from the spatial symmetry of the Dirac-cone modes, which proved to be a powerful tool for the mode assignment.

Synchronously wired infrared antennas for resonant single-quantum-well photodetection up to room temperature

Optical patch antennas sandwiching dielectrics between metal layers have been used as deep subwavelength building blocks of metasurfaces for perfect absorbers and thermal emitters. However, for applications of these metasurfaces for optoelectronic devices, wiring to each electrically isolated antenna is indispensable for biasing and current flow. Here we show that geometrically engineered metallic wires interconnecting the antennas can function to synchronize the optical phases for promoting coherent resonance, not only as electrical conductors. Antennas connected with optimally folded wires are applied to intersubband infrared photodetectors with a single 4-nm-thick quantum well, and a polarization-independent external quantum efficiency as high as 61% (responsivity 3.3 A W⁻¹, peak wavelength 6.7 μm) at 78 K, even extending to room temperature, is demonstrated. Applications of synchronously wired antennas are not limited to photodetectors, but are expected to serve as a fundamental architecture of arrayed subwavelength resonators for optoelectronic devices such as emitters and modulators.

Applications of metasurfaces for optoelectronic devices require wiring to each isolated antenna for biasing and current flow. Here, the authors report optimal wire interconnects design for controlling the optical properties and present antenna-enhanced mid-infrared photodetection incorporating a single quantum well.

P1433 Antiarrhythmic effects of sacubitril-valsartan therapy assessed by mechanical dispersion index

Introduction

Sacubitril/Valsartan (LCZ696) significantly reduced sudden cardiac death in the PARADIGM-HF trial. However, there is little published data regarding the possible explanations for the antiarrhythmic effects found with LCZ696 therapy.

Previous trials have shown that mechanical dispersion by strain echocardiography can predict arrhythmic events in Heart Failure (HF) patients.

The aim of this study was to compare electrocardiographic (ECG) parameters and mechanical dispersion index with left ventricular (LV) global longitudinal strain (GLS) analysis before and after LCZ696 therapy.

Methods

Prospective evaluation of chronic HF patients with LV ejection fraction ≤ 40% despite optimized standard of care therapy, in which LCZ696 therapy was started and no additional HF treatment was expected to change.

ECG and transthoracic echocardiographic data were gathered in the week before starting LCZ696 therapy and 6 months after therapy. A semiautomated analysis of LV GLS was made and mechanical dispersion index was defined as the standard deviation from the 16 time intervals corresponding to each LV segment.

Results

Of the 42 patients, 35 (83.3%) completed the 6 months of follow-up, since 2 (4.8%) patients died and 5 (11.9%) discontinued treatment for adverse events. Mean age was 58.6 ± 11.1 years.

QTc interval (451.9 vs 426.0msec, p < 0.001) and QRS interval (125.1 vs 120.8msec, p = 0.033) were reduced after 6 months of LCZ696 therapy. Mechanical dispersion index (88.4 vs 78.1msec, p = 0.036) was also significantly reduced after therapy.

Conclusion

LCZ696 therapy is associated with antiarrhythmic effects with a reduction in QTc and QRS intervals in ECG and a reduction in mechanical dispersion index as assessed by LV GLS.

Abstract P1433 Figure.

P715 When "wait and see" is the best option: a case report of a spontaneous coronary artery dissection

Introduction

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and is now being identified more frequently, in part because of increased awareness.

Case report

We present the case of a 63-year-old female, without cardiovascular risk factors or relevant past medical history. She complained of atypical chest pain in the last year. The patient was admitted due to acute chest pain at rest, hemodynamically stable, with unremarkable physical examination, including absence of heart failure signs. The EKG revealed a dynamic ST depression in leads V4-V6. The peak of high sensitivity troponin I was 13744pg/mL (ULN< 15.6) and CK 874U/l (ULN <168). The echocardiogram showed preserved left ventricular ejection fraction and hypokinesia of mid-apical segments of anterior wall. Considering the diagnosis of NSTEMI the patient underwent coronary angiography that revealed luminal narrowing of 70% in left main artery, 70% in proximal anterior descending artery (LAD) and 99% in first obtuse marginal. Given the absence of cardiovascular risk factors, the smooth angiographic appearance of coronary lesions and absence of calcium, we suspected of spontaneous dissection or vasculitis. Considering the absence of angina revascularization was delayed. A first coronary angio-CT confirmed the luminal narrowing and suggested a spontaneous dissection. Two weeks later the coronariography and the angio-CT were repeated with a significant improvement, showing only intermediate stenosis of proximal LAD. The additional imaging study revealed a 45mm ascending aortic dilation and a left primitive carotid stenosis without other vascular territory alterations, excluding fibromuscular dysplasia. The auto-immune study was unremarkable. With all these results it was assumed the diagnosis of a spontaneous coronary artery dissection and the patient was discharged asymptomatic under single antiplatelet therapy and Rivaroxaban. Three months later a new coronary angio-CT showed no significant coronary artery stenosis and the patient was asymptomatic.

Discussion and conclusion

The recognition of spontaneous coronary artery dissection is essential to the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in these patients are suboptimal and conservative management is probably the best option.

Abstract P715 Figure. angio-CT

1185 Three-dimensional speckle tracking echocardiography for the global and regional assessment of myocardial deformation in breast cancer patients submitted to anthracyclines

Introduction

Serial echocardiographic assessment of 2D/3D left ventricular ejection fraction (LVEF) and 2D global longitudinal strain (GLS) is the gold standard for screening for cancer therapeutics-related cardiac dysfunction (CTRCD). Although 3D speckle tracking echocardiography (STE) has several technical advantages, is more reproducible, and has a better correlation to magnetic resonance than 2D STE, it is still not currently used in this setting. We aimed to investigate the usefulness of 3D STE in evaluating left ventricle mechanics and its relation to CTRCD.

Methods

Prospective study of female breast cancer patients submitted to anthracycline chemotherapy who underwent one transthoracic echocardiography (ETT) before and at least one ETT during/after chemotherapy. Standard ETT parameters and 3D volumetric measurements were assessed. STE was used to estimate 2D GLS – average and 18 segments – and 3D GLS, global circumferential strain (GCS), global radial strain (GRS) and global area strain (GAS) – average and 17 segments. CTRCD was defined as an absolute decrease in 2D or 3D LVEF >10% to a value <54% or a relative decrease in 2D GLS >15%.

Results

105 patients (mean age 53.8 ± 12.5 years, 52.4% immunotherapy, 77.2% radiotherapy, 2.8 echocardiograms/patient) were included. During a mean follow-up of 12.1 months, 24 patients (22.9%) developed CTRCD. During anthracycline therapy, there was a significant worsening of 2D LVEF (65.6 vs. 57.8), 3D LVEF (61.5 vs. 54.4), 2D GLS (-21.1 vs. -18.0), 3D GLS (-15.6 vs. -10.9), 3D GCS (-14.0 vs. -11.0), 3D GRS (42.0 vs. 28.5) and 3D GAS (-27.0 vs. -20.0) [all p <0.001]. More than 73% of patients presented 3D global strain values below the limits of normal during chemotherapy. On 3D strain regional analysis, impaired contractility was observed in the anterior, inferior and septal walls. Logistic regression analysis showed that 3D GRS and 3D GCS were associated with a higher incidence of CTRCD. In the multivariate model, 3D GRS remained the only independent predictor of CTRCD. The receiver operating curve analysis showed a good calibration and discrimination of 3D GCS and 3D GRS in predicting CTRCD with areas under de curve of 0.748 and 0.719, with the optimal cut-off values being 0.342 for GCS and 0.344 for GRS. These variations were observed a median of 45 days and 22.5 days before the diagnosis of CTRCD, respectively.

Conclusion

3D strain parameters worsened during anthracycline therapy, with predominant involvement of septal, anterior and inferior walls. Variations of 3D GCS and GRS were predictive of subsequent CTRCD, and thus can be considered an earlier sign of CTRCD, with added value over the currently recommended 2D/3D LVEF and 2D GLS. Routine application of this technique should be considered in order to offer targeted monitoring and timely initiation of cardioprotective treatment.

P1256 Salvage mitraclip implantation for postmyocardial infarction mitral regurgitation: 2 case reports

Introduction

Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR.

Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms.

Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic.

Conclusion

Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.

P1260 Chagas disease, a new challenge to the old continent

Case Report

A 53-year-old female patient from the North Region of Brazil with a past medical history of Chagas Disease (CD) with esophageal involvement and permanent atrial fibrillation (AF) presented to the Emergency Department (ED) due to complaints of retrosternal discomfort and dizziness. The patient reported multiple recent syncopal episodes and had performed a recent 24-hour Holter monitoring revealing AF with predominantly slow ventricular rate and frequent ventricular premature beats. Her sister had recently been diagnosed with obstructive hypertrophic cardiomyopathy. During the ED stay, the patient developed a syncopal monomorphic ventricular tachycardia, requiring synchronized electrical cardioversion. Post cardioversion EKG revealed a sinus rhythm with a right bundle branch block, left anterior fascicular block and 1st degree AV block. The patient was admitted in the Cardiology Department for further investigation. Transthoracic echocardiogram revealed a dilated left ventricle with a reduced systolic function (LVEF of 38%, GLS of -7.1%), with an aneurysm of the basal inferior and posterior walls and a markedly dilated left atrium (68mL/m2). Cardiac magnetic resonance imaging showed a marked dilation of both atriums and ventricles, with biventricular systolic dysfunction, hypertrabeculation of the left ventricular wall and the presence of diffuse intramural and subepicardic fibrosis. These features were compatible with chagasic cardiomyopathy. Due to biventricular systolic dysfunction, the documentation of AV conduction disturbance, the natural history of the disease and the need for antiarrhythmic therapy, the patient underwent cardiac resynchronization therapy–defibrillator implantation. 1 week after the procedure, the patient experienced an arrhythmic storm with a total of 6 CRT-D shocks. Amiodarone was initiated and beta-blocker was titulated to the maximum tolerated dose, with no recurrence of ventricular tachycardia. On the 3 month follow-up visit the patient denied symptoms of congestive heart failure. Device interrogation revealed a high percentage of biventricular pacing and no arrhythmic events.

Conclusion

This case describes the most remarkable and characteristic features of chagasic cardiomyopathy. It is almost always progressive and is associated with a worse outcome comparing with other cardiomyopathies. The prevalence of CD is growing in traditionally nonendemic areas and its timely recognition is fundamental.

P1262 If anything can go wrong, it will: management of a pericardial effusion in a young patient

Case Report

A 25 year-old male patient with an unremarkable past medical history presented to the Emergency Department due to a hemodynamically stable wide complex tachycardia at 260bpm with no response to adenosine, which was successfully treated with synchronized electrical cardioversion. Post cardioversion EKG revealed a pre excitation pattern and the transthoracic echocardiogram showed a large pericardial effusion with diastolic right atrial collapse. The patient was admitted in the Cardiology Department for emergent pericardiocentesis and further investigation. A total of 800 mL of bloody pericardial fluid was removed, compatible with an exudate, but fluid culture and cytology were inconclusive. Due to a rapid reaccumulation of pericardial fluid, the patient underwent a pericardial window, after which he developed an intractable pleuritic thoracalgia, refractory to the combination of ibuprofen, colchicine and oral steroid, despite the resolution of the pericardial effusion. He was also submitted to an electrophysiologic study with successful ablation of a right sided accessory pathway. Analysis of the pericardial fluid and biopsy were inconclusive once again, including a low level of adenosine deaminase and negative acid-fast bacilli test and nucleic acid amplification test for Mycobacterium tuberculosis. The patient was afebrile and denied any constitutional symptoms or relevant epidemiological context. The remainder etiological study was unremarkable, with the exception of fluctuating antibody titers for adenovirus, Borrelia burgdorferi and Mycoplasma pneumoniae, which were interpreted as a result of cross-reactivity. Nevertheless, a course of 21 days of doxycycline was tried without any significant improvement. Thoracic-abdominal-pelvic CT and PET scan were normal. Direct inoculation in guinea pig led to positive results for Mycobacterium tuberculosis and antituberculous therapy was started. Despite pathogen directed antibiotic treatment, there was no clinical improvement and the pericardial effusion gradually relapsed, evolving to cardiac tamponade requiring emergent drainage. Histologic examination of pericardial fragments finally revealed massive infiltration by an undifferentiated malignant tumor compatible with a malignant epithelioid hemangioendothelioma. Due to the patient’s poor performance status and rapidly deteriorating clinical course, it was decided not to start chemotherapy. The patient eventually died, 6 months after his admission to the ED and 2 weeks after the neoplasm’s diagnosis.

Conclusion

In regions with a high Tuberculosis incidence, there should be a high degree of suspicion for tuberculous pericarditis, especially in cases of recurrent pericardial effusion. Immunosuppressed individuals, such as oncologic patients, are at an increased risk for tuberculosis. The management of relapsing pericardial effusion remains a diagnostic challenge as described in this clinical case.

P1429 B-Type natriuretic peptide prediction of right catheterization parameters in the first year after heart transplant

Introduction

Despite being the gold-standard for hemodynamic assessment, right heart catheterization (RHC) was overcome by plasma B-Type Natriuretic Peptide (BNP) levels in daily clinical routine. However, in the first year after heart transplantation (HT), the relationship between BNP and adverse hemodynamics have yielded conflicting results.

Purpose

The aim of this study was to evaluate whether BNP values can be used to estimate adverse hemodynamics in the first year after HT.

Methods

Prospective study of consecutive RHC performed in the first year after HT (according to the endomyocardial biopsies program). Plasma BNP levels were measured at the same day.

The area under the curve (AUC) was analysed to find the BNP values with higher sensitivity and specificity to detect adverse hemodynamics.

Results

From 2017 to 2018, 50 RHC were performed. Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

Prediction of adverse hemodynamics by AUC results are represented in the table. BNP values were significantly increased in patients with pulmonary capillary wedge pressure (PCWP) >12mmHg (p < 0.001), cardiac index <2.5L/min/m2 (p = 0.001), mean pulmonary artery pressure (mPAP) ≥25mmHg (p < 0.001), pulmonary vascular resistance > 1,5WU (p = 0.044) and right atrial pressure >5mmHg (p = 0.003).

BNP >500pg/ml had a sensitivity of 78.3% and 87.5% and a specificity of 76.0% and 67.7% to detect PCWP >12mmHg and mPAP ≥25mmHg, respectively.

Conclusion Significant associations were found between BNP values and adverse hemodynamics in RHC, supporting the clinical utility of BNP in the first year after HT.

BNP prediction AUC values SR HEMODYNAMIC PARAMETERS AUC p 95% CI Best BNP value Sensitivity Specificity Pulmonary capillary wedge pressure (PCWP) > 12mmHg 0.798 <0.001 0.671-0.925 > 500pg/ml 78.3% 76.0% Mean pulmonary artery pressure (mPAP) ≥ 25mmHg 0.830 <0.001 0.714-0.946 > 500pg/ml 87.5% 67.7% Cardiac output < 4L/min 0.833 0.002 0.667-1.000 > 1500pg/ml 77.8% 87.5% Cardiac index (CI) < 2.5L/min/m2 0.810 0.001 0.663-0.957 > 1150pg/ml 76.9% 86.1% Pulmonary vascular resistance (PVR) > 1,5WU 0.678 0.044 0.509-0.848 > 200pg/ml 83.3% 47.1% Right atrial pressure (RAP) > 5mmHg 0.744 0.003 0.607-0.880 > 500pg/ml 70.8% 65.4% BNP prediction

P354 Right heart catheterization parameters, echocardiography parameters and B-Type natriuretic peptide prediction of acute cellular rejection in the first year after heart transplant

Introduction

Since the mid-1970s, the diagnosis of acute cellular rejection (ACR) has been made by endomyocardial biopsy (EMB). Whether B-Type Natriuretic Peptide (BNP), transthoracic echocardiography (TTE) parameters and right heart catheterization (RHC) parameters can detect rejection in heart transplant (HT) patients have yielded conflicting results and did not overcome the use of EMB in the first year after HT.

Purpose

The aim of this study was to evaluate whether BNP, TTE and RHC parameters can be used to detect ACR in the first year after HT.

Methods

Prospective study of consecutive EMB performed in the first year after HT. Plasma BNP levels, TTE and RHC were performed at the same day.

Clinical significant ACR was defined as ≥ 2R, according to the ISHLT 2004 grading. The area under the curve (AUC) was analysed for statistically significant associations to detect ACR.

Results

From 2017 to 2018, 50 EMB were performed with the following results: 2R - 5 (10.0%); 1R- 29 (58.0%); 0 – 16 (32%). Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

AUC results of BNP and several TTE and RHC parameters for the prediction of ACR are represented in the table. Right atrial pressure (RAP) value (p = 0.027) was the only significantly predictor of ACR, while isovolumic relaxation time measured by TTE revealed a borderline significant trend (p = 0.076).

RAP > 10mmHg had a sensitivity of 60.0% and a specificity of 84.4% for detecting ACR.

Conclusion

Detecting ACR without EMB remains a clinical challenge, but RAP measured by RHC was a significant predictor of ACR in the first year after HT, while BNP values did not correlate with ACR.

AUC values PARAMETERS AUC p 95% CI BNP 0.658 0.251 0.405-0.911 Troponin I 0.591 0.507 0.260-0.923 Left ventricular ejection fraction 0.416 0.541 0.218-0.614 E/A 0.480 0.895 0.282-0.678 Deceleration time 0.463 0.463 0.161-0.765 Isovolumic relaxion time 0.745 0.076 0.427-1.000 Cardiac index 0.595 0.488 0.346-0.845 Pulmonary capillary wedge pressure 0.628 0.401 0.329-0.926 Mean pulmonary artery pressure 0.684 0.181 0.511-0.857 Right atrial pressure 0.804 0.027 0.631-0.978 AUC values

P175 Cardiac device infection: to extract or not to extract, that is the question

Introduction

The incidence of infectious complications related to intracardiac devices has been increasing in recent year and is associated with a poor prognosis, which is determined not only by the infectious process but also by the severity of the underlying cardiac pathology and the spectrum of comorbidities presented. Appropriate antibiotic therapy and extraction of the devices are fundamental in the management of these patients.

Case report

We describe the case of a 66-year-old patient on a waiting list for transplantation due to non-ischemic dilated cardiomyopathy with poor left ventricular systolic function (LVEF of 10%), with severe functional mitral regurgitation and severe pulmonary hypertension, who received a CRT-D for secondary prevention (non-responder). He was admitted for decompensated heart failure (NYHA functional class IV and "dry-cold" profile) requiring inotropic support becoming dependent on dobutamine. During hospitalization, there was a progressive increase in inflammatory markers accompanied by recurrent febrile peak and inflammatory signs of the central venous catheter, with catheter-tip and serial hemocultures positive for Morganella morganii. Piperacillin / tazobactam was started. Due to the lack of response to pathogen directed antibiotic therapy, he underwent a transesophageal echocardiogram (TEE) that revealed several filiform images associated with the electrodes, with no image of valvular vegetations, which led to the association of gentamicin and device extraction (DE), according to the Pisa technique, that occurred without complications. On the 7th day after DE, there was a progressive clinical deterioration in spite of increasing doses of inotropes and vasopressors. It was considered that patient would not be candidate for cardiac transplantation or mechanical ventricular assist, and died on the 118th day of hospitalization in refractory cardiogenic shock.

Conclusion

Device endocarditis is a class I indication for intracardiac DE and TEE is fundamental in its diagnosis. Despite being a considered a non-responder to cardiac resynchronization therapy based on clinical and echocardiographic criteria, this case illustrates how the loss of cardiac resynchronization may have contributed to the patient’s hemodynamic deterioration and have played a fundamental role in the clinical outcome.

P4704The efficacy of intravascular ultrasound for patients with peripheral artery diseases presenting aorto-iliac artery disease

Background

The use of intravascular ultrasound (IVUS) promotes better clinical outcomes for intervention in complex lesions. However, the data demonstrating whether use of IVUS improves primary patency following stenting for aorto-iliac lesions in patients with peripheral artery disease (PAD) are limited.

Purpose

The purpose of the current study was to investigate the impact of IVUS use on primary patency 12 months after stent implantation for aorto-iliac lesions.

Methods

We analyzed a clinical database of the OMOTENASHI registry (Observational prospective Multicenter registry study on Outcomes of peripheral arTErial disease patieNts treated by AngioplaSty tHerapy in aortoIliac artery), registering symptomatic PAD patients (Rutherford category 2, 3, or 4) undergoing endovascular therapy for aorto-iliac lesions between January 2014 and April 2016 in Japan. The current study analyzed 803 patients who underwent self-expandable stent implantation at 61 centers with the institutional volume known. The primary endpoint was 12-month restenosis, defined as ≥50% stenosis on computed tomography or angiography, or a peak systolic velocity ratio ≥2.5 on duplex ultrasound. When treatment strategies, endovascular procedures and clinical outcomes were compared between the patients treated with IVUS use and those treated without IVUS use, the propensity score matching was performed to minimize the inter-group difference in baseline characteristics.

Results

A total of 545 patients (67.9%) underwent IVUS-supported stent implantation. Patients treated with IVUS use had a lower prevalence of regular dialysis, whereas they had a higher prevalence of TASC II class D and chronic total occlusion. In patients treated with IVUS use, carbon dioxide contrast agent were more often used, and 0.035-inch guidewire was less frequently selected. Implanted stents in these patients were longer and smaller in diameter. The propensity score matching extracted 138 pairs, with no remarkable intergroup difference in baseline characteristics. Procedure time ≤1 hour was less frequent in patients treated with IVUS use; their radiation time was longer. Endovascular strategies, as well as postoperative medication were not significantly different between patients with and without IVUS use. The 12-month restenosis risk was not significantly different between patients with and without IVUS use (10.2% [6.9 to 14.9%] versus 10.3% [5.4 to 18.6%], P=0.99).

Conclusion

IVUS use in aorto-iliac stenting for patients with PAD was not associated with primary patency at 12 months.

Acknowledgement/Funding

None

P2516Cardiac rehabilitation program - experience and outcomes in a tertiary center

Introduction

Cardiac rehabilitation (CR) programs are effective in improving functional capacity and reducing mortality. The level of adherence to them seems to be less than the ideal, and some factors can predict non-compliance with impact on outcomes.

Purpose

The aim was to characterize the population of the cardiac rehabilitation (CR) appointment, determine factors predictive of compliance with the standard CR exercise program and evaluate the benefits of the program.

Methods

Retrospective analysis of patients in a CR appointment at a single center between 2014 and 2017. Patients (P) were divided into two groups: compliance >80% of the program (GI) and non-compliance (GII). We assessed clinical, laboratory, and echocardiographic characteristics and determined predictors for compliance and compared the follow-up to date.

Results

270P (83% men) were included, with a mean age of 57 years. The P had a median follow up of 35 months, with an interquartil interval of 28 months. The majority (92.5%) had at least one cardiovascular risk factor (25.1% diabetes, 57.1% hypertension, 72.8% dyslipidemia, 75.8% obesity or weight excess, with mean body mass index (BMI) 27.3±3.46, 16.7% family history, 19.8% acute myocardial infarction (AMI), 48.2% smoking). 99% of the patients were medicated (93.7% acetylsalicylic acid, 67.3% clopidogrel, 24.1% ticagrelor, 95.6% beta-blocker, 93.7% ACEI/ARB, 95.5% statin). 144P (53.3%) were not from Lisbon. Most patients (77%) were referred after AMI, 8.9% with heart failure (HF), 8.5% with stable or unstable coronary disease and 1.9% with valvulopathy. 69P (25.6%) attended >80% of the CR program. Death occurred in 4.4% of the P (71.4% cardiovascular causes) and 27% had at least 1 hospitalization. Age, sex, economic insufficiency and residence local (Lisbon or non-Lisbo) were not predictors of non-compliance (p=0.859, p=0.656, p=0.914 and p=0.515 respectively). Predictors of non-compliance were higher IMC (CC=-0.141, p=0.014), higher cholesterol (CC=-0.140, p=0.016), higher C reactive protein (CC=-0.120, p=0.043), higher HbA1c (CC=-0.170, p=0.008) and CR for heart failure (HF) (OR = 0.715, IC [0.659–0.775], p=0.002). Of these, higher HbA1C (p=0.018) and CR for HF (p=0.034) were independent predictors. Compliance with>80% of the program was associated with lower overall mortality (OR = 0.732, IC [0.679–0.788], p=0.037), but not as an independent factor (p=0.378). The only independent predictor of mortality were BNP (p<0.0001).

Conclusion

Of the patients referred to the CR consultation one fourth concludes the program. Several factors can predict non-compliance, with higher HbA1c and CR for HF being independent predictors. Compliance with the CR program is associated with lower overall mortality.

P4711The prognostic impact of infrapopliteal arterial calcification on wound healing in patients with critical limb ischemia

Background

Critical limb ischemia (CLI) is the most progressed manifestation of peripheral artery disease. Although patients with CLI commonly complicate with severely calcified lesions in infrapopliteal lesions, the prognostic impact of infrapopliteal arterial calcification on wound healing in patients with CLI has not been systematically studied.

Purpose

The aim of current study was to elucidate the prognostic impact of infrapopliteal arterial calcification on wound healing in CLI undergoing endovascular therapy (EVT).

Methods

This study enrolled 639 CLI patients with tissue loss (age 74±10 years, male 62%, diabetes 69%, hemodialysis 57%, Rutherford class 5 77%, class 6 23%) primarily treated with EVT for the infrapopliteal lesions between April 2010 and December 2015. Arterial calcification was assessed by high intensity fluoroscopy and classified into 3 groups as follows; 1) none, 2) unilateral and 3) bilateral calcification. The primary outcome measure was complete wound healing. The predictors of the outcome were evaluated by Cox proportional hazards regression analysis.

Results

During a mean follow-up period of 22±19 months, 1-year wound healing rate were 59.0%. In Kaplan-Meier analysis, 1-year wound healing rate was worse in patients with bilateral calcification than in those with unilateral or none calcification (Figure, 46.2% versus 55.1% versus 67.8%, P<0.001). After multivariate analysis, the predictors of wound healing were non-ambulatory status (hazard ratio (HR) 0.67 [95% confidential interval (CI) 0.53–0.85], P=0.001) and bilateral calcification (HR 0.75 [95% CI 0.47–0.98], versus none or unilateral calcification, P=0.036).

Figure 1

Conclusion

Infrapopliteal Arterial calcification as well as non-ambulatory status was associated with wound healing in patients with CLI.

P2510Cardiorespiratory optimal point as a predictor of outcomes in patients enrolled in a cardiac rehabilitation program

Introduction

The cardiopulmonary exercise test (CEPT) allows the evaluation of peak and sub-maximal tolerance to the effort, giving us relevant information for clinical decisions. Evidence has emerged that Cardiorespiratory Optimal Point (COP)>30, calculated as the minimum ratio between ventilation and oxygen (VE/VO2) may be a good predictor of events.

Purpose

The aim was to characterize the population of the cardiac rehabilitation (CR) appointment that performed CEPT, evaluate COP as a predictor of events and determine the best cut off for our population.

Methods

Retrospective analysis of CR appointment patients who performed CEPT between 2014 and 2017 in a single center. We compared the mortality and hospitalizations according to COP and COP>30. We established the appropriate Cut Off for our population and compared the same with the occurrence of events.

Results

207Patients (P) (83.6% men) were included, with a mean age of 57 years. The mean COP was 23.6±5.8 (IC [24.06–25.66]). 15.9% P had COP >30 and 33.8% had COP<22. The majority (96.6%) had a cardiovascular disease or risk factors and 99% were medicated. The majority (87.9%) was referred for CR with isquemic cardiopathy (AMI or stable or unstable coronary disease), 9.2% with heart failure (HF) and 9.2% with valvulopathy. 6.9% P died from any cause, 33.8% had an hospitalization (78.6% from a cardiovascular reason). Higher COP values correlated with higher number of all causes hospitalizations (H) (CC = 0.123, p=0.032), cardiovascular H (CC = 0.123, p=0.032), heart failure H (CC = 0.189, p=0.001) and device placement H (CC = 0.173, p=0.003). COP did not correlate with mortality (p=0.453). The cut off of 30 only correlated with HF hospitalization in this population (OR = 5, IC [1.429–17.494] p=0.006). In our population, COP was a good predictor for all cause H and heart failure H (AUC = 0.8 in both). A cut off of 25 had a sensitivity (S) of 78% with a specificity (E) of 70% for all cause hospitalization and S 73% and E 68% for heart failure H. Values above this cut off correlate with more all cause H (OR = 1,928, IC [1.06–3.507], p=0.031) and heart failure H (OR = 5.63, IC [1,44–21.94]), p=0.006). COP was an independent predictor of all-cause H (p=0.018) and heart failure H (p<0.0001). Other independent predictors of HF hospitalization are BNP (p=0.0011) and ejection fraction (p<0.0001).

Conclusion

COP was a good independent predictor of all-cause hospitalizations and HF hospitalization. In our population the cut off 25 for COP had the greatest S and E for predicting events. In our population this factor was not a good predictor of mortality.