Gas Chromatographic Determination of Volatile Congeners in Spirit Drinks: Interlaboratory Study

An interlaboratory study of a gas chromatographic (GC) method for the determination of volatile congeners in spirit drinks was conducted; 31 laboratories from 8 countries took part in the study. The method uses GC with flame ionization detection and incorpo rates several quality control measures which permit the choice of chromatographic system and conditions to be selected by the user. Spirit drink samples were prepared and sent to participants as 10 blind duplicate or split-level test materials for the determination of 1,1-diethoxyethane (acetal), 2-methylbutan-1-ol (active amyl alcohol), 3-methylbutan-1-ol (isoamyl alcohol), methanol (methyl alcohol), ethyl ethanoate (ethyl acetate), butan-1-ol (n-butanol), butan-2-ol (sec-butanol), 2-methylpropan-1-ol(isobutyl alcohol), propan-1-ol (n-propanol), and ethanal (acetaldehyde). The precision of the method for 9 of the 10 analytes was well within the range predicted by the Horwitz equation.The precision of the most volatile analyte, ethanal, was just above statistically predicted levels. This method is recommended for official regulatory purposes.

P726 Cardiac amyloidosis: unmasking the simulator

Introduction

A non-invasive diagnosis of cardiac amyloidosis is a challenge, especially in cases of atypical phenotypic presentation. Differential diagnosis includes hypertrophic cardiomyopathy (HCM), hypertensive cardiomyopathy, and other infiltrative disorders. Multimodality imaging is essential to make a final diagnosis.

Case

We present the case of a 65 years old woman, with a personal history of resistant arterial hypertension and mild hypertensive cardiomyopathy. She was diagnosed 6 years earlier with multiple myeloma, treated with chemotherapy and allogeneic hematopoietic stem cell transplant, presenting with several relapses and in a stable situation at the moment of our first consult. The patient was referred for heart failure in context of acquired community pneumonia one month earlier.

Transthoracic echocardiography showed severe asymmetric left ventricle (LV) hypertrophy (Image A), systolic anterior motion of the mitral valve and diastolic dysfunction suggestive of HCM, not present in the previous examination. Strain imaging of the LV showed a typical amyloid infiltration pattern, with lower longitudinal strain values in the base compared to the apical segments (Image D). Further characterization of the myocardial tissue established the diagnosis along with performing a cardiac magnetic nuclear imaging (MRI). It showed the presence of inferior septum severe LV hypertrophy along with extensive patchy late gadolinium enhancement (LGE) of the lateral wall involving the endocardium (Image C), with normal LV contractility. There was no pleural effusion, but a small pericardial effusion was seen (Image B). With the suspicion of infiltrative heart disease, probably amyloid with an atypical LGE pattern, an oral mucosal biopsy was performed confirming amyloid diagnosis (Images E1,E2). Heart failure treatment was continued, but clinical evolution was poor with the deceasement of the patient 3 years after diagnosis.

Discussion

This case represents an example of the variety of imaging patterns we can see in cardiac amyloidosis. Despite the classical pattern of cardiac amyloidosis, with concentric LV hypertrophy, up to 8% of cases may present with asymmetrical LV hypertrophy, mimicking HCM. LGE extension and pattern can shows this variability as well: global transmural or subendocardial LGE is the most common, but focal patterns (up to 6% of cases) are described. The complexity of the diagnosis in these cases require a clinical and multimodality image approach.

Abstract P726 Figure. Images of the case

P905 Value of global longitudinal strain (GLS) in the short term prognosis of geriatric patients with asymptomatic severe aortic stenosis

Funding Acknowledgements

VII Convocatoria del Banco de Santander and Alfonso X el Sabio University.

Background

Detection of symptoms in geriatric population with aortic stenosis (AS) is challenging, especially when they associate other comorbidities or frailty. Left ventricular global longitudinal strain (GLS) occurs before left ventricular ejection fraction impairment and could be useful for risk stratification and management of these patients.

Purpose

We sought to analyze the usefulness of GLS for predicting major cardiovascular adverse events (MACEs) in geriatric patients with asymptomatic severe AS.

Material and Methods:

Prospective study on 54 patients older than 70 years old with severe asymptomatic AS. Patient evaluation included biochemistry tests, electrocardiogram and echocardiography. We use a GLS cut-off point of 18% to dichotomize patients. Outcomes were defined as the composite of MACEs – occurrence of death from any cause, hospitalization for heart failure, appearance of symptoms or change in treatment.

Results

The mean age was 83.2 ± 7.1, with 60.4% of women. 24.5% showed atrial fibrillation. At 6 months of follow-up, 33% of patients reached the endpoint: 5.6% CHF, 11.1% death, 3.7% symptoms without changes in management and 13% were referred to an invasive treatment. The event-free survival rate at 6 months for the global population was 83%. 41.5 % of the subjects had GLS < 18%. Kaplan Meier analysis showed that the probability of freedom from MACEs was not significant in patients with lower GLS (Log Rank p = 0.39). In the multivariate analysis only AVA was an inverse predictor of events (AVA) HR 0.05 (95% CI 0.007- 0.471, p < 0.05).

Conclusions

The value of GLS was not a predictor of short term events in geriatric patients. Only assessment of AVA was an independent marker of MACES and in this kind of subjects.

Charasteristics of the global population Global N = 53 (%) GLS ≥ 18 N = 31 (58.5%) GLS < 18 N = 22 (41.5%) (p) HBP 42 (79.2) 27 (87.1) 19 (82.6) 0.09 Atrial fibrillation 13 (24.5) 6 (19.4) 7 (31.8) 0.29 CVD 6 (11.3) 1 (3.2) 5 (22.7) 0.02 LVEF: Normal >50% 48 (92) 31 (100) 17 (77.2) 0.05 Peak velocity 3.72 ± 0.72 3.81 ± 0.71 3.60 ± 0.74 0.315 Mean gradient 34.01 ± 14.06 35.61 ± 13.54 32.09 ± 15.07 0.29 Integral ratio 0.25 ± 0.08 0.26 ± 0.09 0.25 ± 0.08 0.83 AVA 0.8 ± 0.26 0.78 ± 0.27 0.83 ± 0.26 0.651 Indexed AVA 0.48 ± 0.16 0.48 ± 0.17 0.48 ± 0.16 0.9 AVA Aortic valve area; CVD: cerebro vascular disease; HBP: High blood presure; LVEF: left ventricule ejection fraction.

Abstract P905 Figure. Kapplan-Meier event-free survival curves

1645 Unexpected aortic bioprosthetic valve thrombosis

Introduction

Prosthetic valve thrombosis (PVT) is a rare but feared complication of cardiac valve replacement which usually represents a difficult diagnostic challenge. Although PVT is not frequent in bioprosthetic valves, the advent of transcatheter heart valves and the advances in computed tomography, allowing the detection of subclinical thrombosis, have yielded growing interest in that field, specially taking into account that there is no consensus on optimal antithrombotic approach in these patients.

Clinical Case

A 74-year-old male with prior cardiac antecedents of aortic valve replacement (April 2010) with a bovine pericardial bioprosthesis (Mitroflow 25, Sorin group Inc.), ischemic dilated cardiomyopathy with moderately depressed left ventricle ejection fraction (33%) and carrier of VDD pacemaker due to third degree atrioventricular block was admitted to advanced heart failure unit. During routine follow-up echocardiograms, prosthetic valve presented no signs of dysfunction except slightly increased gradients (image C): max 38 mmHg (normal <36), med 23 mmHg (normal <20). Because of left ventricle dysfunction, high pacing rate (>95%) and dyspnea NYHA class III the patient was referred for upgrade to cardiac resynchronization therapy (CRT).

Computed tomography to asses epicardial venous anatomy prior to CRT implant was performed. In addition to venous distribution, it was described a repletion defect in aortic bioprosthetic valve suggestive of leaflet thrombosis (image A). To complete the study the patient underwent a transesophageal echocardiography (TOE) revealing a swallow’s nest shaped hypoechoic occupation of non-coronary and left aortic leaflets (image B), and 3D effective orifice area of 0,9 cm2.

Oral anticoagulation was started in association to previously taken acetylsalicylic acid (ASA). Control TOE was performed 3 months after diagnosis showing almost complete resolution of thrombi.

During the follow-up a CRT-D was implanted, with significant response in systolic performance, reaching a LVEF of 45%. Interestingly, despite the increase in anterograde aortic flow, progressive decrease of aortic gradients (max 24 mmHg, med 15 mmHg) until normalization was found (image D). Clinical benefit was also patent, being the patient in NYHA class I at the moment.

Discusion

Valve thrombosis could be difficult to diagnose in the presence of left ventricle dysfunction as gradients shall remain low despite an important compromise in valve motion. We present a case of incidental diagnosis of non-obstructive leaflet thrombosis that was managed conservatively with oral anticoagulation and ASA. The descent in transaortic gradients, moreover taking into account the response to CRT increasing LVEF, indicates that gradients slightly increased or in the upper limit of normality should raise suspicion in valve dysfunction in the presence of decreased LVEF.

Abstract 1645 Figure.

Prospects for observing and localizing gravitational-wave transients with Advanced LIGO, Advanced Virgo and KAGRA

We present our current best estimate of the plausible observing scenarios for the Advanced LIGO, Advanced Virgo and KAGRA gravitational-wave detectors over the next several years, with the intention of providing information to facilitate planning for multi-messenger astronomy with gravitational waves. We estimate the sensitivity of the network to transient gravitational-wave signals for the third (O3), fourth (O4) and fifth observing (O5) runs, including the planned upgrades of the Advanced LIGO and Advanced Virgo detectors. We study the capability of the network to determine the sky location of the source for gravitational-wave signals from the inspiral of binary systems of compact objects, that is binary neutron star, neutron star-black hole, and binary black hole systems. The ability to localize the sources is given as a sky-area probability, luminosity distance, and comoving volume. The median sky localization area (90% credible region) is expected to be a few hundreds of square degrees for all types of binary systems during O3 with the Advanced LIGO and Virgo (HLV) network. The median sky localization area will improve to a few tens of square degrees during O4 with the Advanced LIGO, Virgo, and KAGRA (HLVK) network. During O3, the median localization volume (90% credible region) is expected to be on the order of 10 5 , 10 6 , 10 7 Mpc 3 for binary neutron star, neutron star-black hole, and binary black hole systems, respectively. The localization volume in O4 is expected to be about a factor two smaller than in O3. We predict a detection count of 1 - 1 + 12 ( 10 - 10 + 52 ) for binary neutron star mergers, of 0 - 0 + 19 ( 1 - 1 + 91 ) for neutron star-black hole mergers, and 17 - 11 + 22 ( 79 - 44 + 89 ) for binary black hole mergers in a one-calendar-year observing run of the HLV network during O3 (HLVK network during O4). We evaluate sensitivity and localization expectations for unmodeled signal searches, including the search for intermediate mass black hole binary mergers.

Retinol-binding protein 4 (RBP4), a potential biomarker of frailty in HIV-infected people on stable antiretroviral therapy

OBJECTIVES

A quantitative biomarker for identification of pre-frail and frail persons is still lacking. This study aimed to identify biomarker predictors of frailty in HIV-infected patients.

METHODS

A cross-sectional study of HIV-infected patients who had been on antiretroviral therapy (ART) for at least 1 year and who presented an undetectable viral load (< 50 HIV-1 RNA copies/mL) at baseline was carried out. For each frail patient, up to four pre-frail and robust patients were randomly selected. The frailty status assessment was based on the five-item criteria described by Fried et al. Sociodemographic, anthropometric, biochemical and HIV-related characteristics were evaluated. Multiple potential biomarkers of frailty and a biological age biomarker were analysed.

RESULTS

A total of 73 HIV-infected patients on ART for at least 1 year were evaluated. The patients were categorized as robust (n = 33), pre-frail (n = 32) and frail (n = 8) using the Fried criteria. All patients were on ART, with 100% undetectable viral load (< 50 copies/mL) at baseline. No significant differences in demographic, clinical or analytical characteristics were observed among patients in the different categories based on Fried criteria, with the exception of the veterans aging cohort study index (VACS). Similarly, no differences were observed in HIV-related characteristics, although nucleoside reverse transcriptase inhibitor (NRTI) use was less common in frail persons. The distribution of biomarker values varied according to frailty status, with frail persons having higher levels of interleukin (IL)-8, IL-18, CXC chemokine ligand 10 (CXCL10) and retinol-binding protein 4 (RBP4). In multivariable analysis, the assocation of frailty with RBP4 showed a tendency to statistical significance (odds ratio 1.0; 95% confidence interval 0.99-1.00; P < 0.05).

CONCLUSIONS

Differential biomarker expression was present according to Fried status. Longitudinal studies will clarify the utility of these biomarkers as targets for diagnostic or therapeutic intervention.

P3825Long-term prognostic value of growth differentiation factor-15 in acute coronary syndrome

Introduction

Biomarkers plays a critical role in diagnostic, prognostication, and decision-making in cardiovascular medicine. Growth differentiation factor-15 (GDF-15) has been reported as a potential biomarker in acute coronary syndrome (ACS). However, there is limited data on the long-term prognostic value after an ACS.

Purpose

To study the long-term prognostic value of GDF-15 in ACS.

Methods

We included patients with ACS who underwent coronary angiography. During angiography an arterial blood sample was collected. Plasma GDF-15 were measured and clinical data and long-term events were obtained. As previously reported, risk categories were defined as low risk (<1200ng/L), intermediate (1200–1800ng/L) and high risk (>1800ng/L). Incremental prognostic value of GDF-15 for all-cause death was assessed on top of a clinical model (GRACE score, LVEF<40% and age).

Results

A total of 358 patients were included; 157 as a low risk, 85 as an intermediate and 116 as a high risk. The median (IQR) age was 65 (56–74) years and 27.4% were female. Of all patients, 61.5% were admitted with non-ST-elevation myocardial infarction, 24.0% with ST-elevation myocardial infarction and 14.5% with unstable angina. Higher values of GDF-15 were consistently associated with an increased prevalence of cardiovascular risk factors. During 6 years of follow-up 54 patients died. Of those patients, 7 (4.5%) had values of GDF-15 below 1200ng/L, 6 (7.1%) between 1200–1800ng/L and 41 (35.3%) above 1800ng/L. After adjustment for a multivariate Cox regression model, GDF-15 >1800ng/L were independently associated with all-cause death (HR 4.5; 95% CI 1.8–11.6; p=0.002) and the composite of major adverse cardiovascular events (MACE) which were identified as all-cause death, nonfatal MI and heart failure (HR 2.5; 95% CI 1.4–4.4; p=0.001). For long-term all-cause death a significant increase of the c-statistic was seen after addition of GDF-15 to the clinical model 0.871 (95% CI 0.817–0.924; p=0.019) as well as net reclassification improvement (0.769; 95% CI 0.487–1.051; p<0.001) and integrated discrimination improvement (0.117; 95% CI 0.062–0.172; p<0.001). Of 18 events of heart failure, 17 occurred in patients with GDF>1800ng/L. A multivariate competing risk model showed a significant association between GDF-15>1800ng/L and incidence of heart failure (adjusted HR 30.8; 95% CI 4.1–231.5; p=0.001) but non-significant association were found for myocardial infarction.

KM figures and all-cause death ROC curve

Conclusions

In the setting of ACS GDF-15 can predict long-term all-cause death, MACE and heart failure and provides incremental prognostic value beyond traditional risks factors in the long-term all-cause death.

P3370Prevalence of right ventricular dysfunction according to different parameters: basal and one year after transcatheter aortic valve implantation

Background

Right ventricle (RV) is not often specifically studied in patients with severe aortic stenosis (AS). It's difficult to find the correct tool to assess RV function with echocardiographic parameters, and the percentage of patients with dysfunction may vary depending on the parameter that we use.

The aim of the study was to evaluate the prevalence of RV dysfunction basal and one year after transcatheter aortic valve implantation (TAVI), according to different parameters.

Methods

Consecutive patients with severe AS undergoing TAVI from January 2016 to July 2017 were included. RV anatomical and functional parameters were analyzed according to ESC and ASE guidelines. RV dysfunction was assessed using tricuspid annular plane systolic excursion (TAPSE) <17 mm, fractional area change <35%, systolic movement of the RV lateral wall by tissue Doppler imaging (RV-S'TDI) <9.5 cm/s, global longitudinal (RV-GLS) and free wall strain (RV-FWS) using as cutting point [20]. Pre procedure echo, immediate post procedure and 1 year echo were analyzed. Statistical analysis was performed using SSPS version 22.

Results

The final study population consisted of 78 patients (115 patients were included, 37 were excluded due to suboptimal acoustic window for RV anatomical and functional evaluation), mean age 83.73±6.31 year-old, 38.2% females. We analyzed the percentages of RV dysfunction according to the different parameters evaluated before and in the control one year after. They are shown in Figure 1.

Prevalence of RV dysfunction

Conclusions

The presence of RV dysfunction in patients with severe AS is higher than expected Our data suggest that RV function improve one year after TAVI, in terms of a reduction in the number of patients with dysfunction. The assessment of RV function is difficult, and there is no agreement on what tools are more accurate and useful. RV strain seems to be the most sensible parameter to assess RV function in patients with AS undergoing TAVI. Impact of these measurements in patients management needs further evaluation.

P6437Growth differentiation factor-15 and stromal cell-derived factor-1 as long-term prognosis biomarkers in acute coronary syndrome

Introduction

After an acute coronary syn bdrome (ACS) patients are at high risk of cardiovascular morbidity and mortality. In this scenario, Growth differentiation factor-15 (GDF-15) and Stromal cell derived factor-1 (SDF-1) has been reported as potential biomarkers in ACS. However, there is limited data about their combined use in long-term prognosis.

Purpose

To study the long-term prognostic value of GDF-15 and SDF-1 in ACS.

Methods

We included patients with ACS who underwent coronary angiography. During angiography an arterial blood sample was collected. Plasma SDF-1 and GDF-15 were measured and clinical data and long-term events were obtained. The cut-off point of SDF-1 and GDF-15 was identified individually by receiver operating characteristic curves. Patients were classified into 3 groups: 1) both biomarkers below cut-off points; 2) only one biomarker above cut-off points; 3) both biomarkers above cut-off points.

Results

A total of 238 patients were included. The median (IQR) age was 64 (55–74) year and 27.3% were female. Of all patients, 60.9% were admitted with non-ST-elevation myocardial infarction, 22.7% with ST-elevation myocardial infarction and 16.4% with unstable angina. The cut-off point of SDF-1 was 3283.5pg/mL and GDF-15 was 1849ng/L. A total of 127 patients were in group 1, 64 in group 2 and 47 in group 3. Group 3 patients were associated with older age, hypertension, dyslipidemia, diabetes mellitus and history of myocardial infarction (MI), stroke, chronic kidney disease and peripheral artery disease. Besides, they were more likely to have left ventricular dysfunction (ejection fraction <40%) and significant three vessels stenosis. During 6.5 years of follow-up 8 patients died (6.3%) in group 1, 7 patients died (10.9%) in group 2 and 25 patients died (53.2%) in group 3 (Figure 1). Multivariate Cox analysis showed that high levels of SDF-1 and GDF-15 (group 3) were an independent predictor of all-cause death (HR 5.8; 95% CI 2.4 - 14.1; p<0.001) and the composite of major adverse cardiovascular events (MACE) which were identified as all-cause death, nonfatal MI and heart failure (HR 3.9; 95% CI 2.1 - 7.3; p<0.001). During follow-up 1 patient had heart failure in group 1 (0.8%), 3 patients (4.7%) in group 2 and 9 patients (19.1%) in group 3. Despite the low number of events of heart failure, the multivariate competing risks regression showed association between group 3 and heart failure during follow-up (HR 28.0; 95% CI 3.5 - 225.2; p=0.002). Higher levels of SDF-1 and GDF-15 (group 3) were not associated with new MI in multivariate competing risks regression. Regarding group 2, all multivariate analyses were non-significant.

Cumulative survival and incidence curves

Conclusions

Higher values of combined GDF-15 and SDF-1 are an excellent predictor of all-cause death, MACE and heart failure in long-term follow-up of patients with ACS. The combined use of SDF-1 and GDF-15 may be useful in long-term ACS prognosis.

2139Left atrial dysfunction assessed by strain correlates with symptoms and severity of aortic stenosis

Background

Aortic stenosis (AS) results in high pressure afterload causing detrimental effect especially on the left chambers. Structural and functional changes of the left ventricle (LV) usually corresponds to concomitant remodelling of the left atrium (LA). However, how this pressure afterload specifically affects LA function and whether the study of LA function could help in stratifying patients with different degree of AS it is not known.

Purpose

We aim to evaluate the differences in LA and LV function according different degree of AS by standard and speckle tracking echocardiographic.

Methods

From January 2016 to May 2018 we recruited 135 patients referring to our echo-lab with diagnosis of AS (mean age 79.5±4.4; 60/55% female). We divided this population according to AS severity in patients with moderate AS, severe asymptomatic and severe symptomatic AS and matched with 35 control group with no aortic stenosis (n=45, mean age: 77.6±4.5). All patients underwent standard and 2-dimensional speckle tracking echocardiography computing global longitudinal strain (GLS) of LV and peak atrial strain of LA (PALS).

Results

In all patients PALS was a good predictor of E/e' ratio after correction for LV EF and age (p<0.001, β: −0.48). LVEF and GLS progressively decreased together with worsening of AS degree, as well as parameters of geometry and function of LA (Table1). By excluding patients with LV dysfunction the reduction gradient of parameters of LA geometry and function was still present. However, when severe symptomatic with asymptomatic severe AS are compared, no difference in E/e' ratio was found while both GLS and PALS were significantly reduced (both p<0.0001).

Variables Overall population (180) Control (45) Moderate AS (45) Severe asympt AS (45) Severe sympt. AS (45) p LVEF 65.0±11.1 67.7±5.6 69.4±8.5 66.1±10.7 59.5±13.5 0.0001 GLS −20.4±4.1 −23.1±2.4 −21.5±2.9 −21.4±3.2 −17.1±4.3 0.0001 LA vol index 41.6±21.5 28.2±10.4 40.1±19.7 39.8±16.7 52.3±24.9 0.0001 LA strain 23.6±10.9 30.8±10.3 27.8±9.2 24.4±9.7 15.2±7.1 0.0001 LA reservoir 46.4±15.9 51.9±11.5 53.0±15.0 48.3±14.1 37.2±16.1 0.0001 Ee' ratio 14.8±7.0 9.6±2.7 13.7±6.3 15.4±6.2 19.3±7.2 0.0001

Conclusions

LA function seems to progressively decrease according to the degree of AS, independently from LV function. Significant difference was found between parameters of LA remodelling and dysfunction between symptomatic and asymptomatic AS patients. The assessment of LA function by strain may help stratify the patients with AS, identifying those who need intensive medical/surgical treatment.

New detection configuration for low activity levels of PET tracers during the analysis of plasma samples

A new radio-HPLC detection system for measuring radioactivity in plasma samples during Positron Emission Tomography [PET] studies was developed. It is based on detecting both the positron and one of the annihilation photons. The system focused on improving the measurement of radioactivity concentrations on an unmetabolized positron emitting a radiopharmaceutical [PER] in the presence of its radioactive metabolites, all containing the same positron emitter. This paper presents a new detection configuration that improves the minimal detectible activity (MDA), simplify the measuring systems and reduces the error caused by the metabolites. The detector is based on a plastic scintillator and a BGO scintillation crystal, that produces different light output spectra for signal and noise events. By summing the positron and the annihilated photon light outputs, different spectra are obtained for the metabolite and for the parent compound tracer and for tracer marked by different positron emitting isotopes. This new detection system can improve quantitative analysis of plasma samples. The spectrum change provides up to a three-fold improvement in sensitivity compared to the currently used detection systems that measure only the annihilation coincidence events. Results showed that for ¹¹C the MDA was improved by approximately 520%. Furthermore, it provides the additional advantage of reliability by providing a method for separating the signal and noise readings from the gross detector readout. Accurate reconstruction algorithm of the signal was achieved over a wide measuring range even when the signal was only 5% of the gross measurement.

Tests of General Relativity with GW170817

The recent discovery by Advanced LIGO and Advanced Virgo of a gravitational wave signal from a binary neutron star inspiral has enabled tests of general relativity (GR) with this new type of source. This source, for the first time, permits tests of strong-field dynamics of compact binaries in the presence of matter. In this Letter, we place constraints on the dipole radiation and possible deviations from GR in the post-Newtonian coefficients that govern the inspiral regime. Bounds on modified dispersion of gravitational waves are obtained; in combination with information from the observed electromagnetic counterpart we can also constrain effects due to large extra dimensions. Finally, the polarization content of the gravitational wave signal is studied. The results of all tests performed here show good agreement with GR.