P1716Dual antiplatelet therapy on veno arterial ECMO to bleed or not to bleed?

Background

Patients presenting with INTERMACS-1 cardiogenic shock and necessitating VA-ECMO, often undergo coronary angiography and percutaneous coronary intervention (PCI). Therefore, a substantial subset of VA-ECMO patients will have an indication for dual antiplatelet therapy (DAPT) plus unfractionated heparin (UFH). According to atrial fibrillation registry data, bleeding incidence on DAPT combined with oral anticoagulation is significantly higher as compared to anticoagulation alone. Although it has been reported that the addition of low dose aspirin to UFH did not increase bleeding or transfusion in VenoVenous (VV)-ECMO patients, it remains to be elucidated whether the addition of DAPT to UFH on VA-ECMO-therapy enhances bleeding.

Methods

We report single center data for 100 VA-ECMO patients between 2011 and 2019. VA-ECMO-patients post-surgery were excluded. Patient demographics, blood product transfusions and reported/radiographically diagnosed bleeding or thrombotic complications were analysed. All VA-ECMO patients received UFH, aiming for an anti-Xa levels of at least 0,3 U/ml. Targets were hemoglobin 7 g/dl, fibrinogen 100 mg/dl (or 150 mg/dl when active bleeding) and platelet counts above 50/fL. DAPT-patients were on a low dose aspirin plus a P2Y12-inhibitor (clopidogrel or ticagrelor).

Results

51% Of the VA-ECMO-group received DAPT (59% clopidogrel and 41% ticagrelor). UFH-levels were comparable between both groups. Patients on DAPT were significantly older (DAPT 52.8 vs. Control 41.3; p<0.001) and predominantly male (DAPT 76% vs. Control 63%). Total bleedings (DAPT 52% vs. Control 55%; p=0,68) and major bleedings (BARC score of 3 or more; DAPT 41% vs. Control 45%; p=0,71) did not differ significantly. We observed a significant lower number of clinically or radiographically overt arterial/venous thromboses (DAPT 13.7% vs. Control 36.2%; p=0,02) in the DAPT-group. When comparing fresh frozen plasma (FFP), red blood cell and platelet pool transfusions between both groups, only FFP-tranfusion (DAPT 0.47 units/day vs. Control 1.18 units/day; p=0,047) intends to be lower for the DAPT-group.

DAPT (plus UFH) vs control (plus UFH)

Conclusions

Haemorrhage is frequent during extracorporeal support. However, in our cohort, DAPT on top of UFH in the treatment of VA-ECMO-supported ischemic cardiogenic shock does not increase the risk of major bleeding. Therefore, DAPT should not necessarily be witheld in the setting of VA-ECMO. Interestingly, our data support a lower incidence of overt thromboses and a trend towards less FFP-transfusion. These findings suggest DAPT-induced platelet inhibition being protective against both thrombotic events and posibly consumptive coagulopathy without paying a price for major bleeding.

P1718Veno-arterial ECMO versus Left Impella bleeding complications in cardiogenic shock patients on dual antiplatelet therapy

Background

Selective groups of patients, presenting with INTERMACS-1 cardiogenic shock due to acute ischaemic heart failure, may benefit from mechanical circulatory support (MCS). Patients with biventricular failure, severe septic shock or oxygenation problems should be selected for VA-ECMO, although the left Impella-CP heart pump can be considered as a less invasive alternative in supporting predominantly left ventricular failure. Bleeding issues are a major concern in patients on MCS, especially in this group where triple anticoagulation therapy (unfractionated heparin (UFH) for prevention of pump thrombosis and dual antiplatelet therapy (DAPT) after coronary stenting) is necessitated. We aim to investigate the bleeding and transfusion rate in DAPT-patients on VA-ECMO versus Impella.

Methods

We report single center data for 51 VA-ECMO and 8 Impella patients between 2011 and 2019. Indication for MCS was acute ischaemic cardiogenic shock. Patient demographics, transfusions and reported/radiographically diagnosed bleeding (BARC-classification) complications were analyzed. All patients received UFH and low dose aspirin plus clopidogrel or ticagrelor. Impella flow was at least 2.5 L/min. Transfusion targets were Hb >7 g/dl, fibrinogen >100 mg/dl (or >150 mg/dl when active bleeding) and platelet count >50/fL.

Results

Impella patients were significantly older (VA-ECMO 52.8 vs. Impella 62.4; p=0.02) as compared to the VA-ECMO group. Anti-Xa-levels and length of the MCS-run (mean 7.9 VA-ECMO vs. 6.4 days Impella) were comparable in both groups. Occurrences of minor bleeds was comparable between both groups (mainly oozing from the insertion site in the ImpellaTM group 63% vs. VA-ECMO 72%; p>0.05) but major bleedings with BARC score of 3 or more were significantly lower in the Impella group (13% vs. VA-ECMO 65%; p=0.005). Platelet and red blood cell transfusions were significantly lower in the Impella group (0.1 units of platelets per day vs. 1.1 units of platelets per day on VA-ECMO; p=0.002 and 0.8 units of RBCs per day vs. 2.6 units of RBCs per day on VA-ECMO; p=0.02).

Bleeding/transfusion VA-ECMO vs Impella

Conclusions

Bleeding is a frequent complication of MCS. However, in our cohort, triple anticoagulation in acute cardiogenic shock due to ischaemic left ventricle failure resulted in a lower major bleeding rate when support was given by the left Impella device as compared with VA-ECMO therapy group. As a result, platelet and red blood cell transfusions were lower in the Impella group. These findings are likely to be partly explained by the increased number and size of cannulas in VA-ECMO, as well as the increased risk of haemolysis and consumptive coagulopathy due to the complexity and extensive foreign body surface of the ECMO-circuit. We conclude that Impella support should be considered as a safer option than VA-ECMO with regards to bleeding in patients with ischaemic left ventricular failure who require DAPT and MCS as a bridge to recovery or other definitive therapy.

Free and combined L- and D-amino acids in Arctic aerosol

Aerosol samples were collected with a high-volume cascade impactor with a 10 day sampling frequency at the Gruvebadet observatory, close to Ny-Ålesund (Svalbard Islands). A total of 42 filters were analyzed for free and combined amino acids, as they are key components of bio-aerosol. This article provides the first investigation of free and combined L- and d-amino acids in Arctic atmospheric particulate matter. The main aim of this study was to determine how these compounds are distributed in size-segregated aerosols after short-range and long-range atmospheric transport and understand the possible sources of amino acids. The total load of free amino acids ranged from 2.0 to 10.8 pmol m^-3, while combined amino acids ranged from 5.5 to 18.0 pmol m^-3. At these levels amino compounds could play a role in the chemistry of cloud condensation nuclei and fine particles, for example by influencing their buffering capacity and basicity. Free and combined amino acids were mainly found in the fine aerosol fraction (<0.49 μm) and their concentrations could be affect by several sources, the most important of which were biological primary production and biomass burning.

Characterization of the water soluble fraction in ultrafine, fine, and coarse atmospheric aerosol

Water soluble organic carbon significantly contributes to aerosol's carbon mass and its chemical composition is poorly characterized due to the huge number of species. In this study, we determined 94 water-soluble compounds: inorganic ions (Cl^-, Br^-, I^-, NO₃^-, SO₄^2-,K⁺, Mg⁺, Na⁺, NH₄⁺, Ca²⁺), organic acids (methanesulfonic acid and C₂-C₇ carboxylic acids), monosaccharides, alcohol-sugars, levoglucosan and its isomers, sucrose, phenolic compounds, free l- and d-amino acids and photo-oxidation products of α-pinene (cis-pinonic acid and pinic acid). The sampling was conducted using a micro-orifice uniform deposit impactor (MOUDI) at the urban area of Mestre-Venice from March to May 2016. The main aim of this work is to identify the source of each detected compound, evaluating its particle size distribution. Clear differences in size distributions were observed for each class of analyzed compounds. The positive matrix factorization (PMF) model was used to identify six factors related to different sources: a) primary biogenic aerosol particles with particle size > 10 μm; b) secondary sulfate contribution; c) biomass burning; d) primary biogenic aerosol particles distributed between 10 and 1 μm; e) an aged sea salt input and f) SOA pinene. Each factor was also characterized by different composition in waters soluble compounds and different particles size distribution.

A new method for the determination of primary and secondary terrestrial and marine biomarkers in ice cores using liquid chromatography high-resolution mass spectrometry

The majority of atmospheric compounds measured in ice cores are inorganic, while analysis of their organic counterparts is a less well developed field. In recent years, understanding of formation, transport pathways and preservation of these compounds in ice and snow has improved, showing great potential for their use as biomarkers in ice cores. This study presents an optimised analytical technique for quantification of terrestrial and marine biosphere emissions of secondary organic aerosol (SOA) components and fatty acids in ice using HPLC-MS analysis. Concentrations of organic compounds in snow and ice are extremely low (typically ppb or ppt levels) and thus pre-concentration is required prior to analysis. Stir bar sorptive extraction (SBSE) showed potential for fatty acid compounds, but failed to recover SOA compounds. Solid phase extraction (SPE) recovered compounds across both organic groups but methods improving some recoveries came at the expense of others, and background contamination of fatty acids was high. Rotary evaporation was by far the best performing method across both SOA and fatty acid compounds, with average recoveries of 80%. The optimised preconcentration - HPLC-MS method achieved repeatability of 9% averaged for all compounds. In environmental samples, both concentrations and seasonal trends were observed to be reproducible when analysed in two different laboratories using the same method.

Abstract P4-06-09: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Corsi F, Andreata F, Truffi M, Sorrentino L, D'Addio F, Monieri M, Gambaro A, Bellini M, Prosperi D, Mazzucchelli S. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-06-09.

Free phenolic compounds in waters of the Ross Sea

The presence of free phenolic compounds (PC) in Antarctic sea water has been investigated to explain their source and particle size distribution in the atmospheric aerosols, as determined in our previous research. The sea water samples were filtered to distinguish the PC concentrations in the particulate and dissolved fractions. Two sample preparation procedures were developed to quantify nine PC in both fractions. The highest concentrations were found in the dissolved fraction of Ross Sea water, with vanillin, vanillic acid, acetovanillone and p-coumaric acid being the most abundant PC. Dissolved PC were mainly found in the upper part of water column. This facilitated the sea water-air exchange by bubble busting processes. In the aerosol, they were mainly found in the fine fraction, where these compounds have a higher degree of oxidation than PC detected in seawater, suggesting that they were newly emitted and they have been not yet oxidized. These results supported our previous hypothesis that PC were locally emitted into the atmosphere from the Ross Sea. Three different possible sources of PC are hypothesized for Antarctic sea waters: 1) from the intrusion of Modified Circumpolar Deep Water that may transport oceanic lignin; 2) from phytoplankton biomass that may be a source of PC in Antarctic waters since diatoms produce exudates that contain vanillic acid, p-coumaric acid and syringic acid; 3) from the melting of glaciers and sea ice: glaciers contain lignin that can be degraded, while in the sea ice there are diatoms that may release PC. Statistical analysis and the low value of vanillic acid/vanillin ratio indicated that the most plausible source for PC in the dissolved fraction was the senescence of phytoplankton. As a contrast, particulate PC with higher vanillic acid/vanillin ratios were ascribed to degraded lignin or the sorption of diagenically oxidized material on particles.

Fragrances and PAHs in snow and seawater of Ny-Ålesund (Svalbard): Local and long-range contamination

Polar regions are fragile ecosystems threatened by both long-range pollution and local human contamination. In this context, the environmental distribution of the Personal Care Products (PCPs) represent a major knowledge gap. Following preliminary Antarctic studies, Fragrance Materials (FMs) were analyzed in the seawater and snow collected in the area of Ny-Ålesund, Svalbard, to investigate local and long-range contamination. Polycyclic Aromatic Hydrocarbons (PAHs), including Retene, were determined in parallel to help the identification of the governing processes. Concentrations of FMs up to 72 ng L^-1 were detected in the surface snow near the settlement and at increasing distances, in relation to the prevailing winds. PAHs follow a similar scheme, with levels of Retene up to 1.8 μg L^-1, likely deriving from the occurrence of this compound in the coal dust due to the previous mining activities in the area. The snow seasonal deposition of FMs and PAHs was estimated in a snowpit dug at the top of the Austre Brøggerbreen glacier, indicating the long-range atmospheric transport (LRAT) of these compounds.

Size-segregated trace elements in continental suburban aerosols: seasonal variation and estimation of local, regional, and remote emission sources

We have measured trace element contents in suburban aerosols from six size fractions in the range of PM_0.27-16 from a background station in Belgrade (Serbia). The distribution and concentration of elements were determined within each of the investigated Dp fractions with emphasis on the fine and coarse modes. Fine/coarse mode ratios of element can provide information regarding their anthropogenic or natural origin. Analysis of seasonal variations of element contents in fine and coarse mode show that Cd, Co, K, and V have higher concentrations in the fine mode during heating season, while Fe contents are lower. In the coarse mode, Cu and V have higher concentrations during the heating season, while Al, Fe, Mg, Mn, and Sb contents are lower. We also apply a distribution probability model (normal, log-normal, and three-parameter Weibull) as new approach to estimate the distances of emission sources that can contribute to pollutant contents in particulate matter of the investigated location.

Distribution of fragrances and PAHs in the surface seawater of the Sicily Channel, Central Mediterranean

The Mediterranean Sea is highly influenced by several anthropic pressures, including different kinds of organic pollutants. Fragrance Materials (FMs) and Polycyclic Aromatic Hydrocarbons (PAHs) were investigated in the surface seawater of the Sicily Channel in offshore and coastal areas. Total concentrations of FMs and PAHs resulted respectively up to 112ngL^-1 and 43ngL^-1, with similar distributions of both classes of analytes. Low values were detected in some coastal samples, due to the upwelling of deep and unpolluted waters, while the presence of gyres probably accumulates contaminants in offshore areas. Confirming previous works, the allergenic and oestrogenic Salicylates generally resulted the most abundant FMs and diagnostic ratios indicated combustion processes as the sources of PAHs. The coupling of the well-known PAHs with a new class of Personal Care Products (PCPs) helped the identification of the major environmental drivers: the results highlighted the role of mesoscale hydrodynamics and suggested long-range atmospheric transport as key factors. The first detection of the selected FMs in open sea areas supports the hypothesis of their environmental persistence.

Partitioning of particulate matter and elements of suburban continental aerosols between fine and coarse modes

The results presented in this work demonstrate for the first time a distribution of elements in the spectral analysis of aerosols in the suburban continental Balkan Peninsula. Samples were collected in the suburban area of Belgrade (Serbia) in the period from March 2012 till December 2013. Results presented here are from long-term measurements of masses of size-segregated aerosols and macro- and microelements in the range of PM_0.27-16. The following elements were analyzed: Al, Ag, As, Ba, Ca, Cd, Co, Cr, Cu, Fe, K, Mg, Mn, Mo, Na, Ni, Pb, Sb, Ti, Tl, V, and Zn; levels of Be, Hg, and Se were under the detection limits in all samples. Average concentrations and time and seasonal variations of particulate matter (PM) as well as element contents and their percentage shares are given. The results showed the domination of particle content around the accumulation mode in the range of 0.53 < Dp < 1.06 μm, but the fractional distribution of elements showed maximal average concentrations in different fractions depending on the origin of each element. Crustal elements (Al, Ca, Fe, Mg, Mn, Ti, etc.) dominated in coarse mode, while anthropogenic elements (As, Cd, Cu, Pb, Sb, etc.) were mainly distributed in fine mode fractions. Some elements, such are As and Ni, were detected in investigated aerosols only occasionally, while others, such as Ca, Fe, and Mg, were detected in all analyzed samples. The application of multivariate analysis (PCA) demonstrated the connection between the elements of similar origin, in fine fractions mainly of anthropogenic origin, while in coarse mode of crustal origin, indicating the resuspension with contribution of about 40%. The contents of some measured elements were compared with their contents in aerosols in some European suburban areas.

Levels and spatial distributions of levoglucosan and dissolved organic carbon in snowpits over the Tibetan Plateau glaciers

In this study, we collected 60 snowpit samples in nine glaciers from the northern to the southern Tibetan Plateau (TP), to study the levels and spatial distributions of levoglucosan and dissolved organic carbon (DOC). The lowest concentration of levoglucosan was found in the Yuzhufeng (YZF) glacier with a mean value of 0.24±0.08ngmL^-1, while the highest concentration of levoglucosan was detected in the Gurenhekou (GRHK) glacier with a mean value of 11.72±15.61ngmL^-1. However, the average DOC concentration in TP glaciers were comparable, without significant regional differences. The levoglucosan/DOC ratio ranged from 0.02 to 6.03% in the Tibetan Plateau glaciers. This ratios and the correlations between levoglucosan and DOC suggested that biomass burning products contributed only marginally to DOC levels in the TP glaciers. Moreover, the analysis of air mass backward trajectories suggested that levoglucosan and DOC in TP glaciers should be transported from the northwestern TP, internal TP, Central Asia, South and East Asia regions.

Highly efficient synthesis of C3-symmetric O-alkyl substituted triphenylenes and related Mannich derivatives

C₃-Symmetric tris-benzyl-O-substituted hexahydroxytriphenylene (HHTP) was prepared through selective ring opening with DIBAL-H in 48% yield (38% from HHTP in a two-step synthesis).

Free amino acids in the Arctic snow and ice core samples: Potential markers for paleoclimatic studies

The role of oceanic primary production on climate variability has long been debated. Defining changes in past oceanic primary production can help understanding of the important role that marine algae have in climate variability. In ice core research methanesulfonic acid is the chemical marker commonly used for assessing changes in past primary production. However, other organic compounds such as amino acids, can be produced and emitted into the atmosphere during a phytoplankton bloom. These species can be transported and deposited onto the ice cap in polar regions. Here we investigate the correlation between the concentration of chlorophyll-a, marker of marine primary production, and amino acids present in an ice core. For the first time, free l- and d-amino acids in Arctic snow and firn samples were determined by a sensitive and selective analytical method based on liquid chromatography coupled with tandem mass spectrometry. The new method for the determination of free amino acids concentrations was applied to firn core samples collected on April 2015 from the summit of the Holtedahlfonna glacier, Svalbard (N 79'08.424, E 13'23.639, 1120m a.s.l.). The main results of this work are summarized as follows: (1) glycine, alanine and proline, were detected and quantified in the firn core samples; (2) their concentration profiles, compared with that of the stable isotope δ¹⁸O ratio, show a seasonal cycling with the highest concentrations during the spring and summer time; (3) back-trajectories and Greenland Sea chlorophyll-a concentrations obtained by satellite measurements were compared with the amino acids profile obtained from ice core samples, this provided further insights into the present results. This study suggests that the amino acid concentrations in the ice samples collected from the Holtedahlfonna glaciers could reflect changes in oceanic phytoplankton abundance.

Results of an interlaboratory comparison of analytical methods for quantification of anhydrosugars and biosugars in atmospheric aerosol

An interlaboratory comparison was performed to evaluate the analytical methods for quantification of anhydrosugars - levoglucosan, mannosan, galactosan - and biosugars - arabitol, glucose and mannitol - in atmospheric aerosol. The performance of 10 laboratories in Italy currently involved in such analyses was investigated on twenty-six PM (particulate matter) ambient filters, three synthetic PM filters and three aqueous standard solutions. An acceptable interlaboratory variability was found, determined as the mean relative standard deviation (RSD%) of the results from the participating laboratories, with the mean RSD% values ranging from 25% to 46% and decreasing with increasing sugar concentration. The investigated methods show good accuracy, evaluated as the percentage error (ε%) related to mean values, since method biases ranged within ±20% for most of the analytes measured in the different laboratories. The detailed investigation (ANOVA analysis at p < 0.05) of the contribution of each laboratory to the total variability and the measurement accuracy shows that comparable results are generated by the different methods, despite the great diversity in terms of extraction conditions, chromatographic separation - more recent LC (liquid chromatography) and EC (exchange chromatography) methods compared to more widespread GC (gas chromatography) - and detection systems, namely PAD (pulsed amperometric detection) or mass spectrometry.

Aerosol and snow transfer processes: An investigation on the behavior of water-soluble organic compounds and ionic species

The concentrations of water-soluble compounds (ions, carboxylic acids, amino acids, sugars, phenolic compounds) in aerosol and snow have been determined at the coastal Italian base "Mario Zucchelli" (Antarctica) during the 2014-2015 austral summer. The main aim of this research was to investigate the air-snow transfer processes of a number of classes of chemical compounds and investigate their potential as tracers for specific sources. The composition and particle size distribution of Antarctic aerosol was measured, and water-soluble compounds accounted for 66% of the PM₁₀ total mass concentration. The major ions Na⁺, Mg²⁺, Cl^- and SO₄^2- made up 99% of the total water soluble compound concentration indicating that sea spray input was the main source of aerosol. These ionic species were found mainly in the coarse fraction of the aerosol resulting in enhanced deposition, as reflected by the snow composition. Biogenic sources were identified using chemical markers such as carboxylic acids, amino acids, sugars and phenolic compounds. This study describes the first characterization of amino acids and sugar concentrations in surface snow. High concentrations of amino acids were found after a snowfall event, their presence is probably due to the degradation of biological material scavenged during the snow event. Alcohol sugars increased in concentration after the snow event, suggesting a deposition of primary biological particles, such as airborne fungal spores.

Fragrances in the seawater of Terra Nova Bay, Antarctica

Personal Care Products are emerging pollutants whose distribution in the Antarctic and remote environments is still largely unknown. Among PCPs, long-lasting and stable Fragrance Materials were selected to perform a first pilot study on their occurrence in the coastal surface seawater of Terra Nova Bay in the Ross Sea, Antarctica. Ambrofix, Amyl Salicylate, Benzyl Salicylate, Hexyl Salicylate, Lemonile and Okoumal were detected for the first time in Antarctic natural seawater, and reached total concentrations up to 100ngL^-1. Treated discharges from the Italian research station Mario Zucchelli (MZS) contain FMs, however concentrations in nearby Tethys Bay increase during the seasonal melt of the sea ice and its snow cover: variability in emissions and distribution, as well as a contribution from atmospheric (long or short-range) transport were hypothesized.