P956Improved quality of life and symptomatic atrial fibrillation reduction in patients treated with a standardized ablation index workflow

Background/Introduction

The use of a standardized ‘CLOSE’ ablation workflow for pulmonary vein isolation (PVI), with defined inter-tag distance (ITD) with targeted ablation index (AI) values, has been shown in single centre reports to result in good outcomes. The effect of this approach on patients’ quality of life (QoL) has not been studied.

Purpose

To evaluate the effects of paroxysmal atrial fibrillation (PAF) ablation by the CLOSE workflow on QoL and symptomatic AF reduction in the multicenter VISTAX study.

Methods

329 patients with PAF (61.5% male, 61.3 ± 10.1 year) were treated at 17 European centres by point-by-point radiofrequency ablation using the CLOSE protocol to achieve PVI.  An ITD ≤6mm and AI values of ≥400 on the posterior wall and ≥550 on the anterior wall were targeted. The AI value on the posterior wall was lowered as per investigator discretion in case of safety concerns. Patients were monitored for atrial arrhythmia recurrences via weekly and symptom-activated transtelephonic monitoring (TTM), for 12 months post procedure. Patients completed an Atrial Fibrillation Effect on Quality-of-life (AFEQT) questionnaire at their baseline and 12-month follow up visits.

Results

Majority (83.3% [274/329]) of patients experienced freedom from symptomatic atrial recurrence through 12 months. Of the 70 documented recurrences, 34 (49%) were documented by trans-telephonic monitoring only. All domains captured on the AFEQT questionnaire showed improvement with the overall score improving by 25.7, which exceeded the threshold of clinically meaningful improvement (±5) (Table). Patient reported most improvements in PAF control and symptoms relieved. The overall AFEQT score improvement was seen both in patients with or without documented atrial arrhythmia recurrence, with improvement by 21.5 and 26.8, respectively.

Conclusion

PAF ablation using a standardized CLOSE workflow resulted in consistent improvements in QoL. The improved QoL was observed regardless of atrial arrhythmia recurrence likely reflecting the low residual arrhythmia burden in patients with documented recurrence identified only on TTM.

AFEQT Scores Through 12 Months AFEQT Domain Baseline 12 Months Change from Baseline* Daily Activities 59.2 85.3 26.0 Treatment Concerns 62.2 88.1 26.0 Controlling PAF 50.2 87.8 37.5 Symptoms 63.7 89.0 25.1 Symptoms Relieved 52.0 88.4 36.3 Overall AFEQT Score 61.3 87.2 25.7 *only includes patients who completed both baseline and 12 month AFEQT questionnaire

1242The flexibility, ease of using, and leaving curve of a standardized ablation index workflow for catheter ablation of paroxysmal atrial fibrillation

Background/Introduction

The ‘CLOSE’ protocol, incorporating standardized ablation index (AI) targets in conjunction with defined inter-tag distance (ITD) has been shown to improve the acute and long-term success of pulmonary vein isolation (PVI) when treating paroxysmal atrial fibrillation (PAF). The reproducibility and learning curve for this protocol has not been studied.

Purpose

To assess the acute and long-term efficacy of CLOSE PVI across multiple operators (n = 37) in the 17-centre European study ‘VISTAX’.

Methods

329 patients with PAF (61.8% male, 61.3 ± 10.1 years) underwent PVI according to the CLOSE protocol, with target AI values for each lesion of ≥400 on the posterior wall and ≥550 on the anterior wall, and target ITD of ≤6mm. Each 3-dimensional electroanatomic map was evaluated at a core lab where adherence to each of these criteria was assessed. 281/329 patients (85.1%) fulfilled all standardized workflow requirements and were adjudicated as having their PVI per-protocol (PP). First pass PVI and acute effectiveness (adenosine-proof first pass PVI at 30-minute challenge) were recorded. Clinical effectiveness was assessed as freedom from atrial arrhythmia recurrence through 12 months recorded via transtelephonic monitoring (weekly and symptomatically), in addition to holter and electrocardiogram monitoring during 3,6,12 month follow up visits. Learning curve analysis was evaluated on all investigators.

Results

First pass PVI rates were similar in the overall (86%) and PP cohorts (85%), as was acute effectiveness (82% in both cohorts). Freedom from atrial arrhythmia at 12 months too was identical for both cohorts (79%). Total procedure time and total ablation time decreased by an average 8 minutes and 10 minutes respectively after the first procedure and then showed further steady decreases over the number of ablations performed by the investigator (Figure).  The procedural efficiencies and clinical success were reproducible across different centers. No significant deviations were found from individual sites.

Conclusion

The standardized CLOSE workflow is reproducible across centres, and is ‘forgiving’ without impacting on high efficacy of almost 80%. The learning curve is short, suggesting that the excellent clinical results can be replicated widely and easily.

Abstract Figure. Learning Curves- Procedure & Ablation

1138 OSA In A Patient With PFO, Is It The “Perfect Storm” For A Stroke? A Case Series Of 3 Patients With Stroke At Young Age, Due To PFO And Comorbid OSA

Introduction

Approximately 25% of all strokes are cryptogenic in nature, and about 50% of all young patients with cryptogenic stroke are found to have patent foramen ovale (PFO), which is known to be the most common cause of right-to-left shunting (RTLS). Studies have shown a 2.2-fold increase in right-to-left shunt in patients with OSA and PFO, compared to patients with PFO alone. Hence, increasing the risk of cardio-embolic stroke in such patients. We present a case series of 3 patients with PFO that had embolic stroke at a young age and were found to have comorbid OSA, the likely exacerbating factor of a RTLS.

Methods

A 38-year old female, a 59-year old male, and a 27-year old female presented with stroke-like symptoms without clear vascular pathology. Upon further work-up, all were found to have PFO with RTLS. Subsequently, these patients were referred for sleep evaluation, and each one was found to severe REM-related OSA with prominent oxygen desaturations. All three patients were started on PAP therapy for control of their OSA. Two out of the 3 patients opted for PFO closure, and the 3rd patient opted for anti-platelet therapy alone. He has had no recurrence of TIA/stroke after 12 years so far.

Results

These cases illustrate a correlation between right-to-left shunting and severe REM-related OSA, through possible elevation of right-sided pressure due to nocturnal desaturations/hypoxemia. Hence, it is worth consideration that the increased right-sided pressure induced by apneic events in sleep may be a potential exacerbating factor in producing stroke-like symptoms sooner in patients with PFO than in patients with PFO who are without OSA.

Conclusion

It may be beneficial to assess young patients with stroke due to PFO, for comorbid OSA as a cause of the RTLS. This would help to prevent recurrent stroke in such patients and improve quality of life.

Support

No financial support.

1270 Wobbly Knees: Cataplexy Or Seizure? A Case Report

Introduction

Cataplexy (associated with narcolepsy) is difficult to differentiate from conditions such as seizure, syncope or TIA, but using validated clinical tools can help. We report a case that was mistakenly diagnosed as cataplexy, delaying diagnosis and treatment of his underlying seizures.

Report of Case

A 42 years old male presented with “freezing spells” described as spontaneous episodes of weakness in his knees. He may stagger and drop objects but had never fallen. He denies loss of consciousness. Post-ictally, he takes a moment to readjust his body and returns to baseline. There was no warning or aura before the episodes. These spells initially occurred 1-2 times/year in 2002, then progressed to 1/month by 2006 and then increased to 15 times/day in Jan 2019, lasting 5-10 seconds at a time. He became hesitant to drive. He was evaluated by a pulmonologist/sleep specialist. PSG showed Mild OSA but MSLT wasn’t suggestive of Narcolepsy. He was prescribed CPAP but stopped after 6 months since it didn’t improve his symptoms. He was prescribed Venlafaxine to treat presumptive Cataplexy, without any benefit. Eventually, he was referred to neurology/sleep clinic. Cataplexy questionnaire was administered and was negative: specifically, there were no emotional triggers of his episodes, such as hearing a joke, laughing or crying. Due to the stereotyped nature of his spells, he was referred to epilepsy specialist. He underwent 72 hours video EEG monitoring which showed that his clinical episodes were associated with EEG abnormality, suggestive of frontal lobe epilepsy. He was placed on Keppra and Oxcarbazepine. On follow up visit, he reported improvement in seizure frequency from 10-20/day to 1-2/day.

Conclusion

A validated1 clinical Tool such as Stanford Cataplexy questionnaire helps in differentiation of Cataplexy from other forms of transient muscle weakness. It can prevent 15 years delay in diagnosis and treatment of patients, or use of unnecessary medication.

0809 A Randomized Double-blind, Placebo Controlled Trial With Cross-over, To Assess The Efficacy Of Correcting Vitamin D Deficiency In Improving The Symptoms Of Restless Legs Syndrome (RLS)

Introduction

Recent studies have shown an association of low Vitamin D levels and severity of RLS symptoms. However, effect of treatment of Vit D deficiency on RLS symptoms was not reported, nor were other exacerbating factors for RLS such as iron deficiency or OSA addressed in prior studies, but have been addressed in our study.

Methods

This is an ongoing study at the JFKMC Sleep Clinic. Eligible Patients with RLS include those with vitamin D 25,hydroxy deficiency (<20 ng/ml), or insufficiency (<30 ng/ml). Such patients will be enrolled in the study after comorbid conditions like iron deficiency and OSA have been adequately corrected. Randomization of the patients will be done by the JFK pharmacy so the patient and provider are blinded to the substance. Substance A or B could be either Vitamin D3 Capsule 50,000 IU, or placebo. Each patient takes A for 6 weeks and then crosses over to B for 6 weeks. Weekly iRLS questionnaires will be collected. Actiwatch Device, to assess activity count per minute, will be worn on the ankle at night for one week time periods: at baseline, at end of 6 weeks of taking A and then at the end of 6 weeks of taking B. Vitamin D levels will also be assessed after each course of supplementation and correlated with subjective and objective findings.

Results

Between July 7, 2019 to current, 50 consecutive patients seen in sleep clinic with RLS were assessed for vitamin D levels. Ages ranged from 23-86 years. 27 patients were female (54%). Two patients met inclusion criteria and have started their 13-week study.

Conclusion

This study will help to establish the role of Vitamin D deficiency as a risk factor for RLS, independent of ferritin levels, and comorbid OSA, in affected individuals. This may help to discover a potentially treatable form of RLS.

Support

No financial support.

1149 A Pilot Quality Improvement (QI) Study To Assess Whether Bilevel Positive Airway Pressure (bipap) Support In Acute Ischemic Stroke Patients With Sleep Disordered Breathing, Can Improve Neurological Recovery During Acute Stroke Care

Introduction

Obstructive sleep apnea (OSA) has been associated with adverse outcomes in patients with stroke. While data is limited, it suggests that treatment of OSA may improve neurological recovery. With this quality improvement (QI) project, we aim to develop an interprofessional-team workflow process for screening and correction of OSA in acute ischemic stroke, with the goal to improve outcomes of neurological recovery.

Methods

This is an ongoing study to screen all eligible patients admitted to JFK Medical Center stroke unit, with MRI-proven Supratentorial acute ischemic stroke. The patients are screened using an overnight Pulse Oximetry test. A 3% oxygen desaturation index (ODI) of ≥10/hr or 4% ODI of ≥ 5/hr is considered at high risk for OSA. Such Patients will receive nocturnal Auto-adjusting BIPAP therapy during their acute care stay, for up to 5 days, for at least 4 hours per night. Eligible Patients who refused BiPAP therapy or were non-compliant will be considered as a controls. Baseline NIH stroke scale (NIHSS), and bilateral MCA mean flow velocity (MFV) in the morning, by transcranial doppler (TCD) will be assessed at baseline for cases and controls, and after BiPAP therapy, for the case group. The two groups of patients will also be compared in terms of Modified Rankin Scale at time of discharge and at phone follow-up after 6 weeks.

Results

Between Oct 17th, 2019 to current, 15 patients were admitted to the stroke unit with MRI confirmed stroke. Ages ranged from 34 - 88 years (average age 66.5 years). 8 patients (60%) were female. Of those, 6 patients consented to being screened for OSA. Of these, 1 had 4%ODI >5/hr, and therefore received treatment with BIPAP. However, compliance was < 4 hrs on 2 consecutive nights.

Conclusion

This is ongoing QI project and results will be available after few more months of continued recruitment.

Support

Auto-adjusting BIPAP machines were provided by RESMED.

Impaired decision-making and time perception in individuals with stroke: Behavioral and neural correlates

Several studies have demonstrated that stroke subjects present impairment of functions related to decision-making and timing, involving the information processing in the neural circuits of the cerebellum in association with the prefrontal cortex. This review is aimed to identify the gaps, and demonstrate a better understanding of decision-making and timing functions in the patients with stroke. Electronic literature database was searched and the findings of relevant studies were used to explore the mechanisms of decision-making and timing in patients with stroke, as well as the circuit connections in timing mediated by prefrontal cortex and cerebellum. A literature review was conducted with 65 studies that synthesized findings on decision-making and time perception in individuals with stroke. Types of neurobiological modalities in this study included: Relationships among decision-making, time perception, related cognitive aspects (such as discrimination tasks, verbal estimation, bisection tasks, time production and motor reproduction), and motor control. We demonstrate that the timing processes are important for the performance in cognitive tasks and that the cerebellum and prefrontal cortex are involved in decision-making and time perception. In the context, the decision-making is impaired in stroke patients has a great impact on executive functions, and this seems to be important in determining neurobiological aspects relevant to the time interval interpretation.

Comparative evaluation of Myolaxin and EM LA cream for attenuation of venous cannulation pain: A prospective, randomised, double blind study

We evaluated the efficacy of topical Myolaxin (capsaican ointment, Geno, Mumbai) ointment over EMLA (eutectic mixture of lignocaine, prilocaine; Neon, Goa) cream for attenuating venous cannulation pain in this prospective, randomised, double blind study. Sixty adult patients undergoing elective laparoscopic cholecystectomy were randomly assigned into two equal groups. Group I (EMLA) received EMLA cream, whereas Group II (Myolaxin) received Myolaxin ointment. For both groups the cream was applied at the venous cannulation site (dorsum of the non-dominant hand) one hour prior to venous cannulation and was covered with an occlusive dressing. Following venous cannulation patients were asked if they felt pain during venous cannulation. If the answer was yes, they were asked to rate the severity of venous cannulation pain using a Visual Analogue Scale (VAS) of O-10. The incidence of venous cannulation pain was similar between groups: in the EMLA group 65% (18/28) compared to 67% (20/30) in the Myolaxin group (P=0.19). The severity of pain (median VAS with inter quartile range) was also similar between the groups: in the EMLA group 1.5 (3) compared to 1.5 (2) in the Myolaxin group (P=0.46). As the topical application of Myolaxin ointment is cheaper than EMLA and has similar efficacy, it may be a suitable alternative for reducing the incidence and severity of venous cannulation pain.

Pain during Injection of Propofol: The Effect of Prior Administration of Ephedrine

Propofol causes pain on intravenous injection in 28 to 90% of patients. A number of techniques have been tried to minimize propofol-induced pain, with variable results. In a randomized, double-blind, placebo-controlled trial, we compared the efficacy of ephedrine 30 μg/kg pretreatment to lignocaine 40 mg for prevention of propofol-induced pain. Ninety-three adult patients, ASA 1 and 2, undergoing elective laparoscopic cholecystectomy were randomly assigned to three groups of 31 each. Group 1 received normal saline, group 2 received lignocaine 2% (40 mg) and group 3 received 30 μg/kg ephedrine. All pretreatment drugs were made up to 2 ml. Pain at the time of propofol injection was assessed on a four-point scale: 0=no pain, 1=mild pain, 2=moderate pain, and 3=severe pain. Twenty-seven patients (87%) of ephedrine pretreatment patients had pain during intravenous injection of propofol as compared to 24 (77%) in the normal saline group. In the lignocaine group, propofol-induced pain was observed in only 13 (42%) when compared with other study groups (P<0.05). Pretreatment with ephedrine 30 μg/kg did not attenuate pain associated with intravenous injection of propofol, nor did it improve haemodynamic stability during induction. However, pretreatment with 2% lignocaine (40 mg) was effective in attenuating propofol-associated pain.

Lower eyelid excursion: A functional and cosmetically relevant parameter in the treatment of lower eyelid retraction

The purpose of this study was to assess and quantify lower lid excursion following repair of lower lid retraction. In this retrospective cohort study, a case review of patients who had undergone ear cartilage grafting for lower lid retraction was undertaken. Surgical correction involved the placement of autologous cartilage between the tarsal plate and lower lid retractors. Measurements taken preoperatively and postoperatively were the marginal reflex 2 (MRD2) and the lower scleral show (LSS). The lower lid excursion on downgaze (LLE) was measured only postoperatively with a comparison made between operated eyes and control eyes. Thirteen eyelids of 10 patients were included in the study. Preoperatively, MRD-2 ranged from 4 to 8 mm (6.5 ± 1.5 mm) - mean ± SD. Postoperatively, MRD-2 ranged from 4 to 6 mm (5.1 ± 0.7 mm). The difference in mean MRD2 was statistically significant (p < 0.05). Preoperatively, LSS ranged from 0 to 5 mm (2.5 ± 1.6 mm). Postoperatively, LSS ranged from 0-1 mm (0.1 ± 0.3 mm). The difference in mean LSS was statistically significant (p < 0.01). Postoperatively, all lower eyelids achieved movement on downgaze. On the operated eyes, the eyelid excursion ranged from 2 to 5 mm (3.1 ± 1.0 mm) on downgaze. On the nonoperated (control) eyes (where the operations were not performed bilaterally), the eyelid excursion ranged from 1 to 4 mm (2.8 ± 1.2 mm). There was no statistically significant difference in the lid excursion of operated and nonoperated eyes (p > 0.05). It is possible to correct lower lid retraction in both primary and secondary positions of gaze if an appropriate surgical technique is employed.

Jet outflow and open field line measurements on the C-2W advanced beam-driven field-reversed configuration plasma experiment

Accurate operation and high performance of the open field line plasma surrounding the field reversed configuration is crucial to achieving the goals of successful temperature ramp up and confinement improvement on C-2W. Knowledge and control of the open field line plasma requires extensive diagnostic efforts. A suite of diagnostics, which consists of microwave interferometry, dispersive spectroscopy, and spatial heterodyne spectroscopy, is being developed to measure electron density, ion temperature, and particle outflow velocity at various locations along the open magnetic field lines. A detailed overview of these diagnostics is presented.

Development of a Z eff diagnostic using visible and near-infrared bremsstrahlung light for the C-2W field-reversed configuration plasma

In C-2W, an elevated impurity concentration can lead to significant degradation of plasma performance and energy losses through radiation. To gauge plasma contamination from impurities, the effective ion charge (Z _eff) can be determined from measurements of bremsstrahlung continuum radiation over a small spectral range free from line radiation. To this end, a diagnostic system including visible and near-infrared bremsstrahlung detectors was deployed in C-2W to measure time-dependent radial distributions of Z _eff. The system is complemented by an array of survey spectrometers which enable full-range spectroscopic measurements of impurity emission lines from the vacuum ultraviolet to the near infrared, providing a good picture of the plasma composition. Here, the design scheme for this integrated diagnostic system is presented and discussed.