Bilateral Carotid Patch Infection Occurring 12 years Following Endarterectomy

BACKGROUND

Carotid endarterectomy (CEA) is the most commonly used invasive procedure for treatment of carotid stenosis. Different methods are used to close the arteriotomy including primary closure and patch repair with a graft. Prosthetic patch infection is a rare but serious complication of patch closure, and we will present a unique case of carotid patch infection (CPI) 12 years after implantation.

CASE

Patient is 76-year-old male ex-smoker with history of bilateral CEA with Dacron patch closure 12 years prior to presentation. He had a left neck draining sinus one year prior to presentation that was treated by patch excision and ICA ligation. He presented to us one year later with a right neck draining sinus tract, reaching the carotid sheath on CT scan. Surgery was done under EEG and NIRS oximetry with shunting. Excision of the patch with the involved ICA was done. CCA to distal ICA bypass was done by a reversed GSV graft. Intraoperative cultures of the patch grew Staphylococcus species coagulase negative, so the patient was discharged on antibiotics for one month. The patient had early postoperative swallowing difficulty that resolved over six weeks but no other complications. Patient was followed-up every three months and he was doing well on one-year follow-up.

DISCUSSION

Carotid patch infection is a well-documented complication of CEA with a prevalence between 0.27% and 1%. It most commonly presents as a pseudoaneurysm, draining sinus or neck swelling. The highest incidence is during the first year after the operation, and especially within the first three months postop due to contamination or wound infections; however, late presentations such as our case are rare. Bacterial cultures are positive in around 80% of the cases, growing mostly gram-positive cocci. Other organisms include Pseudomonas and Enterobacter. Management of CPI is challenging; difficulties include distal ICA control, friable arteries and adhesions to cranial nerves. Debridement with ligation of the vessel stump is an option, but may not be tolerated. Best outcomes are obtained with autogenous revascularization after debridement as was done in our case on the right side. Newer endovascular techniques may provide alternatives in urgent or high-risk situations, especially as staged procedures. This case is unique in its bilaterality and the longest time till presentation in the literature.

P2488The 2013 ACC/AHA pooled cohort equations and insulin resistance status for detection of early-stage heart failure in the community

Objectives

Detection of heart failure (HF) in its subclinical phase would allow timely initiation of preventive measures that counter its pathophysiology. Here, we assessed the usefulness of traditional cardiovascular (CV) risk assessment and insulin resistance status to detect early-stage HF.

Methods

In 984 participants (mean age, 57.0 years, 52.3% women), we derived echocardiographic indexes of left ventricular (LV) structure and function and calculated the 10-year risk for a first atherosclerotic CV disease (ASCVD) using the 2013 ACC/AHA risk score. We assessed the discriminatory value of this risk score to detect LV maladaptation and the improvements in reclassification by insulin resistance status (HOMA-IR).

Results

The probability for LV maladaptation rose progressively with the 10-year ASCVD risk increasing. Participants at high 10-year ASCVD risk (>7.5%) had indeed significantly higher odds for LV concentric remodeling (odds ratio, 4.84), LV hypertrophy (OR, 5.93), abnormal LV longitudinal strain (OR, 2.04) and LV diastolic dysfunction (OR, 25.3) as compared to those at low ASCVD risk (<2.5%; P≤0.0003). Adding markers of insulin resistance to the ACC/AHA risk score moderately improved the integrated discrimination and net reclassification of all LV maladaptive phenotypes (P≤0.022) except LV diastolic dysfunction (P≥0.059). LV remodeling and abnormal LS was particularly more likely in insulin-resistant participants with a 10-year ASCVD risk between 5% and 15% than in their insulin-sensitive counterparts.

Prediction of early-stage HF profiles 2013 ACC/AHA risk score Addition of insulin resistance status to the 2013 ACC/AHA risk score AUC (95% CI) Integrated Discrimination Improvement Net Reclassification Improvement Absolute IDI (%) P value NRI (95% CI) P value LV concentric remodeling 0.70 (0.66 to 0.74) 0.0083 (11.3%) 0.022 0.23 (0.067 to 0.39) 0.0058 LV hypertrophy 0.70 (0.66 to 0.74) 0.017 (20.7%) 0.0033 0.27 (0.11 to 0.43) 0.0011 Abnormal LV LS 0.56 (0.53 to 0.62) 0.022 (202.0%) <0.0001 0.33 (0.18 to 0.49) <0.0001 LV diastolic dysfunction 0.82 (0.78 to 0.86) 0.0007 (0.45%) 0.84 0.093 (−0.11 to 0.30) 0.38 ≥2 LV abnormalities 0.76 (0.72 to 0.80) 0.0087 (7.3%) 0.071 0.22 (0.042 to 0.40) 0.016 The integrated discrimination improvement (IDI) and net reclassification improvement (NRI) reflect the improvements in classification by adding insulin resistance (by HOMA-IR) to the 2013 ACC/AHA risk score. HOMA-IR, Homeostatic Model for Assessment of Insulin Resistance; LS, longitudinal strain; LV, left ventricular.

Risk enhancers of LV maladaptation

Conclusions

The 2013 ACC/AHA risk score adequately captured the risk for echocardiographic phenotypes of early-stage HF. As risk enhancer, insulin resistance might improve risk stratification of subclinical HF in subjects at intermediate risk.

Acknowledgement/Funding

The European Union, European Research Council and the Flanders Scientific Research Fund supported this study.

P4419The association between ECG voltage and left-ventricular mass, sex, body size and the distance between the heart and chest wall in college athletes

Background

The ECG is widely used in pre-participation evaluation (PPE) of athletes (ATH). While it is assumed that greater than normal QRS voltages reflect physiologically increased left ventricular mass (LVM), this has not been adequately demonstrated in ATH.

Purpose

To examine the relation between QRS voltage on surface ECG and LVM and explore if the distance from the chest wall to mid-LV (CWLVdis) affects QRS voltage in ATH.

Methods

We examined digitized ECG data and echocardiograms in college ATH, obtained as part of routine PPE in years 2010–16. ECG parameters included R and S-wave voltage components of the Sokolow-Lyon (S-L) and Cornell criteria for LV hypertrophy (i.e. SV1 + RV5-V6 and RaVL + SV3, respectively). Transthoracic 2D echocardiography was used to determine LVM (area-length method) and the CWLVdis (detailed in Fig1A). S-L positive (SV1 + RV5-V6 >35 mV or RaVL >11 mV) ATH were compared to S-L negative by t-test, and univariate correlation and multivariable regression analysis was used to explore independent effects of body characteristics, sex, LVM and CWLVdis on QRS voltage.

Results

Included were 227 ATH (age 18.6±0.7 yr; 85% male; 60%/33% Caucasian/Afro-american). Of these, 66% played American football, 18% volleyball and 16% basketball.

Overall, mean LVM was 174±37 g (range 96–284 g), and BSA-indexed LVM was 78±12 g/m2 (range 49–108 g/m2). Mean CWLVdis was 8.5±1.1 cm (range 5.6–11.3 cm) and was greater in males (p<0.001, Fig1B).

Forty-six ATH (24%, all male) were S-L positive and no ATH were positive according to Cornell criteria. S-L positive ATH had lower BMI (25.3±3.5 vs 26.9±4.9, p=0.012), greater absolute LVM (189.1±31.3 vs. 170.1±37.4 g, p=0.002) and greater BSA-indexed LVM (85.3±10.3 vs. 76.6±11.7 g/m2, p<0.001) than S-L negative ATH. The CWLVdis was similar between S-L positive and negative ATH (8.4±1.2 vs. 8.6±1.1, respectively, p=0.213).

CWLVdis was more strongly correlated to body mass (r=0.73, p<0.001, Fig. 1C) than to height (r=0.34, p<0.001). LVM correlated weakly to ECG voltage as combined in the S-L or Cornell criteria (Fig. 1C). CWLVdis was weakly correlated with R in aVL, V5 and V6 (r=0.21, 0.16 and 0.16, all p<0.02).

In multivariate analysis, male sex (β=0.31), LVM (β=0.45) and body mass index (β=-0.37) were independently associated with the S-L summed voltage (R2 0.26, p<0.001). For Cornell summed voltage, only sex was an independent predictor (β=0.48, R2 0.22, p<001).

Figure 1

Conclusion

The R and S wave ECG amplitudes used in the two most common ECG criteria for LV hypertrophy were weakly related in the highest to lowest order to sex, LVM, body size and the distance from the LV to the chest wall in our college ATH.

P3819Machine learning for predicting early left ventricular abnormalities in the general population

Background

Current heart failure guidelines emphasize the importance of timely detection of subclinical left ventricular (LV) remodelling and dysfunction for more precise risk stratification of asymptomatic subjects. Both LV diastolic dysfunction (LVDD) and LV hypertrophy (LVH) as assessed by echocardiography are known independent prognostic markers of future cardiovascular events in the community. However, selective screening strategies of individuals at risk who would benefit most from in-depth cardiac phenotyping are lacking.

Purpose

We assess the utility of several Machine Learning (ML) classifiers built on clinical and biochemical features for detecting subclinical LV abnormalities.

Methods

We included 1407 participants (mean age, 51 years, 51% women) randomly recruited from the general population. We used echocardiographic parameters reflecting LV diastolic function and structure to define LV abnormalities (LVDD, n=239; LVH, n=135). After that four supervised ML algorithms (Random Forest (RF), Gradient Boosting (GD), Stochastic Gradient Descent (SGD) and Support Vector Machines (SV)) were built based on routine clinical, hemodynamic and laboratory data (features; n=61) to categorize LVDD and LVH (two prediction tasks). We applied a 10-fold stratified cross-validation set-up.

Results

ML classifiers exhibited a high area under the ROC (AUC) for predicting LVDD with values between 88.5% and 93.1% (Figure, left panel). Age, BMI, different components of blood pressure, antihypertensive treatment, routine biomarkers such as serum electrolytes, creatinine, blood sugar, leptin, uric acid, lipid profile, as well as blood cell counts were the top selected features for predicting LVDD. Prediction AUC of ML algorithms for detection of LVH was somewhat lower than for LVDD and ranged from 72.5% to 78.7% (Figure, right panel). The top selected features for LVH classifier were similar to those of LVDD, but also included social class, serum gamma-glutamyl transferase, fasting insulin, plasma renin activity and cortisol.

ROC curves (sensitivity-1-specificity)

Conclusions

ML algorithms combining routinely measured clinical and laboratory data have shown high accuracy of LVDD and LVH prediction. These ML classifiers might be useful to preselect individuals at risk for further in depth echocardiographic examination, monitoring and implementation of preventive strategies in order to delay transition to disease symptoms.

6075Workload adjusted blood pressure response rather than peak systolic blood pressure is associated with increased all-cause mortality in males; results from 7097 treadmill exercise tests

Background

Systolic blood pressure (SBP) is routinely measured during exercise testing (ET) and is in part determined by cardiac output and peripheral vascular resistance. A frequently used threshold for defining hypertensive response to exercise is ≥210 mmHg but this does not account for the fact that SBP is related to workload, via cardiac output.

Purpose

To examine the prognostic implications of considering external workload (METs) adjusted SBP response to exercise.

Methods

We reviewed all symptom-limited treadmill ET in males between 1987 and 2007 at a single centre (inclusion/exclusion criteria detailed in figure 1A). SBP was measured standing at rest and at peak exercise. Workload adjusted BP response with exercise (SBP/MET slope) was calculated as ΔSBP/ΔMET. METs were calculated from peak speed and grade according to the standard American College of Sports Medicine (ACSM) formula. Age-predicted peak METs was calculated as: 18 - 0.15 × age. Ten-year Cox proportional hazard ratios (HR) with 95% confidence intervals were calculated and adjusted as outlined in figure 1B.

Results

7097 subjects were included, of which 1559 (22%) died within 10 years. Survivors were younger (57.2±10.6 y vs. 64.5±10.3 y, p<0.001) and reached higher % of age-predicted METs (97±33% vs. 82±33%, p<0.001). Survivors had higher peak SBP (181±26 vs. 176±27 mmHg, p<0.001) as well as greater ΔSBP (49±22 vs. 42±22 mmHg, p<0.001), while they had lower SBP/MET slope (7.0±4.4 vs. 8.9±6.5 mmHg/MET, p<0.001). A peak SBP ≥210 mmHg was associated with better survival; 10-yr adjusted HR: 0.76 (0.64–0.88, p<0.001). In contrast, a higher SBP/MET slope was associated with increased mortality (table 1).

Table 1. Ten year adjusted hazard ratios Variable HR (95% CI) P Variable HR (95% CI) P Variable HR (95% CI) P Peak SBP, Q1: 100–159 mmHg REF REF Delta SBP, Q1: 1–29 mmHg REF REF SBP/MET slope, Q1: 0.2–4.2 REF REF Peak SBP, Q2: 160–179 mmHg 0.81 (0.71–0.94) 0.006 Delta SBP, Q2: 30–46 mmHg 0.80 (0.70–0.91) 0.001 SBP/MET slope, Q2: 4.3–6.2 0.95 (0.81–1.12) 0.562 Peak SBP, Q3: 180–199 mmHg 0.68 (0.58–0.78) <0.001 Delta SBP, Q3: 47–61 mmHg 0.76 (0.66–0.88) <0.001 SBP/MET slope, Q3: 6.2–9.1 1.18 (1.01–1.37) 0.032 Peak SBP, Q4: ≥200 mmHg 0.60 (0.51–0.69) <0.001 Delta SBP, Q4: ≥62 mmHg 0.59 (0.50–0.69) <0.001 SBP/MET slope, Q4: ≥9.1 1.40 (1.22– 1.62) <0.001 HR, hazard ratio (adjusted according to figure 1B); SBP, systolic blood pressure; MET, metabolic equivalent of task; Q1–Q4, quartiles (Q1 as reference).

Figure 1

Conclusion

Workload adjusted blood pressure response to exercise in contrast to peak BP response was associated with increased mortality in male patients referred for ET. Of note, reaching a BP of at least 210 mmHg (suggested to define a hypertensive response to exercise) was associated with a 24% reduction in all-cause mortality.

Acknowledgement/Funding

K Hedman was supported by post-doc. grants from the Fulbright Commission, the Swedish Society of Medicine, County Council of Östergötland, Sweden

The results of 3000 Fit: A prospective study led at Saint Joseph University of Beirut

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Background: In terms of frequency, colorectal cancer (CRC) is the 3rd cancer in Lebanon with 1093 incidences registered in 2015. To this date not a single screening campaign has been organized in the country. Fecal immunochemical test (FIT) is an advised screening technique. We found it useful to organize a screening campaign using FIT to determine the prevalence of CRC in a population of 3000 healthy Lebanese allowing the extraction of useful data. Methods: 3000 tubes were distributed to Lebanese adults (45-80 years old) at average risk of developing CRC, followed by explanations. FIT analysis was done at the medical genetics unit (UGM) of Saint-Joseph University and patients with positive FIT were asked to undergo further investigations. Results: Out of the 3000 distributed tests, 705 were returned (23.5%) with 459 fully analyzable. The age median was 56 (45-80). Sex ratio F/M 2.3. Out of the 459 patients, 278 (60.5%) showed 0ng/ml, 137 (29.8%) showed 1-79ng/ml, 3 (0.6%) showed 80-99ng/ml (intermediate risk values), 33 (7.1%) showed 100-800ng/ml considered as a positive value and finally 8 (1.7%) showed over range values. Among the 44 positive patients we contacted 41. Out of the 8 (18%) colonoscopies results received: 5 showed hemorrhoids leading to false positive, 1 ulcerative ileitis, 1 tubular adenomas and 1 carcinoma. Conclusions: While it was hard for us to quantify people for whom a free FIT was proposed, the low restitution rate among those who took the test shows the necessity of national screening and sensitization campaigns.

Results of NGS panel of hereditary breast and ovarian cancer in Lebanese women

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Background: Hereditary breast (BC) and ovarian cancer (OC) genetic alterations are considered the most prevalent among familial cancer. To date, four studies have exposed the mutations related to hereditary BC predisposition in the Lebanese population , with percentage of BRCA-related pathogenic mutations ranging between 5 % and 15 %. Methods: Between 2017 and 2019, 117 patients with high risk hereditary breast and ovarian cancer were referred to undergo the testing at the Unité de Génétique médicale (UGM) of Saint-Joseph University of Beirut, Lebanon. The sequencing was accomplished by using the 21-panel Next-Generation Sequencing (NGS) method for all of our patients, to which we also added the MLPA technique followed by the Sanger sequencing for validation whenever a genetic alteration was found. Results: From 117 Lebanese women with high-risk hereditary breast and ovarian cancer predisposition, 19 pathogenic mutations were identified in this study: 11 BRCA1, 1 BRCA2, 2 PALB2, 1 ATM, 1 CDH1, 1 MSH6, 1 RAD51C, and 1 BRIP1. Among those, 13 patients had BC, one had OC and five were healthy individuals. Five similar mutations were found within the BRCA1 gene, the p.C44F mutation, accounting for 45.4 %, thus suggesting a founder effect. Average age at diagnosis in the BC patients carrying a mutation was 41 years and 38.5% had a triple negative BC. Conclusions: The overall pathogenic mutation rate was equal to 16.2% while the BRCA deleterious mutation rate was 10.3% lower to those reported in the literature. The p.C44F mutation appeared five times suggesting a founder effect. [Table: see text]

Epidemiologic and histologic characteristics of central nervous system lesions: A 20-year experience of a single institution in Lebanon

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Background: Lesions of the central nervous system (CNS) are a heterogeneous group of tumoral and non-tumoral lesions, benign or malignant, primary or metastatic. The overall incidence rate of all brain tumors is estimated to be 10.82 per 100 000 person-years. There is no data in Lebanon characterizing the CNS lesions. The aim of our study is to report the epidemiologic and histologic characteristics of these lesions in a Lebanese tertiary center. Methods: This is a retrospective study evaluating the characteristics of the CNS lesions diagnosed in 20 years (from January 1998 to June 2017) in the pathology laboratory of Hôtel Dieu de France, Saint Joseph University hospital of Beirut, Lebanon. The data were extracted from the computerized records of the laboratory. Different variables were evaluated, from the samples types and epidemiologic characteristics, to the revealing symptoms and the histologic subtypes. Statistical analysis was performed using SPSS 24.0. Results: 2025 tumoral lesions over 20 years were interpreted. 25.4% of the samples were obtained by biopsy, 65% by surgical resection, 3.7% were cerebral spinal fluid and 5.9% were undetermined. 52.2% of the patients were men and 47.8% were women with a median age of 50 years, from 0 to 89 years. The most frequent revealing symptoms were epilepsy (22.5%), headache (20.6%) and motor impairment (19.9%). 90.7% of the CNS tumors were primary and 9.3% were metastatic. Lung (35.6%) and breast (16.5 %) were the two most frequent primaries of the metastatic lesions. 46.2% of primary CNS tumors were glial, 42.5% non-glial, 3.5% mixed neuroglial and 6.4% mesenchymal. The two most frequent glial tumors were astrocytic (56.4%) and oligodendroglial (17.9%) tumors, while the most frequent non-glial tumors were meningeal tumors (58%) and cranial nerve and paraspinal tumors (16.3%). Conclusions: The histological and epidemiological characteristics of brain tumors in Lebanon are consistent in many features with what is known in the literature, but the Lebanese population differs by a younger age of onset, a lower rate of meningiomas, and a higher rate of gliomas.

Diagnostic workup, etiologies and management of acute right ventricle failure : A state-of-the-art paper

INTRODUCTION

This is a state-of-the-art article of the diagnostic process, etiologies and management of acute right ventricular (RV) failure in critically ill patients. It is based on a large review of previously published articles in the field, as well as the expertise of the authors.

RESULTS

The authors propose the ten key points and directions for future research in the field. RV failure (RVF) is frequent in the ICU, magnified by the frequent need for positive pressure ventilation. While no universal definition of RVF is accepted, we propose that RVF may be defined as a state in which the right ventricle is unable to meet the demands for blood flow without excessive use of the Frank-Starling mechanism (i.e. increase in stroke volume associated with increased preload). Both echocardiography and hemodynamic monitoring play a central role in the evaluation of RVF in the ICU. Management of RVF includes treatment of the causes, respiratory optimization and hemodynamic support. The administration of fluids is potentially deleterious and unlikely to lead to improvement in cardiac output in the majority of cases. Vasopressors are needed in the setting of shock to restore the systemic pressure and avoid RV ischemia; inotropic drug or inodilator therapies may also be needed. In the most severe cases, recent mechanical circulatory support devices are proposed to unload the RV and improve organ perfusion CONCLUSION: RV function evaluation is key in the critically-ill patients for hemodynamic management, as fluid optimization, vasopressor strategy and respiratory support. RV failure may be diagnosed by the association of different devices and parameters, while echocardiography is crucial.