P5017Factors associated with a negative D-dimer test in patients diagnosed with acute symptomatic pulmonary embolism

Background

The recommended diagnostic strategy for suspected acute pulmonary embolism (PE) combines the assessment of pre-test probability, D-dimer level, and -if indicated- computed tomography pulmonary angiography.

Purpose

To evaluate the frequency and potential explanations for negative D-dimer tests in patients diagnosed with acute PE.

Methods

The multicentre Follow-up of Acute Pulmonary Embolism (FOCUS) cohort study prospectively enrolled 1,100 consecutive patients diagnosed with acute symptomatic PE; two-year follow-up is ongoing. The items of the Simplified revised Geneva Score and the D-dimer levels at diagnosis have been prospectively collected, but they did not necessarily guide management decisions. Quantitative D-dimer was measured on admission either by quantitative latex-based assays or enzyme-linked immunosorbent assays. A negative D-dimer was defined by fixed (0.50 μg/mL) or age-adjusted (age*0.01 μg/mL if age>50) cut-off.

Results

Using the fixed cut-off, a negative D-Dimer was detected in 17 of 773 patients with ultimately diagnosed PE (miss rate 2.2% [95% CI 1.4–3.5]); using the age-adjusted cut-off, the test was discordant with the PE diagnosis in 24 patients (3.1% [2.1–4.6]). In Figure 1, red dots indicate negative D-dimer test by fixed cut-off and blue dots indicate additional negative D-dimer tests by age-adjusted cut-off.

In 448 (59%) patients post-hoc classified as PE-unlikely, 11 (2.5% [1.4–4.3]) and 14 (3.1% [1.9–5.2]) patients had a negative D-dimer using the two different cut-offs, respectively. Haemoptysis on admission, V/Q scan-based diagnosis, and chronic lung disease were associated with a discordant D-dimer, while an inverse association existed for concomitant DVT. In 7 (29%) PE cases with normal D-dimer, PE was verified to be subsegmental also in a post-hoc evaluation. Another seven (29%) patients were receiving anticoagulation at the time of D-dimer assessment.

Figure 1

Conclusions

Our results show that the frequency of discordance between a normal D-dimer test and the diagnosis of acute PE is low, but not negligible. One third of discordant findings were related to subsegmental PE. Physicians should be aware that the risk of obtaining a false-negative D-dimer might be higher in specific subgroups of patients.

Acknowledgement/Funding

The sponsor (University Medical Center of the Johannes Gutenberg University, Mainz) has obtained grants from Bayer Vital GmbH and Bayer Pharma AG

P4720Mitraclip XTR device used for the treatment of functional tricuspid regurgitation provides significant reduction of annular size

Background

Tricuspid valve regurgitation (TR) is a progressive disease strongly associated with increased cardiac and all-cause mortality. The transcatheter approach to this pathology has been recently described with promising results in the treatment of symptomatic patients despite optimal medical therapy. Development of annular dilation and leaflet tethering represent a continuous pattern in the pathophysiology of functional TR; for this reason, to reduce and stabilize the annulus is the goal of an efficacious therapy.

Purpose

In order to simplify leaflet grasping, the novel MitraClip XTRdevice has significantly longer clip arms compared to its predecessor. The increased grasping length could be able to apply a radial tension on the tricuspid annulus, reducing it in dimensions. Despite, the increased tension on the leaflets may theoretically impose a higher risk for leaflet tearing We analyzed our single-center experience in order to clarify the capability of the device in the feature of annular reshapement.

Methods

Five high-risk patients (4 females, 72 (quartiles 69–79) y.o., EuroSCORE II 10 (7.25–11.2)% affected by severe symptomatic functional TR were treated with MitraClip XTR implantation in tricuspid position. Right ventricular function was apparently preserved in all cases and the mean sPAP was 41 (quartiles 38–45) mmHg. Perioperative echo-results were collected prospectively and analyzed.

Results

Procedural success (defined as a reduction of more than 1 degree of TR) was achieved in 4 cases (80%). 3±1 devices were implanted per patient in the antero-septal commissure. The tricuspid annular diameter (measured in four chamber view) was reduced from 39 (quartiles 39–41) mm to 31 (quartiles 30–31) mm (p=0.043). Accordingly, the effective regurgitant orifice area (EROA) decreased from 110 (quartiles 70 to 160) mm2 to 45 (quartiles 9–55) mm2 (p=0.02) and the systolic VTI in the hepatic veins decreased by 42%. No significant increase of trans-valvular mean gradients was observed (2.5 (quartiles 2.25 to 2.75)) mmHg vs 3.75 (quartiles 3,75 to 4) mmHg; p=0.2) as well no cases of acute leaflet tearing.

Conclusion

The reduction in tricuspid annulus size with the novel XTRdevice represents an unexpected and interesting achievement of the procedure. A significant reduction of annular dimensions might provide a more durable reduction of functional TR. Long-term follow-up data will be required to clarify these initial results and as well as patient selection criteria.

P3449Revealing the burden of acute cardiac and arterial complications in 715 patients diagnosed with Lemierre syndrome

Background

Lemierre syndrome is a potentially life-threatening condition occurring in otherwise healthy children and adolescents with head/neck bacterial infections (usually tonsillitis due to anaerobe bacteria). Peculiar complications are neck vein thromboses contiguous to the site of infection and multiple septic embolization. Arterial thrombosis and cardiac complications have been described as possible clinical manifestations of Lemierre syndrome: however, in light of the rarity of this condition (one case/1,000,000 person-years), no comprehensive analysis has ever been conducted.

Purpose

To describe the frequency and the patterns of acute cardiac and arterial complications in patients with Lemierre syndrome.

Methods

We identified 715 cases of Lemierre syndrome (years 2000–2016) and retrieved complete individual patient-level data. Study outcomes assessed on admission or during hospitalization were: i) objectively diagnosed ischemia or arterial infarction/thrombosis, arterial stenosis due to inflammatory process, and septic aneurysms; ii) new objectively diagnosed cardiac complications; iii) all-cause death.

Results

Of the 715 patients with Lemierre syndrome, 56 (7.6%, 95% confidence interval [CI]: 6.1%–10.0%) experienced cardiac or arterial complications. Median age was 19 (interquartile range [IQR]: 16–25) years and 35 (62.5%) were men. Intracranial ischemia or infarction was found in 23 patients, corresponding to 3.2% of the whole study population. Carotid artery thrombosis, stenosis, or septic aneurysm occurred in 28 (3.9% of total), pericardial disease in 11 (1.5% of total), and infective endocarditis in 5 (0.7% of total) (Figure). A total of 32 (57.1%) patients developed these complications during the course of hospitalization after a median of 6 (IQR: 3–12 days) days from admission. A total of 37 (66.1%) patients received anticoagulation. Fatality rate was 10.7% (95% CI: 5.0%–21.4%; n=6).

Cardiac and arterial complications.

Conclusions

An unexpectedly high proportion of patients with Lemierre syndrome developed acute cardiac or arterial complications. In this group, the fatality rate was substantial. Our observation that most of the cardiovascular events occurred during the course of hospitalization may have implications for the development of diagnostic and management strategies. It remains unclear whether antithrombotic therapies may influence prognosis.

Surveillance of patients with differentiated thyroid cancer and indeterminate response: a longitudinal study on basal thyroglobulin trend

PURPOSE

This is a longitudinal study of retrospective data aimed at verifying whether repeated measurements of serum non-stimulated thyroglobulin (Tg) allow the prediction of persistent disease in patients with differentiated thyroid cancer (DTC) and indeterminate response.

METHODS

We examined 145 DTC patients with indeterminate response to therapy followed up for a median time of 68 months. Tg measurements and neck ultrasound (US) were performed every 6-12 months. The changes over time of repeated measurements of basal Tg were analyzed through the multilevel linear regression.

RESULTS

Seventy (48.3%) out of 145 patients spontaneously achieved an excellent response, while persistent indeterminate response was observed in 62 (42.7%) patients. The remaining 13 (9.0%) patients had progression: 3/13 with biochemical disease and 10/13 with structural disease. Tg steadily increased in patients with progressive disease (mean percentage change + 27.1% at each follow-up visit), while Tg decreased in patients without any evidence of progression (mean percentage change - 8.8%). This different trend between the two groups was not related to either different values of median TSH at baseline (0.32 vs 0.28 mIU/l, respectively) or to different trend of TSH during follow-up (p = 0.76). Basal Tg values did not increase in three out of ten patients with structural disease that was identified by neck US.

CONCLUSIONS

The importance of the study is that, in DTC patients with indeterminate response, rising values of unstimulated Tg, independently from the basal levels, may be useful to identify patients with progressive disease. These results are also useful to avoid unnecessary TSH stimulation.

P1005Origin, distribution and timing of the slow pathway potentials recorded inside the Kock's triangle in Avnrt patients through High-density Mapping

Background

Atrial activation during typical atrioventricular nodal reentrant tachycardia (AVNRT) exhibits anatomic variability and spatially heterogeneous propagation inside the Kock's Triangle (KT). The mechanism of the reentrant circuit has not been elucidated yet.

Purpose

To evaluate signal characteristics and find out the origin, distribution, and timing of the slow pathway (SP) potentials recorded in the KT.

Methods

The 3-D KT geometry was created during both sinus rhythm (SR) and tachycardia (TR) from the basket mapping catheter IntellaMap Orion and the Rhythmia Mapping System (Boston Scientific). The KT was divided into 8 regions moving from an antero-septal to postero-septal areas and bounded by tricuspid annulus (TA) anteriorly and tendon of Todaro (TT) posteriorly. Each area was characterized in terms of distribution and timing of Jackman (JP) and Haissaguerre (HP) potentials and signal amplitude.

Results

20 consecutive successful SP ablation cases of AVNRT were included (mean RA acquired points = 6000±1100, 275±63 inside the KT; mean KT area=29±3mm2; mean mapping time=12±5 minutes). During SR, the site of earliest atrial activation within the KT was anterior in 80% of patients whereas a midseptal activation occurred less frequently (20%). The mid-septal regions bounded by TA anteriorly and TT posteriorly showed higher prevalence of JP as compared to antero-/mid-septal regions across TT both in SR and TR (77.4% vs 4.8% during SR, p<0.0001; 84.1% vs 0% during TR, p<0.0001, respectively). HPs seemed to have variable distribution across KT (50% of these potentials recorded in antero- to mid-septal regions across TT for SR, 52.3% for TR). The median signal voltage was 0.44 [0.2–0.9] mV during SR and 0.5 [0.22–0.895] mV during TR. The mid-septal region was the area of lowest voltage compared to other regions (0.2 [0.1–0.7] mV vs 0.5 [0.4–1.5] mV for SR, p<0.0001; 0.2 [0.15–0.6] mV vs 0.6 [0.4–1.5] mV for TR, p<0.0001, respectively).

Conclusion

JPs seem to be associated with low signal-amplitude areas whereas HPs seem to have variable distribution across KT. Although not perfectly known, the typical low-high-type double potential of JP might be therefore explained by wavefront collision in the lowest area of the KT.

Acknowledgement/Funding

None

P1840Mid-term results of bioprosthetic aortic valve replacement with the Trifecta valve: A word of caution

Background

Structural valve deterioration (SVD) with associated bioprosthetic valve dysfunction remains an unsolved problem, exposing patients to the risk of aortic valve re-intervention after surgical aortic valve replacement (SAVR). Several strategies have been proposed to improve prosthesis design for optimal performance. The leaflets of the Trifecta valve are mounted on the outside of the prosthetic stent to achieve a larger orifice area. Although favourable early clinical outcomes have been reported, long-term durability still needs to be assessed.

Purpose

The aim of the current study was to assess the mid-term overall mortality and re-intervention rate in patients who received a Trifecta valve with a follow-up >5 years.

Methods

Patients who underwent SAVR at our centre between 2011 and 2012 were identified in the internal, prospective database. All patients with implantation of a Trifecta valve in aortic position were included. Primary endpoints were freedom from overall mortality and from re-operation at latest follow-up (FU). Additionally, assessment of echocardiographic parameters at baseline and follow-up was performed.

Results

Seventy-six patients (age 77.3±9.5 years, BMI 28.6±5.8, 68% male) were included in the study. EuroScore II was 7.2% (± 7.7) while mean STS-Mortality score was 2.4±1.1%. Of all procedures, 53% were isolated aortic valve replacements, whereas concomitant procedures were performed in 47% of cases (37% CABG, 12% mitral surgery, 8% tricuspid surgery). Baseline echocardiographic assessment showed a mean pressure gradient (MPG) of 51±21 mmHG, a peak pressure gradient (PPG) of 78±36 mmHG and a peak velocity (Vmax) of 4.2±1.1 m/s.

Thirty-day mortality was 7%. Freedom from overall mortality at 1 year and 5 years was 84% and 73%, respectively. Freedom from death and freedom from re-operation at latest FU (6.7±0.5 years) was 68% and 90%, respectively. In a composite endpoint analysis, freedom from death or re-intervention at latest follow up was 60%. A total of 7 patients underwent aortic valve re-interventions (re-replacements n=5, valve-in-valve n=2). Indications for re-interventions were SVD (n=5), NSVD (n=1, pannus ingrowth) and endocarditis (n=1). One case of re-stenosis occurred in a patient who was deemed not feasible for aortic valve re-intervention and died.

Kaplan Meier analysis

Conclusion(s)

To our knowledge, this patient cohort presents with the lowest rate of freedom from re-operation (90%, 6.7±0.5 years) after SAVR with the Trifecta valve. A relatively high number of SVD and NSVD has been observed, which might be attributable to the specific leaflet mounting or the deformable valve frame of the first generation. Current results call for further investigation with prospective echocardiographic follow-up in this patient group.

Acknowledgement/Funding

None

A systematic review of database validation studies among fertility populations

STUDY QUESTION

Are routinely collected data from fertility populations adequately validated?

SUMMARY ANSWER

Of the 19 studies included, only one validated a national fertility registry and none reported their results in accordance with recommended reporting guidelines for validation studies.

WHAT IS KNOWN ALREADY

Routinely collected data, including administrative databases and registries, are excellent sources of data, particularly for reporting, quality assurance, and research. However, these data are subject to misclassification bias due to misdiagnosis or errors in data entry and therefore need to be validated prior to using for clinical or research purposes.

STUDY DESIGN SIZE DURATION

We conducted a systematic review by searching Medline, Embase, and CINAHL from inception to 6 October 2016 to identify validation studies of databases that contain routinely collected data in an ART setting. Webpages of international ART centers were also searched.

PARTICIPANTS/MATERIALS SETTING METHODS

We included studies that compared at least two data sources to validate ART population data. Key words and MeSH terms were adapted from previous systematic reviews investigating routinely collected data (e.g. administrative databases and registries), measures of validity (including sensitivity, specificity, and predictive value), and ART (including infertility, IVF, advanced reproductive age, and diminished ovarian reserve). Only full-text studies in English were considered. Results were synthesized qualitatively. The electronic search yielded 1074 citations, of which 19 met the inclusion criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

Two studies validated a fertility database using medical records; seven studies used an IVF registry to validate vital records or maternal questionnaires, and two studies failed to adequately describe their reference standard. Four studies investigated the validity of mode of conception from birth registries; two studies validated diagnoses or treatments in a fertility database; four studies validated a linkage algorithm between a fertility registry and another administrative database; one study created an algorithm in a single database to identify a patient population. Sensitivity was the most commonly reported measure of validity (12 studies), followed by specificity (9 studies). Only three studies reported four or more measures of validation, and five studies presented CIs for their estimates. The prevalence of the variable in the target population (pre-test prevalence) was reported in seven studies; however, only four of the studies had prevalence estimates from the study population (post-test prevalence) within a 2% range of the pre-test estimate. The post-test estimate was largely discrepant from the pre-test value in two studies.

LIMITATIONS REASONS FOR CAUTION

The search strategy was limited to the studies and reports published in English, which may not capture validation studies from countries that do not speak English. Furthermore, only three specific fertility-based diagnostic variables (advanced reproductive age, diminished ovarian reserve, and chorionicity) were searched in Medline, Embase, and CINAHL. Consequently, published studies with other diagnoses or conditions relevant to infertility may not have been captured in our review.

WIDER IMPLICATIONS OF THE FINDINGS

There is a paucity of literature on validation of routinely collected data from a fertility population. Furthermore, the prevalence of the markers that have been validated are not being presented, which can lead to biased estimates. Stakeholders rely on these data for monitoring outcomes of treatments and adverse events; therefore, it is essential to ascertain the accuracy of these databases and make the reports publicly available.

STUDY FUNDING/COMPETING INTERESTS

This study was supported by Canadian Institutes of Health Research (CIHR) (FDN-148438). There are no competing interests for any of the authors.

REGISTRATION NUMBER

International Prospective Register of Systematic Reviews ID: CRD42016048466.

Massive recurrent post-tonsillectomy bleedings revealing a transient factor XIII deficiency in a 10-year-old boy. A case report

A previously healthy 10-year-old boy was hospitalized for a left cervical abscess associated with massive tonsillar hypertrophy. He underwent abscess drainage and bilateral tonsillectomy. At H36 post-surgery, he presented with tonsillar hemorrhage requiring surgical revision. Hemorrhage relapsed 2 days later, with a total of 7 episodes, 5 of which required surgical revisions. Laboratory investigations were normal except for a markedly low factor XIII (FXIII) activity at 7%. After administration of a single dose of 40 IU/kg plasma-derived FXIII (Fibrogammin^®) I.V., the bleeding stopped with no further recurrence. FXIII activity gradually normalized (75%) at 6 weeks, confirming the transient character of factor XIII deficiency. Severe congenital FXIII deficiency (FXIIID) (<1%) is very rare (1:2,000,000 births), whereas partial congenital deficiency and/or acquired deficiency may be more frequent but likely underreported. Acquired FXIIID may result from impaired synthesis (liver failure) or increased consumption (surgery, sepsis, leukemia, Henoch-Schönlein, inflammatory bowel disease, stroke, disseminated intravascular coagulation). FXIII replacement in form of fresh frozen plasma (FFP) or plasma-derived FXIII may be necessary for the presence of bleeding.

Microencapsulated feruloyl esterase-producing lactobacilli ameliorate lipid profile and glycaemia in high fat diet-induced obese mice

The effect of oral administration of spray-dried microcapsules of feruloyl esterase (FE) producing Lactobacillus fermentum CRL1446 (Lf) and Lactobacillus johnsonii CRL1231 (Lj) on high fat diet-induced obese mice was investigated to evaluate whether these strains could be used as a biotherapeutic for obesity. Swiss albino mice were divided into a normal diet fed group receiving empty microcapsules (control), a high fat diet plus empty microcapsules (HFD group), HFD plus microcapsules with Lf (HFD-Lf group) and HDF plus microcapsules with Lj (HFD-Lj group). Microcapsules containing Lf or Lj at a dose of ~10⁷ cells/day/mouse were given orally for 7 weeks. Body weight gain, adiposity index, plasma leptin, lipid profiles, glycaemia, insulinemia, oral glucose tolerance, intestinal FE, glutathione peroxidase and glutathione reductase (GR) activities were determined. Administration of lactobacilli (HFD-Lf and HFD-Lj groups) improved metabolic parameters (triglyceride, total cholesterol, low-density lipoprotein cholesterol levels) and cardiovascular risk indicators (37-46% decrease of atherogenic index), and reduced body weight gain (29-38%), adiposity index (42-62%), plasma leptin levels, liver weight and fat deposition in liver. Intestinal FE activities significantly increased in HFD-Lf (62%) and HFD-Lj group (48%), thus improving hepatic GR activity (42% increment) compared to HFD group. Moreover, L. johnsonii increased HDL-cholesterol and L. fermentum reduced blood glucose to levels similar to the control. These FE-producing lactobacilli have the potential to improve biomarkers involved in obesity by increasing intestinal FE activity.

Lymph node location is a risk factor for papillary thyroid cancer-related death

PURPOSE

Papillary thyroid cancer (PTC) has good prognosis with a very low chance of mortality. The prognostic role of metastatic lymph node location was judged controversial and more recently (TNM VIII ed.) was considered to have no impact on the prognosis of older patients. The aim of the study was to evaluate the role of metastasized node location on PTC-related mortality.

METHODS

PTC-related mortality was analysed in a consecutive retrospective series of 1653 PTC patients followed at our Thyroid Clinic (mean follow-up 5.9 years).

RESULTS

Sixteen out of 1653 patients (0.96%) died because of PTC. Average age was 68 years at presentation and 74.7 at death. F/M ratio was 1:1. The death rate increased in relation to the lymph node status: 0.2% in N0, 0.3% in N1a and 3.0% in N1b.

CONCLUSIONS

The presence of lymph node metastases in the N1b compartment should be considered as a risk factor for distant metastatic spread and for cancer-related death and included in post-surgery evaluation.

How important are maritime emissions for the air quality: At European and national scale

Due to its dependence on fossil fuel combustion, emissions from the marine transport sector can significantly contribute to air pollution. This work aims to evaluate the impact of maritime transport emissions on air quality in Portugal using a numerical air quality modelling approach, with high-resolution emission data. Emissions from the European TNO inventory were compiled and pre-processed at hourly and high spatial (∼3 × 3 km²) resolutions. Scenarios with and without these maritime emissions were then simulated with the WRF-CHIMERE modelling system, extensively tested and validated for Portugal domain, in order to evaluate their impact on air quality. A simulation was performed for one year (2016) and the resulting differences were analysed in terms of spatial distribution, time series and deltas. The main deltas for NO₂ and PM10 are located over international shipping routes and major ports, while O₃ concentrations are impacted in a larger area. The modelling results also indicate that shipping emissions are responsible for deltas in the concentration of NO₂ higher than 20% over specific urban areas located in the west coast of Portugal, and less than 5% for PM10. For O₃ the relative contribution is low (around 2%) but this contribution is also observed at locations more than 50 km from the coast.

Extranodal lymphomas in the public health system in Chile: Analysis of 1251 patients from the National Adult Cancer Program

The aim of the study was to describe the clinical and epidemiological characteristics, anatomic and histologic distribution, and treatment results of extranodal lymphomas (ENLs), diagnosed and treated in the public health system in Chile. We included patients with ENL diagnosed from 1998 to 2014, in 17 cancer centers, registered prospectively in the database of the National Adult Cancer Program (PANDA) of the Ministry of Health. Treatment was based on the local protocols for each lymphoma subtype. Extranodal lymphoma was documented in 1215 of 4907 non-Hodgkin lymphomas diagnosed in that period (25%). Median age was 59 years (range, 16-95), and 55% were female. The gastrointestinal (GI) tract was the most common location (38%), followed by the head and neck (24%) and the skin (15%). B-cell lymphomas accounted for 78% of cases, diffuse large B-cell lymphoma being the most common histologic subtype (68%). Mycosis fungoides/Sezary syndrome was the most frequent T-cell subtype (36%), followed by NK/T-cell lymphomanasal type (24%). In comparison with western countries, Chile showed a significantly high prevalence of NK/T-cell lymphoma nasal type, while the frequency of B-cell ENL and the anatomic distribution appeared similar, being GI the most commonly involved site.

Early Clinical Experience with Double Ring Implantation for Aortic and Mitral Valve Repair

Reconstruction of cardiac valves is associated with reduced mortality, including in multiple valve surgery. However, multiple valve repair is still considered a challenge, even with established techniques. Recently, internal aortic ring annuloplasty has been introduced and could simplify multiple valve reconstruction. This study reports early results with double ring aortic and mitral valve repair. Three patients with bivalvular degenerative regurgitation were managed with combined aortic and mitral valve repair using double rings. Mean (±SD) age was 41 ± 21 years, preoperative left ventricular end-diastolic volume was 119 ± 53 mL/m², and ejection fraction was 0.50 ± 0.07. Mean aortic ring diameter was 21 mm, and mitral rings averaged 32 mm. No operative mortalities or major complications were observed. No valve-related events occurred. Postoperative echo showed complete resolution of mitral and aortic regurgitation. Postoperative left ventricular end-diastolic volume decreased to 98 ± 10 mL/m²; no left ventricular outflow tract obstruction or significant transvalvular gradients were observed. Postoperative cardiac CTs showed an optimal three-dimensional configuration of aortic and mitral annuloplasty devices. This initial series demonstrated the feasibility and safety of combined aortic and mitral repair with double rings. Clinical and hemodynamic results were promising. Increasing application and more clinical experience with combined aortic and mitral double ring repair seems indicated.