Identification of a Novel Serum Proteomic Signature for Primary Sjögren's Syndrome

Context

Primary Sjögren's syndrome (pSS) is a complex heterogeneous autoimmune disease (AID) which can mimic rheumatoid arthritis (RA) or systemic lupus erythematosus (SLE). Our exploratory study investigated serum biomarkers that may discriminate pSS from RA and SLE.

Methods

Serum concentrations of 63 biomarkers involved in immune cell trafficking, inflammatory response, cellular movement, and cell-to-cell signaling were measured in AID patients, included prospectively into the study at the Montpellier University Hospital. A multivariate analysis by multiple logistic regression was performed, and discriminative power assessed using logistic regression adjusted on significant demographic factors.

Results

Among the 95 patients enrolled, 42 suffered from pSS, 28 from RA, and 25 from SLE. Statistical analysis showed that concentrations of BDNF (OR = 0.493 with 95% CI [0.273-0.891]; p = 0.0193) and I-TAC/CXCL11 (OR = 1.344 with 95% CI [1.027-1.76]; p = 0.0314) can significantly discriminate pSS from RA. Similarly, greater concentrations of sCD163 (OR = 0.803 with 95% CI [0.649-0.994]; p = 0.0436), Fractalkine/CX3CL1 (OR = 0.534 with 95% CI [0.287-0. 991]; p = 0.0466), MCP-1/CCL2 (OR = 0.839 with 95% CI [0.732-0.962]; p = 0.0121), and TNFa (OR = 0.479 with 95% CI [0.247-0.928]; p = 0.0292) were associated with SLE diagnosis compared to pSS. In addition, the combination of low concentrations of BDNF and Fractalkine/CX3CL1 was highly specific for pSS (specificity 96.2%; positive predictive value 80%) compared to RA and SLE, as well as the combination of high concentrations of I-TAC/CXCL11 and low concentrations of sCD163 (specificity 98.1%; positive predictive value 75%).

Conclusion

Our study highlights biomarkers potentially involved in pSS, RA, and SLE pathophysiology that could be useful for developing a pSS-specific diagnostic tool.

Right atrial strain by speckle-tracking echocardiography as a prognostic predictor in a pulmonary hypertension cohort

Funding Acknowledgements

Type of funding sources: None.

Background

Right atrial (RA) strain is as a promising technique for assessment of RA function and several studies have suggested it is a powerful prognostic marker in pulmonary hypertension (PH) patients (pts). Our aim was to assess the prognostic power of RA strain in Pulmonary Arterial Hypertension (PAH) and Chronic Thromboembolic Pulmonary Hypertension (CTEPH) pts.

Methods

Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). Correlation between RA strain and other variables was tested with Pearson"s correlation analysis. Regression and survival analysis were performed to assess the combined endpoint of all-cause mortality or hospitalization in the first follow-up year (MH1).

Results

A total of 51 PH pts (mean age 54 ± 46 years, 33.3% male, baseline BNP of 342.4 ± 439.9pg/mL and baseline pulmonary artery systolic pressure – PASP - of 78 ± 26mmHg), of which 64.7% had PAH and 35.3% presented CTEPH. 19 ots (37.3%) met the primary endpoint. The mean RA strain was -21.9 ± -4.9%, with no significant difference between groups (-23.4% vs -17.8%, p = 0.150), however male pts had a significantly lower RA strain (-15.9% vs -25.1%, p = 0.014). There was a statistically significant (p < 0.05) correlation between RA strain and age (r = -0.287), indexed RA area (r = -0.539), index RA volume (r = -0.522) and right ventricular strain (r = -0.453). There was no correlation between RA strain and BNP value (p = 0.150), 6MWT distance (p = 0.145) or PASP (p = 0.072). RA strain was a predictor of MH1 (OR = 0.94, 95% CI: 0.894-0.998, p = 0.048). Pts who met the primary endpoint had a significantly worse RA strain (-17.0 vs -24.6%, p = 0.032). Those with a RA strain worse than -19% presented a significantly lower survival free of events during the first follow-up year (log rank p = 0.022).

Conclusion

RA strain is a powerful predictor of adverse events in a PH population and should be systematically assessed in order to improve risk stratification.

Abstract Figure.

Anti-inflammatory potential of Portuguese thermal waters

In light of Medical Hydrology, thermal waters (TW) are all-natural mineral waters that emerge inside a thermal resort and have therapeutic applications. Their beneficial effect has been empirically recognized for centuries, being indicated for symptom alleviation and/or treatment of several diseases, almost all associated with inflammation. Indeed, an anti-inflammatory effect has been attributed to many different Portuguese TW but there is no scientific validation supporting this empiric knowledge. In the present study, we aimed to investigate the anti-inflammatory properties of 14 TW pertaining to thermal centers located in the Central Region of Portugal, and grouped according to their ionic profile. Mouse macrophage cells stimulated with lipopolysaccharide (LPS), a Toll-like receptor 4 agonist, were exposed to culture medium prepared in TW. Metabolism, nitric oxide (NO) production, inducible nitric oxide synthase (iNOS) expression levels and the scavenging capacity of TW, were investigated in vitro. 11 out of 14 TW reduced NO production and/or iNOS expression, and/or scavenging activity, in macrophages exposed to LPS. The sulphated/calcic TW did not show any effect on at least one of the inflammatory parameters evaluated. Two sulphurous/bicarbonate/sodic TW and the sulphurous/chlorinated/sodic TW promoted an increase in NO production and/or iNOS expression. Our results validate, for the first time, the anti-inflammatory properties of Portuguese TW, supporting their therapeutic use in the treatment of inflammation-related diseases and promoting their putative application in cosmetic products and medical devices.

Predictors of atrial fibrillation occurrence in patients with hypertrophic cardiomyopathy

Introduction

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of dysrhythmias, especially atrial fibrillation (AF).

Purpose

The aim of this study was to evaluate the incidence of AF in HCM patients (P) and to determine predictors of AF.

Methods

Retrospective analysis of HCM P at a single tertiary center. Baseline clinical, echocardiographic and cardiovascular magnetic resonance (CMR) characteristics were collected. On follow up AF was identified by electrocardiogram and/or 24 hours Holter monitoring.

Results

61P (59% male) were included, with a mean age of 58±2 years. 27.9% had angina (all of them CCS 2), 34.4% were in NYHA II and 14.8% in NYHA III, 8.2% had syncope and 39.3% had palpitations. A family history of sudden cardiac death (SCD) or cardiomyopathy was present in 40.4% of the cases. The mean HCM risk SCD score was 3.35±0.28%. On echocardiography left atrium (LA) diameter was 44.86±0.87mm, LA volume (LAvol) was 89.97±5.39mL (indexed LAvol 46.05±2.55mL/m2), interventricular septum (IVS) was 16.83±0.663mm, left ventricle (LV) mass was 290.94±13.897g and maximum wall thickness (MWT) was 20.59±0.596mm. 77% P had LA enlargement. 88.5%P had late gadolinium enhancement (LGE) in CMR with a median number of 5±7 segments involved. AF developed in 23P (37.7%), with a mean age of 58±3 years. Predictors of AF development were NYHA III (p=0.007), risk score (p=0.007), LA diameter (p=0.007), LAvol (p=0.005) and indexed LAvol (p=0.002), MWT (p=0.0015), LGE in more than 5 segments (p=0.029) and LGE in the inferior basal and inferior median IVS (p=0.033 and p=0.042). The only independent predictor was LAvol (p=0.0012), with an area under the curve of 0.755 and a cut off of 85.9mL being the best predictor (p=0.004). Combining LAvol >85.9mL with LGE involving >5 segments and LAvol >85.9mL with LGE in inferior basal IVS (IBIVS) a statistically significant difference between groups was achieved (p=0.009 in the combined predictor LAvol + LGE >5 segments and p=0.002 in the combined predictor LAvol + LGE in IBIVS) (figure 1 and figure 2). In a multivariable analysis including these 2 combined predictors and LAvol alone the only independent predictor was the combination of LAvol + IBIVS involvement.

Conclusion

AF is frequent in patients with HCM and develops in younger ages than in general population. NYHA III, risk score, LA diameter, LAvol, MWT, LGE >5 segments and LGE in IBIVS and in IMIVS were predictors of AF, with LAvol being the independent predictor. The combination of LAvol with LGE >5 segments and LAvol with LGE in IBIVS presented stronger predictor value comparing with these characteristics alone.

Funding Acknowledgement

Type of funding source: None

Role of tilt-table testing in syncope diagnosis and management: analysis of patients referred to a syncope unit

Introduction

Head-up tilt-testing (HUT) enables the reproduction of reflex syncope in a laboratory setting. Despite being used to confirm the diagnosis of this syncope, there is some concerns regarding the best protocol to use and recent studies with implantable loop recorders have called the value of HUT into question.

Aim

To characterize the population undergoing HUT according to the modified Italian protocol, type of response to HUT and subsequent management at our center in the last 4 years.

Methods

Retrospective analysis of consecutive P who underwent HUT between 2015 and 2018. Descriptive analysis of patients (P) demographics and medical history, indication for HUT, type of response to HUT and management.

Results

A total of 419P (55.1% female) were included with a mean age of 62 years. The majority (n=302, 72.1%) had comorbidities (structural heart disease – 55%, cardiac dysrhythmias – 57.6%, hypertension – 48.3%, diabetes – 15.6%, depression – 15.9%, cerebrovascular disease –10.6%) or was under medication (n=220, 52.5%) with a potential hypotensive or bradycardic effect (44.1% ACEI/ARA, 29.1% beta-blocker, 27.7% diuretic, 23.6% antidepressant, 22.7% calcium channel blocker, 19.1% benzodiazepines). Syncope/presyncope episodes accounted for 56.1% of the HUT, with falls and disequilibrium accounting for 52%. In 21 cases (5%) suspected dysautonomia or other non-specified reasons were the indication for HUT. HUT were ordered according to the guidelines in 136P (84.6% – indication level I, 3.6% – level IIa, 11.8% – level IIb). HUT was positive in 292P (69.7%) – 77.1% after nitroglycerin administration (vasodepressor – 170P, cardioinhibitory – 53P, mixed – 62P and dysautonomic – 7P). Cardioinhibitory (CI) response predominated in the younger, and vasodepressor in the older P. Of the P with CI response, 41.5% had asystole (median of 41.4s, minimum 7.5s, maximum 115s). All P were instructed in the need to avoid triggering factors and perform counterpressure maneuvers. A pacemaker was implanted in 24P (5.7% of all population, due to long sinus pauses and asystole). Twenty-four P (5.7%) completed a tilt training program.

Conclusion

Most of the HUT were requested for syncope/presyncope, frequently according to the guidelines. There was a high rate of positive tests, with a predominance of vasodepressive response, particularly in the elderly.

Funding Acknowledgement

Type of funding source: None

Individual preparedness for natural disasters: a cross-sectional study from Portugal

Background

Individual preparedness is critical in mitigating the adverse effect of natural disasters (ND). Factors influencing preparedness are complex and multifaceted, with certain groups having different needs and vulnerabilities. We aimed to explore the factors associated with individual ND preparedness in residents from Vila Nova Gaia (VNG), Portugal.

Methods

A cross-sectional study was conducted in VNG, Portugal, in January 2020 (N = 192; ≥18 years). Data on sociodemographic characteristics, risk perception, and preparedness were collected using a structured questionnaire, in parishes randomly selected. Crude and adjusted odds ratio (OR) and respective 95% confidence intervals (CI) were estimated using logistic regression models.

Results

About 33% of participants aged ≥65 years and 66% had low education. Results show that 20% had a survival kit. In univariate comparisons, older (11% vs. 24%, p=.029) and lower educated participants (≤12th grade: 13% vs. >12th grade: 32%, p=.002) were less likely to have a survival kit; only education remained associated after adjustment for age (OR = 2.61, 95%CI:1.22-5.58). About 21% had a family plan for disaster and only education level is associated (≤12th grade: 17% vs. >12th grade: 29%, p=.040). Almost 35% had a family member with basic life support training; older age, lower education and higher risk perception were negatively associated and these remained after adjustment (≥65 vs. <65 years OR = 0.36, 95%CI:0.16-0.77; ≤12th vs. >12th grade OR = 0.40, 95%CI:0.21-0.78; risk perception OR = 0.66, 95%CI:0.45-0.95). Only 22% participated in community drills; older people (6% vs. 31%, p<.001) and less educated (14% vs. 39%, p<.001) were less likely to have ever participated, which persisted in multivariate model.

Conclusions

Our findings revealed a low-level of ND preparedness, and older and less educated people seem to present worse preparedness. This highlights the need to design specific public health interventions among these groups.

Key messages

We found a low-level of individual preparedness for natural disasters in VNG, Portugal. Community-based public health interventions are needed to improve individual preparedness for natural disasters. Specific interventions targeting older and less educated people should be designed to decrease their vulnerability facing a natural disaster.

AB1304-HPR KNOWLEDGE OF HIGH SCHOOL STUDENTS ABOUT RHEUMATIC DISEASES: EFFECT OF AN EDUCATIONAL SESSION JOINTLY PROVIDED BY PORTUGUESE EULAR ASSOCIATIONS

Background:

International studies have shown that the awareness and knowledge of the general population about rheumatic and musculoskeletal diseases (RMDs) is poor. This is even lower in the young population, which are also affected by these disease but do not have as much awareness campaigns as adult community. Their professors and primary health care professionals may also play here also a key role, promoting early detection of signs and interpretations of symptoms, thus avoiding late health care referrals and diagnosis. (Vlieland, 2016).

Objectives:

To assess the knowledge of high school Portuguese students about the RMDs and raise awareness for RMDs in young people, their professors, vigilants, and primary care nurses, within the school environment.

Methods:

A 1-hour educational session about RMDs was planned (with the inputs from members of the Portuguese EULAR Associations) and performed during school activities. The educational session started with a knowledge questionnaire about RMDs in a paper sheet (9 questions; Graph 1), repeated in the end. An interactive session, using slides, interactive questions (Sli.do®), and practical demonstrations to simulate RMD symptoms (e.g. stiffness and functional limitations) was then lead by a rheumatology nurse, with the testimony from a young patient representative. A primary care nurse assisted in order to be engaged and promote future sessions (“autonomously”). Change in knowledge was assessed with Wilcoxon-test and awareness was documented with “word clouds” (using Sli.do®).

Results:

A total of 75 students participated in four sessions (mode=16 years). Half of students (52%) had never heard about RMDs. Knowledge increased significantly in all questions (p<0.001; Graph 1). Figures 1 and 2 document the most common words representing what defines a RMD and what are the main symptoms, respectively.

Conclusion:

Our results confirm that awareness and knowledge about RMDs are very low high school students. The single and educational session was very well received by all students, and the the knowledge increased. Post-educational feedback was that students especially liked the testimony of a peer. Other sessions are taking place in primary schools.

References:

[1]Vlieland, T. P., et al. RMD Open, 2016;2:e000337. doi:10.1136/rmdopen- 2016-000337

Acknowledgments:

To European League Against Rheumatism for the founding provided through the campaign “Don’t Delay, Connect Today”.

Disclosure of Interests:

None declared

THU0632-HPR DETERMINANTS OF HAPPINESS AND QUALITY OF LIFE IN PEOPLE WITH SYSTEMIC SCLEROSIS: A STRUCTURAL EQUATION MODELLING APPROACH

Background:

In recent years more attention has been given to patients reported outcomes (PROs). Systemic sclerosis (SSc) is no exception. As there is no effective treatment or cure to SSc, it is important to recognize the relevance to patients of the different features of the disease to improve quality and enjoyment of life: the ultimate targets of therapy. Remarkably lacking in PROs is the evaluation of the overall perspective of subjective well being, equivalent to ‘happiness’ or “positive psychological dimensions”.

Objectives:

To examine the determinants of happiness and quality of life (QoL) in patients with SSc with emphasis on disease activity, disease impact and personality traits.

Methods:

This is an observational, cross-sectional and multicenter study from six rheumatology clinics in Portugal. A total of 113 patients with SSc with a complete set of data on disease activity, disease impact, personality, quality of life and happiness were included.

Structural equation modelling (latent variable structural model) was used to estimate the association between the variables using a maximum likelihood estimation with Satorra-Bentler’s correction and performed with STATA® 15.0. Two hypotheses were pursued: H1 – Disease activity and impact of disease are negatively associated to overall QoL and happiness; H2 – ‘Positive’ personality traits are related to happiness both directly and indirectly through perceived disease impact.

Results:

Results obtained in the structural equation measurement model indicated a good fit [χ2/df=1.44; CFI=0.93; TLI=0.90; RMSEA=0.06] and supported all driving hypotheses (Figure 1). Happiness was positively related to ‘positive’ personality (β=0.45, p=0.01) and, to a lesser extent, negatively related with impact of disease (β=-0.32; p=0.01). This impact, in turn, was positively related to EUSTAR activity score (β=0.37; p<0.001) and mitigated by ‘positive’ personality traits (β=-0.57; p<0.001). Impact of disease had a much stronger relation with QoL than with happiness (β=-0.78, p<0.001). Quality of life and happiness had no statistically significant relationship.

Conclusion:

Optimization of Qol and happiness in people with SSc requires effective control of the disease process. Personality and its effects upon the patient´s perception of the disease impact, seems to play a pivotal mediating role in these relations and should deserve paramount attention if happiness and enjoyment of life is taken as the ultimate goal of health care.

Disclosure of Interests:

Tânia Santiago: None declared, Eduardo Santos: None declared, Ana Catarina Duarte: None declared, Patrícia Martins: None declared, Marlene Sousa: None declared, Franscisca Guimarães: None declared, Soraia Azevedo: None declared, Raquel Ferreira: None declared, Miguel Guerra: None declared, Ana Cordeiro Consultant of: Ana Cordeiro has acted as a consultant for Roche, Speakers bureau: Ana Cordeiro has received speaker fees from Boehringer Ingelheim, Lilly, and Vitoria, Inês Cordeiro: None declared, Sofia Pimenta: None declared, Patrícia Pinto: None declared, Maria Joao Salvador: None declared, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis

FRI0293 EFFECTIVENESS OF SWITCHING BETWEEN TNF INHIBITORS IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS: IS THE REASON TO SWITCH RELEVANT?

Background:

It has been common practice to start a second TNF inhibitor (TNFi) in patients with axial spondyloarthritis (axSpA) who discontinue their first TNFi. It remains unclear if the reason for discontinuation of the first TNFi influences the response to the second.

Objectives:

To assess if the reason of discontinuation of the first TNFi influences the response to the second TNFi.

Methods:

Patients with axSpA from the ReumaPt registry, who discontinued their first TNFi and started a second TNFi and who had complete data on Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) at baseline, 3 and 6 months for their first TNFi were included. Then, they were followed every 6 months up to 12 years. The main outcome was the ASDAS clinically important improvement (ASDAS CII). Secondary outcomes were ASDAS major important improvement (ASDAS MI); ASDAS low disease activity (ASDAS LDA); ASDAS inactive disease (ASDAS ID) and BASDAI 50. The reason for discontinuation of the first TNFi was defined as: i) Primary failure, ASDAS CII was not achieved at 3 or 6 months; ii) Secondary failure, ASDAS CII achieved at 3 or 6 months but lost in ≥1 follow-up visit; iii) Adverse events; iv) Other (e.g. pregnancy, surgery). The response to the first TNFi at 3 and 6 months was compared to the response to the second TNFi at the same visits, adjusting for age, gender and C-reactive protein (CRP). The association between the reason of discontinuation of the first TNFi and response the second TNFi over time was tested in generalized estimating equations (GEE) models, adjusted for age, gender and CRP.

Results:

In total, 193 patients (53% male, mean age 45 (SD:11) years) were included, with a median follow-up time on the second TNFi of 1.5 years. Patients had a lower response to the second TNFi compared to the first TNFi according to the main outcome (ASDAS CII) at 3 months (41% vs 51%) and 6 months (35% vs 56%). There was an association between the reason to discontinue the first TNFi and response to the second TNFi as defined by the most stringent outcomes (ASDAS MI and ASDAS ID), but not for ASDAS CII (Table). Compared to patients who discontinued their first TNFi due to primary failure, patients were more likely to achieve ASDAS ID with the second TNFi when they discontinued their first TNFi due to secondary failure (OR: 7.3 [(95%CI: 1.9; 27.7]), adverse events (OR: 9.1 [2.5; 33.3]), or other reasons (OR: 7.7 [1.6; 37.9]).

Conclusion:

In axSpA, response to the second TNFi is worse compared to the first TNFi. Patients with a secondary failure to the first TNFi have a better response to the second TNFi compared to those discontinuing the first TNFi due to primary failure, particularly for most stringent outcomes.

Table.

Association between the reason for discontinuation of the first TNFi and response to the second TNFi

Reason to discontinue first TNFi*Outcome for the second TNFiOR (95% CI)ASDAS-CII (N=135)ASDAS-MII (N=135)ASDAS-LDA (N=166)ASDAS-ID (N=166)BASDAI50 (N=147)(ref Primary failure) -Secondary failure1.9 (0.7;4.8)4.8 (1.3;18.2)1.2 (0.6;2.4)7.3 (1.9;27.7)1.4 (0.6;3.0) -Adverse events1.5 (0.6;3.5)2.4 (0.6;9.6)0.9 (0.5;1.7)9.1 (2.5;33.3)1.1 (0.5;2.3) -Other1.0 (0.3;3.8)1.7 (0.1;19.4)1.0 (0.4;2.4)7.7 (1.6;37.9)0.5 (0.1;1.7)

*GEE models with the reason of discontinuation of the first TNFi as predictor (reference category: primary failure); all models adjusted for age, gender and C-reactive protein. OR in bold are statistically significant (p<0.05).

Disclosure of Interests:

Santiago Rodrigues-Manica Speakers bureau: Jansse, MSD, Novartis, Alexandre Sepriano: None declared, Fernando Pimentel dos Santos Speakers bureau: Novartis, Pfizer, Biogen, Vitoria,, Nélia Gouveia: None declared, Anabela Barcelos Speakers bureau: Bene, Eli-Lilly, Pfizer, MSD, Novartis, Jaime Branco Speakers bureau: Vitoria, Miguel Bernardes Speakers bureau: Abbvie, Amgen, Biogen, Eli-Lilly, Glaxo-Smith-Kline, Pfizer, Janssen, Novartis, Raquel Ferreira: None declared, Elsa Vieira-Sousa: None declared, Sofia C Barreira: None declared, Filipe Vinagre: None declared, Raquel Roque: None declared, Helena Santos Speakers bureau: AbbVie, Eli-Lilly, Janssen, Pfizer, Novartis, Nathalie Madeira: None declared, João Rovisco: None declared, Alexandra Daniel: None declared, Sofia Ramiro Grant/research support from: MSD, Consultant of: Abbvie, Lilly, Novartis, Sanofi Genzyme, Speakers bureau: Lilly, MSD, Novartis

Pharmacogenomics - the state of the art in drug prescription

Introduction The different response to various drugs by individuals has been increasingly debated, since it has been concluded that there are large differences in response and increasing occurrence of adverse reactions. This set of issues led to more and more research on the implementation of genetic testing in the very near future, leading to benefits for the patient. The purpose of pharmacogenetics is to analyse each individual’s genetic variability in response to therapy, increasing efficiency and safety. On the other hand, pharmacogenomics studies how the expression of a set of genes interferes in individual’s responses to drugs, taking into account pharmacokinetics and pharmacodynamics. This concept also seeks to reduce adverse reactions and toxicity, maximizing drug efficiency.

Objectives The present work aims at gathering information on the proposed theme, making the survey of drugs available on the market elucidating how it allows the adjustment of the dose to be administered to the patient according to their genetic profile.

Methodology Databases such as Pubmed, Science Direct and Google Scholar were consulted and data were collected from 2015 until 2019. Paper was selected first by abstract and after by full text reading of the article.

Results On this review we will list the drugs associated with each biomarker and the respective therapeutic area to which they belong, compiled by the Food and Drug Administration (FDA). This list includes the main therapeutic area: oncology, haematology, anaesthesiology and psychology. Biomarkers allow us to identify phenotype-associated variations in drug response, making it possible to understand whether drugs will have a beneficial effect, no effect or if there is a risk of toxicity.

Conclusion This question requires a risk-benefit assessment, since it involves social, ethical and economic problems.

Designing a mobile app to promote healthy behaviors and prevent obesity: analysis of adolescents' preferences

To ensure that adolescents adhere to programmes promoting healthy behaviors, these programmes must be appealing and interesting. This study aims to characterize and assess the devices, operating system and type of mobile apps frequently used by adolescents; understand the features that mHealth apps should have to be appealing; comprehend the facilitators and barriers for adolescents to use mHealth apps. The sample comprised 165 adolescents (12-18 years) from the main population, recruited in 2018. Most participants used smartphones and the Android system. Food and physical activity suggestions were considered the most important features for an mHealth app. 62.6% had never tried an mHealth app. For those who had tried one, 26.0% stated it was to improve health status/lifestyle. Their favorite feature was physical exercise tips/plans (41.8%). Adolescents pointed out that the reasons that made them keep using the app were utility and interest (35.7%). Regarding possible barriers, 48.4% reported a lack of a senseof need/practical utility, and 18.8% considered notifications as their least favorite feature. Lack of interest was pointed out for 38.2% as the main reason for stopping use. Results provide practical information for the planning, design, and implementation of future mHealth apps for the promotion of healthy behaviors - an important implication for future research in this area.

Ecophysiological traits of highly mobile large marine predators inferred from nucleic acid derived indices

Nucleic acid-derived indices such as RNA/DNA ratios have been successfully applied as ecophysiological indicators to assess growth, nutritional condition and health status in marine organisms given that they provide a measure of tissue protein reserves, which is known to vary depending on changes in the environment. Yet, the use of these biochemical indices on highly mobile large predators is scarce. In this study, we tested the applicability of using nucleic acids to provide insights on the ecophysiological traits of two marine mammal species (common bottlenose dolphins and short-finned pilot whales) and explored potential related factors (species, sex, season, and residency pattern), using skin tissue (obtained from biopsy darts) of apparently healthy and adult free-ranging animals. Significantly higher RNA/DNA ratios were obtained for bottlenose dolphins (p < 0.001), and for visitor pilot whales when compared with resident pilot whales (p = 0.001). No significant changes were found between the sexes. Based on the percentile approach, the samples contain individuals in a general good condition (as the 10^th percentile is not closer to the mean than the 75^th percentile), suggesting that the studied region of Macaronesia may be considered an adequate habitat. The combination of this effective tool with genetic sexing and photographic-identification provided an overall picture of ecosystem health, and although with some limitations and still being a first approach, it has the applicability to be used in other top predators and ecosystems.

Ultra-long carrier lifetime in neutral graphene-hBN van der Waals heterostructures under mid-infrared illumination

Graphene/hBN heterostructures are promising active materials for devices in the THz domain, such as emitters and photodetectors based on interband transitions. Their performance requires long carrier lifetimes. However, carrier recombination processes in graphene possess sub-picosecond characteristic times for large non-equilibrium carrier densities at high energy. An additional channel has been recently demonstrated in graphene/hBN heterostructures by emission of hBN hyperbolic phonon polaritons (HPhP) with picosecond decay time. Here, we report on carrier lifetimes in graphene/hBN Zener-Klein transistors of ~30 ps for photoexcited carriers at low density and energy, using mid-infrared photoconductivity measurements. We further demonstrate the switching of carrier lifetime from ~30 ps (attributed to interband Auger) down to a few picoseconds upon ignition of HPhP relaxation at finite bias and/or with infrared excitation power. Our study opens interesting perspectives to exploit graphene/hBN heterostructures for THz lasing and highly sensitive THz photodetection as well as for phonon polariton optics.

Long carrier lifetimes are beneficial for graphene-based optoelectronics, but carrier recombination processes in graphene possess sub-picosecond characteristic times. Here, the authors report carrier lifetimes ~30 ps at low energy in graphene/hBN Zener-Klein transistors, attributed to interband Auger processes.

P715 When "wait and see" is the best option: a case report of a spontaneous coronary artery dissection

Introduction

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and is now being identified more frequently, in part because of increased awareness.

Case report

We present the case of a 63-year-old female, without cardiovascular risk factors or relevant past medical history. She complained of atypical chest pain in the last year. The patient was admitted due to acute chest pain at rest, hemodynamically stable, with unremarkable physical examination, including absence of heart failure signs. The EKG revealed a dynamic ST depression in leads V4-V6. The peak of high sensitivity troponin I was 13744pg/mL (ULN&lt; 15.6) and CK 874U/l (ULN &lt;168). The echocardiogram showed preserved left ventricular ejection fraction and hypokinesia of mid-apical segments of anterior wall. Considering the diagnosis of NSTEMI the patient underwent coronary angiography that revealed luminal narrowing of 70% in left main artery, 70% in proximal anterior descending artery (LAD) and 99% in first obtuse marginal. Given the absence of cardiovascular risk factors, the smooth angiographic appearance of coronary lesions and absence of calcium, we suspected of spontaneous dissection or vasculitis. Considering the absence of angina revascularization was delayed. A first coronary angio-CT confirmed the luminal narrowing and suggested a spontaneous dissection. Two weeks later the coronariography and the angio-CT were repeated with a significant improvement, showing only intermediate stenosis of proximal LAD. The additional imaging study revealed a 45mm ascending aortic dilation and a left primitive carotid stenosis without other vascular territory alterations, excluding fibromuscular dysplasia. The auto-immune study was unremarkable. With all these results it was assumed the diagnosis of a spontaneous coronary artery dissection and the patient was discharged asymptomatic under single antiplatelet therapy and Rivaroxaban. Three months later a new coronary angio-CT showed no significant coronary artery stenosis and the patient was asymptomatic.

Discussion and conclusion

The recognition of spontaneous coronary artery dissection is essential to the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in these patients are suboptimal and conservative management is probably the best option.

Abstract P715 Figure. angio-CT

P1527 Papillary fibroelastomas: diagnostic challenges and clinical and morphologic features

Introduction

Papillary fibroelastomas are rare benign primary cardiac tumors that more frequently involve cardiac valves. They are frequently incidentally discovered by echocardiography but may also cause symptoms.

Purpose

The aim of this study was to characterize several features of histologically confirmed fibroelastomas.

Methods

Retrospective analysis of patients with echocardiographic suspicion of fibroelastoma between 2009 and 2019 in a single tertiary center. Echocardiography was compared with histology, and echocardiographic, surgical and pathological information about confirmed fibroelastomas was collected.

Results

37 patients (P) (54.1% men) with an echocardiographic suspicion and/or histologically confirmed fibroelastoma were included, with a mean age of 58 +- 3 years (min 22, max 82). Echocardiographic report was analyzed in 34P (91.9%), with 32P (94.1%) reporting a likely fibroelastoma and 2P (5.9%) reporting a non-specified mass. 21P (56.8%) had surgery, with 12P (57.1%) having a surgical suspicion of a fibroelastoma, 2P (9.5%) of a mixoma, 1P (4.8%) of a non-specified mass and 6P (28.6%) with undefined suspicion. Of the 21P who had surgery, 66.7% (14P) had a histologically confirmed fibroelastoma, 1P (4.8%) had a mixoma, and 6P (28.6%) had other diagnoses. From the 14P with histologically confirmed fibroelastoma 64.3% had this suspicion by echocardiography and 35.7% had an echocardiogram reporting a non-specified. There was a global concordance between echocardiography and histology in 52.9%. The mean age of confirmed fibroelastoma P was 54 +-5years, and 50% were men. 7P (50%) were asymptomatic, 2 (14.3%) had a stroke, 2 (14.3%) had syncope, 1 (7.1%) had fatigue, 1 (7.1%) had palpitations and 1P had consciousness alteration. In echocardiography most P (71.4%) had only one mass but 1P had 4 different masses. The tumors had a longer axis between 6 and 25mm, with the majority (57.1%) measuring more than 10mm. 12P (85.7%) had valvular fibroelastomas, 50% of these in the aortic valve (3 in non-coronary cusp, 1 in right coronary cusp and 2 non-specified) and 50% in the mitral valve (all in sub-valvular apparatus, involving anterior leaflet, tendinous chord or papillary muscle). 1P had a left ventricular fibroelastoma (apical) and 1P had four masses in the left atrium. Macroscopically 4 lesions had a gelatinous consistency, 2 of them were membranous, 2 were elastic, 2 were friable, 1 was villainous and in 3 of them consistency was not described. The majority (57%) was white, 14% was translucent and in the rest the color was not specified. There was no described recurrence after surgery and there were no deaths registered.

Conclusion

In this population there was a reasonable concordance between echocardiography and histology, but in some cases the diagnosis was undefined or wrong. 50% of the patients were asymptomatic and the majority had valvular fibroelastomas, but a few had a different location.

P672 Predictors of ventricular arrythmias and mortality after implantation of primary prevention antitachycardia devices

Background

Patients (pts) with reduced left ventricular (LV) systolic function have high risk of sudden cardiac death and benefit from implantable cardioverter-defibrillators (ICDs/CRT-Ds). However, the risk for arrhythmic events and device therapies is extremely heterogeneous in this population, so more accurate tools for risk stratification are required.

Purpose

To assess predictors of mortality and arrhythmic events in pts receiving primary prevention ICDs/ CRTs.

Methods

Retrospective analysis of 150 pts submitted to primary prevention ICD/ CRT-D implantation with remote monitoring between 2014-2018. Demographic, clinical and echocardiographic data from implantation and follow-up period were retrieved. Arrhythmic events and device therapies were retrieved from remote monitoring and clinic visits. Univariate analysis was performed followed by a multivariate Cox analysis to evaluate predictors of events. p &lt; 0.05 were considered significant.

Results

150 pts, 80.7% male, with a mean age of 64.30 ± 12.9 years (Y) and a mean follow-up (FU) time of 38 ± 15 months. 66% of pts implanted an ICD. 52.0% of pts presented with an ischemic cardiomyopathy and 41.3% had atrial fibrillation. 35.3% had chronic kidney disease (GFR &lt; 60mL/min) and 24.0% were diabetic. Mean BNP value of 449.6 ± 631.3pg/mL and mean peak VO2 of 15.3mL/kg/min. Mean LV ejection fraction (LVEF) during FU of 35.9 ± 12.1% and a mean average global longitudinal strain (GLS) of -8.7 ± 5.5%. 63pts (42.0%) suffered a ventricular arrhythmia, mostly non-sustained ventricular tachycardia, of which 47.6% received appropriate therapies. Mortality rate of 13.3% during follow-up (20 pts). Baseline diabetes (p = 0.040) and post-procedural pulmonary artery systolic pressure (PASP) (p = 0.002) were independent predictors of overall mortality in the follow-up. Male gender (p = 0.041), baseline diabetes (p = 0.011) and atrial fibrillation (p = 0.038) were associated with ventricular events. In patients with CRT-D, a percentage of biventricular pacing superior to 95% was found to be protective against ventricular arrhythmias. Interestingly despite being associated with a higher overall mortality (p = 0.028), a reduced LVEF wasn’t related to the arrhythmic burden of our population, neither the GLS nor the LV mechanical dispersion were predictors of ventricular arrhythmias.

Conclusion

Baseline diabetes and PASP were independent predictors of mortality in our population of ICD/CRT-D pts implanted in primary prevention setting. An increased percentage of biventricular pacing was associated to improved clinical outcomes in patients receiving cardiac resynchronization therapy. Identification of predictors of events in this population can help individualize its management.

P1256 Salvage mitraclip implantation for postmyocardial infarction mitral regurgitation: 2 case reports

Introduction

Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR.

Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms.

Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic.

Conclusion

Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.

P1260 Chagas disease, a new challenge to the old continent

Case Report

A 53-year-old female patient from the North Region of Brazil with a past medical history of Chagas Disease (CD) with esophageal involvement and permanent atrial fibrillation (AF) presented to the Emergency Department (ED) due to complaints of retrosternal discomfort and dizziness. The patient reported multiple recent syncopal episodes and had performed a recent 24-hour Holter monitoring revealing AF with predominantly slow ventricular rate and frequent ventricular premature beats. Her sister had recently been diagnosed with obstructive hypertrophic cardiomyopathy. During the ED stay, the patient developed a syncopal monomorphic ventricular tachycardia, requiring synchronized electrical cardioversion. Post cardioversion EKG revealed a sinus rhythm with a right bundle branch block, left anterior fascicular block and 1st degree AV block. The patient was admitted in the Cardiology Department for further investigation. Transthoracic echocardiogram revealed a dilated left ventricle with a reduced systolic function (LVEF of 38%, GLS of -7.1%), with an aneurysm of the basal inferior and posterior walls and a markedly dilated left atrium (68mL/m2). Cardiac magnetic resonance imaging showed a marked dilation of both atriums and ventricles, with biventricular systolic dysfunction, hypertrabeculation of the left ventricular wall and the presence of diffuse intramural and subepicardic fibrosis. These features were compatible with chagasic cardiomyopathy. Due to biventricular systolic dysfunction, the documentation of AV conduction disturbance, the natural history of the disease and the need for antiarrhythmic therapy, the patient underwent cardiac resynchronization therapy–defibrillator implantation. 1 week after the procedure, the patient experienced an arrhythmic storm with a total of 6 CRT-D shocks. Amiodarone was initiated and beta-blocker was titulated to the maximum tolerated dose, with no recurrence of ventricular tachycardia. On the 3 month follow-up visit the patient denied symptoms of congestive heart failure. Device interrogation revealed a high percentage of biventricular pacing and no arrhythmic events.

Conclusion

This case describes the most remarkable and characteristic features of chagasic cardiomyopathy. It is almost always progressive and is associated with a worse outcome comparing with other cardiomyopathies. The prevalence of CD is growing in traditionally nonendemic areas and its timely recognition is fundamental.

P1262 If anything can go wrong, it will: management of a pericardial effusion in a young patient

Case Report

A 25 year-old male patient with an unremarkable past medical history presented to the Emergency Department due to a hemodynamically stable wide complex tachycardia at 260bpm with no response to adenosine, which was successfully treated with synchronized electrical cardioversion. Post cardioversion EKG revealed a pre excitation pattern and the transthoracic echocardiogram showed a large pericardial effusion with diastolic right atrial collapse. The patient was admitted in the Cardiology Department for emergent pericardiocentesis and further investigation. A total of 800 mL of bloody pericardial fluid was removed, compatible with an exudate, but fluid culture and cytology were inconclusive. Due to a rapid reaccumulation of pericardial fluid, the patient underwent a pericardial window, after which he developed an intractable pleuritic thoracalgia, refractory to the combination of ibuprofen, colchicine and oral steroid, despite the resolution of the pericardial effusion. He was also submitted to an electrophysiologic study with successful ablation of a right sided accessory pathway. Analysis of the pericardial fluid and biopsy were inconclusive once again, including a low level of adenosine deaminase and negative acid-fast bacilli test and nucleic acid amplification test for Mycobacterium tuberculosis. The patient was afebrile and denied any constitutional symptoms or relevant epidemiological context. The remainder etiological study was unremarkable, with the exception of fluctuating antibody titers for adenovirus, Borrelia burgdorferi and Mycoplasma pneumoniae, which were interpreted as a result of cross-reactivity. Nevertheless, a course of 21 days of doxycycline was tried without any significant improvement. Thoracic-abdominal-pelvic CT and PET scan were normal. Direct inoculation in guinea pig led to positive results for Mycobacterium tuberculosis and antituberculous therapy was started. Despite pathogen directed antibiotic treatment, there was no clinical improvement and the pericardial effusion gradually relapsed, evolving to cardiac tamponade requiring emergent drainage. Histologic examination of pericardial fragments finally revealed massive infiltration by an undifferentiated malignant tumor compatible with a malignant epithelioid hemangioendothelioma. Due to the patient’s poor performance status and rapidly deteriorating clinical course, it was decided not to start chemotherapy. The patient eventually died, 6 months after his admission to the ED and 2 weeks after the neoplasm’s diagnosis.

Conclusion

In regions with a high Tuberculosis incidence, there should be a high degree of suspicion for tuberculous pericarditis, especially in cases of recurrent pericardial effusion. Immunosuppressed individuals, such as oncologic patients, are at an increased risk for tuberculosis. The management of relapsing pericardial effusion remains a diagnostic challenge as described in this clinical case.

P198 Long-term outcomes after mitraclip implantation

Background

Mitraclip implantation (MI) is a well-established option for patients (P) with severe mitral regurgitation (MR) noneligible to surgery. Its impact on long term prognosis is being addressed by several recent studies.

Purpose

To identify predictors of morbidity and mortality in P undergoing MI and evaluate if the COAPT, Everest and MITRAFR exclusion criteria (EC) had any impact on the outcome of our population.

Methods

prospective study of P who underwent MI between 2013 and 2018 in one medical center. EC: COAPT: LVEF &lt; 20%, LV end-diastolic diameter &gt; 70mm or pulmonary artery systolic pressure &gt; 70mmHg; Everest: LVEF &lt; 25% or LV end-systolic diameter (LVESD)&gt;55mm; MITRA-FR: LVEF &lt; 15% or &gt;40% or primary MR. An univariate analysis was performed followed by a multivariate Cox analysis to evaluate overall mortality (M), overall mortality/ heart failure hospitalization (MH) and mortality in the first year post-MI(M1). Survival analysis using Kaplan-Meier plots. p &lt; 0.05 were considered significant.

Results

40P, 60% male, mean age 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months. 67.5% presented with MR grade IV and 75% had functional MR. Successful implantation in 97.5%, with 55% presenting mild MR post-procedure. Overall mortality was 30% (12P), mostly due to cardiovascular causes, with 9P dying in the first year (30%). There was no difference between pts with functional and primary MR: M- 33%vs20% (p = 0.6); MH– 53.3%vs30% (p = 0.5). P who met the COAPT exclusion criteria (N-22) presented an inferior 1Ysurvival (64.5%vs86.7%, p = 0.046). The overall outcome was comparable between P who matched and didn"t match Everest and MITRA-FR exclusion criteria. Basal BNP value (p = 0.037), mean preprocedural MAGGIC score (p = 0.040) and EROA (p = 0.039) were associated to M1. Multivariate Cox analysis revealed that basal BNP was an independent predictor of M (p = 0.017), whereas a higher distance in the pre-procedural 6 minute walk test (p = 0.008) and the "reduction in the MR severity and PASP" (p = 0.008) presented a protective effect. LVESD &gt; 55mm was an independent predictor of MH (p = 0.017), but MR of grade 2 or less after procedure was protective (p = 0.006).

Conclusion

There was no M difference between P with functional and primary MR. P with COAPT exclusion criteria had worse 1Ysurvival. A higher distance in 6MWT and a reduction in MR severity and PASP were protective. An LVESD &gt; 55 mm had a worse prognosis. Careful P selection may be crucial to improve MI"s results

Abstract P198 Figure. Kaplan-Meier Plots

P209 Mitraclip - experience of a portuguese tertiary care center - mid-term review of results

Background

Mitral regurgitation (MR) is a marker of bad prognosis in heart failure (HF) patients (pts). Mitraclip implantation (MI) leads to a clinical improvement.

Purpose

To characterize the adult population submitted to MI and evaluate its mid-term results.

Methods

Prospective analysis of 40 pts with moderate to severe MR (grades III-IV) submitted to MI between 2013 and 2018. Paired sample t-test to assess the procedure’s effect on several variables. P-values &lt; 0.05 were considered significant.

Results

40pts, 60% male, with a mean age of 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months (M), of which 67.5% presented with grade IV MR (mean regurgitant volume - 43.5 ± 29 ml; mean EROA - 34.8 ± 13 mm2 ) and 75% with functional MR. Mean LVEF of 35%±10.3, with 55% presenting a LVEF &lt; 35%. Mean Euroscore II of 6.0 ± 7. 27.5% had already undergone a previous cardiac surgery, in most cases CABG (63.6%). 30% had already suffered an acute coronary syndrome and 62.5% had atrial fibrillation. Mean pre-procedural peak VO2 of 14.5mL/kg/min and mean distance in the 6 minute walk test (6MWT) of 321 ± 100m. The device implantation was successful in 39 pts with a device success rate of 85% (successful implantation and reduction in MR to grade 2 or less), with 55% of pts presenting mild MR before discharge. There were immediate complications related to the procedure in 17.5% of pts, with 4pts experiencing tendinous cord rupture and 2pts leaflet tear. There were no cases of pericardial tamponade or embolic complications. Follow-up mortality of 30% (12pts), 9 deaths (D) due to cardiovascular events. 9D in the first-year post-procedure (1D within the first M), with 1 pt referred to cardiac surgery due leaflet tear and 1pt to heart transplantation. Successful MIwas associated with an improvement in NYHA functional class (3.0vs2.0, p &lt; 0.001) and in several echocardiographic variables in the first 6M following the procedure: left ventricular (LV) end diastolic volume: 194.5mLvs168.4mL, p = 0.012; LV end systolic volume: 132.6mLvs106.7mL, p = 0.008; systolic pulmonary artery pressure: 50.5mmHgvs40.8mmHg, p = 0.013. It was also associated with a significant improvement in both 6M peak VO2 (14.4vs15.5, p = 0.028) and 6MWT distance (321.3mvs374m, p &lt; 0.001).

Conclusion

MI is a safe procedure with a low rate of periprocedural complications. It’s associated with a functional class improvement and a significant reverse left ventricular remodeling.

501 A common finding with an atypical (rare) presentation

Introduction

Hypereosinophilic syndrome (HES) is characterized by persistent eosinophilia and eosinophil-mediated organ damage. Cardiac thrombosis and thromboembolic complications are common causes of morbidity and mortality in these patients. The echocardiogram is the first method of image in the assessment of cardiac involvement by HES.

Clinical Case

An 81 year-old male, with previous history of hypereosinophilia under investigation without specific treatment, presented to the emergency department after several episodes of syncope and exertional dyspnea. The patient denied fever. He was hemodynamically stable and had a holosystolic murmur (III/VI) audible in the entire precordium.

The ECG was normal. The blood tests showed leukocytosis (26.69 x10^9/L) mainly related to hypereosinophilia (17.5 x10^9/L), thrombocytopenia (134.000/uL), elevation of troponin (hsTnT= 276 ng/L, normal range &lt;14) and reactive C-protein (3.27mg/dL, normal range &lt;0.5).

The transthoracic echocardiogram (limited for the acoustic window) showed a mass in the aortic valve with obstruction of the left ventricle outflow tract (LVOT) during systole (maximum velocity= 3.85m/s, maximum gradient = 59mmHg, mean gradient = 31mmHg), moderate mitral regurgitation, left ventricle hypertrophy with normal ejection fraction and mild pericardial effusion.

A transesophageal echo (TEE) was performed confirming the presence of a hyperechogenic sessile mass, with irregular contours, measuring 23x30 mm, attached to the aortic valve causing obstruction of the LVOT (Figure 1 A and B – TEE midesophageal long axis in diastole and systole, respectively; C and D - TEE midesophageal short axis in diastole and systole, respectively).

The patient was submitted to emergent cardiac surgery for excision of the mass and aortic valve replacement (Figure 1E and F- intraoperative and macroscopic views of the mass, respectively). The anatomopathological diagnosis confirmed an aortic valve thrombus.

Discussion/Conclusion: Native aortic valve thrombosis is a rare situation with severe complications like acute myocardial infarction, peripheral ischemia, stroke, cardiogenic shock and sudden death.

In HES, cardiac involvement is present in up to 40-50% of patients, mainly with endomyocardial fibrosis and mural thrombus formation. Native and prosthetic mitral valve thrombosis has also been described, but aortic valve involvement is very unusual.

Thrombi are one of the most common intracardiac masses, but here we present a rare case of native aortic valve thrombosis with high risk of sudden cardiac death, possibly related to HES. The echocardiogram, particularly the transesophageal echo was essential for the identification of the mass and surgical planning, but as usual in intracardiac masses, the final diagnosis was histological.

Abstract 501 Figure.

P175 Cardiac device infection: to extract or not to extract, that is the question

Introduction

The incidence of infectious complications related to intracardiac devices has been increasing in recent year and is associated with a poor prognosis, which is determined not only by the infectious process but also by the severity of the underlying cardiac pathology and the spectrum of comorbidities presented. Appropriate antibiotic therapy and extraction of the devices are fundamental in the management of these patients.

Case report

We describe the case of a 66-year-old patient on a waiting list for transplantation due to non-ischemic dilated cardiomyopathy with poor left ventricular systolic function (LVEF of 10%), with severe functional mitral regurgitation and severe pulmonary hypertension, who received a CRT-D for secondary prevention (non-responder). He was admitted for decompensated heart failure (NYHA functional class IV and "dry-cold" profile) requiring inotropic support becoming dependent on dobutamine. During hospitalization, there was a progressive increase in inflammatory markers accompanied by recurrent febrile peak and inflammatory signs of the central venous catheter, with catheter-tip and serial hemocultures positive for Morganella morganii. Piperacillin / tazobactam was started. Due to the lack of response to pathogen directed antibiotic therapy, he underwent a transesophageal echocardiogram (TEE) that revealed several filiform images associated with the electrodes, with no image of valvular vegetations, which led to the association of gentamicin and device extraction (DE), according to the Pisa technique, that occurred without complications. On the 7th day after DE, there was a progressive clinical deterioration in spite of increasing doses of inotropes and vasopressors. It was considered that patient would not be candidate for cardiac transplantation or mechanical ventricular assist, and died on the 118th day of hospitalization in refractory cardiogenic shock.

Conclusion

Device endocarditis is a class I indication for intracardiac DE and TEE is fundamental in its diagnosis. Despite being a considered a non-responder to cardiac resynchronization therapy based on clinical and echocardiographic criteria, this case illustrates how the loss of cardiac resynchronization may have contributed to the patient’s hemodynamic deterioration and have played a fundamental role in the clinical outcome.