Implantable cardioverter-defibrillator therapy after resuscitation from cardiac arrest in vasospastic angina

Background

Patients with vasospastic angina (VSA) who are resuscitated from sudden cardiac arrest (SCA) are at high risk of recurrent cardiovascular events. However, there are no recommendations for implantable cardioverter-defibrillator (ICD) therapy in the VSA and SCA patient guidelines.

Purpose

This study investigated the prognostic impact of ICD therapy on patients with VSA and SCA.

Methods

The present multi-center registry included 280 patients who were resuscitated from SCA and received ICD implantation as secondary prophylaxis. The patients were divided into two groups according to the presence of VSA. The primary endpoint was a composite of all-cause death and appropriate ICD therapy, including appropriate anti-tachycardia pacing and shock for recurrent ventricular arrhythmias.

Results

Of 280 patients, 51 (18%) had VSA. Among those without VSA, ischemic cardiomyopathy was the leading cause of SCA (38%), followed by non-ischemic cardiomyopathies and Brugada syndrome (Table 1). During the median follow-up period of 3.8 years, 23 (8%) patients died, and 72 (26%) underwent appropriate ICD therapy. The incidence of the primary endpoint was not significantly different between patients with and without VSA (24% vs 33%, p=0.19). Further, the incidence of the primary endpoint was not significantly different among the etiologies (Figure 1)

Conclusions

In a cohort of patients who underwent ICD implantation as secondary prophylaxis, long-term clinical outcomes were comparable between those with VSA and those with other cardiac diseases after SCA. The results suggest that ICD therapy may be considered in patients with VSA and those with other etiologies after resuscitation from SCA.

Funding Acknowledgement

Type of funding sources: None. Table 1. Patient characteristics and outcomesFigure 1. Incidence of the primary endpoint

Effects of oral administration of timothy hay and psyllium on the growth performance and fecal microbiota of preweaning calves

The objective of this study was to evaluate the effects of oral administration of fiber from the first week of life on the growth and hindgut environment of preweaning calves. Twenty newborn female Holstein calves were divided into 2 groups as control and treatment. Calves in both groups were reared under the same feeding program except for oral fiber administration. Timothy hay and psyllium were mixed at a 50-to-6 ratio as a treatment diet for oral fiber administration. Calves in the treatment group were orally administered 50 g of fiber daily from 3 to 7 d of age and 100 g of fiber from 8 d of age until weaning. Feed intake and occurrence of diarrhea were recorded daily, and body weight (BW) was recorded weekly for the individual calf. Fresh feces were collected from calves at 7, 21, 35, 49, and 56 d of age to analyze fermentation parameters and microbiota to characterize the hindgut environment. Higher fiber intake in the treatment group due to oral administration of timothy and psyllium did not affect the starter intake and achieved higher BW at 21 d of age. The fecal pH, total volatile fatty acid, lactate, and ammonia nitrogen concentrations were not affected by oral fiber administration; meanwhile, the molar proportion of propionate was higher in the treatment group at 7 d of age. The difference in fecal microbiota in the calves subjected to the oral administration of fiber was observed within 21 d of life; Lactobacillus spp. and Prevotella spp. showed higher abundance, whereas that of Clostridium perfringens was decreased. These higher abundances of beneficial bacteria and lower abundance of pathogenic bacteria during early life may partly explain the higher BW of calves in the treatment group at 21 d of age. Furthermore, no adverse effect was observed for the BW and health status in the treatment group throughout the preweaning period. Therefore, early fiber feeding via oral administration potentially contributes to improving the hindgut environment in newborn calves, which leads to better growth of calves during the early stage of life.

Ectopic ovary presenting as mesenteric abscess

Ectopic ovary is a rare gynaecological condition that results in problems with menstruation and pregnancy and may develop into a malignant tumour. However, as the condition is often asymptomatic, diagnosis is difficult and frequently delayed. We report a case of a 42-year-old female who presented with a 10-day history of abdominal pain. The patient underwent surgery that confirmed the diagnosis of an ectopic ovary with an internal abscess. The findings of our study indicate that ectopic ovaries can present with an abscess. Ectopic ovaries should be included in the differential diagnosis of masses with internal abscesses.

P–721 Probability of receiving assisted reproductive technology treatment through out-of-pocket payment and household income: A discrete choice experiment in Japan

Study question

What is the probability that patients will receive assisted reproductive technology (ART) treatment based on their out-of-pocket payment and income class?

Summary answer

Higher-income patients opted for ART even at a higher cost, whereas an out-of-pocket payment was the most influential determinant in all income groups.

What is known already

Economic disparities affect access to ART treatment in many countries. At the time of this survey, Japan provided partial reimbursement for ART treatment exclusively for those in low- or middle-income classes due to limited governmental budgets. However, the optimal financial support by income class is unknown.

Study design, size, duration

We conducted a discrete choice experiment (DCE) in Japan in January 2020 including 824 women with fertility problems who were recruited via an online social research panel.

Participants/materials, setting, methods

Participants included women aged 25–44 years undergoing fertility diagnosis or treatment. They completed a DCE questionnaire including 16 hypothetical scenarios, created by orthogonal design, to measure six relevant ART attributes (pregnancy rate, risk of adverse effects, number of visits to outpatient clinics, consultation hours, kindness of staff, and out-of-pocket expense) and their relation to treatment choice. We used mixed-effect logistic regression models to estimate the probability of receiving ART treatment for each attribute.

Main results and the role of chance

Of the 1,247 eligible women recruited, 824 completed the survey (66% participation rate). All six attributes significantly influenced treatment preference, with participants valuing out-of-pocket payment the most, followed by pregnancy rates and kindness of staff. The odds ratios of each attribute to receiving ART treatment were 0.58 (95% confidence interval [CI]: 0.57 − 0.59) for out-of-pocket payments per additional 100,000 Japanese yen (JPY; i.e., 800 euros), 1.47 (95% CI: 1.43 − 1.53) for pregnancy rates per additional 5%, and 4.16 (95% CI: 3.73 − 4.64) for kindness of staff, after adjusting for clinical and socioeconomic factors. Significant interactions occurred between high household income (≥8 million JPY) and high out-of-pocket payment (≥500,000 JPY). However, the mean predicted probability of the highest-income patients (i.e., ≥10 million JPY) to receive ART treatment at the average cost without public funding (i.e., 400,000 JPY) was 47% (interquartile range: 18%−76%), whereas that of middle-income patients (i.e., 6–8 million JPY) to receive ART at the average subsidized cost (i.e., 100,000 JPY) was 60% (interquartile range: 33%–88%).

Limitations, reasons for caution

Other attributes not included in our DCE scenarios might be relevant in real-life settings. Choices made in a DCE would not wholly match the actual treatment choices.

Wider implications of the findings: The present DCE suggested that out-of-pocket payment was the primary determinant in patients’ ART decisions. High-income patients were more likely to receive ART treatment even at a high cost, but their ineligibility for government financial support due to their high income might discourage them from receiving treatment.

Trial registration number

NA

Rumen microbiota and its relation to fermentation in lactose-fed calves

In our previous studies, we revealed the effect of lactose inclusion in calf starters on the growth performance and gut development of calves. We conducted the present study as a follow-up study to identify the shift in rumen microbiota and its relation to rumen fermentation when calves are fed a lactose-containing starter. Thirty Holstein bull calves were divided into 2 calf starter treatment groups: texturized calf starter (i.e., control; n = 15) or calf starter in which starch was replaced with lactose at 10% (i.e., LAC10; n = 15) on a dry matter basis. All calves were fed their respective treatment calf starter ad libitum from d 7, and kleingrass hay from d 35. Rumen digesta were collected on d 80 (i.e., 3 wk after weaning) and used to analyze rumen microbiota and fermentation products. There was no apparent effect of lactose feeding on the α-diversity and overall composition of rumen microbiota. Amplicon sequencing and real-time PCR quantification of the 16S rRNA gene confirmed that the abundance of butyrate-producing bacteria (i.e., Butyrivibrio group and Megasphaera elsdenii) did not differ between the control and LAC10 groups. Conversely, the relative abundance of Mitsuokella spp., which produce lactate, succinate, and acetate, was significantly higher in the rumen of calves that were fed lactose, whereas the lactate concentration did not differ between the control and LAC10 groups. These findings suggest that the lactate production can be elevated by an increase of Mitsuokella spp. and then converted into butyrate, not propionate, since the proportion of propionate was lower in lactose-fed calves. In addition, we observed a higher abundance of Coriobacteriaceae and Pseudoramibacter-Eubacterium in the LAC10 group. Both these bacterial taxa include acetate-producing bacteria, and a positive correlation between the acetate-to-propionate ratio and the abundance of Pseudoramibacter-Eubacterium was observed. Therefore, the higher abundance of Coriobacteriaceae, Mitsuokella spp., and Pseudoramibacter-Eubacterium in the rumen of lactose-fed calves partially explains the increase in the proportion of rumen acetate that was observed in our previous study.

Right ventricular function as a predictor of appropriate therapy of implantable cardioverter defibrillator

Funding Acknowledgements

Type of funding sources: None.

Aim

The purpose of this study was to evaluate the association of RV function and appropriate therapy of ICD.Methods: This study was a single-center retrospective cohort study. Consecutive patients who underwent ICD implantation for any diseases were enrolled except for non-dilated phase hypertrophic cardiomyopathy and channelopathy. Transthoracic echocardiographic parameters including left ventricular ejection fraction (LVEF), RV basal diameter, RV end-diastolic area, and right ventricular fractional area change (RVFAC) were evaluated. RV systolic dysfunction was defined as RVFAC <35%. Cox regression analysis was used to analyze the effects of those parameters on appropriate ICD therapy after the implantation.

Results

In total, 151 patients (60.9 ± 13.6 years, 117 males) consisting of 67 old myocardial infarction, 34 dilated cardiomyopathy, 19 cardiac sarcoidosis, and 31 others were enrolled. Eighty patients received an ICD as a secondary prophylaxis. Mean LVEF and RVFAC were 37.8 ± 13.9% and 33.2 ± 10.8%, respectively. RV systolic dysfunction was present in 86 (57.0%) patients, which was significantly associated with ICD therapy (odds ratio 2.313; 95% confidence interval 1.067-5.014; P = 0.034) according to a univariate analysis. There was no correlation between RVFAC and LVEF (correlation coefficient =0.064). Regarding the subjects LVEF > 35%, RV systolic dysfunction was an independent predictor of ICD therapy in a multivariate analysis.

Conclusion

RV systolic dysfunction was independently associated with increased ICD therapy despite of relatively preserved LVEF.

A compact and stable incidence-plane-rotating second harmonics detector

We describe a compact and stable setup for detecting the optical second harmonics, in which the incident plane rotates with respect to the sample. The setup is composed of rotating Fresnel rhomb optics and a femtosecond ytterbium-doped fiber laser source operating at the repetition frequency of 10 MHz. The setup including the laser source occupies an area of 1 m² and is stable so that the intensity fluctuation of the laser harmonics can be less than 0.2% for 4 h. We present the isotropic harmonic signal of a gold mirror of 0.5 pW and demonstrate the integrity and sensitivity of the setup. We also show the polarization-dependent six-fold pattern of the harmonics of a few-layer WSe₂, from which we infer the degree of local-field effects. Finally, we describe the extensibility of the setup to investigate the samples in various conditions such as cryogenic, strained, ultrafast non-equilibrium, and high magnetic fields.

Magnetic Friedel Oscillation at the Fe(001) Surface: Direct Observation by Atomic-Layer-Resolved Synchrotron Radiation ^{57}Fe Mössbauer Spectroscopy

The surface magnetism of Fe(001) was studied in an atomic layer-by-layer fashion by using the in situ iron-57 probe layer method with a synchrotron Mössbauer source. The observed internal hyperfine field H_{int} exhibits a marked decrease at the surface and an oscillatory behavior with increasing depth in the individual upper four layers below the surface. The calculated layer-depth dependencies of the effective hyperfine field |H_{eff}|, isomer shift δ, and quadrupole shift 2ϵ agree well with the observed experimental parameters. These results provide the first experimental evidence for the magnetic Friedel oscillations, which penetrate several layers from the Fe(001) surface.

Validity of ultrasound arterial wall vascularization for assessment of vascular inflammation

Background

Vascular inflammation plays a fundamental role in most vascular diseases including atherosclerosis and vasculitis syndrome, in which arterial wall vascularization (AWV) frequently develops. Visualization of AWV is informative in detecting the vascular inflammation but is challenging. A new ultrasound technique (superb micro-vascular imaging [SMI]) allows the detection of extremely low-velocity flows. We examined an availability of SMI for assessment of the instability of atherosclerotic plaques and the activity of Takayasu arteritis (TA).

Methods and results

The study consists of two independent and consecutive parts A and B, examined in carotid stenosis (A) and TA (B), respectively. In part A, 12 patients with symptomatic severe carotid stenosis (CS group) scheduled for carotid endarterectomy were enrolled. In six of 12 patients, preoperative ultrasonography with SMI showed intraplaque neovascularization at the plaque shoulder. Postoperatively, histopathology confirmed the neovessels at the corresponding sites of visualized AWV. SMI had a sensitivity of 67%, specificity of 90% for detection of AWV in CS group. In SMI analysis, false positive findings were caused by motion artifact and arterial wall calcification, and a false negative finding is attributed by intraplaque hemorrhage. In part B, 10 patients with TA were enrolled. All patients underwent 18F-FDG-PET/CT, and its vascular uptake were compared with AWV detected by SMI. Bilateral common carotid arteries (CCA), internal carotid arteries and common iliac arteries were examined by SMI. Active vascular 18F-FDG uptake (max SUV >2.1) were found at five sites in three patients, which were not significantly correlated with the prevalence of macaroni sign, increase in C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Of note, SMI revealed AWV at five sites corresponding to uptake of 18F-FDG, with a sensitivity/specificity of 100% and 98%, positive predictive value 71%, and a negative predictive value 100%.

Conclusion

SMI enables visualization of AWV at vulnerable plaque in CS patients and at 18F-FDG positive sites in TA patients. SMI has potential as a modality to detect the vascular inflammation.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research, Japan

Clinical importance and configuration of collateral vessel systems in patients with Takayasu arteritis or with thymoma visualized by three-dimensional volume rendering computed tomographic angiography

Background

Collateral vessels form after gradual blood vessel occlusion. We speculate that in Takayasu arteritis (TA) and thymoma patients, before planning surgical procedures, a complex artery/venous system should be examined using three dimensional (3D) volume rendering computed tomographic (CT) angiography.

Purpose

To seek the clinical importance and actual complex configuration of collateral vessel systems in patients with TA or with thymoma using 3D volume rendering CT angiography with special acquisition method.

Methods

We performed 3D CT angiography in patients with Takayasu arteritis (TA) with occluded arteries (N=6) or thymoma (N=2) with occluded superior-vena-cava (SVC), respectively. For CT angiography in thymoma patients, diluted (1/4) iodinated-contrast was injected in right and left medial cubital-veins simultaneously, and images acquired 10 seconds after contrast-injection.

Results

Occluded and collateral-arteries (TA group) and occluded SVC and collateral-veins (thymoma group) were successfully visualized (Figures a-h). Collateral-arteries form from the inferior mesenteric artery (Figure a) or de novo arteries from the abdominal aorta (Figure b) after superior mesenteric artery occlusion (Figure c, d). In patients with thymoma, an SVC thymoma disrupts venous return in the neck and upper extremities; a complex venous system forms on the abdominal surface (Figure e-h).

Conclusion

In TA and thymoma patients, before planning surgical procedures, a complex artery/venous system should be examined using 3D volume rendering CT angiography. For CT in thymoma, diluted (1/4) iodinated contrast should be injected in both medial cubital veins, and images should be acquired 10 seconds after contrast-injection.

3D volume rendering CT angiography

Funding Acknowledgement

Type of funding source: None

Greater coronary lipid core plaque assessed by near-infrared spectroscopy intravascular ultrasound in patients with elevated xanthine oxidoreductase: a mechanistic insight

Background

Elevated serum uric acid level was reportedly associated with greater coronary lipid plaque. Xanthine oxidoreductase (XOR) is a rate-limiting enzyme in purine metabolism and believed to play important roles in coronary atherosclerosis. However, the relation of XOR to coronary lipid plaque and its mechanism are unclear.

Purpose

The aim of this study was to assess the impact of XOR on coronary lipid plaque and the associated factors with XOR in coronary artery disease (CAD).

Methods

Patients with stable CAD undergoing elective percutaneous coronary intervention under near-infrared spectroscopy intravascular ultrasound (NIRS-IVUS) guidance were prospectively enrolled. They were divided into three groups according to serum XOR activities; low, normal, and high. Coronary lipid core plaques in non-target vessels were evaluated by NIRS-IVUS with lipid core burden index (LCBI) and a maximum LCBI in 4 mm (maxLCBI4mm). Systemic endothelial function and inflammation were assessed with reactive hyperemia index (RHI) and high-sensitivity C-reactive protein, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio.

Results

Of 68 patients, 26, 31, and 11 were classified as low, normal, and high XOR activity groups. LCBI (474.4±171.6 vs. 347.4±181.6 vs. 294.0±155.9, p=0.04) and maxLCBI4mm (102.1±56.5 vs. 65.6±48.5 vs. 55.6±37.8, p=0.04) were significantly higher in high XOR group than in normal and low XOR groups. Although RHI was significantly correlated with body mass index, diabetes, current smoking, and high-density lipoprotein cholesterol, no relation was found between XOR activity and RHI (Figure). There were also no relations between XOR activity and high-sensitivity C-reactive protein, neutrophil-to-lymphocyte ratio, or platelet-to-lymphocyte ratio (Figure).

Conclusion

Elevated XOR activity was associated with greater coronary lipid plaque in patients with stable CAD, without significant relations to systemic endothelial function and inflammation.

Funding Acknowledgement

Type of funding source: None

Impact of percutaneous coronary intervention on short and long-term prognosis of elderly patients with acute myocardial infarction from 2010 to 2017 in Japanese population

Background

Advances in therapies have successfully decreased short-term mortality in patients with acute myocardial infarction (AMI). Although aging population is recently increasing in developed countries, there are few reports about the association between prevalence of percutaneous coronary intervention (PCI) and long-term prognosis in elderly patients with AMI in Japan.

Purpose

The aim of this study was to clarify the prevalence of PCI and the impact of PCI on short and long-term prognosis of elderly patients with AMI.

Methods and results

We investigated the prevalence of PCI and short-term mortality in 4,109 patients with AMI who were registered in Yamagata AMI Registry from 2010 to 2017. Long-term mortality was investigated using data from death certification in July 2019. We divided patients with AMI into three age groups (group 1, <65 years old; group 2, 65–79 years old; and group 3, ≥80 years old). Short-term mortality within 30 days was 6.5%, 12.1%, and 28.6%, respectively. Also, prevalence of PCI was 88.0%, 84.7%, and 62.7%, respectively. Multivariate analysis revealed that age, PCI, and severity of Killip classification were significantly associated with short-term mortality after adjustment for confound factors in group 3. Since the prevalence of PCI in group 3 was the lowest among three groups, the cause of PCI not being executed was investigated in 1,429 patients aged ≥80 years old. Elderly patients who didn't undergo PCI was older, more women, and had higher prevalence of chronic kidney disease, previous stroke, and severe Killip classification. Multivariate analysis revealed that age and Killip III/IV were significantly associated with non-executed PCI after adjustment for confound factors. Next, we investigated impact of PCI on long-term mortality in elderly patients who escaped acute death. Multivariate Cox hazard analysis revealed that PCI was associated with lower mortality after adjustment for confound factors (adjusted hazard ratio 2.47, 95% CI: 1.47–4.06; p=0.0008).

Conclusion

Lower prevalence of PCI and higher short-term mortality were observed in elderly patients with AMI aged ≥80 years old. PCI ameliorated long-term mortality as well as short-term mortality in elderly patients with AMI.

Funding Acknowledgement

Type of funding source: None

Utility of superb microvascular imaging for assessment of foot perfusion in patients with critical limb ischemia

Background

Recently, an increasing attention has been paid to foot microcirculation in critical limb ischemia (CLI). Although skin perfusion pressure (SPP) is the most frequently used marker of microcirculation, SPP is often unmeasurable at the most ischemic site in the foot. A new ultrasound technique (superb micro-vascular imaging [SMI]) allows the detection of extremely low velocity flows and enables the quantitative verification as vascular index (VI). We examined the diagnostic value of SMI-based VI in assessing foot perfusion when planning endovascular treatment (EVT).

Methods

Consecutive 50 patients with CLI were enrolled. All cases underwent EVT for superficial femoral arteries. SMI-based VI of plantar, dorsal, medial heel, lateral heel and toe's area were obtained before and after EVT, and those were compared with SPP (plantar and dorsal) or ankle-brachial index (ABI) representing macrocirculation.

Results

Based on the six angiosomes concept, SMI enabled to visualize microcirculation in all subjects, but SPP was not feasible in 13% of all subjects at the most ischemic site. After EVT, ABIs were significantly increased from 0.64±0.19 to 0.85±0.27 (P=0.0003). Plantar SPP also increased from 39.6±20.4 mmHg to 58.5±27.1 mmHg (p=0.002). SMI-based VI significantly increased in each sites based on the six angiosomes concept. Of note, plantar SMI-based VI significantly increased from 5.1±3.2% to 10.6±6.6% (p<0.0001), suggesting improvement of foot perfusion. Plantar SMI-based VI was well correlated with plantar-SPP both before and after EVT (p=0.002, r=0.663). Plantar VI was also informative in showing a rapid improvement of foot perfusion during EVT.

Conclusion

SMI enabled to visualize the foot microcirculation on the basis of angiosomes concept. SMI has potential as an alternative to SPP.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Grant-in -Aid for Scientific Reseach, Japan

Comparison of clinical characteristics between patients with microvascular and epicardial coronary artery spasm

Background

Coronary functional abnormalities including both epicardial and microvascular coronary artery spasm represent an important role responsible for myocardial ischemia in patients with angina and nonobstructive coronary artery disease. However, clinical characteristics associated with microvascular spasm (MVS) have not been fully evaluated.

Purpose

The aim of this study was to assess differences in clinical features between patients with MVS and epicardial coronary spasm.

Methods

A total of 732 consecutive patients with suspected angina who presented nonobstructive coronary arteries and underwent intracoronary acetylcholine provocation test were retrospectively enrolled in this study. Epicardial coronary spasm was defined as total or subtotal occlusion of epicardial coronary arteries accompanied by chest pain and/or ischemic electrocardiographic changes in response to acetylcholine provocation test. MVS was diagnosed when chest pain and/or ischemic electrocardiographic changes developed after administration of acetylcholine in the absence of epicardial coronary spasm. Clinical characteristics were compared between patients with MVS and epicardial coronary spasm.

Results

Of all patients, 83 patients (11%) had MVS, 367 (50%) had epicardial coronary spasm, and the other patients (39%) showed neither MVS nor epicardial coronary spasm. Patients with MVS tended to be older (65.6±12.7 vs. 63.0±12.3 years, P=0.088) and were more frequently female (60.2% vs. 41.1%, P=0.0016) in comparison with patients with epicardial coronary spasm. Patients with MVS were less likely to be smokers (8.6% vs. 22.9%, P=0.0018), while there were no significant differences in the other coronary risk factors such as hypertension, dyslipidemia, and diabetes mellitus. Serum uric acid were significantly lower in patients with MVS (4.9±1.1 vs. 5.4±1.3 mg/dl, P=0.0018).

Conclusion

Our study demonstrated that patients with MVS had distinctive clinical background from those with epicardial coronary spasm, suggesting different mechanisms may involve the development of MVS.

Funding Acknowledgement

Type of funding source: None

Influence of Nuss surgical operation for pectus excavatum on electrocardiogram abnormality considering anatomical severity as indicated by Haller index acquired by computed tomography and age

Background

Pectus excavatum (PEX) is a depression of the sternum relative to costal cartilages and sometimes depress heart anatomically which cause abnormal ECG change. Nuss operation is minimal invasive technique for PEX repair.

Purpose

We speculated this Nuss operation would improve these ECG abnormalities. We also considered the Haller index (HI) and age to these influences. HI is an anatomical severity indicator of PEX calculated from CT.

Methods

A total of 17 patients (14 male, 12±6 years), who underwent Nuss operation for PEX, underwent unenhanced CT and ECG before and after the Nuss operation.

Results

All Nuss operation was successfully performed. On CT, HI was significantly improved from 5.62±2.29 to 3.29±0.65 (P=0.0002). A P wave with a negative portion >1 mm deep and >40 ms duration in V1 lead, incomplete right bundle branch block (RBBB), sinus arrhythmia, and right-axis deviation of a QRS wave were diagnosed in 15, 6, 12, and 5 patients, respectively. Comparing before with after Nuss operation, there were no significant differences of the degree of electrical axis of QRS waves, the degree of electrical axis of P waves, or the PQ interval, respectively (All P=NS). Absolute values of voltage of a negative portion of the P wave in V1 lead was significantly improved after the operation (1.55±1.25 vs 0.76±0.91mm, P<0.001). Among 12 patients with sinus arrhythmia, only one patient improved to that without. Among 6 patients with incomplete RBBB, only one patient improved to that without. The correlation coefficient (CC) between “values of the improvement of negative portion of the P wave in V1 lead after the operation” and “HI before operation” was 0.305 (P<0.05). The CC between “absolute values of the improvement of negative portion of the P wave in V1 lead after the operation” and “age at the operation” was −0.216 (P<0.05).

Conclusion

In patients with PEX, successful Nuss operation could achieve improvement of negative portion of the P wave in V1 lead positively correlated with “HI before operation” and negatively correlated with “age”. Nuss procedure would be more effective to abnormal ECG change, when anatomical severity is severer or age is younger.

Improvement of negative P wave

Funding Acknowledgement

Type of funding source: None

Subclinical left atrial dysfunction profiles for prediction of cardiac outcome in the general population

Background

Echocardiographic screening for subclinical left atrial (LA) dysfunction might enhance the prediction of cardiac diseases such as atrial fibrillation (AFib) in the community. To date, however, outcome-driven definitions of early-stage LA dysfunction remain scarce.

Purpose

In a large population sample, we sought to extract outcome-driven thresholds for echocardiographic indexes of LA function to define subclinical left atrial (LA) dysfunction and assess the prognostic value of these echocardiographic criteria for prediction of cardiac events.

Methods

In 1306 community-dwelling individuals (mean age, 50.7 years; 51.6% women), we assessed LA function and left ventricular (LV) global longitudinal strain (LS) by echocardiography. Using receiver-operating curve threshold analysis, we derived outcome-driven cut-offs for LA emptying fraction (LAEF) and LA reservoir strain (LARS) that best balanced the cardiac event prediction (i.e. cut-offs yielding the highest Youden index (=sensitivity+specificity-1)). Next, we constructed LA dysfunction profiles and integrative LA/LV strain profiles based on the extracted cut-offs for LAEF and LARS and a validated definition of impaired LV global LS. We assessed the prognostic performance of these profiles in predicting the incidence of cardiac events and AFib (mean follow-up, 8.5 years).

Results

During follow-up, 93 participants experienced a cardiac event (8.3 events/1000 person-years) and 27 developed AFib (2.3 events/1000 person-years). LAEF<55% and LARS<23% yielded the highest Youden indexes and thus provided the most balanced prediction of incident AFib. When applying these cut-offs, abnormal LAEF and LARS were respectively present in 27.0% and 18.1% of the cohort. Abnormal LARS was independently associated with higher risk for cardiac events (hazard ratio (HR) versus normal LA phenotype: 2.11, P=0.0021). Both abnormal LAEF (HR: 2.57) and abnormal LARS (HR: 3.28) predicted incident AFib (P≤0.029). As compared to subjects free from any LA dysfunction, those with both LAEF<55% and LARS<23% had a significantly higher risk to develop cardiac events (HR: 2.10; P=0.014) and AFib (HR: 6.45; P=0.0036). Of the integrative LA/LV strain profiles, the concomitant presence of an impaired LARS and LV global LS independently elevated the risk for cardiac events (HR: 2.81; P=0.0012) and AFib (HR: 4.36, P=0.0071) as compared to normal counterparts. Both the degree of LA dysfunction and the integrative LA/LV strain profiles improved the prognostic accuracy beyond clinical risk models and risk scores.

Conclusions

We validated population-based and outcome-driven definitions of subclinical LA dysfunction predicting cardiac events independent of conventional risk factors. Echocardiographic screening for subclinical LA and LV systolic dysfunction might enhance the prediction of cardiac diseases such as AFib in the community, empowering clinicians to timely intervene with the disease development.

Prediction of cardiac events

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Research Foundation Flanders, Internal Funds KU Leuven

The lower the renal function in patients with chronic renal disease, the greater the improvement in the renal function cardiac rehabilitation provides

Background

Our previous study suggested that cardiac rehabilitation (CR) resulted in a significant improvement in the renal function in cardiac vascular disease (CVD) patients with chronic renal disease (CKD), using cystatin C. However, whether the difference in the severity of the renal impairment at the beginning of the CR affects the degree of the improvement in the renal function after CR is unknown.

Methods

We studied 203 CVD patients (155 males; 73 y/o) with CKD (15≤estimated glomerular filtration rate based on the serum cystatin C concentration [eGFRcys]<60 ml/min/1.73m2) who participated in our 3-month CR program. The eGFRcys was examined at the beginning and end of the CR. In addition, the patients were divided into 3 groups according to the severity of the renal impairment at the beginning of the CR: CKD G3a group (45≤eGFRcys<60 ml/min/1.73m2, n=122), CKD G3b group (30≤eGFRcys<45 ml/min/1.73m2, n=60), and CKD G4 group (15≤eGFRcys<30 ml/min/1.73m2, n=21). We compared the renal function at the beginning and end of the CR in each of the 3 groups. Moreover, we evaluated the correlation between the eGFRcys at the beginning of the CR and the change in the eGFRcys (%ΔeGFRcys).

Results

In all the study patients, the eGFRcys improved after the CR (45.5 to 47.7 ml/min/1.73m2, p<0.001). In the CKD G3b and G4 groups, the eGFRcys also improved (38.4 to 41.5 ml/min/1.73m2, p=0.001; 23.2 to 28.0 ml/min/1.73m2, p=0.016). However, in the CKD G3a group, the eGFRcys did not improve after the CR (52.9 to 54.2 ml/min/1.73m2, p=0.074) (Figure 1). The univariate analysis results showed that the %ΔeGFRcys was significantly negatively correlated with the eGFRcys at the beginning of the CR (p=0.016, r=−0.26, Figure 2).

Conclusion

The greater the renal dysfunction in the CVD patients with CKD was, the greater the improvement in the renal function after participating in the CR program.

Funding Acknowledgement

Type of funding source: None

Prognosis and cause of death in patients with left atrial appendage thrombus treated with or without anticoagulation therapy

Background

Thrombus in left atrial appendage (LAA) is associated with cardiogenic ischemic stroke; however, little is known about prognosis of patients with LAA thrombus detected by transoesophageal echocardiography (TOE).

Purpose

This study is to investigate the prognosis of patients with LAA thrombus and their cause of death.

Methods

Between 2005 and 2016, the patients who were performed TOE in our hospital were enrolled in this retrospective observational study. Five-year stroke free and survival curves were constructed by Kaplan-Meir method and cause of death were assessed.

Results

Among the 1263 study patients, LAA thrombus was detected in 146 (12%) patients. The patients with LAA thrombus were elder (74 y [66–79 y] vs. 70 y [62–76 y], P<0.001), than those without LAA thrombus, respectively. The prevalence of male sex (67% vs. 69%, P=0.63) were similar between the 2 groups. The prevalence of CHA2DS2-VASc score ≥2, d-dimer (1.7 mcg/ml [0.9–3.5 mcg/ml] vs. 0.8 mcg/ml [0.5–2.2 mcg/ml], P<0.001), and plasma brain natriuretic peptide (315 pg/ml [128–515 pg/ml] vs. 126 pg/ml [47–284 pg/ml], P<0.001) were higher in the patients with LAA thrombus than those without (89% vs. 78%, P=0.003). The LAA velocity was slower in the patients with LAA thrombus than those without (23 cm/s [15–34 cm/s] vs. 51 cm/s [35–72 cm/s], P<0.001). The prevalence of receiving anticoagulation therapy before (34% vs. 24%, P=0.01) and after (98% vs. 66%, P<0.001) TOE 1 month were higher in the patients with LAA thrombus than those without. The 5-year stroke free rate was lower in the patients with LAA thrombus than those without (82% vs. 93%, P<0.001); however, the 5-year survival were similar between the 2 groups (84% vs. 84%, P=0.93) (Figure). The cause of death as ischemic stroke was only 7% (1/14) and 3% (3/94), (P=0.43); the cardiac cause (14% vs. 43%, P=0.07) and the malignancy (35% vs. 29%, P=0.75) were the frequent cause of death in the patient with LAA thrombus and those without, respectively.

Conclusions

The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke; however, the 5-y survival were similar. The ischemic stroke was not major cause of death in the patients with and without LAA thrombus. The higher rate of receiving anticoagulation therapy may be one of the causes of the discrepancy.

Figure 1

Funding Acknowledgement

Type of funding source: None

Short-term risk stratification using CADILLAC risk score in patients with ST elevation myocardial infarction

Background

The recent reperfusion therapy for ST-elevation myocardial infarction (STEMI) has made the length of hospital stay shorter without adverse events. CADILLAC risk score is reportedly one of the risk scores predicting the long-term prognosis in STEMI patients.

Purpose

To invenstigate the usefulness of CADILLAC risk score for predicting short-term outcomes in STEMI patients.

Methods

Consecutive patients admitted to our university hospital and our medical center with STEMI (excluding shock, arrest case) who underwent primary PCI between January 2012 and April 2018 (n=387) were enrolled in this study. The patients were classified into 3 groups according to the CADILLAC risk score: low risk (n=176), intermediate risk (n=87), and high risk (n=124). Data on adverse events within 30 days after hospitalization, including in-hospital death, sustained ventricular arrhythmia, recurrent myocardial infarction, heart failure requiring intravenous treatment, stroke, or clinical hemorrhage, were collected.

Results

In the low risk group, adverse events within 30 days were significantly less observed, compared to the intermediate and high risk groups (n=13, 7.4% vs. n=13, 14.9% vs. n=58, 46.8%, p<0.001). In particular, all adverse events occurred within 3 days in the low risk group, although adverse events, such as heart failure (n=4), recurrent myocardial infarction (n=1), stroke (n=1), and gastrointestinal bleeding (n=1), were substantially observed after day 4 of hospitalization in the intermediate and high risk groups.

Conclusions

In STEMI patients with low CADILLAC risk score, better short-term prognosis was observed compared to the intermediate and high risk groups, and all adverse events occurred within 3 days of hospitalization, suggesting that discharge at day 4 might be safe in this study population. CADILLAC risk score may help stratify patient risk for short-term prognosis and adjust management of STEMI patients.

Initial event occurrence timing

Funding Acknowledgement

Type of funding source: None

Long-term prognostic significance of dispersion of ventricular repolarization in patients with cardiac sarcoidosis

Background

Although the presence of cardiac involvement is recognised as a determinant of worse clinical outcomes in sarcoidosis patients, the determinants of adverse outcomes in patients with cardiac sarcoidosis (CS) have not been well understood. T-peak to T-end interval (TpTe) on the surface electrocardiogram (ECG) was proposed as a marker of dispersion of ventricular repolarisation. Prolonged TpTe to QT interval ratio (TpTe/QT) represents a period of potential vulnerability to reentrant ventricular arrhythmias. Notably, prolonged TpTe/QT has been associated with increased risk of mortality in hypertrophic cardiomyopathy, congenital long-QT syndrome, and Brugada syndrome. However, its prognostic implication in patients with CS is unclear.

Purpose

We sought to investigate whether TpTe/QT was associated with long-term clinical outcomes in patients with CS.

Methods

A total of 108 consecutive CS patients between August 1986 and March 2019 in two academic hospitals who had ECG data before initiation of immunosuppressive therapy were examined. We excluded patients who received pacemaker (n=15) or cardiac resynchronization therapy (n=3) at the time of ECG. Ultimately, 90 CS patients were included in this study. All standard 12-lead ECGs were recorded at 25 mm/s with an amplification of 10 mm/mV. TpTe was measured from the peak of T wave to the end of T wave which defined as the intersection of the tangent to the down slope of the T wave and the isoelectric line. Lead V5 was selected for the analyses. If V5 is not suitable for analyses, V4 was selected. The primary outcome was the composite of advanced atrioventricular block (AVB), ventricular tachycardia or ventricular fibrillation (VT/VF), heart failure hospitalisation and all-cause death.

Results

During a median follow-up period of 4.70 (interquartile range [IQR] 2.06–7.23) years, adverse events occurred in 21 patients (23.3%), including 2 advanced AVB, 12 VT/VF, 4 heart failure hospitalisation and 3 all-cause death. Events group had higher TpTe/QT compared to no events group (0.231 [IQR 0.193–0.261] vs. 0.282 [IQR 0.263–0.304] P<0.001). Kaplan-Meier analyses revealed that the primary outcome, especially VT/VF or sudden cardiac death more frequently occurred in patients with higher TpTe/QT (≥0.242, the median) compared to those with lower TpTe/QT (Figure 1). Multivariable Cox regression analysis showed that higher TpTe/QT was independently associated with increased subsequent risk of adverse events (hazard ratio 1.09, 95% confidence interval [CI] 1.02–1.17, P=0.014) even after adjustment for age, sex and left ventricular ejection fraction. Furthermore, the optimal cut-off value of TpTe/QT for the discriminatory of primary outcome was 0.257, and c-index was 0.77 (95% CI 0.64–0.89).

Conclusions

Higher TpTe/QT was associated with worse long-term clinical outcomes in patients with CS. Our findings indicate the importance of assessing TpTe/QT for risk stratification in patients with CS.

Figure 1

Funding Acknowledgement

Type of funding source: None

Age-related differences and vascular function test findings in patients with vasospastic angina

Background

Vasospastic angina (VSA) accounts for the majority of angina cases with no epicardial stenosis and develops amongawide range of age, which is reportedly induced by coronary functional abnormalities including endothelial dysfunction and smooth muscle hypercontraction. However, the relation of noninvasive vascular function tests to VSA remains to be fully elucidated.

Purpose

The aim of this study was to assess differences in clinical characteristics and findings from noninvasive vascular function tests among groups by age in patients with VSA.

Methods

We enrolled a total of 732 patients with angina who underwent intracoronary acetylcholine provocation test. VSA was defined as total or subtotal occlusion of epicardial coronary arteries accompanied by chest pain and/or ischemic electrocardiographic changes in response to acetylcholine administration. Patients with VSA were divided into 3 groups by age (young [<50 years], intermediate [50–64 years], and elderly group [≥65 years]). Noninvasive vascular function test findings such as ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), andpercentage of mean arterial pressure (%MAP) were compared among groups by age in patients with VSA.

Results

Of all patients, 367 (50.1%) were diagnosed as VSA with intracoronary acetylcholine test, including 66 (18.0%), 113 (30.8%), and 188 (51.2%) patients in the young, intermediate, and elderly groups. Among groups by age, there was no significant difference in gender (female, 31.8% vs. 40.7% vs. 44.7%, P=0.19). Patients in the young group were more often smokers and alcohol drinkers than those in the intermediate and elderly groups, while the prevalence of hypertension, dyslipidemia, and diabetes were lower in younger patients. A history of percutaneous coronary intervention was less frequently found in the young group compared tothe intermediate and elderly groups (7.6% vs. 16.8% vs. 20.7%, P=0.033). The baPWV was higher in the elderly group (1424±232 vs. 1537±247 vs. 1774±358 cm/s, P<0.0001), while there was no difference in ABI between the 3 groups. %MAP at arms was significantly and progressively decreased with an increase in age (54.0±4.5% vs. 53.0±2.6% vs. 51.2±2.8%, P<0.0001).

Conclusion

Our study demonstrated that there were distinct age-related differences in clinical characteristics of patients with VSA. The higher %MAP in younger patients suggests that more impaired endothelial dysfunction may play a role in the development of VSA in this age group.

Funding Acknowledgement

Type of funding source: None