Serial evaluation of cardiac allograft vasculopathy after heart transplantation by dual-modality intravascular ultrasound and optical coherence tomography

Background

Cardiac allograft vasculopathy is a combination of the development of de novo plaque and the progression of donor-transmitted plaque.

Purpose

This study aimed to evaluate the development of de novo plaque and the progression of donor-transmitted plaque within 12-month after heart transplantation (HTx) using serial intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The association between inflammatory cytokines and plaque progression was also examined.

Methods

We prospectively enrolled 40 recipients to conduct serial three-vessel IVUS and OCT analysis at 8-week and 12-month after HTx. De novo plaque was defined as having maximum intimal thickness (MIT) ≥0.5 mm at 12-month in the absence of donor-transmitted plaques (MIT ≥0.5 mm at 8-week). Serum cytokines were screened with a bead-based multiplex assay.

Results

A total of 13 de novo plaques (fibrous, n=10; fibroatheroma, n=3) were detected in eight recipients. Serum interleukin (IL)-31 at 8-week was associated with the development of de novo plaques (p=0.009). A total of 31 donor-transmitted plaques (fibrous, n=12; fibroatheroma, n=11; fibrocalcific, n=8) were detected in 17 recipients. Multiple regression analysis revealed that fibrous (p=0.026) and fibroatheroma (p=0.012) observed at 8-week were significantly associated with subsequent plaque progression within 12-month after HTx. ΔPlaque burden was significant higher in de novo plaque than donor-transmitted plaque (38.8% [29.6–41.2] versus 8.7% [1.3–13.6], p<0.001). The prevalence of macrophage accumulation was lower in de novo plaque than in donor-transmitted plaque (8% versus 52%, p=0.006). Serum IL-31 at 8-week was correlated with the progression of donor-transmitted plaque as well as de novo plaque (r=0.663, p=0.029) although other cytokines like IL-1β, IL-6, IL-17, and tissue necrotic factor alpha were not.

Conclusions

In de novo plaques, fibrous plaque was the most common and macrophage accumulation was rarely observed. In donor-transmitted plaque, fibrous and fibroatheroma were independent predictor for the subsequent plaque progression. Serum interleukin-31 surge at subacute phase may play pathogenic role in cardiac allograft vasculopathy.

Funding Acknowledgement

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

(Hexafluoroacetylacetonato)copper(I)-cycloalkyne complexes as protected cycloalkynes

A protection method for cycloalkynes by the formation of (hexafluoroacetylacetonato)copper(i)-cycloalkyne complexes is disclosed. Various complexes having functional groups were efficiently prepared, which are easily purified by silica-gel column chromatography. Selective click reactions were realized through the complexation of cycloalkynes with copper.

Selective strain-promoted azide-alkyne cycloadditions through transient protection of bicyclo[6.1.0]nonynes with silver or gold

Complexation of bicyclo[6.1.0]nonynes with a cationic silver or gold salt results in protection from a click reaction with azides. The cycloalkyne protection using the silver or gold salt enables selective strain-promoted azide-alkyne cycloadditions of diynes keeping the bicyclo[6.1.0]nonyne moiety unreacted.

Synthesis of multisubstituted cycloalkenes through carbomagnesiation of strained cycloalkynes

An efficient synthetic method of seven- and six-membered cycloalkenes through the generation of strained cycloalkynes and following carbomagnesiation is described. Further bond formations of the resulting cycloalkenylmagnesium intermediates with a wide variety of electrophiles enabled us to prepare diverse cycloalkene derivatives including benzoxepine analogs having a fully substituted alkene structure.

Facile assembly of three cycloalkyne-modules onto a platform compound bearing thiophene S,S-dioxide moiety and two azido groups

An efficient method to assemble three cycloalkyne-modules onto a platform bearing a thiophene S,S-dioxide moiety and two azido groups has been developed. The sequential reactions without catalysis or additives enabled the facile preparation of trifunctional molecules by a simple procedure.

P4512Impact of pulmonary artery catheter on all-cause death of patients with acute heart failure with preserved ejection fraction: Short-term results from the PURSUIT-HFpEF registry

Background

Appropriate pulmonary artery catheter (PAC) use may effectively decrease mortality in acute heart failure patients. The concept that the pulmonary artery catheter (PAC) is a valuable tool for hemodynamic monitoring when used in appropriately selected patients and by physicians trained well to interpret and apply the data correctly provided has not been evaluated adequately yet in acute heart failure patients with preserved ejection fraction (HFpEF).

Methods

The PERSUIT-HFpEF Registry is a prospective, observational, multicenter cohort study on prognosis of HFpEF in Japan. Patients hospitalized for heart failure (diagnosed by using Framingham criteria) who met both of the following criteria were enrolled: 1) a left ventricular ejection fraction of 50% or more as measured at the local site by echocardiography; 2) an elevated level of N terminal pro brain natriuretic peptide (NT proBNP) (400 pg per milliliter or more) or brain natriuretic peptide (BNP) (100 pg per milliliter or more). In the present study, we evaluated the impact of PAC on all-cause death of the patients with HFpEF. PAC use was left at the discretion of attending physicians.

Results

The PERSUIT-HFpEF Registry enrolled 486 patients (81±9 years, 259 females, mean follow-up duration 198±195 days). Of these, data of PAC usage was available in 434 patients. Patients were further stratified according to use of a PAC: PAC 153 patients vs. non-PAC 281 patients. Length of hospitalization was numerically shorter in the PAC group than in the non-PAC group [20.3±14.7 vs. 22.5±17.4 days, p=0.182]. Kaplan-Meier estimated 1-year all-cause death rate was significantly lower in the PAC group than in the non-PAC group (9.5% vs. 19.1%, p=0.019). PAC use was associated with significant risk reduction of all-cause death [hazard ratio (HR) 0.425, 95% confidence interval (CI), 0.203–0.890, p=0.023] in the crude analysis. The significant risk reduction still existed after multivariate adjustment including potential confounders [HR 0.427, 95% CI, 0.185–0.984, p=0.046]

Kaplan Meier analysis

Conclusions

In the real-world Asian registry data, PAC use was associated with the improved all-cause death rate, suggesting that the PAC might be a useful guidance tool for treatment of the patients with HFpEF.

Acknowledgement/Funding

Roche diagnostics FUJIFILM Toyama Chemical

P321A single factor related to left atrial pressure overload is useful for prognosis in elderly patients with heart failure with preserved ejection fraction: PURSUIT HFpEF study

Background

E/e' and the ratio of diastolic elastance (Ed)/arterial elastance (Ea) = (E/e')/(0.9 × systolic blood pressure), indices of left atrial (LA) pressure overload, are elevated in elderly women with heart failure with preserved ejection fraction (HFpEF). The severity of diastolic dysfunction is assessed by a combination of several indices of LA volume and pressure overload. However, which overload is more important as a single factor for the prognosis of these patients remains undefined.

Methods

We enrolled patients with HFpEF showing sinus rhythm (n=145; left ventricular ejection fraction >50%; men/women, 56/89; mean age, 80.5 years). Blood examination and transthoracic echocardiography were performed before discharge. All-cause mortality and admission for cardiac events were evaluated after more than 1 year (mean, 370 days).

Results

The all-cause mortality rate was 11% (16/145). There were significant differences in age (p=0.005), serum N-terminal pro-brain natriuretic peptide (NT-proBNP) level (p<0.001), LA volume index (p=0.018), E/e' (p=0.022), and Ed/Ea (p=0.016) between patients with and without all-cause mortality. When cutoff points for mortality by receiver operating characteristic curve analysis were examined, the area under the curve in LA volume index (0.564) was slightly smaller than that in age (0.734), NT-proBNP level (0.732), E/e' (0.695), and Ed/Ea (0.709). Kaplan-Meier survival analysis clearly showed that age >85 years (p<0.001), NT-proBNP level >888 pg/mL (p=0.003), E/e' >14.4 (p=0.020), and Ed/Ea >0.153 (p<0.001) were determinant factors for mortality. Cox hazard ratios were also significant in these indices (p=0.002, p=0.012, p=0.028, and p=0.001, respectively). In the case of all-cause mortality or admission for cardiac events, the results were nearly similar as those in the case of all-cause mortality. Ed/Ea exhibited a larger Cox hazard ratio for prognosis than E/e' in the multivariate analysis.

Conclusions

LA pressure overload compared to volume overload was a useful marker for prognosis in elderly patients with HFpEF. As a single index for LA pressure overload in noninvasive echocardiographic findings, Ed/Ea may be more suitable than E/e'.

P786Plasma volume status is associated with the change in nutritional status during hospitalization in acute decompensated heart failure patients with preserved left ventricular ejection fraction

Introduction

Plasma volume (PV) expansion has an essential role in heart failure (HF). PV can be estimated by a simple formula using hematocrit and body weight, and PV status (PVS) provides prognostic information in patients (pts) with chronic HF. Nutritional status (NS) based on the prognostic nutritional index (PNI) and NS change during hospitalization have been shown to predict prognosis in pts admitted with acute decompensated HF (ADHF).

Purpose

We sought to assess the hypothesis that PVS is associated with NS change during hospitalization in pts with HF with preserved LVEF (HFpEF) who are admitted with ADHF.

Methods

We prospectively studied 411 pts who were admitted for ADHF with LVEF ≥50% and survived to discharge. Body weight measurement and venous blood sampling were performed on admission and at discharge. PVS was defined as follows: actual PV = (1 − hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females); and PVS = [(actual PV − ideal PV)/ideal PV] × 100 (%). PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (per mm3). The pts were divided into 3 groups by PNI: normal (>38), moderate malnutrition (35–38), and severe malnutrition (<35). During admission, pts who remained in the moderate or severe malnutrition group or whose NS worsened were defined as no improvement in NS. Follow-up data was obtained in 203 cases. They were followed for up to 18 months, and the incidence of all-cause death was evaluated.

Results

On admission, PVS in the moderate (n=71, 13.3±13.9%) or severe malnutrition group (n=69, 14.8±10.8%) was significantly higher than in the normal PNI group (n=271, 5.4±10.8%, p<0.001). During hospitalization, 123 pts had no NS improvement. Admission PVS was significantly higher in pts with no NS improvement than in pts with improved NS (13.9±11.2% vs 5.9±12.8%, p<0.0001). In multivariate logistic regression analysis, admission PVS was independently associated with no NS improvement during hospitalization (OR 1.06, 95% CI 1.03–1.08, p<0.0001). Receiver operating characteristics curve analysis revealed that the optimal cut-off value of admission PVS for predicting no NS improvement was 9.4% (sensitivity: 72%, specificity: 63%). The area under the curve for predicting no NS improvement using admission PVS was significantly greater than for other independent factors (Figure 1A). During the follow-up period (median 12.4 months), 68 of 203 patients had all-cause death. Kaplan-Meier analysis showed that the patients with no NS improvement had a significantly higher risk of all-cause death (Figure 1B).

Figure 1

Conclusions

In this multicenter study, admission PVS was shown to be associated with poor improvement in NS during hospitalization in HFpEF pts admitted for ADHF.

Acknowledgement/Funding

Roche diagnostics, FUJIFILM Toyama Chemical

P3575Clinical importance of fractional flow reserve in patients with organic coronary stenosis and vasospastic angina

Background

Vasospastic angina (VSA), which is one of the important functional cardiac disorders, may also play a role in the pathogenesis of atherosclerosis. Conversely, organic coronary stenosis is also known as an independent predictor for poor clinical outcomes in VSA patients. Although VSA patients have a variable degree of organic coronary stenosis in clinical setting, the functional importance of organic stenosis in those patients remains to be elucidated.

Purpose

The aim of this study was to examine the clinical importance and prognostic impact of fractional flow reserve (FFR) in patients with VSA and organic coronary stenosis.

Methods

We enrolled 236 consecutive patients with suspected vasospastic angina who underwent acetylcholine provocation test for coronary spasm (M/F 148/88, 63.6±12.0 [SD] yrs.). Among them, 175 patients (74.1%) were diagnosed as having VSA, while the remaining non-VSA patients were regarded as controls (Group-C, n=61). We divided the VSA patients into 3 groups based on angiographical findings and FFR values; VSA with no organic stenosis (>50% luminal stenosis) (Group-N, n=110), organic stenosis and high FFR (≥0.80) (Group-H, FFR 0.87±0.05, n=36), and organic stenosis and low FFR (<0.80) (Group-L, FFR 0.71±0.07, n=29). We evaluated the incidence of major adverse cardiovascular events (MACE), including cardiovascular death (CVD), non-fatal myocardial infarction (MI), urgent percutaneous coronary intervention (PCI), and hospitalization due to unstable angina pectoris (UAP) during the median follow-up period of 656 days.

Results

The groups with organic stenosis (Groups H and L) were characterized by higher prevalence of diabetes mellitus (Group-C/N/H/L, 23.0/20.9/44.4/34.5%, P=0.03) and dyslipidemia (Group-C/N/H/L, 37.7/39.1/50.0/65.5%, P=0.03) as compared with Group-C. After provocation test, all VSA patients received calcium channel blockers (CCBs). In addition, 20 days (median) after provocation test, 26 patients (92.9%) in Group-L underwent elective PCI with coronary stents, while no patient underwent PCI in Groups N or H. The incidence of MACE during follow-up was significantly higher in Group-L (Group-C/N/H/L; 1.6/3.6/5.6/27.6%, log-rank P<0.001), whereas clinical outcomes were comparable among the remaining 3 groups (Figure). Importantly, all 8 patients with MACE in Group-L had poor outcomes (CVD/MI/urgent PCI/UAP; 2/1/3/2) despite complete revascularization and the prevention of coronary spasm with CCBs, indicating that they might be resistant to standard contemporary therapies. They were characterized by less frequent use of angiotensin convert enzyme inhibitor (0 vs. 47.6%, P=0.02) and higher prevalence of multi-vessel organic lesions (37.5 vs. 4.8%, P=0.052) compared with those without MACE.

Figure 1

Conclusions

These results provide the first evidence that evaluation of coronary functional abnormalities with FFR is useful for making therapeutic strategies in VSA patients with organic coronary stenosis.

P5734The outcome of intra-aortic balloon pumping support for acute myocardial infarction with extracorporeal membrane oxygenation therapy

Background

It has been reported that intra-aortic balloon pumping (IABP) support for acute myocardial infarction (AMI) with cardiogenic shock did not reduce short and long-term mortality. However, the significance of IABP support for AMI patients with extracorporeal membrane oxygenation (ECMO) therapy remains unclear. The aim of this study was to investigate the effect of IABP support for the short and long-term outcome in AMI patients who received ECMO.

Methods

Using the database of the Osaka Acute Coronary Insufficiency Study (OACIS), 12,093 consecutive AMI patients were enrolled in this analysis. Among these, we analyzed 520 patients with ECMO. We classified the patients into two groups, patients who received IABP support [IABP group (n=460)] and patients who did not [no IABP group (n=60)]. Primary outcome was all-cause death.

Results

Study patients had following baseline clinical characteristics, age: 66.8±12.0 year old, male: 78.3%, diabetes mellitus: 41.0%, Killip class≥II: 66.2%, multi-vessel disease: 72.3%, peak creatine phosphokinase >3000IU/L: 68.1%. During a mean follow-up period of 349±625 days, Kaplan-Meier analysis revealed that the all-cause death was significantly lower in IABP group than no IABP group for 30-day (45.5% vs 72.7%, log-rank p<0.001) and long-term (66.2% vs 78.4%, Log rank p=0.005) follow-up period. Cox multivariate analysis revealed that IABP support was significantly associated with a reduced risk of mortality (Hazard ratio 0.445, 95% confidence interval 0.289 to 0.687, p<0.001).

Conclusions

IABP support for AMI patients with ECMO was significantly associated with reduced risks of the short and long-term mortality, suggesting that IABP support might contribute to improvement of the survival in AMI patients with ECMO.

P6356Comparisons of clinical outcomes in patients with heart failure with preserved ejection fraction with and without atrial fibrillation: results from a multicenter PURSUIT-HFpEF registry

Background

The presence of atrial fibrillation (AF) has been demonstrated to be associated with poor clinical outcomes in heart failure patients with reduced ejection fraction.

Objective

This study aimed to elucidate the impact of the presence of atrial fibrillation (AF) on the clinical characteristics, therapeutics, and outcomes in patients with heart failure and preserved ejection fraction (HFpEF).

Methods

PURSUIT-HFpEF is a multicenter prospective observational study including patients hospitalized for acute heart failure with left ventricular ejection fraction of >50%. Patients with acute coronary syndrome or severe valvular disease were excluded.

Results

Of 486 HFpEF patients (age, 80.8±9.0 years old; male, 47%) from 24 cardiovascular centers, 199 (41%) had AF on admission. Patients with AF had lower systolic blood pressures (142±27 vs. 155±35mmHg, p<0.0001) and higher heart rates (91±29 vs. 82±26bpm, p<0.0001) than those without. There was no difference in the usage of inotropes or mechanical ventilation between the 2 groups. A higher quality of life score (EQ5D, 0.72±0.27 vs. 0.63±0.30, p=0.002) was observed at discharge in patients with than without AF. In addition, AF patients tended to demonstrate lower in-hospital mortality rates (0.5% vs. 2.4%, p=0.09) and shorter hospital stays (20.3±12.1 vs. 22.6±18.4 days, p=0.09) than those without. During a mean follow up of 360±111 days, mortality (14.1% vs. 15.3) and heart failure re-hospitalization rates (13.1% vs. 13.9%) were comparable between the 2 groups.

Conclusion

In contrast to heart failure patients with reduced ejection fraction, AF on admission was not associated with poor long-term clinical outcomes among HFpEF patients. Several in-hospital outcomes were better in patients with AF than in those without.

Acknowledgement/Funding

None

P1649Prognostic significance of serum cholinesterase in patients with acute decompensated heart failure with preserved ejection fraction: insights from PURSUIT-HFpEF registry

Background

Comorbidities strongly influence the prognosis in heart failure with preserved ejection fraction (HFpEF). Malnutrition is one of the most important comorbidities among heart failure patients. Serum cholinesterase (CHE), one of the markers of malnutrition, was reported to be a prognostic factor in patients with chronic heart failure. In addition, we previously reported prognostic significance of CHE from a single center registry data of acute decompensated heart failure (ADHF). The aim of this study is to conduct external validation of the prognostic role of CHE using multi-center HFpEF registry.

Methods and results

Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals in Osaka recorded clinical, echocardiographic, and outcome data of patients with ADHF and preserved ejection fraction. Between June 2016 and January 2018, 381 patients were enrolled and we excluded patients without sufficient laboratory data and in-hospital death. Finally, we analyzed 204 patients with survival discharge. Laboratory data including CHE and echocardiography were obtained just before discharge. The endpoint of this study is the composite of all-cause death and worsening heart failure re-admission (cardiac event). During a follow up period of 0.92±0.37 years, 49 patients had cardiac event. CHE was significantly lower in patients with than without cardiac event (183±67 vs 223±71 U/L, p<0.0001). At multivariate Cox analysis, CHE (p=0.0020) was significantly associated with cardiac event, independently of NT-pro BNP after adjustment of age, sex, eGFR and hemoglobin. ROC curve analysis showed that AUC of CHE for the prediction of cardiac event was 0.706 (95% CI 0.638–0.768). Kaplan-Meier analysis showed that patients with low CHE (<211U/L defined by median) had a significantly greater risk of cardiac event (35% vs 13% p=0.0002).

Figure 1

Conclusion

Serum cholinesterase level is the useful prognostic marker for the prediction of cardiac event in patients with ADHF with preserved ejection fraction.

Acknowledgement/Funding

Roche diagnostics, FUJIFILM Toyama Chemical

P842Calculated plasma volume status provides additional prognostic value to global registry of acute coronary event (GRACE) score in patients with acute myocardial infarction

Background

Plasma volume status (PVS) has been shown to be a well-validated prognostic indicator which relate to morbidity and mortality in heart failure. However, it remains unclear whether PVS would have the prognostic significance in patients with acute myocardial infarction (AMI). Global Registry of Acute Coronary Events (GRACE) risk score is a powerful predictor of prognosis after acute coronary event, but there is no information available on the additional prognostic value of PVS to GRACE in AMI patients.

Methods

We retrospectively studied 3930 AMI patients. GRACE score and PVS was obtained on the admission. PVS was calculated as follows: actual PV = (1 - hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females); and PVS = [(actual PV - ideal PV)/ideal PV] × 100 (%). The endpoint was All cause of death (ACD) within 5 years.

Results

During a mean follow-up period of 2.4±1.9 years, 406 patients had ACD. PVS was significantly greater in patients with ACD than without ACD (8.1±14.9% vs −1.7±13.3%, p<0.001). Each 5% increase in PVS was linked to a 27% estimated risk of 5-year mortality (p<0.001, HR: 1.05 [1.03–1.08]). PVS was still independently associated with ACD, after adjustment with GRACE score as a potential confounding factor. Kaplan-Meier analysis revealed that patients with PV expansion (PVS>0%) were significantly higher risk of ACD than those without PV expansion in patients both with high risk in GRACE score (>140) (28% (225/803) vs 19% (78/412), p=0.01, HR: 7.5) and with low risk in GRACE score (≤140) (6% (52/894) vs 3% (51/1821), p=0.009, HR: 6.2).

Survival rate curves

Conclusion

PVS, which represents intravascular compartment and congestion, could identify poor prognosis in patients with AMI. In addition, PVS would provide additional prognostic information to GRACE score.

128Change in geriatric nutritional risk index predicts one-year mortality in patients with heart failure with preserved ejection fraction

Background

Malnutrition is associated with adverse prognosis in heart failure patients. However, in patients with heart failure with preserved ejection fraction (HFpEF), the effects of change in nutritional status during hospitalization on prognosis is unknown. Geriatric nutritional risk index (GNRI) is a widely used objective index for evaluating nutritional status. Low GNRI (<92) has moderate or severe nutritional risk and high GNRI (≥92) has no or low nutritional risk.

Purpose

The purpose of this study was to clarify the effect of change in GNRI during hospitalization on one-year mortality and the association between the value of GNRI and one-year mortality in patients with HFpEF.

Methods

We prospectively registered patients with HFpEF in PURSUIT-HFpEF registry when they were hospitalized for heart failure in 29 hospitals. Preserved ejection fraction was defined as more than 50% of left ventricular ejection fraction. Of the 486 patients who registered PURSUIT-HFpEF, 228 cases with one-year follow-up data were examined. GNRI was calculated as follows: 14.89 × serum albumin (g/dl) + 41.7 × body mass index/22.

Results

Mean age was 81±10 years and 100 patients (44%) were male. During a median [interquartile range] follow-up period of 374 [342, 400] days, 28 patients (12%) died. Mortality was significantly higher in patients with low GNRI at admission (n=65) than those with high GNRI at admission (n=163) (26% vs. 9%, log-rank P=0.011) and higher in patients with low GNRI at discharge (n=109) than those with high GNRI at discharge (n=119) (22% vs. 6%, log-rank P=0.002). Multivariate analysis with Cox proportional hazard model with patient characteristics at admission revealed that low GNRI at admission was independently associated with mortality (hazard ratio: 0.96, 95% CI: 0.93–0.99, P=0.035) and that with patient characteristics at discharge revealed that low GNRI at discharge was independently associated with mortality (hazard ratio: 0.94, 95% CI: 0.91–0.97, P<0.001). We also compared mortality by dividing patients into 4 group according to whether GNRI was high or low at the time of admission and discharge. Patients with low GNRI at admission and at discharge (n=59) exhibited the highest mortality, on the other hand, patients with high GNRI at admission and low GNRI at discharge (n=50) exhibited higher mortality than those with high GNRI both at admission and at discharge (n=113) (Low and low: 28% vs. High and low: 14% vs. High and high: 6% vs. Low and high: 0%, log-rank P=0.010).

All cause mortality

Conclusion

GNRI at admission or at discharge was independently associated with one-year mortality in patients with HFpEF. Moreover, worsening GNRI during hospitalization is associated with the worse prognosis. It is important to prevent lowering GNRI during treatment of acute decompensated HFpEF.

Acknowledgement/Funding

Roche Diagnostics, FUJIFILM Toyama Chemical

P5605The impact of institutional case volume on the Ppognosis of ruptured aortic aneurysms: a Japanese nationwide study

Background

To improve outcome for ruptured aortic aneurysms (rAA), centralization of treatment is potentially effective. However, there is no nationwide survey for the current managements and outcomes of rAA in Japan.

Purpose

The aim of this study was to assess the volume-outcome relationship for rAA treatment using the nationwide claim-based database.

Methods

Using the Japanese Registry Of All cardiac and vascular Diseases- Diagnostic Procedure Combination database, we identified patients admitted to 564 certified teaching-hospitals with rAA between April 1, 2012 and March 31, 2015. Institutional case volume (cardiovascular surgeries per year) was categorized into quartiles (Lowest, Low, High, and Highest) and the odds ratios (ORs) for in-hospital mortality and neurological status at discharge were analyzed for each quartile.

Results

Of 7086 eligible patients, 3925 (55.4%) died in hospital. Mortality rates decreased from 69.4% in the lowest-volume to 43.8% in the highest-volume category (P<0.001). The favourable impact of institutional case volume was sustained even after adjustment for covariates (Low-volume: OR, 0.83; 95% confidence interval [CI], 0.65–1.07; P=0.147; High-volume: OR, 0.69; 95% CI, 0.54–0.89; P=0.005; and Highest-volume: OR, 0.55; 95% CI, 0.42–0.72; P<0.001 vs. Lowest-volume). Additionally, other three institutional parameters (increased aortic surgery volume, cardiovascular surgeons' volume, and certified cardiologists' volume) were consistently associated with reduced in-hospital mortality. The rate of coma at discharge was the lowest in the Highest-volume group (P<0.001).

Institutional volume and mortality

Conclusions

Increased institutional volume was associated with lower in-hospital mortality. Establishing regionally tailored systems to transfer patients to high-volume centers is needed to improve outcomes.