P1528 Prognostic impact of pulmonary arterial wave reflection in heart failure

Background

Pulmonary hypertension (PH) is prevalent and is associated with adverse outcomes in heart failure. The pathophysiology of PH is heterogeneous, including pre-capillary PH and combined pre- and post-capillary PH. The latter PH has been reported in experimental studies to cause wave reflection in pulmonary circulation, putting additional burden on right ventricle. This study tested the hypothesis that separating wave reflection would enhance risk stratification in heart failure.

Methods

This study included 152 patients with clinical stable heart failure associated with PH who were referred to echocardiography for hemodynamic assessment (age = 72 ± 13 years old, ejection fraction = 49 ± 21%). Pulmonary arterial wave reflection was characterised by separating PA pressure waveform into forward (Pf) and backward pressure (Pb) waves, based on the concept of wave intensity. PA pressure waveform was estimated from continuous Doppler tracing of tricuspid regurgitation. Flow velocity was measured by pulse Doppler at right ventricular outflow tract. Outcome data was obtained by reviewing medical charts. The endpoint was hospitalization for worsening heart failure (WHF).

Results

Figure A compares PA pressure waveforms (total and separated waves) obtained from 2 patients with and without WHF event. The patient with event had higher total pressure associated with late peak than the patient without event. Pb appeared later than Pf; it was markedly higher in the patient with event than the patient without event, although Pf was similar between both patients. Kaplan-Meier analysis demonstrated a significant separation of survival curves stratified by Pb (chi-square = 25.1, p < 0.001, figure B). During follow-up period of 1.5 ± 1.8 years, 65 patients (43%) experienced the endpoint. Sequential Cox analysis revealed that PASP remained significant after adjusted for left ventricular ejection fraction and E/e’ (hazard ratio = 1.017, p = 0.019). Pb also remained significant after the same adjustment (hazard ratio = 1.066, p = 0.003); the addition of Pb to a baseline model resulted in greater increase in predictive power than the addition of PASP (model chi-square: from 27.4 (baseline), to 37.6 (p = 0.004) for Pb, to 31.6 (p = 0.027) for PASP, figure C)

Conclusions

Pressure wave reflection in pulmonary artery is associated with early decompensation in heart failure.

Abstract P1528 Figure.

P289 Aortic valve resistance risk-stratifies low-gradient aortic stenosis

Background

Grading the severity of aortic stenosis (AS) is challenging, since there is a discrepancy between aortic valve area (AVA) and mean pressure gradient (mPG). Arotic valve resistance (RES) has been proposed as a usuful descriptor of AS severity, but it is not commonly used for clinical decision-making, because its robust validation of clinical-outcome efficacy is lacking. This study aimed to investigate whether RES holds an incremental value for risk-stratifying AS.

Methods

This study recuited 565 AS patients (AVA < 1.5cm²) referred to echocardiography for valve assessment. The patients were divided into three different groups, according to the guidelines: high-gradient AS (HG-AS, mPG≥40mmHg, n = 157), low-gradient AS (LG-AS, mPG < 40mmHg + AVA ≤ 1.0cm², n = 155) and moderate AS (Mod-AS, mPG < 40mmHg + AVA > 1.0cm², n = 253). RES was calculated from Doppler measurement of mPG and stoke volume. The diagnositic cutoff point for RES was determined at 190 dynes × s×cm-5 by substituting AVA = 1.0cm² and mPG = 40mmHg into the definition formula of RES and Gorlin formula. The patients were followed up for 2 years. The endpoint was a composite of cardiac death, hospitalization for heart failure and aortic valve replacement necessitated by the development of AS-related symptoms.

Result

Kaplan-Meier analyses showed that LG-AS exhibited an intermediate outcome between HG-AS and Mod-AS (event-free survival at 2 years = 20.9% for HG-AS, 59.7% for LG-AS, 89.9% for Mod-AS, p < 0.001, figure A). When LG-AS was stratified by RES, the survival curves showed a significant separation (event-free survival at 2 years = 35.3% for high RES, 70.7% for low RES, p < 0.001, figure B). This trend persisted even when analysed separately for norml (stroke volume index > 35ml/m²) and low (stroke volume index ≤ 35ml/m²) flow state ((normal flow) event-free survival at 2 years = 38.7% for high RES, 70.4% for low RES, p = 0.023, figure C; (low flow) event-free survival at 2 years = 26.7% for high RES, 74.6% for low RES, p < 0.001, figure D).

Conclusion

This study confirmed the clinical efficacy of RES for risk-stratifying LG-AS patients.

Abstract P289 Figure.

P893 Left ventricular flow energetics predicts worsening heart failure in dilated cardiomyopathy

Background

Blood flows through healthy hearts form optimal flow structures; they store flow kinetic energy (KE) that can be used for ejection. In contrast, in failing hearts, intracardiac flows become disorganized so that they may be energetically inefficient. However, it remained unknown whether left ventricular (LV) flow energetics prognosticates in heart failure.

Methods

This study included 61 patients with dilated cardiomyopathy (DCM). The temporal change in KE during early diastole (ED), atrial contraction (AC) and isovolumic contraction (IVC) was measured using Vector Flow Mapping particle tracking (Hitachi, figure top). LV inflow (total flow) were divided, based on whether they were ejected (direct flow, DF) or stayed in LV (retained flow, RF) in the following systole. KE of DF can be made use of for ejection, whereas KE of RF is supposed to be wasted. Diastolic function was graded, according to current EACVI/ASE guidelines. The patients were followed up for three years. Primary endpoint was hospitalization for worsening heart failure (WHF).

Results

12 patients had hospitalizations for WHF in the follow-up period. KE of total flow did not show any significant difference through the cardiac cycle between patients with and without WHF. KE of DF was slightly, but not significantly, smaller (ED: p = 0.252, AC: p = 0.119, IVC: p = 0.122), and KE of RF was slightly, but not significantly, larger (ED: p = 0.971, AC: p = 0.085, IVC: p = 0.134) in patients with WHF than those without events. The ratio of DF and RF (DF/RF ratio) showed significant differences between these two groups, especially from AC through IVC (figure, bottom-left). Cox proportional hazard analyses demonstrated that DF/RF ratio during IVC showed a significant correlation with clinical outcomes (p = 0.033, hazard ratio = 0.067). It remained significant even after adjusted for diastolic function grade (p = 0.046, hazard ratio = 0.074). Kaplan-Meier analysis confirmed the above results (figure, bottom-right). Conclusion: Efficiency of KE recruitment for LV ejection during IVC is associated with clinical outcomes in DCM.

Abstract P893 Figure. LISA

Recurrent hyperactive ESR1 fusion proteins in endocrine therapy-resistant breast cancer

Background

Estrogen receptor-positive (ER-positive) metastatic breast cancer is often intractable due to endocrine therapy resistance. Although ESR1 promoter switching events have been associated with endocrine-therapy resistance, recurrent ESR1 fusion proteins have yet to be identified in advanced breast cancer.

Patients and methods

To identify genomic structural rearrangements (REs) including gene fusions in acquired resistance, we undertook a multimodal sequencing effort in three breast cancer patient cohorts: (i) mate-pair and/or RNAseq in 6 patient-matched primary-metastatic tumors and 51 metastases, (ii) high coverage (>500×) comprehensive genomic profiling of 287-395 cancer-related genes across 9542 solid tumors (5216 from metastatic disease), and (iii) ultra-high coverage (>5000×) genomic profiling of 62 cancer-related genes in 254 ctDNA samples. In addition to traditional gene fusion detection methods (i.e. discordant reads, split reads), ESR1 REs were detected from targeted sequencing data by applying a novel algorithm (copyshift) that identifies major copy number shifts at rearrangement hotspots.

Results

We identify 88 ESR1 REs across 83 unique patients with direct confirmation of 9 ESR1 fusion proteins (including 2 via immunoblot). ESR1 REs are highly enriched in ER-positive, metastatic disease and co-occur with known ESR1 missense alterations, suggestive of polyclonal resistance. Importantly, all fusions result from a breakpoint in or near ESR1 intron 6 and therefore lack an intact ligand binding domain (LBD). In vitro characterization of three fusions reveals ligand-independence and hyperactivity dependent upon the 3' partner gene. Our lower-bound estimate of ESR1 fusions is at least 1% of metastatic solid breast cancers, the prevalence in ctDNA is at least 10× enriched. We postulate this enrichment may represent secondary resistance to more aggressive endocrine therapies applied to patients with ESR1 LBD missense alterations.

Conclusions

Collectively, these data indicate that N-terminal ESR1 fusions involving exons 6-7 are a recurrent driver of endocrine therapy resistance and are impervious to ER-targeted therapies.

The effect of low body mass index on the development of chronic obstructive pulmonary disease and mortality

BACKGROUND

Sarcopenia may worsen disease progression and lead to poor outcomes in chronic obstructive pulmonary disease (COPD).

OBJECTIVES

We aimed to determine the effect of BMI on the development of COPD and mortality.

METHODS

We enrolled 437 584 participants registered in the physical health check-up cohort database of the Korean National Health Interview Survey from 2002 to 2003, and we defined COPD diagnosis based on the ICD-10 code and prescribed medication. BMI (kg m^-2 ) classified them to five groups (low BMI < 18.5, normal BMI 18.5-23, overweight 23-25, obesity 25-30, severe obesity ≥30) at baseline.

RESULTS

Participants in the low BMI group had a significantly higher rate of COPD development for 13 years (7.6%) than those in other groups (3.4-4.1%, P < 0.0001). Amongst never or light smokers, COPD development in the low BMI group (5.6-6.7%) was significantly higher than that in other groups (2.8-4.7%). Similarly, amongst participants with a smoking history of ≥30 years, COPD development in the low BMI group (20.1%) was higher than those in other groups (8.4-12.4%). On multivariable analysis, normal or higher than normal body weight was significantly protective against the development of COPD (hazard ratio [HR], 0.609-0.739,) compared to low BMI. COPD-free-survival (HR, 0.491-0.622) and overall survival (HR, 0.440-0.585) were also better in them compared to those with low BMI (all P < 0.0001).

CONCLUSIONS

Low BMI is an important risk factor for COPD development and mortality. Maintaining adequate body weight may reduce the risk for COPD development and mortality.

Effect of carvacrol essential oils on immune response and inflammation-related genes expression in broilers challenged by lipopolysaccharide

This experiment was conducted to study the effects of orally administered carvacrol essential oils on immune response and inflammation-related genes expression in broilers challenged by lipopolysaccharide (LPS). Eighty 28-day-old (1.28 ± 0.15 kg) ROSS 308 broilers were assigned to a 2 × 2 factorial arrangement of treatments (20 pens of 1 chick/trt). Factors were carvacrol essential oil (orally administered or non-orally administered) and LPS (challenged or non-challenged). Individually housed broilers were randomly assigned (n = 20 broilers per treatment: 10 males and 10 females) to four treatments: (1) basic diet (CTR), (2) basic diet + carvacrol (CAR), (3) basic diet + LPS-challenge (LPS), (4) basic diet + carvacrol + LPS-challenge (CAR+LPS). All were fed with the same diet. The experimental period was for 15 d, after which injecting LPS significantly up-regulated the gene expression levels of TNF-α (P < 0.05), IL-1β (P < 0.05), IL-6 (P < 0.05), IL-8 (P < 0.05), TLR2 (P < 0.05), TLR4 (P < 0.05), NF-κB p65 (P < 0.05), AVBD-9 (P < 0.05), and SIgA(P < 0.05) compared with the CTR group; the broilers were challenged by LPS after oral administration of carvacrol, they had significant lower on the gene expression levels of TNF-α (P < 0.05), IL-1β (P < 0.05), IL-6 (P < 0.05), TLR4 (P < 0.05), NF-κB p65 (P < 0.05), and AVBD-9 (P < 0.05) than the LPS group. In conclusion, the broilers orally administrated carvacrol essential oils inhibited the secretion of inflammatory cytokines caused by LPS, affected the pathway of TLRs/NF-κB, and showed an anti-inflammatory function.