Coronary arteritis: a case series

Background

The present article describes two cases of patients with coronary arteritis (CA) whose identification of CA diagnosis (late vs. early) resulted in different clinical courses and outcomes.

Case summary

Case 1 is a 53-year-old woman with multiple coronary risk factors who was admitted with acute coronary syndrome (ACS) and significant stenosis in the left main trunk (LMT). Although clues suggested arteritis (LMT lesion without any other stenosis, occlusion of left internal thoracic artery, etc.), the diagnosis of CA (coronary involvement of unclassified arteritis) was delayed and revascularization, including coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), was performed under uncontrolled inflammatory status. As a result, Case 1 experienced repeated ACS episodes due to graft failure and in-stent restenosis, and repeatedly underwent PCI. Case 2 is a 76-year-old woman with no significant coronary risk factors who was admitted with ACS. This patient was successfully diagnosed with coronary involvement of Takayasu arteritis before revascularization. Coronary artery bypass grafting was performed after stabilizing inflammation with prednisolone, and the patient remains angina-free beyond 1-year post-CABG. In both cases, intravascular imaging clearly identified the localization and degree of inflammation related to CA by demonstrating specific findings (ambiguous typical three-layer structure of arterial wall and extended low-echoic areas within adventitia).

Discussion

Accurate and early diagnosis with meticulous diagnostic and therapeutic strategies appear to be important for favourable clinical outcomes in the medical treatment of patients with coronary involvement of arteritis. Intravascular imaging has the potential to contribute to optimizing clinical management of CA.

Utility of synthetic MRI in predicting the Ki-67 status of oestrogen receptor-positive breast cancer: a feasibility study

AIM

To evaluate the utility of synthetic magnetic resonance imaging (MRI) of the breast in predicting the Ki-67 status in patients with oestrogen receptor (ER)-positive breast cancer.

MATERIALS AND METHODS

Forty-nine patients with 50 histopathologically proven breast cancers who underwent additional synthetic MRI were enrolled in the present study. Using synthetic MRI images, T1 and T2 relaxation times and their standard deviations (SD) in the breast lesions before (T1-Pre, T2-Pre, PD-Pre, SD of T1-Pre, SD of T2-Pre, SD of PD-Pre) and after (T1-Gd, T2-Gd, PD-Gd, SD of T1-Gd, SD of T2-Gd, SD of PD-Gd) contrast agent injection were obtained. These quantitative values were compared between the low Ki-67 expression (<14%) lesions (low-proliferation group: n=23) and high Ki-67 expression (≥14%) lesions (high-proliferation group: n=27).

RESULTS

The univariate analysis showed that the SD of T1-Gd (p<0.001) and T2-Gd (p=0.042) were significantly higher in the high-proliferation group than in the low-proliferation group. Multivariate analysis further showed that the SD of T1-Gd was a significant and independent predictor of Ki-67 expression, with an area under the receiver operating characteristic (AUROC) curve of 0.885. The sensitivity, specificity, and accuracy of the SD of T1-Gd with an optimal cut-off value of 98.5 were 77.8%, 87%, and 82%, respectively.

CONCLUSION

The SD of T1-Gd obtained from synthetic MRI was useful to predict Ki-67 status.

P295 Impact of Pre-existing Mitral Regurgitation on the Mid-Term Left Ventricular Mass Regression following Transcatheter Aortic Valve Implantation for Aortic Valve Stenosis

Background

Transcatheter aortic valve implantation (TAVI) results in an immediate and greater aortic pressure gradient improvement in patients with severe aortic valve stenosis (AS), and induces early left ventricular (LV) mass regression, which may be related to favorable effects on the mid to long term outcomes. However, the extent of LV mass regression after unloading of chronic pressure overload is varying, and its determinants are still unknown. Thus, the study aims to identify echocardiographic determinants of LV mass regression following TAVI.

Methods

We retrospectively screened all TAVI procedures in symptomatic AS from 2017 to 2019, and selected 74 successful TAVI cases that had serial echocardiographic studies both at the baseline and at the mid-term follow-up (4 to 6 months after the procedure). Through the digitalized medical records, clinical and echocardiographic data as well as angiographic grading (0-3) of post-procedure paravalvular leakage (PVL) were obtained. LV mass was calculated by using Cube formula. Thus, the extent of LV mass regression was defined as the differences of left ventricular mas index (LVMI) between at the baseline and at the follow-up (ΔLVMI). Quantification of the baseline mitral valve regurgitant volume was performed by stroke volume method with pulmonic site measurement on the assumption of no pre-existing intra/extra cardiac shunt. Cases with prior mitral valve replacement were excluded.

Results

At the post-procedure angiogram, only 3 cases had significant PVL (grade 2≤). At the mid-term follow–up, average LVMI decreased significantly from the baseline (165 ± 38 g/m2vs 140 ± 37 mg/ m2, P &lt; 0.0001) and 57 cases (70%) experienced the reduction of LVMI, although average relative wall thickness (2 × posterior wall thickness/left ventricular diastolic dimension) did not change (0.565 ± 0.135 vs 0.586 ± 0.168, P = 0.314). Among the baseline clinical and echocardiographic variables, the baseline peak A wave velocity, E/A ratio, mitral valve regurgitant volume and LVMI revealed simple correlation with ΔLVMI (γ=-0.298, p = 0.0188;γ=0.251, P = 0.0417;γ=0.354, p = 0.0041;γ=0.375, p &lt; 0.0010; respectively), whereas no correlation was observed in angiographic PVL grade. Stepwise multiple regression analysis demonstrated baseline mitral valve regurgitant volume and LVMI as the determinants of ΔLVMI (β=0.344, p = 0.032; β=0.335 P &lt; 0.0001; respectively).

Conclusions

Pre-existing mitral regurgitation has an impact on the mid–term left ventricular mass regression following TAVI. In severe AS, mitral regurgitation might be functioning as an afterload adjuster, and thus, produces protective effects on LV structure.

Impact of Cardio-Ankle Vascular Index on Long-Term Outcome in Patients with Acute Coronary Syndrome

Aim: The purpose of this study is to investigate the impact of arterial stiffness assessed using Cardio-ankle Vascular Index (CAVI) on long-term outcome after acute coronary syndrome (ACS).

Methods: A total of 387 consecutive patients (324 males; age, 64 ± 11 years) with ACS were enrolled. We examined CAVI and brachial-ankle pulse wave velocity (ba PWV) as the parameters of arterial stiffness. The patients were divided into two groups according to the cut-off value of CAVI determined using the receiver operating characteristic curve for the prediction of major adverse cardiovascular events (MACE): low-CAVI group, 177 patients with CAVI < 8.35; high-CAVI group, 210 patients with CAVI ≥ 8.35. The primary endpoint was the incidence of MACE (cardiovascular death, recurrence of ACS, heart failure requiring hospitalization, or stroke).

Results: A total of 62 patients had MACE. Kaplan-Meier analysis demonstrated a significantly higher probability of MACE in the high-CAVI group than in the low-CAVI group (median follow-up: 62 months; log-rank, p < 0.001). Multivariate analysis suggested that CAVI was an independent predictor of MACE (hazard ratio [HR], 1.496; p = 0.02) and cardiovascular death (HR, 2.204; p = 0.025), but ba PWV was not. We investigated the incremental predictive value of adding CAVI to the GRACE score (GRS), a validated scoring system for risk assessment in ACS. Stratified by CAVI and GRS, a significantly higher rate of MACE was seen in patients with both higher CAVI and higher GRS than the other groups (p < 0.001). Furthermore, the addition of CAVI to GRS enhanced net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI, 0.337, p = 0.034; and IDI, 0.028, p = 0.004).

Conclusion: CAVI was an independent long-term predictor of MACE, especially cardiovascular death, adding incremental clinical significance for risk stratification in patients with ACS.

P5483Prognostic impact of skeletal muscle, fat, and bone mass in male patients with ST-segment elevation myocardial infarction

Introduction

Muscle, fat and bone mass may play some roles to keep physical activity and favorable outcome in patients with cardiovascular diseases. However, there is a paucity of data regarding the effects on the prognosis of skeletal muscle, fat, and bone mass in patients with ST-segment elevation myocardial infarction (STEMI).

Purpose

Our purpose was to examine whether skeletal muscle, fat, and bone mass each affect the prognosis after STEMI.

Methods

A total of 354 male patients with STEMI were enrolled in this study. Dual-energy X-ray absorptiometry scan was performed before discharge. All patients were followed up for the primary composite outcome of all-cause death, nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for congestive heart failure, and unplanned revascularization.

Results

During a median follow-up of 32 months, 57 patients experienced primary composite outcome. Each of skeletal muscle, fat, and bone mass were indexed by height squared (kg/m2) and divided into two groups using the cut-off value obtained from the maximum Youden index to predict the primary composite outcome. The event rate was significantly higher in patients with low appendicular skeletal muscle mass index (ASMI) (29.2% vs 11.7%, p<0.001), low fat mass index (FMI) (22.9% vs 13.3%, p=0.030), and low bone mass index (23.8% vs 11.6%, p=0.002). After adjustment for age, renal function, diabetes mellitus, infarct size, Killip classification, and body mass index, low ASMI but not FMI (p=0.150) and bone mass index (p=0.159) was independently and significantly associated with the primary composite outcome (adjusted hazard ratio 2.12, 95%-confidence interval 1.05–4.31, p=0.035).

Conclusions

Index about muscle mass rather than fat and bone mass have prognostic impact in male patients with STEMI.

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.

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

P2657Prognostic impact of skeletal muscle mass in upper and lower extremities in patients with ST-segment elevation myocardial infarction

Introduction

Sarcopenia, characterized by the loss of skeletal muscle mass and muscle strength, has been demonstrated the importance in cardiovascular diseases including ST-segment elevation myocardial infarction (STEMI). However, there is few data comparing the effects on the prognosis of skeletal muscle mass of upper and lower extremities in STEMI patients.

Purpose

Our purpose was to examine whether skeletal muscle mass of upper and lower extremities affect the prognosis after STEMI.

Methods

A total of 432 patients with STEMI were enrolled in this study. Dual-energy X-ray absorptiometry scan was performed before discharge. Each of upper and lower extremity skeletal muscle masses was indexed by height squared (kg/m2), and divided into two groups using the first quartile value for each sex. All patients were followed up for the primary composite outcome of all-cause death, nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for congestive heart failure, and unplanned revascularization.

Results

During a median follow-up of 32 months, 68 patients experienced primary composite outcome. The event rate was significantly higher in patients with low-lower extremity skeletal muscle mass index (LESMI) than in those with high-LESMI (24.3% vs 12.9%, log-rank p<0.001), as well as in those with low-upper extremity muscle mass index than in those with high-upper extremity muscle mass index (UESMI) (19.6% vs 14.5%, log-rank p=0.047). However, after adjustment for age, gender, renal function, diabetes mellitus, infarct size, body mass index, and body fat percentage, only low-LESMI was independently and significantly associated with the primary composite outcome (adjusted hazard ratio for LESMI 2.11, 95%-confidence interval 1.06–4.14, p=0.034, adjusted hazard ratio for UESMI 1.04, 95%-confidence interval 0.52–2.08, p=0.906,).

Conclusions

Decreased muscle mass of lower extremity, rather than upper extremity, might have prognostic impact in patients with STEMI.

Urgent Control of Rapid Atrial Fibrillation by Landiolol in Patients With Acute Decompensated Heart Failure With Severely Reduced Ejection Fraction

Background: We investigated the clinical usefulness of landiolol for rapid atrial fibrillation (AF) in patients with acute decompensated heart failure (ADHF) and identify the patients eligible for landiolol.

Methods and Results: A total of 101 ADHF patients with reduced ejection fraction (HFrEF) with rapid AF were enrolled. Immediately after admission, an initial dose of landiolol was given (1 μg/kg⁻¹/min⁻¹), and then the dose was increased to decrease heart rate (HR) to <110 beats/min and change HR (∆HR) >20% in ≤24 h. Thirty-seven were monitored using right heart catheterization at 3 points (baseline, 1 μg/kg⁻¹/min⁻¹, and maximum dose). We checked the major adverse events (MAE) during initial hospitalization, which included cardiac death, HF prolongation (required i.v. treatment at 30 days), and worsening renal function. The average maximum dose of landiolol was 3.8±2.3 μg/kg⁻¹/min⁻¹. HR (P<0.0001) and pulmonary capillary wedge pressure (P=0.0008) decreased safely. MAE occurred in 39 patients. The patients with left ventricular (LV) end-diastolic volume index <84.0 mL/m² and mean blood pressure (mean BP) >97 mmHg had less frequent MAE (P<0.0001).

Conclusions: Landiolol was effective for safely controlling rapid AF in patients with HFrEF with ADHF, leading to hemodynamic improvement and avoidance of short-term MAE, especially in patients with relatively smaller LV and higher BP.

Visualization and quantification of anastomotic perfusion in colorectal surgery using near-infrared fluorescence

BACKGROUND

Anastomotic leakage (AL) is one of the most troublesome complications in colorectal surgery. Recently, near-infrared fluorescence (NIRF) imaging has been used intraoperatively to detect sentinel lymph nodes and visualize the blood supply at the region of interest (ROI). The aim of this study was to evaluate the role of visualization and quantification of bowel perfusion around the anastomosis using NIRF system in predicting AL.

METHODS

A prospective study was conducted on patients who had laparoscopic surgery for colorectal cancer at our institution. Perfusion of the anastomosis was evaluated with NIRF imaging after intravenous injection of indocyanine green (ICG). The time course of fluorescence intensity was recorded by an imaging analyzer We measured the time from ICG injection to the beginning of fluorescence (T₀), maximum intensity (I_max), time to reach I_max (T_max), time to reach I_max 50% ([Formula: see text]) and slope (S) after the anastomosis.

RESULTS

Tumor locations were as follows; cecum: 2, ascending colon: 2, transverse colon: 7, descending colon: 1, sigmoid colon: 2, rectosigmoid colon: 3 and rectum: 6 (one case with synchronous cancer). All operations were performed laparoscopically. Four patients were diagnosed with or suspected to have AL (2 patients with grade B anastomotic leakage after low anterior resection, 1 patient with minor leakage in transverse colon resection and 1 patient needing re-anastomosis intraoperatively in transverse colon resection). T₀ was significantly longer in the AL group than in patients without AL (64.3 ± 27.6 and 18.2 ± 6.6 s, p = 2.2 × 10^-3).

CONCLUSIONS

Perfusion of the anastomosis could be successfully visualized and quantified using NIRF imaging with ICG. T₀ might be a useful parameter for prediction of AL.

Microbiota-derived Trimethylamine N-oxide Predicts Cardiovascular Risk After STEMI

Trimethylamine N-oxide (TMAO), a metabolite derived from the gut microbiota, is proatherogenic and associated with cardiovascular events. However, the change in TMAO with secondary prevention therapies for ST-segment elevation acute myocardial infarction (STEMI) remains unclear. The purpose of this study was to investigate the sequential change in TMAO levels in response to the current secondary prevention therapies in patients with STEMI and the clinical impact of TMAO levels on cardiovascular events We included 112 STEMI patients and measured plasma TMAO levels at the onset of STEMI and 10 months later (chronic phase). After the chronic-phase assessment, patients were followed up for cardiovascular events. Plasma TMAO levels significantly increased from the acute phase to the chronic phase of STEMI (median: 5.63 to 6.76 μM, P = 0.048). During a median period of 5.4 years, 17 patients experienced events. The chronic-phase TMAO level independently predicted future cardiovascular events (adjusted hazard ratio for 0.1 increase in log chronic-phase TMAO level: 1.343, 95% confidence interval 1.122–1.636, P = 0.001), but the acute-phase TMAO level did not. This study demonstrated the clinical importance of the chronic-phase TMAO levels on future cardiovascular events in patients after STEMI.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Peak systolic velocity ratio derived from quantitative vessel analysis for restenosis after femoropopliteal intervention: a multidisciplinary review from Endovascular Asia

With technological improvements in the endovascular armamentarium, there have been tremendous advances in catheter-based femoropopliteal artery intervention during the last decade. However, standardization of the methodology for assessing outcomes has been underappreciated, and unvalidated peak systolic velocity ratios (PSVRs) of 2.0, 2.4, and 2.5 on duplex ultrasonography have been arbitrarily but routinely used for assessing restenosis. Quantitative vessel analysis (QVA) is a widely accepted method to identify restenosis in a broad spectrum of cardiovascular interventions, and PSVR needs to be validated by QVA. This multidisciplinary review is intended to disseminate the importance of QVA and a validated PSVR based on QVA for binary restenosis in contemporary femoropopliteal intervention.