Atrophic change of the abdominal rectus muscle significantly influences the onset of parastomal hernias beyond existing risk factors after end colostomy

PURPOSE

To investigate optimal risk factors, including atrophy of the abdominal rectus muscle (ARM) for postoperative parastomal hernia (PH) in patients who underwent end colostomy at left lower quadrant.

METHODS

This single-institution retrospective study included 91 patients who underwent end colostomy between April 2004 and December 2015. The surgical and long-term outcomes among patients with or without PH were collected and compared.

RESULTS

Altogether, 22 (24.2%) patients had a PH including 15 (68.2%) patients with a simultaneous incisional hernia. Univariate analysis showed that older patients (71 ± 11.9 vs. 64 ± 12.2 years, p = 0.03) and those with higher body mass index (BMI) (23.8 ± 3.8 vs. 20.9 ± 3.3 kg/m², p < 0.001) had a statistically significant relation with having PHs. Relative atrophy of left abdominal rectus muscle was more frequently found in patients with PH (ratio of left side/right side; caudal level and medial side: 0.66 vs. 0.92, p < 0.01, caudal level and lateral side: 0.95 vs. 1.03, p = 0.04). Multivariate analysis revealed that BMI > 25 kg/m² [odds ratio (OR) 9.05, 95% confidence interval (CI) 2.06-39.76, p = 0.003] and atrophy of the left lower medial portion of the abdominal rectus muscle (OR 12.85, 95% CI 2.49-66.39, p = 0.002) were independent risk factors for PHs. Neither the laparoscopic approach nor the extraperitoneal route of the colostomy was proven to correlate with a lower rate of PHs.

CONCLUSIONS

High BMI and atrophic change of ARM were significantly associated with PH development. Surgical techniques for prevention of atrophic change of ARM are expected to reduce the incidence of PHs.

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 &lt; 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.

P1480 A case of triple left ventricular aneurysms diagnosed by CT and echocardiography

【Background】

Left ventricular aneurysms is complication of myocardial infarction (MI) that can lead to death or serious morbidity. False aneurysm is rare complications of myocardial infarction or iatrogenic perforation and represent a contained myocardial rupture. False aneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus. Definitive diagnosis is achieved by echocardiography, computed tomography (CT), angiography, or magnetic resonance imaging. Coexistence of true and false aneurysms is rare.

【Case】 A 58 years old man with a history of hypertension and MI was referred to our hospital for aneurysmectomy. During the course of prior MI, he got fever and pericardial effusion.

CT revealed that three left ventricular aneurysms were present. Also, three aneurysms were connected by narrow ducts each other. Transthoracic echocardiography (TTE) revealed that three ventricular aneurysms were connected via acceleration blood flow which swirling in the spherical aneurysm. We determined that this triple ventricular aneurysms were at high risk for rupture, so we performed surgery.

The postoperative course was good and he was discharged without any complications.

【Discussion】

False aneurysms occur after hemorrhagic dissection into an area of transmural infarction and most commonly result in free intrapericardial rupture of the heart, cardiac tamponade, and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture.

We were able to evaluate the mechanism of development with triple left ventricular aneurysms using CT and TTE. We could know about spatial comprehension of triple aneurysms using CT. False aneurysms were restricted enlargement due to stiff pericardium because of complicating Dressler syndrome. We hypothesis that aneurysms were enlarging in the direction of the base of heart in the adhered pericardium space.

We were able to evaluate the thickness of aneurysms and blood flow condition using TTE. TTE revealed that the wall of aneurysm was fragile. Multimodality imaging like TTE or cardiac CT are useful diagnostic methods in this case.

Abstract P1480 Figure. Triple aneurysms

1638 A case of capturing changes in interatrial blood flow and anatomical structure during percutaneous PFO closure with platypnea orthodeoxia syndrome using intra-cardiac echocardiography

Background

Platypnea–orthodeoxia syndrome (POS) is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO). The most commonly associated conditions included pneumonectomy, ascending aortic dilation, and arch surgery, as previously reported. Percutaneous closure of PFO is useful treatment for POS.

Case

A 76 year old man used home oxygen therapy because of unexplained hypoxemia. A decrease in blood oxygen saturation was observed in sitting and standing positions. The patient was diagnosed as "POS" because a shunt blood flow with PFO and atrial septal aneurysm (ASA) and eustachian valve was observed at transesophageal echocardiography. He was admitted for the purpose of percutaneous PFO closure.

He was treated with intra-cardiac echocardiography (ICE) guidance under local anesthesia because of poor lung function.

PFO closure was performed successfully with 30mm AMPLATZER Cribriform. The ICE findings prior to PFO closure showed a right-to-left shunt blood flow through the PFO in the sitting position but almost disappeared after closure. Furthermore, it was observed that the aortic artery compression was stronger in the sitting position than in the supine position with right-to-left shunt blood flow. After PFO closure, hypoxia associated with postural change improved and patient’s symptom as shortness of breath also significantly improved.

Discussion

POS is a position-dependent condition of dyspnea and hypoxemia due to right-to-left shunting. It often remains unrecognized in clinical practice, possibly because of its complex underlying pathophysiology. It is considered that the cause of POS in this patient was multiple factors such as ASA, aortic displacement, and venous valve remnant. In addition, being able to observe the change of the atrium due to compression from the aortic artery using ICE during the operation was very significant to explain the mechanism of POS.

Abstract 1638 Figure. Intra-cardiac echocardiography

P1713 A case of quadricuspid aortic valve complicated with infective endocarditis diagnosed by 3D transesophageal echocardiography

Background

Quadricuspid aortic valve (QAV) is a rare congenital heart disease with an estimated incidence of 0.008% to 1.46%. The functional status of QAV is predominantly a pure aortic regurgitation. The extensive use of echocardiography has allowed an early and accurate diagnosis of this malformation. In many cases, the transthoracic echocardiography (TTE) is suitable for the diagnosis but, transesophageal echocardiography (TEE), especially 3-dimensional (3D) TEE, is a tool for the accurate definition of the valve anatomy.

Clinical case

A 60-year-old female underwent a head CT for intermittent headaches for one month ago. She was admitted to neurosurgery in our hospital diagnosed of subarachnoid hemorrhage. Four mm aneurysm was found on the periphery of the right middle cerebral artery on CT examination, and a cerebral aneurysm coil embolization was performed with a catheter in emergency. The possibility of infectious cerebral aneurysm was pointed out, and we examined in cardiovascular internal medicine. TTE revealed moderate aortic regurgitation. The ventricular septum exhibits sigmoid septum. A mobile mass was found near the left ventricular outflow tract in the sigmoid septum. TEE revealed a hypoplasia cusp (accessory cusp) is found between non coronary cusp and right coronary cusp. Aortic valve leaflets have become thickened and regurgitation from the central part of the cusps. 3DTEE was able to more accurately visualize that only the accessory cusp was hypoplastic, and the size of the other three leaflets appears almost the same. Similarly, vegetation on the left ventricular outflow tract were clearly revealed by 3DTEE.

Based on the above, it was diagnosed that quadricuspid aortic valve complicated with infective endocarditis (IE) with aortic valve regurgitation. After treatment with antibiotics according to IE, surgical treatment was scheduled.

Discussion

QAV is a rare congenital heart disease, and TTE is an important imaging tool for accurate diagnosis. Furthermore, TEE, especially 3DTEE, was a more appropriate diagnostic method in QAV and IE.

Abstract P1713 Figure. 3DTEE

148 Inappropriate elevation of angiopoietin-2 relative to hemodynamic stability is associated with bleeding events in patients with continuous flow mechanical circulatory support

Funding Acknowledgements

none

Background

Elevated angiopoietin-2 (Ang-2) has been attributable to a potential cause of gastrointestinal bleeding among patients with continuous flow (CF) mechanical circulatory support (MCS) in the US, but Ang-2 levels have not been examined in the Japanese MCS patients who are likely to have less gastrointestinal bleeding.

Methods

We enrolled 18 patients (64 ± 16y; LVEF 26 ± 9%) with advanced heart failure (HF) who received temporary or durable MCS, or were given intravenous inotropes from August 2018 to January 2019. Serum Ang-2 and plasma BNP were simultaneously measured at various treatment status. The relationship between each value and any spontaneous bleeding events requiring hemostasis or blood transfusion was examined.

Results

103 blood samples were collected and divided into 2 groups. One was the CF group, which consisted of samples from patients under CF-MCS (Impella, ECMO, Jarvik2000, HeartMateII), and the others were assigned to the Non-CF group. Ang-2 levels had a positive correlation with BNP levels (r = 0.33, p = 0.0006, Fig). CF-MCS efficiently lowered BNP levels (353 ± 125 in CF vs 1053 ± 119 in Non-CF, pg/mL, p &lt; 0.0001), but Ang-2 levels relative to BNP levels were significantly higher in the CF group as shown in the Figure (Ang-2/log10(BNP) ratio: 3.77 ± 0.30 in CF vs 2.43 ± 0.29 in Non-CF, p = 0.0017). Bleeding events were remarkably frequent when Ang-2/log10(BNP)&gt;3.17 (77.8%) than ≦3.17 (22.2%, p = 0.0002).

Conclusions

High Ang-2 level is normally a marker for hemodynamic compromise, but CF-MCS may stimulate Ang-2 production despite hemodynamic stabilization. Most of spontaneous bleeding events accompany inappropriately high Ang-2 relative to BNP level among Japanese patients with advanced HF.

Abstract 148 Figure. Correlation between Ang-2 and BNP

P92 A novel method of correcting the left ventricular stroke volume by Doppler echocardiography: comparison with multidetector computed tomography

Background

Although transthoracic Doppler echocardiography is widely used for estimating left ventricular stroke volume (SV), accelerated blood flow in the left ventricular (LV) outflow tract may lead to overestimation. SV can be calculated accurately from left ventricular end-systolic and end-diastolic volume determined by multi-detector computed tomography (MDCT). However, radiation exposure as well as the use of contrast medium hampers its routine use.

Purpose

The purpose of this study was to examine whether the correction of SV measured by pulsed wave Doppler echocardiography (SVdop) can accurately predicts SV obtained by MDCT (SVct).

Methods： We enrolled consecutive 61 patients who underwent both MDCT and transthoracic echocardiography. Patients with moderate or severe valvular diseases and valve replacement surgery were excluded. Correction of SV was explored with SVct as a reference.

Results： Univariate analysis showed that SVdop (r = 0.42, P = 0.0007) and patient age (r=-0.50, P &lt; 0.0001) were significantly correlated with SVct. On the other hand, left ventricular ejection fraction calculated by Teicholz method (EFteich) (r = 0.19, P = 0.14), systolic blood pressure (r = 0.07, P = NS), and LV mass index (r=-0.02, P = NS) were not correlated with SVct. Multivariate analysis showed that SVdop, patient age and EFteich were the independent predictive factors for SVct (R2 = 0.49, P &lt; 0.0001). Based on these correlations, we postulated SV as: corrected SV = SVdop × 0.40 + EFteich × 0.46 – age × 0.67 + 44.77. As expected, the correlation between corrected SV and SVct significantly improved (r = 0.70, P &lt; 0.0001). Bland-Altman plot analysis showed that corrected SV significantly reduced the variation between SVdop and SVct, and diminished the overestimation of SVdop (Figure).

Conclusion： The new correction formula of SVdop may correct the overestimation of SV obtained by pulsed wave Doppler echocardiography, although the formula remains to be validated in a separate cohort of patients.

Abstract P92 Figure

P3535Prognostic value of congestion status by bioelectrical impedance analysis and natriuretic peptide levels in acute heart failure with preserved versus reduced left ventricular ejection fraction

Background

N-terminal pro-brain natriuretic peptide (NT-proBNP) is a well-known predictor of acute heart failure (HF). Congestion volume status estimated by bioelectrical impedance analysis (BIA) is also associated with adverse cardiovascular events in HF patients. However, it is unclear whether these biomarkers reflecting pathophysiological pathways are different between HF with preserved (HFpEF) and reduced ejection fraction (HFrEF).

Purpose

The aim of this study was to investigate whether the prognostic value of NT-proBNP and extracellular water/free fat mass (ECW%) assessed by BIA is different between HFrEF and HFpEF in acute HF patients.

Methods and results

One hundred-and-forty-three patients admitted for acute HF between November 2013 and January 2015 were estimated for NT-proBNP levels and ECW% by BIA on admission. A total of 49 HFrEF (LVEF<40%) and 75 HFpEF (LVEF≥50%) patients were included in this study (mean age: 76±14 years, male: 63%). The median of NT-proBNP levels in HFrEF patients was higher than in HFpEF (6022 [IQR: 2531–9163] pg/mL and 3179 [1076–6054] pg/mL, respectively, p=0.012). Conversely, ECW% was similar between HFrEF and HFpEF (29.0 [25.7–33.7] % and 31.7 [27.3–38.8] %, respectively, p=0.088). The primary endpoint was the composite of all-cause mortality and/or hospitalisation due to HF. During a median follow-up of 5.9 months, 16 (35.6%) and 35 (50.7%) patients were observed to have composite events in HFrEF and HFpEF, respectively, (p=0.111). Elevated NT-proBNP levels in HFrEF patients were associated with an increased risk of composite events after adjustment for traditional risk factors (hazard ratio [HR]: 2.39; 95% Confidence interval [CI]; 1.04–5.47; p=0.040), but not in HFpEF (p=0.063). Meanwhile, a high ECW% in HFrEF patients was associated with increasing composite events risk (HR: 3.30; 95% CI; 1.32–8.25; p=0.011), as well as in HFpEF patients (HR: 1.62; 95% CI; 1.03–2.55; p=0.037). Furthermore, the ECW% in addition to NT-proBNP in HFpEF patients resulted in a significant improvement in prediction for composite events (net reclassification improvement 0.67 [95% CI 0.24–1.11]; p=0.002 and integrated discrimination improvement 0.12 [0.004–0.20]; p=0.004).

Conclusion

Elevated levels of NT-proBNP in acute HF were predictive for mortality and hospitalisation due to HF in HFrEF but may not be for HFpEF patients, and ECW% had a better predictive value than NT-proBNP in HFpEF patients.

4328Short-term effects of dapagliflozin versus canagliflozin on acute decompensated heart failure in patients with type 2 diabetes

Background

The CANVAS program and DECLERE-TIMI 58 reported that SGLT2i had been demonstrated to reduce hospitalization for heart failure (HF) in type 2 diabetic mellitus (T2DM) patients with high cardiovascular disease risk. However, it remains unclear whether the effectiveness of SGLT2i on acute decompensated HF is also observed in T2DM patients irrespective of acting types of SGLT2i.

Methods

In this single center, open-label, prospective study, fifty-eight T2DM patients hospitalized due to decompensated HF were enrolled (mean age 73 years, HbA1c 7.2%). After treatment for HF, 5mg/day of dapagliflozin (n=24, from February 2016 to February 2017) or 100mg/day of canagliflozin (n=34, from March 2017 to July 2018) was administered and clinical parameters about HF and T2DM were followed for 7 days. Statistical comparison of parameters between groups taking dapagliflozin or canagliflozin was performed using the two-way repeated measures analysis of variance (MANOVA).

Results

In both groups, urine glucose excretion increased significantly after administration of SGLT2i. Fasting blood glucose level tended to be decreased in both groups. Urine volume increased significantly one day after administration of SGLT2i, and returned to the baseline after one week in both groups. Interestingly, urine volume one day after administration of SGLT2i tended to increase more in the group taking canagliflozin than in the group taking dapagliflozin (interaction P value = 0.088). Importantly, plasma BNP levels and Nt-proBNP levels were decreased significantly in both groups.

Parameters before and after treatment Baseline Day 7 (Day 1) P value Interaction P value Fasting blood glucose, mg/dL All 137±57 122±51 0.013 0.900 Dapa 144±64 133±53 0.089 Cana 128±64 118±40 0.069 log BNP All 5.31±1.11 4.91±1.09 <0.001 0.102 Dapa 5.48±1.04 4.94±1.00 <0.001 Cana 5.20±1.15 4.89±1.16 <0.001 log Nt-proBNP All 7.25±1.35 6.96±1.41 <0.001 0.735 Dapa 7.54±1.16 7.22±1.25 0.048 Cana 7.04±1.45 6.79±1.50 0.005 Urine volume (Day 1), mL/24h All 1218±523 1584±614 <0.001 0.088 Dapa 1261±564 1486±568 0.038 Cana 1186±498 1654±644 <0.001 Urine volume (Day 7), mL/24h All 1218±523 1305±408 0.128 0.428 Dapa 1261±564 1295±468 0.700 Cana 1186±498 1313±367 0.097 Urine glucose, g/24h All 1.6±5.5 23.7±23.5 <0.001 0.330 Dapa 1.7±6.8 20.3±21.7 <0.001 Cana 1.5±4.6 26.0±24.7 <0.001

Conclusion

SGLT2i are useful for correcting volume overload and recovering from the decompensated state in HF patients with T2DM irrespective of acting types of SGLT2i.

P827EXPLORE-J: Lipid management and 2-year long-term clinical outcome in Japanese patients with acute coronary syndrome

Background

The cardiovascular event rate in Japan is much lower than that in Western countries. However, the incidence of atherosclerotic CV disease and its burden are expected to increase in the Japanese society with rapid aging, westernization of lifestyles and metabolic derangement. An increase in patients with CAD has been remarkable in spite of various preventive measures. The positive linear correlation of LDL-C level with CAD incidence along with LDL-C lowering and CAD event reduction is established by large-scale studies in Western countries, but data in Japan are limited. EXPLORE-J, observational study, was conducted to gain insights into the relationship between LDL-C management and CV events in the Japanese ACS patients.

Purpose

The primary objective was to evaluate the status of post-ACS lipid management and CV events in Japan.

Method

ACS patients aged ≥20 years were enrolled and followed up for 2 years. The primary endpoint was the incidence proportion of major adverse cardiovascular events (MACE), including CV death (death associated with MI/stroke and other CV deaths), non-fatal ACS/stroke requiring hospitalization during the observation period. Other endpoints were medications and metabolic parameters. Additional stratified analyses of MACE incidence proportions by median LDL-C reduction category (above/below absolute or % reduction) from the first measurement after ACS to V1 (Day 1 + 14 days) was also conducted.

Result

Of the 2016 registered patients, 1944 were analyzed. The mean age and BMI were 66.0 years and 24.2 kg/m2, respectively. At 2-year follow up, the cumulative incidence proportion of MACE was 6.8%. The cumulative incidence proportions of CV death, non-fatal ACS and stroke were 0.7%, 4.5% and 1.7%, respectively. Statin, intensive statin, and ezetimibe were prescribed, respectively, to 93.6%, 8.2%, and 3.9% at V1, and 92.3%, 10.5%, and 11.6% at V5 (Day 730±30 days).

The mean LDL-C levels were 121.2, 99.4, 80.9, and 79.8 mg/dL at the first measurement after ACS, V1, V2 (Day 30±7 days) and V5, respectively. The proportions of patients who achieved LDL-C <70 and <100 mg/dL at V1 and V5 were 14.4% to 34.6% and 56.5% to 82.8%, respectively. The incidence rate of MACE was lower among patients with larger than median absolute reduction in LDL-C level than among those with smaller reduction (median −17.0 mg/dL; 5.5% vs 8.3%, p=0.0435). The same trend was observed in patients with higher LDL-C reduction rate (median −15.36%; 6.3% vs 7.6%, p=0.4302).

Kaplan-Meier estimates of MACE incidence

Conclusion

The results show the status of medical management and CV event rates in post-ACS Japanese patients. It also shows that half of the ACS patients did not achieve the recommended LDL-C levels of <70 mg/dL per guidelines, indicating the need to intensify lipid lowering therapy. To further characterize and quantify the patient population and the benefit of lipid management, we plan to conduct additional analyses with risk stratification of the population.

Acknowledgement/Funding

This study was sponsored by Sanofi and Regeneron Pharmaceuticals, Inc.

Treatment of twin-reversed arterial perfusion sequence using high-intensity focused ultrasound

We describe our experience of high-intensity focused ultrasound (HIFU) for fetal therapy in twin-reversed arterial perfusion (TRAP) sequence. Six pregnant women underwent HIFU therapy, five before 16 weeks and one at 26 weeks. Two types of HIFU system were used: the first-generation system, which comprised a biaxial transducer and continuous exposure pattern, and the second-generation system, which comprised a coaxial transducer and sequential exposure pattern. The first-generation apparatus was used in four cases and the second-generation apparatus was used in two. In three cases, occlusion of the blood vessels mediating flow to the acardiac twin was achieved by HIFU. Two cases experienced intrauterine fetal death despite vessel occlusion. The total survival rate of pump fetuses 2 years after HIFU was 67% and the efficiency rate (the proportion of cases with occlusion or reduced blood flow on ultrasound after HIFU) was 83%. After more than 2 years of follow-up, the surviving infants had no severe clinical complications and no postnatal developmental problems. There was no significant difference in survival rate compared with TRAP cases managed expectantly. Given that complete occlusion of the blood vessels was not achieved in half of the cases, we could not show that HIFU therapy is superior to other treatments. However, HIFU can reduce the cardiac load of the pump fetus and, as it does not require uterine puncture for fetal therapy, there were no fatal complications, such as bleeding, rupture of membranes or infection. Thus, HIFU therapy may represent a less-invasive treatment for TRAP sequence in early pregnancy. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.