459Direct oral anticoagulants are an effective therapy for left ventricular thrombus formation

Background and aim

Left ventricular thrombus is a frequent complication of myocardial infarction (MI) and heart failure with severely depressed ejection fraction. Once diagnosed, anticoagulation for up to 6-months is recommended, but clinical experience with direct oral anticoagulation (DOAC) is limited to a few case reports. Our aim is to test DOAC LV thrombus resolution efficacy against warfarin.

Methods

Single-centre retrospective cohort study of consecutive patients with recently diagnosed LV thrombus, either after acute myocardial infarction or heart failure with reduced ejection fraction, from January 2009 till December 2018. Thrombus diagnosis and subsequent assessments were performed with echocardiography and complemented with cardiac magnetic resonance, when appropriate. Decisions regarding the type, dose and duration of anticoagulation and any concomitant antiplatelet therapy were left to physician's judgement.

Results

In a population of 66 patients (51 male, mean age 69±12 years), 13 received DOAC therapy, with the remainder receiving vit. K antagonists. One from each group was lost to follow up. The DOAC subgroup had higher prevalence of atrial fibrillation, higher left ventricular end-diastolic volumes and worse wall motion severity score index (WMSI). The duration of anticoagulant therapy, concomitant single or dual antiplatelet therapy and overall follow up were similar between strategies. Thrombus remission was observed in 91.7% (n=11) and 59.6% (n=31) patients within DOAC and warfarin group, respectively. Risk of unsuccessful resolution was reduced by 35% relative to the warfarin group (RR 0.65; 95% CI [0.491–0.862]; p-value 0.035) (figure).

figure

Conclusion

DOAC seems to be an effective alternative to vitamin-K antagonists in patients with LV thrombus.

P3382Vascular calcium Index: an imaging tool to predict vascular complications and major bleeding in TF-TAVI

Introduction

Vascular calcification has been associated with worse outcomes in transfemoral TAVI (TF-TAVI). However, there is currently no simple method to assess it and identify different patterns of calcification in an objective and quantitative manner. The purpose of this study was to develop a quantitative score of aortic (Ao) and ileofemural (IF) calcification and to assess its ability to predict life-threatening bleeding (LTB) and major vascular complications during TF-TAVI.

Methods

Case-control single center retrospective study of patients undergoing TF-TAVI between Nov2015 and Aug2018 including 183 consecutive patients (99 women, mean age 83±3 years, mean Euroscore II - ESII - 6.0±4.1). The Vascular Calcium Score was calculated for the entire Ao and IF vessels using a modified Agatston score derived from contrast-enhanced CT images, with calcium threshold locally adjusted for luminal attenuation (mean attenuation + 5x SD). A luminal attenuation threshold >600UH impaired vascular calcium evaluation and patients were excluded. LTB and major vascular complications were adjudicated according to the VARC-2 classification and identified by chart review by and independent team.

Results

Thirty patients (16%) suffered major bleeding and 13 (7%) experienced LTB. Major vascular injury occurred in 11 patients (6%). The median total vascular calcium score (TCS) was 11752 AU (IQR: 6388–19844) and median IF score (IFS) was 2210AU (IQR: 865–4170). TCS indexed for body surface area (TCSi) was predictor of LTB (AUC: 0.78±0.07, p<0.05) and of major vascular complications (AUC: 0.85±0.05, p<0.05). After multivariate analysis, iTCS and glomerular filtration rate (GFR) remained as predictors of LTB with an HR of 1.11 for each increase in 1000UA/m2 of TCSi (95% CI: 1.03–1.18) and 0.94 (95% CI: 0.88–0.985) respectively, independently of the ESII. iTCS and GFR were also independently associated with major vascular complications (p<0.05). Patients with an iTCS above 9750AU/m2 have an odds ratio of 7.7 (95% CI: 2.0 - 29.2) for LTB. This cut-off has a sensitivity of 77% and a specificity of 70% for LTB. Similarly, patients with an iTCS above 9750AU/m2 have an odds ratio of 10.3 (95% CI: 22 - 49.3) for major vascular injury.

Conclusions

A quantitative score for vascular calcification in contrast-enhanced CT images was developed. iTCS was independently associated with life-threatening bleeding and major vascular complications.

Effects of temporal frequency on binocular deficits in amblyopia

Amblyopia is associated with a range of well-known visual spatial deficits, which include reduced contrast sensitivity, spatial distortions, interocular suppression, and impaired stereopsis. Previous work has also pointed to deficits in processing dynamic visual information, but it is unknown whether these deficits influence performance under binocular conditions. We examined the effects of temporal modulation on contrast sensitivity and binocular interactions in a preliminary study of 8 adults with amblyopia and 14 normally-sighted control subjects. For each observer, we measured interocular balance and stereopsis thresholds with binocular flicker across a range of four temporal (0, 4, 7.5, and 12 Hz) and spatial (1, 2, 4, and 8 cpd) frequencies. Interocular balance was estimated by varying the relative contrast of dichoptic letter pairs to produce perceptual reports of each letter with equal frequency, and stereopsis thresholds were measured by determining the minimum disparity at which subjects identified a front-depth target with 75% accuracy. Consistent with previous findings, we observed greater interocular imbalance and impaired stereoacuity at high spatial frequencies in amblyopes. In contrast, the effects of temporal frequency on performance were smaller: across both groups, interocular imbalance was largest at mid-to-low temporal frequencies, and stereopsis thresholds were unaffected by temporal frequency. Our results suggest that there may be a previously unreported effect of temporal frequency on interocular balance, as well as a possible dissociation between the effects of flicker on interocular balance and stereopsis.

P4657Cardiac myxomas: are we dealing with distinct clinical entities?

Background

Cardiac myxomas are rare, despite being the most common primary cardiac tumours. A significant number of myxomas are discovered accidentally in asymptomatic patients (pts), as there is increased use of non-invasive cardiac imaging. Our aim was to describe the experience of a cardiac surgery centre managing cardiac myxomas during the last 28 years.

Methods

Single-center retrospective study of consecutive pts admitted with the diagnosis of a cardiac myxomas between 1990 and 2018. Registry data concerning clinical presentation, non-invasive imaging assessment and definitive histopathology were collected.

Results

From 154 pts with the diagnosis of cardiac tumours, we identified 106 (68.8%) myxomas (67% females; mean age at diagnosis 61,5±13,1 years). Myxoma diagnosis increased throughout the 3 decades (27 cases until 2000; 26 cases in the second decade; 52 cases from 2010 until present). 30% of the pts were asymptomatic at diagnosis. Obstructive symptoms (heart failure and syncope) and embolic events were the most common complaints among symptomatic pts. Transthoracic echocardiography firstly identified the tumours in 88% of the cases. Cardiac magnetic resonance and computed tomography were performed for further investigation in 7% of the cases. Presumptive pre-operative diagnosis was correct in 83.8% pts.

Surgical excision was successfully achieved in all cases. 89% of the tumours were located in the left atrium with inter-atrial septum implantation (13 in right chambers; 1 valvular tumour). There were 10 multifocal tumours.

At histopathology myxomas were grossly described as mucous jelly appearance (80%), solid (15%) and mixed type lesions (5%). Rare histologic findings were described in 30% of the cases (8 tumours with bone tissue; 1 with forming bone marrow; 4 with endocrine type glandular epithelium; 16 with lympho-plasmocytic infiltrates; 3 with high mitotic grade; 5 with concomitant thrombus).

For a median follow up of 86 [31–214] months there were 15 deaths (2 of them with tumour related deaths). There were 3 recurrences (2 with high mitotic grade histology), mostly occurring 3 years after the first intervention.

Conclusion

In this case series cardiac myxomas are the most common cardiac tumours, with a significant proportion of asymptomatic lesions. Clinical heterogeneity followed polymorphic histology, with recognized differences when compared to classical descriptions of this kind of tumour.

Aspectos da biologia reprodutiva de Boa constrictor constrictor: um estudo histológico dos testículos nos períodos reprodutivos de quiescência e máxima atividade

RESUMO As serpentes pertencem ao segundo maior grupo dentro dos répteis, podendo apresentar sazonalidade quanto à espermatogênese, com produção descontínua ou contínua. O presente trabalho tem como objetivo caracterizar aspectos da biologia reprodutiva de Boa constrictor constrictor com base nos achados histológicos dos testículos nos períodos de máxima atividade (período de gametogênese) e quiescência. Os testículos de dois espécimes de Boa c. constrictor (7767 e 11752) foram cortados a uma espessura de 3μm em micrótomo, corados com azul de toluidina 1%, fotodocumentados e descritos. A presença de espermatozoides na luz do túbulo seminífero no indivíduo 7767 indica um período de máxima gametogênese, enquanto o lúmen dos túbulos seminíferos pouco evidentes, sem a presença de espermatozoides e de células gaméticas em divisão, caracteriza o indivíduo 11752 em período quiescente. Mediante os achados histológicos descritos no presente estudo, concluiu-se que Boa c. constrictor apresenta sazonalidade em relação à gametogênese, sendo esse padrão de sazonalidade associado ao período de cópulas relatado em literatura característico de serpentes com padrão pré-nupcial.

P6326Which results of the cardiopulmonary exercise test deserve greatest attention to establish the prognosis in heart failure?

Background and aim

Limitation of exercise tolerance is one of the cardinal manifestations of heart failure (HF). Cardiopulmonary exercise testing (CPET) provides a thorough assessment of exercise integrative physiology involving the pulmonary, muscular, and oxidative cellular systems. We aimed to identify which data collected during a CPET shows the best prognostic performance with respect to predicting mortality or the need for heart transplantation (HT).

Methods

Single-centre retrospective cohort study of consecutive HF patients performing a CPET for functional and prognostic HF evaluation from October 1996 till May 2018. Left ventricular ejection fraction was not an exclusion criterion. A Cox model was fit with time to death or heart transplantation (whichever recorded first within 5 years) as the dependent variable and CPET parameters as the independent variables. Both unadjusted and adjusted covariate Cox regressions were performed. ROC curve analysis was used to determine whether the significant variables, as a model, could reliably predict the study endpoint.

Results

The study population consisted of 513 patients, median age 58 (IQ 16) years, and 74.9% male. The majority had reduced ejection fraction (75.4%), and the most common HF aetiology was ischemic heart disease (55.8%). During the 5-years follow up, 126 patients died and 60 underwent heart transplantation. In unadjusted Cox regression, nearly all CPET variables were significantly associated with the study endpoint. After covariate adjustment, with prior exclusion of redundant variables, three measures remained associated with the study endpoint: peak VO2 consumption (hazard ratio [HR] 0.85; 95% confidence interval [CI], 0.81–0.90); VE/VCO2 slope (HR 1.02; 95% CI, 1.00–1.02); presence of oscillatory ventilatory pattern (HR 3.73; 95% CI, 2.43–5.72). As a model, these 3 variables showed a strong discriminatory ability (c-statistic 0.87; 95% CI, 0.83–0.90) (see figure) for the study endpoint.

Figure 1

Conclusion

When using the CPET for prognostic stratification of HF patients, the presence of an oscillatory ventilatory pattern, the peak VO2 and the VE/VCO2 slope are the most important tools on which clinicians should focus.

P5423Exercise oscillatory ventilation improves the performance of prognosis scores currently used for heart failure

Background and aim

Several prognostic risk scores are available for heart failure with reduced ejection fraction (HFrEF), and are used, together with other criteria, to help decide the ideal timing for listing candidates for a heart transplant. The detection of an oscillatory ventilatory pattern (OVP) during cardiopulmonary exercise testing (CPET) has been associated with more advanced HF and a worse prognosis, but was not considered in the development of all the current risk scores. We evaluated whether OVP adds significant prognostic information to four contemporary HF scores.

Methods

Single-centre retrospective cohort study of consecutive HFrEF patients undergoing CPET for functional and prognostic assessment from October 1996 till May 2018. The Heart Failure Survival Score (HFSS), Seattle Heart Failure Model (SHFM), Meta-analysis Global Group in Chronic Heart Failure (MAGGIC) and Metabolic Exercise Cardiac Kidney Index (MECKI) were obtained in each patient. Cox model was fit with time to death or urgent transplant (whichever came first within 2 years) as the dependent variable and OVP and respective HF score as the independent variables. We further assessed the added discriminative power by performing ROC curve comparisons.

Results

We studied 387 patients, median age 58 (IQR 49; 65) years, and 77% were male. The most common HFrEF aetiology was ischemic heart disease (54%). Median peak oxygen consumption was 15,7 mL/kg/min (IQR 12,8; 20,0). OVP was present in 150 (39%) patients. Over the 2-year follow-up period, 48 patients died, and 52 underwent heart transplantation (of which 25 were urgent). HFSS showed the weakest (c-statistic 0,625; 95% [CI] 0,54–0,71) and MECKI score the strongest (c-statistic 0,819; 95% [CI] 0,76–0,88) discriminatory ability. Contrasting with NTproBNP value, the presence of OVP predicted the study endpoint independently of the HF prognosis score used (see table). Adding the occurrence of OVP to the HFSS and the MAGGIC scores significantly improved their prognostic performance (see Table).

Conclusion

An OVP is a common finding in HFrEF patients undergoing CPET, and adds prognostic information to contemporary HF prognosis scores. Systematic evaluation of this easily available criterion may assist the decision on the appropriate timing for heart transplantation listing.

Altered Cytoskeletal Composition and Delayed Neurite Elongation in tau45-230-Expressing Hippocampal Neurons

Calpain-mediated tau cleavage into the neurotoxic tau_45-230 fragment plays an important role in Alzheimer's disease (AD). This tau fragment accumulates mainly in the cytoplasm of degenerating neurons. However, subcellular localization studies indicated that a pool of tau_45-230 associates with the cytoskeleton in hippocampal neurons. In the present study, we assessed whether such localization could underlie tau_45-230 neurotoxic effects. Quantitative Western blot analysis showed decreased levels of full-length tau bound to microtubules in tau_45-230-expressing hippocampal neurons when compared to controls. In addition, the presence of this tau fragment induced a transient increase in tyrosinated tubulin, a marker of unstable microtubules, followed by a significant decrease in the levels of this tubulin isoform. The data obtained also showed a significant reduction in actin filaments in tau_45-230-expressing neurons. These changes in microtubules and actin filaments correlated with delayed neurite elongation and axonal differentiation in the presence of this tau fragment. Together, these results suggest that tau_45-230 could exert its toxic effects, at least in part, by modifying the composition of the neuronal cytoskeleton and impairing neurite elongation in neurons undergoing degeneration.

Abstract P6-18-16: Ribociclib (RIBO) + letrozole (LET) in older patients with hormone receptor-positive (HR+), human epidermal growth factor receptor-2–negative (HER2–) advanced breast cancer (ABC): Preliminary subgroup results from the phase 3b CompLEEment-1 trial

Background: The cyclin-dependent kinase (CDK)4/6 inhibitor RIBO is approved in combination with an aromatase inhibitor (AI) for HR+, HER2– ABC in postmenopausal women with no prior therapy for ABC, based on the MONALEESA-2 trial (Hortobagyi et al. NEJM 2016). Although a high proportion of patients with HR+, HER2– ABC are &gt;65 years of age, older patients are often under-represented in clinical trials. Furthermore, treatment decisions may be complicated by comorbidities, functional status, and concurrent medications. Here, we report early safety results for patients ≥65 years of age enrolled in CompLEEment-1, an open-label, phase 3b trial evaluating RIBO+LET as first-line endocrine-based therapy in an expanded patient population.

Methods: Patients with HR+, HER2– ABC, ≤1 line of prior chemotherapy (CT), and no prior endocrine therapy for ABC received RIBO (600 mg/day, 3 weeks on/1 week off) + LET (2.5 mg/day); men and premenopausal women received concomitant goserelin (3.6-mg subcutaneous implant every 28 days). The primary outcome was safety and tolerability. A pre-planned interim analysis was conducted ˜15 months after first patient first visit.

Results: Of the first 1,008 patients enrolled who completed 56 days of follow-up or discontinued before the data cut-off date, 377 were ≥65 years of age. Of these, 157 (41.6%) were 65-&lt;70 years, 107 (28.4%) were 70-&lt;75 years, and 113 (30%) were ≥75 years. The majority of patients (94.4%) had an Eastern Cooperative Oncology Group performance status ≤1; 33.2% presented with stage IV disease at diagnosis; 9 patients were male. The most common sites of metastasis were bone (70.0%), lung (44.8%), and lymph nodes (29.7%). The most common all-grade adverse events (AEs) were neutropenia (58.4%), nausea (31.8%), and fatigue (24.1%). The most common grade 3/4 AEs were neutropenia (37.7%) and alanine aminotransferase increase (4.2%). QT prolongation events were mild (majority grade 1/2) and occurred in 6.1% of patients (0.5% grade 3/4). Dose reduction or interruption due to AEs occurred in 54.5% of patients; 6.9% of patients had AEs leading to treatment discontinuation. In the overall patient population, the most frequent grade 3/4 AEs were neutropenia (42.8%), leukopenia (3.4%), and increased alanine aminotransferase (2.9%); QT prolongation occurred in 5.4% of patients (0.5% grade 3/4).

Conclusions: Initial safety results from CompLEEment-1, from the first 56 days of follow-up, demonstrate the tolerability of RIBO+LET in older patients, consistent with the overall patient population. NCT02941926.

Citation Format: Ring A, Borstnar S, Ferreira A, Azim HA, Cottu P, Lu J, Martin M, Zamagni C, Beck JT, Zhou K, Wu J, Menon L, De Laurentiis M. Ribociclib (RIBO) + letrozole (LET) in older patients with hormone receptor-positive (HR+), human epidermal growth factor receptor-2–negative (HER2–) advanced breast cancer (ABC): Preliminary subgroup results from the phase 3b CompLEEment-1 trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-18-16.

Abstract P1-15-19: Carboplatin-addition in neoadjuvant treatment of women with triple negative breast cancer (TNBC): Prognostic value in real-world patients

Background

The addition of carboplatin to an anthracycline/taxane-based chemotherapy(CT) in neoadjuvant setting has been suggested to improve pathological complete response(pCR) in TNBC. However, the impact of pCR in prognosis is unknown. We aim to study the value and feasibility of the addition of carboplatin in neoadjuvant setting.

Methods

Demographic and clinical data of TNBC patients treated with neoadjuvant CT in a comprehensive cancer center between 2010-2018 were retrospectively collected. Two cohorts were defined: one treated with Carboplatin/Paclitaxel followed by dose-dense Doxorrubicin/Cyclophosphamide(CP-AC) and other with AC followed by Docetaxel(AC-D). Median follow-up time was 3.1 and 6.9 years, respectively. pCR was defined as absence of residual invasive tumor in breast/axilla. Survival analysis using Kaplan-Meier method and Cox proportional-hazards model were applied. Statistical significance was set at p&lt;0.05.

Results

One-hundred and sixty patients were enrolled: 78 CP-AC and 38 AC-D. Groups were balanced regarding patients and tumor characteristics with exception of pre-menopausal status, more frequent in CP-AC(68% vs 47%;p=.04). Age at diagnosis was 47(28-76)years, the majority had ECOG 0(92%) ductal carcinomas(82%), clinicalT2/3 stages(76%), grade 3(81%) with lymph node involvement(N+)(57%). 14% had Inflammatory breast cancer(IBC)(CP-AC 14%;AC-D 13%; p=.9).

Neutropenia was the most prevalent adverse event(G3/4: CP-AC 61%;AC-D 16%;p=.02), 12% and 16% of febrile neutropenia(p=.8). G3/4 thrombocytopenia occurred only in CP-AC(6%). Hypersensitivity reactions were more prevalent in CP-AC(19% vs 2.7%;p=.02), majority to paclitaxel, all G1/2. Hospital admission occurred in 12%(CP-AC 13%;AC-D 9%; p=.8). There were no treatment-related deaths. Treatment schedule was complete in 89%(CP-AC 87%;AC-D 92%;p=.5), with 20% dose reductions(CP-AC 25%;AC-D 11%;p=0.9).

pCR was achieved in 42%(CP-AC 50%;AC-D 28%;p=.03). 1- and 3-year disease-free survival(DFS) was 94%/85% for CP-AC and 72%/58% for AC-D(p=.3). Risk of recurrence was higher in IBC(HR 25.1;CI95% 7.7-81.3;p&lt;.0001), N+ disease(HR 3.6;CI95% 1.2-10.5;p=.02) and non-pCR(HR 10.9;CI95% 2.3-52.3,p=.003). N+ disease was associated with higher recurrence only in AC-D(HR 11.7;CI95% 1.3-104;p=.03).

Cancer-related deaths were 20%(CP-AC 10%;AC-D 40%;p=.001). 1- and 2-year overall survival (OS) was 99%/95% for CP-AC and 70%/61% for AC-D(p=.06). N+ disease was associated with higher risk of death in AC-D(HR 6.3;CI95% 1.1-24.6;p=.04). Risk of death was independently associated with IBC(HR 4.1;CI95% 2.1-18.7; p=.001) but not with N+ disease(HR 2.7;CI95% 0.8-9.5;p=.13) or pCR(HR 4.1;CI95% 0.9-19.7;p=.08) although pCR was statistically significant in univariate analysis (1- and 2-year OS 97% vs 92% and 94% vs 86% for pCR and non-PCR;p=.003).

Conclusions

Carboplatin addition clearly increased pCR with a trend to DFS and OS benefit. This regimen was associated with more, nevertheless manageable, adverse events with most of the patients able to tolerate and complete the full-dose regimen. Though we did not find a subgroup of patients that benefit with carboplatin regimen, we should consider avoiding AC-D at least in N+ disease.

Citation Format: Coelho S, Abreu MH, Sales C, Lopes AR, Sousa MF, Couto R, Pousa I, Ferreira A, Ferreira M, Vieira C, Leal C, Castro F, Sousa S, Pereira D. Carboplatin-addition in neoadjuvant treatment of women with triple negative breast cancer (TNBC): Prognostic value in real-world patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-19.