Concordant low and discordant fractional flow reserve and instantaneous wave-free ratio measurements are associated with reduced myocardial perfusion

Background

In patients undergoing invasive coronary angiography with functional lesion assessment, both fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) measurements can be used to guide coronary revascularization decision-making. The hemodynamic significance of lesions with discordant FFR and iFR measurements is debated.

Purpose

This study compared quantitative myocardial perfusion indices as assessed by [15O]H2O positron emission tomography (PET) perfusion imaging in vessels with concordant high, discordant and concordant low FFR/iFR measurements

Methods

This post-hoc analysis of the PACIFIC I and II studies included 198 patients suspected of obstructive coronary artery disease who had undergone [15O]H2O PET imaging and subsequent FFR/iFR interrogation in 468 vessels. Resting myocardial blood flow (MBF), hyperemic MBF and coronary flow reserve (CFR) were compared between 4 vessel subgroups: FFR+/iFR+ (n=79), FFR−/iFR+ (n=22), FFR+/iFR− (n=22) and FFR−/iFR− (n=345).

Results

Discordant FFR/iFR indices were found in 44 (9%) vessels. Hyperemic MBF was significantly lower for vessels with FFR+/iFR+ (2.09±0.67 mL min–1 g–1), FFR−/iFR+ (2.41±0.80 mL min–1 g–1) and FFR+/iFR− (2.40±0.69 mL min–1 g–1) compared to FFR−/iFR− vessels (2.91±0.84 mL min–1 g–1) (p<0.01, p=0.03 and p<0.01, respectively). Hyperemic MBF did not differ between vessels with FFR+/iFR+ compared to FFR−/iFR+ (p=0.38) and FFR+/iFR− (p=0.35) vessels. In addition, resting MBF was lower and CFR did not differ in the FFR+/iFR− versus the FFR−/iFR− group (resting MBF: 0.80±0.16 mL min–1 g–1 vs. 0.90±0.24 mL min–1 g–1, p=0.03 and CFR: 3.05±0.84 vs. 3.35±1.07, p=0.56). Finally, CFR was similar in FFR+/iFR+ and FFR−/iFR+ vessels (2.37±0.76 vs. 2.64±0.84, p=0.92).

Conclusions

We found lower baseline flow and similar flow reserve in FFR+/iFR− compared to FFR−/iFR− vessels. Importantly, [15O]H2O PET imaging demonstrated reduced hyperemic MBF in vessels with concordant low and discordant FFR and iFR measurements.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of coronary flow capacity derived from [15O]H2O positron emission tomography perfusion imaging

Background

Coronary flow capacity (CFC) is a cross-modality framework integrating hyperemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) to quantify the physiological impact of coronary atherosclerotic disease on vasodilator capacity.

Purpose

This study explores the prognostic value of CFC derived from [15O]H2O positron emission tomography (PET) perfusion imaging in addition to traditional perfusion metrics.

Methods

Quantitative perfusion measurements were obtained from 1300 patients with suspected or known coronary artery disease who underwent [15O]H2O PET imaging. Patients were classified as having myocardial steal, severely reduced CFC, moderately reduced CFC, minimally reduced CFC or normal flow using previously defined perfusion thresholds. The endpoint was a composite of death and non-fatal myocardial infarction (MI).

Results

The composite endpoint occurred in 153 (12%) patients during a median follow-up of 5.5 (interquartile range 3.7–7.8) years. Myocardial steal (HR 10.65, 95% CI 4.45–25.49, p<0.001), severely reduced CFC (HR 3.77, 95% CI 1.88–7.58, p<0.001), moderately reduced CFC (HR 2.03, 95% CI 1.25–3.29, p=0.004) and minimally reduced CFC (HR 1.72, 95% CI 1.05–2.81, p=0.030) were independently associated with worse outcome after adjusting for clinical risk factors. Similarly, increased resting MBF (HR 3.19, 95% CI 1.74–5.83, p<0.001), decreased hMBF (HR 0.72, 95% CI 0.57–0.90, p=0.004) and decreased CFR (HR 0.59, 95% CI 0.47–0.73, p<0.001) were significant prognostic factors for events. In a combined perfusion model, only resting MBF (p=0.018) and CFC (overall p=0.012) demonstrated independent prognostic value.

Conclusions

[15O]H2O PET-derived resting MBF, hMBF, CFR and CFC were prognostic factors for death and non-fatal MI. Notably, in a combined model including all perfusion metrics, only resting MBF and CFC were independently associated with adverse outcome.

Funding Acknowledgement

Type of funding sources: None.

Predicting success of the retrograde approach in percutaneous coronary intervention of chronic total coronary occlusions as guided by collateral grading systems

Background

Retrograde chronic total coronary occlusion (CTO) percutaneous coronary intervention (PCI) requires selection of appropriate interventional collaterals. At present, utilization of the Rentrop and Werner grading systems are encouraged to assess the collateral channels (CCs) prior to attempted guidewire (GW) crossing [1]. The J-Channel score was recently introduced to predict CC GW crossing difficulty, yet data on its applicability is lacking [2].

Purpose

To investigate the predictive ability of the J-Channel score for CC GW crossing success and technical CTO-PCI success compared to the Rentrop and Werner grading systems.

Methods

A total of 262 patients who underwent single-vessel retrograde CTO-PCI were prospectively recruited in a single-center registry. The J-Channel score, Rentrop and Werner grade were assessed by invasive coronary angiography. Crossing of CCs was considered successful if the GW reached the distal cap of the CTO body. Technical CTO-PCI success was defined as Thrombolysis in Myocardial Infarction flow grade 3 and residual stenosis <30%.

Results

Mean J-Channel score was found at 1.9±1.2. Median Rentrop and Werner grade were 3 [IQR 2–3] and 1 [IQR 1–2]. Technical CTO-PCI success was 90%. In 211 (81%) cases, CC GW crossing was successful. Receiver operating characteristics analysis showed comparable discriminatory capacity for Rentrop and Werner grade (AUC 0.67 and 0.65, p=0.611), whereas the predictive ability of the J-Channel score (AUC 0.74) was superior to the Werner grade (p<0.001). A high J-Channel score was inversely associated with CC GW crossing success (p<0.001). For technical CTO-PCI success, overall performance of all grading systems weakened, wherein Rentrop grade was numerically highest, followed by the J-Channel score and Werner grade (AUC 0.69, 0.67, and 0.58, respectively). Notably, a high Rentrop grade was associated with increased CC GW crossing and technical CTO-PCI success (p<0.001).

Conclusions

In retrograde CTO-PCI, there is limited incremental value of the J-Channel score, Rentrop classification and Werner grade in predicting technical CTO-PCI success. However, their application might aid in strategic collateral channel selection prior to attempted guidewire crossing.

Funding Acknowledgement

Type of funding sources: None.

O-283 Evidence based management of endometriosis – what has changed since 2013?

In 2005, under the auspices of ESHRE, a group of international experts evaluated the existing best evidence and published the first European guideline on the management of endometriosis. This highly successful project was the first guideline by ESHRE and was adopted by many counties as their national standard. A second, fully-updated edition was presented in 2013.

For the new ESHRE Endometriosis Guideline, published in February 2022, all available evidence for twelve chosen topics was gathered by a senior research specialist. Subgroups comprised of patient representatives and experts in healthcare, reproductive science and epidemiology evaluated the data according to GRADE criteria. Each subgroup wrote a chapter and formulated their recommendations which were then presented by a representative to the core group. There, a provisional document was generated and made available for stakeholder review. The resulting comments were taken into account and where relevant incorporated into the final guideline document for which approval was sought and gained from the ESHRE Executive Committee.

35 PICO (Patients, Interventions, Comparison, Outcome) and seven narrative questions were addressed resulting in 78 Research Recommendations were formulated. Where sufficient scientific evidence was lacking and the Guideline Development Group (GDG) was of the opinion that an important topic needed to be highlighted Good Clinical Practice Points where created based on experts’ experience.

During the process of reviewing the literature it became apparent that large knowledge gaps of the best clinical approach to endometriosis exist. As a result, 30 research recommendations were also produced.

One of the main differences to the 2013 version of the ESHRE guidelines is that laparoscopy is no longer the gold standard for endometriosis per se as there exist sufficient data to support the use of transvaginal ultrasound performed by an experienced operator or MRI can equally identify or rule out ovarian and most of deep endometriosis. However, it is recognised by the GDG that the required imaging standards are not ubiquitously available and for peritoneal disease both sensitivity and specificity using either imaging modalities are still poor. As opposed to the 2013 recommendation, the GDG does not anymore recommend an ultralong protocol for the women with rASRM stage III/IV endometriosis to improve IVF success rates. Furthermore, gonadotropin releasing hormone antagonists seem to be effective in the treatment of endometriosis-associate pain and, where available, could be considered as second-line treatment.

Other changes were specific chapters on endometriosis in adolescents and in menopausal women as the GDG strongly felt that these groups are concerningly underrepresented in clinical care and research. Finally, a chapter focussing on the association of endometriosis with certain forms of cancer namely subgroups of ovarian cancer, breast and thyroid cancer was added to give both patients and clinicians a better insight into the current evidence of this complex topic.

The GDG hope that the new ESHRE Endometriosis Guideline will improve the clinical management of a highly prevalent and heterogenous disease and that the freely-available patient-friendly version of the guideline empowers symptomatic and asymptomatic women to seek the best available advice, support and treatment.

Intracervical insemination versus intrauterine insemination with cryopreserved donor sperm in the natural cycle: a randomized controlled trial

STUDY QUESTION

Is intracervical insemination (ICI) non-inferior to IUI with cryopreserved donor sperm in the natural cycle in terms of live birth?

SUMMARY ANSWER

ICI with cryopreserved donor sperm in the natural cycle was inferior to IUI in terms of live birth.

WHAT IS KNOWN ALREADY

Both ICI and IUI in the natural cycle are performed as first-line treatments in women who are eligible for donor sperm treatment. High-quality data on the effectiveness of ICI versus IUI with cryopreserved donor sperm in the natural cycle in terms of live birth is lacking.

STUDY DESIGN, SIZE, DURATION

We performed an open-label multicentre randomized non-inferiority trial in the Netherlands and Belgium.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We randomly allocated women who were eligible for donor sperm treatment with cryopreserved donor semen to six cycles of ICI in the natural cycle or six cycles of IUI in the natural cycle. The primary outcome was conception within 8 months after randomization leading to a live birth. Secondary outcomes were ongoing pregnancy, multiple pregnancy, clinical pregnancy, miscarriage and time to conception leading to live birth. We calculated relative risks (RRs) and risk differences (RDs) with 95% CI. Non-inferiority would be shown if the lower limit of the 95% RD CI was <-12%.

MAIN RESULTS AND THE ROLE OF CHANCE

Between June 2014 and February 2019, we included 421 women, of whom 211 women were randomly allocated to ICI and 210 to IUI. Of the 211 women allocated to ICI, 2 women were excluded, 126 women completed treatment according to protocol and 75 women did not complete 6 treatment cycles. Of the 210 women allocated to IUI, 3 women were excluded, 140 women completed treatment according to protocol and 62 women did not complete 6 treatment cycles. Mean female age was 34 years (SD ±4) in both interventions. Conception leading to live birth occurred in 51 women (24%) allocated to ICI and in 81 women (39%) allocated to IUI (RR 0.63, 95% CI: 0.47 to 0.84). This corresponds to an absolute RD of -15%; 95% CI: -24% to -6.9%, suggesting inferiority of ICI. ICI also resulted in a lower live birth rate over time (hazard ratio 0.58, 95% CI: 0.41-0.82). Our per-protocol analysis showed that, within the 8 months treatment horizon, 48 women (38%) had live births after ICI and 79 women (56%) had live births after IUI (RR 0.68, 95% CI: 0.52-0.88; RD -18%, 95% CI: -30% to -6%).

LIMITATIONS, REASONS FOR CAUTION

The study was non-blinded owing to the nature of the interventions. We consider it unlikely that this has introduced performance bias, since pregnancy outcomes are objective outcome measures.

WIDER IMPLICATIONS OF THE FINDINGS

Since ICI in the natural cycle was inferior to IUI in the natural cycle with cryopreserved donor sperm in terms of live birth rate, IUI is the preferred treatment.

STUDY FUNDING/COMPETING INTEREST(S)

This trial received funding from the Dutch Organization for Health Research and Development (ZonMw project number 837002407). B.W.J.M. is supported by an NHMRC Investigator grant (GNT1176437), reports consultancy for ObsEva and has received research funding from Guerbet, Ferring and Merck. The other authors do not declare a COI.

TRIAL REGISTRATION NUMBER

NTR4462.

TRIAL REGISTRATION DATE

11 March 2014.

DATE OF FIRST PATIENT’S ENROLMENT

03 June 2014.

The effect of chronic total coronary occlusion percutaneous coronary intervention on absolute perfusion in remote myocardium

Background

Successful revascularization of a chronic total coronary occlusion (CTO) impacts coronary physiology of the remote myocardial territory.

Purpose

This study evaluated the effect of CTO percutaneous coronary intervention (PCI) on changes in absolute perfusion in remote myocardium as assessed by serial [15O]H2O positron emission tomography (PET) perfusion imaging.

Methods

A total of 164 patients underwent [15O]H2O PET imaging at baseline and 3 months after successful single-vessel revascularization of a CTO to evaluate changes in hyperemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) in the remote myocardial territory supplied by both non-target coronary arteries.

Results

Remote hMBF and CFR improved (2.29±0.67 to 2.48±0.75 mL min–1 g–1 and 2.48±0.76 to 2.74±0.85, respectively) after CTO revascularization (p&lt;0.01 for both). Absolute perfusion indices in the CTO vessel and the remote myocardium showed a positive linear correlation, both before (r=0.75, p&lt;0.01 and r=0.77, p&lt;0.01 for hMBF and CFR, respectively) and after (hMBF: r=0.87, p&lt;0.01 and CFR: r=0.81, p&lt;0.01) CTO PCI. Absolute increases in remote myocardial perfusion were largest in patients with a higher increase in hMBF (βeta [β] 0.56; 95% CI: 0.47–0.65; p&lt;0.01) and CFR (β 0.51 (0.42–0.60); p&lt;0.01) in the CTO territory, independent of clinical, angiographic and procedural characteristics. Furthermore, baseline (hMBF: β −0.24 (−0.39, −0.08); p&lt;0.01 and CFR: β −0.26 (−0.41, −0.11); p&lt;0.01) and post-PCI perfusion (hMBF: β 0.36; (0.27, 0.46); p&lt;0.01 and CFR: β 0.30 (0.21, 0.40); p&lt;0.01) in the CTO vessel were independently associated with the increase in remote myocardial perfusion after CTO PCI.

Conclusions

An overall increase in remote myocardial perfusion was observed following CTO PCI. Absolute perfusion indices in the remote myocardium showed a positive linear correlation with perfusion in the CTO vessel, before and after CTO revascularization. Importantly, baseline, post-PCI and the absolute increase in perfusion in the CTO territory were independently associated with increases in remote myocardial perfusion after revascularization.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2

The association between invasive microvascular function and CMR-derived microvascular injury indicators and left ventricular function and infarct size at 1-month after reperfused STEMI

Background

The restoration of the coronary microcirculation in ST-segment elevation myocardial infarction (STEMI) patients remains hampered in up to 50% of the STEMI patients after successful primary percutaneous coronary intervention (PCI). The association between the coronary microvascular function and injury indicators and functional outcome remains debated.

Purpose

This study aims to investigate the relation between post-PCI invasive microvascular function and cardiovascular magnetic resonance (CMR)-derived microvascular injury indicators and left ventricular (LV) function and infarct size (IS) at 1-month after STEMI.

Methods

The study was performed in 110 STEMI patients who underwent angiography for primary PCI and at 1-month follow-up. Invasive assessment of coronary microcirculation physiology in the culprit artery was performed during both procedures and included coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR). Data were available for 101 patients. A ratio of &gt;2 for CFR and a value of &lt;25 U for IMR were considered normal. CMR was performed during the acute phase (2 to 7 days after PCI) and at 1-month and provided assessment of LV function, IS and non-invasive information of microvascular injury in 78 patients by microvascular obstruction (MVO) and intra-myocardial hemorrhage (IMH).

Results

Over 1-month, CFR, IMR, LV function, and IS all significantly improved (p≤0.001). In univariable linear regression analysis, the post-PCI normal index CFR and IMR (both p=0.04), MVO presence, MVO size, IMH presence, IMH size (all, p&lt;0.001) were significantly associated with LV ejection fraction at 1-month. Additionally, the post-PCI index CFR (p=0.04), MVO presence, MVO size, IMH presence, IMH size (all, p&lt;0.001) were all associated with 1-month IS. In a multivariable linear regression analysis model including invasive and non-invasive coronary microcirculation function and injury indicators, MVO presence was identified as the only independent marker related to both 1-month LV ejection fraction and IS (both p&lt;0.001).

Conclusion(s)

In STEMI patients, CMR-derived coronary microcirculation injury indicators reveal a closer association with 1-month LV function and IS outcome than invasive microcirculatory measurements. MVO presence is independently associated with 1-month LV ejection fraction and IS.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The REDUCE-MVI study was funded by Astra Zeneca to MvL and NvR.

Residual quantitative flow ratio to estimate post-intervention fractional flow reserve

Objective

To assess the performance of residual quantitative flow ratio (QFR) to estimate post percutaneous coronary intervention (PCI) fractional flow reserve (FFR).

Background

QFR computes FFR based on invasive coronary angiography (ICA) images. Residual QFR is a novel tool that assesses the functional outcome of an intervention by estimating post-PCI FFR.

Methods

Residual QFR analyses, using pre-PCI ICA images, were attempted in 159 vessels with post-PCI FFR measurements. QFR lesion location was matched with the treated segment to allow virtual removal of the lesion similar to the performed PCI and computation of residual QFR (Picture 1: case example of residual QFR analysis). A post-PCI FFR &lt;0.90 was used to define a suboptimal PCI result.

Results

Residual QFR computation was successful in 128 (81%) vessels. Median residual QFR was higher than post-PCI FFR (0.96 interquartile range (IQR): 0.91–0.99 vs. 0.91 IQR: 0.86–0.96, p&lt;0.001). A moderate correlation and agreement was observed between residual QFR and post-PCI FFR (Spearman correlation coefficient=0.56 and Intraclass correlation coefficient=0.47, p&lt;0.001 for both). Following PCI, an FFR &lt;0.90 was observed in 54 (42%) vessels. Specificity, positive predictive value, sensitivity, and negative predictive value of residual QFR for determining a suboptimal PCI result were 96% (95% confidence interval (CI): 87–99%), 89% (95% CI: 72–96%), 44% (95% CI: 31–59%), and 70% (95% CI: 65–75%), respectively. Overall, residual QFR had an accuracy of 74% (95% CI: 66–82%) and an area under the receiver operating characteristic curve of 0.79 for assessing a post PCI FFR &lt;0.90.

Conclusion

A moderate correlation and agreement between residual QFR and post-PCI FFR was observed. Residual QFR ≥0.90 does not necessarily commensurate with an optimal PCI result. However, residual QFR &lt;0.90 is a good indicator of a post-PCI FFR &lt;0.90 and might therefore be utilized to determine PCI location in order to obtain a satisfactory PCI result (Picture 2: central illustration).

Funding Acknowledgement

Type of funding sources: None. Case example of residual QFR analysisCentral illustration

O-103 The impact of the COVID-19 pandemic on infertility and endometriosis patients in the Netherlands: The use of telemedicine, quality of life and patient-centeredness

Study question

How do infertility patients, endometriosis patients and health care providers rate the virtual care that was provided during the first lockdown of the COVID-19 pandemic?

Summary answer

Patients and health care providers rate telephone- and video consultations as good alternatives during the pandemic but it cannot replace future physical consultations.

What is known already

Virtual alternatives to regular care such as telephone and video consultations are gaining more attention as replacement for physical consultations and are ideal for use in a social distancing situation as the COVID-19 pandemic. However, infertility and endometriosis patients often rely on physical consultations for reassurance as well as for treatments such as artificial reproductive technology and surgery. Not being able to receive these reassurances and treatments may cause stress especially as infertility patients are known to experience a high sense of urgency to obtain treatment. For patients with endometriosis, regular follow-up visits are important for continuity of care.

Study design, size, duration: A cross-sectional cohort study was performed, including 555 patients and 101 health care providers in the field of infertility and endometriosis in the Netherlands. Online questionnaires were sent between May and October 2020.

Participants/materials, setting, methods

Patients with infertility and endometriosis patients from a university hospital and members of the respective national patients organizations, as well as health care providers in the fields of infertility and endometriosis were asked to participate. The questionnaires consisted of demographics, appraisal of telephonic and video consultations (TCs and VCs) and assessment of fertility related quality of life (FertiQoL) and patient-centeredness of endometriosis care (ENDOCARE).

Main results and the role of chance

The questionnaires were completed by 374 infertility patients, 181 endometriosis patients and 101 health care providers. 75.9% of the infertility patients, 64.8% of the endometriosis patients and 82.7% of the health care providers rated TCs as a good alternative for physical consultations during the COVID-19-pandemic. Only 21.3%, 14.8% and 21.3% rated TCs as a good replacement of physical consultations in general. 76.6% and 35.9% of the infertility and endometriosis patients reported to experience an increase in stress due to the altered care during the COVID-19 pandemic. 38.7% and 58.0% reported to have received sufficient information from their care givers. Infertility patients scored lower on the FertiQoL than the reference population, while the ENDOCARE results of endometriosis patients were comparable to the reference.

Limitations, reasons for caution

This study was limited to the Dutch population. As the organization of infertility care varies internationally, the results will not be directly applicable to other countries or health care systems.

Wider implications of the findings: Virtual care options are a good alternative for infertility and endometriosis patients in situations where physical consultations are not possible. Self-reported stress is especially high in infertility patients during the COVID-19-pandemic. Health care providers should provide more information to patients in order to increase their ability to cope with stress.

Trial registration number

N/A

Impact of coronary revascularization on regional artery-specific coronary flow capacity: a serial [15O]H2O positron emission tomography perfusion imaging study

Funding Acknowledgements

Type of funding sources: None.

Background. Coronary flow capacity (CFC) combines absolute hyperemic myocardial blood flow (hMBF) and coronary flow reserve (CFR) in a graphical representation of the severity of myocardial perfusion impairment. Studies evaluating the impact of coronary revascularization on CFC as assessed by [15O]H2O positron emission tomography (PET) are lacking.

Purpose. The present study explored the impact of coronary revascularization on regional, artery-specific CFC as assessed by [15O]H2O PET.

Methods. A total of 315 patients (mean age 62 ± 10 years) underwent absolute myocardial perfusion imaging at baseline and directly after either percutaneous or surgical coronary revascularization (at 110 ± 50 days). Revascularized perfusion regions were stratified in 3 CFC groups at baseline: severely reduced CFC (defined as myocardial ischemia), moderately reduced CFC and normal CFC.

Results. Baseline CFC was severely reduced in 262 vessels (70%), moderately reduced in 95 vessels (25%) and normal in 17 vessels (5%). Regional, artery-specific CFC, hMBF and CFR improved after successful revascularization (P &lt; 0.01). In 127/262 regions, CFC increased from severely reduced to moderately reduced and in 29/262 to normal flow after revascularization (p &lt; 0.01 for both). Additionally, 28/95 revascularized regions increased from moderately reduced to normal flow (P = 0.18). Changes in hMBF (severe vs. moderate vs. normal: 0.84 ± 0.73; 0.41 ± 0.60 and 0.35 ± 0.84 mL·min-1·g-1 ) and CFR (0.92 ± 0.83; 0.49 ± 1.00 and -0.39 ± 1.15) were significantly different comparing baseline CFC groups (both p &lt; 0.01). Furthermore, mixed-model analysis including traditional CAD risk factors revealed that baseline CFC and gender were independent predictors of changes in CFC, hMBF and CFR between baseline and follow-up.

Conclusions. Successful revascularization demonstrated a significant and positive impact on regional, artery-specific CFC, hMBF and CFR. Improvements were largest among lower baseline CFC groups. Furthermore, baseline CFC was an independent predictor of change in CFC, hMBF and CFR. These results suggest that the assessment of flow capacity by [15O]H2O PET prior to revascularization may aid in the selection of regions in which absolute myocardial perfusion is most likely to improve.

Abstract Figure 1.

Evolution of coronary artery calcium and absolute myocardial perfusion after percutaneous revascularization: a 3-year serial hybrid [15O]H2O PET/CT imaging study

Funding Acknowledgements

Type of funding sources: None.

Background. The value of serial coronary artery calcium (CAC) scores to predict changes in absolute myocardial perfusion and epicardial vasomotor function is poorly documented.

Purpose. This study explored the association between progression of CAC score and changes in absolute myocardial perfusion.

Methods. Fifty-three patients with single-vessel coronary artery disease (CAD) underwent [15O]H2O Positron Emission Tomography/Computed Tomography at 1 month (baseline), 1 year, and 3 years after percutaneous coronary intervention (PCI) to assess CAC scores, hyperemic myocardial blood flow (hMBF), coronary flow reserve (CFR) and cold pressor test MBF (CPT-MBF), within the context of the VANISH (Impact of Vascular Reparative Therapy on Vasomotor Function and Myocardial Perfusion) trial. Relationships between baseline CAC score and evolution of perfusion indices were explored with a mixed model-analysis.

Results. Baseline CAC score was 0 in 9%, 0.1-99.9 in 40%, 100-399.9 in 36% and ≥400 in 15% of patients, respectively. In higher baseline CAC groups, scores increased more over time (overall p &lt; 0.01). Mixed model-analysis allowed for averaging perfusion indices over all time points: hMBF (3.74 ± 0.83; 3.33 ± 0.79; 3.08 ± 0.78 and 2.44 ± 0.74 mL·min-1·g-1) and CFR (3.82 ± 1.12; 3.17 ± 0.80; 3.19 ± 0.81; 2.63 ± 0.92) were lower among higher baseline CAC  groups (p &lt; 0.01; p = 0.03). However, no significant interaction was found between baseline CAC groups and time after PCI for all perfusion indices, denoting that evolution of perfusion indices over time were not significantly different between CAC groups. Furthermore, CAC progression was not correlated with evolution of hMBF (r = 0.08, p = 0.57), CFR (r = 0.09, p = 0.53) or CPT-MBF (r = 0.03, p = 0.82) during 3 years follow-up.

Conclusions. Higher baseline CAC was associated with lower hMBF and CFR. However, both baseline CAC and its progression were not associated with evolution of absolute hMBF, CFR and CPT-MBF over time, suggesting that CAC score and progression of CAC are poor indicators of change in absolute myocardial perfusion.

A computed tomography algorithm for crossing coronary chronic total occlusions: riding on the wave of the proximal cap and distal vessel segment

With wider adoption of coronary computed tomography angiography (coronary CTA), chronic total occlusions (CTOs) are being increasingly identified and characterised by non-invasive angiography. In particular, the ability of coronary CTA to clearly delineate atherosclerotic plaque, as well as to display three-dimensional vessel trajectories, has garnered particular attention in the context of preprocedural planning and periprocedural guidance of CTO percutaneous coronary intervention (PCI). Single CTO features and combined scoring systems derived from CTA (mostly exceeding the diagnostic performance of the angiographic J‑CTO score) have been used to predict time-efficient guidewire crossing, and thus grade the CTO difficulty level prior to PCI. In addition, the introduction of three-dimensional CTA/fluoroscopy co-registration for periprocedural navigation during CTO PCI offers the unprecedented opportunity to resolve proximal cap ambiguity and clearly visualise the distal CTO segment, thereby potentially influencing CTO PCI strategies and techniques. In this review, the potential advantages of non-invasive evaluation of CTO by coronary CTA are described, and a CTA-based hybrid algorithm is introduced for further enhancing the efficiency of CTO PCI. Further studies are clearly needed to verify the proposed approach. However, several luminary operators have already implemented coronary CTA for planning and periprocedural guidance of CTO interventions using the hybrid algorithm.

Ischemic burden reduction after chronic total occlusion percutaneous coronary intervention related to patient prognosis

Background

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) leads to major reductions in ischemic burden. However, to date, studies investigating if more ischemia reduction after CTO PCI translates into an improved patient prognosis, are lacking.

Purpose

To evaluate if change in absolute myocardial perfusion after CTO PCI is related to patient prognosis.

Methods

Between 2013–2019, 219 prospectively recruited patients with a CTO underwent quantitative [15O]H2O positron emission tomography perfusion imaging before and 3 months after successful CTO PCI in a single high-volume CTO PCI center (175 procedures/year). Changes in perfusion defect size (in myocardial segments) and hyperemic myocardial blood flow (MBF, in mL min–1 g–1) within the CTO territory after PCI were related to the combined endpoint of death or myocardial infarction (MI). Kaplan-Meier curves (log-rank test) and multivariable Cox regression (including covariates age, gender, prior MI, and left ventricular function) were used to analyze unadjusted and risk-adjusted event-free survivals with HR [95% CI].

Results

Out of 213 (97%) patients with a median follow-up of 3.2 [2.1–4.7] years, 22 (10%) patients experienced the composite of death (19, 9%) or MI (5, 2%). Event-free survival was significantly improved in patients with a perfusion defect size reduction of ≥3 segments (N=132, 62%) after CTO PCI compared to &lt;3 segments (p=0.01, risk-adjusted: p=0.02 with HR 0.36 [0.15–0.87]), as well in patients with increase in hyperemic MBF above the median of the population (delta &gt;1.13 mL min–1 g–1) as compared to below the median (p&lt;0.01, risk-adjusted: p=0.01 with HR 0.27 [0.10–0.75]). After PCI, patients with ≥1 segment residual perfusion defect size in the CTO territory at follow-up (N=114, 54%) had a significantly worse event-free survival compared to patients with no residual defect size (p&lt;0.01, risk-adjusted: p=0.01 with HR 4.12 [1.35–12.59]), whereas patients with a residual hyperemic MBF &gt;2.30 mL min–1 g–1 (N=105, 49%) showed a better event-free survival compared to patients with lower residual hyperemic MBF levels (p=0.02, risk-adjusted: p=0.04 with HR 0.33 [0.12–0.95]).

Conclusions

Patients with more ischemic burden reduction and less residual ischemia following CTO PCI showed a major improved survival free of death or MI. A limitation was the low absolute number of events that prohibited more extensive risk-adjustment of the analyses.

Funding Acknowledgement

Type of funding source: None

Infarct characteristics and outcome of patients with transient ST-segment elevation myocardial infarction compared to ST-segment and non-ST-segment elevation myocardial infarction

Background

Up to one out of four patients with signs of ST-segment elevation myocardial infarction (STEMI) express complete normalization of ST elevation before primary revascularization procedure. This condition is commonly referred to as “transient ST-segment elevation myocardial infarction” (TSTEMI) and recent data suggests that this group of patients may have favorable outcome compared to STEMI patients. However, it is currently unknown how these patients compare to both STEMI and non-ST-segment elevation myocardial infarction (NSTEMI) patients with respect to infarct size characteristics and outcome.

Objective

This study aims to explore cardiac magnetic resonance (CMR) derived scar tissue and 1-year outcome in patients with TSTEMI by comparison to STEMI and NSTEMI.

Methods

Patients with STEMI were enrolled from two prospective studies (n=170); the patients with TSTEMI were recruited from the TRANSIENT trial (n=141); the patients with NSTEMI were prospectively and consecutively collected from local registries of Amsterdam UMC (n=57) and Maastricht UMC (n=51). All patients underwent CMR examination 2–8 days after the index event. Cine imaging was done for volume and function assessment. Late gadolinium enhancement imaging was performed to identify infarct size (in grams) and the presence of microvascular obstruction (MVO). All CMR images were processed in a single core laboratory (Amsterdam UMC). Clinical outcome after 1 year was measured by the incidence of major adverse cardiac events (MACE), defined as recurrent myocardial infarction (MI), revascularization and all cause death.

Results

The TSTEMI group demonstrated the lowest end-systolic left ventricular volume and highest left ventricular ejection fraction across the groups (overall p&lt;0.001). Although there was a remarkably lower infarct size in TSTEMI patients compared to STEMI (1.41g [0.00–3.91] vs 13.48g [5.31–26.81], p&lt;0.001), there was only a trend towards lower infarct size compared to NSTEMI patients (1.41g [0.00–3.91] vs 2.13g [0.00–8.64], p=0.06). Whilst MVO was observed less frequently in TSTEMI compared to STEMI patients (5 (4%) vs 53 (31%), p&lt;0.001), no significant difference was seen between TSTEMI and NSTEMI patients (5 (4%) vs 5 (5%), p=0.72). Multivariable linear regression analysis identified infarct type, smoking, peak troponin-T and pre-PCI TIMI flow as predictors for infarct size (p=0.03, p=0.03, p&lt;0.001 and p&lt;0.001, respectively). One-year mortality rate was low in all 3 MI types (TSTEMI 3 (2.2%), NSTEMI 3 (3.1%), 4 (2.4%), log-rank test p=0.91). However, there was a significant difference in MACE at 1 year across the 3 MI types (TSTEMI 18 (13.2%), NSTEMI 19 (19.4%), STEMI 11 (6.7%), overall p&lt;0.01).

Conclusion

In comparison to NSTEMI and STEMI, TSTEMI yielded favorable cardiac left ventricular function and scar mass. However, this did not lead to benefit in short term (1-year) outcome; further studies are needed with longer follow-up.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): European Association of Cardiovascular Imaging (EACVI) Research Grant

Viability and functional recovery after chronic total occlusion percutaneous coronary intervention

Background

Current guidelines advocate viability assessment to guide percutaneous coronary intervention (PCI) of chronic coronary total occlusions (CTO).

Purpose

Aim of the present study was to evaluate viability as well as global and regional functional recovery after successful CTO PCI using quantitative cardiac magnetic resonance (CMR) imaging.

Methods

132 patients with sequential CMR at baseline and 3-months after successful CTO PCI were prospectively recruited between 2013 and 2018. Segmental wall thickening (SWT) and percentage late gadolinium enhancement (LGE) were quantitatively measured per segment. Viability was defined as dysfunctional myocardium (&lt;2.84mm SWT) with no or limited scar (≤50% LGE).

Results

Significant improvements in left ventricular (LV) ejection fraction (from 48.1±11.8 to 49.5±12.1%, p&lt;0.01), LV end-diastolic volume (from 99.1±31.8 to 95.7±30.2ml, p&lt;0.01), and LV end-systolic volume (from 54.4±30.5 to 51.2±29.3ml, p&lt;0.01) were observed after CTO PCI. CTO segments with viability (N=216, (31%)) demonstrated a significantly higher increase in SWT (0.80±1.39mm) compared to CTO segments with pre-procedural preserved function (N=456 (65%), 0.07±1.43mm, p&lt;0.01) or extensive scar (LGE &gt;50%, N=26 (4%), −0.08±1.09mm, p&lt;0.01). Improvement in SWT was comparable between segments with viability if further stratified to 0, &gt;0–25, and &gt;25–50% hyperenhancement (p=0.94). Patients with ≥2 CTO segments viability showed more SWT increase in the CTO territory compared to patients with 0–1 segment viability (0.49±0.93 vs. 0.12±0.98mm, p=0.03).

Conclusions

Improvements in LV function and volumes were significant but modest following CTO PCI. Detection of dysfunctional myocardial segments without extensive scar (≤50% LGE) as a marker for viability may aid in identifying subjects with significant regional functional recovery after CTO PCI.

Funding Acknowledgement

Type of funding source: None

Prophylactic veno-arterial extracorporeal membrane oxygenation in patients undergoing high-risk percutaneous coronary intervention

PURPOSE

Complex high-risk percutaneous coronary intervention (PCI) is challenging and frequently accompanied by haemodynamic instability. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide cardiopulmonary support in high-risk PCI. However, the outcome is unclear.

METHODS

A two-centre, retrospective study was performed of all patients undergoing high-risk PCI and receiving VA-ECMO for cardiopulmonary support.

RESULTS

A total of 14 patients (92% male, median age 69 (53-83) years), of whom 50% had previous coronary artery disease in the form of a coronary artery bypass graft (36%) and a PCI (14%) underwent high-risk PCI and received VA-ECMO support. The main target lesion was a left main coronary artery in 78%, a left anterior descending artery in 14%, a right coronary artery in 7%, and 71% underwent multi-vessel PCI in addition to main target vessel PCI. The median SYNTAX score was 27.2 (8-42.5) and in 64% (9/14) there was a chronic total occlusion. Left ventricular function was mildly impaired in 7% (1/14), moderately impaired in 14% (2/14) and severely impaired in 64% (9/14). Cannulation was femoral-femoral in all patients. Median ECMO run was 2.57 h (1-4). Survival was 93% (13/14). One patient died during hospitalisation due to refractory cardiac failure. All other patients survived to discharge. Complications occurred in 14% (2/14), with one patient developing a transient ischaemic attack post-ECMO and one patient developing a thrombus in the femoral vein used for ECMO cannulation.

CONCLUSION

VA-ECMO in high-risk PCI is feasible with a good outcome. It can be successfully used for cardiopulmonary support in selected patients.

P3126Immediate versus delayed revascularization in patients with transient ST-elevation myocardial infarction: 1-year follow-up of the randomized clinical TRANSIENT trial

Background

Up to 24% of acute coronary syndrome patients present with ST-elevation but show complete resolution of ST-elevation and symptoms before revascularization. The current guidelines do not clearly state whether these transient ST-elevation myocardial infarction (TSTEMI) patients should be treated with a ST-elevation myocardial infarction (STEMI)-like or a non-STEMI-like invasive approach.

Purpose

The aim of the present study is to determine the effect of an immediate versus a delayed invasive strategy on infarct size measured by 4-month cardiac magnetic resonance imaging (CMR) and clinical outcome up to one year.

Methods

In this multicenter trial, 142 TSTEMI patients were randomized 1:1 to either an immediate or a delayed intervention. CMR was performed at four days and at 4-month follow-up to assess infarct size and myocardial function. Clinical follow-up was performed at four months and one year.

Results

Both in the immediate (0.4 h) and the delayed invasive group (22.7 h) CMR-derived infarct size at four months was very small and left ventricular function was good. In addition, major adverse cardiac events and all-cause mortality at one year were low and not different between both groups (table 1).

CMR and clinical outcomes up to one year Outcome Immediate invasive group (n=70) Delayed invasive group (n=72) p-value Myocardial infarct size (% of LV), median (IQR) 0.4 (0.0–3.5) 0.4 (0.0–2.5) 0.79 LVEF (%), mean ± SD 59.9±5.4 59.3±6.5 0.63 LVEF recovery (%), mean ± SD 2.2±5.4 1.7±5.3 0.66 MVO present, No. (%) 0 (0.0) 1 (1.9) 0.50 MACE (death, reinfarction, target lesion revascularization), No. (%) 3 (4.4) 4 (5.7) 1.00 Death from any cause, No. (%) 0 (0.0) 3 (4.3) 0.24 Reinfarction, No. (%) 2 (3.0) 1 (1.4) 0.62 Target lesion revascularization, No. (%) 2 (3.0) 1 (1.4) 0.62 Definite stent thrombosis, No. (%) 1 (1.5) 1 (1.4) 1.00 Abbreviations: IQR, interquartile range; LV, left ventricle; LVEF, left ventricle ejection fraction; MACE, major adverse cardiac events; MVO, microvascular obstruction; NA, not applicable; SD, standard deviation.

Conclusions

We demonstrated that patients with TSTEMI have limited infarct size and preserved left ventricular function and that an immediate or delayed approach has no effect on clinical outcome up to one year. Therefore, patients with TSTEMI can be treated with both an immediate or a delayed invasive strategy with similar outcome. These findings extend our current knowledge about the optimal timing of coronary intervention in patients with TSTEMI and complement the guidelines.

Acknowledgement/Funding

AstraZeneca, Biotronik

P964Relationships between extent of ischemic burden and changes in absolute myocardial perfusion after chronic total occlusion percutaneous coronary intervention

Background

The patient benefits after chronic coronary total occlusion (CTO) percutaneous coronary intervention (PCI) are being questioned.

Purpose

The present study explored the relationships between baseline ischemic burden findings and subsequent changes in absolute myocardial perfusion after CTO PCI.

Methods

Consecutive patients underwent serial [15O]H2O positron emission tomography perfusion imaging prior and 3 months after successful CTO PCI. Change in perfusion defect size (in myocardial segments), quantitative (hyperemic) myocardial blood flow (MBF) and coronary flow reserve (CFR) in the CTO area were compared between patients with a limited (0–1 segment), moderate (2–3 segments) and large perfusion defect (≥4 segments).

Results

193 patients were included, with 15, 61 and 117 patients having a limited, moderate and large perfusion defect at baseline. Hyperemic MBF and CFR were lower in a large perfusion defect compared to smaller defects (all comparisons p&lt;0.01). The median decrease in defect size was 1 [0–1] vs 2 [1–3] vs 4 [2–5] in patients with a limited, moderate and large defect (all comparisons p&lt;0.01), whereas hyperemic MBF and CFR improved significantly regardless of baseline defect size (between groups p=0.45 and p=0.55, respectively). Furthermore, when all 193 patients were divided in a low, median and high tertile based on hyperemic MBF and CFR at baseline, changes in hyperemic MBF and CFR after CTO PCI were comparable between patients in different tertiles (between groups p=0.75 and p=0.79, respectively)

Conclusions

Patients with a CTO and a larger perfusion defect have more severe hyperemic MBF and CFR levels. Major reductions in ischemic burden can be achieved by CTO PCI, with more defect size reduction in patients with a larger perfusion defect, whereas hyperemic MBF and CFR significantly improve irrespective of starting values before PCI.

Acknowledgement/Funding

None

P5748Impact of specific crossing techniques in chronic total occlusion percutaneous coronary intervention on recovery of absolute myocardial perfusion

Background

Multiple techniques in chronic coronary total occlusion (CTO) percutaneous coronary intervention (PCI) have been developed to cross CTOs.

Purpose

To compare recovery of quantitative myocardial blood flow (MBF) after different CTO PCI techniques.

Methods

Consecutive patients with [15O]H2O positron emission tomography perfusion imaging before and three months after successful CTO PCI were included. Change in quantitative hyperemic MBF, coronary flow reserve (CFR) and perfusion defect size were compared between antegrade wire escalation (AWE), retrograde wire escalation (RWE), antegrade dissection and reentry (ADR) and retrograde dissection and reentry (RDR), and further between specific subintimal crossing and reentry techniques.

Results

193 patients were treated with AWE (N=90), RWE (N=24), ADR (N=35) and RDR (N=44). Significant improvements (all p<0.01) in hyperemic MBF (1.19±0.77, 0.94±0.65, 1.09±0.63, and 1.02±0.75 mL min–1 g–1, respectively), CFR (1.34±1.08, 1.14±1.09, 1.31±0.96, and 1.24±0.99, respectively), and perfusion defect size (3.17±2.13, 3.00±2.21, 2.74±2.09, and 2.93±1.92 segments, respectively) were comparable between the four approaches (p=0.40, p=0.84, and p=0.77, respectively). Recovery of hyperemic MBF was less pronounced after subintimal crossing with a knuckle-wire-technique compared to the use of CrossBoss in controlled ADR and RDR (p=0.02), and less after reentry with subintimal tracking and reentry (STAR) in ADR compared with controlled ADR (Stingray) or limited antegrade subintimal tracking (LAST) (p=0.02 and p<0.01).

Conclusions

Recovery of hyperemic MBF, CFR, and perfusion defect size was significant after CTO PCI and comparable between different crossing techniques. Improvement of hyperemic MBF was inferior after using the knuckle-wire subintimal crossing technique and STAR compared to other subintimal crossing and reentry techniques.

Acknowledgement/Funding

None

P6002Impaired peripheral endothelial function is associated with microvascular injury assessed by cardiac magnetic resonance imaging and decreased coronary flow in patients with STEMI

Background

Microvascular injury (MVI) occurs in about 50% of successfully revascularized ST-elevation myocardial infarction (STEMI) patients and is associated with a decreased clinical outcome. MVI results from myocardial reperfusion injury, subsequent inflammation and coronary endothelial dysfunction. A correlation between peripheral and coronary endothelial function has been suggested and peripheral endothelial dysfunction is associated with the occurrence of cardiovascular events. Therefore we hypothesize a relation between peripheral and coronary endothelial function.

Purpose

The primary aim of our study was to assess the relationship between peripheral endothelial function and microvascular injury in successfully resvascularized STEMI patients.

Methods

Peripheral endothelial function and laboratory values were measured in the acute and stable setting (at 1 year follow-up). Reactive hyperemia-pulse amplitude tomography on the index finger was used to assess peripheral endothelial function by means of the reactive hyperemia index (LnRHI). After revascularization of the culprit vessel, we measured intracoronary coronary flow reserve (CFR). Cardiac magnetic resonance imaging (CMR) at day 5 evaluated the occurrence of MVI defined as microvascular obstruction (MVO) or intramyocardial hemorrhage. Myocardial salvage index (MSI) was calculated as (area at risk − final infarct size) / area at risk.

Results

We included 110 STEMI patients with the age of 60.1±9.5 years. Acute LnRHI was 0.56±0.33 and stable LnRHI was 0.64±0.27 (p=0.070). In the acute setting, LnRHI was impaired in patients with MVI compared to patients without MVI (0.44±0.37 vs. 0.61±0.34, p=0.045). The quantity of MVO (in grams) correlated with acute LnRHI (rho=-0.24, p=0.028). Acute LnRHI correlated to CFR in the revascularized culprit vessel (rho=0.25, p=0.015). In patients with decreased coronary blood flow after successful revascularization (TIMI-flow≤2), stable LnRHI was decreased (0.51±0.36 vs. 0.67±0.24, p=0.019). Stable LnRHI correlated to MSI (rho=0.28, p=0.020). Acute LnRHI correlated to leukocyte count (rho=-0.21, p=0.028) and LDH (rho=-0.25, p=0.018). LnRHI was impaired in patients who were hospitalized during 1 year follow-up (0.45±0.35 vs. 0.66±0.25, p=0.024).

Conclusion(s)

In patients with successfully revascularized STEMI, impaired peripheral endothelial function is associated with microvascular injury, decreased coronary flow and an increased inflammatory status. Furthermore, impaired peripheral endothelial function was associated with the occurrence of clinical events.

Safety and long-term effects of renal denervation: Rationale and design of the Dutch registry

BACKGROUND

Percutaneous renal denervation (RDN) has recently been introduced as a treatment for therapy-resistant hypertension. Also, it has been suggested that RDN may be beneficial for other conditions characterised by increased sympathetic nerve activity. There are still many uncertainties with regard to efficacy, safety, predictors for success and long-term effects. To answer these important questions, we initiated a Dutch RDN registry aiming to collect data from all RDN procedures performed in the Netherlands.

METHODS

The Dutch RDN registry is an ongoing investigator-initiated, prospective, multicentre cohort study. Twenty-six Dutch hospitals agreed to participate in this registry. All patients who undergo RDN, regardless of the clinical indication or device that is used, will be included. Data are currently being collected on eligibility and screening, treatment and follow-up.

RESULTS

Procedures have been performed since August 2010. At present, data from 306 patients have been entered into the database. The main indication for RDN was hypertension (n = 302, 99%). Patients had a mean office blood pressure of 177/100 (±29/16) mmHg with a median use of three (range 0-8) blood pressure lowering drugs. Mean 24-hour blood pressure before RDN was 157/93 (±18/13) mmHg. RDN was performed with different devices, with the Simplicity™ catheter currently used most frequently.

CONCLUSION

Here we report on the rationale and design of the Dutch RDN registry. Enrolment in this investigator-initiated study is ongoing. We present baseline characteristics of the first 306 participants.

Intrauterine insemination or intracervical insemination with cryopreserved donor sperm in the natural cycle: a cohort study

STUDY QUESTION

Does intrauterine insemination in the natural cycle lead to better pregnancy rates than intracervical insemination (ICI) in the natural cycle in women undergoing artificial insemination with cryopreserved donor sperm.

SUMMARY ANSWER

In a large cohort of women undergoing artificial insemination with cryopreserved donor sperm, there was no substantial beneficial effect of IUI in the natural cycle over ICI in the natural cycle.

WHAT IS KNOWN ALREADY

At present, there are no studies comparing IUI in the natural cycle versus ICI in the natural cycle in women undergoing artificial insemination with cryopreserved donor sperm.

STUDY DESIGN, SIZE, DURATION

We performed a retrospective cohort study among all eight sperm banks in the Netherlands. We included all women who underwent artificial insemination with cryopreserved donor sperm in the natural cycle between January 2009 and December 2010. We compared time to ongoing pregnancy in the first six cycles of IUI and ICI, after which controlled ovarian stimulation was commenced. Ongoing pregnancy rates (OPRs) over time were compared using life tables. A Cox proportional hazard model was used to compare the chances of reaching an ongoing pregnancy after IUI or ICI adjusted for female age and indication.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included 1843 women; 1163 women underwent 4269 cycles of IUI and 680 women underwent 2345 cycles of ICI with cryopreserved donor sperm.

MAIN RESULTS AND THE ROLE OF CHANCE

Baseline characteristics were equally distributed (mean age 34.0 years for the IUI group versus 33.8 years for the ICI group), while in the IUI group, there were more lesbian women than in the ICI group (40.6% for IUI compared with 31.8% for ICI). Cumulative OPRs up to six treatment cycles were 40.5% for IUI and 37.9% for ICI. This corresponds with a hazard rate ratio of 1.02 [95% confidence interval (CI) 0.84-1.23] after controlling for female age and indication. Increasing female age was associated with a lower OPR, in both the IUI and ICI groups with a hazard ratio for ongoing pregnancy of 0.94 per year (95% CI 0.93-0.97).

LIMITATIONS, REASONS FOR CAUTION

This study is prone to selection bias due to its retrospective nature. As potential confounders such as parity and duration of subfertility were not registered, the effect of these potential confounders could not be evaluated.

WIDER IMPLICATIONS OF THE FINDINGS

In women inseminated with cryopreserved donor sperm in the natural cycle, we found no substantial benefit of IUI over ICI. A randomized controlled trial with economic analysis alongside, it is needed to allow a more definitive conclusion on the cost-effectiveness of insemination with cryopreserved donor sperm.

STUDY FUNDING/COMPETING INTERESTS

No funding was used and no conflicts of interest are declared.

ESHRE guideline: management of women with endometriosis

STUDY QUESTION

What is the optimal management of women with endometriosis based on the best available evidence in the literature?

SUMMARY ANSWER

Using the structured methodology of the Manual for ESHRE Guideline Development, 83 recommendations were formulated that answered the 22 key questions on optimal management of women with endometriosis.

WHAT IS KNOWN ALREADY

The European Society of Human Reproduction and Embryology (ESHRE) guideline for the diagnosis and treatment of endometriosis (2005) has been a reference point for best clinical care in endometriosis for years, but this guideline was in need of updating.

STUDY DESIGN, SIZE, DURATION

This guideline was produced by a group of experts in the field using the methodology of the Manual for ESHRE Guideline Development, including a thorough systematic search of the literature, quality assessment of the included papers up to January 2012 and consensus within the guideline group on all recommendations. To ensure input from women with endometriosis, a patient representative was part of the guideline development group. In addition, patient and additional clinical input was collected during the scoping and review phase of the guideline.

PARTICIPANTS/MATERIALS, SETTING, METHODS

NA.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 83 recommendations on diagnosis of endometriosis and on the treatment of endometriosis-associated pain and infertility, on the management of women in whom the disease is found incidentally (without pain or infertility), on prevention of recurrence of disease and/or painful symptoms, on treatment of menopausal symptoms in patients with a history of endometriosis and on the possible association of endometriosis and malignancy.

LIMITATIONS, REASONS FOR CAUTION

We identified several areas in care of women with endometriosis for which robust evidence is lacking. These areas were addressed by formulating good practice points (GPP), based on the expert opinion of the guideline group members.

WIDER IMPLICATIONS OF THE FINDINGS

Since 32 out of the 83 recommendations for the management of women with endometriosis could not be based on high level evidence and therefore were GPP, the guideline group formulated research recommendations to guide future research with the aim of increasing the body of evidence.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the implementation of the guideline. The guideline group members did not receive payment. All guideline group members disclosed any relevant conflicts of interest (see Conflicts of interest).

TRIAL REGISTRATION NUMBER

NA.

Triphasic pattern in the ex vivo response of human proliferative phase endometrium to oestrogens

The aim of this study was to evaluate the ex vivo oestrogen responsiveness of human proliferative phase endometrium using short-term explant cultures. The effects of oestrogen (17beta-E2) on proliferation and the expression of oestrogen-responsive genes known to be involved in regulating endometrial function were evaluated. Three distinct response patterns could be distinguished: (1) the menstrual (M) phase pattern (cycle days 2-5), which is characterised by a complete lack in the proliferative response to 17beta-E2, while an increased expression of AR (2.6-fold, P<0.01), PR (2.7-fold, P<0.01) and COX-2 (3.5-fold, P<0.01) at the mRNA level was observed and a similar upregulation was also found for AR, PR and COX-2 at the protein level; (2) the early proliferative (EP) phase pattern (cycle days 6-10) with 17beta-E2 enhanced proliferation in the stroma (1.7-fold, P<0.05), whereas the expression of AR, PR and COX-2 were not affected at the mRNA and protein levels and ER-alpha mRNA and protein levels were significantly reduced by 17beta-E2; (3) the late proliferative (LP) phase pattern (cycle days 11-14), which is characterised by a moderate stimulation of proliferation (1.4-fold, P<0.05) and PR mRNA expression (1.7-fold, P<0.01) by 17beta-E2. In conclusion, three distinct response patterns to 17beta-E2 could be identified with respect to proliferation and the expression of known oestrogen-responsive genes in human proliferative phase endometrium explant cultures.

AT1-receptor blockade and sympathetic neurotransmission in cardiovascular disease

1. The present survey is dealing with the interactions between the renin-angiotensin-aldosterone system (RAAS) and the sympathetic nervous system (SNS) in various organs and tissues, with an emphasis on the angiotensin AT-receptors located at the sympathetic nerve endings. 2. Angiotensin II, the main effector of the RAAS is known to stimulate sympathetic nerve traffic and its sequelae in numerous organs and tissues, such as the central nervous system, the adrenal medulla, the sympathetic ganglia and the sympathetic nerve endings. These stimulatory effects are mediated by AT(1)-receptors and counteracted by AT(1)-receptor antagonists. 3. Sympatho-inhibition at the level of the sympathetic nerve ending appears to be a class effect of the AT(1)-receptor blockers, mediated by presynaptic AT(1)-receptors. With respect to the ratio pre-/postsynaptic AT(1)-receptor antagonism important quantitative differences between the various compounds were found. 4. Both the pre- and postjunctional receptors at the sympathetic nerve endings belong to the AT(1)-receptor population. However, the presynaptic receptors belong to the AT(1B)-subtype, whereas the postjunctional receptors probably belong to a different AT(1)-receptor subpopulation. 5. Sympatho-inhibition is a class effect of the AT(1)-receptor antagonists. In conditions in which the SNS plays a pathophysiological role, such as hypertension and congestive heart failure, this property may well be of therapeutic relevance.

Characterisation of a modified approach to the study of sympathetic neurotransmission and its presynaptic modulation in the isolated rabbit thoracic aorta

INTRODUCTION

The quantification of [(3)H]noradrenaline spillover from electrically stimulated, sympathetic nerves is a widely used method to study presynaptic effects of hormones, transmitters and drugs. Although a straightforward approach, the execution of the experiments is not trivial. This holds true mainly for a reliable control of the experimental conditions, a major pitfall of the commonly used superfusion setup, and problems concerning the sampling of the tritium containing probes.

METHODS

These difficulties prompted us to develop a variant of this method, which is based on a classical organ bath setup. Rabbit thoracic aortic rings were incubated with [(3)H]-labeled noradrenaline. Instead of being constantly washed away by superfusion, the [(3)H]noradrenaline is allowed to accumulate in the medium.

RESULTS

Electrical field stimulation (EFS) (2 Hz, 3 ms, 150 mA) caused a significant increase of [(3)H]noradrenaline outflow by approximately a factor 4.2 (P<.05). The fractional release of noradrenaline during consecutive periods of stimulation remained unaltered (FR(2)/FR(1) 0.99+/-0.03). The EFS-evoked release could be nearly abolished by the selective sodium channel blocker tetrodotoxin (1 microM) (FR(2)/FR(1) 0.06+/-0.03, P<.05). The N-type calcium antagonist omega-conotoxin GVIA (0.3 microM) abolished the stimulation-evoked outflow (FR(2)/FR(1) 0.01+/-0.06, P<.05), whereas the antisympathotonic agent guanethidine (10 microM) attenuated the EFS-evoked noradrenaline outflow by approximately a factor 2 (FR(2)/FR(1) 0.46+/-0.07, P<.05). Angiotensin II (0.1 and 1 nM) enhanced the EFS-evoked [(3)H]noradrenaline outflow by nearly a factor 1.5 and 2, respectively (FR(2)/FR(1) of 1.43+/-0.11 (0.1 nM) and 2.03+/-0.11 (1 nM); n=6-8, P<.05). All agents failed to influence basal outflow.

DISCUSSION

Our modified experimental approach appears to be suitable to study presynaptic influences on sympathetic transmission in the rabbit thoracic aorta. In addition to optimal control of the experimental conditions, the method offers the advantage of a safe and reliable sampling.

Effect of the AT1-receptor antagonists losartan, irbesartan, and telmisartan on angiotensin II-induced facilitation of sympathetic neurotransmission in the rat mesenteric artery

SUMMARY

The effect of the AT1-receptor antagonists losartan, irbesartan, and telmisartan on angiotensin II (Ang II)-induced facilitation of noradrenergic neurotransmission was investigated in the isolated rat mesenteric artery under isometric conditions. Electrical field stimulation (2, 4, and 8 Hz) caused a frequency-dependent increase of contractile force. At stimulation frequencies of 2, 4, and 8 Hz, Ang 11 (10 nM) increased the stimulation-induced vasoconstrictor responses by a factor 4.8 +/- 0.9, 2.9 +/- 0.7, and 1.3 +/- 0.1, respectively (p < 0.05 compared with control for all frequencies). The enhancement could be concentration-dependently antagonized by losartan (1 nM-1 microM), irbesartan (0.1 nM-0.1 microM), and telmisartan (0.01 nM-0.01 microM). At a stimulation frequency of 2 Hz, the relation between stimulation-induced vasoconstrictor responses (in presence of Ang II 10 nM) and the concentration of the AT1-antagonists used could be described by linear regression. The order of potency concerning sympathoinhibition was telmisartan > irbesartan > losartan (p < 0.05 between linear regression lines). Contractile responses to exogenous noradrenaline were unaltered in the presence of Ang II 10 nM. We conclude that the facilitating effect of Ang II on noradrenergic neurotransmission is mediated by presynaptically located AT1-receptors. Conversely, this facilitating effect can be dose-dependently counteracted by blockade of these receptors. Sympathoinhibitory properties are likely to contribute to the therapeutic effect of AT1-blockers, in particular in conditions in which the sympathetic nervous system is activated, such as congestive heart failure and hypertension.

Effects of handling on extracellular levels of glutamate and other amino acids in various areas of the brain measured by microdialysis

Upon a physiological and pharmacological challenge, the responsiveness of extracellular glutamate levels in the prefrontal cortex, ventral tegmental area and locus coeruleus were studied using microdialysis. A 10-min handling period was used as a mild stressful stimulus. In all three brain areas, handling induced an immediate and short-lasting increase in glutamate levels, but the responses were highly variable. Only in the ventral tegmental area and the locus coeruleus, but not in the prefrontal cortex, the increases were significantly different from basal values. In rats with relatively low basal glutamate levels, both in the ventral tegmental area and locus coeruleus, handling had a more pronounced effect on glutamate levels than in rats with high basal levels, although in some rats with relatively low basal levels of glutamate, handling had hardly any effect. Potassium stimulation also induced variable responses in all three brain areas. Again, relatively low basal glutamate levels were more responsive to the stimulation than higher basal values, although there appeared to be a lower limit. These data suggest that relatively high basal levels contain sources of glutamate that mask the neuronal pool of glutamate and are therefore less responsive to physiological or pharmacological stimulation. However, this interpretation was questioned by the findings that basal levels and handling-induced increases in glutamate levels were found to be (partly) TTX-independent. As carrier-mediated release as a possible non-exocytotic release mechanism has only been described in vivo under pathological conditions, it seems plausible to ascribe TTX-independent glutamate increases to aspecific, non-neuronal processes. This interpretation was further supported by the observation that in all three brain areas, other amino acids, i.e., aspartate, taurine, glutamine, serine, alanine and glycine also increased upon handling in a very similar way as glutamate did. Thus, these results question a direct correlation between stimulated extracellular glutamate levels induced by handling and measured by microdialysis and glutamatergic neurotransmission.