Chemical characterization of polysaccharides from Gracilaria gracilis from Bizerte (Tunisia)

Polysaccharides were extracted from Gracilaria gracilis collected from Manzel Jemil Lake in Bizerte Tunisia, with two different solvents (water and NaOH 0.3 M). Different assays were performed on samples (total sugars, neutral sugars, uronic acids, anhydrogalactose, proteins, sulphates, pyruvates), followed by high performance anion-exchange chromatography (HPAEC) to observe the monosaccharide composition, high pressure size exclusion chromatography with multi-angle laser light scattering (HPSEC-MALS) to obtain the molecular mass, Fourier transform infrared spectroscopy (FTIR), and 1D and 2D nuclear magnetic resonance (NMR) to access to structural data. Results have shown that the polysaccharide extracted from Gracilaria gracilis collected from Manzel Jemil Lake in Bizerte Tunisia, is of agar type but with high molecular mass and some original structural features. Hence, the sample was found to contain 9 % of pyruvate groups and is partly sulphated at the C4 of β-d-galactose and methylated on C2 of anhydro-α-l-galactose. The polymer from G. gracilis from Bizerte thus presents a never described structure that could be interesting for further rheological or biological activities applications.

Socio-economic factors determine maternal and noenatal outcomes in women with peripartum cardiomyopathy: a study of the ESC EORP PPCM registry

Background

Peripartum cardiomyopathy (PPCM) is a global disease associated with substantial morbidity and mortality.

Purpose

The aim of this study was to analyse to what extent country- and individual-level socioeconomic factors were associated with maternal and neonatal outcomes.

Methods

In 2011, >100 national and affiliated member cardiac societies of the European Society of Cardiology (ESC) were contacted to contribute to a global registry on PPCM, under the auspices of the ESC EORP Programme. Country-level sociodemographic factors were Gini coefficient (GINI), health expenditure (HE) and human developmental index (HDI). Individual-level sociodemographic factors were income and educational attainment. We investigated the characteristics and outcomes of women with PPCM and their babies according to individual and country-specific socioeconomic status.

Results

739 women from 49 countries were enrolled (Europe [33%], Africa [29%], Asia-Pacific [15%], Middle East [22%]). Overall, 142 (19%) of women were from countries with low HDI, 307 (42%) medium HDI and 290 (39%) high HDI. Patients of Black African ethnicity were almost all from low HDI countries (99.3%), Middle Eastern and Asian patients from medium HDI (37.7% and 26.2%), and Caucasian patients were mostly from high HDI (72%, p<0.001). Women from countries with low HDI had lower income and educational attainment. They also underwent fewer Caesarian sections, but breastfed for longer (20 versus 6 months, p<0.001). Low HDI and low GINI were associated with greater LV dilatation at time of diagnosis (p<0.001), but LV ejection fraction (LVEF) did not differ according to HDI, HE or GINI. Countries with low HE prescribed guideline-directed heart failure therapy less frequently. Low HE was associated with more frequent mortality (p<0.002), whereas HDI and GINI were not. Women from countries with low HDI and low HE had significantly less recovery of LV function. Analysis of maternal outcome as per highest level of educational attainment (i.e., primary [n=154], secondary [n=342], tertiary [n=126]), showed significant differences in LVEF at 6 months (43.7+12.9, 46.5+13.0 and 48.9+11.7 respectively, p=0.022). Low maternal income, irrespective of region of origin, was independently associated with poor outcome (composite of maternal death, re-hospitalization, or LV non-recovery). Neonatal death was more prevalent in countries with low HE (p=0.009) and low HDI (p=0.023) but was not influenced by maternal sociodemographic parameters.

Conclusion

Maternal and neonatal outcomes depended on country-specific socioeconomic characteristics, with a greater prevalence of maternal and neonatal deaths in women from countries with low HE. Globally, women with low income and lower levels of educational attainment had poorer outcomes, irrespective of region. Attempts should be made to improve patient education, and allocation of adequate health resources to improve maternal and neonatal outcomes in PPCM.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): 1. EurObservational Research Programme in conjunction with the Heart Failure Association of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy2. Cape Heart Institute, University of Cape Town, Cape Town, South Africa

Tricuspid regurgitation: frequency, management and outcome among patients with severe left-sided valvular heart disease in Europe. Insights from the ESC-EORP valvular heart disease II survey

Background

Tricuspid regurgitation (TR) is frequent among patients with severe left-sided valvular heart disease (LS-VHD).

Objectives

This study sought to assess TR frequency, management and outcome in this population.

Methods

Among 6883 patients with severe LS-VHD or previous valvular intervention in the EURObservational Research Programme prospective VHD II survey, we analyzed frequency and grade of TR according to LS-VHD, and 6-month survival according to TR grade. Among 2081 patients who underwent an intervention for severe LS-VHD, we analyzed frequency and outcome of concomitant TV intervention, and concordance between Class I indications for concomitant TV surgery (patients with severe TR) and real-practice decision-making.

Results

Moderate to severe TR was very frequent among patients with severe mitral VHD (≥30%), especially in patients with secondary mitral regurgitation (46%), and rare among patients with aortic VHD (<5%). Higher TR grade was associated with a poorer 6-month survival (P<0.001). Rates of concomitant tricuspid valve (TV) intervention at the time of left-sided heart valve surgery were high at the time of mitral valve surgery (more than 40%). Concomitant TV intervention at the time of left-sided heart valve surgery (LS-HVS) was not associated with an increase in-hospital mortality (P=0.93). Concordance between Class I indications for concomitant TV surgery at the time of LS-HVS according to guidelines and real-practice decision-making was very good (88% overall).

Conclusion

TR was frequent in patients with mitral VHD and was associated with a poorer outcome as TR grade increased. Compliance to guidelines for Class I indications for concomitant TV surgery at the time of LS-HVS was very good. With the trend toward more transcatheter treatment for left-sided VHD, there is a critical need for safe and efficient tricuspid valve transcatheter treatment for patients with concomitant TR.

Funding Acknowledgement

Type of funding sources: None.

Infective endocarditis in adult patients with congenital heart disease: results from the ESC EORP EURO-ENDO registry

Background

Congenital Heart Disease (CHD) predisposes to Infective Endocarditis (IE)

Purpose

To characterize and to determine the prognosis of IE in this specific population.

Methods

The ESC EORP EURO-ENDO study is a prospective international study in patients (n=3111) diagnosed with IE. In this pre-specified ancillary analysis, we aimed to describe adult patients with CHD (n=365, 11·7%) and compare them with patients without CHD (non-CHD, n=2746) in terms of baseline characteristics and 1-year outcome.

Results

CHD patients (73% men, age 44·8±16·6 years) were younger and had less comorbidities. Of the CHD patients, 14% had a dental procedure in the 6 months before hospitalization versus 7% in non-CHD patients (p<0·001) and more often positive blood cultures for Streptococcus viridans (16·4% vs 8·8%, p<0·001). As in non-CHD patients, IE affected most often the left-sided valves. For CHD patients, in-hospital mortality was 9·0% vs 18·1% in non-CHD patients (p<0·001), and also 1-year outcome was more favourable (log-rank for all-cause mortality p<0·0001), even after adjustment for age (Hazard Ratio (HR) 0·61; 95% CI 0·45–0·81). Within the CHD population, multivariable Cox regression revealed the following predictors for mortality: fistula (HR 6·97), cerebral embolus (HR 4·64), renal insufficiency (HR 3·44), Staphylococcus aureus as causative agent (HR 2·06) and failure to undertake surgery when indicated (HR 5·93).

Conclusion

CHD patients with IE have better outcome in terms of all-cause mortality. The observed high incidence of dental procedures prior to IE fuels the discussion about the need for antibiotic prophylaxis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the program: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer AG (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2019), Daiichi Sankyo Europe GmbH (2011–2020), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2016), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), Servier (2009–2021), Vifor (2019–2022). Survival CHD vs non-CHD patients

Impact of chronic coronary syndromes on cardiovascular hospitalization and mortality: the ESC-EORP CICD-LT registry

Background

In Europe, global data on guideline adherence, potential geographic variations and determinants of major clinical events in chronic coronary syndromes (CCS) remain suboptimal. The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Chronic Ischemic Cardiovascular Disease Long-Term (CICD-LT) registry, a prospective European registry, was designed and conducted to describe the profile, care and outcomes of patients with CCS across the ESC countries

Purpose

We aimed to investigate clinical events at one-year follow-up from the ESC EORP CICD-LT Registry and identify the variables associated with an increased risk of clinical events.

Methods

Consecutive adults presenting with a diagnosis of CCS during a routine ambulatory visit or an elective coronary revascularisation procedure at participating centres were recruited across 154 centers from 20 countries between 1 May 2015 and 31 July 2018. Information on clinical and survival status was collected after 1 year from study inclusion. Composite events were cardio-vascular (CV) mortality and/or CV rehospitalisations, all-cause mortality and/or all cause rehospitalisation. A multivariable Cox regression analysis was performed to identify the independent predictors of each composite. Cox models were also performed with age, sex and region forced in the model. Significance levels of 0.05 were required to allow a variable to stay within the model. Co-linearity between all candidate variables (variables with p<0.05 in univariable) within the model and variables considered of relevant clinical interest were tested before proceeding to the multivariable model. Missing data were not imputed.

Results

One-year outcomes of 6655 patients from the 9174 recruited in this European registry were analyzed. Overall, 168 patients (2.5%) died, mostly from CV causes (n=97, 1.5%). Northern Europe had the lowest CV mortality rate, while southern Europe had the highest (0.5% vs 2.0%, p=0.04). Women had a higher rate of CV mortality compared with men (2.0% vs 1.3%, p=0.02). During follow-up, 1606 patients (27.1%) were hospitalised at least once, predominantly for CV indications (n=1220, 20.6%). Among the population with measured LDL-cholesterol level at one year, 1434 patients (66.5%) were above the currently recommended target. Age, history of atrial fibrillation, previous stroke, liver disease, chronic obstructive pulmonary disease or asthma, increased serum creatinine and impaired left ventricular function were each independently associated with an increased risk of CV death or hospitalization.

Conclusion

In the CICD registry, the majority of patients with CCS have uncontrolled CV risk factors. The mortality rate at one year was low, but these patients are frequently hospitalised for CV causes. Early identification of comorbidities may represent an opportunity for enhanced care and better outcomes.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The study was funded by the EORP program.

Association between thromboembolic and bleeding risk with adverse outcomes in contemporary European atrial fibrillation patients: final analysis from the ESC-EHRA EORP AF general long-term registry

Funding Acknowledgements

Type of funding sources: None.

Introduction

The ESC-EHRA EORP AF General Long-Term Registry provides a contemporary snapshot of European atrial fibrillation (AF) patients’ characteristics and management. Aims: We present data about the final 2-years follow-up observation of AF patients enrolled in the ESC-EHRA EORP AF General Long-Term Registry.

Methods

A contemporary evaluation of residual risk of adverse outcomes in a cohort of largely anticoagulated AF patients according to the baseline thromboembolic and bleeding risk, defined according to CHA2DS2-VASc and HAS-BLED scores. We determined cardiovascular (CV) events, CV death and all-cause death as outcomes.

Results

Among the original 11069 patients enrolled, 8409 (76.0%) patients had available follow-up status at the end of the 2-years follow-up. Patients age, female sex and most comorbidities were progressively more prevalent across the spectrum of thromboembolic and bleeding risk. Data on adverse outcomes were available for 10087 (91.1%), over the 2-year observation period. Outcome rates were progressively higher across CHA2DS2-VASc and HAS-BLED scores (all p < 0.0001). A fully adjusted Cox multivariable regression analysis, adjusted for clinical covariates selected by a univariate procedure and not included in the scores, showed that increasing baseline CHA2DS2-VASc score was associated with an higher risk for CV events (hazard ratio [HR]: 1.25, 95% confidence interval [CI]: 1.21-1.30), CV death (HR: 1.31, 95%CI: 1.25-1.38) and all-cause death (HR: 1.30, 95%CI: 1.25-1.36). Similarly, increasing baseline HAS-BLED score was associated with an increased risk for all 3 outcomes (HR: 1.21, 95%CI: 1.13-1.28; HR: 1.24, 95%CI: 1.14-1.34; HR: 1.22, 95%CI: 1.14-1.31, respectively). An association with a progressively higher risk was found for all outcomes across the spectrum of thromboembolic and bleeding risk [Figure]. Both CHA2DS2-VASc and HAS-BLED scores showed a modest to good predictive ability for cardiovascular (CV) events, CV death and all-cause death, in terms of c-index and 95% CI[0.66 (0.64-0.68) and 0.62 (0.61-0.64), 0.70 (0.68-0.72) and 0.65 (0.63-0.67), 0.69 (0.68-0.71) and 0.64 (0.63-0.66) for CHA2DS2-VASc and HAS-BLED for each outcome respectively.

Conclusions

In this large contemporary European-wide cohort of AF patients, both baseline thromboembolic and bleeding risks were associated to an increased risk of major clinical outcomes. Both scores are reflective of high risk clinical states, and are predictive of major adverse outcomes even in a large cohort of largely anticoagulated patients with a lower residual risk of adverse outcomes. Abstract Figure.

Genetic counselling and testing of adult patients with cardiomyopathies: insight from the EORP cardiomyopathy and myocarditis registry of the European Society of Cardiology

Introduction

Cardiomyopathies comprise a heterogeneous group of diseases, often of genetic origin.

Purpose

We assessed the current practice of genetic counselling and testing of adult cardiomyopathy patients in the prospective ESC EORP cardiomyopathy registry.

Methods

3 208 adult patients from sixty-nine centres in 18 countries were enrolled. Clinical data on genetic counselling and testing and on the presentation of cardiomyopathies were gathered.

Results

Genetic counselling was performed in 60.8% of all patients (75.4% in hypertrophic (HCM), 39.2% in dilated (DCM), 70.8% in arrhythmogenic right ventricular (ARVC) and 49.2% in restrictive cardiomyopathy (RCM), p<0.001). Comparing European geographical areas, genetic counselling was performed from 42.4% to 83.3% (p<0.001). It was provided by a cardiologist (85.3%), geneticist (15.1%), genetic counsellor (11.3%), or a nurse (7.5%), (p<0.001). Genetic testing was performed in 37.3% of all patients (48.8% in HCM, 18.6% in DCM, 55.6% % in ARVC and 43.6% in RCM, p<0.001). Index patients with genetic testing were younger at diagnosis, had more familial disease, family history of sudden cardiac death or implanted cardioverter defibrillators but less comorbidities than those not tested (p<0.001 for each comparison). At least 1 disease causing variant was found in 41.7% of index patients with genetic testing (43.3% in HCM, 33.3% in DCM, 51.4% in ARVC and 42.9% in RCM, p=0.13).

Conclusion

We report on the practice of genetic counselling and testing in cardiomyopathies in Europe. Genetic counselling and testing were performed in a substantial proportion of patients but less often than recommended by European guidelines, and much less in DCM than in HCM and ARVC, despite evidence for genetic background.

Funding Acknowledgement

Type of funding source: None

High prevalence of familial and genetic disease in children with cardiomyopathies: baseline paediatric data from the ESC EORP Cardiomyopathy and Myocarditis registry

Background

Previous studies on paediatric cardiomyopathies have provided useful information on their epidemiology and clinical presentation but have been limited by a lack of detailed data on genetic testing and aetiology.

Purpose

The purpose of this study was to examine the frequency of familial and genetic disease among children with cardiomyopathy enrolled in the European Society of Cardiology (ESC) Cardiomyopathy and Myocarditis EORP Long-Term Registry (CMY-LT).

Methods

633 individuals aged <18 years with hypertrophic cardiomyopathy [HCM; n=387 (61%)], dilated cardiomyopathy (DCM; n=205 (33%)], restrictive cardiomyopathy [RCM; n=28 (4%)] and arrhythmogenic right ventricular cardiomyopathy [ARVC; n=11 (2%)] were enrolled by 26 centres from 14 countries. Mean age at diagnosis was 5.2 (±5.4) years and there was a male predominance [n=372 (59%)] across all cardiomyopathy subtypes, with the exception of DCM in those diagnosed <10 years of age (p=0.005). 541 (87%) were probands compared to 83 (13%) first-degree relatives.

Results

Overall, 253 patients (47% of those reported) had familial disease; in those diagnosed between 10 and 18 years of age, familial disease was most frequent in HCM and least frequent in DCM [57 (55%) vs 12 (32%); p=0.046]. Genetic testing was performed in 414 (68%) patients. In those diagnosed <10 years, genetic testing was more frequently performed in HCM [128 (67%) vs 33 (37%) in DCM, 10 (56%) in RCM and 1 (50%) in ARVC; p=0.008]; in those aged 10–18, genetic testing was most frequent in ARVC [n=8 (89%)] followed by HCM [n=81 (69%)], RCM [n=1 (50%)] and DCM [n=22 (46%); p=0.007]. A causative mutation was reported in 250 patients (60%), with a higher yield in those aged 10–18 vs <10 years [77 (69%) vs 172 (57%), p=0.032]. In those <10 years, the prevalence of reported causative mutations was highest in HCM [128 (67%) vs 10 (56%) in RCM, 1 (50%) in ARVC and 33 (37%) in DCM; p<0.001]; in those 10–18 years, there was no significant difference in prevalence of reported causative variants between cardiomyopathy subtypes. Rare disease phenocopies were reported in 171 patients (27%): malformation syndromes [n=75 (12%)]; neuromuscular disorders [n=49 (8%)]; inborn errors of metabolism [n=20 (3%)]; mitochondrial [n=18 (3%)]; and chromosomal [n=15 (2%)]. Phenocopies were reported most frequently in patients <10 years [135 (30%) vs 35 (20%) in those aged 10–18 years; p=0.008], particularly in HCM in those <10 years [n=110 (41%); p<0.001 vs other subtypes] and DCM in those aged 10–18 years [n=18 (38%); p=0.03 vs other subtypes].

Conclusion

This study confirms the heterogeneous aetiology of childhood cardiomyopathies and demonstrate a higher prevalence of familial disease than previously reported in paediatric populations. Genetic testing is performed in a high proportion of patients, with a high yield of reported causative variants.

Funding Acknowledgement

Type of funding source: None

Baseline features and management in adult and pediatric clinically suspected and biopsy-proven myocarditis in the cardiomyopathy and myocarditis long-term EORP registry

Background

The Myocarditis section of the EORP Cardiomyopathy and Myocarditis Long-term Registry is a prospective, observational, multinational registry of adult and pediatric patients enrolled using the ESC 2013 diagnostic criteria of clinically suspected (CS) or biopsy-proven (BP) myocarditis (myoc).

Purpose

i) To obtain a real-world snapshot of features and management of myoc; ii) to assess features at presentation in CS and in BP myoc and by age.

Methods

581 patients (68% male), 493 adults, aged 34.9 (SD 18.5) years, and 88 children, aged 8.1 (SD 5.2) years, were divided into 3 groups (G): G1 (n=234, 40%), CS myoc plus cardiac magnetic resonance (CMR) confirmed; G2 (n=222, 38,2%), BP myoc; G3 (n=125, 21.5%), CS myoc, no or normal or inconclusive CMR. Baseline features, procedures, medications were analysed in the total population, in adults vs children, and among G.

Results

In all patients: pseudo-infarct presentation with normal coronary arteries is common (58%), as is heart failure (HF) with or without chest pain and troponin release (58%), followed by arrhythmia (41.9%). In children new-onset HF is more common than in adults (29/32, 90% vs 90/190, 47%, p=0.001). In both adult and pediatric G2 BP myoc, HF and arrhythmia were more common than in CS myoc. Left and right ventricular (RV) echocardiography and CMR function indexes and troponins were lower, NT-pro BNP was higher in G2 BP myoc vs G1 and G3 CS myoc. On CMR oedema and/or Late Gadolinium Enhancement (LGE) were found in 57.4% of adult and in 31.3% of paediatric G2 BP myoc. Endomyocardial biopsy (EMB) was obtained in a similar proportion in children (31/88, 35.2%) and adults (185/493, 37.5%, p=NS), ventricular assist devices were more commonly implanted in G2 children (8/32, 25%) than in G2 adults (4/190, 2.1%, p=0.001), ICD tended to be less common in G2 children (2/32, 6.3%) than in G2 adults (48/190, 25%, p=0.07). In all patients EMB, mainly RV (75.8%), had a low complication rate (4.7%), similar in adults vs children, with no procedure-related death. Histology findings were: lymphocitic myoc (78.9%), giant cell (10.9%), sarcoid (6.9%), non specific (16%). Viral genome was found in 44% of patients (most common PVB19, 21.7%, HHV6, 9.5%). In all patients HF and antiarrhytmic drugs were more frequently used in G2, antivirals in a patient minority, steroids in 24.7%, immunosuppression (IS) in 22.6%. In children steroids or IS were given regardless of G, in adults mainly to G2 BP myoc patients, in keeping with the ESC 2013 expert reco's.

Conclusions

EMB is safe in children and adults and is still the diagnostic gold standard, since CMR failed to identify myoc in a high proportion of G2 BP patients. Etiology-directed therapy was used in a minority of G2 cases, and/or regardless of etiology, thus there is room for improved management. G2 BP patients were older, sicker, had worse biventricular function, more medications and ICDs; follow-up may show their worse outcome.

Funding Acknowledgement

Type of funding source: None

Impact of body mass index on outcomes in European patients with atrial fibrillation: the ESC EHRA EORP Atrial Fibrillation General Long-Term registry (AFGen LT)

Introduction

The impact of body mass index (BMI) on outcomes in patients with atrial fibrillation (AF) has been largely debated.

Aims

To describe the relationship between BMI categories and clinical outcomes in a large cohort of European AF patients.

Methods

We included all AF patients with available baseline BMI and creatinine clearance and 1-year follow-up data enrolled in the EORP-AF General Long-Term Registry. Outcomes considered were: i) a composite of any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death; ii) CV death; iii) all-cause death.

Results

A total of 7,759 patients were included in this analysis. Of these, 55 (0.7%) were underweight, 2,074 (26.7%) were normal weight, 3,170 (40.9%) were overweight, 1,703 (21.9%) were obese and 757 (9.8%) were severe obese. Mean age was progressively lower across the categories (p<0.0001), with proportion of patients aged≥75 years also progressively lower (52.7% in underweight to 19.4% in severe obese patients; p<0.001). Both underweight (41.8%) and severe obese (25.0%) patients were more likely symptomatic (p<0.001). Mean CHA2DS2-VASc score was higher in underweight patients (p=0.0325). Use of any oral anticoagulant therapy was progressively higher across the BMI categories (p<0.001). At 1-year follow-up the rate of all outcomes considered were highest for underweight patients and lowest in severe obese [Figure 1]. On univariate Cox regression analysis, being underweight was consistently associated to a higher risk for all outcomes, while increasing of weight categories was associated with progressively lower risk for adverse outcomes. After full adjustment with clinical and pharmacological characteristics, no effect of higher BMI classes was found for any outcome, but an independent association with an increased risk of CV death and all-cause death was seen for underweight patients (Table 1).

Conclusions

In a large cohort of European AF patients a progressively lower rate of outcomes was found across increasing BMI classes. After full adjustments, no significant association was found between the higher BMI classes and outcomes. Underweight was associated with an increased risk for CV death and all-cause death.

Figure 1. Outcomes at 1-year Follow-up

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Since the start of EORP programme, several companies have supported it with unrestricted grants

Availability and applicability of cardiac magnetic resonance imaging in diagnosis in cardiomyopathies: the Cardiomyopathy/Myocarditis registry of the EURObservational Research Programme of the ESC

Background

Cardiac magnetic resonance (CMR) constitutes a gold standard in the diagnosis of cardiomyopathies. Regardless of CMR advantages, the method is time-consuming, high-cost, with limited availability in some European regions.

Purpose

To assess the availability and applicability of CMR for establishing the diagnosis in different populations of patients with cardiomyopathies.

Methods

Overall, 3208 adult patients with cardiomyopathy (1119 / 34.9% females; median age at diagnosis: 49.0 years): 1260 with dilated (DCM), 1739 with hypertrophic (HCM), 66 with restrictive (RCM) and 143 with arrhythmogenic right ventricular cardiomyopathy (ARVC) enrolled in EURObservational Research Programme (EORP) – Cardiomyopathy/Myocarditis Long-Term Registry were analysed.

Results

CMR scan was performed as a baseline diagnostic method in 29.4% of patients; CMR was a single diagnostic method in 0.9% of patients and in 28.6% of patients CMR was used along with transthoracic echocardiography (TTE). In 67.6% of patients TTE was at the baseline the single diagnostic imaging method. Prevalence of CMR use in different cardiomyopathies was as follows: 20.6% in DCM, 33.8% in HCM, 36.4% in RCM and 51.1% in ARVC (p<0.001). Range of CMR applicability in different European regions was diverse from 0% up to 63.2%.

The population with CMR use was younger, less symptomatic, with decreased prevalence of other cardiovascular risk factors and of associated cardiovascular diseases as compared to the population diagnosed without CMR scanning (p<0.001).

Abnormal CMR results were present in 93.4% of patients with the highest percentage in RCM (95.8%) and HCM (94.9%) followed by DCM (91.5%) and the lowest abnormal CMR scan ratio in ARVC (87.7%) (p=0.030). The majority of CMR examinations comprised the assessment of late gadolinium enhancement (LGE, 93.3% at baseline). Presence of CMR LGE was observed in 69.3% of all patients: 59.1% in DCM, 73.8% in HCM, in 63.9% in ARVC and with the highest prevalence in RCM (83.3%) (p<0.001).

Conclusion

The study reveals real-life data on the low availability and applicability of CMR in adult patients with cardiomyopathies. The analysis shows the advantages of CMR imaging but also identifies the gaps between recommendations and clinical practice. Improvement regarding access, training and reimbursement is necessary to offer CMR to cardiomyopathy patients in accordance with the ESC guidelines.

Funding Acknowledgement

Type of funding source: None

P5656Heart failure clinical phenotypes and outcomes in patients with atrial fibrillation: an analysis from the eurobservational research programme in atrial fibrillation long-term general registry

Introduction

Heart failure (HF) is a well-known risk factor for atrial fibrillation (AF). Moreover, HF is associated with worse clinical outcomes in patients with known AF. Recently, phenotypes of HF have been redefined according to the level of ejection fraction (EF). New data are needed to understand if a differential risk for outcomes exists according to the new phenotypes' definitions.

Purpose

To evaluate the risk of major adverse outcomes in patients with AF and HF according to HF clinical phenotypes.

Methods

We performed a subgroup analysis of AF patients enrolled in the EORP-AF Long-Term General Registry with a history of HF at baseline, available EF and follow-up data. Patients were categorized as follows: i) EF<40%, i.e. HF reduced EF [HFrEF]; ii) EF 40–49%, i.e. HF mid-range EF [HFmrEF]; iii) EF ≥50%, i.e. HF preserved EF [HFpEF]. Any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death, CV death and all-cause death were recorded.

Results

A total of 3409 patients were included in this analysis: of these, 907 (26.6%) had HFrEF, 779 (22.9%) had HFmrEF and 1723 (50.5%) had HFpEF. An increasing proportion with CHA2DS2-VASc ≥2 was found across the three groups: 90.4% in HFrEF, 94.6% in HFmrEF and 97.3% in HFpEF (p<0.001), while lower proportions of HAS-BLED ≥3 were seen (28.0% in HFrEF, 26.3% in HFmrEF and 23.6% in HFpEF, p=0.035). At discharge patients with HFpEF were less likely treated with antiplatelet drugs (22.0%) compared to other classes and were less prescribed with vitamin K antagonists (VKA) (57.0%) and with any oral anticoagulant (OAC) (85.7%). No differences were found in terms of non-vitamin K antagonist oral anticoagulant use. At 1-year follow-up, a progressively lower rate for all study outcomes (all p<0.001), with an increasing cumulative survival, was found across the three groups, with patients with HFpEF having better survival (all p<0.0001 for Kaplan-Meier curves). After full adjustment, Cox regression analysis showed that compared to HFrEF, HFmrEF and HFpEF were associated with risk of all study outcomes (Table).

Cox Regression Analysis HR (95% CI) Any TE/ACS/CV Death CV Death All-Cause Death HFmrEF 0.65 (0.49–0.86) 0.53 (0.38–0.74) 0.55 (0.41–0.74) HFpEF 0.50 (0.39–0.64) 0.42 (0.31–0.56) 0.45 (0.35–0.59) ACS = Acute Coronary Syndrome; CI = Confidence Interval; CV = Cardiovascular; EF = Ejection Fraction; HF = Heart Failure; HR = Hazard Ratio.

Conclusions

In this cohort of AF patients with HF, HFpEF was the most common phenotype, being associated with a profile related to an increased thromboembolic risk. Compared to HFrEF, both HFmrEF and HFpEF were associated with a lower risk of all major adverse outcomes in AF patients.

P3784Impact of progressively impaired renal function on major adverse outcomes in European patients with atrial fibrillation: a report from the ESC EORP-AF long-term general registry

Background

Renal function is an important predictor of major adverse outcomes in the general population. In the setting of atrial fibrillation (AF), renal dysfunction may act both as a risk factor and a proxy of vascular risk factors and comorbidities.

Methods

We analyzed the association of renal function, as estimated glomerular filtration rate (eGFR) using the CKD-EPI formula, with 1-year outcomes in a “real-world” cohort of European AF patients from the EORP-AF Long-Term General Registry.

Results

7725 were available for this analysis. Of these, 1294 (16.7%) had normal renal function (≥90 mL/min/1.73 m2), 3848 (49.8%) mildly reduced renal function (60–89 mL/min/1.73 m2), 2311 (29.9%) moderately reduced renal function (30–59 mL/min/1.73 m2) and 272 (3.5%) severely reduced renal function (<30 mL/min/1.73 m2). CHA2DS2-VASc and HAS-BLED scores values increased across eGFR strata (p<0.0001). Among patients qualifying for oral anticoagulant (OAC) therapy, those with severely impaired renal function were less often prescribed with any OAC (79.8%, p<0.0001), more likely with vitamin K antagonist (62.9%) than non-vitamin K antagonist oral anticoagulants (16.9%) (p<0.0001). At 1-year follow-up the rates of any thromboembolic event (TE)/acute coronary syndrome (ACS)/cardiovascular (CV) death progressively increased with worsening renal function, up to 20.7% in patients with severe dysfunction (p<0.0001). Rates of CV death and all-cause death were higher in severe renal dysfunction (16.9% and 21.3%; p<0.0001). Cox regression analysis (adjusted for known predictors) showed that eGFR <30 mL/min/1.73 m2, compared to normal renal function was associated with an increased risk of all the adverse outcomes (Table). eGFR decrease by 10 mL/min/1.73 m2 was associated with increased risks (Table).

Any TE/ACS/CV Death CV Death All-Cause Death mL/min/1.73 m2 HR (95% CI) HR (95% CI) HR (95% CI) eGFR ≥90 (ref.) – – – eGFR 60–89 0.99 (0.67–1.46) 0.81 (0.44–1.51) 0.74 (0.47–1.19) eGFR 30–50 1.12 (0.74–1.69) 1.00 (0.53–1.89) 0.95 (0.59–1.54) eGFR <30 2.47 (1.52–3.99) 2.73 (1.36–5.49) 2.16 (1.25–3.72) eGFR (by 10 mL/min/1.73 m2 decrease) 1.11 (1.05–1.17) 1.18 (1.10–1.27) 1.11 (1.03–1.18) ACS = Acute coronary syndrome; CI = Confidence interval; CV = Cardiovascular; eGFR = estimated Glomerular Filtration Rate; HR = Hazard ratio; TE = Thromboembolic event.

Conclusions

In AF patients, impaired renal function at baseline is associated with a progressive increase in the risk of major adverse outcomes during follow up. Severe renal dysfunction is an independent predictor of all the adverse outcomes.

5971Clinical impact of antithrombotic therapy in transvenous lead extraction complications: a sub-analysis from the ESC-EHRA ELECTRa (European Lead Extraction ConTRolled) Registry

Introduction

The complexity of candidates for transvenous lead extraction (TLE) has shown a parallel increase, both in terms of comorbidities, and of concomitant therapy, including antithrombotic therapy (AT). The management of candidates for TLE receiving concomitant AT is a debated issue, and only marginally the object of evidence-based recommendations in current guidelines. The ESC-EHRA European Lead Extraction ConTRolled Registry (ELECTRa) is a prospective registry of consecutive TLE procedures conducted by the European Heart Rhythm Association (EHRA) in order to identify the safety and efficacy of the current practice of TLE.

Purpose

The present study is a sub-analysis of the ESC-EHRA ELECTRa Registry conducted with the aim of evaluating the clinical impact of AT on TLE safety and efficacy.

Methods

All consecutive TLE patients enrolled in the ELECTRa registry were included. Success rate and procedural-related complications, including death, were compared between patients without AT therapy (No AT Group) and with different pre-operative AT regimens (AT subgroups), including antiplatelets (AP), anticoagulants (AC) or both (AP + AC).

Results

Out of 3510 TLE pts, 2398 (68%) were under AT pre-operatively. AT patients were older with more co-morbidities (p<0.0001). AT subgroups, defined as AP, AC or AP+AC, were 1096 (31.2%), 985 (28%) and 317 (9%), respectively. Regarding AP patients, 1413 (40%) were under AP, 1292 (91%) with a single AP and 121 (9%) with a dual AP therapy. AP was interrupted in 26% of pts 3.8±3.7 days before TLE. Regarding AC patients, 1302 (37%) patients were under AC,881 were under VKA (68%), 221 (17%) under DOAC, 155 (12%) under LWMH and 45 (3.5%) under UFH.AC pre-procedural management strategy included “interruption without bridging” in 696 (54%), “interruption with bridging” in 504 (39%) and a “continued” strategy in 87 (7%). AC was interrupted about 3.3±2.3 days before TLE.

TLE clinical success rate was high (98%) in all subgroups. Only the incidence of overall death (1.4%), but not the procedure-related, was higher in the AT subgroups (p=0.0500). (Figure A) Age >65 years and NYHA Class III/IV, but not AT regimens, were independent predictors of death for any cause.

Regarding minor complications, hematomas were more frequently observed between AC “continued” patients (p=0.025), whereas pulmonary embolism in the No-AT group (p<0.01). (Figure B)

Figure A and B

Conclusions

The AT subgroups showed a comparable TLE success rate, with a higher in-hospital, but non intra-procedural, mortality and more minor bleedings compared to no-ATs. Neither AT regimens or pre-procedural management strategies predicted major complications. AT therapy minimization seems to be safe in patients under chronic AT therapy who undergo TLE. AT do not seem to predict death but identifies a subset of fragile patients with a worse in-hospital TLE outcome.

Acknowledgement/Funding

The following companies have supported the study: Medtronic, Cook Medical, Boston Scientific, Spectranetics and Zoll

P334Prospective FU in various subtypes of cardiomyopathies: insights from the EORP Cardiomyopathy Registry of the ESC

Background

The EORP Cardiomyopathy Registry is a prospective, observational, multinational registry of consecutive patients with cardiomyopathies. The objective of this report is to describe the outcomes at one year of follow-up of adult patients (>18 years old) enrolled in the registry.

Methods

A total of 3,208 patients (median age: 55.0 (43.0; 64.0) years, males: 65.1%) were recruited at baseline. Follow-up data at 1 year were obtained in 2,713 patients (84.6%), including 1,420 with hypertrophic (HCM), 1,105 dilated (DCM), 128 arrhythmogenic right ventricular (ARVC) and 60 restrictive cardiomyopathy (RCM).

Results

Improvement of symptoms (NYHA, chest pain, syncope) was globally observed over time (p<0.001 for each). Additional invasive therapeutics were performed during follow-up: implantation of ICD (primary prevention) (N=109 patients, 5.2%), pacemaker (N=28, 1.2%), heart transplant (N=30, 1,1%), ablation for atrial or ventricular arrhythmia (0.5% & 0.1%). The proportion of patients with history of AF increased from baseline to FU in 3.6% (from 28.2% to 31.8%). ICD therapy at 1 year was delivered more frequently in ARVC then in DCM, HCM and RCM (11.4%, 9.0%; 8.1%, 0% respectively for primary prevention). Major cardiovascular events (MACE) occurred in 29.3% of RCM, 10.5% of DCM, 7.9% of ARVC and 5.3% of HCM. MACE were globally higher in index patients compared to relatives (10.8% vs 4.4%, p<0.001).

When considering geographical areas, MACE were higher in East Europe (13.1%) and lower in South Europe (5.3%) (univariate); heart transplant was higher in West Europe (2.40%) and lower in South Europe (0.25%) (univariate).

Conclusions

Despite symptomatic improvement in most cases, there is still a significant burden of arrhythmic and heart failure events in patients with cardiomyopathies. Outcomes were different not only according to cardiomyopathy subtypes but also in relatives versus index patients.

Acknowledgement/Funding

None

P3759Comparison of equations for renal function assessment and major adverse outcomes in atrial fibrillation: an analysis from the EORP-AF long-term general registry

Background

Several equations exist to estimate creatinine clearance according to serum creatinine values and baseline characteristics. The CKD-EPI equation is usually recommended in general population, while the Cockroft-Gault (CG) equation has been used in atrial fibrillation (AF) clinical trials.

Purpose

To perform a comparison between 6 different equations for evaluation of renal function in AF patients.

Methods

We calculated CKD-EPI, CG, body surface area adjusted CG (CG BSA), MDRD, BIS1 and FAS equations in AF patients enrolled in the EORP-AF Long-Term General Registry. Outcomes at 1-year follow-up were considered.

Results

Renal equations were calculated in 7725 patients. According to CKD-EPI mean (SD) creatinine clearance was 69.14 (21.06) mL/min/1.73 m2. Taking CKD-EPI as reference, the MDRD equation showed the highest agreement (weighted kappa [95% CI]: 0.843 [0.833–0.852]), while CK showed the lowest agreement (weighted kappa [95% CI]: 0.593 [0.580–0.606]. The remaining equations showed moderate agreement. Cox regression analysis showed that all equations were inversely associated with all major adverse outcomes [Figure]. The CKD-EPI equation showed modest predictive ability for the three outcomes (c-statistics: any TE/ACS/CV Death: 0.63379; CV Death: 0.68512; All-Cause Death: 0.67183), with all other equations reporting higher c-statistics (delta-c statistic ranging from +0.01497 for FAS equation for any TE/ACS/CV Death to +0.04547 for CG BSA for all-cause death) for all outcomes (all p<0.0001, for any equation for any outcome). Compared to CKD-EPI, all the other equations showed an improvement in prediction of outcomes, according to IDI and NRI, with the exception of FAS equation for any TE/ACS/CV Death. CG BSA equation showed the greatest improvement in prediction of outcomes compared to CKD-EPI (relative IDI: 21.9% for any TE/ACS/CV Death, 28.8% for CV Death, 34.4% for All-Cause Death).

Cox Regression Analysis

Conclusions

Compared to CKD-EPI equation, all the other equations for creatine clearance has stronger associations with adverse outcomes, with the CG BSA reporting the higher yield for all the outcomes considered.

Quantitative structure-property relationship approach to predicting xylene separation with diverse exchanged faujasites

Streamlining the xylene separation process on faujasites is a promising way to design innovative adsorbents for this application. For this purpose, we present herein an original quantitative structure-property relationship (QSPR) approach. It deals with the development of a multi-linear predictive model correlating the separation properties with a set of structural descriptors for the adsorbents. The implementation of such an approach makes it necessary to (i) set an appropriate design of experiment (DOE), (ii) prepare an adsorbent database, (iii) test the adsorbent database for xylene separation and (iv) compute a set of relevant descriptors. The selected descriptors essentially characterize the nature of the confinement in the faujasite supercage, i.e., the size of the cations localized in adsorption sites II, as well as the occupancy ratio of both adsorption sites II and III. Two different statistical methods were applied to develop a structure-property relationship model linking experimental selectivity and the set of descriptors. A multiple linear regression model enables the prediction of para/meta-xylene selectivity with a correlation coefficient R2 of 0.78, while a linear discriminant analysis predicts the assignment of the adsorbents to four identified classes with a total prediction percentage of 76%.

Pressure dependence of the electrical transport in granular materials

We report on systematic measurements of the electrical resistance of one- and three-dimensional (1D and 3D) metallic and oxidized granular materials under uni-axial compression. Whatever the dimension of the packing, the resistance follows a power law versus the pressure ([Formula: see text]), with an exponent [Formula: see text] much larger than the ones expected either with elastic or plastic contact between the grains. A simple model based on a statistical description of the micro-contacts between two grains is proposed. It shows that the strong dependence of the resistance on the pressure applied to the granular media is a consequence of large variabilities and heterogeneities present at the contact surface between two grains. Then, the effect of the three-dimensional structure of the packing is investigated using a renormalization process. This allows to reconcile two extreme approaches of a 3D lattice of widely distributed resistances: the effective medium and the percolation theories.

Monovalent and bivalent cations exchange isotherms for faujasites X and Y

This study addresses the modeling of exchange isotherms for faujasite-type zeolites X and Y with K⁺, Cs⁺, Ca²⁺ and Ba²⁺ cations based on a large experimental dataset obtained under operating conditions of 0.5 N total normality and an exchange temperature of 80 °C.

[Multicentric study of medical care and practices in spinal muscular atrophy type 1 over two 10-year periods]

AIM

Questions about care practices and the role of palliative care in pediatric neurodegenerative diseases have led the Neuromuscular Committee of the French Society of Neurology to conduct a retrospective study in spinal muscular atrophy type 1, a genetic disease most often leading to death before the age of 1 year.

MATERIAL AND METHODS

A retrospective multicenter study from pediatricians included in the reference centers of pediatric neuromuscular diseases was carried out on two 10-year periods (1989-1998 and 1999-2009).

RESULTS

The 1989-1998 period included 12 centers with 106 patients, the 1999-2009 period 13 centers with 116 children. The mean age of onset of clinical signs was 2.1 months (range, 0-5.5 months), the median age at diagnosis was 4 months (range, 0-9 months) vs 3 months. The median age of death was 7.5 months (range, 0-24 months) vs 6 months. The care modalities included physiotherapy (90 %), motor support (61 % vs 26 % for the previous period), enteral nutrition by nasogastric tube (52 % vs 24 %), and 3.4 % of children had a gastrostomy (vs 1.8 %). At home, pharyngeal aspiration was used in 64 % (vs 41 %), oxygen therapy in 8 %, noninvasive ventilatory support in 7 %. The mean age at death was 8.1 months (range, 0-24 months) vs 7 months, the time from diagnosis to death was 4 months vs 3 months. Death occurred at home in 23 % vs 17 %, in a pediatric unit in 62 % vs 41 %. The use of analgesics and sedative drugs was reported in 60 % of cases: 40 % morphine (vs 18 %) and benzodiazepines in 48 % (vs 29 %). Respiratory support was limited mostly to oxygen by nasal tube (55 % vs 54 %), noninvasive ventilation in 9 % of the cases, and intubation and assisted mechanical ventilation (2 %).

DISCUSSION AND CONCLUSION

These results confirm a change in practices and the development of palliative care in children with a French consensus of practices quite different from the standard care in North-America and closer to the thinking of English medical teams. A prospective study within the 2011 national hospital clinical research program (PHRC 2011) is beginning in order to evaluate practices and the role of families and caregivers.