Accessible and reliable neurometric testing in humans using a smartphone platform

Tests of human brain circuit function typically require fixed equipment in lab environments. We have developed a smartphone-based platform for neurometric testing. This platform, which uses AI models like computer vision, is optimized for at-home use and produces reproducible, robust results on a battery of tests, including eyeblink conditioning, prepulse inhibition of acoustic startle response, and startle habituation. This approach provides a scalable, universal resource for quantitative assays of central nervous system function.

CIMT 2023: report on the 20th Annual Meeting of the Association for Cancer Immunotherapy

The Association for Cancer Immunotherapy (CIMT) celebrated the 20th anniversary of the CIMT Annual Meeting. CIMT2023 was held 3-5 May 2023 in Mainz, Germany. 1051 academic and clinical professionals from over 30 countries attended the meeting and discussed the latest advances in cancer immunology and immunotherapy research. This report summarizes the highlights of CIMT2023.

Prophylactic clipping using the over-the-scope clip (OTSC) system after complex ESD and EMR of large colon polyps

BACKGROUND

Delayed bleeding is the most frequent complication after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) of large colon polyps. Today, prophylactic clipping with through-the-scope clips (TTSCs) is commonly used to reduce the risk of bleeding. However, the over-the-scope clip (OTSC) system might be superior to TTSCs in achieving hemostasis. This study aims to evaluate the efficacy and safety of prophylactic clipping using the OTSC system after ESD or EMR of large colon polyps.

METHODS

This is a retrospective analysis of a prospective collected database from 2009 until 2021 of three endoscopic centers. Patients with large (≥ 20 mm) colon polyps were enrolled. All polyps were removed by either ESD or EMR. After the resection, OTSCs were prophylactically applied on parts of the mucosal defect with a high risk of delayed bleeding or/and perforation. The main outcome measurement was delayed bleeding.

RESULTS

A total of 75 patients underwent ESD (67%, 50/75) or EMR (33%, 25/75) in the colorectum. The mean resected specimen diameter was 57 mm ± 24.1 (range 22-98 mm). The mean number of OTSCs placed on the mucosal defect was 2 (range 1-5). None of the mucosal defects were completely closed. Intraprocedural bleeding occurred in 5.3% (ESD 2.0% vs. EMR 12.0%; P = 0.105), and intraprocedural perforation occurred in 6.7% (ESD 8% vs. EMR 4%; P = 0.659) of the patients. Hemostasis was achieved in 100% of cases of intraprocedural bleeding, whereas two patients required surgical conversion due to intraprocedural perforation. Among the remaining 73 patients who received prosphylactic clipping, delayed bleeding occurred in 1.4% (ESD 0% vs. EMR 4.2%; P = 0.329), and delayed perforation occurred in 0%.

CONCLUSIONS

The prophylactic partial closure of large post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. The prophylactic partial closure of large complex post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation.

Rivaroxaban attenuates neutrophil maturation in the bone marrow niche

Pharmacological inhibition of factor Xa by rivaroxaban has been shown to mediate cardioprotection and is frequently used in patients with, e.g., atrial fibrillation. Rivaroxaban's anti-inflammatory actions are well known, but the underlying mechanisms are still incompletely understood. To date, no study has focused on the effects of rivaroxaban on the bone marrow (BM), despite growing evidence that the BM and its activation are of major importance in the development/progression of cardiovascular disease. Thus, we examined the impact of rivaroxaban on BM composition under homeostatic conditions and in response to a major cardiovascular event. Rivaroxaban treatment of mice for 7 days markedly diminished mature leukocytes in the BM. While apoptosis of BM-derived mature myeloid leukocytes was unaffected, lineage-negative BM cells exhibited a differentiation arrest at the level of granulocyte-monocyte progenitors, specifically affecting neutrophil maturation via downregulation of the transcription factors Spi1 and Csfr1. To assess whether this persists also in situations of increased leukocyte demand, mice were subjected to cardiac ischemia/reperfusion injury (I/R): 7 d pretreatment with rivaroxaban led to reduced cardiac inflammation 72 h after I/R and lowered circulating leukocyte numbers. However, BM myelopoiesis showed a rescue of the leukocyte differentiation arrest, indicating that rivaroxaban's inhibitory effects are restricted to homeostatic conditions and are mainly abolished during emergency hematopoiesis. In translation, ST-elevation MI patients treated with rivaroxaban also exhibited reduced circulating leukocyte numbers. In conclusion, we demonstrate that rivaroxaban attenuates neutrophil maturation in the BM, which may offer a therapeutic option to limit overshooting of the immune response after I/R.

Microvascular tissue perfusion after postcatheterization pseudoaneurysm treatment

BACKGROUND

Femoral pseudoaneurysm (PSA) is a severe complication after endovascular procedures. Ultrasound-guided manual compression (MC) and percutaneous thrombin injection (TI) are frequently used treatments. MC is less effective, TI may cause thromboembolic events.

OBJECTIVE

Up to date, there is no data regarding impairment of microvascular tissue perfusion after PSA treatment.

METHODS

In this single-center, prospective study 22 patients with PSA were included. We compared macro- and microcirculatory perfusion in the treated and untreated leg at baseline before, after and one day after treatment. Leg perfusion was assessed with ultrasound and ankle-brachial index (ABI). Microcirculatory perfusion of the feet was measured with a near-infrared spectroscopy (NIRS) camera generating StO2-tissue-maps.

RESULTS

Successful PSA thrombosis was achieved in 16 (100%) patients in TI group and in 4 (66.7%) patients in MC group. There was no evidence of arterial thrombi on ultrasound and the ABI did not differ between groups. NIRS StO2-tissue-maps of the feet showed no significant difference in both groups concerning the treated (p = 0.121) or the untreated (p = 0.198) leg during follow up.

CONCLUSIONS

In this small exploratory study, there was no evidence of micro- and macrovascular tissue perfusion impairment after treatment of postcatheterization femoral pseudoaneurysm with thrombin injection underscoring the safety of this approach.

Analyse des patients hospitalisés pour COVID-19 lors du premier confinement de 2020 à l'aide de méthodes d'explicabilité

Introduction

La pandémie de COVID-19 a rapidement mis une forte pression sur les centres hospitaliers et en particulier sur les services de réanimation [1]. Il y eut lors du premier confinement un besoin urgent d'outils permettant d'identifier les patients hospitalisés les plus à risque de subir une aggravation de leur état, ainsi qu'une meilleure compréhension de la typologie des patients COVID-19.

Méthodes

Les données contiennent des informations sur des patients hospitalisés au Centre Hospitalier Intercommunal de Créteil à cause de la COVID-19 lors de la première vague de l'épidémie (printemps 2020). Les variables explicatives disponibles sur les patients étaient l'âge, le sexe, plusieurs comorbidités et les résultats des examens radiologiques et biologiques. Un modèle d'ensemble d'arbres stimulé (« Boosted Tree Ensemble » [2, 3]) a été appliqué pour détecter si l'état du patient allait s'aggraver pendant l'hospitalisation. L'analyse des effets de chaque variable explicative ainsi que des effets d'interaction entre deux variables ont été effectuées en utilisant des méthodes d'explicabilité, domaine aussi appelée intelligence artificielle explicable [4]. Une stratification de la typologie des patients [5] a été réalisée en utilisant techniques de regroupement (clustering) et de sélection d'instances.

Résultats

Il y avait 409 patients, dont 176 (43 %) avaient subi une aggravation pendant leur séjour hospitalier. La précision globale (« accuracy ») du modèle prédictif était de 75 % pour le modèle de risque tandis que le score ROC AUC était de 81 %. Les variables explicatives les plus importantes étaient l'âge, la gravité du scanner thoracique et les variables biologiques telles que la CRP, la saturation en oxygène et les éosinophiles. Plusieurs variables ont montré de forts effets non linéaires, en particulier pour la sévérité du scanner, comme indiqué dans la Figure 1. Des effets d'interaction ont également été détectés entre l'âge et le sexe ainsi qu'entre l'âge et les éosinophiles. Trois principaux sous-groupes de patients ont été identifiés. Le patient le plus représentatif de chaque groupe est indiqué dans la Figure 2. Le premier groupe présentait un risque très faible d'aggravation de l'état de santé (pas de facteur de risque), le deuxième groupe présentait un risque plus élevé d'aggravation, mais toujours inférieur à 50 % (leur seul facteur de risque était un âge avancé), tandis que le troisième groupe avait le pronostic le plus défavorable (plusieurs facteurs de risque comprenant un âge avancé, plusieurs comorbidités, une sévérité CT élevée et des valeurs biologiques anormales).

Discussion

Les méthodes d'explicabilité ainsi que les techniques de regroupement et de sélection d'instances ont permis de mieux comprendre les effets des variables explicatives. Cela a aussi permis de déterminer les principales typologies des patients hospitalisés, facilitant ainsi la définition et l'amélioration des protocoles médicaux pour fournir les soins les plus appropriés à chaque profil [6].

Mots clés

COVID19; Intelligence artificielle; Explicabilité; Clustering

Déclaration de liens d'intérêts

Les auteurs n'ont pas précisé leurs éventuels liens d'intérêts.

Evolution du profil des patients hospitalisés au cours des trois premières vagues de COVID-19 par des techniques d'apprentissage automatique

Introduction

La COVID-19 a rapidement évolué d'une épidémie locale à une pandémie mondiale, obligeant la plupart des pays à prendre de fortes mesures pour contenir la propagation au cours des différentes vagues et soulager la pression sur les centres hospitaliers, en particulier sur les unités de soins intensifs. Une abondante littérature a détaillé les caractéristiques des patients et les facteurs de protection et de risque lors du l'éclatement de la pandémie [1]. Malheureusement, très peu d'études ont ensuite été menées pour décrire l'évolution de ces caractéristiques au cours des vagues ultérieures [2,3]. De plus, comme les premiers facteurs de risque identifiés étaient pluriels (de l'âge aux comorbidités, multiples interactions) les méthodes classiques d'analyse ne suffisent pas à obtenir une compréhension précise de la population à risque de développer des formes sévères de COVID-19.

Méthodes

Les données ont été recueillies prospectivement au Centre hospitalier intercommunal de Créteil sur plus d'un an, correspondant aux trois premières vagues de COVID-19 en France. Les caractéristiques disponibles étaient l'âge, le sexe et de nombreuses comorbidités. La variable cible indiquant si le patient avait développé une forme sévère (ventilation mécanique, réanimation, décès) de COVID-19 pendant son l'hospitalisation. L'évolution des caractéristiques entre les cas non sévères et sévères au fil des vagues a été analysée en couplant un modèle d'apprentissage automatique [4] à une méthode d'explicabilité produisant des influences locales [5]. Ainsi, chaque patient se voit associé un niveau de risque (une probabilité d'être un cas sévère) et un score de contribution de chacune de ses variables explicatives, permettant de repérer les facteurs de protection et de risque.

Résultats

Il y avait 1076 patients sur les trois vagues: 429 pour la première vague, 214 pour la deuxième et 433 pour la troisième. Les formes sévères concernaient respectivement 29 %, 31 % et 18 % de chaque vague. Les facteurs de risque de la première vague comprenaient l'âge avancé (≥70 ans), être un homme et des comorbidités telles que le diabète et l'obésité, tandis que les problèmes cardiovasculaires apparaissaient comme un léger facteur de protection. Il y avait de plus des effets d'interaction entre l'âge et les autres variables importantes. La deuxième vague présentait moins de facteurs de risque, puisque seuls l'âge avancé (≥70 ans) et le fait d'être un homme étaient des informations importantes. Lors de la troisième vague, l'âge avancé (≥70 ans) a également été identifié comme un facteur de risque mais de manière plus hétérogène que pour les vagues précédentes. Être un homme et les comorbidités telles que l'obésité, la grossesse ainsi que les problèmes cardiovasculaires et pulmonaires sont également apparus comme des facteurs de risque mais il n'y avait pas d'interaction avec l'âge.

Discussion

La typologie des patients hospitalisés atteints de formes sévères de COVID-19 a rapidement évolué au fil des vagues. L'analyse a notamment mis en évidence que les facteurs de risque étaient beaucoup plus hétérogènes pour la troisième vague. Cette évolution peut être due aux changements des pratiques hospitalières à mesure que la maladie était mieux comprise ainsi qu'à la campagne de vaccination [6] ciblant en premier lieu les personnes comme à haut risque telles les personnes âgées ou présentant des comorbidités.

Mots clés

COVID; 19; Intelligence artificielle; Explicabilité

Déclaration de liens d'intérêts

Les auteurs n'ont pas précisé leurs éventuels liens d'intérêts.

Excess mortality in Aspirin and Dipyrone (Metamizole) co-medicated in patients with cardiovascular disease: a nationwide study

Background

Pain is a serious issue in our aging society. Metamizole is one of the most commonly used analgesics. In addition, metamizole has been shown to attenuate the pharmacodynamics response to aspirin as measured by platelet function tests. However, the extent to which this laboratory effect translates to clinical outcome in patients is unknown.

Methods

We conducted a nationwide analysis based on health insurance database including 9.2 million patients in Germany. All patients with a cardiovascular event in 2014 and subsequent secondary prevention with aspirin were followed up for 36 months. Inverse probability of treatment weighting (IPTW) analysis was performed to examine mortality rates between patients on aspirin-metamizole co-medication and aspirin medication alone. Myocardial infarction (MI) and stroke/transient ischemic attack (TIA) events were also documented.

Results

26,200 patients received continuous aspirin medication alone and 5,946 received co-medication with aspirin and metamizole. In the IPTW analysis, significantly increased mortality was observed in the co-medication group (15.6% vs. 24.4%, hazard ratio (HR)=1.66, 95% confidence interval (CI) 1.56–1.76; p<0.0001). MI and stroke/TIA were also increased (MI: 1,370 [5.2%] vs. 355 [5.9%]; HR=1.18, 95% CI 1.05–1.32; p=0.0066, relative risk (RR) 1.14, absolute risk increase (ARI) 0.71%, number needed to harm (NNH) 140. Stroke/TIA: 1,901 [7.3%] vs. 506 [8.5%]; HR=1.22, 95% CI 1.11–1.35; p<0.0001, RR 1.17, ARI 1.21%, NNH 82).

Conclusion

In this nationwide observational study, aspirin-metamizole co-medication was associated with excess mortality. This was partly due to ischemic events (MI and stroke/TIA), which were also more frequent in the co-medication patients. Therefore, metamizole should be used with caution in aspirin-treated patients for secondary prevention

Funding Acknowledgement

Type of funding sources: None.

Development of CMR-derived aortic stiffness parameters in patients with metabolic comorbidities after ST-segment elevation myocardial infarction

Background

Aortic stiffness has demonstrated an independent prediction of adverse cardiovascular events after ST-segment elevation myocardial infarction (STEMI) [1]. The general impact of the comorbidities diabetes mellitus (DM), chronic kidney disease (CKD), anemia on aortic stiffness is well known [2,3]. Therefore, the present study aimed to investigate the influence of metabolic comorbidities on cardiovascular magnetic resonance (CMR)-derived aortic parameters early and 6 months after STEMI.

Methods

From the prospective STEMI pathway, 161 patients (mean age: 63.7 years; 75% male) with initial CMR 5 days after STEMI were included. 105 patients pursued in a 6-month follow-up CMR. Aortic stiffness was assessed using different parameters: 1) pulse wave velocity (PWV) from velocity-encoded phase-contrast images, 2) aortic distensibility, and 3) radial strain from the ascending aorta obtained from cine images. DM was diagnosed when either pre-existing, HbA1c ≥6.5% at index hospitalization or 2-hour OGCT ≥200 mg/dl. CKD was present when glomeruli filtration rate (GFR) was less than 60 ml/min/m2, Anemia was defined according to WHO classifications.

Results

Of the 161 patients, 46 presented with anemia at admission, 79 with anemia at day 5, 26 with CKD and 57 with DM. Initial anemia resulted in a significantly lower distensibility (p=0.003) and aortic strain (p=0.02). A correlation between initial haemoglobin levels and distensibility (r=0.253; p=0.002) was found. CKD Patients showed a lower distensibility (p=0.012). There were correlations between GFR and PWV (r=−0.298; p<0.001), distensibility (r=0.370; p<0.001), and radial strain (r=−0.388; p<0.001). After 6 month this significant correlation remained. The DM group showed higher PWV values (p=0.02) and a lower radial strain (p=0.003). PWV showed a correlation with the 2-hour OGCT value (r=0.249; p=0.011) while the radial strain correlated with HbA1c (r=0.216; p=0.007). After multivariable analyses, diabetes remained the only significant predictor to show higher PWV (p=0.004) and poorer radial strain values (p=0.0045) while initial anemia remained the only significant predictor of lower distensibility (p=0.0033). Aortic stiffness parameters did not show any changes after 6 months in all groups. Only NTproBNP 5 days after STEMI correlated significantly with 6-months PWV (r=0.247; p=0.02), radial strain (r=0.36; p=0.001), distensibility (r=−0.226; p=0.018).

Conclusion

Anemia, DM and CKD show a detrimental impact on values of aortic stiffness early after STEMI. Diabetes remains the only significant predictor of higher PWV and poorer radial strain values after multivariable analysis while initial anemia remains significant predictor of lower distensibility. After 6 months none of the groups showed improvement in aortic stiffness parameters.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Sonderforschungsbereich 1116

The impact of pre-existing chronic heart failure on the intensive care treatment and outcome of old intensive care patients suffering from COVID-19

Background

Patients suffering from COVID-19 with pre-existing chronic heart failure (CHF) are considered to have a significant risk regarding morbidity and mortality. Similarly, older patients on the intensive care unit (ICU) constitute another vulnerable subgroup. This study investigated the association between pre-existing CHF and clinical practice in critically ill older ICU patients with COVID-19.

Methods

Patients with severe COVID-19 and who were ≥70 years old were recruited from this prospective multicenter international study. Patients' treatment, follow-up, and pre-existing heart failure data were collected during ICU stay. Univariate and multivariate logistic regression analyses examined the association between pre-existing heart failure and the primary endpoint of 30-day mortality.

Results

The study included 3,917 patients, with 407 patients (17%) evidencing pre-existing CHF. These patients were older (77±5 versus 76±5, p<0.001) and more frail (Clinical Frailty Scale 4±2 versus 3±2, p<0.0001). The other comorbidities were also significantly more common in CHF patients. Before hospital admission, CHF patients suffered fewer days from symptoms (5 days (3–8) versus 7 days (4–10), p<0.001), but there was no difference in the days in the hospital before ICU admission (2 days (1–5) versus 2 (1–5) days, p=0.21). At ICU admission, disease severity assessed by SOFA scores was significantly higher in CHF patients (7±3 versus 5±3). During ICU-stay, intubation, mechanical ventilation, and tracheostomy occurred significantly more often in patients without CHF (63% versus 69%, p=0.017; and 13% versus 18%, p=0.002, respectively). In contrast, there was no difference regarding non-invasive ventilation (28% versus 27%, p=0.20), and the need for vasoactive drugs (66% versus 64, p=0.30). Regarding the limitation of life-sustaining therapy, therapy was significantly more often withheld (32% versus 25%, p=0.001) but not withdrawn (18% versus 17%, p=0.21) in CHF patients. Length of ICU stay was significantly shorter in CHF patients (166 (72–336) hours versus 260 hours (120–528), p<0.001). CHF patients had significantly higher ICU- (52% versus 46%, p=0.007), 30-day mortality (60% vs. 48%, p<0.001; OR 1.87, 95% CI 1.5–2.3) and 3-month mortality (69% vs. 56%, p<0.001). In the univariate regression analysis, having pre-existing CHF was significantly associated with 30-day mortality (OR 1.89, 95% CI 1.5–2.3; p<0.001), but after adjusting for confounders (SOFA, age, gender, frailty), heart failure was not independently associated any more (aOR 1.2, 95% CI 0.5–1.5; p=0.137).

Conclusion

In critically ill old COVID-19 patients, pre-existing chronic heart failure is associated with significantly increased short- and long-term mortality, but heart failure is not independently associated with increased 30-day mortality when adjusted for confounders.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): This study was endorsed by the ESICM. Free support for running the electronic database and was granted from the dep. of Epidemiology, University of Aarhus, Denmark. The support of the study in France by a grant from “Fondation Assistance Publique-Hôpitaux de Paris pour la recherche” is greatly appreciated. In Norway, the study was supported by a grant from the Health Region West. In addition, the study was supported by a grant from the European Open Science Cloud (EOSC). EOSCsecretariat.eu has received funding from the European Union's Horizon Programme call H2020-INFRAEOSC-05-2018-2019, grant agreement number 831644. This work was supported by the Forschungskommission of the Medical Faculty of the Heinrich-Heine-University Düsseldorf, No. 2018-32 to GW and No. 2020-21 to RRB for a Clinician Scientist Track.

A short review of ciraparantag in perspective of the currently available anticoagulant reversal agents

Despite the improved safety-profile of direct oral anticoagulants (DOACs), bleeding complications remain an important side effect of anticoagulant treatment. Although anticoagulant-specific antidotes are available, an universal anticoagulant reversal agent in case of life-threatening bleeding or emergency surgery is not yet available. Ciraparantag, a synthetic small molecule that inactivates heparins and DOAC, is a promising new reversal agent that has been investigated in phase 2 trials. In this short review we provide an overview of the preclinical and clinical evidence of ciraparantag, and compare strengths and weaknesses of ciraparantag and the currently available anticoagulant reversal strategies.

From the original SARS-CoV-2 strain to the Omicron variant: predictors of COVID-19 in ambulatory symptomatic children

OBJECTIVES

To determine the predictors of a positive SARS-CoV-2 test in a pediatric ambulatory setting.

PATIENTS AND METHODS

We performed a cross-sectional prospective study (November 2020-February 2022) of 93 ambulatory settings in France. We included symptomatic children < 15 years old tested for SARS-CoV-2. For each period corresponding to the spread of the original strain and its variants (period 1: original strain; period 2: Alpha, period 3: Delta; period 4: Omicron), we used a multivariate analysis to estimate adjusted odds ratios (aORs) associated with COVID-19 among age, signs, symptoms or contact, and 95 % confidence intervals (95CIs).

RESULTS

Of 5,336 children, 13.9 % (95CI 13.0-14.8) had a positive test. During the first three periods, the positivity rate ranged from 5.6 % (95CI 4.6-6.7) to 12.6 % (95CI 10.8-14.6). The main factors associated with a positive test were contact with an infected adult at home or outside the home (aOR 11.5 [95CI 4.9-26.9] to 38.9 [95CI 19.3-78.7]) or an infected household child (aOR 15.0 [95CI 4.8-47.1] to 28.4 [95CI 8.7-92.6]). By contrast, during period 4, aORs for these predictors were substantially lower (2.3 [95CI 1.1-4.5] to 5.5 [95CI 3.2-7.7]), but the positivity rate was 45.7 % (95CI 42.3-49.2).

CONCLUSIONS

In pediatric ambulatory settings, before the Omicron period, the main predictor of a positive test was contact with an infected person. During the Omicron period, the odds of these predictors were substantially lower while the positivity rate was higher. An accurate diagnostic strategy should only rely on testing and not on age, signs, symptoms or contact.

Predictors and Impact of Sulcal SAH after Mechanical Thrombectomy in Patients with Isolated M2 Occlusion

BACKGROUND AND PURPOSE

Data on SAH after M2 mechanical thrombectomy are limited. We aimed to determine the prevalence of sulcal SAH after mechanical thrombectomy for M2 occlusion, its associated predictors, and the resulting clinical outcome.

MATERIALS AND METHODS

The study retrospectively reviewed the data of patients with acute ischemic stroke who underwent mechanical thrombectomy for isolated M2 occlusion. The patients were divided into 2 groups according to the presence of sulcal SAH after M2 mechanical thrombectomy. Angiographic and clinical outcomes were compared. Multivariable analysis was performed to identify independent predictors of sulcal SAH and unfavorable outcome (90-day mRS, 3-6).

RESULTS

Of the 209 enrolled patients, sulcal SAH was observed in 33 (15.8%) patients. The sulcal SAH group showed a higher rate of distal M2 occlusion (69.7% versus 22.7%), a higher of rate of superior division occlusion (63.6% versus 43.8%), and a higher M2 angulation (median, 128° versus 106°) than the non-sulcal SAH group. Of the 33 sulcal SAH cases, 23 (66.7%) were covert without visible intraprocedural contrast extravasation. Distal M2 occlusion (OR, 12.04; 95% CI, 4.56-35.67; P < .001), superior division (OR, 3.83; 95% CI, 1.43-11.26; P = .010), M2 angulation (OR, 1.02; 95% CI, 1.01-1.04; P < .001), and the number of passes (OR, 1.58; 95% CI, 1.22-2.09; P < .001) were independent predictors of sulcal SAH. However, covert sulcal SAH was not associated with an unfavorable outcome (P = .830).

CONCLUSIONS

After mechanical thrombectomy for M2 occlusion, sulcal SAH was not uncommon and occurred more frequently with distal M2 occlusion, superior division, acute M2 angulation, and multiple thrombectomy passes (≥3). The impact of covert sulcal SAH was mostly benign and was not associated with an unfavorable outcome.

Evolution des facteurs de risque de forme grave de la COVID-19 à travers les trois vagues à partir des données du PMSI

Introduction

De nombreuses études ont établi une typologie des patients à risque de développer une forme grave de COVID-19. La grande majorité de ces études ne portent que sur la première vague de la COVID-19 alors que les profils à risque de développer des formes graves évoluent après les campagnes de vaccination. Cette étude a pour but d'analyser l’évolution des facteurs de risque cliniques de COVID-19 graves lors des différentes vagues afin d'ajuster l'offre de soins au contexte actuel.

Méthodes

Les données du PMSI du Centre hospitalier intercommunal de Créteil ont été analysées pendant les trois premières vagues de l'épidémie. Les variables cliniques disponibles étaient l’âge, le sexe et les comorbidités connues comme à risque de forme grave. Les formes graves étaient définies par le passage en réanimation, le recours à un support ventilatoire non invasif ou le décès du patient. L'évolution de la typologie des patients à risque a été analysée avec des méthodes classiques comme la régression multivariée ainsi qu'avec des techniques provenant de l'apprentissage automatique et de son sous-domaine qu'est l'explicabilité.

Résultats

Sur 1076 patients hospitalisés, les formes sévères concernaient 29 % (123/429) des patients de la vague 1, 31 % (66/214) de la vague 2 et 18 % (79/433) de la vague 3. Les facteurs de risque de la vague 1 étaient l'âge élevé ( ≥ 70 ans), le sexe masculin, le diabète et l'obésité, tandis que les problèmes cardiovasculaires apparaissaient comme des facteurs protecteurs. Les impacts de l'âge, du sexe étaient moins marqués pour la vague 3, de même que l'interaction entre l'âge et les comorbidités.

Discussion/Conclusion

Le profil des patients à risque a rapidement évolué au cours des vagues, la troisième vague ayant eu un écart bien moins net entre les formes sévères et non-sévères. Cette évolution peut provenir des changements des procédures médicales hospitalières ainsi que du début de la campagne de vaccination ciblant en premier lieu les personnes avec un risque élevé telles les personnes âgées ou présentant certaines comorbidités.

Real-world experience with the cusp overlap deployment technique for procedural optimization during self-expanding transcatheter aortic valve implantation: our city best practice trial

Background

Aortic valve stenosis treated by transcatheter aortic valve implantation (TAVI) is a fast-growing section in interventional cardiology. Optimal implantation depth (ID) of self-expanding TAVI devices is an important condition for hemodynamic and clinical outcomes. The cusp overlap technique (COT) offers optimized fluoroscopic projections for TAVI with self-expanding devices due to improved anatomic discrimination by elongation of the left ventricular outflow tract and isolation of the non-coronary cusp (NCC) for better assessment of ID.

Purpose

This single-center observational study aims to investigate short-term clinical performance, safety, and efficiency outcomes regarding optimized ID in patients undergoing transfemoral TAVI with self-expanding prostheses and COT.

Methods

From September 2020 to December 2020, a total of 71 patients underwent TAVI with a newer-generation self-expanding device and COT. The optimal fluoroscopic projection was generated by overlapping the right (RCC) and left coronary cusps (LCC) on the multidetector computed tomography annular plane. Final ID was assessed by the arithmetic mean of distances measured from NCC and LCC to the distal prosthesis end. Outcomes were compared with a control cohort of 339 patients who underwent TAVI from January 2016 to August 2020 with a three-cusp coplanar view only during valve deployment.

Results

ID was significantly reduced in the COT cohort (4.3±1.9 vs. 5.0±2.3 mm; p=0.012) with better achievement of optimal ID (2–4 mm) (63.4% vs. 49.9%; p=0.03) and optimization of delta NCC-LCC ID symmetry (1.4±1.3 vs. 1.7±1.3 mm; p=0.026). The rate of pacemaker implantation following TAVI could be reduced (9.9% vs. 19.4%; p=0.05). Six of the seven patients receiving pacemaker in the COT cohort (85.7%) showed ID above membranous septum length. COT resulted in notably higher rates of device repositioning by recapturing (57.8% vs. 16.2%; p&lt;0.001) compared to control cohort. Though, procedure time was prolonged in the COT cohort (82.0±26.5 vs. 74.9±27.5 min; p=0.05) while radiation dose and amount of contrast medium did not differ between the cohorts. No difference was observed in hemodynamic outcomes regarding transvalvular pressure gradients and at least moderate paravalvular leak. Patients implanted with COT had a shorter length of hospital stay (7.1±6.0 vs. 10.3±6.8 days; p&lt;0.001), possibly due to a lower complication rate regarding new conduction disturbances and pacemaker implantation.

Conclusion

TAVI using the cusp overlap deployment technique is associated with an optimized implantation depth and a low rate of procedural complications. Therefore, a reduction of new pacemaker implantations and shortened length of hospital stay could be achieved.

Funding Acknowledgement

Type of funding sources: None.

Crucial role of extra-domain A containing fibronectin for the development of pulmonary hypertension and associated right heart failure

Background

Pulmonary vascular and right ventricular myocardial remodelling are unique phenomena in PH progression. Both processes are accompanied by an abundant re-expression of the extra-domain A of fibronectin (ED-A+ Fn) therefore qualifying as promising biomarker or even therapeutic target. Nevertheless, its functional role in PH pathogenesis remains unclear until now. Objective: The purpose of our study was to analyse the development of PH and RHF in a mouse model of monocrotaline (MCT)-induced PH comparing C57BL/6 ED-A+ Fn knockout (KO) and wild-type (WT) mice.

Methods

PH was induced by subcutaneous injection of a single dose of MCT (60 mg/kg body weight). Subgroups were additionally treated with the dual endothelin receptor antagonist Macitentan (MAC, 15mg/kg body weight per day from day 14 to 28). There were 6 experimental groups: sham-treated control WT mice (WTco, n=4); MCT induced PH WT mice (WTPH, n=6); MCT induced PH WT mice treated with MAC (WTPH_MAC, n=6); sham-treated control KO mice (KOco, n=4); MCT induced PH KO mice (KOPH, n=6); MCT induced PH KO mice treated with MAC (KOPH_MAC, n=6). Between day 26 and 28, transthoracic echocardiography and right heart catheterization were performed. Both, lung and cardiac tissue samples were subjected to histological analyses.

Results

Right heart catheterization revealed significantly increased RVPsys values in WTPH (87.0±16.4mmHg) compared to WTco (36.1±9.4mmHg; p=0.034) animals, which showed, at least in trend, a diminution in the WTPH_MAC group (67.1±20.9mmHg; p=n.s.). There was a non-significant increase in RVPsys in the KOPH (55.6±14.9mmHg) compared to KOco mice (37.2±5.6mmHg; p=n.s.) without any differences compared to the KOPH_MAC group (60.9±14.0mmHg; p=n.s.). When comparing the WTPH and the KOPH group, RVPsys was significantly lower in the KO animals (p=0.014), while there were no differences between the WTPH_MAC and the KOPH_MAC group (p=n.s.). Echocardiographic evaluation including surrogate parameters of right ventricular (RV) overload and failure were significantly altered in WTPH compared to WTco animals (p&lt;0.05) and could not be shown to be relevantly improved in the WTPH_MAC group (p=n.s.). The majority of echocardiographic parameters did not significantly differ between the KOPH and the KOco group (p=n.s.). Lung tissue analysis revealed significant alterations in both, the WTPH and the KOPH group, each compared to the corresponding control (p&lt;0.05). The level of lung tissue damage was significantly decreased in KOPH compared to WTPH mice (p&lt;0.05). In RV, the amount of interstitial fibrosis was increased in the WTPH (p=0.009) but not in the KOPH group (p=n.s.), each compared to the corresponding controls.

Conclusions

The findings of the current study underline the hypothesis that ED-A+ Fn is a key player in the pathogenesis of PH and associated RHF. Thus, it might represent a promising therapeutic target, e.g., by the administration of neutralizing antibodies.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Jena

Rapid pacing is an independent predictor for high implantation depth using self-expandable devices in TAVR

Background/Introduction

Optimizing valve implantation depth (ID) plays a crucial role in minimizing conduction disturbances and achieving optimal functional integrity. Until now, the impact of intraprocedural fast (FP) or rapid ventricular pacing (RP) on the implantation depth has not been investigated.

Purpose

Therefore, we aimed to 1) evaluate the impact of different pacing maneuvers on ID, and 2) identify the independent predictors of deep ID.

Methods

562 TAVR patients with newer-generation self-expandable devices were retrospectively enrolled and further separated into patients undergoing TAVR under FP (n=331; 58.9%) and RP (n=231; 41.1%). The final ID was analyzed, and the underlying functional, anatomical, and procedural conditions were evaluated by univariate and multivariate analysis.

Results

The highest ID was reached under RP in severe aortic valve calcification and valve size 26 mm. Multivariate analysis identified left ventricular outflow (LVOT) calcification (OR 0.56 [0.37–0.85], p=0.006*), a bicuspid valve (OR 0.34 [0.11–1.0], p=0.049*), valve size 26 mm (OR 0.47 [0.28–0.81], p=0.006*), and RP (OR 0.57 [0.37–0.87], p=0.010*) as independent and highly preventable predictors for deep valve deployment. Independent risk factors for deep ID were the use of a 34 mm device (OR 1.96 [1.22–3.15], p=0.005*) and mild aortic valve calcification (OR 1.62 [0.01–2.61], p=0.046*). In a model of protective factors, ID was significantly reduced with the number of protective criteria (0–2 criteria: −5.6±2.6 mm vs. 3–5 criteria: −4.5±2.0 mm; p&lt;0.0001*).

Conclusion

Data from this retrospective analysis indicate that RP is an independent predictor to reach a higher implantation depth using self-expandable devices.

Funding Acknowledgement

Type of funding sources: None.

Electrocardiographic predictors of recovery from pacemaker dependency after transcatheter aortic valve implantation: a meta-analysis

Background

Transcatheter aortic valve implantation (TAVI) is a well-established alternative to surgery for the treatment of patients with severe symptomatic aortic stenosis at high and intermediate surgical risk. The occurrence of electrical conduction disturbances with the need for permanent pacemaker (PPM) implantation remains one of the most frequent complications of the procedure. But PPM dependency after TAVI is often transient and conduction abnormalities may improve over time.

Purpose

We performed a meta-analysis to summarize available studies that reported the incidence of new PPM after TAVI and investigated the rate and possible predictors of recovery from PPM dependency during follow-up.

Methods

The authors conducted a literature search in PubMed and MEDLINE databases from January of 2012 until February of 2021. Eleven observational studies (n=6794) met inclusion criteria for the final analysis. The effect size was estimated using a random-effects model with 95% confidence interval (CI).

Results

PPM implantation was performed in 902 patients after TAVI (13.3%), mostly due to high degree atrioventricular (AV) block (81.3%). A follow-up of 683 patients was performed after a median period of 139 days. 322 of the patients examined during follow-up (48.6%) showed recovery from PPM dependency. Regarding secondary endpoints' analysis of relative risk (RR) and mean difference (MD) predictors of PPM recovery during follow-up were female sex (RR 1.37; 95% CI 1.10–1.71; p=0.006), preexisting coronary artery disease (RR 1.12; 95% CI 0.99–1.27; p=0.08) and reduced left ventricular ejection fraction (MD −2.08%; 95% CI 0.23–3.93%; p=0.03). ECG predictors for long-term PPM dependency after TAVI appeared to be preexisting right bundle branch block (RBBB) (RR 1.84; 95% CI 1.38–2.45; p&lt;0.0001), bifascicular block (RR 4.41; 95% CI 1.64–11.86; p=0.003) and prolonged QRS duration (MD 8.69 ms; 95% CI 0.11–17.28 ms; p=0.05). While postprocedural complete heart block was highly predictive for long-term PPM dependency after TAVI (RR 1.35; 95% CI 0.97–1.89; p&lt;0.0001), patients with recovery of PPM dependency showed more indications other than complete heart block for PPM implantation like lower degree AV block or sick sinus syndrome (RR 2.28; 95% CI 1.53–3.38; p&lt;0.0001). Especially postprocedural AV block grade I (RR 1.73; 95% CI 0.96–3.14; p=0.07) and new left bundle branch block (LBBB) (RR 1.94; 95% CI 1.22–3.08; p=0.005) turned out to be predictors of PPM recovery during follow-up.

Conclusion

This structured meta-analysis proved new PPM implantation in 13.3% of patients following TAVI with half of the cases (48.6%) recovering from PPM dependency during follow-up. Therefore, it should be considered to carefully reassess the indication for PPM rather than to immediately implant PPM after TAVI, especially regarding postprocedural ECG predictors for early pacemaker recovery (lower degree AV block, postprocedural LBBB).

Funding Acknowledgement

Type of funding sources: None.

Random antral follicle count performed on any day of the menstrual cycle has the same predictive value as AMH for good ovarian response in IVF cycles

OBJECTIVE

To determine whether the predictive value of AFC for ovarian response to stimulation for IVF depends on the day of the menstrual cycle when ultrasound is performed.

METHODS

410 women undergoing their first IVF cycle were included. All the women had AFC performed twice. The first measurement, random AFC (r-AFC), was performed during the fertility workup whatever the day of their menstrual cycle. Three groups were constituted according to the period of ultrasound performance: at early follicular phase i.e., day 1 to day 6 (eFP-AFC); at mid follicular phase i.e., day 7 to 12 (mFP-AFC) and at luteal phase i.e., day 13 or after (LP-AFC). A second AFC measurement was performed before the start of the ovarian stimulation (SD1-AFC). AMH dosing was done in the early follicular phase.

RESULTS

Random AFC (r-AFC) was correlated to AMH (r = 0.69; p<0.001), SD1-AFC (r = 0.75; p<0.001) and number of oocytes retrieved (r = 0.49; p<0.001). When regarding AFC depending on the cycle day group, the correlation with AMH was 0.65, 0.66 and 0.85 for the eFP-AFC, the mFP-AFC and the LP-AFC respectively (all p were <0.001). The ROC analysis showed the same predictive value for good ovarian response (more than 6 oocytes retrieved) for the eFP-AFC, mFP-AFC and LP-AFC (AUC 0.73, 0.75 and 0.84 respectively; p = 0.28). The AUC of r-AFC (0.76) were similar to those of AMH (0.74) and SD1-AFC (0.74) (p = 0.21 and 0.92 respectively).

CONCLUSION

AFC is strongly correlated with AMH and highly predictive of good ovarian response during the whole menstrual cycle.

Local Intra-arterial Thrombolysis during Mechanical Thrombectomy for Refractory Large-Vessel Occlusion: Adjunctive Chemical Enhancer of Thrombectomy

BACKGROUND AND PURPOSE

Data on adjunctive intra-arterial thrombolysis during mechanical thrombectomy for refractory thrombus are sparse. The aim of this study was to evaluate the efficacy and safety of local intra-arterial urokinase as an adjunct to mechanical thrombectomy for refractory large-vessel occlusion.

MATERIALS AND METHODS

We retrospectively evaluated patients with acute ischemic stroke who underwent mechanical thrombectomy for anterior circulation large-vessel occlusion between January 2016 and December 2019. Patients were divided into 2 groups based on the use of intra-arterial urokinase as an adjunctive therapy during mechanical thrombectomy for refractory thrombus: the urokinase and nonurokinase groups. Herein, refractory thrombus was defined as the target occlusion with minimal reperfusion (TICI 0 or 1) despite >3 attempts with conventional mechanical thrombectomy. The baseline characteristics, procedural outcomes, and clinical outcome were compared between the 2 groups.

RESULTS

One hundred fourteen cases of refractory thrombus were identified. A total of 45 and 69 patients were in the urokinase and the nonurokinase groups, respectively. The urokinase group compared with the nonurokinase group showed a higher rate of successful reperfusion (82.2% versus 63.8%, P = .034), with lower procedural times (54 versus 69 minutes, P = .137). The rates of good clinical outcome, distal embolism, and symptomatic intracranial hemorrhage were similar between the 2 groups. The use of intra-arterial urokinase (OR = 3.682; 95% CI, 1.156-11.730; P = .027) was an independent predictor of successful reperfusion.

CONCLUSIONS

The use of local intra-arterial urokinase as an adjunct to mechanical thrombectomy may be an effective and safe method that provides better recanalization than the conventional mechanical thrombectomy for refractory thrombus in patients with embolic large-vessel occlusion.

P–599 random antral follicle count, performed at any day of the menstrual cycle, demonstrates the same predictive value for ovarian response in in vitro fertilization cycles

Study question

Does antral follicle count (AFC) retains its predictive value for ovarian response to stimulation for in vitro fertilization (IVF) throughout the whole menstrual cycle?

Summary answer

AFC is strongly correlated to anti-mullerian hormone (AMH) and highly predictive of good ovarian response whatever the day of cycle the ultrasound is performed.

What is known already

Usually performed in the early follicular phase (at day 2–3 of the menstrual cycle), AFC and AMH are the most accurate markers of ovarian reserve. They are routinely used to predict ovarian response to ovarian stimulation for IVF and eventually to individualize the gonadotropin starting dose.

Study design, size, duration

Retrospective cohort study performed between January, 2017 and December, 2019.

Participants/materials, setting, methods

410 consecutive women aged 20 to 42 years were included. Random AFC (r-AFC) was performed during the fertility workup whatever the day of their menstrual cycle was: early follicular phase i.e. day 1 to day 6 (eFP-AFC), mid follicular phase i.e. day 7 to 12 (mFP-AFC) and luteal phase i.e. day 13 or after (LP-AFC). A second AFC was performed before the start of the stimulation (SD1-AFC). AMH was measured in the early follicular phase.

Main results and the role of chance

Random AFC (r-AFC) was correlated to AMH (r = 0.692; p &lt; 0.001), SD1-AFC (r = 0.756; p &lt; 0.001) and number of oocytes retrieved (r = 0.491; p &lt; 0.001). When regarding AFC depending on the cycle day group, the correlation with AMH was significantly higher for the LP-AFC, (LP-AFC) (r = 0.853) than for the eFP-AFC (r = 0.657; p &lt; 0.001) and for the mFP-AFC (r = 0.668). The correlation with SD1-AFC was similar regardless of the time of performance of r-AFC (r = 0.739, 0.783, 0.733, respectively for eFP, mFP and LP-AFC). Moreover, the ROC analysis showed the same predictive value for good ovarian response (more than 6 oocytes retrieved) for the eFP-AFC, mFP-AFC and LP-AFC (AUC 0.73, 0.75 and 0.84 respectively) as well as for AMH and SD1-AFC (AUC 0.74 and 0.74, respectively).

Limitations, reasons for caution

This is a retrospective analysis, however data were prospectively collected and the method for ultrasound acquisition of AFC was standardized.

Wider implications of the findings: The absence of significant variation of AFC across the menstrual cycle allows to its random performance. Ultrasound performed besides early follicular phase discloses informations on ovaries, the uterus and the endometrium. It is more comfortable and convenient for women and physicians by limiting targeted appointment during menstruation and reiterated examination.

Trial registration number

Not applicable

Selective Photocoagulation of Capillary Macroaneurysms by Navigated Focal Laser

BACKGROUND AND OBJECTIVE

To evaluate the anatomical and functional outcome of selective photocoagulation of capillary macroaneurysms (CMAs) by navigated focal laser.

PATIENTS AND METHODS

Consecutive patients with solitary or secondary CMAs greater than 150 mm in diameter were included in this analysis. All patients were treated with navigated focal laser and received multimodal imaging.

RESULTS

Seventeen eyes of 17 patients were retrospectively analyzed. Navigated laser photocoagulation of the CMAs successfully occluded 100% of the CMAs, inducing significative improvement in best-corrected visual acuity at 3 (P = .002) and 6 months (P = .001) and a decrease in central macular thickness (CMT) at 3 (P = .0004) and 6 months (P = .0004).

CONCLUSIONS

Solitary or secondary CMAs arising from retinal capillaries are candidates for navigated laser treatment. Navigated focal treatment was able to close all CMAs in this series with an improvement in vision and CMT. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:366-373.].

Impact of COVID-19 on surgical emergencies: nationwide analysis

Background

The COVID-19 pandemic has had a major impact on healthcare in many countries. This study assessed the effect of a nationwide lockdown in France on admissions for acute surgical conditions and the subsequent impact on postoperative mortality.

Methods

This was an observational analytical study, evaluating data from a national discharge database that collected all discharge reports from any hospital in France. All adult patients admitted through the emergency department and requiring a surgical treatment between 17 March and 11 May 2020, and the equivalent period in 2019 were included. The primary outcome was the change in number of hospital admissions for acute surgical conditions. Mortality was assessed in the matched population, and stratified by region.

Results

During the lockdown period, 57 589 consecutive patients were admitted for acute surgical conditions, representing a decrease of 20.9 per cent compared with the 2019 cohort. Significant differences between regions were observed: the decrease was 15.6, 17.2, and 26.8 per cent for low-, intermediate- and high-prevalence regions respectively. The mortality rate was 1.92 per cent during the lockdown period and 1.81 per cent in 2019. In high-prevalence zones, mortality was significantly increased (odds ratio 1.22, 95 per cent c.i. 1.06 to 1.40).

Conclusion

A marked decrease in hospital admissions for surgical emergencies was observed during the lockdown period, with increased mortality in regions with a higher prevalence of COVID-19 infection. Health authorities should use these findings to preserve quality of care and deliver appropriate messages to the population.

Assessment of the severity of infant crying and its impact on parents: Development and validation of the ColiQ Questionnaire in France

OBJECTIVES

The purpose of this study was to develop and validate a questionnaire that comprehensively assesses symptoms and severity of crying, symptoms suggesting infant functional gastrointestinal discomfort, and its impact on parents' quality of life: the Infant Colic Questionnaire (ColiQ©). For the first time, parents had access to a web application to follow their infants' evolving symptoms with a daily questionnaire.

METHODS

The ColiQ was developed with a board of clinical experts (physicians and psychologists) based on extensive parent input. A longitudinal, observational study was conducted in France for 3 months. ColiQ assessments were collected online at six different time points. Psychometric testing demonstrated that ColiQ has acceptable psychometric properties (reliability, internal consistency, construct validity, and responsiveness).

RESULTS

The ColiQ is a 16-question instrument developed in French including ten questions describing symptoms (Infant score) and six questions describing impacts (Parent score). The ColiQ demonstrated good test-retest reliability (ICC >0.70), internal consistency for both the Symptom and Impact subscale scores (Cronbach's α >0.70), and construct validity. Responsiveness was good; the ColiQ was able to detect significant improvement in the target population as early as 1 month (p<0.05). The global ColiQ score discriminated between severity levels (mild, medium, severe).

CONCLUSIONS

The ColiQ was developed with input from parents and healthcare professionals and has shown validity, reliably, and responsiveness to change. Parents can use the web application to follow how their infants' symptoms evolve. The ColiQ can help parents quantify and verbalize their concerns during consultations, and provides an opportunity to facilitate conversations between the physician and parents.

Clot Meniscus Sign: An Angiographic Clue for Choosing between Stent Retriever and Contact Aspiration in Acute Basilar Artery Occlusion

BACKGROUND AND PURPOSE

The efficacy of mechanical thrombectomy methods may differ depending on the characteristics of the occlusion. The purpose of this study was to compare the recanalization efficacy and treatment outcome of a stent retriever versus contact aspiration in patients with acute basilar artery occlusion according to the angiographic characteristics of the occlusion.

MATERIALS AND METHODS

One hundred sixty-one patients with acute basilar artery occlusion who underwent mechanical thrombectomy were retrospectively analyzed. A stent retriever was compared with contact aspiration thrombectomy according to the clot meniscus sign, defined as a meniscoid/tram-track-like sidewall contrast opacification of the thrombus. A propensity score matching analysis was performed. Clinical/angiographic characteristics and treatment and clinical outcomes were compared.

RESULTS

Overall, a stent retriever (n = 118) and contact aspiration (n = 43) did not show significant differences in the successful recanalization (82.2% versus 86.0%) and good clinical outcome rates (32.2% versus 39.5%). In patients with the positive meniscus sign, contact aspiration was associated with shorter procedural time (44 versus 26 minutes, P = .018), a lower number of passes (2 versus 1, P = .041), a higher complete recanalization rate (58.8% versus 85.7%, P = .021), and a higher rate of first-pass effect (27.9% versus 53.6%, P = .031) compared with a stent retriever. After propensity score matching, contact aspiration was associated with higher complete recanalization rates (59.3% versus 85.7%, P = .033). No significant differences in the outcomes were noted between a stent retriever and contact aspiration in patients negative for the meniscus sign.

CONCLUSIONS

The efficacy of the mechanical thrombectomy techniques may differ according to the angiographic characteristics of occlusion in patients with basilar artery occlusion. Contact aspiration may be more effective in terms of recanalization compared with a stent retriever in patients with the clot meniscus sign.

Stroke after transcatheter aortic valve implantation: new insights into risk prediction

Background

Stroke is still a feared complication following transcatheter aortic valve implantation (TAVI), associated with increased mortality and severe impact on patients' daily living. Despite technological development and knowledge improvement, cerebrovascular events (CVE) are still not predictable so far and simple risk scores are lacking.

Purpose

This study aimed to evaluate different preprocedural factors that may favour stroke after TAVI, especially regarding severity of aortic calcification.

Methods

From May 2011 to January 2018 a total of 1365 patients underwent TAVI with a balloon-expandable (n=442, 32.4%) or self-expandable (n=923, 67.6%) device at our institution. All patients underwent multi-slice computed tomography (MSCT) before TAVI. To obtain the significant factors for stroke risk prediction we performed multivariate regression analysis and selected the optimal cut-off values according to the maximum Youden index for dichotomization of the risk score items. Finally, we used receiver operating characteristics (ROC) analysis and areas under the ROC curves (AUC) to validate our risk score in comparison to other existing models.

Results

60 of 1365 patients (4.4%) had new neurological impairment after TAVI during hospital stay (mean 11.2±6.7 days). We performed propensity score matching (1:10) to balance baseline characteristics between patients with and without stroke following TAVI, resulting in 56 patients with in-hospital stroke and 521 patients without. Preprocedural factors associated with stroke turned out to be history of prior stroke (OR 1.94; 95% CI 0.85–4.43; p=0.114), aortic valve area ≥0.545 cm2 (OR 3.11; 95% CI 1.16–8.34; p=0.024), atrioventricular angle ≥48.5° (OR 2.32; 95% CI 1.20–4.49; p=0.013), RCC Agatston Score ≥447.2 AU (OR 1.8; 95% CI 0.94–3.44; p=0.077), LVOT Agatston Score ≥262.4 AU (OR 2.01; 95% CI 1.08–3.75; p=0.028) and ascending thoracic aorta Agatston Score ≥116.4 AU (OR 2.21; 95% CI 1.17–4.17; p=0.015). ROC analysis showed that our risk model had an AUC of 0.73 (95% CI 0.66–0.80; p&lt;0.001), a sensitivity of 70.6%, a specificity of 69.0%, a positive predictive value of 19.5% and a high negative predictive value of 95.7%. Our risk model appeared to be the best for stroke prediction after TAVI compared to other risk scores used in literature before like EuroSCORE II (AUC 0.50; 95% CI 0.43–0.58; p=0.950) or CHA2DS2-VASc Score (AUC 0.62; 95% CI 0.55–0.70; p=0.004).

Conclusion

Especially aortic root calcium volume assessed by MSCT predicts CVE after TAVI and could be integrated into a six items risk model for preprocedural prediction of stroke after TAVI. This model could guide us in identifying those patients who are most likely to benefit from transcatheter cerebral embolic protection devices.

Funding Acknowledgement

Type of funding source: None

Mechanical circulatory support with impella in patients with non-acute myocardial infarction related cardiogenic shock

Background

Percutaneous left ventricular assist devices such as the Impella pump, are used to hemodynamically stabilize patients with cardiogenic shock (CS) caused by acute myocardial infarction (AMI) until cardiac function has recovered after revascularization. Whether Impella mechanical circulatory support (MCS) is effective in stabilizing patients with CS not caused by AMI has so far not been thoroughly investigated.

Purpose

The aim of this study is to analyze whether MCS with Impella is effective to stabilize patients with non-AMI related CS compared to patients with AMI related CS.

Method

We retrospectively analyzed 106 patients with CS and Impella support in the years from 2011 to 2018. Efficacy to stabilize the patient was assessed by laboratory values such as lactate, hemodynamic parameters and clinical scores. The difference in mortality was calculated with the Log-Rank-Test, comparing Kaplan-Meier curves.

Results

36 patients suffered from non-AMI CS and in 70 patients CS was caused by AMI. Regarding the clinical scores and hemodynamic parameters, both groups were severely ill, with no significant difference in APACHE II score, with a mean score of 17.9 in the non-AMI group compared to 20.5 in the AMI-group (p=0.103), the SOFA score (mean score of 6.3 in non-AMI group vs 6.8 in AMI group, p=0.467) and cardiac index (mean CI of 1.9 l/min/m2 in non-AMI group vs 2.2 l/min/m2 in AMI group, p=0.176). There was a comparable mean decrease in lactate levels in both groups 48 hours after initiation of MCS, from initially 4.1 mmol/l to 1.7 mmol/l (p&lt;0.001) in the non-AMI group and from initially 3.6 mmol/l to 2.2 mmol/l (p=0.025) in the AMI group. The non-ACS group exhibited a trend of lower mortality compared to the AMI group, with 47% in the non-AMI group and 57% in the AMI group (p=0.067). In multivariate analysis, age, lactate levels, cardiopulmonary resuscitation, low platelets and higher doses of inotropes and vasopressors were independent predictors for mortality. An upgrade to LVAD was performed for 22% of the non-AMI group and for 6% of the AMI group (p=0.020).

Conclusion

Impella support is effective to hemodynamically stabilize patients with non-AMI related CS. Therefore, MCS can be used as bridge to recovery or enables further treatment options as upgrade to longterm mechanical support devices.

Funding Acknowledgement

Type of funding source: None

Use and success evaluation of percutaneous aortic balloon valvuloplasty in different hemodynamic entities of severe aortic stenosis in the TAVR era

Background

In the era of transcatheter aortic valve replacement (TAVR), there is renewed interest in percutaneous balloon aortic valvuloplasty (BAV), which may qualify as the primary treatment option of choice in special clinical situations. Success of BAV is commonly defined as a significant mean pressure gradient reduction after the procedure.

Purpose

To evaluate the correlation of the mean pressure gradient reduction and increase in the aortic valve area (AVA) in different flow and gradient patterns of severe aortic stenosis (AS).

Methods

Consecutive patients from 01/2010 to 03/2018 undergoing BAV were divided into normal-flow high-gradient (NFHG), low-flow low-gradient (LFLG) and paradoxical low-flow low-gradient (pLFLG) AS. Baseline characteristics, hemodynamic and clinical information were collected and compared. Additionally, the clinical pathway of patients (BAV as a stand-alone procedure or BAV as a bridge to aortic valve replacement) was followed-up.

Results

One-hundred-fifty-six patients were grouped into NFHG (n=68, 43.5%), LFLG (n=68, 43.5%) and pLFLG (n=20, 12.8%) AS. Underlying reasons for BAV and not TAVR/SAVR as the primary treatment option are displayed in Figure 1. Spearman correlation revealed that the mean pressure gradient reduction had a moderate correlation with the increase in the AVA in patients with NFHG AS (r: 0.529, p&lt;0.001) but showed no association in patients with LFLG (r: 0.145, p=0.239) and pLFLG (r: 0.030, p=0.889) AS. Underlying reasons for patients to undergo BAV and not TAVR/SAVR varied between groups, however cardiogenic shock or refractory heart failure (overall 46.8%) were the most common ones. After the procedure, independent of the hemodynamic AS entity, patients showed a functional improvement, represented by substantially lower NYHA class levels (p&lt;0.001), lower NT-pro BNP levels (p=0.003) and a numerical but non-significant improvement in other echocardiographic parameters like the left ventricular ejection fraction (p=0.163) and tricuspid annular plane systolic excursion (TAPSE, p=0.066). An unplanned cardiac re-admission due to heart failure was necessary in 23.7% patients. Less than half of the patients (44.2%) received BAV as a bridge to TAVR/SAVR (median time to bridge 64 days). Survival was significantly increased in patients having BAV as a staged procedure (log-rank p&lt;0.001).

Conclusion

In daily clinical practice, the mean pressure gradient reduction might be an adequate surrogate of BAV success in patients with NFHG AS but is not suitable for patients with other hemodynamic entities of AS. In those patients, TTE should be directly performed in the catheter laboratory to correctly assess the increase of the AVA. BAV as a staged procedure in selected clinical scenarios increases survival and is a considerable option in all flow states of severe AS. (NCT04053192)

Figure 1

Funding Acknowledgement

Type of funding source: None

GLP-1 is an independent predictor of long-term mortality in patients with myocardial infarction complicated by cardiogenic shock – a substudy of the IABP-SHOCK II trial

Background

The incretin hormone Glucagon-like-peptide 1 (GLP-1) is a major stimulus for glucose dependent insulin secretion and holds cardioprotective efficacy. This has made the GLP-1 system a preferred target for diabetes therapy. Secretion of GLP-1 happens in response to nutritional but also inflammatory stimuli. Consequently, marked elevation of circulating GLP-1 levels were found in critically ill patients featuring marked association to markers of inflammation.

Purpose

Our study sought to investigate GLP-1 levels in patients with cardiogenic shock (CS) complicating myocardial infarction and a possible prognostic correlation to short- and long-term outcome.

Methods

We serially assessed circulating GLP-1 levels in a prospectively planned biomarker substudy in the IABP-SHOCK II trial. Blood samples were drawn during index PCI and at day 2. The blood was centrifuged immediately, and serum was frozen at −87°C. GLP-1 was measured with a standard ELISA-kit. All-cause mortality at short- (30 days), intermediate- (1 year) and long-term (6 years) follow-up was used for outcome assessment.

Results

In this study we found circulating GLP-1 to be markedly elevated in patients with myocardial infarction complicated by CS (n=172) at time of index PCI. Patients with fatal short-term outcome (n=70) exhibited higher GLP-1 levels (86 [45–130] pM) at ICU admission in comparison to patients with 30-day survival (48 [33–78] pM; p&lt;0.001) (n=102). In repeated measures ANOVA the course of GLP-1 levels between baseline and day 2 showed a significant interaction between survivors and non-survivors (p=0.04). By univariate Cox-regression analysis GLP-1 levels &gt;median were predictive of short- (hazard ratio [HR] 2.43; 95% confidence interval [CI] 1.50–3.94; p&lt;0.001), intermediate- (HR 2.46; 95% CI 1.62–3.76; p&lt;0.001) and long-term (HR 2.12; 95% CI 1.44–3.11; p&lt;0.001) outcome. This association remained after multivariable correction (HR 2.01; 95% CI 1.37–3.07; p&lt;0.001). In a landmark analysis we found a significant higher mortality in patients with GLP-1 levels &gt;median from day 30 to 1 year (HR 2.56; 95% CI 1.08–6.09; p=0.03). In contrast, beyond 1 year up to 6 years no difference has been observed anymore (HR 1.02; 95% CI 0.41–2.58; p=0.96).

Conclusions

Elevated plasma levels of GLP-1 are an independent predictor for impaired prognosis in patients with myocardial infarction complicated by CS at short-, intermediate and long-term follow-up. In a landmark analysis this prognostic effect is sustained up to 1 year. The functional relevance of GLP-1 in this context is currently unknown and needs further investigations.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): German Research Foundation (DFG), German Heart Research Foundation

Performance of the Corevalve Evolut R and PRO in severely calcified anatomies: a propensity-score matched analysis

Background

The Corevalve Evolut R and PRO belong to the newer generation of self-expandable valves and are increasingly used to treat patients with severe aortic stenosis. Over the years, technical advancements and increasing experience with the procedure itself are responsible for excellent clinical and hemodynamic results. Patients with severely calcified native aortic valve anatomies still pose a special task to the implanting team since the risk for intraprocedural complications might be increased.

Purpose

To evaluate the hemodynamic and clinical performance of the CoreValve Evolut R and PRO in patients with severely calcified native aortic valve anatomies.

Methods

Baseline characteristics, imaging data and procedural outcome of patients undergoing transfemoral transcatheter aortic valve implantation with the CoreValve Evolut R and PRO from 09/2015 to 03/2018 were prospectively collected. Patients underwent high-resolution multisclice computed tomography (MSCT). A pre-specific threshold of 600 Hounsfield units was set to account for the hyperdensity of the applied contrast medium and to enable comparability with MSCT thresholds, derived by non-contrast enhanced MSCT scans. Patients were divided by the extent of calcification into a severely calcified anatomy group (men &gt;2062AU, woman &gt;1377AU) or a not severely calcified anatomy group (men &lt;2062AU, woman &lt;1377AU). Propensity score matching with the variables log EuroSCORE, LVOT calcium load and the cover index in a 1:2 fashion was performed and clinical and hemodynamic results in accordance with VARC II were collected.

Results

Ninety-eight patients with severely calcified anatomies (SC) could be identified and were matched with 196 patients with lower calcified (LC) anatomies. Patients with severely calcified anatomies were older (SC: 83.1 years vs. LC: 80.3 years, p&lt;0.001) and had a smaller aortic valve area (SC: 0.63cm2 vs. LC: 0.70cm2, p=0.028). The mean implantation depth did not differ (SC 5.4mm±2.4 vs. LC: 5.1±2.2, p=0.554). Pre-dilatation was more often performed in the SC group (SC: 30.6% vs. LC: 15.8%, p=0.003) and the stroke/TIA rate did not differ (SC: 5.1% vs. LC: 3.5%, p=0.532). In SC patients, a permanent pacemaker implantation was significantly more often needed (SC: 28.5% vs. LC:7.6%, p&lt;0.001). The mean pressure gradient after the procedure was effectively reduced (SC: 7.1mmHg±3.9 vs. LC: 7.8±3.7mmHg, p=0.477). No aortic regurgitation (AR) was more often present in patients with SC anatomies (SC: 72.5% vs. LC: 85.2%, p=0.011). The aortic regurgitation index numerically differed between groups without reaching statistical significance (SC: 24.1±7.1 vs. LC: 27.3±6.7, p=0.067).

Conclusion

The CoreValve Evolut R and PRO show a good clinical safety profile and excellent hemodynamic results even in patients with severely calcified anatomies. In those patients, a permanent pacemaker implantation was more often necessary.

Funding Acknowledgement

Type of funding source: None

Computed tomography derived predictors of permanent pacemaker implantation after transcatheter aortic valve implantation: a meta-analysis

Background

Transcatheter aortic valve implantation (TAVI) is a well-established alternative to surgery for the treatment of patients with severe symptomatic aortic stenosis at high and intermediate surgical risk. Unfortunately, the occurrence of electrical conduction disturbances remains one of the most frequent complications of the procedure. While the impact of electrocardiographic and procedural predictors on PPI is well examined, there is still a lack of knowledge regarding anatomical predictors screened by multislice computed tomography (MSCT).

Purpose

We performed a meta-analysis to summarize available studies that reported the incidence of PPI after TAVI with new-generation devices and provided raw data for preprocedural MSCT.

Methods

The authors conducted a literature search in PubMed database until December 31, 2019 to identify studies that investigated preprocedural MSCT data and rate of PPI following TAVI with new-generation devices. Twelve observational studies (n=3133) met inclusion criteria for final analysis.

Results

PPI was performed in 509 patients (16.2%) after TAVI, mostly due to high degree atrioventricular (AV) block (80.8%). The rate of PPI varied widely from 7.9% to 35.8% in individual studies. Regarding secondary endpoints' analysis of relative risk (RR) and mean difference (MD) electrocardiographic PPI-predictors after TAVI appeared to be pre-existing atrial fibrillation (AF) (RR 1.21; 95% CI 1.05–1.40; p=0.008), right bundle branch block (RBBB) (RR 4.22; 95% CI 3.30–5.41; p&lt;0.0001) and AV block grade I (RR 1.63; 95% CI 1.16–2.29; p=0.005). Patients requiring PPI had larger annulus perimeter (MD 1.66 mm; 95% CI 0.67–2.66 mm; p=0.001) and shorter membranous septum length (MD −0.86 mm; 95% CI −1.74–0.02 mm; p=0.05) assessed by preprocedural MSCT. Concerning calcium load of device landing zone, pacemaker dependent patients showed increased calcification of the non-coronary cusp (MD 39.76 mm3; 95% CI 18.60–60.93 mm3; p=0.0002), the left-coronary cusp (LCC) (MD 47.60 mm3; 95% CI 19.40–75.81 mm3; p=0.0009) and the total left ventricular outflow tract (LVOT) (MD 19.17 mm3; 95% CI 6.68–31.66 mm3; p=0.003). Lower implantation depth (MD 0.83 mm from NCC; 95% CI 0.20–1.47 mm; p=0.01) and oversizing by annulus diameter/area (MD 1.76%; 95% CI 0.68–2.84%; p=0.001) were procedural predictors of PPI following TAVI.

Conclusion

This structured meta-analysis proved PPI rate in 16.2% of patients following TAVI. Beside well-known electrocardiographic (AF, RBBB, AV block grade I) and procedural predictors (implantation depth, oversizing) this meta-analysis showed for the first time that MSCT derived anatomical values (annulus perimeter, membranous septum length) and distribution of device landing zone's calcification (NCC, LCC, LVOT) are associated with increased risk of PPI following TAVI.

Funding Acknowledgement

Type of funding source: None

[Evaluation of the microcirculation in critically ill patients : Relevance, practical possibilities and scientific evidence]

Für die Aufrechterhaltung der Organdurchblutung ist eine intakte Makro- und Mikrozirkulation essentiell. Sowohl das wachsende Verständnis um die Bedeutung der Mikrozirkulation im Organversagen als auch die Möglichkeit, diese zu visualisieren, lenken die Aufmerksamkeit der Intensivmedizin auf die mikrovaskuläre Endstrombahn. Als Surrogat-Parameter sind die Rekapillarisierungszeit, der „mottling score“ und die Messung des Serum-Laktats bereits lange in der klinischen Praxis etabliert. Neuere Studien messen der Echtzeit-Darstellung der sublingualen Mikrozirkulation mittels Intravital-Videomikroskopie eine immer größere Bedeutung bei. Verschiedene Studien unterstreichen hierbei die Mikrozirkulation als prognostischen Parameter. Darüber hinaus ermöglicht die Erhebung von objektivierbaren Messwerten, diese in der Zukunft zur individuellen Therapiesteuerung weitergehend zu untersuchen.

Using a mobile application to detect health needs among children and adolescents who are newly arrived migrants in Europe

BACKGROUND

Unprecedented numbers of migrants have arrived in Europe, including children and adolescents. Little is known about their unique health needs. Prospective data collection has been sparse. Mobile applications may help to facilitate global health surveillance.

METHODS

A pre-validated survey instrument was converted into a mobile application covering self-reported exposures and disruptions of healthcare before/during migration, communicable and non-communicable diseases. Participation was voluntary, anonymous and confidential.

RESULTS

Data were obtained from 405 migrant children and adolescents in Berlin, Germany, between 7 October 2015 and 15 March 2016 (median age 19 years, range: 1-24; 80.7% males) with the majority from Syria (62.5%), Afghanistan (9.1%) and Iraq (8.2%). In total, 55% were without family, 64% registered asylum-seekers with access to healthcare; 54% had seen a doctor since arrival, with colds or respiratory complaints (37.5 and 13.6%), followed by pain (26.7%) gastrointestinal (12.4%) and skin problems (11.1%). Underlying conditions were reported in 15.6%, predominantly asthma. Overall, 73% reported being up-to date on immunizations, but only 22% held a vaccination record with 46.4% having lost it during migration.

CONCLUSIONS

The lack of medical and immunization records among newly arrived migrants provides a challenge to healthcare systems. Mobile applications offer rapid screening tools in times of crisis, helping stakeholders with timely information.

Visualization of spatial and temporal temperature distributions with magnetic particle imaging for liver tumor ablation therapy

Temperature-resolved magnetic particle imaging (MPI) represents a promising tool for medical imaging applications. In this study an approach based on a single calibration measurement was applied for highlighting the potential of MPI for monitoring of temperatures during thermal ablation of liver tumors. For this purpose, liver tissue and liver tumor phantoms embedding different superparamagnetic iron oxide nanoparticles (SPION) were prepared, locally heated up to 70 °C and recorded with MPI. Optimal temperature MPI SPIONs and a corresponding linear model for temperature calculation were determined. The temporal and spatial temperature distributions were compared with infrared (IR) camera results yielding quantitative agreements with a mean absolute deviation of 1 °C despite mismatches in boundary areas.

First magnetic particle imaging angiography in human-sized organs by employing a multimodal ex vivo pig kidney perfusion system

OBJECTIVE

Magnetic particle imaging (MPI) is a new, fast 3D imaging technique, which is considered promising for angiographies. As available MPI scanners suffer from restricted spatial resolution and are mostly constructed for small animal imaging, no vessels within one organ have been depicted by MPI, yet. The purpose of this study was to develop an ex vivo organ perfusion system to display vessels within one organ of human size by MPI and to compare the results to an established 3D imaging technique.

APPROACH

An ex vivo porcine kidney perfusion system compatible with digital subtraction angiography (DSA), magnetic resonance tomography and MPI was developed. DSA was used to exemplarily prove intact vessel structures under ex vivo perfusion in two organs. Perfusion in nine organs was displayed by the 3D imaging techniques magnetic resonance angiography (MRA) and MPI angiography. All visible vessels in MRA and MPI were counted and their number compared between both techniques.

MAIN RESULTS

The ex vivo organ perfusion system allowed us to perform angiographies by DSA, MRA and MPI. With it, organs of human size could be imaged in small animal scanners, which permitted us to depict vessels within one organ by MPI for the first time. In comparison to MRA, 33% of all vessels were visible in MPI, a difference probably caused by restricted spatial resolution in MPI.

SIGNIFICANCE

The presented ex vivo organ perfusion system can serve to practically evaluate MPI's potential for angiography in human-sized organs. This is especially relevant as long as available, for angiography-suited MPI scanners still suffer from size and spatial resolution restrictions.

P6287Analysis of novel cardiac markers sST2 and IL-33 in chronic heart failure with reduced ejection fraction

Background

Soluble (s) ST-2 has been recently evaluated as a monitoring parameter in heart failure (HF). Besides being a marker for cardiac strain and hemodynamic stress, studies also found an influence of ST2 on the immune system, above all mediated through its Janus-Face ligand IL-33, an alarmin released under stress conditions or by cellular death. In contrast to sST2, the role of IL-33 in HF is yet unknown.

Objective

In this project, we aimed for an analysis of the ST2/IL33 pathway in patients with heart failure with reduced ejection fraction (HFrEF).

Methods

In total, 200 patients were included in the study: 59 with ischemic (ICM), 65 with dilated (DCM) cardiomyopathy (mean LVEF 38%), as well as 76 control patients without coronary artery disease or signs of heart failure. Serum samples were analyzed by use of ELISA after informed consent.

Results

sST2 showed a significant elevation in all HF patients (p<0.0001) compared to the control group. No significant differences in levels of sST2 were observed between ICM and DCM patients. In contrast to sST2, no differences between HF patients and control group were observed for IL-33. Furthermore, sST2 showed a significant correlation with CRP (p<0.001, r=0.28), NT-pro-BNP (p<0.0001, r=0.40) and an inverse correlation with ejection fraction (p<0.0001, r=−0.40). Additionally, sST2 showed a significant elevation in patients in NYHA stages I-II (p=0.030) and NYHA stages III-IV (p<0.01). Again, no significant correlations were observed between IL-33 and parameters mentioned above.

Analysis of sST2 in heart failure

Conclusions

We observed a significant increase and correlation with disease severity of sST2 in chronic HFrEF patients of both ischemic and non-ischemic origin, but contrary to our expectations, no significant changes in serum levels of IL-33. Thus, a mechanism independent of ST2/IL33 axis could be responsible of sST2 secretion in HF. Further studies including acute decompensated patients could provide a better understanding of the IL-33 role in HF.

P3742Transcatheter aortic valve implantation in large annuli: incidence and predictors of specific adverse events with the largest self-expanding device

Background

The recently released largest self-expanding transcatheter aortic valve device (STHV-34) is characterized by good results but nevertheless demands an experienced team for the implantation in large annuli.

Purpose

Looking at multi slice computed tomography (MSCT) and procedural data, we tried to identify characteristics that could explain intraprocedural VARC-2 and valve specific non-VARC-2 events.

Methods

We performed a single center retrospective analysis in 80 patients treated with STHV-34. STHV-34 patients were separated into subjects without events (NE, n=43, 54%) and the following adverse events: resheathing/-capture processes (RS/C, n=19, 24%), valve dislodgments (VD, n=21; 26%), infolding (IF, n=6, 8%) and complete dislocation with bail-out valve-in-valve implantation (ViV, n=3, 4%). Events were further categorized in non-VARC-2 and VARC-2. The analysis sought for underlying anatomical conditions and defined risk factors by multivariate analysis.

Results

Primary device success was reached in 96% and immediate postprocedural absence of moderate-to-severe aortic regurgitation was 100%. We identified specific anatomical conditions predisposing for non-VARC-2 and VARC-2 events: RS/C: annular calcium load<1600 AU (OR 47 [CI 1.4–216], p=0.0004). IF: peripheral kinking (RR 5.0 [CI 1.0–24], p=0.0478) and previous RS/C maneuvers (83%). ViV: annular ellipticity index (NS 1.2±0.1 vs. ViV 1.4±0.1, p=0.0049), aortic angulation (AA) angle (NS 54.0±7.0° vs. ViV 61.7±1.5°, p=0.0240) and LVOT-AO angle (NS 149.1±18.9° vs. ViV 130.3±3.5°, p=0.0470).

Conclusion

We confirm high procedural success for the largest currently available STHV-34. The incidence of intraprocedural non-VARC-2 and VARC-2 events are associated with anatomical characteristics that may influence valve selection and implantation strategy.

P3668In non-critically ill patients suffering from endocarditis partial oral antibiotic therapy is non-inferior to intravenous therapy

Introduction

Antibiotic treatment for infective endocarditis is paramount typically consisting of intravenous therapy for up to eight weeks leading to long hospital stays. This often is associated with reduced quality of life for patients and might heighten complication rates. Recently, several trials evaluating the efficacy of partial oral treatment (switching to an oral antibiotic after an initial intravenous therapy for stabilization) versus an intravenous therapy were published. We here meta-analyze all available data.

Methods and results

Overall after screening 1848 studies at title and abstract level four studies including a total of 788 patients were included. Heterogeneity was assessed using the I2 statistic. Primary endpoint was all-cause mortality, secondary endpoint endocarditis relapse. Pooled event rates were obtained for each subset of studies and combined in a fixed-effect meta-analysis, and odds ratios were calculated using a fixed-effects model (Mantel-Haenszel).

A total of 765 patients suffered from primary left-sided endocarditis. From right-sided endocarditis suffered 72 patients. All treatment regimes were adjusted to susceptibility testing. Included patients were evaluated clinically and non-critically ill.

Rate of mortality was lower in partial oral versus intravenous strategy (OR 0.34 95% CI 0.17–0.68; p=0.003; I2 30%): In partial oral group, 11 of 379 patients died, whereas in the intravenous group, 33 of 409 patients died. Endocarditis relapse rates were not dissimilar between intravenous versus oral group (OR 0.55 95% CI 0.26–1.20; p=0.13; I2 0%) with, 10 of 459 patients in the partial oral group and 18 of 456 patients in the intravenous group evidencing a relapse.

Conclusion

Partial oral therapy is non-inferior to intravenous therapy with regards to endocarditis relapse in non-critically-ill patients suffering from both left- and right-sided endocarditis. In this meta-analysis, partial oral therapy was associated with lower mortality rates. This finding certainly needs validation in further future randomized trials comparing partial oral versus intravenous antibiotic treatment in non-critically-ill patients. As partial oral therapy allows shorter hospitalization it might be preferable and improve both quality of care and patients quality of life.

P2687Impact of cardiovascular risk factors on effectiveness of remote ischemic preconditioning in the setting of ischemia/reperfusion-injury in a langendorff heart model

Introduction

Cardiovascular diseases are the most frequent cause of death in the western world. During myocardial infarction both, ischemia and reperfusion after therapeutic intervention cause myocardial damages, resulting in ischemia/reperfusion-injury (I/R-injury). Research therefore searches cardio protective interventions, aiming to reduce myocardial injury and following consequences such as heart failure. A promising method, named Remote Ischemic Preconditioning (RIPC), consists of transient local ischemia distant from the heart. Its cardio-protective effects were already proved in basic research but failed in clinical trials.

Purpose

The aim of the study is to examine the impact of cardiac risk factors like diabetes mellitus (DM) or age on effectiveness of RIPC in order to identify distinct groups of patients who might benefit from RIPC in the clinical setting and to reveal the effectiveness of cardioprotection delivered by plasma samples of these groups of patients.

Methods

RIPC (3 x 5 min arm ischemia, induced by an inflated blood pressure cuff) was performed on young and healthy volunteers and elderly patients with coronary heart disease with or without diabetes mellitus. Blood was taken before (Baseline) and 30 minutes after the intervention. The coronary system of murine hearts in a Langendorff heart model was perfused using dialysate from the human plasma obtained before and after RIPC. This was followed by 40 minutes of global ischemia. After 60 minutes of reperfusion left ventricular function was analysed. The infarct size was measured after 120 minutes reperfusion time using a TTC staining.

Results

Addition of dialysate of plasma obtained from healthy volunteers after RIPC to the coronary system of Langendorff perfused murine hearts significantly improved the recovery of left ventricular developed pressure (39±15.1 vs 26±8.5% of baseline levels, p=0.04) and reduced the infarct size (37.5±15.6 vs 21.2±11.4% of the ventricular volume, p=0.03) compared to baseline-dialysate treated controls. While plasma dialysate obtained from elderly patients with DM undergoing RIPC failed to show significant cardio protective effects of RIPC, murine hearts treated with plasma dialysate of elderly patients with coronary heart disease without diabetes after undergoing RIPC showed significant improvement of cardiac function (20±6.5 vs 24±7% of baseline levels, p=0.02) and infarct size (33.2±8.0 vs 11.1±2.5% of the ventricular volume, p=0.01).

Conclusion

The cardio-protective effect of RIPC on myocardial function and infarct size after I/R is influenced by diabetes but not by age or the presence of coronary heart disease. In consequence, RIPC might protect patients with coronary heart disease without DM but not diabetic patients from cardiac I/R injury. This important finding potentially explains why RIPC yielded promising results in various basic science experiments but failed to show cardio protective effects in clinical trials.

Acknowledgement/Funding

Forschungskommission of the Faculty of Medicine of the Heinrich-Heine-University Düsseldorf