Psychosocial interventions for cardiac surgery patients: continuity at clinical stages

Introduction

More often, cardiac surgery patients (CSP) receive systematic psychological aid after surgery. However, their need for psychosocial interventions in the perioperative period is underestimated.

Objectives

The goal is to determine the stages of psychosocial interventions for CSP that could cover the whole period of their treatment and rehabilitation.

Methods

Analysis of scientific papers and practical experience gained in cardiologic clinic allowed dividing the system of psychosocial interventions for cardiac surgery patients into periods in accordance with actual stages of medical aid for CSPs.

Results

According to the principles of personalized approach, we determined six consecutive semantically different stages of psychosocial interventions: out-of-hospital pre-surgery, in-hospital pre-surgery, early post-surgery, in-hospital post-surgery, post-surgery rehabilitation, and out-of-hospital rehabilitation. They have different duration and cover the whole period of treatment and rehabilitation of CSPs beginning with the moment of indication to surgery up to the complete rehabilitation and full adaptation to their post-surgery somatic condition. Each stage has its own goals, main objectives and expectations. Duration of the stages is conditional and can change depending on the nature of every clinical situation.

Conclusions

Determination of clinical stages in the process of psychosocial interventions for CSPs gives ground for selecting optimal psychological methods and techniques for each stage and sets exact goals, achievement of which becomes possible only through a properly organised work of an interdisciplinary team of specialists.

Disclosure

No significant relationships.

Long-term post-discharge coagulation abnormalities in patients with moderate to severe COVID-19

Introduction

Coagulopathy plays a significant role in COVID-19 pathogenesis. Benefit from anticoagulation is well established in hospitalized patients. But since there is a lack of data on coagulopathy resolution: there is no consensus in guidelines if extended anticoagulation is required.

Purpose

The purpose of our work was to analyze coagulation abnormalities at 2 to 5 months after moderate to severe COVID-19.

Methods

COVID-19 reconvalescents (CR), discharged from our hospital, were called for follow-up at 2–3 (CR1 group, 21 patients) or 5–6 (CR2 group, 26 patients) months after discharge. All CR were not on the anticoagulation therapy by that time. In addition to clinical examination and standard lab tests, we performed an FMD-test to analyze endothelial function, impedance aggregometry to analyze platelet aggregation, and a thrombodynamics test to assess thrombogenesis and fibrinolysis. The control group was recruited before the pandemic started.

Results

All CR were free from thrombotic complications after discharge from the hospital.

Endothelial function was not significantly impaired in CR compared with control, and was still in the normal range (7,07, IQR (3,36; 11,56) vs. 7,87 (5,42; 13,45)).

Platelet aggregation was significantly lower in CR1 than in the control group in ADP-induced mode (37, IQR (19; 47) vs. 46, IQR (41; 50), p=0,02) and didn't differ in other groups and other modes (Asa, TRAP-induced).

Thrombodynamics tests revealed suppression of the clot formation process in both CR1 and CR2 compared with control. There were decreased clot growth rates (μm/min) (CR1/CR2: 27,1, IQR (26,1; 29,2)/27,6, IQR (26,4; 30,0) vs. 32,2, IQR (30,0; 35,1), both p<0,001); decreased clot size (μm) (CR1/CR2: 1099, IQR (1069; 1194)/1199, IQR (1058; 1221) vs. 1304, IQR (1164; 1380), both p<0,001), and decreased optical density (arb units) (CR1/CR2: 21'607, IQR (20'363; 24'545)/22'741, IQR (21'344; 25'961) vs. 26'556, IQR (24'672; 29'387, p<0,001 and p=0,09 respectively.

Fibrinolysis was enhanced in CR groups compared with control (lysis progression was significantly higher for CR2 only, CR1/CR2: 2,9, IQR (2,5; 3,8)/3,8, IQR (2,6; 5,4) vs. 2,5, IQR (1,1; 3,4) %/min, p=0,087 and p=0,007 respectively; expected clot lysis time was shorter in both CR1 and CR2: 36,5, IQR (29,8; 44,2)/31,7, IQR (24,3; 42,7) vs. 65,9. IQR (36,3; 95,5) min, p=0,019 and p=0,016 respectively).

There was no statistical difference in clot formation and in fibrinolysis between CR1 and CR2.

Conclusion

In the deferred period (2–5 months) of COVID-19 the fibrinolysis process remains still active whereas the process of clot formation is mostly suppressed. Endothelial function assessed via the FMD test is within the normal range in the post COVID period.

FUNDunding Acknowledgement

Type of funding sources: None.

Is endothelial dysfunction a driving force of COVID-19 induced coagulopathy?

Background/Introduction

There are numerous reports regarding the direct endothelial damage by the SARS-CoV-2 that can lead to activation of both plasma hemostasis and platelet aggregation. However, the mechanism of interaction between endothelium and haemostasis in COVID-19 remains unclear.

Purpose

The aim of our study was to assess the relationship between each link of clot formation process (endothelial function, plasma coagulation, platelet aggregation) with the severity of the disease.

Methods

58 COVID-19 patients were included in our study. Patients were divided into moderate (n=39) and severe (n=18) subgroups. All patients underwent a flow-mediated dilation (FMD) test, impedance aggregation, rotational thromboelastometry, thrombodynamics and von Willebrand factor antigen (vWF: Ag) quantification. All measurements were repeated on days 3 (point 2) and 9 (point 3) of hospitalization.

Results

COVID-19 patients demonstrated the enhanced plasma coagulation (clotting time, s 613,0 [480; 820], clot growth rate, μm/min 32,75 [29,3; 38,7]). At point 1 no significant difference in parameters of plasma coagulation between patients' subgroups was noted. At point 2 a significant decrease in the size (CS, μm 1278.0 [1216.5; 1356.5] vs 965.0 [659.8; 1098.0], p<0,01) and clot growth rate (μm/min 32,4 [29,2; 35,0] vs 17,7 [10,3; 24,4], p<0,01) under the influence of anticoagulants in the moderate subgroup compared with point 1 was observed. We didn't observe such phenomenon in severe subgroup.

There was no significant difference in platelet aggregation between subgroups at point 1. During the course of the disease the patients in the moderate and severe subgroups demonstrated a significant increase in platelet aggregation induced by arachidonic acid and ADP (severe: AUC ARA 48,0 [25,0; 59,0] vs 77,5 [55,8; 92,7], p=0,04; AUC ADP 44,0 [41,0; 56,0] vs 58,0 [45,5; 69,0], p=0,04; moderate: AUC ARA 31,5 [19,8; 50,7] vs 56,0 [39,0; 76,0], p=0,01; AUC ADP 43,0 [20,0; 59,0] vs 56,6 [50,3; 70,5], p=0,04;), in moderate subgroup the significant increase in TRAP-induced aggregation was also noted (AUC TRAP 58,0 [41,0; 69,5] vs 76,0 [58,3; 81,5], p=0,048).

There were no significant differences in the FMD-test results between the patient subgroups. FMD-test results were predominantly within the reference ranges (7,1 [4,0; 8,8]).

Patients in the severe subgroup had significantly higher levels of vWF: Ag (228,0 [205,3; 240,7] vs 232,0 [226,0; 423,0], p=0,03).

Conclusion

SARS-CoV-2 infection was characterized by increased levels of vWF:Ag, that could represent the local endothelial damage, meanwhile there was no generalized endothelial dysfunction assessed via FMD-test in moderate to severe patients. At the same time the enhanced plasma coagulation in COVID-19 patients was observed.

FUNDunding Acknowledgement

Type of funding sources: None.

Body modification in university students: Attitudes and role of personal body alteration experience

Introduction

Body modifications are a common practice in altering one’s appearance. Some authors refer to such practices body injuring (tattooing, piercing) and indirect body modification (dieting, bodybuilding).

Objectives

To study the attitudes of university students to body modifications considering their personal adaptation potential and experience of body injuring when modifying it.

Methods

We surveyed 104 university students aged 17–24 (65.3% males). The first group included 52 students who had experienced body altering (tattooing, piercing), the second group – 52 students without such an experience. We used the Maddi Hardiness Scale to assess the personal adaptation potential and a 14-point questionnaire to estimate the attitude to body modification.

Results

Over the half of the students in both groups consider that an insufficiently beautiful body needs “improving” (63.4% и 51.9%), but people do not have to intensively build up their muscles (51.9% и 84.7%). Students with modified bodies look more positively at piercing (z=5.4; p=.0001), weight control (z=5.20; p=.0001) and plastic surgery (z=4.02; p=.0001). Students with unmodified bodies credibly more rarely regard tattoo as decoration (z=3.7; p=.0002) and have a more negative attitude to pediatricians having tattoos (z=2.9; p=.003). Indicators of psychological hardiness in the first group are credibly lower – commitment (р=.01), control (р=.001) and challenge (р=.0001).

Conclusions

Students with a higher adaptation potential limit themselves to indirect body modifications (physical exercises). Students with a lower adaptation potential more often resort to body injuring (tattooing, piercing), which may reflect peculiarities of their personal response to stress or peculiarities of their mental status.

Disclosure

No significant relationships.

Long-term differences in clot formation and endothelial function between STEMI patients with occlusion of infarct-related artery and those with spontaneous reperfusion

Introduction

Enhanced activation of endogenous fibrinolysis in ST-elevation myocardial infarction (STEMI) patients is the main cause of spontaneous reperfusion of the infarct-related artery (IRA) in the acute period. Whether this enhanced activation remains in the deferred period of myocardial infarction remains unclear.

Purpose

The main purpose of our work was to analyze the process of clot formation and endogenous fibrinolysis in patients with a history of myocardial infarction.

Methods

We included 51 patients with a history of myocardial infarction (median, 35 months). Of these patients, 19 had a spontaneous reperfusion of the IRA (SR group) during the index event, and 32 had a total occlusion of the IRA (occlusion group). We assessed parameters of clot formation and endogenous fibrinolysis using thromboelastometry and a thrombodynamics assay. We analyzed endothelial function using the flow-mediated dilation test (FMD).

Results

The process of clot formation was more active in the occlusion group than in the SR group. Thus, the initial, mean, and total clot velocity times were significantly higher in the occlusion group than in the SR group: 57.2 mcm/min vs. 60.25 mcm/min; 28,1 mcm/min vs. 31.9 mcm/min; and 28.7 mcm/min vs. 31.9 mcm/min, respectively; p&lt;0.01. The clot size was much bigger in the occlusion group than in the SR group (1,190.5 mcm vs. 1,315 mcm; p&lt;0.01). No differences in endogenous fibrinolysis parameters were observed between the two groups. Endothelium function was better in the SR-group than in the occlusion group (FMD 17.4% vs 11.3%, p&lt;0.01).

Conclusion

STEMI patients with occlusion of the IRA and those with spontaneous reperfusion remain different in clot formation and endothelial function even after many years.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported by the Russian Science Foundation grant

Long-term follow up after renal denervation for the electrical storm management

Background/Introduction

Electrical storm (ES) is a potentially lethal state developing in 4–28% of ICD patients. Neuroaxial modulation (beta-blockers, deep sedation, epidural anesthesia, stellate ganglion blockade etc) is used to decrease arrhythmogenic predisposition of ventricular myocardium to trigger and maintain ventricular arrhythmias. Catheter renal arterial denervation (RDN) is recently described to prevent atrial fibrillation recurrence after pulmonary vein isolation. We used this procedure in addition to standard care to improve the results of ES treatment.

Purpose

This retrospective single-center case-series is aimed to analyze ES patient population and describe the effect of RDN on the in-hospital number of ventricular tachycardia (VT) episodes and ICD shocks and on the mid-term survival.

Methods

Pts admitted to the CCU for more than 3 sustained VT episodes or more than 3 appropriate ICD shocks during the 24h period in 2017–18 were enrolled into study. Demographic, echocardiographic, ICD check up, renal arteries anatomy and mid-term mortality/transplant data were retrospectively analyzed.

Results

Twelve pts (10 male, age 69,3±9,8 years; 2 female, age 72,0±8,5) were included. Nine pts (75%) had CAD, 3 pts (25%) – DCM. Echocardiography revealed LVEF 30±9%, and LV EDV – 216±38 ml. Time from ICD implantation to ES onset was from 4 mos to 13 yrs. In 2 pts RDN was performed after VT ablation, in 1 pt – both RDN and VT ablation were performed during the same procedure, in 4 pts – RDN was done prior to VT ablation and in 5 pts - without VT ablation. Mean number of ablations was 4,8 per artery. The power was 2 to 11 Wt and lesion duration was 90 sec. In 1 pt RF-balloon-based technology was used to achieve RDN. Dramatic decrease in the number of VT episodes (49c52 vs. 6±2) was found in 6/12 pts directly after RDN procedure. In-hospital rhythm control was accessed in 10/12 pts, 1 pt with DCM was transferred for heart transplant despite VT ablation and RDN. There were no RDN procedure related complications in this group of pts. During mean 22 mos of follow-up 2/11 pts needed repeat hospitalization due to ES recurrence (VT ablation and 2-chamber ICD to CRT-D upgrade, respectively, were performed), 2/11 died (1-probably arrhythmic death, 1-other cause), 1/11 was lost for follow up. Total efficacy of RDN after almost 2 years in this study was 50%. Mean LVEF increased to 38±7%.

Conclusion(s)

Catheter renal artery denervation is effective and safe additional procedure to treat ES patients. It allows decreasing the number of ICD shocks and decreases arrhythmogenic potential of ventricular myocardium. Prospective registry is warranted.

Funding Acknowledgement

Type of funding source: None

Impact of hypoxia on immune cells in human atherosclerotic plaques

Background

Inflammation plays a major role in atherosclerotic plaques' progression and was shown to be associated with the formation of hypoxic areas within the plaques. However, the data about the impact of hypoxia on atherosclerosis are contradictory, in part due to inadequacy of in vitro and animal models to reproduce faithfully the complexity of human atherosclerotic plaques.

Purpose

The aim of this study was to investigate the effect of hypoxia on immune status in the ex vivo system of human atherosclerotic plaques.

Methods

We collected 25 atherosclerotic plaques from patients undergoing carotid endarterectomy, cut plaques into ring-shaped slices and cultured them for 24 hours at the liquid/air interface on collagen sponges under hypoxic (2% O2) and normoxic (12% O2) conditions. After 24 hours we evaluated T-cell activation status within plaques according to the presence of membrane activation markers by means of multiparametric flow cytometry and the activity of cytokine production using xMAP technology.

Results

We found that CD8 T cells from human atherosclerotic plaques cultured under hypoxic conditions compared to normoxic conditions have a decreased expression of CD69 activation marker (42.7 [34.3; 50.9]% vs 53.8 [33.3; 63.3]%, n=10, p=0.047) and lower level of CD69 and HLA-DR coexpression (16.0 [10.5; 22.3] vs 22.6 [11.3; 28.2], n=10, p=0.02). CD4 T cells did not show any significant changes in expression of activation markers under hypoxia. Hypoxic conditions also resulted in a reduced IL-10 production (104.2 [53.8; 170.9] vs 235.2 [158.5; 335.3] pg/100 mg of tissue, n=20, p=0.0001) and increased VEGF production (116.1 [79.8; 253.5] vs 89.9 [71.1; 148.8] pg/100 mg of tissue, n=20, p=0.033).

Conclusions

Our results indicate that hypoxia causes a decrease in the activity of cytotoxic T cells and increases stimuli for angiogenesis within the human atherosclerotic plaques. The established ex vivo model of human atherosclerotic plaques culture under hypoxia enables further studies of the hypoxia impact on atherosclerosis.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Russian Science Foundation grant

5208Use of renal denervation in the electrical storm management

Background/Introduction

Electrical storm (ES) is a potentially lethal state developing in 4–28% of ICD patients. Neuroaxial modulation (beta-blockers, deep sedation, epidural anesthesia, stellate ganglion blockade etc) is used to decrease arrhythmogenic predisposition of ventricular myocardium to trigger and maintain ventricular arrhythmias. Catheter renal arterial denervation (RDN) is recently described to prevent atrial fibrillation recurrence after pulmonary vein isolation. We used this procedure in addition to standard care to improve the results of ES treatment.

Purpose

This retrospective single-center case-series is aimed to analyze ES patient population and to describe the effect of RDN on the in-hospital number of ventricular tachycardia (VT) episodes and ICD shocks and on the mid-term survival.

Methods

Pts admitted to the CCU for more than 3 sustained VT episodes or more than 3 appropriate ICD shocks during the 24h period in 2017–18 were enrolled into study. Demographic, echocardiographic, ICD check up, renal arteries anatomy and mid-term mortality/transplant data were retrospectively analysed.

Results

Eleven pts (all male, age 69±9 years) were included. Seven pts (73%) had CAD, 3 pts (27%) – DCM. Echocardiography revealed LVEF 28±8%, and LV EDV - 226±91 ml. Time from ICD implantation to ES onset was from 4 mos to 13 yrs. In 5 pts RDN was performed without VT ablation, in 3 pts – prior to VT ablation, in 2 – after VT ablation and in 1 pt – both RDN and VT ablation were performed during the same procedure. Mean number of renal arteries was 2,5 per pt. Mean number of ablations was 4,8 per artery. The power was 2 to 11 Wt and lesion duration was 90 sec. Dramatic decrease in the number of VT episodes (49±52 vs. 6±2) was found in 6/11 pts directly after RDN procedure. In-hospital rhythm control was accessed in 10/11 pts, 1 pt with DCM was transferred for heart transplant due to recurrence of VT after VT ablation and RAD (excluded from survival analysis). There were no RDN procedure related complications in this group of pts. In mean 6 mos of follow-up 9/10 pts are free from ES recurrence, 1/10 was lost for the follow up.

Conclusion(s)

Catheter renal artery denervation is effective and safe additional procedure to treat ES patients. It allows to decrease the number of ICD shocks and stabilize arrhythmogenicity of ventricular myocardium. Larger multi-center randomized trials are warranted.

P694Evaluation of preclinical atherosclerosis in chronic myeloid patients continuously treated with tyrosine kinase inhibitors

Patients and method

In our study 126pts with CML obtained TKIs as any line at least 6mos were included. Males were 56 (44,5%). The median age was 52 (20–76)yrs. Pts with previous history of atherosclerotic CV events were excluded. There were 115 (91%), 61 (48%), 48 (38%), 12 (11%) pts ever obtained Imatinib (IMA), Nilotinib (NILO), Dasatinib (DASA) or Bosutinib (BOSU) with median treatment duration 22mos, 14mos, 16mos and 15,5mos, respectively. Median time since the first TKI was 48 mos. There are 79, 46, 12 pts obtained 2, 3 or 4 TKIs.

To assess PA ankle-brachial index (ABI) and intima media thickness (IMT) were measured. To evaluate ABI Vascular Screening System VaSera VS-1500 was used. Normal values for ABI and IMT were >0,9 and ≤1,1.

Results

ABI was abnormally low in 14/108 (13%) evaluable pts. Previous TKIs of IMA, NILO, DASA and BOSU were in 12 (86%) and 87 (93%), 9 (64%) and 41 (43%), 5 (35%) and 29 (31%), 1 (7%) and 9 (10%) pts with or w/t low ABI. All NILO its were pretreated with IMA. Only 2 pts previously obtained other TKIs. Median time on NILO was 23 mos and 15mos in pts with or w/t abnormal ABI, respectively. Median age for pts with or w/t low ABI was 53 and 52 yrs. The proportion of male pts were lower in abnormal vs normal ABI group – 29% and 44%. In NILO group 2 pts were male and median age for all pts was 51yrs.

IMT was evaluable in 86 pts. The median value of IMT was 0,8mm for all pts. It was abnormal in 12 (14%) pts with median thickness 1,3mm. All pts previously ever obtained IMA. NILO, DASA and BOSU were exposed in 5 (42%) and 33 (46%), 5 (42%) and 23 (31%), 1 (8%) and 7 (10%) pts with or w/t IMT abnormalities. The proportion of males was 4 (33%) and 34 (46%) among pts with or w/t abnormal IMT. Pts with high vs normal IMT were older with median age 64 vs 44yrs.

TKIs2 were ever obtained in 13/14 (93%) and 11/12 (92%)pts with abnormal ABI and IMT< respectively. Both ABI and IMT were abnormal only in 4 pts.

Heart SCORE was high and very high only in 18/80 (22,5%) pts. Median age for low vs high risk pts were much lower (40 vs 52yrs). There were no differences between treatment groups according to SCORE distribution.

Overall 9/50 (18%) and 3/32 (9%), 5/38 (13%) and 3/28 (11%)pts on NILO and DASA, had abnormal ABI and IMT.

Conclusion

CML pts heavily pretreated with different TKIs were included In the study. The most pts with abnormal ABI and IMT have ever been obtaining TKIs2. Pts with NILO more frequently experienced low ABI. There were not significant differences among TKIs groups regarding heart SCORE or IMT. It seems that extended PA is low on TKIs including NILO in CML pts w/t previous SVEs.

Acknowledgement/Funding

Funded from government assignment

Identification and mapping of new chromosomal sites affecting response to beta-lactams in Staphylococcus aureus

Seven new sites leading to increased beta-lactam susceptibility were identified and mapped in Staphylococcus aureus by Tn551 or Tn917 mediated insertional inactivation. Their effect was more pronounced in methicillin resistant than in susceptible strains. Except for inserts each in SmaI-K and SmaI-B, all were located on SmaI-A, which covers 25% of the staphylococcal chromosome. The physical position of the femAB operon involved in the expression of methicillin resistance was mapped on SmaI-A. Close to this site we identified a further site with almost as strong an effect on methicillin resistance as femAB. A second cluster of sites affecting methicillin resistance was identified at approximately 30 kb from the femAB operon, showing that multiple unlinked factors may affect beta-lactam resistance. Interestingly, insert Omega2016 located in SmaI-B produced small colonies and was found to inactivate a gene of the electron transport chain, reminiscent of small colony variants observed in recurrent infections.