[Morphological and functional diagnostics of coronary artery disease by computed tomography]

Computed tomography coronary angiography (cCTA) is a safe option for the noninvasive exclusion of significant coronary stenoses in patients with a low or moderate pretest probability for coronary artery disease (CAD). Furthermore, it also allows functional and morphological assessment of coronary stenoses. The European Society of Cardiology (ESC) guidelines on the diagnosis and management of chronic coronary syndrome published in 2019 have strengthened the importance of cCTA in this context and for this reason it has experienced a considerable upgrade. The determination of the Agatston score is a clinically established method for quantifying coronary calcification and influences the initiation of drug treatment. With technologies, such as the introduction of electrocardiography (ECG)-controlled dose modulation and iterative image reconstruction, cCTA can be performed with high image quality and low radiation exposure. Anatomic imaging of coronary stenoses alone is currently being augmented by innovative techniques, such as myocardial CT perfusion imaging or CT-fractional flow reserve (FFR) but the clinical value of these methods merits further investigation. The cCTA could therefore develop into a gatekeeper with respect to the indications for invasive coronary diagnostics and interventions.

Novel clinical data on cardiac contractility modulation in NYHA II patients – Results from the MAINTAINED Observational Study

Background

Cardiac contractility modulation (CCM) is an FDA-approved device therapy for patients with medication refractory systolic heart failure and normal QRS width. Pivotal trials have been performed primarily in patients with advanced heart failure (NYHA class III or ambulatory IV). As observed in clinical practice, CCM might also be beneficial in patients with low-grade but persistent heart failure that limits daily activity (NYHA class II).

Purpose

To facilitate an individualized indication in these patients, we evaluated the long-term effects of CCM in patients with baseline NYHA class II versus baseline NYHA class III or ambulatory IV from our large clinical registry (MAINTAINED Observational Study).

Methods

CCM effectiveness was measured by changes in functional parameters (i.e., NYHA class, left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE), NT-proBNP levels, and KDIGO CKD stage). In addition, mortality within 3 years was compared with the prediction of the Meta-Analysis Global Group in Chronic (MAGGIC) heart failure survival risk score.

Results

172 patients were included (10% with NYHA class II). Patients with NYHA class III/IV showed a significant improvement in NYHA class over 5 years of CCM (II: 0.1±0.6; p=0.96 vs. III/IV: −0.6±0.6; p<0.0001). In contrast, LVEF improved significantly in each group (II: 4.7±8.3; p=0.0072 vs. III/IV: 7.0±10.7%; p<0.0001; p=0.67 for the comparison of changes between both groups). TAPSE improved significantly only in NYHA class III/IV patients (II: 2.2±1.6; p=0.20 vs. III/IV: 1.8±5.2 mm; p=0.0397). NYHA class II patients had significantly lower NT-proBNP levels at baseline (858 [175/6887] vs. 2632 [17/28830] ng/L; p=0.0044), which was offset under therapy (399 [323/1497] vs. 901 [13/18155] ng/L; p=0.48). KDIGO CKD stage did not experience significant improvement in any group. Actual 3-year mortality was 17 and 26% vs. a predicted mortality of 31 and 42%, respectively (p=0.0038 for NYHA III/IV).

Conclusions

In clinical practice, CCM was infrequently performed in NYHA class II patients. No significant improvement in NYHA class/dyspnea was observed in these patients over 5 years. Because of the improvement in LVEF, sustainable positive effects on long-term cardiac reverse remodeling might be expected in young patients. Patients with advanced heart failure showed improvements in NYHA class, LVEF, and TAPSE also in clinical practice.

Funding Acknowledgement

Type of funding sources: None.

Recurrence of atrial fibrillation after pulmonary vein isolation in dependence of arterial stiffness

Background

Arterial stiffness (AS) has emerged as a strong predictor of cardiovascular (CV) diseases. Although increased AS has been described as a predictor of atrial fibrillation (AF), its role as a risk marker for AF recurrence has not yet been elucidated.

Methods

Patients with AF who underwent pulmonary vein isolation (PVI) were included in this study. Presence of AS was evaluated by measuring aortic distensibility (AD) of the descending aorta by transoesophageal echocardiography.

Results

In total, 151 patients (mean ± standard deviation (SD) age 71.9 ± 9.8 years) were enrolled and followed for a median duration of 21 months (interquartile range 15.0–31.0). During follow-up, AF recurred in 94 (62.3%) patients. AF recurrence was seen more frequently in patients with permanent AF (27% vs 46%, p = 0.03) and in those who had undergone prior PVI (9% vs 23%, p = 0.02). AD was significantly reduced in patients with AF recurrence (mean ± SD 2.6 ± 2.3 vs 1.5 ± 0.7 × 10⁻³ mm Hg⁻¹, p < 0.0001), as well as left atrial volume index (LAVI) (mean ± SD 29 ± 12 vs 44 ± 15 ml/m², p < 0.0001). Multivariable analysis revealed LAVI (odds ratio (OR) 2.9, 95% confidence interval (CI) 1.2–3.4) and AS (OR 3.6, 95% CI 2.8–4.1) as independent risk factors of AF recurrence.

Conclusion

Increased AS and left atrial size were independent predictors of AF recurrence after PVI. AD as surrogate marker of AS seemed to reflect the overall CV risk. In addition, AD was significantly correlated with left atrial size, which suggests that increased AS leads to atrial remodelling and thus to AF recurrence.

Trial registration

German registry for clinical studies (DRKS), DRKS00019007.

Supplementary Information

The online version of this article (10.1007/s12471-021-01644-w) contains supplementary material, which is available to authorized users.

Outcomes of endovascular management of the aorta in connective tissue disorders

Background

Endovascular management of type B aortic dissection has been well established and accepted in the community. However, due to the lack of information on long-term outcome, endovascular management remains controversial in the setting of connective tissue disorders such as Marfan syndrome. Although surgical repair is recommended in type B aortic dissection with connective tissue disorders, recent studies demonstrated both feasibility and safety of endovascular interventions in those patients at least short term.

Purpose

Single centre experience and documentation of long-term outcomes after endovascular management of aortic conditions in patients with connective tissue disorders.

Methods

All patients with genetic confirmation of connective tissue disorders who underwent endovascular repair of the thoracic aorta were identified and evaluated retrospectively. Perioperative, procedure-specific and follow-up data were extracted from medical records of a structured surveillance program.

Results

Between 2002 and 2020, 18 patients were identified having undergone TEVAR procedures and protocol follow-up. The median age was 35.5 (IQL 30.0 – 42.7), and 12 (66.7%) were males; median ACEF II score was 0.6 (IQL 0.5 – 0.925).

This cohort comprised 15 (83.3%) patients with genetically confirmed Marfan syndrome, two (11.1%) with Loeys-Dietz, and one (5.6%) with Ehlers-Danlos syndrome. Of these, 13 (72.2%) patients had undergone aortic root or aortic root/ascending aorta replacement independently in the past. The indication for a TEVAR procedure was seen in one case for degenerative aneurysmal disease (5.6%), in one case for elephant trunk stenosis (5.6%), in five cases for residual aortic dissection (27.8%), and in 11 cases for new type B dissection (61.1%).

The most frequently used stent-graft was Valiant™ (Medtronic) in 10 cases (55.6%), followed by TAG® (Gore®) in four cases (22.2%), Zenith® (COOK®) in two cases (11.1%), and for Relay® (Bolton) and Sinus-XL® (Optimed) in one case each (5.6%). The average total covered length was 192.2±40.2 mm.

Median follow-up duration was 77.5 months (IQR 35.8 - 131); three (16.7%) cases revealed failure of TEVAR and led to conversion to open surgery. Two patients (11.1%) had died including one patient in the perioperative phase. At the last follow-up, complete thrombosis of the false lumen was observed in 14 cases (82.3%), and 15 cases (88.2%) showed no aortic expansion or progression during the follow-up period resulting in an overall endovascular success rate of 72.2%.

Conclusion

Thoracic endovascular aortic repair can be performed for selected patients with connective tissue disorders at relatively low long-term mortality and morbidity. With improved devices and technical skills, mid- and long-term surveillance revealed promising outcomes and a low rate of aneurysmal degeneration. Structured surveillance remains crucial to detect emerging late complications and to accumulate more long-term data.

Funding Acknowledgement

Type of funding sources: None.

Body mass index and efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndromes

Background

The efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndromes (ACS) according to body mass index (BMI) remain unknown.

Purpose

To assess the efficacy and safety of ticagrelor versus prasugrel in patients with ACS according to BMI.

Methods

This post-hoc analysis of the ISAR-REACT 5 trial included 3987 patients with BMI data available. BMI was grouped in 3 categories: low (BMI&lt;25 kg/m2, n=1084), intermediate (BMI ≥25 to &lt;30 kg/m2, n=1890) and high (BMI≥30 kg/m2, n=1013). The primary endpoint was the 12-month incidence of all-cause death, myocardial infarction, or stroke. The secondary endpoint was the 12-month incidence of Bleeding Academic Research Consortium (BARC) type 3 to 5 bleeding.

Results

There was no significant treatment arm-by-BMI interaction regarding the primary endpoint (Pint=0.578). However, the primary endpoint occurred in 63 patients assigned to ticagrelor and 39 patients assigned to prasugrel in the low BMI group (11.7% vs. 7.5%; hazard ratio [HR]=1.62; 95% confidence interval [CI], 1.09–2.42; P=0.018), 78 patients assigned to ticagrelor and 58 patients assigned to prasugrel in the intermediate BMI group (8.3% vs. 6.2%; HR=1.36 [0.97–1.91]; P=0.076), and 43 patients assigned to ticagrelor and 37 patients assigned to prasugrel in the high BMI group (8.6% vs. 7.3%; HR=1.18 [0.76–1.84]; P=0.451). BARC type 3 to 5 bleeding events did not differ between ticagrelor and prasugrel in patients with low (6.5% vs. 6.6%), intermediate (5.6% vs. 5.0%), or high (4.4% vs. 2.8%) BMI.

Conclusions

BMI of patients with ACS did not impact significantly on the treatment effect of ticagrelor vs. prasugrel in terms of both efficacy and safety.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Center for Cardiovascular Research;Deutsches Herzzentrum München, Germany

Functional characterization of drug responses in induced pluripotent stem cell-derived cardiomyocytes from a short QT syndrome type 5 patient

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): ETH Zurich Personalized Health and Related Technologies; German Centre for Cardiovascular Research

Introduction

Short QT syndrome (SQTS) and Brugada syndrome (BrS) are rare channelopathies causing sudden cardiac death (SCD). There are only few investigations of effective therapies of SQTS and BrS linked to CACNB2 variants. Since treatment data of SQTS are sparse, we studied drug responses of induced pluripotent stem cell-derived cardiomyocyte (iPSC-CM) 2D cultures carrying a mutation in the CACNB2 gene from a SQTS type 5 (SQT5) patient with an established phenotype. We used high-density microelectrode arrays (HD-MEAs), patch clamp, and calcium-transient imaging.

Purpose

To investigate the electrophysiological responses of SQT5 patient-derived iPSC-CMs upon exposure to antiarrhythmic drugs.

Methods

Human iPSCs, derived from a SQT5 patient and a healthy donor, were cultured and differentiated into cardiomyocytes by temporal modulation of the Wnt signaling. For electrophysiological measurements, spontaneously beating cardiomyocytes at day 40-60 were dissociated and plated a) on petri dishes for patch clamp and calcium-transient measurements and b) directly on HD-MEAs. Antiarrhythmic drugs, including sotalol, quinidine, and flecainide, were dosed to the cells after plating as soon as stable activity levels were measured. After baseline measurements, drug doses were sequentially increased from low to high concentrations.

Results

We observed spontaneous and synchronous beating of SQT5 patient- and healthy donor-derived iPSC-CMs. Quinidine, which is known to be effective for treatment of SQTS with possible differences for subtypes, prolonged field-potential duration (FPD) and action-potential duration in SQT5 patient-derived iPSC-CMs. Sotalol slightly increased FPD at 30µM as measured with HD-MEAs, whereas action-potential duration (APD) measured through patch clamp did not exhibit a notable effect at 30 µM. APD became shorter at higher concentrations, which is in line with clinical data of SQTS patients. HD-MEA measurements showed that flecainide shortened the FPD of SQT5 patient-derived CMs at 20µM. For healthy donor-derived iPSC-CMs, quinidine, sotalol, and flecainide prolonged FPDs in HD-MEA measurements. Using calcium-transient imaging, quinidine showed a slight antiarrhythmic effect, whereas sotalol did not have antiarrhythmic effects.

Conclusion

We used HD-MEAs, patch clamp, and calcium-transient imaging to analyze electrophysiological responses of SQT5 patient-derived iPSC-CMs upon dosage of antiarrhythmic drugs. Our preliminary results show that quinidine - but not flecainide - could prolong the repolarization duration in SQT5 patient-derived iPSC-CMs.

Impact of atrial fibrillation pattern on left atrial appendage closure: insights from the prospective LAARGE registry

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Stiftung für Herzinfarkforschung

Background

 Non-paroxysmal (NPAF) forms of atrial fibrillation (AF) have been reported to be associated with an increased risk for systemic embolism or death compared with paroxysmal AF (PAF). This study investigates the procedural safety and long-term outcomes of left atrial appendage closure (LAAC) in patients with different forms of AF.

Methods

 Comparison of procedural details and long-term outcomes in patients (pts) with PAF against controls with NPAF in the prospective, multicentre observational registry of patients undergoing LAAC in Germany (LAARGE). 

Results

 A total of 638 pts (PAF 274 pts, NPAF 364 pts) were enrolled. NPAF consisted of 31.6% patients with persistent AF and 68.4% with longstanding persistent AF or permanent AF. In both groups, a history of PVI was rare (4.0% vs 1.6%, p = 0.066). The PAF group had significantly less history of heart failure (19.0% vs 33.0%, p &lt; 0.001) while the current median LVEF was similar (60% vs 60%, p = 0.26). The total CHA2DS2-VASc score was lower in the PAF group (4.4 ± 1.5 vs 4.6 ± 1.5, p = 0.033), but no difference in the HAS-BLED score (3.8 ± 1.1 vs 3.9 ± 1.1, p = 0.40) was observed. The rate of successful implantation was equally high (97.4% vs 97.8%, p = 0.77) in both groups. In the three-month echo follow-up, device-related thrombi (2.1% vs 7.3%, p = 0.12) and peridevice leak &gt;5 mm (0.0% vs 7.1%, p= 0.53) were numerically higher in the NPAF group. Overall, in-hospital complications occurred in 15.0% of the PAF cohort and 10.7% of the NPAF cohort (p = 0.12). In the one-year follow-up, unadjusted mortality (8.4% vs 14.0%, p = 0.039) and combined outcome of death, stroke and systemic embolism (8.8% vs 15.1%, p = 0.022) were significantly higher in the NPAF cohort. After adjusting for CHA2DS2-VASc and previous bleeding, NPAF was associated with increased death/stroke/systemic embolism (HR 1.67, 95%-CI: 1.02-2.72).

Conclusion

 Atrial fibrillation type did not impair periprocedural safety or in-hospital MACE of patients undergoing LAAC. However, after one year, NPAF was associated with higher mortality and combined outcome of death, stroke and systemic embolism.

Abnormal thyroid function is common in takotsubo syndrome and depends on two distinct mechanisms: results of a multicentre observational study

BACKGROUND

Several reports have described Takotsubo syndrome (TTS) secondary to thyrotoxicosis. A complex interaction of central and peripheral catecholamines with thyroid homeostasis has been suggested. In this study, we analysed sequential thyroid hormone profiles during the acute phase of TTS.

METHODS

Thyrotropin (TSH), free T4 (FT4) and free T3 (FT3) concentrations were analysed at predefined time points in 32 patients presenting with TTS or acute coronary syndrome (ACS, n = 16 in each group) in a 2-year period in two German university hospitals. Data were compared to age- and sex-matched controls (10 samples, each of 16 subjects), and an unsupervised machine learning (ML) algorithm identified patterns in the hormone signature. Subjects with thyroid disease and patients receiving amiodarone were excluded from follow-up.

RESULTS

Among patients with TTS, FT4 concentrations were significantly higher when compared to controls or ACS. Four subjects (25%) suffered from subclinical or overt thyrotoxicosis. Two additional patients developed subclinical or overt thyrotoxicosis during stay in hospital. In four subjects (25%), FT4 concentrations were increased, despite nonsuppressed TSH concentration, representing an elevated set point of thyroid homeostasis. The thyroid hormone profile was normal in only six patients (38%) presenting with TTS.

CONCLUSION

Abnormal thyroid function is frequent in patients with TTS. Primary hyperthyroidism and an elevated set point of thyroid homeostasis are common in TTS, suggesting a stress-dependent endocrine response or type 2 thyroid allostasis. Thyroid function may be a worthwhile target in treating or preventing TTS.

Gen-editing to model Short QT syndrome type 5 using human-induced pluripotent stem cell-derived cardiomyocytes

Aims

Short QT syndrome (SQTS), a disorder associated with characteristic electrocardiogram QT-segment abbreviation, predisposes afflicted patients to sudden cardiac death. Despite some progress in assessing the organ level pathophysiology and genetic changes of the disorder, the understanding of the human cellular phenotype and discovering of an optimal therapy has lagged due to a lack of appropriate human cellular models of the disorder. The aim of this study was to establish a cellular model of SQTS type 5 using human-induced pluripotent stem cell–derived cardiomyocytes (hiPSC-CMs) and gene-edited cell line using CRISPR/CAS9.

Methods and results

This study recruited one patient with short QT syndrome type 5 carrying a mutation in CACNb2 gene as well as one healthy control subject. We generated hiPSCs from their skin fibroblasts, and differentiated hiPSCs into cardiomyocytes (hiPSC-CMs) for physiological. Isogenic control hiPSC-CMs generated by the CRISPR/CAS9 technique were also used for the study.

The hiPSC-CMs from the patient showed a reduced calcium current (ICa-L) density and shortened action potential duration (APD) compared with healthy control hiPSC-CMs and isogenic hiPSC-CMs. Furthermore, they demonstrated abnormal rhythmic activities. Carbachol increased the arrhythmic events in SQTS significantly but not in healthy and isogenic control cells. Gene and protein expression profiling showed a decreased CACNb2 expression in SQTS cells. Quinidine prolonged the APD and abolished arrhythmic activity.

Conclusions

Patient-specific hiPSC-CMs are able to recapitulate single-cell phenotype features of SQTS type 5 and provide novel opportunities to further elucidate the cellular disease mechanism and test drug effects.

Funding Acknowledgement

Type of funding source: None

Risk stratification of patients with Brugada syndrome (BrS): the impact of myocardial strain analysis using cardiac magnetic resonance myocardial feature tracking (CMR-FT)

Objectives

This study evaluated the prognostic significance of cardiac magnetic resonance myocardial feature racking (CMR-FT) in patients with Brugada syndrome (BrS) to detect subclinical alterations and predict major adverse events (MAE).

Methods and results

CMR was performed in 106 patients (pts) with BrS. Biventricular global strain analysis was assessed using CMR-FT. Pts were followed for a mean of 11.1±3.5 years.

The study cohort was subdivided according to the presence of a spontaneous type 1 ECG (sECG), into sBrS (BrS with sECG, n=34 (32.1%)) and diBrS (BrS with drug-induced type 1 ECG, n=72 (67.9%)). Both left and right ventricular (RV) ejection fraction were reduced within the normal range in sBrS pts. CMR-FT revealed morphological differences between sBrS and diBrS pts regarding RV strain (circumferential (%) (sBrS 7.9±2.9 vs diBrS −9.5±3.1, p=0.02) and radial strain (%) (sBrS 12.0±4.3 vs diBrS 15.4±5.4, p&lt;0.01)). During follow up, MAE were noted in 12 pts (11.3%). The presence of a sECG was the strongest predictor for MAE (OR 0.70, 95% CI 0.53–0.90; p=0.008). RV global circumferential strain (GCS) was also associated with MAE (OR 0.16, 95% CI 0.03–0.82; p=0.03). A risk model which combined these two identified predictors showed a substantial risk increase for patients with both sECG and reduced RV-GCS.

Conclusion

Myocardial strain analysis detected early subclinical alterations, prior to apparent changes in myocardial function, in patients with BrS. Moreover, RV-GCS provided additional prognostic information on the occurrence of MAE during follow-up.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Deutsches Zentrum für Herz- und Kreislaufforschung (DZHK), German Centre for Cardiovascular Research

WATCHMAN versus ACP or amulet for left atrial appendage closure. Results from the LAARGE registry

Background

Several left atrial appendage (LAA) closure systems are available and due to differences in device design safety and efficacy of specific occluders derived from trials cannot be simply generalized to all devices.

Purpose

The present analysis sought to assess two contemporary LAA closure devices in clinical practice.

Methods

The present work represents a non-randomized sub-analysis of the prospective, multicenter, Left-Atrium-Appendage Occluder Register - GErmany (LAARGE) registry. The WATCHMAN (group 1) and the Amplatzer Cardiac Plug (ACP) or Amulet occluder (group 2) were assessed regarding technical success and procedural safety.

Results

A total of 641 patients at 38 centers were enrolled. Of them, 278 (43%) and 340 (53%) patients received the WATCHMAN and ACP/Amulet occluder, respectively. High technical success was achieved with a slight difference between the groups (96% in group 1 vs. 99% in group 2; p=0.007). Procedural safety did not differ (98% in group 1 vs. 97% in group 2; p=0.55). Chicken wing morphology of the LAA seemed to trigger the use of the ACP/Amulet (chicken wing in 36% of the cases in group 1 vs. 55% in group 2; p&lt;0.001). The Kaplan Meier estimated 1-year composite of death or stroke was 12.0% and 12.9%, respectively (Figure 1A). The respective rates for the composite endpoint of death, stroke or systemic embolism were 12.0% and 13.2% (Figure 1B).

Conclusions

Both the WATCHMAN and the ACP/Amulet occluder provide excellent procedural results with comparable implantation success and no differences regarding procedural safety and long-term effectiveness.

Figure 1. Composite endpoints at 1-year

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Stiftung Institut für Herzinfarktforschung (IHF)

Cardiac contractility modulation efficacy: is there a difference between ischemic vs. non-ischemic patients?

Background/Introduction

Cardiac contractility modulation (CCM) is an FDA approved device therapy for systolic heart failure patients with narrow QRS complex who are symptomatic despite optimal medical therapy. It is used in patients with a wide range of different cardiomyopathies. However, little is known whether the therapy is comparably effective in different entities.

Purpose

This work investigated the long-term therapeutic effect in patients with ischemic (ICMP) compared to patients with non-ischemic cardiomyopathy (NICMP).

Methods

102 patients of our single center registry with known form of cardiomyopathy were included in this retrospective analysis (from 2011–2019). In 68 patients data of a clinical 3-year follow-up were available. The actual mortality rate within one and three years was compared with the one predicted by the MAGGIC risk score and compared between the two groups. In addition, changes in NYHA class, left ventricular ejection fraction (LVEF), LV end-diastolic diameter (LVEDD) and NT-proBNP values were compared as functional parameters.

Results

Patients with an ICMP (65%) were older (67±1 vs. 57±2 years (SD±SEM); p&lt;0.001) but had a comparable MLHFQ score (42±3 vs. 48±6; p=NS), mean peak VO2 (9.7±1.2 vs. 14.5±2.2 ml/kg/min; p=NS) and QRS width (115±3 vs. 112±4 ms; p=NS). Both groups initially had a comparably advanced limitation during physical activity (median NYHA class III; p=NS); 40% of patients responded with an improvement of at least 1 NYHA class within 3 years (p=NS). The LVEF was 24±1 vs. 22±1% in the beginning and improved to 32±2 vs. 38±2% within 3 years (+33 vs. +73%; p&lt;0.001 in comparison over time; p&lt;0.001 in comparison of the percentage changes ICMP vs. NICMP). While LVEDD was initially significantly wider in NICMP patients (51±2 vs. 67±2 mm; p&lt;0.001), this was offset under therapy, mainly due to a reduction in LVEDD in NICMP patients (+3±2 vs. −7±3 mm; p=0.023). The NT-proBNP values decreased from 4872±776 vs. 5354±1153 to 2051±578 vs. 843±363 ng/l (−58 vs. −84%; p=NS in comparison over time; p=0.093 in comparison of the percentage changes ICMP vs. NICMP). ICMP patients had a higher MAGGIC risk score (27±1 vs. 24±1; p=0.019). Mortality rates at 1 year were 7.4 vs. 17.1% and at 3 years 40.5 vs. 35.5% (each p=NS) compared to mortality rates estimated from the MAGGIC risk score of 21.2 vs. 16.0% (p=0.028) and 44.0 vs. 37.2% (p=0.071), respectively. Chi-square test for comparison of observed and expected frequencies revealed that the number of deaths during 1-year follow-up was significantly lower than predicted only in ICMP patients (p=0.018 compared to the estimated risk).

Conclusions

NICMP patients had a significantly greater increase in LVEF. Moreover, reverse remodeling with reduction of the LVEDD was only observed in NICMP patients. In summary, significant differences in functional therapy response could be identified between ICMP vs. NICMP patients.

Funding Acknowledgement

Type of funding source: None

Impact of pre-hospital resuscitation on short-and long-term mortality in patients with cardiogenic shock and multivessel disease. Results of the CULPRIT trial

Background

There are only a few prospective data on the outcome of patients with cardio-pulmonary resuscitation (CPR) admitted with acute myocardial infarction (AMI) complicated by cardiogenic shock and an invasive strategy including primary percutaneous coronary intervention (PCI). Therefore, we evaluated the impact of pre-hospital CPR on outcomes in a large group of patients with AMI complicated by cardiogenic shock.

Methods

We used the data of the prospective CULPRIT-Shock trial and registry and including patients with acute myocardial infarction complicated by cardiogenic shock. The primary endpoint was 30-day mortality or renal replacement therapy.

Results

Between 2013 and 2017, a total of 1055 patients were included in the randomized trial (n=686) and in the registry (n=369), 550 (54%) had CPR, 40 had no information regarding CPR. Baseline characteristics, procedural features and outcomes in the two groups with and without CPR are given in the table.

Conclusion

Patients with pre-hospital CPR represent more than half of the population with AMI complicated by cardiogenic shock. They are younger, have less risk factors and more often LAD as infarct vessel. Despite the younger age and a high success rate of PCI patients with CPR have a high 30-day mortality.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum fuer Herz-Kreislauf-Forschung - DZHK

P6179Correlation of computed tomography-based fractional flow reserve with instantaneous wave free ratio to detect hemodynamically significant coronary stenoses

Background

Based on coronary computed tomography angiography (cCTA), stenoses can be detected but provides anatomical assessment solely. Fractional flow reserve based on coronary CT angiography (ML-cFFR) is gaining in importance for non-invasive hemodynamic assessment of obstructive coronary artery disease (CAD), as several large trials demonstrated significantly improvements in diagnostic accuracy to cCTA. Comparably instantaneous wave free ratio (iFR) is a novel resting index for the invasive determination of haemodynamic relevant stenoses, finds consideration in the ESC guideline on myocardial revascularization and is now of equal standing with FFR as a class IA recommendation.

Purpose

The aim of our study was to evaluate the on-site ML-cFFR in terms of diagnostic accuracy and clinical practicability in comparison to the iFR as the current invasive gold standard to detect hemodynamically significant coronary artery stenoses.

Methods

In our prospective, multi-center study, patients with CAD who had a clinically indicated cCTA and subsequent invasive coronary angiography with iFR-measurement were included. To analyse the acquired cCTA dataset we used a third-generation dual-source CT with on-site prototype ML-cFFR software that is based on a machine-learning algorithm, to determine the hemodynamic relevance of coronary stenoses.

Results

Between July 2017 and December 2018, in 40 of 42 cases (95%), the on-site ML-cFFR calculation was successful. Finally we enrolled 40 patients (72.5% males, mean age 66.7±11.9 years) with ML-cFFR calculation based on cCTA and iFR-measurement during ICA. The mean calculation time of the ML-cFFR values was 10.6±1.9minutes. 57 vessel specific lesions were analysed, of which 15 (26%) were determined as hemodynamically relevant stenoses by iFR (iFR≤0.89) whereas ML-cFFR classified only 14 (24.5%) as hemodynamic significant coronary stenoses (ML-cFFR≤0.80). We observed that cCTA overestimated the severity of stenoses in 27 of 40 cases, which might lead to unnecessary coronary angiographies. However, ML-cFFR detected no obstructive CAD in 26 of 40 patients (65%) and this would have resulted in a reduction of initially performed pure diagnostic coronary angiography. Estimated values sensitivity, specificity, PPV and NPV were 86.7%, 97.4%, 92.9% and 95.0%. The diagnostic accuracy of ML-cFFR in terms of iFR on a per-patient and per-lesion level was 95.0% and 96.5%. The area under the curve (AUC) on a per-lesion and per-patient basis by ML-cFFR to detect lesion specific ischemia was 0.97 and 0.96. The analysis of the correlation (Pearson's product-moment) on a per-lesion level was r=0.82 (p<0.0001) between the ML-cFFR algorithm and iFR.

Conclusion(s)

On-site ML-cFFR correlates excellently with the novel gold standard iFR to non-invasively detect hemodynamic significant coronary stenoses in routine clinical practice.

Acknowledgement/Funding

Doctor S. Baumann receives research support from Siemens and Philips Volcano. All other authors declare that they have no financial disclosure.

P5737Use of the IMPELLA mechanical support device in patients with acute myocardial infarction complicated by cardiogenic shock - Results of the CULPRIT-SHOCK trial

Background

Mortality in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) is still high despite the use of early revascularization therapy. While IABP support has been shown not improve outcome more effective mechanical support devices such as the IMPELLA are increasingly used. We sought to study the use of the IMPELLA device in patients with multivessel coronary artery disease and CS.

Methods

The CULPRIT-SHOCK shock trial included 686 patients with AMI complicated by cardiogenic shock and multivessel coronary artery disease treated with early PCI. Patients were randomized to immediate multivessel PCI or culprit lesion only PCI. In the current subanalysis, we investigated the patients treated with an IMPELLA support device compared these to patients without IMPELLA.

Results

Of the 686 patients 82 (12%) were treated with an IMPELLA device, 32 (39%) with IMPELLA 2.5 and 50 (61%) with IMPELLA CP. The device has been implanted in 34 patients before and 48 patients after PCI. The table shows the baseline characteristics of the patients with and without IMPELLA. In an unadjusted analysis mortality was higher with IMPELLA (63% versus 45.5%). Patients with IMPELLA CP had somewhat lower mortality than IMPELLA 2.5 (59.2% versus 68.8%), while there was no difference for pre- and post-PCI implantation.

IMPELLA (n=82) No IMPELLA (n=606) p-value Age (years) 70 68 0.17 Women 22.2% 23.3% 0.88 Diabetes 37.7% 31.8% 0.30 Triple vessel disease 66.7% 62.9% 0.13 Left main disease 28.4% 14.1% 0.001 LV-EF 31% 34% 0.18 Lactate on admission 20 mmol/l 8 mmol/l 0.0001 Multivessel PCI 50.6% 51.1% 0.9 Mechanical ventilation 88.9% 80.2% 0.06 SAPS-2 score 65 55 0.0008

Conclusion

Currently the IMPELLA support device is used primarily in patients with higher risk indicated by a higher incidence of left main disease, higher lactate on admission and higher SAPS II scores. This is associated with a higher mortality. Therefore randomized trials are needed to determine the effect of IMPELLA on outcome in patients with cardiogenic shock.

1155Prognostic impact of SYNTAX Score in patients with myocardial infarction with multivessel coronary artery disease and cardiogenic shock: insight from the CULPRIT-SHOCK Trial

Background

The majority of patients presenting with myocardial infarction (MI) and cardiogenic shock (CS) have multivessel coronary artery disease. The prognosis impact of the SYNTAX score (SS) in this setting remains unknown.

Purpose

To evaluate the prognosis value of the SS in this high-risk population undergoing percutaneous coronary intervention (PCI)

Methods

The CULPRIT-SHOCK trial was an international, open-label trial, where patients presenting with MI and multivessel disease complicated by CS were randomized to a culprit-lesion-only or an immediate multivessel PCI strategy. Pre-PCI SS was assessed by a central core laboratory and patients were categorized as low SS (SS ≤22), intermediate SS (22<SS≤32) and high SS (SS>32). Adjudicated endpoints of interest were the risks of all-cause death or renal replacement therapy at 30 days and all-cause death at 1 year. Associations between SYNTAX score and outcomes were assessed using multivariate logistic regression.

Results

SS was available in 632 patients, of whom 265 (41.9%), 211 (33.4%) and 156 (24.7%) presented with low, intermediate and high SS, respectively. Patients with higher SS were older, with more frequent peripheral artery disease, less current smoking, lower creatinine clearance, and higher use of catecholamine. A stepwise increase in the incidence of adverse events transitioning from low to intermediate and high SS was observed with the 30-day risk of death or renal replacement therapy as well as the 1-year risk of all-cause death (p for trend <0.001, for all). After multiple adjustment, intermediate and high SS remained strongly associated with 30-day risk of death and renal replacement therapy and 1-year risk of all-cause death (Figure). There was no significant interaction between SYNTAX score and the coronary revascularization strategy for all endpoints.

Conclusion

In patients presenting with acute MI, multivessel disease and CS, the SYNTAX score was strongly associated to 30-day and 1-year mortality</ss≤<ss≤32)>

Acknowledgement/Funding

The CULPRIT-SHOCK trial was Supported by a grant agreement (602202) from the European Union Seventh Framework Program and by the German Heart Research

P2268Incidence and prognostic impact of sepsis in patients with acute myocardial infarction complicated by cardiogenic shock - Results of the CULPRIT-SHOCK study and registry

Background

Patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) have a high mortality. It has been proposed that one component is a systemic inflammatory response to shock. Some of these patients even develop sepsis. Therefore,we analyzed a large cohort of patients with AMI and CS and sought to determine the incidence of sepsis and its impact on outcome.

Methods

The CULPRIT-SHOCKtrial and registry included 1009 patients with AMI complicated by CStreated with early PCI. In the trial 686 patients were randomized to immediate multivessel PCI or culprit lesion only PCI. In the current subanalysis patients were compared in those developing sepsis during the ICU phase to thosewithout sepsis.

Results

From the total of 1009 patients 103 (10%) developed sepsis. The baseline characteristics and 30-day outcomes are shown in the table.

Sepsis (n=103) No sepsis (n=906) p-value Age (yrs) 68 68 0.8 Women 22.3% 25.3% 0.5 Diabetes 34.3% 29.7% 0.3 GFR <60 ml/min 5.8% 6.4% 0.8 CPR 54.4% 54.2% 0.8 Lactat >5 mmol/l 54.2% 50.8% 0.6 Mechanical support device 35.0% 29.1% 0.2 Bleeding 28.2% 18.8% 0.02 Need for renal replacement therapy 37.9% 9.6% <0.0001 Mortality 54.4% 45.7% 0.08

Conclusion

About 10% of patients with AMI complicated by CSdevelop sepsis. Sepsis is associated with a higher incidence of the need for renal replacement therapy, bleeding and and a trend towards higher mortality. Therefore,further research is needed to improve outcome of these very high risk patients.

P1725Current spectrum and 1-year mortality of cardiogenic shock in Europe. Results of the CULPRIT-SHOCK randomized clinical trial and registry

Background

An early invasive strategy with coronary revascularization has been shown to improve prognosis in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). Little is known about the current spectrum, treatment and 1-year mortality in patients with CS undergoing early angiography in Europe.

Methods

We evaluated baseline characteristics, treatments and 1-year outcome in a large number of patients with CS included into the prospective CULPRIT-SHOCK randomized trial and the accompanying registry. Between April 2013 and April 2017, a total of 1075 patients with cardiogenic shock were screened at 83 European centers, of whom 706 (65.6%) were included in the randomized trial RCTand 369 into the registry.

Results

The median age was 67 years and 25% were female. In total, 55% of patients had pre-hospital resuscitation, 6% underwent fibrinolysis before angiography, 65% presented with ST-elevation myocardial infarction, 15% with left bundle branch block, and 20% with non-ST-elevation myocardial infarction. The majority of patients (80%) needed mechanical ventilation. Catecholamines were used in 90% and mechanical support in 29.5% of the patients (IABP 38.5%, ECMO 22%, Impella 33%, other 7%). Total 30-day and 1-year mortality was 46% and 52%, respectively. Mechanical complications were observed in 2.1% of patients, the latter had a 30-day and 1-year mortality of 62% and 67%, respectively. The mortality related to the extent of coronary artery disease is shown in the table.

1-vessel (14%) 2-vessel (31%) 3-vessel (55%) Left main (15%) 30-day mortality 36% 44% 51% 53% 1-year mortality 39% 50% 57% 64%

Conclusions

This first report including data of the prospective CULPRIT-SHOCK randomized trial as well as the accompanying registry demonstrates the high-risk clinical characteristics of patients with AMI complicated by CS undergoing contemporary treatment. Despite an early invasive strategy mortality in patients with AMI complicated by CS in Europe is still high and is related to the extent of coronary artery disease.

P2809Comparison between treatment of “established” versus complex “off-label” coronary lesions with Absorb bioresorbable scaffold implantation: results from the GABI-R registry

Objectives

The purpose of this study was to compare the clinical outcomes of patients treated with bioresorbable scaffold (BRS) for off-label versus approved indications.

Background

The BRS promised some advantages in terms of complete biodegradation, however, the implication of BRS for off-label indications is not well described.

Methods

The short- and long-term outcome after implantation of a bioresorbable scaffold system (ABSORB, Abbott Vascular, USA) was evaluated in the prospective, non-interventional, multicenter real-world German-Austrian ABSORB RegIstRy (GABI-R).

Results

A total of 3,188 patients were enrolled. Patients were divided into two groups: on-label BRS use (33.0%) and off-label use (66.9%) if at least one off-label use criteria was met. The incidence of scaffold thrombosis in confirmed cases was significantly higher in off-label group (1.36% vs. 0.57%, p=0.04; OR 2.41 (95% CI: 1.00–5.82) with also a trend towards higher myocardial infarction rate (2.39% vs. 1.42%, p=0.077; OR 1.70 (95% CI: 0.95–3.03) and cardiovascular death (1.27% vs. 1.14%, p=0.76, OR 1.11 (95% CI: 0.56–2.21) at 6 months follow up.

Clinical outcome at 6 months Total Off-label On-label p-value* OR (95%-CI) Patients with 6m FU record 99.0% 99.0% 99.1% 0.82 0.92 (0.43–1.95) Confirmed cardiovascular death 1.22% 1.27% 1.14% 0.76 1.11 (0.56–2.21) Confirmed non-cardiovascular death 0.22% 0.14% 0.38% 0.18 0.37 (0.08–1.66) Cause unknown 0.22% 0.28% 0.09% 0.29 2.97 (0.36–24.73) Hospitalisation 27.5% 27.9% 26.7% 0.51 1.06 (0.89–1.27) MI 2.07% 2.39% 1.42% 0.07 1.70 (0.95–3.03) ARC definite scaffold thrombosis 1.10% 1.36% 0.57% 0.04 2.41 (1.00–5.82) TLF 2.70% 3.00% 2.09% 0.13 1.45 (0.89–2.37) TVF 3.98% 4.31% 3.32% 0.18 1.31 (0.88–1.95) MACE 4.33% 4.64% 3.70% 0.22 1.27 (0.87–1.85) Values are mean ± standard deviation (SD) or number and percentage (n, %). *Comparison between off-label and on-label use. The p-values are from Chi-squared test or Mann-Whitney-Wilcoxon test. ARC, academic research consortium; FU, follow up; MACE, major adverse cardiac events; PCI, percutaneous coronary intervention; TLF, target lesion failure; TVF, target vessel failure.

Kaplan-Meyer curve stent thrombosis

Conclusions

The off-label use of BRS compared to confirmed indications appears to be associated with a higher rate of clinical endpoints considering more complex lesions and higher morbidity in this patients' group.

Acknowledgement/Funding

This research was supported by a grant from Abbott Vascular.

P3727Left atrial appendage closure in patients with a reduced left ventricular ejection fraction: results from the prospective multicenter German LAARGE registry

Background and purpose

Atrial fibrillation (AF) patients with increased thromboembolic risk and contraindications for standard oral anticoagulation (OAC) can profit from an interventional left atrial appendage closure (LAAC). While impaired left ventricular ejection fraction (LVEF) is associated with an increased thromboembolic risk in AF patients, cardiac interventions are often associated with an increase in complications in this patient population, and, therefore, the LAAC procedure's success and benefit has yet to be investigated in this subgroup.

Methods

This prospective, observational LAAC registry included 622 patients with documented LVEF from 37 German centers between April 2014 and January 2016. Patients were categorized into one of three groups: LVEF >55% (preserved; p), LVEF 35–55% (mid-range; mr) and LVEF <35% (reduced; r). Procedure was conducted in a standard fashion, and baseline characteristics, imaging as well as procedural data, intra-hospital and one-year follow-up outcome were registered for each group.

Results

55.3% of patients had a pLVEF, 38.7% a mrLVEF and 5.9% a rLVEF. Patients with rLVEF were more often affected by coronary artery disease (p<0.001 for trend), and had an elevated CHA2DS2-VASc (4.3±1.5 vs. 4.8±1.5 vs. 5.3±1.6; p<0.001) and HAS-BLED score (3.7±1.1 vs. 4.1±1.2 vs. 4.3±0.9; p<0.001). Percentage of prior cerebrovascular events and major bleedings was comparable at baseline (each p=n.s.). Procedural success was high (97.9%), while rates of intra-hospital MACCE (0.5%) and other major complications (4.2%) were low, with no significant difference between the groups (each p=n.s.). MACCE during follow-up was more frequent in rLVEF patients (11.0 vs. 11.3 vs. 27.8%; p=0.013), which was mainly driven by myocardial infarctions and all-cause deaths in this high risk collective. Likewise, Kaplan-Meier estimation showed a lower overall survival in this group (89.7 vs. 89.3 vs. 74.6%; p<0.01). On the contrary, rates of stroke were extremely low across all groups and statistically similar (0.3 vs. 1.0 vs. 0%; p=n.s.). This was 93.4, 82.7 and 100.0% less in comparison to the estimated risk calculated from the CHA2DS2-VASc score

Conclusions

The LVEF had no influence on the procedural success as well as the intra-hospital complications after LAAC. Annual rate of stroke was low across all groups, and risk reduction was substantial especially in this high risk collective, as compared to the estimated risk.

Acknowledgement/Funding

Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany

P3724Impact of chronic kidney disease on efficacy and safety of interventional left atrial appendage closure – results from the prospective multicenter LAARGE registry

Background

The interventional left atrial appendage closure (LAAC) is an effective and safe alternative to standard oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) patients with contraindications for long-term OAC. Chronic kidney disease (CKD) has a high prevalence among AF patients, and was shown to increase the number of peri-procedural complications in cardiac interventions.

Purpose

This subanalysis of the LAARGE registry aimed to investigate CKD's impact on outcomes after LAAC.

Methods

This prospective, real-world LAAC registry included 625 patients with documented renal function from 37 German centers between April 2014 and January 2016. CKD was defined by an eGFR <60 mL/min/1.73 m2. Procedure was conducted with different LAAC devices considering the relevant recommendations. Baseline characteristics, procedural data, intra-hospital and one-year follow-up outcome were registered for CKD and non-CKD patients stratified by the different CKD stages.

Results

CKD patients (n=300; 48.0%) had a more pronounced cardiovascular risk profile, a higher stroke (CHA2DS2-VASc score 4.9±1.5 vs. 4.2±1.5; p<0.001) and bleeding risk (HAS-BLED score 4.3±1.0 vs. 3.5±1.0; p<0.001), and had experienced more prior bleedings (83.7 vs. 76.3%; p=0.022). Implantation success was similarly high between both groups (97.9%; p=n.s.). In CKD patients, MACCE during one-year follow-up was more frequent (18.1 vs. 6.8%; p<0.001) mainly being triggered by all-cause deaths, but in-hospital MACCE was not (0.3 vs. 0.3%; p=n.s.). Kaplan-Meier estimation showed a lower one-year survival among CKD patients (82.4 vs. 94.4%; p<0.001) without significant accentuation in patients with advanced CKD (i.e., <30 mL/min/1.73 m2; p=n.s. to other CKD patients). While annual rate of device associated complications (2.6 vs. 2.8%; p=n.s.) and strokes (0 vs. 1.0%; p=n.s.) was comparable during follow-up, annual severe bleeding rate was higher in CKD patients (2.6 vs. 0.3%; p=0.027) which was 71.4 and 94.4% less than expected from the HAS-BLED score (p<0.01 for the comparison to the estimated risks, but no significant interaction between groups).

Conclusions

Despite an increased cardiovascular risk profile of CKD patients, device implantation was safe, and annual stroke rate was statistically indifferent to non-CKD patients across all CKD stages after LAAC. Moreover, a substantial reduction of annual stroke and major bleeding risk was observed, as compared to the estimated annual risk.

Acknowledgement/Funding

Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany

P1719Sex-specific PCI strategies in patients with AMI and cardiogenic shock: a substudy of the culprit-shock trial

Background and purpose

Women are more likely to suffer from a cardiogenic shock (CS) as the most severe complication of an acute myocardial infarction (AMI) and tend to have a higher mortality. Data concerning optimal management among women with CS are lacking. Aim of this study was therefore to better define characteristics of women suffering a CS and to investigate the influence of sex on different coronary revascularisation strategies

Methods and results

In the CULPRIT-SHOCK trial, patients with CS complicating AMI and multivessel coronary artery disease were randomly assigned to one of the following coronary revascularisation strategies: either percutaneous coronary intervention (PCI) of the culprit lesion only or immediate multivessel PCI. Primary end-point was a composite of death from any cause or severe renal failure leading to renal-replacement within 30 days after randomisation. We investigated sex-specific differences in general and according to the revascularisation strategies.

Among all 706 randomised patients 26% were women. After 30 days, the primary end-point occurred in 55% women and 49% men (p=0.20), showing a relative risk of 1.14; 95% CI 0.94–1.38; p=0.17, women vs. men. Those women were older, more frequent diabetic and had more peripheral artery disease and less frequent smokers and less often family history of coronary artery disease.

Regarding revascularisation strategy the composite end-point occurred in 55.8% women treated with the culprit-only strategy (vs. 42.4% men, p=0.04) and in 54.7% women in the multivessel group (vs. 55.6% men, p=0.99). This resulted in a no-significant difference among both groups (interaction p-value of 0.11).

Conclusions

In this large randomised trial among patients with multivessel coronary disease and CS complicating AMI, women had similar outcome for mortality and severe renal failure. Sex did not show to influence mortality and renal failure according to the different coronary revascularisation strategies. These data suggest that women and men presenting with CS should be treated equally.

P3124Predictive value of the residual SYNTAX score following primary PCI in multivessel patients with MI-related cardiogenic shock - a CULPRIT SHOCK sub-analysis

Background

Complete revascularization (CR) – assessed by the residual SYNTAX score (rSS) – following PCI is associated with a better prognosis – in stable coronary disease, acute coronary syndrome and myocardial infarction (MI). Whether, the completeness of revascularization impacts the prognosis of patients in cardiogenic shock (CS) remains unclear.

Aim

Assess the prognosis value of rSS following primary PCI in multivessel patients undergoing MI-related CS.

Methods

The CULPRIT SHOCK trial – the largest randomized trial (n=706) to date in CS – compared an immediate multivessel PCI (MVPCI) strategy to a culprit lesion only PCI (with possible staged revascularization) strategy in multivessel patients with MI-related CS. The rSS were retrospectively assessed following last PCI (either index or staged) by a central core laboratory and patients were allocated in 4 different groups according to rSS: CR (rSS=0), 0< rSS ≤5, 5< rSS ≤14, rSS >14. The prognostic impact of rSS on the 30-day composite endpoint (mortality and/or severe renal failure) and 30-day and 1-year mortality were assessed using multivariate logistic regression.

Results

Among the 604 patients with last rSS available, aged 68.2±11.4, the median rSS was 9.0 [4.0–17.0]. CR was achieved in 75 (25%) patients in the MVPCI strategy and in 31 (10.2%) in the culprit lesion only PCI strategy. One hundred and six (17.5%), 102 (16.9%), 198 (32.8%) and 198 (32.8%) patients had a rSS=0, 0< rss ≤5, 5< rSS ≤14 and rSS >14, respectively. Patients with a higher rSS were older, less active smoker, had more triple vessel disease, chronic total occlusion, post-PCI culprit coronary TIMI flow <3 and require more mechanical circulatory support and catecholamine. Univariate analysis shows a stepwise increase in adverse events according to rSS: patients with 5< rss ≤14 and rSS >14 had higher rates of 30-day primary endpoint (OR [95% CI]: 2.02 [1.24; 329] and 2.75 [1.69; 4.49]), 30-day mortality (OR [95% CI]: 2.13 [1.29; 3.51] and 3.14 [1.90; 5.18]) and 1-year mortality (OR [95% CI]: 2.39 [1.46; 3.90] and 3.47 [2.11; 5.71]) compared to patients with CR. After multiple adjustment, rSS – tested as continuous variable – was independently associated with 30-day primary endpoint, 30-day and one-year mortality (Figure)

Conclusion

Among multivessel patients with MI-related cardiogenic shock, 1) complete revascularization is achieved only in one fourth of the patients using a MVPCI strategy and, 2) the residual SYNTAX score is independently associated with early and late mortality.

Acknowledgement/Funding

Funded by the European Union 7th Framework Program and others

P962Follow-up of protected high-risk percutaneous coronary intervention with microaxial Impella pump. Results from the retrospective German Impella Registry

Background

Percutaneous coronary intervention (PCI) presents a relevant alternative to coronary bypass surgery for the treatment of patients with complex coronary artery disease and high perioperative risk. By temporary implantation of a percutaneous ventricular assist devices (pVAD) interventionalists attempt to anticipate the hemodynamic risk of those high-risk patients in a so-called protected PCI. The Impella® system presents the currently most common device for protected PCI and could show hemodynamic stability in earlier trials.

Methods

This study is a retrospective, observational multi-center registry of ten hospitals in Germany. We included patients undergoing protected high-risk PCI with Impella® support. The primary endpoint was defined as major adverse cardiac events (MACE) during a 180-day follow-up and consisted of all-cause mortality, myocardial infarction (MI) and stroke.

Results

Six of the participating hospitals performed a follow-up. In total, 157 patients (80.3% male; mean age 71.8±10.8 years) were included in the present study. Prior to PCI, median left ventricular ejection fraction was 39.0% (25.0%-50.0%) and median SYNTAX-Score I was 33.0 (24.0–40.5). The 180-day follow-up was available for 149 patients (94.9%). Eight patients (5.1%) were lost to follow-up. During the follow-up period, 34 patients (22.8%) suffered from a MACE. A total of 27 patients (18.1%) died. Nine patients (6.0%) sustained a MI, while 4 patients (2.7%) had a stroke.

Kaplan-Meier curves for primary endpoint

Conclusions

Patients undergoing protected high-risk PCI with Impella® support show a good 180-day clinical outcome regarding rates of MACE and mortality. However, a head-to-head comparison of Impella supported patients to protected PCI with other pVADs is pending.

Acknowledgement/Funding

S.B., N.W., F.A.-R., J.-M.S., A.S., R.S., I.A. receive consulting fees/honoraria from Abiomed (Danvers, MA, USA).

P3691Intra-aortic balloon counterpulsation in takotsubo syndrome complicated by cardiogenic shock: short- and long-term results from a cohort of 2250 patients of the German-Italian-Spanish registry

Background

Takotsubo syndrome (TTS) is featured by an acute and reversible left ventricular dysfunction and can be complicated by cardiogenic shock. Intra-aortic balloon pumping (IABP) use in this setting is controversial, and few data are available from large populations. Aim of this study was therefore to evaluate short- and long-term impact of IABP on mortality in TTS complicated by cardiogenic shock.

Methods

The GEIST registry is a multicenter, international registry on TTS involving 38 centers from Germany, Italy and Spain. Between 2006 and 2017, 2250 consecutive patients with TTS were enrolled.

Results

Of the 2250 patients, 211 (9%) experienced cardiogenic shock during hospitalization for TTS. Admission left ventricular ejection fraction (LVEF) was 30±15% and systolic blood pressure was 90±35 mmHg. Apical ballooning pattern was found in 77%, mid-ventricular/basal pattern in 11%, and 2% of the patients, respectively.

Forty-two patients out of 211 (19%) received IABP after coronary angiography. Patients receiving IABP compared to standard medical therapy did not differ in terms of age, gender, cardiovascular risk factors and admission LVEF.

No differences were found in term of in-hospital mortality (9.5% vs 17% p=0.35), length of hospitalization (19.3 vs 16.3 days p=0.34), need of invasive ventilation (35% vs 41% p=0.60), stroke (4.7% vs 11% p=0.17) and LV thrombus (0.5% vs 1.7%, p=0.98).

At long-term follow-up, with a median of 2 years, overall mortality in patients with cardiogenic shock and TTS was 34.1%. Mortality was not different between the IABP and the control group (33.7% vs 35.0%; p=0.85).

Conclusions

In this large multicenter observational registry, the use of IABP has no impact on mortality at short and long-term follow-up. Further studies are needed to evaluate the best therapeutic strategy in TTS complicated by cardiogenic shock.

Gender-based comparison of takotsubo syndrome versus myocardial infarction

BACKGROUND

Takotsubo Syndrome (TTS) is an acute reversible left ventricular dysfunction. Recently published studies have highlighted a similar mortality rate as acute coronary syndrome (ACS). We compared the impact of gender differences on the outcome of TTS patients as compared to ACS patient.

DESIGN AND METHODS

We included a collective of 138 patients TTS between 2003 and 2016 at our institution. Patients were divided according to their gender into two groups (Males n=21, 15% and females, n=117, 85%). They were compared with a cohort of 300 patients with a diagnosis of ACS.

RESULTS

On the acute phase, in male patients with TTS, a treatment with inotropic was more often required (33.3 vs. 11.5%, P<0.01), were more susceptible to cardiogenic shock (28.6 vs. 12.5%, P<0.04). Concerning the long-term prognosis after the acute event, male patients had higher all-cause mortality over long-term follow-up. A Kaplan-Meier analysis indicated that the mortality of male patients with TTS was significantly higher compared to male patients with ACS (log-rank <0.01), while there was no significant difference between female patients with TTS and ACS (log-rank =0.60, P=0.45). In a multivariate cox regression analysis, male gender (HR 2.7, 95% CI: 1.1-6.5, P=0.02) GFR <60 ml/min (HR 2.8, 95% CI: 1.2-6.0, P=0.01) and history of cancer (HR 3.6, 95% CI 1.4-9.3, P<0.01) were independent predictors of 5-year mortality.

CONCLUSIONS

Considerable evidence suggests that TTS compared to ACS implicates more significant clinical short-term events on male patients and it may be associated with poorer long-term prognosis.

[ARENA-Project atrial fibrillation in the Rhein-Neckar region]

Atrial fibrillation (AF) is the most common form of cardiac tachyarrhythmia. It is estimated that in the Rhein-Neckar region approximately 40,000-50,000 out of 2 million people are affected. Due to demographic changes in the near future there will be a significant increase in the prevalence of AF within the next decades. The ARENA project was initiated by the Foundation Institute for Cardiac Infarction Research (IHF) Ludwigshafen in cooperation with cardiological and neurological departments of neighboring hospitals, resident doctors and pharmacies to improve the awareness and care of patients with AF. The particular aim is the prevention of stroke as one of the most dreaded complications. The project focusses on the following three subtopics: interventions, medication, migration. The aim of the intervention project is to raise awareness of AF as a risk factor for stroke and to improve the diagnostic work-up and care for patients with diagnosed or unknown AF. The subproject medication focusses on the adherence of patients with AF to the prescribed antithrombotic medication. To evaluate differences concerning patients with and without a migration background the subproject migration was initiated.

[Cardiac contractility modulation for treatment of chronic heart failure]

The worldwide prevalence of heart failure is 1-2% with a portion of >10% in patients older than 70 years. In addition to treatment of causal determined factors and lifestyle modification, basic treatment consists of guideline-directed medical therapy with angiotensin-converting enzyme inhibitors (ACE), β‑blockers (BB), mineralocorticoid receptor antagonists (MRA), diuretics, digitalis (class IIb recommendation), angiotensin receptor blockers (ARB), Iƒ-channel blockers plus recently recommended in the guidelines angiotensin receptor neprilysin inhibitor (ARNI) to substitute the ACE inhibitor (class I b). Cardiac contractility modulation (CCM) is a device-based electrical therapy for the treatment of refractory heart failure symptoms. CCM signals are relatively high intensity, nonexcitatory signals applied during the absolute refractory period that have been shown to enhance the strength of left ventricular (LV) contraction and improve exercise tolerance and quality of life. The mechanisms of action appear to involve effects on myocardial gene expression and normalization of myocardial key-proteins. So far, more than 3500 CCM devices have been implanted worldwide. For patients with symptomatic heart failure and narrow QRS complex, CCM is together with baroreceptor activation the only additive electrical therapy which had been approved in Germany. Actually, for the first time, CCM has been referenced in the current Heart Failure Guidelines. Prognostic data with regard to mortality are currently being evaluated in case series; some of which have since been published. Approval by the US Food and Drug Administration (FDA) is expected within the next months.

[Cardiac contractility modulation]

Cardiac contractility modulation (CCM) is a device-based electrical therapy for the additive treatment of chronic drug-refractory heart insufficiency. High-amplitude signals are applied during the absolute refractory period and have been shown to enhance the strength of left ventricular (LV) contraction and improve exercise tolerance and quality of life. The mechanisms of action appear to involve effects on myocardial gene expression and on normalization of key myocardial proteins. So far, more than 3500 CCM devices have been implanted worldwide. For patients with therapy refractory heart insufficiency and narrow QRS complex, CCM is together with baroreceptor activation the only additive electrical therapy which had been approved in Germany. For the first time CCM has been referenced in the current guidelines on cardiac insufficiency. Prognostic data with respect to mortality have been evaluated in case series. Ongoing randomized trials and registries will address these specific endpoints and have to a significant extent already been recently published. A Food and Drug Administration (FDA) approval is expected within the next few months.

Long term outcome of patients suffering from cancer and Takotsubo syndrome or myocardial infarction

BACKGROUND

The pathophysiology of takotsubo syndrome (TTS) is unclear so far. There is strong association of the occurrence of TTS and malignant diseases. An association between malignant diseases and myocardial infarction (MI) was found recently and ascribed to common molecular and lifestyle mechanisms.

AIM

To compare the outcome of patients with MI or TTS and malignant diseases in a matched cohort.

METHODS

Patients with TTS or with MI (n = 138 per group) were matched for age and sex and assessed retrospectively and prospectively. Occurrence of malignant diseases and clinical outcome was followed up over 4 years.

RESULTS

At the time of the index event, 8 (5.8%) MI patients and 17 (12.3%) TTS patients were already diagnosed with cancer. During follow up, the rate of patients who developed cancer was significantly higher in the TTS group than in the MI group (log rank P = 0.01). Mortality was higher in the TTS group, but also in the subgroup of TTS patients with cancer (log rank P < 0.05). In the multivariate analysis, male gender, renal impairment and the history of cancer was associated with an increased risk for death.

CONCLUSIONS

Patients with TTS have more often malignant diseases than patients with MI. Cancer patients with TTS have a worse clinical outcome. The underlying mechanism is unclear yet, but the results point at TTS being the syndrome of an extracardiac disease rather than a disease of cardiac origin. Longer and closer follow up of patients with TTS and further studies addressing the mechanism of TTS are needed.

Percutaneous Closure of Left Atrial Appendage significantly affects Lipidome Metabolism

Patients with non-valvular atrial fibrillation (AF) and a high risk for oral anticoagulation can be treated by percutaneous implantation of left atrial appendage occlusion devices (LAAC) to reduce the risk of cardio-embolic stroke. This study evaluates whether LAAC may influence lipid metabolism, which has never been investigated before. Patients with successful LAAC were included consecutively. Venous peripheral blood samples of patients were collected immediately before (T0, baseline) and 6 months after (T1, mid-term) LAAC. A targeted metabolomics approach based on electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements was performed. A total of 34 lipids revealed a significant change from baseline to mid-term follow-up after successful LAAC. Subgroup analysis revealed confounding influence by gender, age, diabetes mellitus type II, body mass index, left ventricular ejection fraction, creatinine and NT-proBNP. After multivariable adjustment within logistic regression models, these 34 lipids were still significantly altered after LAAC. Successful percutaneous LAAC may affect lipid metabolism and thereby may potentially affect pro-atherogenic and cardio-toxic effects.

Risk stratification in Takotsubo syndrome: a role of mitral annular plane systolic excursion

AIM

Takotsubo syndrome (TTS) patients have a higher mortality rate than the general population. Our study was conducted to determine the short- and long-term outcome of TTS patients associated with a significantly compromised mitral annular plane systolic excursion (MAPSE) on hospital admission.

METHODS AND RESULTS

Our institutional database constituted a collective of 53 patients diagnosed with TTS between 2003 and 2016. The patients were classified into two groups based on the MAPSE, with those presenting with an MAPSE <1 cm on admission categorized into one group (n = 20, 38%) and those presenting with MAPSE ≥1 cm (n = 33, 62%) categorized into another group. Preliminary results indicated that patients with an MAPSE < 1 cm had a greater risk of developing thromboembolic events. The long-term mortality was significantly higher in TTS patients with an MAPSE < 1 cm. In the multivariate Cox regression analysis, cardiogenic shock (hazard ratio 3.5; 95% confidence interval: 1.2-10.7; P = 0.02) and MAPSE < 1 cm (hazard ratio 5.1; 95% confidence interval: 1.3-19.2; P = 0.01) figured as independent predictors of the mortality.

CONCLUSION

Although the short-term mortality rates among TTS patients diagnosed with a reduced MAPSE on admission were as similar as without reduced MAPSE, the long-term mortality rates among TTS patients diagnosed with a reduced MAPSE on admission were significantly higher. There is an urgent need for randomized trials, which could help define uniform clinical management strategies for high-risk TTS patients.