Determinants of myocardial injury following transcatheter aortic valve implantation: a pre-specified substudy from the POPular TAVI trial

Background

Myocardial injury is frequently observed in patients undergoing transcatheter aortic valve implantation (TAVI) and has been linked to worse prognosis [1,2]. Yet, knowledge concerning the underlying mechanisms and preventive strategies is scarce.

Purpose

To identify clinical determinants and the effect of periprocedural antithrombotic strategies on markers of myocardial injury after TAVI.

Methods

The POPular TAVI trial was a prospective, open label, multicentre randomized controlled trial, investigating the addition of clopidogrel to aspirin (cohort A) or oral anticoagulation (OAC) (cohort B) in patients undergoing TAVI [3] Patients randomised to clopidogrel received a 300mg loading dose before TAVI, followed by a 75mg maintenance dose once daily. In patients using OAC, this was continued during TAVI with an international normalized ratio aimed at 2.0. All OAC patients used a vitamin-K antagonist. Blood samples were taken at baseline, 6, 24, 48, and 72 hours following TAVI to determine myocardial injury using Creatine Kinase-MB (CK-MB) and high-sensitive cardiac troponin T (hs-cTnT) according to the VARC-2 criteria. Also, baseline and procedural variables were collected in detail. A linear mixed effects model was used for pair-wise analysis of the changes in enzyme levels at different time points between groups. Regression analysis was performed using the logistic regression model. Statistical analyses were performed using R (version 3.4.1).

Results

In total, 131 patients undergoing transfemoral TAVI were included at two study sites, of whom 63 (48%) received clopidogrel and 68 (52%) did not. Almost half of the patients (45%) were on OAC. The rise in CK-MB (mean peak 23.4±13.3 U/l) and hs-cTnT (mean peak of 0.23±0.33 ug/) was maximal at 6 and 24 hours, respectively. The CK-MB and hs-cTnT levels did not differ between the clopidogrel and no clopidogrel group at any time point (figure 1). Myocardial injury occurred in 18 (30.1%) patients receiving OAC versus 39 (54.2%) patients not receiving OAC (p=0.007). The course of hs-cTnT reached higher levels in patients with chronic kidney disease (p<0.001) and in patients with a preserved left ventricular ejection fraction (LVEF) (p=0.008). Also, the use of a controlled mechanical expanding prosthesis was associated with a higher rise of hs-cTnT (p=0.007). (Figure 2) In multivariable analysis, predictors of a maximal increase in hs-cTnT were a preserved LVEF (OR 1.15, 95% CI 1.02–1.30) and chronic kidney disease (OR 1.13, 95% CI 1.01–1.28). Other procedural factors, like balloon dilation and rapid ventricular pacing, were not associated with myocardial injury.

Conclusions

The addition of clopidogrel to aspirin or OAC during TAVI was not associated with a reduction in myocardial injury. Instead, OAC therapy, as compared to aspirin, was associated with a reduction in rise and fall of hs-cTnT. Also, patients with a preserved LVEF or chronic kidney disease observed higher levels of hs-cTnT.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMWSt. Antonius Research Fund

We mind your step: understanding and preventing drop-out in the transfer from paediatric to adult tertiary endocrine healthcare

Introduction

Transition from paediatric to adult endocrinology can be challenging for adolescents, their families and healthcare professionals. Previous studies have shown that up to 25% of young adults with endocrine disorders are lost to follow-up after moving out of paediatric care. This poses a health risk for young adults, which can lead to serious and expensive medical acute and long-term complications.

Methods

In order to understand and prevent dropout, we studied electronic medical records of patients with endocrine disorders. These patients were over 15 years old when they attended the paediatric endocrine outpatient clinic (OPC) of our hospital in 2013-2014 and should have made the transfer to adult care at the time of the study.

Results

Of 387 adolescents, 131 had an indication for adult follow-up within our university hospital. Thirty-three (25%) were lost to follow-up. In 24 of them (73%), the invitation for the adult OPC had never been sent. We describe the failures in logistic processes that eventually led to dropout in these patients.

Conclusion

We found a 25% dropout during transfer from paediatric to adult tertiary endocrine care. Of all dropouts, 73% could be attributed to the failure of logistic steps. In order to prevent these dropouts, we provide practical recommendations for patients and paediatric and adult endocrinologists.

Cardiac CT derived 3D reconstruction discriminates for complexity and hemodynamic effect of transcatheter mitral valve repair

Background

Transcatheter mitral valve repair (TMVR) is increasingly used to treat mitral regurgitation (MR) in high risk patients. Optimal transseptal access and guiding catheter position are essential to perform adequate repair. Anatomy of the inter-atrial septum (IAS) and mitral annulus (MA) are often complex and difficult to determine from echocardiography.

Purpose

The aim of the current study was to evaluate whether pre-TMVR cardiac CT and 3D reconstruction of the IAS and MA could discriminate for complexity and hemodynamic effect of TMVR.

Methods

Patients planned for TMVR, underwent cardiac CT scan (if eligible). Post-processing software was used to segment and reconstruct the aortic root, IAS, fossa ovalis (FO) and MA, resulting in a 3D model. The following parameters were measured in each model: (1) IAS angle (°) (2) Posterior-FO angle (°) (3) FO-perpendicularity angle (°) (4) MA area (cm2). Patient specific anatomy was categorized in 4 groups as either (1) Posterior-perpendicular (PP) FO + limited IAS angle, (2) PP FO + wide IAS angle, (3) non-PP FO + limited IAS angle or (4) non-PP FO + wide IAS angle. PP FO was defined as posterior-FO angle >65° and FO-perpendicularity angle >135°. IAS angle was considered limited if <110°. Device implantation time (min) was used to assess complexity of the procedure and was compared between the different groups. MR reduction (grades), number of clips used and mitral valve (MV) gradient (mmHg) were compared for patients with MA area <14 cm2 vs. ≥14 cm2.

Results

46 patients (mean age 75 years, 41% male) were included. Anatomy was classified (1) PP FO + limited IAS angle in 13, (2) PP FO + wide IAS angle in 13, (3) Non-PP FO + limited IAS angle in 8 and (4) Non-PP FO + wide IAS angle in 12. Median device implantation time was 20 min in group 1, compared to 39 min in group 2 (p=0.02), 33 min in group 3 (p=0.03) and 29 min in group 4 (p=0.08). In patients with MA area <14 cm2, MR reduction was greater (2.22 vs. 1.68, p=0.02), number of clips used was lower (1.44 vs. 1.79, p=0.05) and MV gradient was higher, though not significant (3.15 vs. 2.58, p=0.26)

Conclusion

The current study showed that TMVR seemed less complex in patients with an optimal anatomy. In patients with limited mitral annulus area a more favorable hemodynamic effect was achieved. Cardiac CT and 3D reconstruction could therefore be of strong aid for procedural planning of TMVR.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Abbott Vascular Anatomy and device implantation timeHemodynamic effect of annulus area

Transcatheter tricuspid valve repair: early experience in the Netherlands

Background

Symptomatic tricuspid regurgitation (TR) is increasingly prevalent and impairs quality of life and survival, despite medical treatment. Transcatheter tricuspid valve repair (TTVR) has recently become available as a treatment option for patients not eligible for tricuspid valve surgery. In this study we describe the early experience with TTVR in the Netherlands.

Methods

All consecutive patients scheduled for TTVR in two tertiary hospitals were included in the current study. Patients were symptomatic and had severe functional TR. TTVR was performed either with the MitraClip (off-label use) or dedicated TriClip delivery system and device. Procedural success was defined as achievement of clip implantation, TR reduction ≥ 1 grade and no need for re-do surgical or transcatheter intervention. Clinical improvement was evaluated after 4 weeks.

Results

Twenty-one patients (median age 78 years, 33% male, 95% New York Heart Association class ≥ 3, 100% history of atrial fibrillation) underwent TTVR. Procedural success was achieved in 16 patients, of whom 15 reported symptomatic improvement (New York Heart Association class 1 or 2). There was no in-hospital mortality and no major complications occurred. Baseline glomerular filtration rate and TR coaptation gap size were associated with procedural success.

Conclusion

The current study showed that TTVR seems a promising treatment option for patients with severe functional TR deemed high risk for surgery. Successful TR reduction is most likely in patients with limited coaptation gap size and strongly determines clinical benefit. Adequate patient selection and timing of treatment seem essential for an optimal patient outcome.

Supplementary Information

The online version of this article (10.1007/s12471-021-01613-3) contains supplementary material, which is available to authorized users.

A novel image fusion technique to improve transseptal puncture during percutaneous mitral valve repair

Background

Percutaneous mitral valve repair (PMVR) using the MitraClip (Abbott Vascular), has gained popularity to treat mitral regurgitation (MR) in high risk patients. Accurate transseptal puncture (TSP) is a crucial step to achieve optimal guiding catheter position during the procedure.

Purpose

The aim of this study was to determine whether a planned optimal TSP site, using a novel computed tomography (CT) and echo image fusion methodology, corresponded with the actual TSP site, and if this was related to procedure time and outcome.

Methods

The mitral annulus and inter atrial septum were segmented in 26 patients (mean age 75 years, 50% female) undergoing PMVR. The optimal transseptal puncture (TSP) site was based on (1) perpendicular distance of 35–45mm from the TSP site to the mitral annulus, and (2) posterior position relative to the aorta. Optimal TSP was planned using a cardiac CT scan and 3Mensio software (Pie Medical imaging). The CT scan was exported to a Vivid E95 ultrasound system (GE Healthcare). After alignment with the three-dimensional echo image, the coordinates of the actual TSP site were determined. The distance between the optimal and actual TSP site was measured as (1) difference in height above the mitral annulus, and (2) absolute distance to the actual TSP site. Comparisons were made on procedure time, which was measured from the TSP to the achievement of optimal MitraClip position.

Results

The distance between the optimal and actual TSP site showed to be more than 5mm in 85% of the cases. The mean difference in height above the mitral annulus was 6.9mm. The mean procedure time was 21% longer when the absolute distance was more than 10mm. However, this did not reach statistical significance yet (p=0.4), likely due to small sample size.

Conclusion

CT-echo image fusion is an applicable method to plan TSP. This ongoing study suggests that image fusion based guiding may improve TSP site, reduce PMVR procedure time and potentially lead to more effective reduction of MR.

Bar chart of optimal and actual TSP site

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Abbott

Favorable course of tricuspid regurgitation after percutaneous mitral valve repair is associated with improved survival and clinical outcome

Background

Tricuspid Regurgitation (TR) is often present in patients with mitral regurgitation (MR) and is associated with increased mortality and morbidity after percutaneous mitral valve repair (PMVR) using the MitraClip (Abbott Vascular). It is unclear to what extent TR is reduced after PMVR and whether the reduction of TR is related to survival and functional outcome.

Purpose

The aim of this study was to determine (1) the TR course after PMVR and (2) if this was related to survival and clinical outcome.

Methods

Patients who underwent PMVR and had complete echocardiographic data at baseline and follow-up were included. TR severity was graded as none, mild, moderate or severe (according to current guidelines) and was determined before treatment and at 6-months of follow up. Favorable TR course was defined as improvement of ≥1 grade or ≤ mild TR at 6-months. Clinical endpoints were all-cause mortality during 1-year of follow-up and improvement in New York Heart Association (NYHA) functional class after 6 months.

Results

A total of 67 patients were included (mean age 76 years, 57% male, 81% NYHA class ≥3 and 69% baseline TR ≥ moderate). Favorable TR course was achieved in 31 patients (46%) (figure 1A). All-cause mortality at 1 year was 7.5%, and was lower in the favorable TR course group (0% vs. 13.9%, p=0.057) (figure 1B). Improvement in NYHA class at 6-months was seen in 45% of patients without vs. 81% of patients with favorable TR course (p=0.01) (figure 1C).

Conclusion

A favorable TR course is achieved in 46% of PMVR patients and is associated with improved survival and improvement of NYHA class. The relatively high rate of an unfavorable TR course at 6-months, indicates that interventional treatment of the tricuspid valve might benefit these patients.

TR course (A) and NYHA improvement (B)

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Abbott

Diabetes mellitus in transfemoral transcatheter aortic valve implantation in 11,440 patients from the CENTER collaboration

Background

Diabetes mellitus (DM) is a well-known cardiovascular risk factor present in up to a third of patients undergoing transcatheter aortic valve implantation (TAVI). How DM might influence outcomes after TAVI procedures remains controversial. The aim of this study was to determine differences in outcomes after TAVI according to diabetes status.

Methods

The CENTER (Cerebrovascular EveNts in patients undergoing TranscathetER aortic valve implantation with balloon-expandable valves versus self-expandable valves)-collaboration was a global patient level dataset of patients undergoing transfemoral TAVI from 2007 to 2018. In this analysis, the study examined differences in baseline patient characteristics, 30-day stroke and mortality, and in-hospital outcomes between DM and non-DM patients.

Results

Of the 11,440 patients included, 31% (n=3,550) were diabetic and 69% (n=7,890) were non-diabetic. Diabetics were younger, had a higher body mass index (BMI) and overall a worse cardiovascular risk profile than non-diabetics. There were no differences between DM and non-DM patients regarding in-hospital mortality (4.8% vs 5.3%, RR: 0.9, 95% CI: 0.7–1.1, p=0.46), myocardial infarction (0.9% vs 0.7%, RR: 1.4, 95% CI: 0.9–2.2, p=0.17), stroke (1.7% vs 2.0%, RR: 0.9, 95% CI: 0.6–1.2, p=0.36), major or life threatening bleeding (5.9% vs 6.3%, RR: 0.9, 95% CI: 0.8–1.1, p=0.44) and permanent pacemaker implantation (13.6% vs 13.4%, RR: 1.0, 95% CI: 0.9–1.1, p=0.69). Similarly, 30-day rates of all-cause mortality (5.4% vs 6.1%, RR: 0.9, 95% CI: 0.8–1.1, p=0.30) and stroke (2.0% vs 2.4%, RR: 0.8, 95% CI: 0.6–1.1, p=0.23) did not differ between diabetic and non-diabetic patients. Accordingly, in multivariate analysis, DM was not an independent predictor of mortality.

Conclusions

In this global collaboration, diabetic patients undergoing transcatheter aortic valve replacement had more cardiovascular comorbidities, were younger and had a higher body mass index than non-diabetics. They had similar periprocedural complications, in-hospital and 30-day mortality rates. In multivariate analysis, diabetes was not associated with increased mortality.

Predicted vs observed mortality in DM

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Dutch Heart Foundation; the Netherlands Organisation for Health Research and Development

The history of transcatheter aortic valve implantation: The role and contribution of an early believer and adopter, the Netherlands

This paper describes the history of transcatheter aortic valve implantation (TAVI) from its preclinical phase during which visionary pioneers developed its concept and prototype valves against strong head wind to first application in clinical practice (2002) and the clinical and scientific role of an early believer and adopter, the Netherlands (2005).

Ongoing transcatheter aortic valve implantation (TAVI) practice amidst a global COVID-19 crisis: nurse-led analgesia for transfemoral TAVI

The current coronavirus disease 2019 (COVID-19) crisis has led to a relative unavailability of anaesthesiological support for non-acute cardiac care. Currently, transfemoral transcatheter aortic valve implantation (TF-TAVI) is predominantly performed as an elective catheterisation laboratory (cath lab) procedure. Hence, the performance of TAVI could come to a halt amidst the COVID-19 crisis. Our study population comprised 90 patients treated with TF-TAVI, with local analgesia performed by our dedicated cath lab nurses. The patients had a mean age of 80 ± 5 years and 59% were male, with a predicted surgical risk of 2.2 ± 0.9/3.1 ± 2.4% (Society of Thoracic Surgeons Predicted Risk of Mortality [STS-PROM] score/EuroSCORE II), depicting a contemporary, lower-risk population. The composite endpoint of device success (Valve Academic Research Consortium [VARC]-2) was reached in all patients. No patients showed more than mild paravalvular leakage (3/90, 3.3%). Overall, intravenous medication was sparsely used during the procedure, with 48 of the 90 (53%) patients receiving no unplanned intravenous medication. There was neither procedural nor in-hospital mortality. The performance of TF-TAVI using local analgesia only, managed by a dedicated nurse instead of an anaesthesiologist, was shown to be feasible and safe in a selected group of patients. This strategy may (temporarily) eliminate the need for an anaesthesiologist to be present in the cath lab and enables ongoing TAVI treatment amidst the global COVID-19 crisis.

MON-284 Systematic Screening Reveals Large Number of Undiagnosed and Untreated Cardiovascular Risk Factors in Adults with Prader-Willi Syndrome

Introduction: Prader-Willi syndrome (PWS) is a complex hypothalamic disorder, combining hypotonia, intellectual disability (ID), pituitary hormone deficiencies and hyperphagia. In PWS, up to 3% of patients die every year. In half of the patients, the cause of death is obesity related and / or of cardiovascular (CV) origin.

Obesity is caused by hyperphagia combined with a low energy expenditure. Untreated hormone deficiencies like hypogonadism and hypothyroidism can cause low muscle mass and low basal rest metabolism (BRM) leading to this low energy expenditure. Patients with PWS should exercise one hour daily to compensate for their low BRM. However, hormone deficiencies usually cause fatigue, leading to exercise intolerance. Musculoskeletal and / or behavioral problems can also cause reduced physical activity. The subsequent sedentary lifestyle can induce CV risk factors like hypertension, hypercholesterolemia and diabetes mellitus (DM).

Another risk factor often present in PWS is sleep apnea, which can be central (CSA), obstructive (OSA) or both. Both CSA and OSA can lead to pulmonary hypertension and a further increase in obesity.

The above mentioned health problems often remain unnoticed and untreated, which is partly due to the behavioral phenotype of PWS (patients seldomly report pain and hardly ever complain about physical problems). However, if left untreated, these risk factors can cause CV complications leading to hospital admission or even death. To reveal yet undiagnosed health problems, we performed a systematic health screening among adults with PWS.

Methods: We systematically screened 115 adults with PWS (mean age 31.4 ± 12.1 y, mean BMI 31.8 ± 9,5 kg/m2) for the presence of undiagnosed health problems and cardiovascular risk factors. Based on a medical questionnaire, medical file search, extensive interview, thorough physical examination and biochemical measurements we made an overview of the undiagnosed health problems in adults with PWS. If possible, we performed polygraphy to test for sleep apnea.

Results: Undiagnosed health problems (hypertension, DM, hypercholesterolemia, sleep apnea, hypothyroidism and hypogonadism) were present in 50% of the patients. 10% had multiple undiagnosed health problems simultaneously. All males and 94% of females had hypogonadism and 15% had hypothyroidism. Hypertension and / or hypercholesterolemia were present in 20% and DM was present in 16%. One third of patients was not on a diet and 22% exercised less than 30 minutes a day. Sleep apnea was present in 17 of 26 patients tested.

Conclusion: We detected a striking number of undiagnosed health problems among adults with PWS which, if left untreated, can pose a serious health threat. Systematic screening is needed to detect these problems in an early phase. This will prevent burdensome and expensive complications and might even reduce mortality in this vulnerable patient population.

SUN-080 We Mind Your Step: Understanding and Preventing Drop-Out in the Transition from Paediatric to Adult Tertiary Endocrine Healthcare

Introduction Transition from paediatric to adult endocrinology is a challenge for adolescents, their families and their healthcare professionals. Previous studies show that up to 25% of young adults with endocrine disorders are lost to follow-up once they move out of paediatric care. This poses a health risk for young adults, as lack of medical treatment and surveillance can have both psycho-social and physical consequences. Apart from absenteeism from school or work, this can lead to serious and expensive medical complications like Addison crisis.

Methods In 2019 we studied electronic medical records of 387 patients who were over 15 years old when they attended the paediatric endocrine outpatient clinic (OPC) of our medical centre in 2013-2014. We collected data from medical charts, the hospital digital agenda and medical correspondence.

Results Of 387 adolescents, 161 (42%) did not need adult endocrine follow-up because paediatric endocrine care was only puberty- or growth-related. Forty-six patients did not enter regular transition because they 1) participated in a pilot to improve transition (N=10), 2) had intellectual disability (ID) and transferred to ID care (N=28), or 3) died (N=8, mostly cancer-related). Hundred-and-eighty patients entered regular transition: 49 (27%) to a regional hospital and 131 (73%) within our university hospital.

Of these 131 patients, 33 (25%) were lost to follow up; in 24 of them (73%), the invitation for the adult OPC had never been sent. Loss to follow up occurred when three subsequent critical steps failed: 1) the adult endocrinologist had not received or read the paediatrician’s referral letter and/or had not invited the patient; 2) the paediatrician had not checked whether the appointment was really made and received by the patient and 3) the patients and/or caregivers had not alarmed the hospital when no invitation for an appointment was received.

Conclusion We found a 25% dropout during transfer from paediatric to adult tertiary endocrine care. Starting the transition process early and in a structured manner, as well as assigning a transition coordinator, can prevent part of the dropouts. However, 73% of all dropouts appeared to be attributable to failure of practical, logistic steps. In order to prevent this part of the dropouts, we provide practical recommendations for all three parties involved:

1) the adult endocrinologist should carefully read paediatricians’ letters and check whether action is required (i.e. check whether an appointment is requested)

2) the paediatrician should ascertain whether the appointment is really made and received by the patient

3) the patients and/or caregivers should be instructed to alarm the hospital when they do not receive the appointment.

These actions require relatively little effort and may prevent the part of drop-outs that is caused by logistic failures.

Early mobilisation after transfemoral transcatheter aortic valve implantation: results of the MobiTAVI trial

Background

Immobilisation of patients after transfemoral transcatheter aortic valve implantation (TF-TAVI) is the standard of care, mostly to prevent vascular complications. However, immobilisation may increase post-operative complications such as delirium and infections. In this trial, we determine whether it is feasible and safe to implement early ambulation after TF-TAVI.

Methods

We prospectively included TF-TAVI patients from 2016 to 2018. Patients were assessed for eligibility using our strict safety protocol and were allocated (based on the time at which the procedure ended) to the EARLY or REGULAR group.

Results

A total of 150 patients (49%) were deemed eligible for early mobilisation, of which 73 were allocated to the EARLY group and 77 to the REGULAR group. The overall population had a mean age of 80 years, 48% were male with a Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score of 3.8 ± 1.8. Time to mobilisation was 4 h 49 min ± 31 min in the EARLY group versus 20 h 7 min ± 3 h 6 min in the REGULAR group (p < 0.0001). There were no differences regarding the primary endpoint. No major vascular complications occurred and a similar incidence of minor vascular complications was seen in both groups (4/73 [5.5%] vs 6/77 [7.8%], p = 0.570). The incidence of the combined secondary endpoint was lower in the EARLY group (p = 0.034), with a numerically lower incidence for all individual outcomes (delirium, infections, pain and unplanned urinary catheter use).

Conclusion

Early mobilisation (ambulation 4–6 h post-procedure) of TF-TAVI patients is feasible and safe. Early ambulation decreases the combined incidence of delirium, infections, pain and unplanned urinary catheter use, and its adoption into contemporary TAVI practice may therefore be beneficial.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01374-5) contains supplementary material, which is available to authorized users.

Treatment decision for transcatheter aortic valve implantation: the role of the heart team : Position statement paper of the Dutch Working Group of Transcatheter Heart Interventions

The current paper presents a position statement of the Dutch Working Group of Transcatheter Heart Valve Interventions that describes which patients with aortic stenosis should be considered for transcatheter aortic valve implantation and how this treatment proposal/decision should be made. Given the complexity of the disease and the assessment of its severity, in particular in combination with the continuous emergence of new clinical insights and evidence from physiological and randomised clinical studies plus the introduction of novel innovative treatment modalities, the gatekeeper of the treatment proposal/decision and, thus, of qualification for cost reimbursement is the heart team, which consists of dedicated professionals working in specialised centres.

The Absorb bioresorbable vascular scaffold in real-world practice: long-term follow-up of the AMC Single Centre Real World PCI Registry

BACKGROUND

Bioresorbable scaffolds have been introduced to overcome the shortcomings of drug-eluting stents. Higher rates of device thrombosis, however, have been reported up to 3 years after implantation of the Absorb bioresorbable vascular scaffold (BVS). In the current article, we therefore report long-term clinical outcomes of the AMC Absorb Registry.

METHODS AND RESULTS

In the AMC Absorb Registry, all patients who underwent a percutaneous coronary intervention with Absorb BVS implantation between 30 August 2012 and 5 August 2013 at the Amsterdam University Medical Centre-Academic Medical Centre were included. The composite endpoint of this analysis was target-vessel failure (TVF). The median follow-up of the study cohort of the AMC Absorb Registry was 1534 days. At the time of the cross-sectional data sweep the clinical status at 4 years was known in 124 of 135 patients (91.9%). At long-term follow-up, the composite endpoint of TVF had occurred in 27 patients. The 4‑year Kaplan-Meier estimate of TVF was 19.8%. At 4 years cardiac death had occurred in 4 patients (3.2%) and target-vessel myocardial infarction in 9 (6.9%) patients. Definite scaffold thrombosis occurred in 5 (3.8%) patients. We found 1 case of very late scaffold thrombosis that occurred at 911 days after device implantation in a patient who was not on dual anti-platelet therapy.

CONCLUSION

In a patient population reflecting routine clinical practice, we found that cases of TVF continued to accrue beyond 2 years after Absorb BVS implantation.

P1849Predictors of high radiation exposure in patients undergoing contemporary transfemoral transcatheter aortic valve implantation (TF-TAVI)

Background

Transfemoral transcatheter aortic valve implantation (TF-TAVI) is a minimally invasive and life-saving treatment option in patients with severe aortic valve stenosis. The number of TAVI procedures has rapidly expanded over the past decade and will continue to expand, as will the total occupational radiation exposure for the interventional cardiologist. Therefore, interventional cardiologist are at increasing risk for developing radiation induced diseases like cataract, premature vascular aging and left-sided brain tumors.

Objectives

In the current study we determined pre-procedural characteristics associated with high radiation exposure during transfemoral TAVI to raise awareness and increase the use of adequate radiation protection.

Methods

Radiation exposure (patient exposure in DAP in mGy·cm2) was collected during (TF)-TAVI procedures (July 2014- August 2018). Univariate and multiple regression analyses were performed to identify pre-procedural factors associated with high radiation exposure.

Results

A total of 654 TF-TAVI procedures were included. Patients had a median STS-score of 4% and 47% was male. The median radiation exposure was 38,016 mGy·cm2 (24,451–55,747) and the median fluoroscopy time was 16 minutes (IQR: 11–19). During the four year study period, the mean radiation exposure per TAVI procedure decreased with 30%, while the total fluoroscopy time declined with 28%.

The majority of the population underwent the TAVI procedure under local anesthesia (99%) and were implanted with the Edwards SAPIEN 3 valve (92%). Balloon predilatation was used during 88% and balloon post-dilatation was performed in only 5% of the procedures.

Patient characteristics associated with high radiation exposure included BMI >25 (OR: 6.0, 95% CI: 3.9–9.4, p<0.001), male gender (OR: 2.8, 95% CI: 1.8–4.4, p<0.001), a large pre-procedural CT-measured valve area (>450 mm2) (OR: 1.8, 95% CI: 1.1–2.8, p=0.01), presence of a pacemaker or ICD (OR: 2.0, 95% CI: 1.0–3.9, p=0.04) and a history of atrial fibrillation (OR: 1.5, 95% CI: 1.0–2.3, p=0.04). Moreover, the performance of predilatation (OR: 2.7, 95% CI: 1.5–4.8, p=0.001) and valve-in-valve procedures (OR: 3.3, 95% CI: 1.1–10.2, p=0.04) was associated to high radiation exposure.

Predictors of radiation exposure

Conclusions

The performance of transfemoral TAVI in patients with a large stature (male, BMI >25, valve area >450 mm2), in certain groups of fragile patients (presence of pacemaker or ICD, atrial fibrillation), and performing relatively complex procedures (predilatation and valve-in-valve) was associated with high radiation exposure. These patient characteristics and procedural strategies are known before the patient enters the catheterization laboratory. Hence, in the current era of a rapidly expanding number of TAVI procedures, operators should minimize their own health risk in these high-radiation-exposure-risk TAVI procedures.

Acknowledgement/Funding

None

Value of machine learning in predicting TAVI outcomes

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become a commonly applied procedure for high-risk aortic valve stenosis patients. However, for some patients, this procedure does not result in the expected benefits. Previous studies indicated that it is difficult to predict the beneficial effects for specific patients. We aim to study the accuracy of various traditional machine learning (ML) algorithms in the prediction of TAVI outcomes.

METHODS AND RESULTS

Clinical and laboratory data from 1,478 TAVI patients from a single centre were collected. The outcome measures were improvement of dyspnoea and mortality. Three experiments were performed using (1) screening data, (2) laboratory data, and (3) the combination of both. Five well-established ML techniques were implemented, and the models were evaluated based on the area under the curve (AUC). Random forest classifier achieved the highest AUC (0.70) for predicting mortality. Logistic regression had the highest AUC (0.56) in predicting improvement of dyspnoea.

CONCLUSIONS

In our single-centre TAVI population, the tree-based models were slightly more accurate than others in predicting mortality. However, ML models performed poorly in predicting improvement of dyspnoea.

Can stress echocardiography identify patients who will benefit from percutaneous mitral valve repair?

The aim of the current study was to investigate whether stress echocardiography improves selection of patients who might have clinical benefit from percutaneous mitral valve repair with the MitraClip. In total, 39 patients selected for MitraClip implantation underwent preprocedural low-dose stress (dobutamine or handgrip) echocardiography from which stroke volume, ejection fraction and MR grade were measured. Outcome after MitraClip implantation was determined by New York Heart Association classification and Quality of Life questionnaires. Clinical benefit from MitraClip treatment was defined as survival and NYHA class I–II at 6 months follow-up. In total, 36 patients with a technically successful procedure were included in the analysis (mean age 79 ± 8 years, 47% male, 50% functional MR). Clinical benefit was achieved in 18 patients. All seven patients with MR decreasing during stress remained in NYHA III–IV or died within 6 months, while 62% (18 out of 29) of the patients with stable or increased MR during stress had clinical benefit (p = 0.008). Significant increase in Quality of Life on 4/8 subscales of the RAND Short Form-36 questionnaire was observed: Physical Functioning (p < 0.001), Social Functioning (p < 0.001), Mental Health (p = 0.022) and Vitality (p = 0.026) was seen in patients with an increase in stroke volume during stress echocardiography. Patients with a decreased MR during preprocedural stress echocardiography remained more symptomatic than patients with a stable or increased MR during stress. Stress echocardiography may support patient selection for percutaneous mitral valve repair.

CTCA for detection of significant coronary artery disease in routine TAVI work-up : A systematic review and meta-analysis

Transcatheter aortic valve implantation (TAVI) has evolved to standard treatment of severe aortic stenosis in patients with an intermediate to high surgical risk. Computed tomography coronary angiography (CTCA) could partially replace invasive coronary angiography to diagnose significant coronary artery disease in the work-up for TAVI. A literature search was performed in MEDLINE and EMBASE for papers comparing CTCA and coronary angiography in TAVI candidates. The primary endpoint was the diagnostic accuracy of CTCA, compared to coronary angiography, for detection of significant (>50% diameter stenosis) coronary artery disease, measured as sensitivity, specificity, positive—(PPV) and negative predictive value (NPV). Seven studies were included, with a cumulative sample size of 1,275 patients. The patient-based pooled sensitivity, specificity, PPV and NPV were 95, 65, 71 and 94% respectively. Quality assessment revealed excellent and good quality in terms of applicability and risk of bias respectively, with the main concern being patient selection. In conclusion, on the basis of a significance cut-off value of 50% diameter stenosis, CTCA provides acceptable diagnostic accuracy for the exclusion of coronary artery disease in patients referred for TAVI. Using the routinely performed preoperative computed tomography scans as a gatekeeper for coronary angiography could decrease additional coronary angiographies by 37% in this high-risk and fragile population.

Short versus conventional hydration for prevention of kidney injury during pre-TAVI computed tomography angiography

BACKGROUND

Computed tomography angiography (CTA) is required in the work-up for transcatheter aortic valve implantation (TAVI). However, CTA may cause contrast-induced acute kidney injury (CI-AKI). We hypothesised that a short (1 h, 3 ml/kg/h sodium bicarbonate) hydration protocol is not inferior to conventional (24 h, 1 ml/kg/h saline) hydration in avoiding a decline in renal function in patients with impaired renal function.

METHODS AND RESULTS

Single-centre randomised non-inferiority trial in patients with impaired renal function who underwent pre-TAVI CTA. Patients were randomised on a 1:1 ratio to short hydration (SHORT; 1 h sodium bicarbonate, 3 ml/kg/h) or conventional hydration (CONV; 24 h saline, 1 ml/kg/h). Outcomes included percentage change in serum creatinine until 2-6 days after CTA with a non-inferiority margin of 10% and an increase on the Borg dyspnoea scale ≥1 point. Seventy-four patients were included. Increase in creatinine was 6 µmol/l (95% CI 2.5-9.3) in the SHORT versus 2 µmol/l (95% CI-1.4 to 6.3) in the CONV arm (p = 0.167). The percentage change was 4.6% (95% CI 2.0-7.3%) in the SHORT arm versus 2.5% (95% CI: 0.8 to 5.8%) in the CONV arm. The difference in percentage increase in creatinine between the two arms was 2.1% (95% CI: 2.0-6.2%; p-value non-inferiority: <0.001). CI-AKI and a need for dialysis were not observed. An increase of ≥1 point on the Borg scale (dyspnoea scale ranging from 1 (lowest) to 10 (highest)) was seen in 1 patient in the SHORT arm versus 5 patients in the CONV arm (2.9% vs 16.1%, p = 0.091).

CONCLUSION

For patients with impaired renal function undergoing pre-TAVI CTA, a short 1‑h, low-volume hydration protocol with sodium bicarbonate is not inferior to conventional 24-h, high-volume saline hydration.

Transcatheter aortic valve replacement alters ascending aortic blood flow and wall shear stress patterns: A 4D flow MRI comparison with age-matched, elderly controls

BACKGROUND

With the implementation of transcatheter aortic valve replacement (TAVR) in lower-risk patients, evaluation of blood flow characteristics and the effect of TAVR on aortic dilatation becomes of considerable interest. We employed 4D flow MRI in the ascending aorta of patients after TAVR to assess wall shear stress (WSS) and compare blood flow patterns with surgical aortic valve replacement (SAVR) and age- and gender-matched controls.

METHODS

Fourteen post-TAVR patients and ten age- and gender-matched controls underwent kt-PCA accelerated 4D flow MRI of the thoracic aorta at 3.0 Tesla. Velocity and wall shear stress was compared between the two groups. In addition, aortic flow eccentricity and displacement was assessed and compared between TAVR patients, controls and 14 SAVR patients recruited as part of an earlier study.

RESULTS

Compared to controls, abnormally elevated WSS was present in 30±10% of the ascending aortic wall in TAVR patients. Increased WSS was present along the posterior mid-ascending aorta and the anterior distal-ascending aorta in all TAVR patients. TAVR results in eccentric and displaced flow in the mid- and distal-ascending aorta, whereas blood flow displacement in SAVR patients occurs only in the distal-ascending aorta.

CONCLUSION

This study shows that TAVR results in increased blood flow velocity and WSS in the ascending aorta compared to age- and gender-matched elderly controls. This finding warrants longitudinal assessment of aortic dilatation after TAVR in the era of potential TAVR in lower-risk patients. Additionally, TAVR results in altered blood flow eccentricity and displacement in the mid- and distal-ascending aorta, whereas SAVR only results in altered blood flow eccentricity and displacement in the distal-ascending aorta.

KEY POINTS

• TAVR results in increased blood flow velocity and WSS in the ascending aorta. • Longitudinal assessment of aortic dilatation after TAVR is warranted in the era of potential TAVR in lower-risk patients. • Both TAVR and SAVR result in altered blood flow patterns in the ascending aorta when compared to age-matched controls.

Trends in patient characteristics and clinical outcome over 8 years of transcatheter aortic valve implantation

Aim

In the evolving field of transcatheter aortic valve implantations (TAVI) we aimed to gain insight into trends in patient and procedural characteristics as well as clinical outcome over an 8‑year period in a real-world TAVI population.

Methods

We performed a single-centre retrospective analysis of 1,011 consecutive patients in a prospectively acquired database. We divided the cohort into tertiles of 337 patients; first interval: January 2009–March 2013, second interval: March 2013–March 2015, third interval: March 2015–October 2016.

Results

Over time, a clear shift in patient selection was noticeable towards lower surgical risks including Society of Thoracic Surgeons predicted risk of mortality score and comorbidity. The frequency of transfemoral TAVI increased (from 66.5 to 77.4%, p = 0.0015). Device success improved (from 62.0 to 91.5%, p < 0.0001) as did the frequency of symptomatic relief (≥1 New York Heart Association class difference) (from 73.8 to 87.1%, p = 0.00025). Complication rates decreased, including in-hospital stroke (from 5.0 to 2.1%, p = 0.033) and pacemaker implantations (from 10.1 to 5.9%, p = 0.033). Thirty-day mortality decreased (from 11.0 to 2.4%, p < 0.0001); after adjustment for patient characteristics, a mortality-risk reduction of 72% was observed (adjusted hazard ratio [HR]: 0.28, 95% confidence interval [CI]: 0.13–0.62). One-year mortality rates decreased (from 23.4 to 11.4%), but this was no longer significant after a landmark point was set at 30 days (mortality from 31 days until 1 year) (adjusted HR: 0.69, 95% CI: 0.41–1.16, p = 0.16).

Conclusion

A clear shift towards a lower-risk TAVI population and improved clinical outcome was observed over an 8‑year period. Survival after TAVI improved impressively, mainly as a consequence of decreased 30-day mortality.

Electronic supplementary material

The online version of this article (10.1007/s12471-018-1129-x) contains supplementary material, which is available to authorized users.

Genetic analysis of IRF6, a gene involved in craniofacial midline formation, in relation to pituitary and facial morphology of patients with idiopathic growth hormone deficiency

INTRODUCTION

Growth hormone is secreted by the pituitary gland, which forms part of the craniofacial midline. IRF6 encodes a transcription factor involved in the development of the craniofacial midline and mutations in IRF6 are known to disturb craniofacial development. Craniofacial and pituitary development are closely related. After whole exome sequencing revealed a new mutation in IRF6 in a family with Idiopathic Growth Hormone Deficiency (IGHD), we screened the remainder of our IGHD cohort for mutations in this gene and related their genotypes to pituitary and craniofacial morphology.

MATERIALS AND METHODS

We sequenced all coding exons and exon-intron boundaries of IRF6 in 81 patients with IGHD. We performed a multiplex ligation-dependent probe amplification (MLPA) in order to exclude copy number variations in IRF6. We analyzed facial measurements taken from standardized digital pictures of 48 patients.

RESULTS

We found two new variants and eleven polymorphisms. Apart from the new mutation found in the index family (p.Arg233Cys), we found one other new heterozygous missense mutation in IRF6 (Pro456Ser). p.Arg233Cys was reported as extremely rare in exome databases (1 allele out of 120.852 alleles sequenced), strictly conserved among species and was predicted deleterious by all variant predictor programs. Pro456Ser was predicted to be benign. MLPA did not reveal any exon deletions or duplications in any of the patients.

CONCLUSION

This is the first report of IRF6 analysis in an IGHD cohort. We found one new mutation which, based on in silico analysis, could be of functional relevance. However, we did not find any mutations in the other patients. Therefore, we conclude that IRF6 defects are rare in IGHD patients and further research should focus on new candidate genes.

Antithrombotic therapy in patients undergoing TAVI: an overview of Dutch hospitals

Purpose

To assess current antithrombotic treatment strategies in the Netherlands in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods

For every Dutch hospital performing TAVI (n = 14) an interventional cardiologist experienced in performing TAVI was interviewed concerning heparin, aspirin, thienopyridine and oral anticoagulation treatment in patients undergoing TAVI.

Results

The response rate was 100 %. In every centre, a protocol for antithrombotic treatment after TAVI was available. Aspirin was prescribed in all centres, concomitant clopidogrel was prescribed 13 of the 14 centres. Duration of concomitant clopidogrel was 3 months in over two-thirds of cases. In 2 centres, duration of concomitant clopidogrel was based upon type of prosthesis: 6 months versus 3 months for supra-annular and intra-annular prostheses, respectively.

Conclusions

Leaning on a small basis of evidence and recommendations, the antithrombotic policy for patients undergoing TAVI is highly variable in the Netherlands. As a standardised regimen might further reduce haemorrhagic complications, large randomised clinical trials may help to establish the most appropriate approach.

Electronic supplementary material

The online version of this article (doi:10.1007/s12471-013-0496-6) contains supplementary material, which is available to authorized users.

Imaging for approach selection of TAVI: assessment of the aorto-iliac tract diameter by computed tomography-angiography versus projection angiography

The choice of preferred access route for transcatheter aortic valve implantation (TAVI) is mainly guided by the minimal aorto-femoral tract diameter. Currently, projection angiography (XA) and CT-angiography (CTA) are used interchangeably to assess this diameter in the TAVI work-up. We aimed to assess the agreement of XA and CTA diameter measurements in TAVI candidates. Diameters of 700 aorta-iliac segments of 102 TAVI candidates were analyzed on both XA and CTA. The diameters on XA were measured manually, for the CTA-based analysis semi-automated segmentation software was used. Paired sample T test was used to evaluate differences in diameter measurements between the modalities. Disagreement on the suitability for a transfemoral (TF)-TAVI approach was identified. The interobserver agreement for both measurements was assessed by calculating the intraclass correlation coefficient (ICC). The average diameters were 10.1 ± 1.8 mm and 8.4 ± 1.7 for XA and CTA respectively. The mean paired difference was 1.73 mm (p < 0.001). For 18 patients (17.6 %) diameters measured on CTA images, were bilaterally less than 6 mm, whilst XA indicated a minimum diameter exceeding 6 mm. For both modalities, the interobserver agreement was excellent (ICC 0.95). Diameters measured semi-automatically on CTA were statistically significantly smaller compared to XA. This should be acknowledged in the work-up for selecting the most appropriate approach for TAVI. In our population 17.6 % of patients would have been denied a transfemoral TAVI based on CTA measurements, whilst XA suggested diameters sufficient for a TF approach.

Mechanical circulatory support with the Impella 5.0 device for postcardiotomy cardiogenic shock: a three-center experience

AIM

Postcardiotomy cardiogenic shock (PCCS) is associated with high mortality rates, despite full conventional treatment. Although the results of treatment with surgically implantable ventricular assist devices have been encouraging, the invasiveness of this treatment limits its applicability. Several less invasive devices have been developed, including the Impella system. The objective of this study was to describe our three-center experience with the Impella 5.0 device in the setting of PCCS.

METHODS

From January 2004 through December 2010, a total of 46 patients were diagnosed with treatment-refractory PCCS and treated with the Impella 5.0 percutaneous left ventricular assist device at three european heart centers. Baseline and follow-up characteristics were collected retrospectively and entered into a dedicated database.

RESULTS

Within the study cohort of 46 patients, mean logistic and additive EuroSCORES were 24 ± 19 and 10 ± 4. The majority of patients underwent coronary artery bypass grafting (48%) or combined surgery (33%). Half of all patients had been treated with an intra-aortic balloon pump before 5.0-implantation, 1 patient had been treated with an Impella 2.5 device. All patients were on mechanical ventilation and intravenous inotropes. The Kaplan-Meier estimate of overall 30-day survival was 39.5%.

CONCLUSION

Thirty-day survival rates for patients with PCCS, refractory to aggressive conventional treatment and treated with the Impella 5.0 device, are comparable to those reported in studies evaluating surgically implantable VADs, whereas the Impella system is much less invasive. Therefore, mechanical circulatory support with the Impella 5.0 device is a suitable treatment modality for patients with severe PCCS.

Coronary microcirculatory dysfunction is associated with left ventricular dysfunction during follow-up after STEMI

BACKGROUND

Coronary microvascular resistance is increased after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI), which may be related in part to changed left ventricular (LV) dynamics. Therefore we studied the coronary microcirculation in relation to systolic and diastolic LV function after STEMI.

METHODS

The study cohort consisted of 12 consecutive patients, all treated with primary PCI for a first anterior wall STEMI. At 4 months, we assessed pressure-volume loops. Subsequently, we measured intracoronary pressure and flow velocity and calculated coronary microvascular resistance. Infarct size and LV mass were assessed using magnetic resonance imaging.

RESULTS

Patients with an impaired systolic LV function due to a larger myocardial infarction showed a higher baseline average peak flow velocity (APV) than the other patients (26 ± 7 versus 17 ± 5 cm/s, p = 0.003, respectively), and showed an impaired variable microvascular resistance index (2.1 ± 1.0 versus 4.1 ± 1.3 mmHg cm(-1)∙s(-1), p = 0.003, respectively). Impaired diastolic relaxation time was inversely correlated with hyperaemic APV (r = -0.56, p = 0.003) and positively correlated with hyperaemic microvascular resistance (r = 0.48, p = 0.01). LV dilatation was associated with a reduced variable microvascular resistance index (r = 0.78, p = 0.006).

CONCLUSION

A larger anterior myocardial infarction results in impaired LV performance associated with reduced coronary microvascular resistance variability, in particular due to higher coronary blood flow at baseline in these compromised left ventricles.

Efficacy and timing of intra-aortic counterpulsation in patients with ST-elevation myocardial infarction complicated by cardiogenic shock

BACKGROUND

Guidelines strongly recommend additional intra-aortic balloon pump (IABP) therapy in STEMI patients with cardiogenic shock (CS) treated by primary percutaneous coronary intervention (PCI). However, there is no randomised evidence suggesting survival benefit of IABP treatment in CS. It is suggested that timing of initiation of IABP therapy could be of great importance. Therefore, we compared mortality rates of IABP therapy versus no IABP therapy in the setting of STEMI complicated by CS. In addition, we investigated the effect of initiation of IABP therapy on mortality.

METHODS

From a cohort of 292 STEMI patients with CS treated by primary PCI, 199 patients received IABP therapy (IABP group) and 93 patients received no support (no IABP group). The IABP group was divided into two subgroups based on timing of initiation of support, i.e. 'IABP pre PCI' (n = 59) and 'IABP post PCI' (n = 140). Outcomes were assessed by propensity stratification and multivariate logistic regression.

RESULTS

All-cause 30-day mortality for the IABP versus the no IABP group was 47 % vs. 28 %, respectively, in univariate analysis resulting in an odds ratio (OR) of 1.67 (95%CI, 1.16 to 2.39). However, analyses adjusting outcomes by propensity stratification and logistic regression, respectively, neutralised this OR. In the IABP pre-PCI group vs. the post-PCI group 30-day mortality was 64 % vs. 40 %, resulting in an OR of 1.56 (95 % CI, 1.18 to 2.08). However, after propensity stratification analysis and multivariate logistic regression analysis, there were no significant differences in odds of 30-day mortality.

CONCLUSION

In our cohort of patients with STEMI complicated by CS treated with primary PCI we observed a difference in mortality between those treated with IABP and those treated without IABP in favour of the 'no IABP' group. The mortality difference was eliminated after adjustment for differences in case mix by propensity stratification or by logistic regression analysis. Neither did we observe any difference in mortality between patients whose IABP treatment was initiated before or immediately after PCI.

Six-month clinical outcomes of the Tryton Side Branch Stent for the treatment of bifurcation lesions

AIMS

Percutaneous coronary intervention (PCI) of a bifurcation lesion (BL) is still associated with poorer clinical outcomes when compared with PCI of a non-BL. Therefore, several dedicated coronary bifurcation stents, such as the Tryton Side Branch Stent™ (Tryton Medical, Durham, NC, USA), were developed to improve clinical outcomes. We investigated 6-month clinical outcomes after placement of a Tryton stent in 91 patients treated for 93 BLs in our centre.

METHODS AND RESULTS

All consecutive patients who have undergone PCI of a BL treated with the Tryton stent in our centre were included. Outcomes were defined as any death, cardiac death, myocardial infarction (MI), any revascularisation, ischaemia-driven target vessel revascularisation (TVR), ischaemia-driven target lesion revascularisation (TLR), stent thrombosis, and target vessel failure (TVF; composite of cardiac death, MI, and ischaemia-driven TVR). Event rates were estimated using the Kaplan-Meier method. Thirty-eight (42 %) patients with acute coronary syndrome (ACS) were included (16 % ST-segment elevation MI (STEMI)). The 6-month event rates were 5.4 % (death), 4.3 % (cardiac death), 2.2 % (MI), 4.5 % (any revascularisation), 4.5 % (TVR), 4.5 % (TLR) and 9.7 % (TVF).

CONCLUSION

In a real-world all-comers single-centre registry, the use of the Tryton Side Branch Stent was associated with acceptable procedural and promising clinical outcomes at 6 months, including ACS and STEMI patients.

[A man with pain in epigastrio]

A 22-year-old man was admitted to the hospital with epigastric pain. At first the diagnosis 'pneumonia' was made, based on a chest X-ray. CT-thorax revealed herniation of the colon in a diaphragmatic rupture, which was caused by an old stab wound.

Long-term follow-up of organ-specific antibodies and related organ dysfunction in type 1 diabetes mellitus

OBJECTIVE

Diabetes mellitus type 1 (DM1) is associated with other autoimmune disorders. To our knowledge, there are no longitudinal data considering the long-term clinical relevance of organ-specific antibodies (OS-Ab) in DM1 patients. We performed a long-term retrospective longitudinal study in order to investigate the presence and diagnostic accuracy (positive predictive value: PPV and negative predictive value: NPV) of OS-Ab in DM1 patients.

RESEARCH DESIGN AND METHODS

In a retrospective longitudinal study, the presence of OS-Ab and related organ function were analysed in 396 DM1 patients (184 F/212 M, age 44 ± 13 years, age at onset of DM1 21 ± 13 years), with a median follow-up time of 23 ± 10 years.

RESULTS

OS-Ab frequencies at baseline were: antibodies against thyroglobulin (Tg-Ab) 4.3%, antibodies against thyroid peroxidase (TPO-Ab) 8.1%, Tg- and/or TPO-Ab 10.4%, antibodies against parietal cells (PCA) 5.8% and antibodies against adrenal cortex (ACA) 0.5%. The occurrence of (sub)clinical hypothyroidism was higher in patients with Tg-Ab (47%) or TPO-Ab (42%) than in those without these antibodies (6.2 and 5.1%, respectively, p<0.001). PPV and NPV for Tg-Ab were 0.60 and 0.88, respectively, for TPO -Ab 0.54 and 0.91. Also in patients with PCA, organ dysfunction occurred more often (61%) than in patients without PCA (9.7%, p<0.001). PPV for PCA was 0.61 and NPV 0.90. NPV and PPV for ACA could not be calculated because of the low prevalence.

CONCLUSION

Long-term follow-up of 396 DM1 patients shows that the presence of thyroid antibodies and/ or parietal cell antibodies is clearly associated with dysfunction of the corresponding organ.