Endovascular thrombectomy is cost-saving in patients with acute ischemic stroke with large infarct

Objective

Endovascular thrombectomy (EVT) is the standard of care for acute large vessel occlusion stroke. Recently, the ANGEL-ASPECT and SELECT 2 trials showed improved outcomes in patients with acute ischemic Stroke presenting with large infarcts. The cost-effectiveness of EVT for this subpopulation of stroke patients has only been calculated using data from the previously published RESCUE-Japan LIMIT trial. It is, therefore, limited in its generalizability to an international population. With this study we primarily simulated patient-level costs to analyze the economic potential of EVT for patients with large ischemic stroke from a public health payer perspective based on the recently published data and secondarily identified determinants of cost-effectiveness.

Methods

Costs and outcome of patients treated with EVT or only with the best medical care based on the recent prospective clinical trials ANGEL-ASPECT, SELECT2 and RESCUE-Japan LIMIT. A A Markov model was developed using treamtment outcomes derived from the most recent available literature. Deterministic and probabilistic sensitivity analyses addressed uncertainty.

Results

Endovascular treatment resulted in an incremental gain of 1.32 QALYs per procedure with cost savings of $17,318 per patient. Lifetime costs resulted to be most sensitive to the costs of the endovascular procedure.

Conclusion

EVT is a cost-saving (i.e., dominant) strategy for patients presenting with large ischemic cores defined by inclusion criteria of the recently published ANGEL-ASPECT, SELECT2, and RESCUE-Japan LIMIT trials in comparison to best medical care in our simulation. Prospective data of individual patients need to be collected to validate these results.

Effects of a music-based intervention on psychophysiological outcomes of patients undergoing medical imaging procedures: A systematic review and meta-analysis

INTRODUCTION

Musical intervention (MI) is a valuable strategy for addressing the psychological and emotional challenges faced by patients undergoing imaging procedures. This study explores MI's impact on psychophysiological outcomes during imaging procedures, detailing the sound repertoire and technical characteristics employed in MI.

METHODS

A systematic review (SR) and meta-analysis (MA) were conducted. Electronic database searches of PubMed, Web-of-Science, and Scopus were performed encompassing original randomised research and quasi-experimental articles published until June 2023.

RESULTS

Thirteen articles were included in this SR, scoring between 23 and 68 on the Joanna Briggs Institute (JBI) Checklist. Four articles were included to perform a MA concerning anxiety and heart rate (HR) outcomes. Most studies utilised digital playlists as the medium for MI. Headphones were commonly used, with an average volume of 50-60 dB and a musical frequency of 60-80 beats/min. While authors generally preferred selecting musical genres for the repertoire, two articles specifically chose Johann Pachelbel's "Canon in D major" as their musical theme. In terms of psychological parameters, the experimental groups exhibited lower anxiety values than the control groups, with further reductions after MI. However, MA shows that this trend is only marginally significant. Patient comfort and overall examination experience showed improvement with MI. Regarding physiological parameters, HR, especially in the final phase of the examination, was significantly lower in the experimental group compared to the control group.

CONCLUSION

Across multiple studies, MI demonstrated the ability to reduce anxiety and HR. However, no specific music repertoire emerged as the most effective.

IMPLICATIONS FOR PRACTICE

MI arises as a painless, reliable, low-cost, and side-effect-free strategy, presenting imaging departments with a practical means to enhance patient comfort and mitigate anxiety and stress during medical procedures.

Velocity-Selective Arterial Spin Labeling Perfusion in Monitoring High Grade Gliomas Following Therapy: Clinical Feasibility at 1.5T and Comparison with Dynamic Susceptibility Contrast Perfusion

MR perfusion imaging is important in the clinical evaluation of primary brain tumors, particularly in differentiating between true progression and treatment-induced change. The utility of velocity-selective ASL (VSASL) compared to the more commonly utilized DSC perfusion technique was assessed in routine clinical surveillance MR exams of 28 patients with high-grade gliomas at 1.5T. Using RANO criteria, patients were assigned to two groups, one with detectable residual/recurrent tumor ("RT", n = 9), and the other with no detectable residual/recurrent tumor ("NRT", n = 19). An ROI was drawn to encompass the largest dimension of the lesion with measures normalized against normal gray matter to yield rCBF and tSNR from VSASL, as well as rCBF and leakage-corrected relative CBV (lc-rCBV) from DSC. VSASL (rCBF and tSNR) and DSC (rCBF and lc-rCBV) metrics were significantly higher in the RT group than the NRT group allowing adequate discrimination (p < 0.05, Mann-Whitney test). Lin's concordance analyses showed moderate to excellent concordance between the two methods, with a stronger, moderate correlation between VSASL rCBF and DSC lc-rCBV (r = 0.57, p = 0.002; Pearson's correlation). These results suggest that VSASL is clinically feasible at 1.5T and has the potential to offer a noninvasive alternative to DSC perfusion in monitoring high-grade gliomas following therapy.

Isthmocele correction: resectoscopic, laparoscopic or both?

Background

An isthmocele is a myometrial defect in the site of the caesarean scar. In symptomatic women with abnormal uterine bleeding and secondary infertility, surgical correction can be considered. Most authors advocate that when there's a residual myometrium ≥ 3mm it can be corrected through resectoscopic approach and when < 3mm the treatment should be laparoscopic, eventually guided by diagnostic hysteroscopy. Both these techniques have important limitations; therefore, the authors propose combining both techniques, in the same procedure, in order to overcome them.

Objectives

To demonstrate the advantages of a surgical technique for correction of an isthmocele using both resectoscopic and laparoscopic resection.

Material and Methods

A stepwise demonstration of the technique with narrated video footage.

Main outcome measures

Intraoperative data and outcomes in the patient's follow-up.

Results

One month after the surgery the patient was asymptomatic, reporting a resolution of the uterine abnormal bleeding, and the ultrasound showed a full correction of the isthmocele.

Conclusion

A combination of resectoscopic and laparoscopic resection, in correcting bigger isthmoceles, is a good option to fully excise all the fibrotic tissue.

Learning objective

This video aims to demonstrate the benefits of using a technique combining resectoscopic and laparoscopic resection for correcting larger isthmoceles.

Stereotactic radiosurgery and combined immune checkpoint therapy with ipilimumab and nivolumab in patients with melanoma brain metastases: A retrospective monocentric toxicity analysis

Purpose and objective

Adding stereotactic radiosurgery (SRS) to combined immune checkpoint therapy with ipilimumab and nivolumab (IPI + NIVO) has led to promising results for patients with melanoma brain metastases (MBM). This study retrospectively analyzes the toxicity profile depending on the timing of SRS with regard to IPI + NIVO.

Materials and methods

For this study, the clinical database was searched for all patients with MBM who were treated with SRS and IPI + NIVO. The patients were separated into three groups: group A completed IPI + NIVO (usually up to four cycles) >14 days before SRS, in group B IPI + NIVO was initiated>14 days after SRS, and group C received SRS concurrently to IPI + NIVO. Treatment related toxicity was obtained from clinical and neuroradiological records. Analyses were performed using the Fisher-Yates-test.

Results

31 patients were assessed including six (19.4 %), seven (22.6 %) and 18 (58.1 %) patients, in groups A, B and C, respectively. Baseline prognostic markers between groups were balanced. In total, five (16.1 %) patients experienced neurological grade 3 toxicities related to SRS. All of these five patients were in group C, which was near-significantly correlated with a risk for grade 3 toxicities (p = 0.058). Post-hoc analyses showed that a maximum time period of seven days between SRS and IPI + NIVO was significantly correlated with grade 3 toxicity (p = 0.048).

Conclusion

Application of SRS to IPI + NIVO within a seven-day span was related to higher toxicity rates in this retrospective analysis. After previous studies focused on immune checkpoint monotherapies with SRS and declared it as safe, this study indicates that concomitant application of IPI + NIVO and SRS might increase side effects. Prospective validation is warranted to corroborate these findings.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Applying genomic approaches to delineate conservation strategies using the freshwater mussel Margaritifera margaritifera in the Iberian Peninsula as a model

Effective conservation actions to counteract the current decline of populations and species require a deep knowledge on their genetic structure. We used Single Nucleotide Polymorphisms (SNPs) to infer the population structure of the highly threatened freshwater pearl mussel Margaritifera margaritifera in the Iberian Peninsula. A total of 130 individuals were collected from 26 locations belonging to 16 basins. We obtained 31,692 SNPs through Genotyping by Sequencing (GBS) and used this dataset to infer population structure. Genetic diversity given as observed heterozygosity was low. Pairwise F_ST comparisons revealed low levels of genetic differentiation among geographically close populations. Up to 3 major genetic lineages were determined: Atlantic, Cantabrian and Douro. This structure suggests a close co-evolutionary process with brown trout (Salmo trutta), the primordial fish host of this mussel in the studied area. Some sub-basins showed some genetic structuring, whereas in others no intrapopulation differentiation was found. Our results confirm that genetic conservation units do not match individual basins, and that knowledge about the genetic structure is necessary before planning recovery plans that may involve relocation or restocking. The same reasoning should be applied to strictly freshwater species that are sessile or have restricted dispersal abilities and are currently imperiled worldwide.

Trajectories of psychiatric care in an innovative outpatient program designed for transitional age youth (16 to 24 years old) in French-speaking Belgium: results of a retrospective study

Introduction

Transitional age youth (TAY), from 16 to 24 years old, are a particularly at-risk population in mental health. They have specific needs, not currently covered between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS), mainly because of existing barriers.

Objectives

This retrospective study was carried out to describe sociodemographic and clinical characteristics of 243 patients who attended a new TAY-tailored outpatient psychiatric program.

Methods

Outcomes related to trajectories of psychiatric care were analysed, such as leading symptom, consultation’s referral and requester, and final orientation.

Results

The sample was mainly composed by female; the average age was 18.7 (± 2.0) years. Leading symptoms were divided into three dimensions: internalizing (67.5%), externalizing (21.8%) and psychotic (10.7%). Leading symptom differed according to sex (p<0.001), with internalizing symptoms more frequent in women, externalizing and psychotic symptoms more frequent in men. Patients presenting psychotic symptoms were significantly older than both those with internalizing (p=0.016) and externalizing symptoms (p=0.008). After first assessment, 81.5% of youth were followed-up in our specific outpatient program, without any difference according to sex (p=0.081) or leading symptom (p=0.092). Overall and final psychiatric orientation are showed in the flowchart.

Conclusions

This TAY-tailored psychiatric outpatient program represents an innovative contribution to reinforce CAMHS-AMHS interface in French-speaking Belgium. This study enlightens the importance to enhance clinical expertise in youth mental health. Classical boundaries, determined by artificial variables such as age or type of psychopathology, do not seem to be efficient criteria to achieve a good quality psychiatric evaluation and continuity of care in TAY.

Disclosure

The authors declare no potential conflicts of interest. The study was carried out as part of the University Chair “Psychiatry in Transition in a World in Transition” (Université Libre de Bruxelles - ULB) with the support of Julie Renson Fund, the Queen Fa

MRI-based contrast clearance analysis shows high differentiation accuracy between radiation-induced reactions and progressive disease after cranial radiotherapy

Background

Pseudoprogression (PsP) or radiation necrosis (RN) may frequently occur after cranial radiotherapy and show a similar imaging pattern compared with progressive disease (PD). We aimed to evaluate the diagnostic accuracy of magnetic resonance imaging-based contrast clearance analysis (CCA) in this clinical setting.

Patients and methods

Patients with equivocal imaging findings after cranial radiotherapy were consecutively included into this monocentric prospective study. CCA was carried out by software-based automated subtraction of imaging features in late versus early T1-weighted sequences after contrast agent application. Two experienced neuroradiologists evaluated CCA with respect to PsP/RN and PD being blinded for histological findings. The radiological assessment was compared with the histopathological results, and its accuracy was calculated statistically.

Results

A total of 33 patients were included; 16 (48.5%) were treated because of a primary brain tumor (BT), and 17 (51.1%) because of a secondary BT. In one patient, CCA was technically infeasible. The accuracy of CCA in predicting the histological result was 0.84 [95% confidence interval (CI) 0.67-0.95; one-sided P = 0.051; n = 32]. Sensitivity and specificity of CCA were 0.93 (95% CI 0.66-1.00) and 0.78 (95% CI 0.52-0.94), respectively. The accuracy in patients with secondary BTs was 0.94 (95% CI 0.71-1.00) and nonsignificantly higher compared with patients with primary BT with an accuracy of 0.73 (95% CI 0.45-0.92), P = 0.16.

Conclusions

In this study, CCA was a highly accurate, easy, and helpful method for distinguishing PsP or RN from PD after cranial radiotherapy, especially in patients with secondary tumors after radiosurgical treatment.

•

CCA is accurate in distinguishing treatment reactions from true PD.

•

CCA was more accurate for irradiated metastases than primary BTs.

•

CCA is not feasible for lesions with no contrast media uptake.

Training responsiveness of cardiorespiratory fitness and arterial stiffness following moderate-intensity continuous training and high-intensity interval training in adults with intellectual and developmental disabilities

BACKGROUND

Cardiorespiratory fitness (CRF) prompts antiatherogenic adaptations in vascular function and structure. However, there is an extraordinary interindividual variability in response to a standard dose of exercise, wherein a substantial number of adults with intellectual and developmental disabilities (IDD) do not improve CRF. We (1) evaluated the effects of 12-month of moderate-intensity continuous training (MICT) on CRF and arterial stiffness and (2) tested whether an additional 3-month of high-intensity interval training (HIIT) would add to improvements in CRF responsiveness and arterial stiffness.

METHODS

Fifteen adults with mild-to-moderate IDD (male adults = 9, 30.1 ± 7.5 years old) met 3 days per week for 30 min MICT for 12 months, after which the incidence of CRF responsiveness was calculated (≥5.0% change in absolute peak VO₂ ). Thereafter, responders and non-responders started HIIT for 3 months with identical daily training load/frequency. Peak VO₂ , local and regional indices of arterial stiffness were assessed prior to and after each period.

RESULTS

Sixty per cent of the participants were non-responders following MICT, but the incidence dropped to 20% following HIIT (P = 0.03). Absolute peak VO₂ values reached significant difference from pre-intervention (+0.38 ± 0.08 L min^-1 , P = 0.001) only when HIIT was added. Lower limb pulse wave velocity (PWV) decreased following MICT (-0.8 ± 1.1 m s^-1 , P = 0.049), whereas central PWV only decreased following HIIT (-0.8 ± 0.9 m s^-1 , P = 0.013).

CONCLUSIONS

Cardiorespiratory fitness responsiveness and reductions in PWV to a 12-month MICT period in adults with IDD improved following a period of HIIT programme inducing higher metabolic stress.

The impact of resilience and loneliness during COVID-19 pandemic on youth’s (18 – 25 years old) mental health

Background

Mental health, particularly among young adults, has been severely affected during the COVID-19 pandemic, partially because of both forced social isolation measures and loneliness. Numerous papers on the short-term consequences of lockdown measures reported high psychological distress, as well as an increase of depressive and anxiety symptoms and psychotropic drug use. This study evaluated potential risk and protective factors, such as resilience, loneliness, social and family context, in order to detect vulnerable individuals.

Methods

This prospective longitudinal study was carried out in a two-phase survey: the first one, during lockdown in Spring 2020 (T1), and, the second one, in Summer 2020 (T2), when restrictive measures were slackened. The main outcomes included the Resilience Scale for Adults (RSA) and the University of California Los Angeles (UCLA) Loneliness Scale. The secondary outcomes included mental health care needs (MHCN), use of psychotropic drugs and family and social contacts.

Results

This study evaluated risks and protective factors in mental health in 825 emerging adults aged from 18 to 25 years old in Belgium and in Italy. Participants were divided into three groups according to their MHCN before and after lockdown measures. 5% of the participants experienced an increase in MHCN at T1, including the start of a psychotropic treatment. At T1, statistically significant differences were found in mean RSA total scores and RSA Perception of Self scores between groups. At T2, the group who experienced an increase in MHCN displayed a significant decrease of mean loneliness scores compared with the other groups. This decrease is linearly correlated with resilience competencies.

Conclusions

The COVID-19 pandemic and its associated restrictive measures cause a negative impact on youth's mental health, particularly among vulnerable individuals. Resilience and social contacts are protective factors that need to be taken into account.

Virtual fractional flow reserve derived from coronary angiography – artery and lesion specific correlations

Introduction

Virtual Fractional flow reserve (vFFR) from standard non-hyperaemic invasive coronary angiography (ICA) has emerged as a promising non-invasive test to assess hemodynamic severity of coronary artery disease (CAD).

Purpose

To investigate the difference in vFFR analysis between vessels and specific lesions.

Methods

Retrospective analysis of consecutive patients (pts) who underwent invasive functional assessment (iFA) in a tertiary center between 2019 and 2020. vFFR was calculated using dedicated software (CAAS Workstation 8.4) based on coronary angiograms of the acquired in ≥2 different projections, by operators blinded to iFA results. Diagnostic performance of vFFR was evaluated and correlated with iFA, according to coronary vessel, vessel diameter at stenosis, diameter stenosis and area stenosis at lesion. vFFR was considered positive when &lt;0.80. FFR &lt;0.8 and iFR/RFR &lt;0.90 were classified as positive according to current clinical standards.

Results

106 coronary arteries of 95 pts (78% male, mean age 67.8±9.7 years) underwent vFFR evaluation. ICA indications were chronic coronary syndrome in 63% or acute coronary syndrome (non-culprit lesion) in the remaining pts. VFFR accuracy was good (AUC 0.839 (p&lt;0.001) and Pearson's correlation coefficient 0.533 (p&lt;0.001) when vFFR was measured in the distal vessel segment. The correlation improved when vFFR were assessed at lesion site (r=0.631, p&lt;0.001) or up to 1cm below the stenosis (0.610, p&lt;0.001). Binary concordance of 89% were observed in RCA and LAD (Sensibility -S 68%, Specificity-Sp 96%, False positive -FP 3.8%, False negative - FN 31%, predictive positive value-PPV 87%, predictive negative value- PNV 89%), while in the circumflex coronary artery binary concordance were of 77% (S 50%; Sp 82%; FP 18%; FN 50%; PPV 33% and PNV 90%). Correlation between vFFR and iFA was higher in vessels ≥2mm (r=0.730, p&lt;0.001). and in lesions in the extremes of the severity spectrum (Table 1).

Conclusion

vFFR has a moderate to high linear correlation to iFA, depending on the artery and type of lesion studied. The higher correlation was found when vFFR were measured at lesion site, in non-circumflex artery stenosis, in vessels ≥2mm and in vessels with mild or severe stenosis.

Funding Acknowledgement

Type of funding sources: None.

Quantification of epicardial fat with cardiac CT and association with cardiovascular risk factors and obstructive coronary disease

Introduction

Recent studies advocate epicardial fat (EF) as a biologically active organ that influence coronary atherosclerosis development through endocrine and paracrine pathways. We aim to study the relations between EF, thoracic adipose tissue (TAT), cardiovascular risk factors (CRF) and obstructive coronary disease (OCD).

Methods

Retrospective analysis of patients (pts) referred to 64-multislice cardiac computed tomography (CT) in one center. The authors underwent a standardized protocol for quantification of EAT, TAT (subcutaneous and visceral), abdominal visceral fat, coronary calcium score and angiography.

Results

Total of 178 pts: male 99 (56%), mean age 65.9±12.9 years. Indications for performing CT were coronary disease (76%), valvular heart disease (15%), atrial fibrillation (6%) and congenital heart disease (2%). Regarding CRF, EF was only significant higher in patients with diabetes (115±60 vs 95±47, p=0.018), in male gender (114±60 vs 91±42, p=0.04) and was linear correlated with age (p=0.004). The authors also found that EF volume is significant higher in patients with typical angina (p=0.02) and with coronary atherosclerosis: non-obstructive (p=0.0049) and OCD (p=0.001) – Graphic 1. ROC analysis of EF (AUC 0.659, p=0.0039) and EF/TAT relation (AUC 0.704, p=0.003) allowed to estimate that EF&gt;100 ml and EF/TAT &gt;0.06 had a sensibility to predict OCD of 53% and 58%, respectively, and specificity of 66% and 60%. We did not find a correlation between EF, EF/TAT or TAT and coronary calcium score.

Conclusion

EF is higher in patients with diabetes and coronary atherosclerosis. EF and EF/TAT relation had moderate sensibility and specificity to predict OCD, irrespective of calcium score. EF and EF/TAT are promising atherosclerotic markers that could be routinely use in the near future.

Funding Acknowledgement

Type of funding sources: None.

Malignant cardiac tumors: a single-centre 25-year review

Background

Primary cardiac tumors are extremely rare and are usually diagnosed late due to the nonspecific symptoms. Surgery is the main treatment option, and despite chemotherapy, the prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome. The aim of this study was to review patients (P) with malignant cardiac tumors that were diagnosed by transthoracic echocardiogram (TTE) or transoesophageal echocardiogram (TOE) in a tertiary center between 1995 and 2020.

Methods

Retrospective analysis of clinical data, echocardiographic assessment of tumor location and morphology, histology results and survival outcomes.

Results

A total of 44 malignant cardiac tumors were diagnosed: 12 primary tumors (A) and 32 metastatic tumors (B). A: Regarding primary cardiac tumors, the most common types were angiosarcomas (6), undifferentiated pleomorphic sarcomas (2), fibrosarcomas (2), myxofibrosarcoma (1) and primary cardiac lymphoma (1). The mean age of P at time of diagnosis was 43±15 years, 50% male. The most frequent presentation was heart failure symptoms (50%) followed by arrhythmias (20%). 1 P presented with pruritus and polyarthralgias. On TTE, the most prevalent tumor location was in the right-heart chambers (70%) – mostly the right atrium (50%), with mean dimensions of 40±18x27±11 mm. 85% of P had preserved biventricular systolic function and there was severe pericardial effusion in 38%. The most frequent metastatic involvement at diagnosis was pulmonary (33%) and hepatic (33%). 50% of P were submitted to tumor resection and 40% to chemotherapy. Regarding angiosarcomas, the most common immunohistochemical markers were vimentin, CD31 and CD34. The authors found a mortality rate of 10P (83%) in P with primary cardiac tumors, with a median time to mortality of 5.5 (IQR 2–10) months (Figure 1), in a median follow-up of 6.2 (IQR 2.5–15) months (minimum of 20 days and maximum of 19 years). In the latter case, the P was submitted to heart transplantation after diagnosis of a fibrosarcoma and is still alive and well.

B: Regarding secondary cardiac invasion, there was a diagnosis of the following primary tumor sites: 12 lung carcinomas, 7 thymomas, 4 lymphomas, 3 hepatocellular carcinomas, 2 bladder carcinomas, 1 parathyroid carcinoma, 1 soft tissue sarcoma, 1 uterine sarcoma and 1 melanoma. The mean age of P was 57±19 years, 57% male. On TTE/TOE the authors found a right-sided chambers predominance (12 P, 38%) vs left-sided chambers in (8 P, 25%), with pericardial metastasis also present in 13 P (41%). Cardiac tamponade occurred in 6P (19%). The mortality rate was 75% (24P), with a median time to mortality of 1.1 (IQR 0.6–3.8) months (minimum of 7 days, maximum of 44 months), in a median follow-up of 2.3 (IQR 0.8–14) months.

Conclusion

Cardiac malignant tumors generally present in a late stage with a dismal prognosis. When possible, heart transplantation can be an option with a favourable outcome.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier analysis

Feasibility of virtual fractional flow reserve derived from coronary angiography and its correlation with invasive functional assessment

Introduction

Invasive functional assessment (iFA) of coronary artery disease (CAD) needs expensive devices, has potential procedure-related complications and is still underutilized. Virtual Fractional Flow Reserve (vFFR) derived from invasive coronary angiography (ICA) has the potential to overcome these limitations.

Purpose

To investigate the feasibility of vFFR analysis and its correlation with iFA (iFR, RFR or FFR).

Methods

Retrospective analysis of consecutive patients (pts) who underwent iFA in a tertiary center between 2019 and 2020. vFFR was calculated using a dedicated software (CAAS Workstation 8.4) based on standard non-hyperaemic coronary angiograms acquired in ≥2 different projections, by operators blinded to iFA results. Diagnostic performance and accuracy of vFFR were evaluated. vFFR was considered positive when &lt;0.80. FFR &lt;0.8 and iFR/RFR &lt;0.90 were classified as positive according to current clinical standards.

Results

Out of 113 coronary arteries of 102 pts, vFFR was successfully analysed in 106 (94%). Reasons for vFFR analysis failure were: vessel projection overlap (48%), &lt;2 angiographic projections (28%) and table movement while acquisition (24%). From 106 coronary arteries of 95 pts with analysable vFFR (78% male, mean age 67.8±9.7 years), 90 (85%) showed agreement with the respective iFA result. The vFFR predicted which lesions were physiologically significant and which were not with accuracy, sensitivity, specificity, positive and negative predictive values of 73%, 73%, 83%, 53%, and 92% respectively. The mean difference between vFFR and iFA were −0.0484±0.096 and Pearson's correlation coefficient was 0.533 (p&lt;0.001). The ROC area under the curve was 0.839 (0.751–0.928, p&lt;0.001).

Conclusion

FFR were feasible in 94% of cases analysed retrospectively. As compared to gold-standard iFA, vFFR had an overall moderate accuracy in detecting ischemia-producing lesions and a negative predictive value &gt;90%. vFFR has the potential to substantially simplify physiological coronary lesion assessment and thus improve its current uptake.

Funding Acknowledgement

Type of funding sources: None. Bland-Altman plot between vFFR and IFA

P05.01 Prospective validation trial of magnetic resonance imaging based Contrast Clearance Analysis (CCA) to differentiate between pseudoprogression/radiation necrosis and progressive disease following cranial radiotherapy

BACKGROUND

Pseudoprogression (PsP) or radiation necrosis (RN) may frequently occur after cranial radiotherapy and show a similar imaging pattern compared to progressive disease (PD). Even for experienced neuroradiologists, it remains challenging to distinguish between these clinically relevant disease states. We aimed to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) based Contrast Clearance Analysis (CCA) in this clinical setting.

MATERIAL AND METHODS

Patients with equivocal imaging findings after cranial radiotherapy were consecutively included into this monocentric prospective study. Assuming a true accuracy of 90% and setting the significance level to 0.05, N=33 patients are required to show that accuracy is larger than 70% with a power of 80% using a one-sided binomial test. CCA was performed by subtraction of imaging features in late vs early T1-weighted sequences after contrast-agent application. Two experienced neuroradiologists evaluated CCA with respect to PsP/RN and PD being blinded for FET PET and histological findings; histopathological diagnosis was based on stereotactic biopsy or resection for space-occupying processes. The radiological assessment was compared with the histopathological results, and its accuracy was calculated statistically.

RESULTS

Thirty-three patients were included; sixteen (48.5%) were treated because of a primary brain tumors, and 17 (51.1%) with brain metastases. In one patient, CCA was technically infeasible. The accuracy of CCA in predicting the histological result was 0.84 (95% CI 0.67–0.95; one-sided p=0.05; N=32). An accuracy of 0.85 (95% CI 0.68–0.95; one-sided p=0.04) would have been obtained in case of a correct classification in the non-analyzable case. Sensitivity and specificity of CCA were 0.93 (95%-CI 0.66–1.00) and 0.78 (95% CI 0.52–0.94), respectively. The accuracy in metastases patients was 0.94 (95% CI 0.71 - 1.00) and non-significantly higher compared to primary brain tumor patients with accuracy of 0.73 (95% CI 0.45 - 0.92), p=0.16.

CONCLUSION

In this study, CCA was a highly accurate, easy and helpful method for distinguishing PsP or RN from PD after cranial radiotherapy, especially in brain metastases patients after radiosurgical treatment.

An amyotrophic lateral sclerosis hot spot in the French Alps associated with genotoxic fungi

Between 1990 and 2018, 14 cases of amyotrophic lateral sclerosis (ALS) were diagnosed in residents of, and in visitors with second homes to, a mountainous hamlet in the French Alps. Systematic investigation revealed a socio-professional network that connected ALS cases. Genetic risk factors for ALS were excluded. Several known environmental factors were scrutinized and eliminated, notably lead and other chemical contaminants in soil, water or home-grown vegetation used for food, radon and electromagnetic fields. Some lifestyle-related behavioral risk factors were identified: Prior to clinical onset of motor neuron disease, some patients had a high degree of athleticism and smoked tobacco. Recent investigations on site, based on a new hypothesis, showed that all patients had ingested wild mushrooms, notably poisonous False Morels. Half of the ALS cohort reported acute illness following Gyromitra gigas mushroom consumption. This finding supports the hypothesis that genotoxins of fungal origin may induce motor neuron degeneration.

POS0037 DOES IMAGING OF THE SACROILIAC JOINT DIFFER IN PATIENTS PRESENTING WITH UNDIAGNOSED BACK PAIN AND PSORIASIS, ACUTE ANTERIOR UVEITIS, AND COLITIS: AN INCEPTION COHORT STUDY

Background:

Axial spondyloarthritis (axSpA) presents diagnostic challenges incurring a delay of up to a decade and relies considerably on radiographic and MRI evidence of sacroiliitis which has led to the development of classification criteria which also rely on imaging. However, it has been suggested that such criteria may not be appropriate for axSpA patients presenting with other forms of SpA, especially psoriatic, because imaging features may vary in frequency and/or may be atypical. This hypothesis has never been tested in a prospective inception cohort of patients presenting with undiagnosed back pain.

Objectives:

We aimed to compare the spectrum of radiographic and MRI abnormalities in the sacroiliac joint (SIJ) of an inception cohort of patients presenting with undiagnosed back pain and psoriasis, iritis, and colitis.

Methods:

We used data from the prospective multicenter Screening for Axial Spondyloarthritis in Psoriasis, Iritis, and Colitis (SASPIC) Study, which is aimed at early detection of axial SpA in patients referred by the respective specialist after first presenting with these disorders. Consecutive patients ≤45 years of age with ≥3 months undiagnosed back pain with any one of psoriasis, AAU, or colitis undergo routine clinical evaluation by a rheumatologist for axial SpA followed by imaging. In SASPIC I, MRI evaluation of the SIJ was ordered per rheumatologist decision. In SASPIC II, MRI evaluation was ordered for all patients. Radiographs and MRI scans were assessed by two central readers and comparisons of the three groups were based on concordant assessments of imaging features. Evaluation of MRI scans included both global assessment for presence/absence of axSpA with confidence scale (-10 to +10), active and structural lesions typical of axSpA per recent ASAS definitions, and granular assessment of individual lesions according to SIJ quadrants and halves in consecutive semicoronal slices through the SIJ. Groups were compared by ANOVA and the chi-square test.

Results:

A total of 240 patients were recruited, 143 from SASPIC I and 97 from SASPIC II, 101 (42.1%) being diagnosed with axSpA (65.3% male, mean age 34.4 years, mean symptom duration 8.7 years, B27 positive 55.4%). Mean age of colitis (N=101), psoriasis (N=61), iritis (N=78) patients were 33.4, 36.6, 34.3 years, respectively, mean symptom duration was 6.8, 7.2, 9.4 years, respectively, and % males were 45.5%, 52.5%, 51.3%, respectively. There were no significant group differences for unilateral versus bilateral radiographic sacroiliitis and no significant differences in the frequencies, type, or distribution of MRI lesions (Table 1).

Conclusion:

Data from the SASPIC prospective inception cohort does not support the view that imaging of the SIJ differs in psoriatic axSpA, which appears similar to axSpA associated with iritis or colitis. These data support the umbrella concept of axSpA.

Imaging FeatureColitis (n=30)Psoriasis (n=19)Iritis (n=52)P valueUnilateral sacroiliitis (grade ≥2), N(%)1 (3.3%)0 (0%)2 (3.8%)0.69mNY criteria +, N(%)5 (16.7%)6 (31.2%)15 (28.8%)0.39Grade of sacroiliitis, mean(SD)1.8 (2.2)2.1 (2.7)2.2 (2.4)0.76MRI indicative of axSpA, N(%)15 (50.0%)11 (57.9%)32 (61.5%)0.60MRI indicative of axSpA (confidence ≥5/10), N(%)14 (46.7%)10 (52.6%)30 (57.7%)0.63MRI active lesion typical of axSpA, N(%)6 (20.0%)6 (31.6%)18 (34.6%)0.37MRI structural lesion typical of axSpA, N(%)11 (36.7%)7 (36.8%)18 (34.6%)0.98MRI with unilateral lesion (any)2 (6.7%)3 (15.8%)11 (21.2%)0.22MRI with unilateral lesion (BME)1 (3.3%)2 (10.5%)5 (9.6%)0.54MRI with unilateral lesion (Erosion)0 (0%)0 (0%)3 (5.8%)0.23MRI with unilateral lesion (Sclerosis)1 (3.3%)1 (5.3%)3 (5.8%)0.89MRI with unilateral lesion (Fat)0 (0%)0 (0%)0 (0%)NAMRI with iliac lesion17 (56.7%)12 (63.2%)32 (61.5%)0.88MRI with sacral lesion12 (40.0%)11 (57.9%)31 (59.6%)0.21

Disclosure of Interests:

Walter P Maksymowych Speakers bureau: Abbvie, Janssen, Novartis, Pfizer, UCB, Consultant of: Abbvie, BMS, Boehringer, Galapagos, Gilead, Lilly, Novartis, Pfizer, UCB, Grant/research support from: Abbvie, Novartis, Pfizer, Ulrich Weber: None declared, Jon Chan: None declared, Raj Carmona: None declared, James Yeung: None declared, Sibel Aydin: None declared, Jodie Reis: None declared, Liam Martin: None declared, Ariel Masetto: None declared, Olga Ziouzina: None declared, Dianne Mosher: None declared, Stephanie Keeling: None declared, Sherry Rohekar: None declared, Rana Dadashova: None declared, Joel Paschke: None declared, Amanda Carapellucci: None declared, Robert G Lambert: None declared.

Oxcarbazepine-induced hyponatremia: A case report

Introduction

Oxcarbazepine (OXC) is an antiepileptic drug widely used in the treatment of bipolar disorder (BD), specially when there are side effects with other mood stabilizers. Nevertheless, it isn’t innocuous of adverse effects and its consequences can even endanger the patient’s life.

Objectives

Brief review of the literature on OXC-induced hyponatremia and exposure of a case report.

Methods

Review of the literature through research in the PubMed database, using the following keywords: “oxcarbazepine”, “hyponatremia” and “adverse effects”.

Results

Although most of the patients are asymptomatic, hyponatremia is one of the most important side effects of OXC. About 29.9% of the patients develop hyponatremia, but only 2.5-3% of psychiatric patients develop severe hyponatremia. The risk of hyponatremia is higher during the first three months of treatment. Severe and/or symptomatic hyponatremia has important clinical implications and may be associated with neurological damage, including seizures, brain stem herniation and death. A 44-year-old woman diagnosed with BD started OXC due to drug intoxications with other mood stabilizers. Six days after initiating treatment, she presented persistent vomiting and severe hyponatremia was detected in blood tests. OXC was suspended with symptomatic resolution.

Conclusions

Healthcare professionals should be alert to symptoms that may arise in patients under OXC. Periodic evaluations of serum sodium levels should be carried out. Cases of severe and/or symptomatic hyponatremia should be rapidly identified and treated in order to reduce the risk of developing brain injury and death.

Advanced MRI Findings in Medulloblastomas: Relationship to Genetic Subtypes, Histopathology, and Immunohistochemistry

BACKGROUND AND PURPOSE

For diagnosis of medulloblastoma, the updated World Health Organization classification now demands for genetic typing, defining more precisely the tumor biology, therapy, and prognosis. We investigated potential associations between magnetic resonance imaging (MRI) parameters including apparent diffusion coefficient (ADC) and neuropathologic features of medulloblastoma, focusing on genetic subtypes.

METHODS

This study was a retrospective single-center analysis of 32 patients (eight females, median age = 9 years [range, 1-57], mean 12.6 ± 11.3) from 2012 to 2019. Genetic subtypes (wingless [WNT]; sonic hedgehog [SHH]; non-WNT/non-SHH), histopathology, immunohistochemistry (p53, Ki67), and the following MRI parameters were correlated: tumor volume, location (midline, pontocerebellar, and cerebellar hemisphere), edema, hydrocephalus, metastatic disease (presence/absence and each), contrast-enhancement (minor, moderate, and distinct), cysts (none, small, and large), hemorrhage (none, minor, and major), and ADC_mean . The ADC_mean was calculated using manually set regions of interest within the solid tumor. Statistics comprised univariate and multivariate testing.

RESULTS

Out of 32 tumors, three tumors were WNT activated (9.4%), 13 (40.6%) SHH activated, and 16 (50.0%) non-WNT/non-SHH. Hemispherical location (n = 7/8, P = .003) and presence of edema (8/8; P < .001, specificity 100%, positive predictive value 100%) were significantly associated with SHH activation. The combined parameter "no edema + no metastatic disease + cysts" significantly discriminated WNT-activated from SHH-activated medulloblastoma (P = .036). ADC_mean (10^-6 mm² /s) was 484 for WNT-activated, 566 for SHH-activated, and 624 for non-WNT/non-SHH subtypes (P = .080). A significant negative correlation was found between ADC_mean and Ki67 (r = -.364, P = .040).

CONCLUSION

MRI analysis enabled noninvasive differentiation of SHH-activated medulloblastoma. ADC alone was not reliable for genetic characterization, but associated with tumor proliferation rate.

Environmental neurology in the tropics

We address the impact of the tropical environment on the human nervous system using the multifaceted approach characteristic of environmental neurology. First, environmental factors are examined according to their nature (physical, chemical and biological) and in relation to human activity and behavior. Some factors are specific to the tropics (climate and infections), while others are non-specific (chemicals, human communities and their way of life). Second, we examine the major role of human adaptation to the success of Homo sapiens, with emphasis on the linkage between thermoregulation and sleep-wake regulation. Third, we examine the performance of environmental neurology as a clinical discipline in tropical climates, with focus on the diagnostic and therapeutic challenges posed by human African trypanosomiasis. Finally, the prevention, early detection and monitoring of environmental neurological diseases is examined, as well as links with political and economic factors. In conclusion, practitioners of environmental neurology seek a global, multidisciplinary and holistic approach to understanding, preventing and treating neurological disorders within their purview. Environmental neurology integrates an expanded One Health concept by linking health and wellness to the interaction of plants, animals, humans and the ecosystem. Recent epidemics and the current COVID-19 pandemic exemplify the need for worldwide action to protect human health and biodiversity.

Insights from microRNAs into the pathophysiology of coronary and multiterritorial atherosclerosis

Introduction

The mechanisms underlying the different phenotypic presentations of atherosclerosis are still poorly understood. MicroRNAs regulate genetic expression at the post-transcriptional level and each has specific biological functions. MicroRNAs could therefore be useful for understanding the epigenetic drivers for development of isolated coronary atherosclerosis and more extensive disease (coronary and extra-coronary). We evaluated if the expression profile of circulating microRNAs was associated with coronary and multiterritorial atherosclerosis.

Methods

We prospectively recruited three groups of age- and sex-matched participants, with: 1) no coronary atherosclerosis (calcium score=0, no soft plaques in coronary angioCT scan), neither carotid or inferior limbs atherosclerosis (controls); 2) isolated obstructive coronary artery disease (CAD) (≥50% for the left main, ≥70% for other epicardial vessels) (isolated CAD group); 3) obstructive disease of the coronary, inferior limbs and carotid arterial beds (multi-territorial disease group). Obstructive atherosclerosis of carotid and inferior limbs arteries (≥50% stenosis by Doppler or angioCT imaging) was assessed in all participants. Acute atherosclerotic events or coronary revascularization within 12 months, heart failure, infections, malignancy and severe renal dysfunction were exclusion criteria. Six microRNAs with diverse mechanisms of action were selected (mir-21, miR-27b, miR-29a, miR-126, miR-146, miR-218) and measurements of their circulating levels were performed in a blinded fashion, using RT-PCR SYBR Green.

Results

Twenty four patients were included, including 8 patients in each group. Mean age was 61±9 years, and 83% were male. In patients with atherosclerosis, classical cardiovascular risk factors were globally more prevalent. The expression of miR-146 and miR-218, both of which regulate endothelial function, was significantly decreased in the isolated CAD group compared to controls (Figure; data are expressed as median [IQR]). There was a further decrease in the expression of both microRNAs in patients with multiterritorial atherosclerosis compared to patients with isolated CAD. The expression of other microRNAs did not differ. Smoking was associated with the presence of isolated CAD and multiterritorial atherosclerosis (14% vs 30% vs 56% of smokers across groups, p=0.002), and with a decreased expression of miR-218 (1.6 [0.02–83] fold vs 0.1 [0.001–0.7] fold, p=0.023).

Conclusions

The expression of the endothelial regulators miR-146 and miR-218 was decreased in patients with isolated CAD compared to controls, and even more hampered in patients with multiterritorial atherosclerosis. Higher degrees of endothelial dysfunction may therefore contribute to a more diffuse atherosclerotic presentation through miR-146 and miR-218. Atherogenesis related to smoking may be partially mediated by miR-218.

Funding Acknowledgement

Type of funding source: None

New onset atrial fibrillation after percutaneous Patent Foramen Ovale closure: how serious is this problem?

Background

Percutaneous Patent Foramen Ovale (pPFO) closure benefits for secondary prevention after cardio-embolic stroke have recently been proved. With the increasing number of cases and procedures, a concern with new onset atrial fibrillation (NOAF) has been raised.

Purpose

To evaluate long-term outcome regarding NOAF rate and to identify its predictors and clinical impact, in a real population submitted to pPFO closure.

Methods

From 2000 to 2017, consecutive patients (P) submitted to pPFO closure in a tertiary centre were prospectively enrolled. The primary endpoint was NOAF rate and secondary endpoints were all-cause, neurologic and cardiac mortality rates and recurrent ischemic events. Previous and follow-up electrocardiographic, echocardiographic and 24-hour heart rhythm monitoring data were analysed. Follow-up was performed through medical visits, medical charts consultation and a phone call based system, in order to assess clinical status, on-going treatment and events.

Results

496 patients were submitted to pPFO. Immediate success was achieved in 98.8% and 9.1% presented a residual shunt on the 1st year TEE. Mean age was 45.0±11.2 years-old with 50.2% of males. The prevalence of hypertension, hypercholesterolemia and atrial septum aneurysm (ASA) was 25.7%, 45.0% and 46.3%, respectively. Pre-procedural mean left atrial (LA) diameter was 36.0±5.3 mm. FU data was available for 490 (98.6%), for a mean FU time of 7.41±3.51 years. 34 P (6.9%) presented ischemic events recurrence (26 strokes and 8 TIA). The primary endpoint was observed in 21 P (4.3%) during the FU period.

Median time to 1st AF episode since PFO closure was 5.90±5.53 years. 11 P (52.3%) initiated oral anticoagulation. In univariate analysis, age (44.6±11.3 vs 51.8±6.0 years, p=0.005) and hypertension (24.7% vs 47.6%, p=0.019) were predictors of NOAF in this population. In multivariated analysis, only age remained a predictor of NOAF (OR 1.05 (1.007–1.101), p=0.025). LA pre pPFO closure dimensions, ASA, device type or size and the presence of residual shunt in TEE were not determinants of AF occurrence. The incidence of NOAF was associated with the need for hospitalization due to cardiac causes (19% vs 3.2%, p=0.001) and a trend towards higher rate of recurrent stroke (4.9% vs 14.3%, p=0.06).

Conclusion

Despite being a highly successful and safe procedure in most patients, pPFO closure was associated with a non-negligenciable rate of NOAF during long-term follow-up. NOAF predictors were related with classical cardiovascular risk factors, such as age and hypertension. None of the procedure or device features were associated with NOAF. Yet, a clinical impact was attributed to NOAF, with more hospitalizations and a trend towards ischemic events recurrence.

As young patients submitted to pPFO closure grow older, prevention strategies to diagnose and treat NOAF should be endeavoured.

Funding Acknowledgement

Type of funding source: None

Innate immunity is linked to the severity of stable coronary artery disease through sCD40L pathway

Introduction

Soluble CD40 ligand (sCD40L) activates different cell types involved in innate immunity, including macrophages and platelets. The influence of innate immunity, particularly of sCD40L pathway, on stable coronary artery disease (SCAD) expression is not fully understood. We evaluated if sCD40L expression is related to the presence of SCAD and to its clinical and anatomical severity.

Methods

We prospectively recruited two groups of age- and sex-matched participants: 1) without coronary artery disease (CAD) (calcium score=0, no soft plaques on coronary angioCT scan) (controls); and 2) with stable obstructive CAD (≥50% for the left main, ≥70% for other epicardial vessels, on invasive coronary angiography). Acute atherosclerotic events or coronary artery bypass grafting (CABG) within 12 months, previous percutaneous coronary intervention, heart failure, infection, malignancy and severe renal dysfunction were exclusion criteria. Clinical, laboratorial and anatomical data were prospectively collected. Serum was stored at −80°C and measurements were performed in a blinded fashion, by ELISA (sCD40L Human Quantikine).

Results

Sixty-three participants were included: 14 controls and 49 patients with SCAD. In SCAD patients, classical cardiovascular risk factors were globally more prevalent and the serum levels of sCD40L (5553±3356 vs 3099±644 ng/mL, p&lt;0.001), leucocytes counts (7.6±1.8 vs 6.4±1.7x109/L, p=0.010), neutrophils counts (4.4±1.5 vs 3.5±1.5x109/L, p=0.010) and neutrophils/lymphocytes ratio (2.4±1.1 vs 1.9±0.7, p=0.019) were significantly higher, while c-reactive protein (CRP) levels did not differ, compared to controls. sCD40L levels were positively correlated with leucocytes (r=0.36) and neutrophils (r=0.28) counts (all p&lt;0.05), but not with CRP. Clinically, sCD40L levels were associated (ANOVA p&lt;0.001) and positively correlated (Pearson r=0.54, p&lt;0.001) with angina severity (Fig. 1A). Anatomically, patients with a higher number of significant coronary artery lesions presented higher sCD40L levels (Fig. 1B); sCD40L levels were positively correlated with the number of: diseased vessels (r=0.33), significant coronary artery lesions (r=0.31), and all coronary artery lesions (r=0.33) (all p&lt;0.05), without correlation with the Gensini score. Linear regression analysis considering clinical and laboratorial data revealed that sCD40L was an independent predictor of CAD severity, as assessed by the number of significant lesions (model: sCD40L β 0.28, 95% CI 0.03–0.34; hypertension β 1.1, 95% CI 0.97–3.64). Among SCAD patients, those with previous CABG (n=15) had lower sCD40L levels than patients waiting for revascularization (n=34) (3317±1680 vs 6793±3631 ng/mL, p&lt;0.001).

Conclusions

Increased expression of sCD40L was associated with the presence of SCAD, with angina severity and with CAD severity, while previous revascularization was associated with decreased sCD40L levels.

Funding Acknowledgement

Type of funding source: None

New onset atrial fibrillation after dual chamber pacemaker implantation: long term predictors

Background

Preserving atrioventricular synchrony has been accepted as a significant advantage of atrial and dual-chamber (DDD) pacing. However, little is known about the incidence of atrial fibrillation (AF) after DDD implantation and its prognostic predictors in long term.

Purpose

To determine the incidence of new AF episodes and to identify risk factors and prognostic predictors for new-onset AF and all-cause mortality after implantation of dual-chamber pacemakers.

Population and methods

713 consecutive patients (P) who underwent colocation of DDD pacemaker, due to AV block (AVB) or sinus node disease (SND), with no prior history of AF, from 2011 to 2015. Through periodic PM interrogation, occurrence of AF (“automatic mode switch” episodes with documented AF), switch to ventricular pacing (VVIR), pacing site (apical or septal) and cumulative right ventricular (RV) pacing % were analysed.

Results

Follow-up data was available for 669 patients (93.8%) for a mean follow-up (FU) time of 47.8±22.7 months. Mean age was 72.9±10.8 years with 60.1% male. New occurrence of AF was observed in 345 P (51.6%) during the FU period; 45.7% of them were consequently anticoagulated (59.0% with NOACs). Median time to 1st AF episode since implantation was 21.6 months and in 50.9% of the cases it lasted ≥1h. In univariate analysis, 1st AF episode lasting more than 1 hour and existence of at least one episode longer than 24 hours were directly related to switch to VVIR (p&lt;0.0005; p&lt;0.0005; p&lt;0.0005) as well as prescription of anticoagulation (p=0.001; p=0.011; p&lt;0.0005).

Compared to non-AF P, those with AF were older (74.0±9.9 vs. 71.8±11.7 years; p=0.008), had higher prevalence of SND (50.0% vs 40.20%; p=0.015), had superior % of RV pacing (65.9±39.3% vs. 58.3±44.3%; p=0.021) and more frequently had RV apical pacing (70.1% vs 57.3%; p=0.001). The prevalence of hypertension, diabetes mellitus and dyslipidemia were similar in the two groups. With multivariable Cox-regression, age (HR 1.02; p=0.017), SND (HR 1.49; p=0.010), admission for HF (HR 1.55; p=0.012) and % RV pacing (HR 1.01; p=0.003) were significantly associated with the incidence of FA. Predictors of all-cause mortality in Cox regression were the occurrence of AF in 1st of FU (HR 1.67; p=0.018) and % RV pacing (HR 1.01; p=0.043).

Conclusions

New onset AF is a frequent finding after DDD pacemaker implantation and is associated with all-cause mortality in long term. Age, admission for heart failure, sinus node disease and % of RV pacing were independent predictors for AF during follow-up.

Funding Acknowledgement

Type of funding source: None

Jean Rodier: History of Manganism in Morocco

Jean Rodier (1920-2003), distinguished researcher and scientist, directed the Toxicology Department of Hygiene Institute of Rabat under the French Protectorate. From 1946, he developed numerous lines of research in occupational health, in particular on Manganism, a neurological disorder that impacted miners in his home country of Morocco. His many papers on Manganism, only one of which was published in English, describe field and laboratory research studies that focused its prevention and management.

Comparison of 3 supraspinatus tendon repair techniques - a 3D computational finite element analysis

Considering that optimal contact area and pressure at the tendon-bone interface are associated with better footprint repair and outcomes, the aim of this study was to compare the performance of standard double-row, transosseous equivalent (TOE), and partial articular supraspinatus tendon avulsion (PASTA) techniques for the treatment of full-thickness tears of the supraspinatus tendon using 3D finite element models. Loading consisted, alternately, in a preloading of 10 N and 20 N of the sutures. The footprint coverage of the standard double-row, TOE, and PASTA techniques was estimated to represent 19%, 30%, and 35%, respectively, of the repair area. The average contact pressures followed an opposite trend, i.e., the largest was estimated for the standard double-row technique, whereas the lowest was estimated for the PASTA technique. Despite the present study advancing the computational modelling of rotator cuff repair, and the results being consistent with the literature, its findings must be evaluated cautiously, bearing in mind its limitations.

Progressive secondary exo-focal dopaminergic neurodegeneration occurs in not directly connected midbrain nuclei after pure motor-cortical stroke

Transsynaptic anterograde and retrograde degeneration of neurons and neural fibers are assumed to trigger local excitotoxicity and inflammatory processes. These processes in turn are thought to drive exo-focal neurodegeneration in remote areas connected to the infarcted tissue after ischemic stroke. In the case of middle cerebral artery occlusion (MCAO), in which striato-nigral connections are affected, the hypothesis of inflammation-induced remote neurodegeneration is based on the temporal dynamics of an early appearance of inflammatory markers in midbrain followed by dopaminergic neuronal loss. To test the hypothesis of a direct transsynaptic mediation of secondary exo-focal post-ischemic neurodegeneration, we used a photochemical induction of a stroke (PTS) in Sprague-Dawley rats restricted to motor cortex (MC), thereby sparing the striatal connections to dopaminergic midbrain nuclei. To dissect the temporal dynamics of post-ischemic neurodegeneration, we analyzed brain sections harvested at day 7 and 14 post stroke. Here, an unexpectedly pronounced and widespread loss of dopaminergic neurons occurred 14 days after stroke also affecting dopaminergic nuclei that are not directly coupled to MC. Since the pattern of neurodegeneration in case of a pure motor stroke is similar to a major stroke including the striatum, it is unlikely that direct synaptic coupling is a prerequisite for delayed secondary exo-focal post ischemic neurodegeneration. Furthermore, dopaminergic neurodegeneration was already detected by Fluoro-Jade C staining at day 7, coinciding with a solely slight inflammatory response. Thus, inflammation cannot be assumed to be the primary driver of exo-focal post-ischemic cell death. Moreover, nigral substance P (SP) expression indicated intact striato-nigral innervation after PTS, whereas opposing effects on SP expression after striatal infarcts argue against a critical role of SP in neurodegenerative or inflammatory processes during exo-focal neurodegeneration.

P1433 Antiarrhythmic effects of sacubitril-valsartan therapy assessed by mechanical dispersion index

Introduction

Sacubitril/Valsartan (LCZ696) significantly reduced sudden cardiac death in the PARADIGM-HF trial. However, there is little published data regarding the possible explanations for the antiarrhythmic effects found with LCZ696 therapy.

Previous trials have shown that mechanical dispersion by strain echocardiography can predict arrhythmic events in Heart Failure (HF) patients.

The aim of this study was to compare electrocardiographic (ECG) parameters and mechanical dispersion index with left ventricular (LV) global longitudinal strain (GLS) analysis before and after LCZ696 therapy.

Methods

Prospective evaluation of chronic HF patients with LV ejection fraction ≤ 40% despite optimized standard of care therapy, in which LCZ696 therapy was started and no additional HF treatment was expected to change.

ECG and transthoracic echocardiographic data were gathered in the week before starting LCZ696 therapy and 6 months after therapy. A semiautomated analysis of LV GLS was made and mechanical dispersion index was defined as the standard deviation from the 16 time intervals corresponding to each LV segment.

Results

Of the 42 patients, 35 (83.3%) completed the 6 months of follow-up, since 2 (4.8%) patients died and 5 (11.9%) discontinued treatment for adverse events. Mean age was 58.6 ± 11.1 years.

QTc interval (451.9 vs 426.0msec, p &lt; 0.001) and QRS interval (125.1 vs 120.8msec, p = 0.033) were reduced after 6 months of LCZ696 therapy. Mechanical dispersion index (88.4 vs 78.1msec, p = 0.036) was also significantly reduced after therapy.

Conclusion

LCZ696 therapy is associated with antiarrhythmic effects with a reduction in QTc and QRS intervals in ECG and a reduction in mechanical dispersion index as assessed by LV GLS.

Abstract P1433 Figure.

1226 Prognostic impact of concomitant cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)&gt;12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull’s eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2 ± 5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57 ± 15% and 26.6% presented EF &lt; 50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS &gt; 1 was identified in 22 P (23.4%). An EF/GLS ratio &gt; 4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4 ± 25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p = 0.002), new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p = 0.05) and MACE (48.7% vs 22.2%, p = 0.01). All-cause mortality was also higher in P with RALS (31.8% vs. 12.5%, p = 0.04). P with GLS&gt;-14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p = 0.003) and MACE (p = 0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR = 4.49, p = 0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Abstract 1226 Figure. Kaplan–Meier curves and ASPB

P1787 Pharmacologic stress test: still an important prognostic factor? a follow-up study

Introduction

Dobutamine stress echocardiography (DSE) is an established exam for evaluation of extent and severity of coronary artery disease.

Purpose

To analyse the results and complications of DSE and identify prognostic predictors in patients (P) who underwent DSE for myocardial ischemia detection.

Methods

220P who underwent consecutive DSE from 2013 to 2017. P with significant valvular disease were excluded. Clinical data, echocardiographic parameters and data from follow up (FU) regarding all-cause mortality and MACEs were analysed. Mean age 64.8 ± 12.0 years(Y), 143 men (65%).

Results

88P (40%) had positive, 102 had negative and 30 had inconclusive DSE; complications rate of 15%. Prevalence of hypertension, diabetes mellitus (DM), dyslipidemia, prior MI, percutaneous coronary interventionc (PCI), coronary arterial bypass graft (CABG) and HF was 82.7%, 42.3%, 67.7%, 35.9%, 31.8%, 10.9% and 9.5%, respectively. Mean left ventricular endsystolic (LVSD) and enddiastolic dimensions were 33.7 ± 8.9 and 52.8 ± 7.1 mm. Mean resting wall motion score index (rWMSI) and peak (pWMSI) were 1.16 ± 0.28 and 1.24 ± 0.34. Mean resting GLS (rGLS) and peak GLS (pGLS) were -16.3 ± 4.3 and -16.6 ± 4.3. Mean no. of ischemic segments was 1.7 ± 2.4 and 16.8% had ischemia &gt;3 segments. There was ischemia in left anterior descending (LAD) coronary in 53P and in circumflex and right coronary territories in 18 and 68P. 22.6% had more than one ischemic territory. 43P (49.4%) underwent intervention, 38 with PCI and 5 with CABG. During a mean FU of 38.8 ± 16.8 months, 47 MACEs were observed, including 32 deaths (14.5%). Positive DSE (p = 0.012), no. of ischemic segments (p = 0.019), ischemia in the LAD (p = 0.003), rGLS (p = 0.038) and pGLS (p = 0.038) were related to the occurrence of MACEs. In Cox regression analysis, age (p = 0.005), DM (p = 0.005), HF (p = 0.006), prior CABG (p = 0.015), LVSD (p = 0.026), rWMSI (p = 0.029), pWMSI (p = 0.013) and pGLS (p = 0.038) were associated with increased all-cause mortality. Kaplan–Meier survival analysis showed that survival was significantly worse for ischemia &gt; 3 segments (log rank 0.005), ischemia of more than one territory (log rank 0.025) and pWMSI &gt;1.5 (log rank &lt; 0.0005). With multivariate Cox regression analysis, age &gt;65Y (HR 4.22, p = 0.004), DM (HR 2.49,p = 0.038) and pWMSI &gt; 1.5 (HR 9.73,p = 0.007) were independently associated with all-cause mortality.

Conclusion

In patients who underwent DSE there were some baseline and DSE-related independent predictors of long-term prognosis: age, DM and peak WMSI.

Abstract P1787 Figure. Kaplan–Meier curves

P1429 B-Type natriuretic peptide prediction of right catheterization parameters in the first year after heart transplant

Introduction

Despite being the gold-standard for hemodynamic assessment, right heart catheterization (RHC) was overcome by plasma B-Type Natriuretic Peptide (BNP) levels in daily clinical routine. However, in the first year after heart transplantation (HT), the relationship between BNP and adverse hemodynamics have yielded conflicting results.

Purpose

The aim of this study was to evaluate whether BNP values can be used to estimate adverse hemodynamics in the first year after HT.

Methods

Prospective study of consecutive RHC performed in the first year after HT (according to the endomyocardial biopsies program). Plasma BNP levels were measured at the same day.

The area under the curve (AUC) was analysed to find the BNP values with higher sensitivity and specificity to detect adverse hemodynamics.

Results

From 2017 to 2018, 50 RHC were performed. Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

Prediction of adverse hemodynamics by AUC results are represented in the table. BNP values were significantly increased in patients with pulmonary capillary wedge pressure (PCWP) &gt;12mmHg (p &lt; 0.001), cardiac index &lt;2.5L/min/m2 (p = 0.001), mean pulmonary artery pressure (mPAP) ≥25mmHg (p &lt; 0.001), pulmonary vascular resistance &gt; 1,5WU (p = 0.044) and right atrial pressure &gt;5mmHg (p = 0.003).

BNP &gt;500pg/ml had a sensitivity of 78.3% and 87.5% and a specificity of 76.0% and 67.7% to detect PCWP &gt;12mmHg and mPAP ≥25mmHg, respectively.

Conclusion Significant associations were found between BNP values and adverse hemodynamics in RHC, supporting the clinical utility of BNP in the first year after HT.

BNP prediction AUC values SR HEMODYNAMIC PARAMETERS AUC p 95% CI Best BNP value Sensitivity Specificity Pulmonary capillary wedge pressure (PCWP) &gt; 12mmHg 0.798 &lt;0.001 0.671-0.925 &gt; 500pg/ml 78.3% 76.0% Mean pulmonary artery pressure (mPAP) ≥ 25mmHg 0.830 &lt;0.001 0.714-0.946 &gt; 500pg/ml 87.5% 67.7% Cardiac output &lt; 4L/min 0.833 0.002 0.667-1.000 &gt; 1500pg/ml 77.8% 87.5% Cardiac index (CI) &lt; 2.5L/min/m2 0.810 0.001 0.663-0.957 &gt; 1150pg/ml 76.9% 86.1% Pulmonary vascular resistance (PVR) &gt; 1,5WU 0.678 0.044 0.509-0.848 &gt; 200pg/ml 83.3% 47.1% Right atrial pressure (RAP) &gt; 5mmHg 0.744 0.003 0.607-0.880 &gt; 500pg/ml 70.8% 65.4% BNP prediction

P354 Right heart catheterization parameters, echocardiography parameters and B-Type natriuretic peptide prediction of acute cellular rejection in the first year after heart transplant

Introduction

Since the mid-1970s, the diagnosis of acute cellular rejection (ACR) has been made by endomyocardial biopsy (EMB). Whether B-Type Natriuretic Peptide (BNP), transthoracic echocardiography (TTE) parameters and right heart catheterization (RHC) parameters can detect rejection in heart transplant (HT) patients have yielded conflicting results and did not overcome the use of EMB in the first year after HT.

Purpose

The aim of this study was to evaluate whether BNP, TTE and RHC parameters can be used to detect ACR in the first year after HT.

Methods

Prospective study of consecutive EMB performed in the first year after HT. Plasma BNP levels, TTE and RHC were performed at the same day.

Clinical significant ACR was defined as ≥ 2R, according to the ISHLT 2004 grading. The area under the curve (AUC) was analysed for statistically significant associations to detect ACR.

Results

From 2017 to 2018, 50 EMB were performed with the following results: 2R - 5 (10.0%); 1R- 29 (58.0%); 0 – 16 (32%). Mean age was 48.7 ± 8.3 years, with mean BNP value of 964.4 ± 1114.7pg/ml.

AUC results of BNP and several TTE and RHC parameters for the prediction of ACR are represented in the table. Right atrial pressure (RAP) value (p = 0.027) was the only significantly predictor of ACR, while isovolumic relaxation time measured by TTE revealed a borderline significant trend (p = 0.076).

RAP &gt; 10mmHg had a sensitivity of 60.0% and a specificity of 84.4% for detecting ACR.

Conclusion

Detecting ACR without EMB remains a clinical challenge, but RAP measured by RHC was a significant predictor of ACR in the first year after HT, while BNP values did not correlate with ACR.

AUC values PARAMETERS AUC p 95% CI BNP 0.658 0.251 0.405-0.911 Troponin I 0.591 0.507 0.260-0.923 Left ventricular ejection fraction 0.416 0.541 0.218-0.614 E/A 0.480 0.895 0.282-0.678 Deceleration time 0.463 0.463 0.161-0.765 Isovolumic relaxion time 0.745 0.076 0.427-1.000 Cardiac index 0.595 0.488 0.346-0.845 Pulmonary capillary wedge pressure 0.628 0.401 0.329-0.926 Mean pulmonary artery pressure 0.684 0.181 0.511-0.857 Right atrial pressure 0.804 0.027 0.631-0.978 AUC values

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