A data-informed timeline for hospital discharge with a reasonably low risk of unplanned readmission after open and minimally invasive liver resections

BACKGROUND

Postoperative complications following liver resection remain high, ranging from 20% to 50%. Patients are hospitalized for a certain period of time following liver resection because of the risk of postoperative complications. We hypothesized that the risk of complications decreases with each complication-free postoperative day after open and minimally invasive liver resections and can be stratified using a recently reported three-level complexity classification.

METHODS

Patients undergoing first liver resection without concomitant other organ resections between 2006 and 2019 were included. The three-level complexity classification was used to categorize liver resection procedures into grades I-III. We assessed the rate of cumulative postoperative complications from the time of liver resection to the time of post-hepatectomy complications (≥ Clavien-Dindo grade II).

RESULTS

Of the 911 patients included, 200 underwent resection of grade I procedures, 185 underwent resection of grade II procedures, and 526 underwent resection of grade III procedures. The risks of post-hepatectomy complications changed over time and were stratified by surgical complexity. For patients at the time of liver resection, the estimated 30-day complication rate was 21.8% for open grade I resection, 26.7% for open grade II resection, 38.4% for open grade III resection, 8.6% for laparoscopic grade I resection, and 12.5% for laparoscopic grade II resection. For patients without complications at 7 days, the estimated 30-day complication rate decreased to 2.1% for open grade I, 9.2% for open grade II, 17.6% for open grade III, 1.3% for laparoscopic grade I, and 4.5% for laparascopic grade II.

CONCLUSIONS

The post-hepatectomy complication risks were stratified by surgical complexity, liver resection approach, and the period without complication after liver resection.

Thick silk fibroin vascular graft: A promising tissue-engineered scaffold material for abdominal vein grafts in middle-sized mammals

Abdominal vein replacement with synthetic tissue-engineered vascular grafts constructed from silk-based scaffold material has not been reported in middle-sized mammals. Fourteen canines that underwent caudal vena cava replacement with a silk fibroin (SF) vascular graft (15 mm long and 8 mm diameter) prepared with natural silk biocompatible thread were allocated to two groups, thin and thick SF groups, based on the graft wall thickness. The short-term patency rate and histologic reactions were compared. The patency rate at 2 weeks after replacement in the thin and thick SF groups was 50% and 88%, respectively (p = 0.04). CD31-positive endothelial cells covered the luminal surface of both groups at 4 weeks. The elastic modulus of the thick SF graft was significantly better than that of the thin SF graft (0.0210 and 0.0007 N/m2, p < 0.01). Roundness of thick SF groups (o = 0.8 mm) was better than thin SF (o = 2.0 mm). There was significant difference between the groups (p = 0.01). SF vascular grafts are a promising tissue-engineered scaffold material for abdominal venous system replacement in middle-sized mammals, with thick-walled grafts being superior to thin-walled grafts.

Incidence, clinicopathological features, and clinical outcomes of low HER2 expressed, inoperable, advanced, or recurrent gastric/gastroesophageal junction adenocarcinoma

BACKGROUND

According to the DESTINY-Breast04 trial, treating patients with breast cancer and low human epidermal growth factor receptor 2 expressions (HER2-low) varies from that of those with no HER2 expression. However, it is interesting to know if HER2-low indicates for anti-HER2 therapy in the gastric or gastroesophageal junction (G/GEJ) adenocarcinoma. Hence we conducted this study to assess the incidence, clinicopathological features, and treatment outcomes of patients with HER2-low G/GEJ adenocarcinoma.

PATIENTS AND METHODS

This was a single-center, retrospective observational study. Patients with previously untreated G/GEJ adenocarcinoma were classified based on their HER2 status using immunohistochemistry (IHC) with or without in situ hybridization (ISH) as follows: HER2 negative (IHC 0), HER2-low (IHC 1+ or 2+/ISH-), and HER2-positive (IHC2+/ISH+ or 3+).

RESULTS

In total, 734 patients with G/GEJ adenocarcinoma were divided into three groups (HER2-negative, n = 410; HER2-low, n = 154, and HER2-positive, n = 170). The intestinal-type histology, peritoneal metastasis, and higher serum carcinoembryonic antigen (CEA) levels differed significantly among patients with negative, low, and positive HER2 statuses: intestinal-type histology (21.0%, 44.2%, and 59.8%, respectively), peritoneal metastasis (56.3%, 44.8%, and 21.8%, respectively), and higher serum CEA level (32.2%, 41.6%, and 56.5%, respectively). Improved survival was observed in the HER2-positive group than in the HER2-negative G/GEJ adenocarcinoma group [hazard ratio (HR) = 0.73, 95% confidence interval (CI) 0.59-0.89; P = 0.002]. However, the prognoses of the HER2-low and HER2-negative groups were similar (HR = 1.01, 95% CI 0.82-1.23; P = 0.843).

CONCLUSIONS

Patients with HER2-low G/GEJ adenocarcinoma exhibited intermediate and distinct characteristics than those in the HER2-negative group. Similarly, the HER2-low group's prognosis was worse than that of the HER2-positive group. Therefore developing novel therapeutic strategies targeting HER2-low G/GEJ adenocarcinoma is required.

Safety and usefulness of fluorescence imaging using methylene blue as a fluorophore in a Japanese population with hepatobiliary and pancreatic diseases: A phase I study

BACKGROUND

Methylene blue (MB) has been used to treat methemoglobinemia. Recently, a fluorescence imaging technique using MB as a fluorophore was used in several region but still not in hepatobiliary and pancreatic surgery; thus, information on the safety of intraoperative fluorescence imaging using MB in a healthy Japanese population is lacking. We aimed to evaluate the usefulness of MB fluorescence imaging in patients undergoing hepatobiliary and pancreatic surgery and the safety of intraoperative administration of MB in patients without methemoglobinemia.

METHODS

Eighteen patients undergoing hepatobiliary and pancreatic surgery were enrolled. We developed and used a fluorescence imaging system to visualize MB as fluorescence. The fluorescence intensity of the blood vessels, tumors, liver, and intestine were measured. The primary endpoint was the ability of the MB fluorescence imaging to visualize vessels and tumors with fluorescence. The secondary endpoint was the safety of fluorescence imaging using MB in patients without methemoglobinemia.

RESULTS

For the 18 patients undergoing MB fluorescence imaging, no intraoperative and postoperative complications related to MB administration occurred. Seventeen patients (94%) successfully visualized the target object as fluorescence by MB fluorescence imaging, including 100% of neuroendocrine tumors (four tumors) and peripancreatic vessels (n = 13).

CONCLUSION

The administration of MB and application of fluorescence imaging using MB can visualize blood vessels and pancreatic neuroendocrine neoplasms. And it also showed the safety of using MB as a fluorophore in Japanese patients without methemoglobinemia.

Usefulness of echocardiographic parameters in predicting the incidence of ischemic stroke in Japanese patients with non-valvular atrial fibrillation

Background

Atrial fibrillation (AF) is a risk factor for ischemic stroke (IS). We developed a novel risk score of IS (HELT-E2S2 score) in non-valvular atrial fibrillation (NVAF) patients from the combined database of 5 major AF registries in Japan. However, this score does not include echocardiographic (Echo) parameters that have been reported to be risk factors of IS, such as left atrial diameter (LAD) enlargement or increased relative wall thickness (RWT) of left ventricle (LV).

Purpose

To investigate the predictive value of Echo parameters in Japanese patients with NVAF.

Methods

After excluding patients without the Echo data, 6,032 NVAF patients were analyzed in the present study. LAD was measured in the parasternal long axis view at the end-ventricular systole. RWT was calculated as (2x posterior wall thickness)/ LV end-diastolic dimension. We compared clinical characteristics and the incidence of IS between NVAF patients divided by LAD level (High/Low LAD group) and RWT level (High/Low RWT group). To balance the follow-up period among the registries, event data from individuals whose follow-up period exceeded 730 days were excluded from the analysis.

Results

The optimal cut-off value of LAD and RWT to predict the incidence of IS with the receiver operating characteristic analysis was 43.3 mm and 0.4167, respectively. Between the High/Low LAD groups (High LAD: n=2,640 vs. Low LAD: n=3,392), age (70.3±12.1 vs. 68.3±12.5 years; p&lt;0.001), CHA2DS2-VASc score (3.02±1.84 vs. 2.57±1.78; p&lt;0.001), HELT-E2S2 score (2.20±1.31 vs. 1.55±1.33; p&lt;0.001), the prescription of oral anticoagulants (OACs) (69.5 vs. 51.5%; p&lt;0.001), LV ejection fraction (60.4±13.4 vs. 64.4±10.7%; p&lt;0.001) and RWT (0.401±0.091 vs. 0.396±0.082; p=0.02) were significantly different. Between the High/Low RWT groups (High RWT: n=2,293 vs. Low RWT: n=3,739), percentage of female (35.6 vs. 27.8%; p&lt;0.001), age (71.2±12.1 vs. 68.0±12.4 years; p&lt;0.001), CHA2DS2-VASc score (3.08±1.82 vs. 2.58±1.79; p&lt;0.001), HELT-E2S2 score (2.10±1.39 vs. 1.67±1.31; p&lt;0.001), the prescription of OACs (62.6 vs. 57.4%; p&lt;0.001), LV ejection fraction (65.5±9.9 vs. 60.9±13.0%; p&lt;0.001) and LAD (43.0±8.1 vs. 42.4±8.3; p=0.004) were significantly different. In Kaplan-Meier analysis, the incidence of IS was different between the groups during the median follow-up period of 730 days (High LAD vs. Low LAD; 1.82 vs. 1.00 per 100 person-years; p&lt;0.001, by log-rank test, High RWT vs. Low RWT; 1.86 vs. 1.06; p&lt;0.001) (Figure). Both High LAD (hazard ratio: 1.65, 95% CI: 1.12–2.46; p=0.01) and High RWT (hazard ratio: 1.43, 95% CI: 1.01–2.04; p=0.045) were independent predictors of the incidence of IS after adjustment by the components of the HELT-E2S2 score and other clinically relevant variables including co-existing diseases, gender, and the prescription of OACs (Table).

Conclusion

Echo parameters, LAD and RWT, were independently associated with the incidence of IS among Japanese patients with NVAF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Electrophysiological characteristics and catheter ablation of atypical fast-slow atrioventricular nodal reentrant tachycardia using an inferolateral left atrial slow pathway

Background

Understandings of subtypes of atypical atrioventricular nodal reentrant tachycardia (AVNRT) using variants of slow pathway (SP) are still growing. Inferolateral (inf-lat-) left atrial (LA) SP is a rare variant extending into an inf-lat-LA along the mitral annulus (MA).

Purpose

To characterize an unknown subtype of atypical fast-slow (F/S-) AVNRT using an inf-lat-LA-SP as a retrograde limb (inf-lat-LA-F/S-AVNRT).

Methods

This Japanese multicenter retrospective study enrolled 4 patients of inf-lat-LA-F/S-AVNRT that was characterized by the earliest site of atrial activation during tachycardia (EAA) between 3 and 6 o'clock along the MA. The diagnosis was made by an exclusion of AV reentrant tachycardia (AVRT) and atrial tachycardia (AT) according to the standard criteria and was confirmed by successful elimination of tachycardia and the inf-lat-LA-SP.

Results

Surface ECG during tachycardia revealed long RP appearance except one who had short RP due to a short conduction time across the inf-lat-LA-SP. During tachycardia, far-field LA activation preceding near-field activation of coronary sinus (CS) musculature was visible in the CS recording in 2. Retrograde conduction via the inf-lat-LA-SP with a decremental delay was consistently reproducible with ventricular stimulation in 2, 1 of whom had double atrial response, while it was always masked by the presence of a retrograde conduction via the fast pathway in 1 and a retrograde block at the lower common pathway in 1. An injection of a small dose of ATP transiently interrupted a retrograde conduction over the inf-lat-LA-SP, suggesting its ATP-sensitivity. Exclusion of AVRT was made by no resetting of tachycardia with left ventricular extrastimulus in 2 and VA dissociation during overdrive pacing of tachycardia in remaining 2. Exclusion of AT was made by V-A-V response after ventricular entrainment in 1 and termination without atrial capture by ventricular pacing in 2. Ablation of the right-sided SP was unsuccessful to eliminate the tachycardia, but ablation at or near the EAA by transseptal approach was successful to cure the tachycardia, associated with an elimination of a retrograde conduction over the inf-lat-LA-SP following a development of an accelerated junction rhythm in all. Low-frequency potentials preceding local atrial activation, consistent with a retrograde activation via the inf-lat-LA-SP were detected along the MA medial to the EAA in 1.

Conclusions

Differential diagnosis of tachycardia with the EAA in the inf-lat-LA and especially long RP appearance should include inf-lat-LA-F/S-AVNRT. Presumed arrhythmogenic substrate of the inf-lat-LA-SP seemed to be consistent with the remnant of embryogenic AV ring tissue in the electropharmacological and locational characteristics. Successful elimination of this AVNRT can be obtained by ablation of the inf-lat-LA-SP, but not of the right-sided SP.

Funding Acknowledgement

Type of funding sources: None.

Advantage of POLARx over ARCTIC FRONT ADVANCE PRO during pulmonary vein isolation for paroxysmal atrial fibrillation

Introduction

The electrical pulmonary vein (PV) isolation has been established as a curative therapy for paroxysmal atrial fibrillation (AF). Arctic Front™cryoballoon has been used worldwide for AF cryoablation. Recently, a new cryoballoon, POLARxTM CRYOABLATION system have been introduced, of which material of the balloon is softer and the N2O gas flow rate is higher.

Purpose

The aim was to investigate the procedural parameter and efficacy of POLARx comparing with Arctic Front.

Methods

This retrospective single center study included 101 consecutive patients who underwent paroxysmal AF ablation using cryoballoon at Keio University hospital from April 2021 to March 2022. The procedural data including the cryoballoon temperature and the number and duration of cryoablation were compared between POLARx (POLARx group) and ARCTIC FRONT ADVANCE PRO (AFA group). After the cryoablation, we added the radiofrequency application in order to maximize the isolated area when the voltage was remained inside PV (Figure 1). The necessities of the additional radiofrequency applications were also compared.

Results

In the present study, 64 patients in AFA group and 37 patients in POLARx group were analyzed. POLARx group included younger population and less females (62.8±9.9 vs 67.5±9.4 year of age, P=0.02; 13.5 vs 32.8%, P=0.04). There was no significant difference in comorbidities and examination data such as left atrium diameter or brain natriuretic peptide level. The minimal cryoballoon temperatures reached in POLARx group were lower than AFA group (−59.3±6.2 vs −47.7±7.5°C, P&lt;0.01). No difference was found in the total number and duration of cryoablation and the time to isolate PV (6.1±2.1 vs 5.9±1.6, P=0.69; 790.2±256.1 vs 776.1±235.0 sec, P=0.69; 41.8±21.3 vs 47.1±29.6 sec, P=0.44, respectively). With regard to individual PVs, the total number and duration were tended to be larger at right superior PV in POLARx group (1.9±1.1 vs 1.4±0.7, P=0.01; 231.8±123.8 vs 193.2±83.0 sec, P=0.07), while there was no significant difference at the other PVs. The rate of successful PV isolation by a single cryo-application was not different between AFA and POLARx group (54.3 vs 61.4%, P=0.17). The additional radiofrequency applications were more frequent in AFA group (14.8 vs. 4.9%, P=0.003). There was a significant difference at right inferior PV (32.8 vs 8.1%, P=0.01), while not at left superior PV, left inferior PV and right superior PV (9.4 vs 2.9%, P=0.42; 9.4 vs 5.7%, P=0.71; 7.8 vs 2.7%, P=0.41). Phrenic nerve injury was occurred 1 case in both group and esophageal ulcer was occurred in 1 case in AFA group. No other complication including cardiac tamponade was occurred.

Conclusion

The total number and duration of cryoablation were not significantly different between AFA and POLARx group, except for right superior PV. There was an advantage in largely isolating right inferior PV in POLARx group comparing with AFA group.

Funding Acknowledgement

Type of funding sources: None.

Tailor-Made Tapering Grafts for Large-Neck Aorta

Patients having a large aortic neck poses a challenge in abdominal aortic aneurysm surgery both in endovascular and open aneurysm repair, sometimes necessitating paravisceral or thoracoabdominal aneurysm repair which carries considerable perioperative risk. Here, we describe techniques of using a tailor-made tapering graft in open surgery that can be adjusted for large neck morphology. This technique helps avoid discrepancies between the proximal aorta and graft, and postoperative acute kidney injury by clamping at lower levels. The conscientious use of this technique in selected patients realizes satisfactory outcomes both in the short term and midterm in the demanding anatomy of large aortic necks.

Determination of physiological cardiac myosin-binging protein levels (cMyc) in healthy populations

Background

Cardiac myosin–binding protein C (cMyC) is a cardiac-restricted protein that has more abundant, rapid release and clearance kinetics than cardiac troponin. The current ESC guideline suggests the cMyC may provide value as an alternative to cardiac troponin. The 99th percentile value is universally endorsed as the reference cut off to aid in the diagnosis of acute myocardial infarction (AMI), however, none of the report of healthy population of cMyC.

Purpose

The aim of this study was to evaluate the distribution of cMyC values in healthy subjects.

Methods

We used two cohorts in this retrospective study. 1) Healthy subjects; a total of 500 subjects (250 men and 250 women) who had annual health examinations in 2012 in the area of Kamigoto, a suburb of Nagasaki city in Southern Japan were enrolled. All participants showed none of abnormal findings including cell blood counts, chemical analysis, liver function tests, general urine tests, occult blood tests of stool, barium swallow, mammography for women, abdominal ultrasound sonography, and electrocardiogram. All blood samples were obtained in a fasting state in the morning. 2) Chest pain subjects; we collected samples from 250 subjects including 50 with non-ST elevation myocardial infarction visited admitted to a university hospital for measurement of high-sensitivity troponin T and coronary artery assessment by coronary angiography. We measured cMyC level in both cohorts by HISCL™-800 system (Sysmex corporation, Japan). The assay has a limit of detection of 0.5 ng/L and a lower limit of quantification of 1.3 ng/L.

Result

In healthy subjects, median age (IQR) was 44 (20, 82) in men and 50 (23, 91) in women. The 99th percentile of cMyC was 27.3 ng/L, which was around one-third lower than that in previous report (87 ng/L). In chest pain subjects, the concentrations of cMyC at presentation were significantly higher in those with versus without AMI (median, 66 ng/L versus 10 ng/L, P&lt;0.001). Discriminatory power for AMI, as quantified by the area under the receiver-operating characteristic curve (AUC), was comparable for cMyC (AUC, 0.85 (95% CI 0.79–0.91) and hs-cTnT (AUC, 0.81 (95% CI 0.76–0.88)).

Conclusion

We defined the normal range of cMyC in healthy Japanese subjects. The level of cMyC at presentation provides discriminatory power comparable to hs-cTnT in the diagnosis of AMI. To determine the physiological value of a biomarker may be necessary to evaluate enough information about their health status.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant-in-Aid for Scientific Research

Efficacy and outcomes of balloon pulmonary angioplasty in elderly vs non-elderly chronic thromboembolic pulmonary hypertension patients

Introduction

Balloon pulmonary angioplasty (BPA) has been reported as an effective and safe treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, its safety and efficacy in elderly patients remains unknown.

Purpose

We investigated the effect of BPA on hemodynamics and respiratory parameters, functional capacity, and short- and long-term outcome in elderly patients.

Methods

From November 2012 to May 2018, 141 consecutive CTEPH patients who underwent BPA in a single university hospital were enrolled (age: 65 [54.5–74] years old, WHO functional class [WHO-FC] II/III/IV; 35/96/10). Patients were divided into two groups according to the age; elderly (≥75 years, N=32) and young groups (&lt;75 years, N=109). Hemodynamics (right-sided heart catheterization), biomarkers (brain natriuretic peptide), respiratory function (spirometry and diffusion capacity measurement), and functional capacity (6-minute walk distance [6MWD] and WHO-FC) were evaluated at baseline and 1-year post BPA. Procedure-related complications (in hospital death, use of percutaneous cardiopulmonary support [PCPS], and pulmonary injury) and all cause death during the follow up period were also assessed.

Results

At baseline, although elderly group had less severe hemodynamics (mPAP: 33.1±6.7 vs 39.0±11.8 mmHg, p&lt;0.05), they had poor exercise capacity and reduced pulmonary diffusion capacity, compared with young group (6MWD: 264.6±101.3 vs 369.7±105.2 m, %DLco: 42.0±12.0 vs 50.2±12.7%, all p&lt;0.05). BPA improved hemodynamics, biomarkers, exercise capacity, and pulmonary diffusion capacity in both elderly and young groups (all p&lt;0.05). There was no in-hospital death or use of PCPS in both groups, although the incidence of pulmonary injury was higher in elderly group (14.3% vs 5.3%, p&lt;0.01). Under the normalized hemodynamics 1-year after BPA in both groups, exercise capacity and pulmonary diffusion capacity were worse in the elderly group than young groups (p&lt;0.01). The incidence of all-cause death in the follow up period was higher in elderly group, all of which were due to non-pulmonary hypertension (PH)-related death (p&lt;0.01).

Conclusion

BPA was effective in improving hemodynamics and respiratory parameters and functional capacity, in associated with no critical complication, regardless of the age. Elderly patients who were treated with BPA were associated with higher incidence of non-PH-related death.

Changes of mean PAP in the two groups

Funding Acknowledgement

Type of funding source: None

A novel causative gene variant, TNFRSF13B p.Gly76Ser, in patients with pulmonary arterial hypertension

Background

Pulmonary artery hypertension (PAH) is a poor prognostic disease. Some causative genes were reported as the PAH-associated genes. However, the pathogenetic variants in PAH-associated genes have not been identified in majority of patients with idiopathic PAH.

Purpose

Our aim was to investigate the new causative gene variants associated with PAH.

Methods

We performed whole-exome sequencing in 272 patients with idiopathic/heritable PAH. Structural analysis simulation was performed to define how the candidate gene variant affected the structure of protein.

Results

We identified the heterozygous substitution change of c.226G&gt;A (p.Gly76Ser, rs146436713) in tumor necrotic factor receptor superfamily 13B gene (TNFRSF13B) (NM_012452.2) in 6 (2.2%) patients with idiopathic/heritable PAH, although the allele frequency of this rare variant is 0% in Integrative Japanese Genome Variation Database (control population database). Two of the six cases were blood relatives, although they did not have the known causative gene variants of PAH. One of these two relatives died of right heart failure despite the combination medical therapy, and her pathological anatomy demonstrated intimal thickening and medial hypertrophy in the pulmonary arteries, formation of plexiform lesions (Heath-Edwards classification grade V). Time-lapse images from structural analysis simulation showed the instability of N-terminal in the protein, which regulates the vascular inflammation, synthesized from TNFRSF13B p.Gly76Ser variant (Figure), suggesting that p.Gly76Ser variant may be involved in the development of PAH via aberrant inflammation in pulmonary vessels.

Conclusions

TNFRSF13B p.Gly76Ser variant is a candidate of causative gene variant for PAH.

Structural analysis of proteins

Funding Acknowledgement

Type of funding source: None

One-year outcome of the rule-out group according to the 0-h /1-hour algorithm with suspected myocardial infarction in Asian countries

 

Background/Introduction; A rapid rule-out or rule-in protocol based on the 0-h/1-hour algorithm using high-sensitivity cardiac troponin T (hs-cTnT) is recommended by the European Society of Cardiology (ESC). Around 40–50% were stratified into “rule-out” group, and their 30-days prognosis was excellent. However, the one-year prognosis is uncertain. We aimed to better characterize these patients.

Methods

This study was a prospective, multi-center, observational study of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS) admitted to 5 hospitals in Japan and Taiwan from 2014 November to 2018 December, respectively.

All patients underwent a clinical assessment the included medical history, physical examination, 12-lead ECG, standard blood test, chest radiography. Exclusion criteria were ST elevated myocardial infarction, chronic kidney disease (serum creatinine more than 3 mg/dL) and congestive heart failure, arrhythmia, or infection disease. The patients were divided into three groups according to the algorithm; “rule-out”, “observe” and “rule-in”. The final diagnosis was then adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, stress electrocardiography and follow-up data. The presence of acute myocardial infarction (AMI) was defined according to the Fourth Universal Definition of Myocardial Infarction. After hospital discharge patients were follow after one-year b telephone or in written form. Major adverse cardiovascular events (including death myocardial infarction, coronary artery bypass grafting, percutaneous coronary intervention (PCI)) were recorded by establishing contact with the patient and the family physicians. The primary prognosis end point was all-cause mortality.

Results

Of the 1,187 patients were analyzed after exclusion. The prevalence rate of AMI was 16.1%. According to the algorithm, 42% (n=493) of patients were assigned to “rule-out” group and had no AMI nor death. The most common final adjudicated diagnoses were atypical chest pain (80%), gallstone attack (3%) and vasospastic angina pectoris (2%). All patients with unstable angina (4.7%) underwent PCI.

Conclusion(s)

Our findings suggest that the “rule-out” group patients according to ESC 0-h/1-hour algorithm provides very high safety and efficacy for the triage toward AMI.

Funding Acknowledgement

Type of funding source: None

De-escalation/discontinuation of oxygen-therapy and medication is feasible and safe in chronic thromboembolic pulmonary hypertension patients treated with balloon pulmonary angioplasty

Introduction

There has been increasing evidence of the efficacy of balloon pulmonary angioplasty (BPA) in improving the hemodynamics, exercise capacity, and biomarkers of patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, there is no consensus on the adjustment of home oxygen therapy (HOT) and pulmonary hypertension (PH)-specific medications after BPA in patients with CTEPH.

Purpose

We aimed to examine the current status of the de-escalation/discontinuation of HOT and PH-specific medications post-BPA, and clarify its effect on subsequent hemodynamics, biomarkers, and long-term clinical outcomes.

Methods and results

From November 2012 to July 2019, 134 consecutive CTEPH patients who underwent BPA at a single university hospital were enrolled (age; 63.6±13.4 years, female; n=87 [64.9%], WHO functional class [WHO-FC] II/III/IV; 33/92/9). Hemodynamic data, functional capacity (6-minute walk distance and WHO-FC), biomarkers (brain natriuretic peptide [BNP] and high-sensitivity troponin T [hs-TropT]), and respiratory function were evaluated at baseline, immediately and 1 year post-BPA. Clinical outcomes (all-cause death and heart failure [HF] admission) were also assessed during the follow up period. The total number of sessions was 6.3±2.0, and the number of target vessels was 14.3±2.0. Mean pulmonary arterial pressure decreased from 37.8±11.2 to 20.4±5.1 mmHg 1-year after BPA (p&lt;0.01). The proportion of patients who required HOT (at rest or on exertion) and combination medical therapy (≥2 PH-specific medications) decreased 1 year post-BPA (from 59.0% to 7.5%, and from 41.8% to 10.4%, respectively; Figure). Among 79 patients who required HOT during daytime, 64 patients (81.0%) discontinued HOT just after BPA completion. Among 56 patients who required combination medical therapy, 29 (51.8%) discontinued combination therapy. Baseline factors influencing the continuation of HOT and combination medical therapy post-BPA were almost identical (i.e. lower exercise capacity and pulmonary diffusion capacity, and worse hemodynamics). Results showed that discontinuation of HOT and combination medical therapy did not affect the maintenance of improved hemodynamics and levels of BNP and hs-TropT, and no adverse clinical outcomes (all-cause death and HF hospitalization) were observed during 1 year post-BPA.

Conclusions

Most CTEPH patients discontinued HOT and PH-specific combination medical therapy after BPA, which was not associated with the deterioration of hemodynamics, functional capacity, or biomarkers. No adverse long-term outcomes were observed. De-escalation/discontinuation of HOT and PH-specific combination medical therapy after BPA is feasible and safe for patients with CTEPH.

De-escalation of HOT and medical therapy

Funding Acknowledgement

Type of funding source: None

Change of the pulmonary vein anatomy after cryoballoon ablation reflecting left atrial reverse remodeling

Background

Cryoballoon ablation (CBA) is a widely used procedure for atrial fibrillation (AF). However, the anatomical change of pulmonary veins (PVs) and the risk factors of PV stenosis is less clear. We aimed to decipher the prevalence and the predictive factors for PV stenosis after CBA.

Methods

We analyzed the data of 320 PVs from 80 patients who underwent CBA for AF (age: 62±10 years, 59 males, 75 paroxysmal AF). All patients underwent pre- and post-procedural cardiac computed tomography (mean 6.7±3.3 months after ablation). We defined the PV stenosis when the cross sectional area of PV was less than 50% compared with that of PV before the CBA.

Results

The average cross sectional PV area decreased significantly after CBA (pre- vs. post-CBA; 2.4±1.0cm2 vs. 2.3±1.1cm2, P&lt;0.001), whereas the volume of left atrium (LA) also decreased significantly (pre- vs. post-CBA; 75.0±23.2cm3 vs. 70.7±21.9cm3, P&lt;0.001). There was a weak but significant correlation between the reduction rate of PV area and that of LA volume (Pearson's correlation coefficient 0.411, p&lt;0.001). Only 6 PV stenosis were revealed, in which area reduction of more than 75% and 50–75% were observed in 2 PVs and 4 PVs, respectively. The incidence of PV stenosis was greater in female (male vs. female; 0.8% vs. 4.8%, P=0.043) and tend to be frequent in left PVs (left PVs vs. right PVs; 3.1% vs. 0.6%: P=0.107). Moreover, patients who developed PV stenosis tended to have lower weight and shorter height (PV stenosis group vs. non-PV stenosis group; 58.2±12.4kg vs. 67.7±13.0kg: P=0.078, 161.2±9.1cm vs. 167.2±8.8cm: P=0.094). There were no significant differences in the number of freezing, minimum temperature and total freezing time between PV stenosis group and non-PV stenosis group.

Conclusions

The ostial PV area decreased significantly but little after CBA, possibly due to LA reverse remodeling. The PV stenosis was more common in women and tend to be frequent in left PVs, lower weight, and shorter height patients, though severe stenosis after CBA was not observed in this study.

Funding Acknowledgement

Type of funding source: None

AB0089 THE ANALYSIS FOR THE INHIBITION OF ANGIOGENESIS BY JAK INHIBITOR

Background:

Many blood vessels are generated in the hyperplastic synovial tissue of patients with rheumatoid arthritis (RA), and lead to chronic tissue inflammation and joint destruction [1]. Janus kinase (JAK) family consisting of JAK1, JAK2, JAK3 and tyrosine kinase 2 (TYK2) are chain receptors which phosphorylate signal transducers and activators of transcription (STAT) and mediate inflammatory diseases including RA [2]. Nowadays, several JAK inhibitors such as Tofacitinib (TOF), Baricitinib (BAR) and Peficitinib (PEF) have been developed and demonstrated to have the inhibitory effects on inflammatory arthritis [3-5]. However, there were few reports concerning their effects on angiogenesis in vitro.

Objectives:

The purpose of the present study is to investigate the influence of JAK inhibitors on angiogenesis of human umbilical vein endothelial cell (HUVEC) activated by vascular endothelial growth factor (VEGF).

Methods:

The cell line of HUVECs were used for this study. The activity of proliferation and tube formation were analyzed by counting assay and tube formation assay, respectively.

In counting assay, HUVECs (5 × 104cells/ml) were seeded onto 96-well cell culture plate with 20 ng/ml VEGF including various doses (0.1µM, 1µM, 5µM) of TOF, BAR or PEF. After 48 hours incubation at 37°C in a humidified atmosphere containing 5% CO2, cell proliferation of each groups was assessed using cell counting kit. In tube formation assay, HUVECs (5 × 104cells/ml) were treated with 20ng/ml VEGF including various dose (0.1µM, 1µM, 5µM) of TOF, BAR or PEF for 00 hours, then seeded onto 48-well plate applied with Matrigel. After 24 hours incubation on Matrigel, the capillary-like tube formation of each well was photographed using phase contrast microscopy. Tube formation were quantitated by measurement of the length of branch.

Results:

HUVECs were activated in proliferation and tube formation by VEGF treatment. And, the proliferation and tube formation of HUVECs activated by VEGF were suppressed by All of TOF, BAR and PEF. In particular, TOF and PEF could suppress them highly.

Conclusion:

This study showed the inhibitory effect of JAK inhibitors on proliferation and tube formation of HUVECs activated by VEGF. In particular, the angiogenesis of HUVECs activated by VEGF was highly suppressed by TOF and PEF. VEGF is reported to regulate the angiogenesis through multi JAK-STAT signaling pathways [6]. The inhibitory effects on angiogenesis of TOF, BAR and PEF might depend on the differences in their affinity for JAKs. VEGF has been shown to a have a central involvement in the angiogenic process in RA [7]. JAK inhibitors might suppress the angiogenesis in RA synovial tissues by inhibiting VEGF signaling.

References:

[1]Scott DL, et al. Rheumatoid arthritis. Lancet. 2010.

[2]Banerjee S, et al. JAK-STAT signaling as a target for inflammatory and autoimmune diseases: current and future prospects. Drugs. 2017.

[3]William D, et al. JAK inhibitors in dermatology: the promise of a new drug class. Journal of the American Academy of Dermatology. 2017.

[4]Dhillon S. Tofacitinib: A Review in Rheumatoid Arthritis. Drugs. 2017.

[5]Markham A, et al. Peficitinib: First Global Approval. Drugs. 2019.

[6]Zhang HY, et al. Three important components in the regeneration of the cavernous nerve: brain-derived neurotrophic factor, vascular endothelial growth factor and the JAK/STAT signaling pathway. Asian journal of andrology. 2011.

[7]Paleolog EM. Angiogenesis in rheumatoid arthritis. Arthritis research. 2002.

Acknowledgments:

none

Disclosure of Interests:

None declared

SAT0019 HISTOPATHOLOGICAL CHANGES OF SYNOVIAL TISSUE IN RHEUMATOID ARTHRITIS PATIENTS TREATED WITH TNF INHIBITORS

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by hyperplasia of synovial tissues [1]. Tumor necrosis factor (TNF)-α is one of the pro-inflammatory cytokines that play a crucial role in the pathogenesis of RA synovitis, and TNF inhibitors (TNFi) were reported to force the RA to go into remission or low disease activity and have brought revolutionary impacts on RA treatment [2]. TNFi have been shown to act on inflammatory cells and form the discoid fibrosis in the sublining layers [3,4]. However, the changes of synovial tissue and the cause of discoid fibrosis in RA patients treated with TNFi has not been determined in detail.

Objectives:

The purpose of this study is to demonstrate the histological changes and the types of cells around discoid fibrosis in RA synovium treated with TNFi.

Methods:

Synovial tissues were obtained from 30 patients with RA during joint surgeries. 6 patients were treated with TNFi (1 patient with golimumab, 3 patients with etanercept, 2 patients with infliximab). As a control, synovial tissues were obtained from 6 patients who were treated only with csDMARDs (6 patients with MTX). The frozen sections were stained by hematoxylin and eosin (HE). To detect the apoptosis, TdT-mediated dUTP nick end labeling (TUNEL) was performed. The immunohistochemical characterization of the synovial cells was performed by using following antibodies: CD20 and CD3 for detecting B and T lymphocytes respectively, CD163 and CD86 for detecting M1 and M2 macrophage respectively.

Results:

In the sections stained with HE, the formation of discoid fibrosis and the other characteristic changes including hydropic degeneration, vacuolation, sclerosis of small vasculature, and the number of multilayered synovial cells was decreased in synovium from RA patients treated with TNFi. In the sections with TUNEL stain, apoptosis of lining cells around the discoid fibrosis was detected in RA synovium treated with TNFi (Figure 1a, 1b). In the sections with immunohistochemistry stain, CD86 expression increased in lining layer of RA synovium treated with TNFi. CD163 positive cells showed diffuse expression in RA synovium treated with TNFi. In contrast, CD20 and CD3 positive cells decreased around discoid fibrosis compared to control sections. These results showed indicated that the types of cells in lining and sublining layers were mainly macrophages and that the apoptosis of macrophages might form the discoid fibrosis in lining layers.

Conclusion:

This study showed the apoptosis of lining cells derived from macrophages resulted in the formation of the discoid fibrosis. These findings indicated TNFi might induce apoptosis of macrophage leading to the suppression of RA synovitis.

References:

[1] Scott Dl, et al. Progression of radiological changes in rheumatoid arthritis. Ann Rheum Dis. 1984.

[2]van der Heijde D,et al. Comparison of etanercept and methotrexate, alone and combined, in the treatment of rheumatoid arthritis: two-year clinical and radiographic results from the TEMPO study, a double-blind, randomized trial. Arthritis Rheum. 2006.

[3] Hirohata S,et al. TNF inhibitors induce discoid fibrosis in the sublining layers of the synovium with degeneration of synoviocytes in rheumatoid arthritis. Rheumatol Int. 2013.

[4] Yamanaka H,et al. Scoring evaluation for histopathological features of synovium in patients with rheumatoid arthritis during anti-tumor necrosis factor therapy. Rheumatol Int. 2010.

Acknowledgments :

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Disclosure of Interests:

None declared

AB0090 DEATH RECEPTOR 3 REGULATES THE GENE EXPRESSIONS OF VARIOUS KEY MOLECULES IN RHEUMATOID SYNOVIAL FIBROBLASTS

Background:

Rheumatoid arthritis (RA) is a chronic inflammatory disease that causes hyperplasia of synovial tissue. Death receptor 3 (DR3) is a tumor necrosis factor receptor and binds to TL1A, a member of the TNF family. DR3 is involved in the mechanism of cell proliferation and apoptosis through NF-κB signaling. Suppression of DR3 in rheumatoid synovial fibroblasts (RA-FLS) is associated with hyperplasia of rheumatoid synovial tissue [1]. We previously revealed the expression profiles regulated by TL1A, suggesting that TL1A might affect the pathogenesis of RA, including proliferation, regulation of B cells and T cells, inflammation, and cytokine processing [2].

Objectives:

In this study, we investigated the gene expression profiles regulated by DR3 in RA-FLS to reveal how DR3 is involved in the pathogenesis of RA.

Methods:

RA-FLS were from patients with RA. Four individual lines of primary cultured RA-FLS were incubated either with 1000 ng/ml of human DR3-Fc protein or 1000ng/ml of human IgG1 as a control for 12h. Gene expressions were detected by microarray assay.

Results:

Microarray data analysis revealed that DR3 up-regulated or down-regulated the expression of various genes in RA-FLS (Figure). The function of regulated genes included protein-L-isoaspartate (D-aspartate) O-methyltransferase activity, carboxyl-O-methyltransferase activity, protein carboxyl O-methyltransferase activity, regulation of cilium assembly, O-methyltransferase activity, regulation of plasma membrane bounded cell projection assembly, regulation of cell projection assembly, regulation of organelle assembly, protein methyltransferase activity, and S-adenosylmethionine-dependent methyltransferase activity. The most up-regulated 2 genes by DR3 were KIAA1109 (KIAA1109), and adhesion G protein-coupled receptor A3 (ADGRA3). The most down-regulated 2 genes by DR3 were RNA exonuclease 2 (REXO2), and family with sequence similarity 120A (FAM120A).

Conclusion:

In this study, we first revealed the expression profiles of genes regulated by DR3 in RA-FLS. KIAA1109/TENR/IL2/IL21 gene is strongly associated with RA in European descent populations [3]. ADGRA3 is a member of G protein-coupled receptors (GPCRs). GPCRs associates with the regulation of cytoskeletal organization, the cell adhesion and migration, cell proliferation and apoptosis, and cell differentiation [4]. Loss of REXO2 affects cell growth and morphology [5], and REXO2 was identified as a target gene for inflammatory bowel disease-associated variants [6]. FAM120A regulates activity of Src kinase to protect cells from oxidative stress-induced apoptosis [7]. DR3 regulates the gene expressions of various key molecules in RA-FLS and may affect the pathogenesis of RA by regulating gene expression of RA-FLS.

References:

[1]Takami N. et al., Arthritis Rheuma. 2006;54:779-787.

[2]Fukuda K. et al., Biomed Rep. 2019;1:1-5.

[3]Teixeira VH. et al., Arthritis Research & Therapy. 2009;11:R45.

[4]Hamann J. et al., Pharmacol Rev. 2015;67:338-367.

[5]Bruni F, et al., PLoS One. 2013;8:e64670.

[6]Hulur I, et al., BMC Genomics. 2015;16:138.

[7]Tanaka M. et al., Mol Cell Biol. 2009;29:402-413.

Disclosure of Interests:

None declared

Efficacy of guselkumab in a subpopulation with pustulotic arthro-osteitis through week 52: an exploratory analysis of a phase 3, randomized, double-blind, placebo-controlled study in Japanese patients with palmoplantar pustulosis

Background

Previous studies of guselkumab have demonstrated clinical benefits in patients with plaque‐type psoriasis, generalized pustular psoriasis, erythrodermic psoriasis and palmoplantar pustulosis (PPP).

Objective

The aim of this exploratory analysis of a double‐blind, multicenter, placebo‐controlled, phase 3 study in Japanese patients with PPP was to evaluate the efficacy of guselkumab in the subset of patients with pustulotic arthro‐osteitis (PAO).

Methods

Patients were randomized to receive guselkumab 100 or 200 mg at weeks 0, 4, 12 and every 8 weeks, or placebo with cross‐over to guselkumab 100 or 200 mg at week 16 (placebo group). Efficacy endpoints were changes from baseline in magnetic resonance imaging (MRI) score, EuroQOL‐5 dimensions (EQ‐5D) index score, EQ‐5D pain/discomfort dimension score and C‐reactive protein (CRP, mg/L) level in all PAO patients through week 52. Data from both guselkumab groups were combined and presented as results for a single overall guselkumab group.

Results

Among 159 patients with PPP, 66 with PAO were randomized across treatment groups. For patients with MRI data for all regions assessed, the proportion of patients in the guselkumab group with PAO characterized as severe decreased from 23.8% (10/42) at baseline to 5.4% (2/42) at week 52. The mean (SD) change from baseline at week 52 in EQ‐5D index score was 0.20 (0.17) among PPP patients with PAO and 0.15 (0.17) among those without PAO in the guselkumab group. Among all PAO patients, the proportions with an EQ‐5D pain/discomfort dimension score of no or slight pain/discomfort in the guselkumab group increased from baseline to week 52 [33.3% (7/21) vs. 87.5% (35/40)]. The mean (SD) CRP levels decreased in all PAO patients in the guselkumab group at week 52 compared to baseline [−1.71 (8.16) mg/L].

Conclusion

Guselkumab treatment showed beneficial outcomes for PAO signs and symptoms in Japanese patients with PPP.

Minimally invasive oesophagectomy with extended lymph node dissection and thoracic duct resection for early-stage oesophageal squamous cell carcinoma

BACKGROUND

Oesophageal squamous cell carcinoma is an aggressive disease owing to early and widespread lymph node metastases. Multimodal therapy and radical surgery may improve prognosis. Few studies have investigated the efficacy of radical lymph node and thoracic duct resection.

METHODS

Patients with oesophageal squamous cell carcinoma who underwent transthoracic minimally invasive oesophagectomy (TMIE) for cancer at Keio University Hospital between January 2004 and December 2016 were selected. Between 2004 and 2008, TMIE was performed in the lateral decubitus position without thoracic duct resection (standard TMIE). From 2009 onwards, TMIE with extended lymph node and thoracic duct resection was introduced (extended TMIE). Demographics, co-morbidity, number of retrieved lymph nodes, pathology, postoperative complications and recurrence-free survival (RFS) were compared between groups.

RESULTS

Forty-four patients underwent standard TMIE and 191 extended TMIE. There were no significant differences in clinical and pathological tumour stage or postoperative complications. The extended-TMIE group had more lymph nodes removed at nodal stations 106recL and 112. Among patients with cT1 N0 disease, RFS was better in the extended-TMIE group (P < 0·001), whereas there was no difference in RFS between groups in patients with advanced disease.

CONCLUSION

Extended TMIE including thoracic duct resection increased the number of lymph nodes retrieved and was associated with improved survival in patients with cT1 N0 oesophageal squamous cell carcinoma.

2206Prevalence and determinants of complicated grief in bereaved caregivers of patients admitted for cardiovascular diseases

Introduction

Few studies have examined complicated grief in bereaved caregivers of patients with cardiovascular diseases (CVD), in contrast with studies in caregivers of patients with cancers. We examined the prevalence and determinants of complicated grief among bereaved caregivers of patients with CVD.

Methods

We conducted a cross-sectional survey using a self-administered questionnaire for bereaved family members of CVD patients who had died in the cardiology departments of 9 tertiary care centers in Japan. We assessed bereaved caregiver grief status using the Brief Grief Questionnaire (BGQ), and its association with their depression (Patient Health Questionnaire-9 [PHQ-9]). Questionnaire also covered following associated factors: bereaved family member and patient characteristics, end-of-life care (Care Evaluation Scale [CES], a scale for assessment of the structure and process of care); and the quality of the deceased patients' death (Good Death Inventory [GDI]).

Results

A total of 269 bereaved caregivers (mean age, 64±12 years; 35% male) of patients with CVD (heart failure n=155 myocardial infarction n=32, cardiopulmonary arrest n=15, arrhythmia n=8, and others n=59) were enrolled in the study. Overall, 14.1% of the bereaved caregivers had complicated grief (BGQ≥8), 32.3% had subthreshold complicated grief (BGQ=5–7), and 13.3% had depression (PHQ-9≥10). Bereaved caregivers with complicated grief frequently developed depression (58% vs. 6%, p<0.001). Among the bereaved caregivers with complicated grief, the assessment of end-of-life care was worse (CES score: 28 [21–40] vs. 23 [19–39], p=0.04), and the assessment of the deceased patients' quality of death tended to be worse (GDI score: 4.0 [3.0–4.8] vs. 4.3 [3.7–4.9], p=0.05). The cause of admission as well as preferences of the patient and family (e.g., treatment [focusing on extending life vs. relieving discomfort], desire for information, place of end-of-life) were not associated with the prevalence of complicated grief. The prevalence of complicated grief was associated with loss of a spouse, poor psychological health during the deceased patients' admission, and poor preparation for the patient's imminent death (all p<0.05). Bereaved caregivers with complicated grief had experienced more decisional burdens regarding the deceased patients' treatment (55% vs. 25%, p=0.001). Notably, 64% of bereaved caregivers with complicated grief were not treated (i.e., neither routine follow-up by psychiatrists/psychotherapist nor prescription for anti-depressants/tranquilizers).

Conclusions

The prevalence of complicated grief of bereavement was 14.0%. When subthreshold complicated grief was included, the prevalence of complicated grief increased to include half of the caregivers; therefore, routine screening of the bereaved could be recommended. Clinicians should pay particular attention to bereaved families with high risk factors to identify those at risk for future development of complicated grief.

P5411Prognostic communication with hospitalized heart failure patients; the patients' perspective

Background

Informing heart failure (HF) patients about their prognosis is an important part of clinical management, particularly at the time of hospitalization. Current European Society of Cardiology guidelines recommend communicating this information to HF patients at the time of hospitalization and with any change in clinical status. However, little is known about actual patient preferences, understanding, and attitudes towards prognostic communication with their treating physicians.

Methods

We surveyed 113 consecutive hospitalized HF patients in a single university hospital. We assessed patient understanding of prognosis (likelihood of survival beyond 2 years), and compared patient expectations to model predictions. Model-predicted 2-year survival rate was calculated by the Seattle Heart Failure Model (SHFM). We also assessed patient preferences for information disclosure using the Prognosis and Treatment Perception Questionnaire (PTPQ). The PTPQ assesses patient beliefs regarding 1) the importance of knowing about prognosis, 2) the importance of knowing about treatment option, and 3) frequency of having a conversation about prognosis during the hospital stay.

Results

Enrolled patients were predominantly male (65.5%), with a mean age of 73.6±9.6 years and mean left ventricular ejection fraction was 46.2±15.4%. Median SHFM-estimated 2-year survival rate was 89.2% (interquartile range: 83.8–92.9%). Overall, patient understanding about prognosis was suboptimal. Among patients with a guarded 2-year survival (SHFM <90%: N=60), 44% reported that their likelihood of 2-year survival was >90% (Figure; red box). However, among patients with favorable 2-year survival (>90%: N=53), 38% reported a likelihood of <90% (Figure; blue box). Regarding treatment options, most patients (98%) desired to learn as many details as possible. Responses varied with regard to information on individual prognosis; whereas 51% wanted to know more about prognosis than their present status alone, a significant number (28%) of subjects answered “never” or “less often” to a query on the frequency of discussion about prognosis. Patient preference for more information about prognosis was associated with female sex (odds ratio [OR]: 2.52; 95% confidence interval [CI]: 1.12–5.69), fewer symptoms of depression (1-point increase on Patient Health Questionnaire-2, OR: 0.66; 95% CI: 0.49–0.87), and previous stroke (OR: 2.92; 95% CI: 1.04–8.19), but not other social/demographic or clinical factors (e.g., age, education, caregiver support, HF phenotype and severity, and other comorbid conditions).

Figure 1

Conclusions

There were substantial discrepancies in patient understanding of prognosis and in desire for more information from physicians. Interventions to improve prognostic understanding are warranted for HF patients, and hospitalization for HF could represent an opportunity for optimization.

P3755Left atrial enlargement as an independent risk factor for ischemic stroke in Japanese atrial fibrillation patients: pooled analysis of five major Japanese atrial fibrillation registries

Background

Atrial fibrillation (AF) increases the risk of ischemic stroke. It remains unknown whether left atrial diameter determined by routine trans-thoracic echocardiography is a risk factor for ischemic stroke in non-valvular AF (NVAF) patients.

Purpose

The aim of this study is to investigate the impact of left atrial enlargement (LAE) on the incidence of ischemic stroke in a large-scale cohort of Japanese NVAF patients.

Methods

We combined the data of 5 major AF registries in Japan, J-RHYTHM Registry, Fushimi AF Registry, Shinken Database, Keio interhospital Cardiovascular Studies, and Hokuriku AF Registry. After excluding patients without echocardiographic data, 7,672 NVAF patients were analyzed in the present study (mean age, 69.3±12.3 years; mean CHADS2 score, 1.6±1.3). We compared clinical characteristics and the incidence of ischemic stroke between NVAF patients with LAE (left atrial diameter >45 mm; LAE group) and those without (non-LAE group).

Results

The mean left atrial diameter was 43.1±8.6 mm, and the LAE group accounted for 40.0% (n=3,066) of the entire cohort. Compared with non-LAE group (60.0%, n=4,606), the LAE group was older (LAE vs. non-LAE; 70.3±12.0 vs. 68.0±12.5, p<0.01), more often non-paroxysmal type (73.7% vs. 32.1%, p<0.01), had higher CHADS2 (1.86±1.34 vs. 1.46±1.29, p<0.01) and CHA2DS2-VASc (3.02±1.83 vs. 2.53±1.78, p<0.01) scores, and more frequently received oral anticoagulant (72.9% vs. 55.0%, p<0.01).

During the median follow-up period of 774.5 days (interquartile range: 567–1466 days), ischemic stroke occurred in 241 patients (131 vs. 110 patients; 1.52 vs. 0.82 per 100 person-years). In Kaplan Meier analysis, LAE was associated with a higher incidence of ischemic stroke (unadjusted hazard ratio (HR): 1.83, 95% confidence interval (CI): 1.42–2.36; log rank p<0.01) (Figure). LAE was independently associated with increased risk of ischemic stroke (adjusted HR: 1.63, 95% CI: 1.25–2.11; p<0.01) after adjustment by the components of CHADS2 score and the use of oral anticoagulant, on multivariate Cox proportional hazard analysis.

Conclusion

In this large-scale cohort of Japanese patients with AF, LAE was an independent predictor of ischemic stroke, suggesting that this simple echocardiographic parameter could refine thromboembolic risk stratification of NVAF patients.

Acknowledgement/Funding

Japan Agency for Medical Research and Development, AMED

P6009Poor outcomes in pulmonary arterial hypertension as a member of RNF213-associated vascular diseases

Background

A variant of c.14429G>A (p.Arg4810Lys, rs112735431) in the ring finger protein 213 gene (RNF213; NM_001256071.2) has been recently identified as a risk allele for pulmonary arterial hypertension (PAH), suggesting that PAH can be added as a new member of RNF213-associated vascular diseases including Moyamoya disease and peripheral pulmonary stenosis.

Purpose

Our aim was to identify the clinical features and outcomes of PAH patients with RNF213 p.Arg4810Lys variant.

Methods

Whole-exome sequencing was performed in 139 idiopathic (or possibly heritable) PAH patients. Hemodynamics and prognosis were evaluated in the patients with RNF213 p.Arg4810Lys variant and the patients with bone morphogenic protein receptor type 2 (BMPR2) mutations.

Results

The RNF213 p.Arg4810Lys variant was identified in a heterozygous state in 11 patients (7.9%). Time-course changes in hemodynamics after combination therapy in the patients with the RNF213 p.Arg4810Lys variant were significantly poorer compared with those in BMPR2 mutation carriers (n=36) (comparison of changes in mean pulmonary arterial pressure, P=0.007). The event-free rate of death or lung transplantation was significantly poorer in RNF213 p.Arg4810Lys variant carriers than in BMPR2 mutation carriers (5-year event-free rate since the introduction of prostaglandin I2 infusion, 0% vs. 93%, P<0.001) (Figure).

Time to death or lung transplantation

Conclusions

PAH patients with the RNF213 p.Arg4810Lys variant were associated with a poor reactivity to vasodilator drugs and poor clinical outcomes even in the recent era. Earlier consideration of lung transplantation might be required for RNF213 p.Arg4810Lys variant carriers developing PAH. Documentation of the RNF213 p.Arg4810Lys variant, as well as already known pathogenic genes, can provide clinically relevant information for therapeutic strategies, leading to a personalized approach for the treatment of PAH.

P684Long-term outcomes in patients with cancer undergoing percutaneous coronary intervention: analysis from a Japan multicenter registry

Background

Cancer and cardiovascular disease (CVD) is the most common cause of death in developed countries, and substantial overlap exist in their medical care. However, the detailed and updated information on outcome of cancer patients with cardiovascular disease (CVD), particularly in clinically significant coronary artery disease (CAD) remain unknown.

Purpose

We sought to describe the prevalence and long-term outcomes of cancer patients undergoing percutaneous coronary intervention (PCI), which has become a coronerstone in the management of CVD.

Methods

Patient data extracted from a regional prospectiveprocedure-based multicenter registry for PCI was analyzed. A total of 4,455 patients who underwent PCI at 15 hospitals within metropolitan Tokyo from September 2008 to 2012 were followed for 2 years. “Active” cancer patient was defined as having a history of cancer not cured or in remission. We analyzed in acute and stable presentation.The occurrence of clinical outcomes was assessed via Kaplan-Meier survival curve, and Cox-regression hazard model to adjust for known clinical predictors.

Results

Within the studied patients, 173 (3.9%) had a concomitant “active” cancer at the time of intervention. There was a significant difference between the patients with and without active cancer in each situation. In stable presentation, cancer group were older, lower BMI, frequently had silent ischemia, COPD and cerebrovascular/peripheral disease, and less often had dyslipidemia compared with non-cancer group. In acute presentation, cancer group were older, frequently had COPD, CKD, peripheral disease and history of HF compared with non-cancer group. The prescription rate of RAAS inhibitor was lower in the cancer group than in the non-cancer group in acute presentation. Notably, in both acute and stable presentation, these patients had significantly higher risk of all-cause mortality (HR 8.01: 95%, p<0.001 and HR5.53: 95%, p<0.001, respectively), and they were also at higher risk of major cardo- and cerebrovascular events (MACCE; HR2.38, p<0.001, HR2.33, p=0.001), when referenced to non-cancer patients after 2 year of follow-up.

Conclusion

Cancer patient was present in 3.9% of all PCI patients and was strongly associated with both non-cardiac and cardiac adverse events.

P2677A combination of HEART score and a 0-hour/1-hour algorithm for early and safe triage tool for patients in observe zone

Background

The European Society Cardiology guidelines recommend that a 0-hour/1-hour (0–1hr) algorithm using high sensitivity cardiac troponin T (hs-cTnT) improves the early triage of patients with suspected non-ST elevation acute coronary syndrome (NSTE-ACS). However, diagnostic uncertainty remains in the 25–30% of patients assigned to “observe” group.

Purpose

To establish a step wise risk score system using HEART score and 0-hour/1-hour algorithm to identify the low risk group from observation group.

Methods

This study was a prospective, multi-center, observational study of patients with suspected NSTE-ACS admitted to five hospitals in Japan and Taiwan from 2014 to 2018, respectively. We applied the algorithm and calculated HEART score simultaneously. Patients were divided into three groups according to the algorithm: hs-cTnT below 12 ng/L and delta 1 hour below 3 ng/L were the “rule out” group; hs-cTnT at least 52 ng/L or delta 1 hour at least 5 ng/L were in the “rule in” group; the remaining patients were classified as the “observe” group. All patients underwent a clinical assessment the included medical history, physical examination, 12-lead ECG, continuous ECG monitoring, pulse oximetry, standard blood test, chest radiography, cardiac and abdominal ultrasonography. Patients presenting with congestive heart failure, terminal kidney disease on hemodialysis state, arrhythmia, or infection disease (which causes to increase troponin level) were excluded. Thirty-day MACE was defined as acute myocardial infarction, unstable angina (UA), or death.

Results

Of the 1,332 patients enrolled, 933 patients were analyzed after exclusion. NSTE-ACS was the final diagnosis for 122 (13.1%) patients and none of death. The HEART score less than 4 points in observation groups identified as very low risk with a negative predictive value (NPV) of 98.1% (95% confidential interval (CI); 90.1%-100%) and sensitivity of 98.0% (95% CI; 89.6%-100%). There were only one patient (0.5%) with AMI. In case of the HEART score less than 5 points, it could also identify as very low risk with a NPV of 96.7% (95% CI; 90.8%-99.3%%) and sensitivity of 94.1% (95% CI; 83.8%-98.8%). There were only three patients (1.2%) with AMI.

Conclusion

A combination of HEART score and the 0-hour/1-hour algorithm strategy rapidly identified the patient in observation group of 30-day MACE including UA where nor further cardiac testing would be needed.

Acknowledgement/Funding

JSPS KAKENHI Grant Number JP18K09554

P6531Evidence-practice gap in the preprocedural risk assessment for contrast-induced acute kidney injury

Background

Contrast-induced acute kidney injury (CI-AKI) is one of the frequently encountered and costly complications after percutaneous coronary intervention (PCI). Clinical practice guidelines strongly recommend that PCI patients should universally undergo preprocedural assessment for the risk of CI-AKI, and the contrast volume (CV) should be minimized to an achievable level, particularly among the high AKI risk patients. However, data on the CV use based on the comprehensive preprocedural risk assessment is still lacking.

Purpose

Our study aimed to 1) assess the impact of CV increase with the incidence of AKI among high AKI risk patients, and 2) retrospectively evaluate the used CV based on the preprocedural comprehensive risk assessment for patients undergoing PCI within multicenter longitudinal registry.

Methods

Between 2009 and 2018, 22,373 patients underwent PCI in 14 participating facilities, and consecutive patient data was registered. AKI was defined as a >0.3mg/dl absolute or >1.5-fold relative increase in post-PCI creatinine or new initiation of dialysis, based on the Acute Kidney Injury Network criteria. The post-procedural creatinine was defined as the highest value within 30 days after the indexed procedure. Congruent with the National Cardiovascular Data Registry (NCDR) definition, if more than 1 post-procedural creatinine level was measured, the highest value was used for determining AKI. We divided the patients into four groups according to quartile of NCDR AKI risk scores.

Results

Mean age of the patients were 68.7±11.1 years, and 79.1% were male. Mean CV use was 161.4±74.8ml. The incidence of CI-AKI was 8.9%, and was particularly high among high AKI risk patients (21.1%); CV (per 1ml linear increase) was directly associated with the occurrence of AKI (OR: 1.002 per unit in CV; 95% CI: 1.001–1.003; P<0.001) in these patients. CV during PCI decreased with the progression of chronic kidney disease (CKD), but it did not alter by the overall NCDR AKI risk score (Figure). After multivariable adjustment, CV was predicted by stage of CKD (−13.68ml; 95% CI: −12.05 to −15.30ml; P<0.001), but not by the value of pre-procedure prediction score (NCDR AKI risk score, P=0.575).

CV according to CKD/NCDR AKI risk score

Conclusions

Higher CV was directly associated with the occurrence of AKI among higher AKI risk patients. However, CV use was largely influenced by the stage of renal disease, and not with overall patient risk presented by contemporary risk scores. Our results have identified an important evidence-practice gap and emphasizes the importance of total preprocedural assessment to minimize CV and prevent subsequent AKI.

Acknowledgement/Funding

KAKENHI (16KK0186, 16H05215, 25460630, 25460777), Bayer, Daiichi Sankyo, Bristol-Myers Squibb, Teikoku Seiyaku, Sumitomo Dainippon, AstraZeneka, Pfizer

P2622Use of intravenous vasodilators in patients hospitalized with acute heart failure: insights from Tokyo cardiovascular care unit network database

Background

Despite recommendations from clinical practice guidelines, there is scant evidence confirming the effects of vasodilators on clinical outcomes in patients with acute heart failure (AHF).

Purpose

We sought to investigate the effects of intravenous vasodilators on clinical outcomes and to identify the potential patient populations that would benefit from its use.

Methods

Data of 26 212 consecutive patients urgently hospitalized for AHF between 2009 and 2015 were extracted from a multicenter data registration system (Tokyo Cardiovascular Care Unit Network Database, including 72 institutions within the Tokyo metropolitan area in Japan). Patients who did not present with typical AHF episodes, including those without pulmonary congestion on physical and/or chest X-ray and serum B-type natriuretic peptide level <500 pg/ml, as well as those who had hypotension and/or hypoperfusion (systolic blood pressure [SBP] <100 mmHg) as dominant presentation, were excluded. Propensity scores were calculated with multiple imputation and 1:1 matching performed between patients with and without vasodilators. The primary endpoint was in-hospital mortality and the secondary endpoints were length of intensive/cardiovascular care unit (ICU/CCU) stay and hospital stay.

Results

Overall, 8 863 patients were included in the present analysis; they were predominantly male (57%) with a median age of 79 (interquartile range: 70–86) years. Compared with the group without vasodilator use, the vasodilator group had higher SBPs and heart rates and higher frequency of assisted ventilation use, but lower frequency of intravenous diuretics use. After propensity score matching, there were no significant differences in in-hospital mortality rates (7.8% vs. 8.9% in patients without vasodilators, p=0.16) or in length of ICU/CCU stay (5.8 days vs. 5.4 days, p=0.44) and hospital stay (22.7 days vs. 23.8 days, p=0.22) between the groups. However, in subgroup analyses, favorable impacts of vasodilator use on in-hospital mortality were observed among patients who had higher SBPs and among those who had no atrial fibrillation upon admission (Figure). In addition, vasodilators were likely to be more effective in AHF patients with SBP increasing; while levels below 140 mmHg of SBP appeared to be associated with an increased risk for mortality among patients treated with vasodilators compared with those without vasodilators.

Figure 1

Conclusions

In patients with AHF, vasodilator use was not universally associated with improved in-hospital outcomes; however, its effect was dependent of individual clinical presentation. Detailed phenotyping might aid tailoring of treatment strategies for patients with AHF.

Acknowledgement/Funding

the Tokyo Metropolitan Government

P2676Prospective validation of the 2015 ESC 0-hour/1-hour algorithm using high-sensitivity cardiac troponin T in Asian countries

Background/Introduction

Implementation of the 2015 ESC 0-hour/1-hour algorithm using high-sensitivity troponin (hs-cTn) T in Asian countries presents a challenge for clinical practice.

Purpose

We aimed to prospectively validate the 0-hour/1-hour algorithm in Asian countries.

Methods

We conducted a prospective, multi-center, international cohort already utilizing 0-hour/1-hour algorithm using hs-cTnT for evaluation of patients with suspected of non-ST elevation acute coronary syndrome (NSTE-ACS). All patients underwent a clinical assessment the included medical history, physical examination, 12-lead ECG, continuous ECG monitoring, pulse oximetry, standard blood test, chest radiography, cardiac and abdominal ultrasonography. Patients presenting with congestive heart failure, terminal kidney disease on hemodialysis state, arrhythmia, or infection disease (which cause to increase troponin level) were excluded. Patients were divided into three groups according to the algorithm: hs-cTnT below 12 ng/L and delta 1 hour below 3 ng/L were the “rule out” group; hs-cTnT at least 52 ng/L or delta 1 hour at least 5 ng/L were in the “rule in” group; the remaining patients were classified as the “observational” group. The final diagnosis was then adjudicated by 2 independent cardiologists using all available information, including coronary angiography, coronary computed tomography, stress electrocardiography and follow-up data. The presence of acute myocardial infarction (AMI) was defined according to the Fourth Universal Definition of Myocardial Infarction.

Results

Of the 1,332 patients enrolled in 2014 to 2018, 933 patients were analyzed after exclusion. AMI was the final diagnosis for 122 (13.1%) patients. The algorithm ruled out AMI in 401 patients with a negative predictive value and sensitivity of 100% (95% confidential interval [CI], 98.6%-100%) and 100% (95% CI, 94.0%-100%), respectively, in the rule-out group. None of the patients were diagnosed with AMI. Among the 211 patients classified into the rule-in group, 90 were diagnosed as having AMI. The positive predictive value and specificity were 43.1% (95% CI, 36.2%-50.2%) and 78.3% (95% CI, 74.5%-81.7%), respectively. The median length of hospital stay was 159 min (142–180) in rule out group.

Conclusion(s)

Our findings suggest that the 0-hour/1-hour algorithm using hs-cTnT provides very high safety and efficacy for the triage toward rapid rule-out to rule-in of AMI.

Acknowledgement/Funding

JSPS KAKENHI Grant Number JP18K09554

Purification, Rheological Characterization, and Visualization of Viscous, Neutral, Hetero-exopolysaccharide Produced by Lactic Acid Bacteria

Viscous exopolysaccharide (EPS)-producing lactic acid bacteria (LAB) have received increasing interest in the dairy industry because of their capability to improve the texture and mouthfeel of fermented dairy products. To date, enormous efforts have been made to reveal the relationship between texture and EPS production in fermented milk products such as yogurt. However, the structure-rheology relationship of EPSs themselves is not yet well understood due to their low yields in general and their wide variety of chemical structures. In this chapter, we describe common techniques for the purification, visualization, and rheological analysis of viscous EPSs produced by LAB.

Size of recurrent laryngeal nerve as a new risk factor for postoperative vocal cord paralysis

Recurrent laryngeal nerve paralysis (RLNP) is a frequent and serious complication following esophageal cancer surgery. Therefore, this study aims to evaluate the correlation between recurrent laryngeal nerve (RLN) size and RLNP. This was a retrospective study of esophageal cancer patients who underwent thoracoscopic esophagectomy from January 2012 to December 2014. Eighty-four patients were included in the primary analysis. Diameter of the RLN was measured using the digital video recording of surgical procedures by the ratio between scissor and RLN. For evaluation of vocal cord paralysis or paresis, indirect laryngoscopy was performed. Because RLNP more frequently occurs on the left side than the right, we evaluated the correlation between size of the left RLN and left RLNP. The median size of the left RLN was 1.51 mm. We found that the incidence of postoperative left RLNP (Clavien-Dindo classification ≥1) was significantly higher (71% vs. 24%; P < 0.001) in thin RLNs (≤1.5 mm) than in thick RLNs (>1.5 mm). Thin RLN (P < 0.001), female sex (P = 0.025), and being overweight (P = 0.034) were identified as significant independent risk factors for postoperative RLNP. RLNP more easily occurred when the RLN was thin. It is difficult to confirm occurrence of postoperative RLNP before and at extubation. Therefore, it is helpful to know its risk factors including size of RLN.

Meta-analysis of the impact of postoperative complications on survival after oesophagectomy for cancer

Background

Oesophagectomy has a high risk of postoperative morbidity. The impact of postoperative complications on overall survival of oesophageal cancer remains unclear. This meta‐analysis addressed the impact of complications on long‐term survival following oesophagectomy.

Methods

A search of PubMed and Cochrane Library databases was undertaken for systematic review of papers published between January 1995 and August 2016 that analysed the relation between postoperative complications and long‐term survival. In the meta‐analysis, data were pooled. The main outcome was overall survival (OS). Secondary endpoints included disease‐free (DFS) and cancer‐specific (CSS) survival.

Results

A total of 357 citations was reviewed; 21 studies comprising 11 368 patients were included in the analyses. Overall, postoperative complications were associated with significantly decreased 5‐year OS (hazard ratio (HR) 1·16, 95 per cent c.i. 1·06 to 1·26; P = 0·001) and 5‐year CSS (HR 1·27, 1·09 to 1·47; P = 0·002). Pulmonary complications were associated with decreased 5‐year OS (HR 1·37, 1·16 to 1·62; P < 0·001), CSS (HR 1·60, 1·35 to 1·89; P < 0·001) and 5‐year DFS (HR 1·16, 1·00 to 1·33; P = 0·05). Patients with anastomotic leakage had significantly decreased 5‐year OS (HR 1·20, 1·10 to 1·30; P < 0·001), 5‐year CSS (HR 1·81, 1·11 to 2·95; P = 0·02) and 5‐year DFS (HR 1·13, 1·02 to 1·25; P = 0·01).

Conclusion

Postoperative complications after oesophagectomy, including pulmonary complications and anastomotic leakage, decreased long‐term survival.