Understanding addiction in e-cigarette users – the EVAPE project

Background

Electronic cigarettes (e-cigarettes) are often advertised as a healthier option to combustible cigarettes and as smoking cessation aid. However, e-cigarettes are a growing health concern and their addictive potential remains to be fully understood. Within the EValuation of the Addictive Potential of E-cigarettes (EVAPE) project, we studied subjective and objective measures of addiction in relation to e-cigarette use.

Methods

This cross-sectional analysis was based on 832 participants of the first wave (2016) of England from the ITC Four Country Smoking and Vaping (4CV) Survey, who were using e-cigarettes daily or weekly for at least four months. Perceived addiction to e-cigarettes was categorised as very vs. not/somewhat addicted, and perceived addictiveness of e-cigarettes relative to combustible cigarettes as equally/more addictive vs. less addictive. Objective measures of addiction included urge to vape, time to first vape after waking, frequency of use, and used nicotine strength. We examined associations between these objective and subjective measures of addiction using multivariate logistic regression, adjusted for age, gender, education, and cigarette smoking.

Results

17.8% of participants reported feeling very addicted to e-cigarettes and 42.3% considered e-cigarettes equally/more addictive than combustible cigarettes. Those who felt very addicted had higher odds of regarding e-cigarettes as more addictive (OR 3.43 (95%-CI 2.29-5.19)). All objective measures of addiction were associated with higher perceived addiction, whereas only a shorter time to first vape was associated with perceived product addictiveness.

Conclusions

Subjective measures of addiction to e-cigarettes, in particular perceived addiction, correspond with objective measures. Understanding the addictive potential of e-cigarettes is the cornerstone for developing new strategies for prevention and treatment, and ultimately understanding their role from a public health perspective.

Key messages

A matter of freedom? Right-wing populist frames of Austria’s smoke-free policy

Background

Even though right-wing populist parties (RWPP) are increasingly influential in Europe, their position on public health has hardly been researched. I aimed to fill this research gap by focusing on the case of the FPÖ (Freiheitliche Partei Österreichs) and its opposition to Austriás smoke-free policy. Understanding RWWP positions on health policy can help to prevent detrimental influences on health policy making. Therefore, this project aimed to investigate how the FPÖ framed Austria’s smoke-free policy and whether newspaper articles reflect these frames.

Methods

Online archives of the three most-read Austrian newspapers (Standard, Kurier, Kronenzeitung) were searched for articles on the policy published in November 2019, when the policy was implemented. Furthermore, speeches by FPÖ politicians in the parliamentary debate on the policy in June 2019 were identified via the parliamentary archive. Drawing on 4 speeches by FPÖ politicians and 29 newspaper articles, I used frame analysis to answer the research question.

Results

The analysis yielded that FPÖ politicians used authoritarian, populist, and libertarian frames to argue against the implementation of the smoke-free policy. Thus, the policy was portrayed as not being in the interest of the people, restricting personal and economic freedom, and as elitist. These frames were not reflected in newspaper reports that mainly focused on the practical aspects of the policy implementation. However, in contrast to politicians supporting the policy, FPÖ politicians were overrepresented in newspaper reports representing 47% of political actors cited in newspaper articles.

Conclusions

Authoritarian, populist, and libertarian frames were used by the FPÖ in opposition to the smoke-free policy. While these frames were not replicated by Austrian newspapers, RWP politicians were overrepresented in articles on the policy. These findings illustrate the importance of effective counter-framing by health advocates.

Key messages

• RWPP used authoritarian, populist, and libertarian frames to oppose Austria’s smoke-free policy.

• Even though RWPP frames were not replicated in newspaper articles, RWPP politicians were overrepresented in reports on the policy.

OP0279 CAR-T CELL TREATMENT OF REFRACTORY SYSTEMIC LUPUS ERYTHEMATOSUS- SAFETY AND PRELIMINARY EFFICACY DATA FROM THE FIRST FOUR PATIENTS

Background

While treatment of Systemic lupus erythematosus (SLE) has substantially improved, a subset of patients experiences severe progressive disease despite T- and B cell targeted therapy. Furthermore, drug-free remission and seroconversion is difficult to achieve in SLE to date

Objectives

To study the safety, tolerability, and preliminary efficacy of deep B cell depletion using autologous CD19 chimeric antigen receptor (CAR) T cells in patients with severe and treatment-refractory SLE

Methods

The CAR product was manufactured by CliniMACS Prodigy system (Miltenyi Biotec, Bergisch Gladbach, Germany). T-cells were enriched from the patients’ peripheral blood apheresis product and 1x108 cells were used as starting cell population. The cells were transfected with a lentiviral vector encoding an anti-CD19 CAR is composed of the FMC63 scFv, a CD8- derived hinge region, TNFRSF19-derived transmembrane domain, CD3ζ intracellular domain, and 4-1BB co-stimulatory domain (Miltenyi Biotec) and expanded for 12 days. After conditioning with cyclophosphamide/ fludarabine patients received 1x106 CD19-CAR-T cells/kg body weight as a single infusion. All SLE treatments with the exception of low dose prednisolone were stopped before CAR-T cell administration. After CAR-T cell treatment, also prednisolone was stopped. Tolerability was assessed by monitoring for Cytokine-release syndrome (CRS), immune-related effector cell neurotoxicity syndrome (ICANS) and infections. Preliminary efficacy was assessed by reaching a Lupus Low Disease Activity State (LLDAS), seroconversion in dsDNA antibodies and ANA and cessation of all SLE-specific treatments

Results

As of January 22, 2022, our 4 SLE patients had been treated with CD19 CAR-T cells with a follow up of 10 months (patient 1, female aged 20, SLEDAI-2K: 16), 7 months (patient 2, male aged 22; SLEDAI-2K:8), 2 months (patient 3, female aged 22; SLEDAI 2K: 6), and 1 month (patient 4; female aged 24; SLEDAI-2K: 6), respectively. All patients had active severe SLE with failure of standard treatment including pulsed steroids, hydroxychloroquine, mycophenolate, cyclophosphamide, intravenous immunoglobulins, rituximab and belimumab before CD19 CAR-T cell administration. All patients had active kidney disease. No infections occurred. All four patients experienced fever without proof of infectious disease (CRS °I); only one patient was treated with a single dose of tocilizumab. No ICANS and no CRS of other organs occurred. In vivo, CAR-T cells rapidly expanded to a maximum of 27,6% (day 9, patient 1), 41,2% (day 9, patient 2), 11,5% (day 9, patient 3) and 59,1% (day 9, patient 4) of total circulating T cells followed by a typical decline, with circulating CAR-T cells being continuously detectable during the next months. Expansion of CAR T cells preceded the complete and sustained depletion of circulating B cells. Patient 1 experienced sustained drug-free remission (SLEDAI-2K=0) with complete loss of ANA and dsDNA antibodies despite reappearance of B cells at 6 months. Patient 2 also experienced complete loss of ANA and dsDNA antibodies with B cells not yet returned. Low-level proteinuria remained most likely due to previously accrued damage in glomerular filter function (SLEDAI-2K: 2). Patient 3 and patient 4 had a shorter observation period to date but also achieved clinical remission (both SLEDAI-2K 0). All patients met LLDAS and could successfully stop all SLE-specific medication, including glucocorticoids. No SLE flare occurred so far.

Conclusion

Taken together, these data show that CD19 CAR T-cell therapy is well tolerated and may induce rapid remission of severe refractory SLE.

References

[1]Mougiakakos D et al., CD19-Targeted CAR T Cells in Refractory Systemic Lupus Erythematosus. N Engl J Med 2021;385:567-569.

Disclosure of Interests

None declared

Clinical outcomes of pacemaker implantations before and after cancer diagnosis

Background

Cardiotoxicity caused by anticancer treatment affects cardiac conduction. Clinical outcomes of pacemaker patients with newly diagnosed cancer are insufficiently understood.

Purpose

The aim was to investigate the effect of anticancer therapy on pacemaker properties.

Methods

All patients with pacemaker and confirmed cancer diagnosis treated with chemotherapy at our tertiary university hospital were included in this study. The pacemaker database (containing pacemaker related information) was matched with hospital-wide electronic health records (containing cancer types, comorbidities and echo data). Survival data were retrieved from the Statistics Austria Federal Institute. Clinical and pacemaker data of patients with previously diagnosed cancer requiring pacemaker implantation (Group A) were compared to patients with pre-existing pacemaker followed by cancer diagnosis (Group B).

Results

Out of 972 included patients, 295 patients (30.3%) had the pacemaker implantation after their first cancer diagnosis (Group A), and 677 patients (69.7%) had already a pacemaker before their first cancer diagnosis (Group B). Cancer types are displayed in Figure 1. The following cancer types were associated with increased likelihood for pacemaker implantation after cancer diagnosis (Group A): kidney cancer (OR 2.07, 95% CI 1.12 to 3.83, P=0.02), lymphomas (OR 2.27, 95% CI 1.21 to 4.26, P=0.01), and eye cancer (OR 9.29, 95% CI 1.03 to 83.50, P=0.047). Patients in Group A were older at pacemaker implantation (76.0 years [IQR 68.0–82.2] vs. 72.1 years [IQR 64.3–78.0], P<0.001), and single-chamber pacemakers were less frequent (21.8% vs. 32.1%, P=0.001). Pacemaker implantation due to bradycardic atrial fibrillation was less frequent in Group A (15.6% vs. 21.8%, P=0.03), but implantation due to an “unspecified” indication was increased (20.6% vs. 12.7%, P=0.002). Patients in Group A had lower pacing threshold at baseline but had a stronger increase in pacing threshold during the follow-up as indicated in Table 1. No differences regarding left or right ventricular function, left or right end-diastolic diameter, or mitral or tricuspid regurgitation were detected between the groups. Patients in Group A had smaller left atria (59.7±10.7mm vs. 63.9±24.0mm, P=0.02) and smaller right atria (57.9±10.4mm vs. 61.2±11.8mm, P=0.001). Patients with cancer diagnosis requiring pacemaker had worse 10-year survival (31.2% vs. 51.1%, log-rank P<0.001) as shown in Figure 1.

Conclusion

Kidney cancer, lymphoma, and cancer of the eye were associated with increased probability of pacemaker implantation after cancer diagnosis. The significant increase in pacing threshold in patients undergoing chemotherapy could be associated with chemotherapy-induced cardiotoxicity.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union's Horizon 2020 Future and Emerging Technologies Programme Figure 1. Cancer types and survivalTable 1. Baseline characteristics

The prognostic impact of fibroblast growth factor-23 on cardiovascular death after cardiac surgery

Background

Fibroblast growth factor 23 (FGF-23) participates in phosphate and vitamin D metabolism and proved to be associated with an increased risk for fatal events in individuals presenting with cardiovascular disease. In the era of personalized medicine and individualized prognostication, the identification of novel risk markers seems of major importance in terms of state-of-the-art patient care. Since data on the prognostic potential of FGF-23 in individuals undergoing cardiac valve and/or coronary artery bypass graft (CABG) surgery remain scarce, we aimed to investigate the impact of FGF-23 on cardiovascular (CV) death in an unselected patient population after cardiac surgery.

Methods

Within the present investigation, patients undergoing elective cardiac valve and/or CABG surgery were prospectively enrolled at the Department of Cardiac Surgery of our Medical University. Preoperative blood values were assessed immediately before the surgical intervention. FGF-23 concentrations were measured via FGF Quantikine ELISA Kit (R&D Systems, Minneapolis, USA). Patients were followed prospectively until the primary study endpoint (CV death) was reached. Cox regression models were calculated and adjusted for age, sex, diabetes, heart failure, body mass index, prior myocardial infarction, hypertension and coronary artery disease.

Results

In total, 462 patients were included in the present analysis and followed over a median of 3.9 years. During follow-up 67 (14.5%) patients died. The patients' median age was 70 years (interquartile range [IQR] 60 to 75) and 133 (28.8%) were female. The median FGF level in the entire study population was 1.9 pmol/L (IQR 1.2 to 3.5). After stratification into tertiles (T) of FGF-23 (median FGF-23 T1: 0.95 pmol/L [IQR 0.65 to 1.19], T2: 1.93 pmol/L [IQR 1.64 to 2.28] T3: 4.80 pmol/L [IQR 3.54 to 8.09]), patients in the highest FGF-23 tertile had highest rates of CV death (T1: 4.8%, T2: 6.8%, T3: 19.1%; P-logrank <0.001; Figure A). Moreover, there was a strong association between FGF-23 and CV death (Adj. hazard ratio for 1-unit increase in standardized log-transformed biomarker 1.44, 95% CI: 1.19 to 1.75; P-value <0.001). The risk of CV death increased within higher tertiles of FGF-23 (T3: adj. HR 3.59 [95% CI 1.48–8.71], P-value= 0.005) (T1 was chosen as reference). FGF23 also showed good discriminatory performance (area under the curve [AUC] 0.69, 95% CI 0.61–0.77).

Conclusion

FGF-23 proved to be a strong and independent predictor for CV death in individuals undergoing elective cardiac valve and/or CABG surgery. This biomarker may provide improved risk assessment and fosters individualized patient care in this highly vulnerable patient population in the era of personalized medicine.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan Meier curves

Cerebral protection in TAVR – can we do without? Impact on stroke rate, length of hospital stay and 12-month mortality

 

Stroke associated with transcatheter aortic valve replacement (TAVR) is a potentially devastating complication. Until recently, the Sentinel™ Cerebral Protection System (CPS; Boston Scientific) has been the only commercially available device for mechanical prevention of TAVR-related stroke. However, its effectiveness is still undetermined.

Methods

Between January 2019 and August 2020 consecutive patients were randomly assigned to TAVR with or without Sentinel™ in a 1:1 fashion. We defined as primary endpoint clinically detectable cerebrovascular events within 72 hours after TAVR, and as secondary endpoints LOS and 12-month mortality. Logistic and linear regression analyses were used to assess associations of Sentinel™ use with endpoints.

Results

Of 411 patients (80±7 y/o, 47.4% female, EuroSCORE II 6.3±5.9%), Sentinel™ was used in 213 (51.8%), with both filters correctly deployed in 189 (46.0%). 20 (4.9%) cerebrovascular events were recorded, 10 (2.4%) of which were disabling strokes. Sentinel™ reduced cerebrovascular events in univariate analysis by 71% (OR 0.29, 95% CI 0.11–0.82; p=0.02) and after multivariate adjustment by 75% (adj. OR 0.25; 95% CI 0.08–0.80; p=0.02). Sentinel™ use was also significantly associated with shorter LOS (8.4±9.6 versus 6.7±6.1 days; p=0.03) and lower 12-month all-cause mortality (15.7% versus 7.5%, p=0.01).

Conclusions

In the present prospective all-comers TAVR cohort, Sentinel™ significantly 1) reduced cerebrovascular events, 2) shortened LOS, and 3) improved 12-month survival. These data promote the use of a CPS when implanting TAVR valves.

Funding Acknowledgement

Type of funding sources: None.

Plasma and Lung Tissue Pharmacokinetics of Ceftaroline Fosamil in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass: an In Vivo Microdialysis Study

Ceftaroline fosamil, a fifth-generation cephalosporin antibiotic with activity against methicillin-resistant Staphylococcus aureus (MRSA), is currently approved for the treatment of pneumonia and complicated skin and soft tissue infections. However, pharmacokinetics data on free lung tissue concentrations in critical patient populations are lacking. The aim of this study was to evaluate the pharmacokinetics of the high-dose regimen of ceftaroline in plasma and lung tissue in cardiac surgery patients during intermittent and continuous administration. Nine patients undergoing elective cardiac surgery on cardiopulmonary bypass were included in this study and randomly assigned to intermittent or continuous administration. Eighteen hundred milligrams of ceftaroline fosamil was administered intravenously as either 600 mg over 2 h every 8 h (q8h) (intermittent group) or 600 mg over 2 h (loading dose) plus 1,200 mg over 22 h (continuous group). Interstitial lung tissue concentrations were measured by in vivo microdialysis. Relevant pharmacokinetics parameters were calculated for each group. Plasma exposure levels during intermittent and continuous administration were comparable to those of previously published studies and did not differ significantly between the two groups. In vivo microdialysis demonstrated reliable and adequate penetration of ceftaroline into lung tissue during intermittent and continuous administration. The steady-state area under the concentration-time curve from 0 to 8 h (AUCss 0-8) and the ratio of AUCSS 0-8 in lung tissue and AUC in plasma (AUClung/plasma) were descriptively higher in the continuous group. Continuous administration of ceftaroline fosamil achieved a significantly higher proportion of time for which the free drug concentration remained above 4 times the minimal inhibitory concentration (MIC) during the dosing interval (% fT>4xMIC) than intermittent administration for pathogens with a MIC of 1 mg/liter. Ceftaroline showed adequate penetration into interstitial lung tissue of critically ill patients undergoing major cardiothoracic surgery, supporting its use for pneumonia caused by susceptible pathogens.

Right ventricular function and outcome in patients undergoing transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Background. Right ventricular dysfunction (RVD) on echocardiography has been shown to predict outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). However, a comparison with the gold standard, RV ejection fraction (EF) on cardiovascular magnetic resonance (CMR), has never been performed.

Objectives. To compare RV function parameters on echocardiography and CMR for prognostication in TAVI patients.

Methods. Consecutive patients scheduled for TAVI underwent echocardiography and CMR.  RV fractional area change (FAC), TAPSE, RV free-lateral-wall tissue Doppler (S’) and strain were assessed on echocardiography, and RVEF on CMR. Patients were prospectively followed. Adjusted regression analyses were used to report the strength of association per 1-SD decline for each RV function parameter with 1) NT-proBNP levels, 2) prolonged in-hospital stay (>14 days), and 3) a composite of heart failure hospitalization and death.

Results. 204 patients (80.9 ± 6.6y/o; 51% female; EuroSCORE-II: 6.5 ± 5.5%) were included. At a cross-sectional level, all RV function parameters were associated with NT-proBNP levels, but only FAC and RVEF were significantly associated with a prolonged in-hospital stay (adj. OR 1.98 [95%CI: 1.15-3.41], p = 0.013 and 2.29 [95%CI: 1.43-3.67], p = 0.001, respectively). A total of 56 events occurred during follow-up (mean 13.7 ± 9.5months). After adjustment for the EuroSCORE-II and NT-proBNP levels, only RVEF was significantly associated with the composite endpoint (adj. HR 1.69 [95%CI: 1.24-2.30], p < 0.001, Figure 1).

Conclusions. RVD as defined by echocardiography is associated with an advanced disease state, but fails to predict outcomes after adjustment for pre-existing clinical risk factors in TAVI patients. In contrast, RVEF on CMR is independently associated with heart failure hospitalization and death.

Abstract Figure 1. Outcome analysis

Right ventricular rather than left ventricular systolic dysfunction predicts outcome in patients undergoing transcatheter aortic valve implantation: insights from cardiac magnetic resonance imaging

Background

Right ventricular (RV) function is strongly associated with outcome in heart failure. Whether it also adds important prognostic information in patients undergoing transcatheter aortic valve implantation (TAVI) is unknown.

Methods

We consecutively enrolled patients with severe aortic stenosis (AS) scheduled for TAVI and preprocedural cardiac magnetic resonance (CMR) imaging. Kaplan-Meier estimates and multivariate Cox regression analyses were used to identify factors associated with outcome. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint.

Results

423 consecutive patients (80.7±7.3 years; 48% female) were prospectively included, 201 (48%) underwent CMR imaging. 55 (27%) patients presented with RV systolic dysfunction (RVSD) defined by RV ejection fraction (RVEF) <45%. RVSD was associated with male sex (69 vs. 40%; p<0.001), New York Heart Association (NYHA) functional status (NYHA ≥ III: 89 vs. 57%; p<0.001), NT-proBNP serum levels (9365 vs. 2715 pg/mL; p<0.001), and history of atrial fibrillation (AF: 51 vs. 30%; p=0.005). On CMR, RVSD was associated with left ventricular (LV) volumes (end-diastolic: 187 vs. 137 mL, end-systolic: 119 vs. 53 mL; p<0.001) and EF (39 vs. 64%; p<0.001).

A total of 51 events (37 deaths, 14 hospitalizations for heart failure) occurred during follow-up (9.8±9 months). While LVSD (LVEF <50%) was not significantly associated with outcome (HR 0.83, 95% CI: 0.33 – 2.11; p=0.694), RVSD showed a strong and independent association with event-free survival by multivariate Cox regression analysis (HR 2.47, 95% CI: 1.07–5.73; p=0.035), which was adjusted for all relevant CMR parameters (LV volumes and EF), cardiovascular risk factors (sex, NYHA, AF, diabetes mellitus type II, use of diuretics), and routine biomarkers (NT-proBNP, creatinine).

Conclusions

RVSD rather than LVSD, as determined on CMR, is an important predictor of outcome in patients undergoing TAVI. RV function might thus add useful prognostic information on top of established risk factors.

Figure 1. Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

Save your brain – does the sentinel cerebral protection device work?

Background

Transcatheter aortic valve implantation (TAVI) is increasingly used for the treatment of severe symptomatic aortic stenosis (AS), also in low-risk patients. Periprocedural embolic stroke is rare, but potentially associated with considerable morbidity and mortality. Thus, there is great interest in preventing any cerebral embolic event. At present, only one cerebral embolic protection systems (CPS) is commercially available and little is known about its efficacy in preventing stroke during TAVI. The Sentinel CPS is a FDA-approved system consisting of two inter-connected filters that are placed in the brachiocephalic trunk and the left carotid artery via the right radial artery.

Material and methods

Consecutive patients undergoing TAVI between 11/2018 and 11/2019 were enrolled. Consecutive patients treated by one operator received the Sentinel device, if anatomically possible. Periprocedural stroke rate, as defined by VARC2-criteria, and mortality up to 7 days after procedure was assessed. Descriptive statistics was performed to identify baseline variables associated with elevated risk of stroke and Cox-regression analysis was used to investigate its influence on outcome.

Results

268 patients (47.4% female, 81±7 years) were included. In 74 patients (27.6%), a Sentinel CPS was used, in 63 (23.5%) it was positioned correctly in the brachiocephalic trunk and left carotid artery. Only these patients were considered Sentinel-protected. Patients with and without Sentinel presented with similar baseline characteristics with regard to age (no CPS vs CPS; 80.3 vs 81.5 years; p=0.233), sex (female 47.3% vs 47.7%; p=0.967), previous stroke (6.9% vs 3.2%; p=0.373), peripheral artery disease (9.8% vs 4.8%; p=0.305), coronary artery disease (63.1% vs 57.1%; p=0.370), and kidney function (GFR 52 vs 56 ml/min/m2; p=0.283). The EuroScore II (6% vs 6%; p=0.937), periprocedural predilation (48.3% vs 47.6; p=0.925), postdilation (29.3% vs 31.7%; p=0.707) and procedure time (59min vs 66min; p=0.152) were not different. In total, 15 strokes (5.6%) occurred, of which 9 (3.3%) were disabling strokes as defined by the VARC2-criteria. In Sentinel-protected patients undergoing TAVI, no periprocedural stroke was observed (no CPS 7.3% vs 0.0%; p=0.026).

Conclusion

Our results suggest that Sentinel CPS significantly reduces periprocedural stroke rates in patients undergoing TAVI compared to patients without CPS. However, the study population is small and randomized trials are still needed.

Funding Acknowledgement

Type of funding source: None

Acute hemodynamic effects of iatrogenic inter-atrial shunts after percutaneous edge-to-edge mitral valve repair

Background

Implantable interatrial shunt devices improve pulmonary vascular function in patients with heart failure by transferring richly oxygenated blood to the right heart. Whether iatrogenic atrial septum defects (iASDs) after percutaneous edge-to-edge mitral valve repair (pMVR) are also associated with beneficial hemodynamic effects has not been investigated.

Methods

We consecutively enrolled patients with relevant functional (FMR) and degenerative mitral regurgitation (DMR) scheduled for pMVR. Invasive hemodynamic assessments were performed prior to and immediately after the procedure.

Results

97 consecutive patients (75.4±9.1 years; 58% female) were prospectively included, 65 (66%) presented with relevant FMR. At baseline when compared to the DMR group, FMR was associated with worse left ventricular (LV) function (LV ejection fraction: 39 vs. 49%; p=0.001), higher NT-proBNP levels (7404 vs. 5214 pg/mL; p=0.023), worse renal function (serum creatinine: 1.7 vs. 1.3 mg/dL; p=0.019), and higher usage of spironolactone (68 vs. 42%; p=0.018) and sacubitril/valsartan (33 vs. 0%; p<0.001).

Following pMVR, cardiac output (CO) and systemic blood flow (Qs) increased significantly (CO: 4.6 to 5.5 L/min; p<0.001; Qs: 4.9 to 5.8 L/min; p=0.002), with more pronounced changes in the FMR subgroup (ΔCO: 1.0 vs. 0.6 L/min; Figure 1A; ΔQs: 1.2 vs. 0.1 L/min), when compared to DMR. Pulmonary blood flow (Qp) increased by 26% (4.3 to 5.4 L/min; p=0.008), accompanied by a raise in pulmonary artery (PA) oxygen (O2) saturation from 73 to 77% (p<0.001). Arterial O2 saturation levels remained unchanged (98.3 to 98.7%; p=0.165), confirming no significant changes in systemic oxygenation. These changes were associated with a slight decline in pulmonary vascular resistance (PVR: 250 to 225 dynes*sec/cm5; p=0.369, Figure 1B), and a tendency towards improvement of pulmonary compliance (PAC: 3.6 to 4.0 mL/mmHg; p=0.414).

Conclusions

Invasively measured CO, Qs, Qp, and mixed-venous PA O2 saturation increased immediately after pMVR, alongside with potentially beneficial effects on pulmonary vasculature with marked improvements in PVR and PAC. These changes were more pronounced in the FMR subgroup. Further studies are required to assess long-term hemodynamic effects and underlying mechanisms of persistent iASDs on pulmonary vascular function.

Figure 1. Invasive hemodynamics

Funding Acknowledgement

Type of funding source: None

Pacemaker lead-induced progression of primary vs. secondary tricuspid regurgitation

Background

Currently no data are available whether the implantation of right ventricular (RV) pacemaker (PM) lead worsens preexisting primary or secondary (functional due to RV dilatation, RVD) tricuspid regurgitation (TR).

Purpose

The aim of the present retrospective analysis was to assess TR after PM implantation with a RV lead.

Methods

Patients with PM implantation (n=990) were enrolled if they had routine echocardiography including assessment of TR before first implantation and immediately after. RVD and severity of TR were characterized visually. Based on RVD in baseline echocardiography, patients were divided into 2 groups: with primary TR (without preexisting RVD, n=743) or secondary TR (with preexisting RVD, n=243).

Results

Lead-induced worsening of TR was present in both groups (Table 1). Progression from mild/moderate to severe TR was observed in 6.7% of patients with primary TR, compared to 25.6% of patients with secondary TR (P=0.001). Using an ordinal regression model, the probability to progress to severe TR with primary TR was 14.8% (95% CI 11.0%-19.7%), compared to 41.6% (95% CI 40.3%-42.8%) with secondary TR (P<0.001).

Conclusion

Preexisting secondary TR was associated with higher rates of lead-induced progression to severe TR compared to primary TR. Leadless pacing or tricuspid valve clipping post-PM implantation could be an option for patients with preexisting secondary TR and indication for a PM.

Table 1. Patient characteristics.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): This study was supported by the European Union's Horizon 2020 Future and Emerging Technologies Programme [Grant number 732170].

Anticoagulation and outcomes after surgical aortic valve replacement with a biological prosthesis

Background

No strong recommendation exists regarding the use of short-term anticoagulation after surgical aortic valve replacement (SAVR) with a biological prosthesis.

Purpose

Our aim was to analyze outcomes of patients receiving warfarin versus low-molecular weight heparin (LMWH) after isolated SAVR.

Methods

We retrospectively analyzed all adult patients who underwent surgery between 2009 and 2017 at our department (n=598). Exclusion criteria included pre-operative anticoagulation, atrial fibrillation, dialysis, previous aortic valve replacement, or active endocarditis. Patients who were discharged alive were stratified according to the type of anticoagulation (warfarin, n=332, 55.5%; LMWH, n=266, 44.5%). Long-term survival during the follow-up period was analyzed (median follow-up, 5.6 years).

Results

Patients who received warfarin had significantly lower logistic EuroSCORE and were younger (Table 1). Warfarin was more frequently utilized between 2009 and 2014, whereas LMWH was more commonly used between 2015 and 2017. Kaplan-Meier curves in Figure 1 show that patients who received warfarin had significantly superior long-term survival (log-rank test: p=0.002). Multivariable Cox proportional hazards regression analysis confirmed that the use of warfarin was associated with significantly lower risk of long-term mortality when compared with LMWH (hazard ratio [HR] 0.50, 95% confidence interval [CI] 0.34–0.74, p=0.001). Covariables in this model included logistic EuroSCORE, era, and duration of cardiopulmonary bypass.

Conclusions

The present analysis suggests that the use of warfarin is associated with significantly superior survival after SAVR with a biological prosthesis. Our findings require validation in a prospective randomized controlled trial.

Figure 1. Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None

P1763 Impact of disproportionate functional mitral regurgitation

Background

Application of the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) is potentially limited as such lesion-focused metrics inevitably lack flexibility to account for the heterogeneity of left ventricular size and function. A recently proposed conceptual framework seeks to rearrange EROA and RegVol cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF), introducing the novel term "disproportionate FMR" to describe clinically meaningful FMR.

Methods

To test the impact of disproportionate FMR, we embedded data of 291 heart failure patients with reduced ejection fraction (HFrEF) under guideline directed therapy (GDT) into this framework. Regurgitant Volume and EROA were plotted against LVEDV using bubble plots that also account for the heterogeneity of EF (Figure 1 A and C). The black lines depict a regurgitant fraction (RegFrac) of 50% at the median EF (25%) or Vmax (4.3m/s) of the study population. Thus, above individual center lines (illustrated by different bubble sizes) FMR severity is disproportionate, within the area of measurement uncertainty it is proportionate to LV dilation and below, it is likely non-severe. The degree of uncertainty of proportionate FMR is determined by the imprecision of the measurements defined as 2SDs of regurgitant fraction (±6.6%) per Bland-Altmann analysis.

Results

During a median follow-up of 84 months (IQR 84-136), 166 patients died. Disproportionate FMR was associated with excess mortality (RegVol: HR 1.97, 95%CI 1.38-2.81, P < 0.001; EROA: HR 2.22, 95%CI 1.52-3.22), whereas proportionate FMR was not associated with increased long-term mortality (RegVol: HR 1.04, 95%CI 0.71-1.53, P = 0.83; EROA: HR 1.06, 95%CI 0.71-1.58, P = 0.79; Figure 1B&D).

Conclusions

In this contemporary HFrEF cohort every fifth patient has disproportionate FMR which conveys a two-fold increased risk of mortality which provides evidence for the validity of the conceptual framework. Advancement of the proposed framework to clinical practice has several implications: 1)EROA and RegVol are metrics that do not account for the contextual variability of LVEDV and EF. 2)The RegFrac -not incorporated in ESC guidelines but integrated in AHA/ACC definitions- provides a metric proportionated to left ventricular size and function supporting its use to define relevant FMR. However, technical limits suggest its complementary use on top of more robust metrics such as EROA and RegVol. Future studies need to clarify whether disproportionate FMR reflects the subgroup of patients that benefit from mitral valve repair, and provide a robust algorithm that integrates the metrics of FMR severity in a complementary manner.

Abstract P1763 Figure.

State of the art: leadless ventricular pacing : A national expert consensus of the Austrian Society of Cardiology

Background

Cardiac pacing has been shown to improve quality of life and prognosis of patients with bradycardia for almost 60 years. The latest innovation in pacemaker therapy was miniaturization of generators to allow leadless pacing directly in the right ventricle. There is a long history and extensive experience of leadless ventricular pacing in Austria. However, no recommendations of national or international societies for indications and implantation of leadless opposed to transvenous pacing systems have been published so far.

Results

A national expert panel of skilled implanters gives an overview on the two utilized leadless cardiac pacing systems and highlights clinical advantages as well as current knowledge of performance and complication rates of leadless pacing. Furthermore, a national consensus for Austria is presented, based on recent studies and current know-how, specifically including indications for leadless pacing, management of infection, suggestions for qualification, and training of the operators and technical standards.

Conclusions

Leadless pacing systems can be implanted successfully with a low complication rate, if suggestions for indications and technical requirements are followed.

Condensed abstract

An overview of the two utilized leadless cardiac pacing systems is given, specifically highlighting clinical advantages as well as current knowledge of performance and complication rates. Furthermore, a national consensus for Austria is presented, specifically including indications for leadless pacing, management of infection, and suggestions for qualification and technical standards.

P4720Mitraclip XTR device used for the treatment of functional tricuspid regurgitation provides significant reduction of annular size

Background

Tricuspid valve regurgitation (TR) is a progressive disease strongly associated with increased cardiac and all-cause mortality. The transcatheter approach to this pathology has been recently described with promising results in the treatment of symptomatic patients despite optimal medical therapy. Development of annular dilation and leaflet tethering represent a continuous pattern in the pathophysiology of functional TR; for this reason, to reduce and stabilize the annulus is the goal of an efficacious therapy.

Purpose

In order to simplify leaflet grasping, the novel MitraClip XTRdevice has significantly longer clip arms compared to its predecessor. The increased grasping length could be able to apply a radial tension on the tricuspid annulus, reducing it in dimensions. Despite, the increased tension on the leaflets may theoretically impose a higher risk for leaflet tearing We analyzed our single-center experience in order to clarify the capability of the device in the feature of annular reshapement.

Methods

Five high-risk patients (4 females, 72 (quartiles 69–79) y.o., EuroSCORE II 10 (7.25–11.2)% affected by severe symptomatic functional TR were treated with MitraClip XTR implantation in tricuspid position. Right ventricular function was apparently preserved in all cases and the mean sPAP was 41 (quartiles 38–45) mmHg. Perioperative echo-results were collected prospectively and analyzed.

Results

Procedural success (defined as a reduction of more than 1 degree of TR) was achieved in 4 cases (80%). 3±1 devices were implanted per patient in the antero-septal commissure. The tricuspid annular diameter (measured in four chamber view) was reduced from 39 (quartiles 39–41) mm to 31 (quartiles 30–31) mm (p=0.043). Accordingly, the effective regurgitant orifice area (EROA) decreased from 110 (quartiles 70 to 160) mm2 to 45 (quartiles 9–55) mm2 (p=0.02) and the systolic VTI in the hepatic veins decreased by 42%. No significant increase of trans-valvular mean gradients was observed (2.5 (quartiles 2.25 to 2.75)) mmHg vs 3.75 (quartiles 3,75 to 4) mmHg; p=0.2) as well no cases of acute leaflet tearing.

Conclusion

The reduction in tricuspid annulus size with the novel XTRdevice represents an unexpected and interesting achievement of the procedure. A significant reduction of annular dimensions might provide a more durable reduction of functional TR. Long-term follow-up data will be required to clarify these initial results and as well as patient selection criteria.

P1840Mid-term results of bioprosthetic aortic valve replacement with the Trifecta valve: A word of caution

Background

Structural valve deterioration (SVD) with associated bioprosthetic valve dysfunction remains an unsolved problem, exposing patients to the risk of aortic valve re-intervention after surgical aortic valve replacement (SAVR). Several strategies have been proposed to improve prosthesis design for optimal performance. The leaflets of the Trifecta valve are mounted on the outside of the prosthetic stent to achieve a larger orifice area. Although favourable early clinical outcomes have been reported, long-term durability still needs to be assessed.

Purpose

The aim of the current study was to assess the mid-term overall mortality and re-intervention rate in patients who received a Trifecta valve with a follow-up >5 years.

Methods

Patients who underwent SAVR at our centre between 2011 and 2012 were identified in the internal, prospective database. All patients with implantation of a Trifecta valve in aortic position were included. Primary endpoints were freedom from overall mortality and from re-operation at latest follow-up (FU). Additionally, assessment of echocardiographic parameters at baseline and follow-up was performed.

Results

Seventy-six patients (age 77.3±9.5 years, BMI 28.6±5.8, 68% male) were included in the study. EuroScore II was 7.2% (± 7.7) while mean STS-Mortality score was 2.4±1.1%. Of all procedures, 53% were isolated aortic valve replacements, whereas concomitant procedures were performed in 47% of cases (37% CABG, 12% mitral surgery, 8% tricuspid surgery). Baseline echocardiographic assessment showed a mean pressure gradient (MPG) of 51±21 mmHG, a peak pressure gradient (PPG) of 78±36 mmHG and a peak velocity (Vmax) of 4.2±1.1 m/s.

Thirty-day mortality was 7%. Freedom from overall mortality at 1 year and 5 years was 84% and 73%, respectively. Freedom from death and freedom from re-operation at latest FU (6.7±0.5 years) was 68% and 90%, respectively. In a composite endpoint analysis, freedom from death or re-intervention at latest follow up was 60%. A total of 7 patients underwent aortic valve re-interventions (re-replacements n=5, valve-in-valve n=2). Indications for re-interventions were SVD (n=5), NSVD (n=1, pannus ingrowth) and endocarditis (n=1). One case of re-stenosis occurred in a patient who was deemed not feasible for aortic valve re-intervention and died.

Kaplan Meier analysis

Conclusion(s)

To our knowledge, this patient cohort presents with the lowest rate of freedom from re-operation (90%, 6.7±0.5 years) after SAVR with the Trifecta valve. A relatively high number of SVD and NSVD has been observed, which might be attributable to the specific leaflet mounting or the deformable valve frame of the first generation. Current results call for further investigation with prospective echocardiographic follow-up in this patient group.

Acknowledgement/Funding

None

P5573Disproportionate functional mitral regurgitation: advancing a conceptual framework from bench to bedside

Introduction

A recently proposed conceptual framework seeks to rearrange the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF) in functional mitral regurgitation introducing “disproportionate FMR” to describe clinically meaningful FMR. The conceptual framework, however, remains hypothetical.

Purpose

To test the significance of disproportionate FMR.

Methods

Data of 291 heart failure patients with reduced ejection fraction (HFrEF) under guideline directed therapy were embedded into this conceptual framework (Figure 1A). The black line represents the relationship when the degree of FMR is proportionate to LVEDV with a regurgitant fraction of (RegFrac) of 50%. The dashed lines represent the degree of uncertainty determined by the imprecision inherent to the measurement of RegFrac defined as 2SD for inter- and intraobserver variability by Bland-Altmann analysis (equals ±6.6%). Cox-regression and Kaplan-Meier analysis were applied to assess the association between FMR proportionality and mortality.

Results

Median age was 68 years (IQR 61–75), 77% were male. Median LVEF was 25% (IQR 18–33) and LVEDV was 214ml (IQR 165–267). Disproportionate FMR was present in 71 patients (24%) (red dots Figure 1A) with a median EROA of 0.26cm2 (IQR 0.18–0.34) and a median RegVol of 42ml (IQR 28–52), proportionate FMR (yellow dots Figure 1 A) in 81 patients (28%) with a median EROA of 0.12cm2 (IQR 0.09–0.17) and a median RegVol of 18ml (IQR 14–27). During 7-years follow-up, 166 patients died. Disproportionate FMR was associated with excess mortality compared to patients with non-severe FMR (HR 1.97, 95% CI 1.04–0.71, P<0.001), whereas proportionate FMR was not associated with increased long-term mortality (HR 1.04, 95% CI −1.53–0.71, P=0.83, Figure 1B).

Figure 1. Panel A and B

Conclusion

Every fifth patient suffers from disproportionate FMR which conveys a two-fold increased risk of mortality. Disproprtionate FMR corresponds to an EROA of roughly 0.3cm2 and a RegVol of 45ml – the unifying intersection between ESC and ACC/AHA guidelines to define severe FMR. The RegFrac provides a measure proportionated to left ventricular size and function supporting its use to define clinically relevant FMR. However, RegFrac is subject to compound error due to imputation of multiple measurements limiting its use as the leading contender for FMR grading. Regardless of the term used to describe clinically significant FMR, the conceptual framework emphasizes the unmet clinical need for recalibrated cut-offs for FMR severity condensed to an algorithm that combines the strengths of several measurements of FMR severity in an integrated manner.

P4128The right heart in patients undergoing transcatheter aortic valve replacement: insights from cardiac magnetic resonance imaging

Background

Cardiac magnetic resonance (CMR) provides the gold standard for the assessment of ventricular volumes and mass. However, data on right ventricular systolic dysfunction (RVSD) and its prognostic significance on outcome in patients undergoing transcatheter aortic valve replacement (TAVR) are lacking.

Methods

We consecutively enrolled patients with severe aortic stenosis scheduled for TAVR who underwent preprocedural CMR. Kaplan-Meier estimates and multivariate Cox-regression analysis were used to identify factors associated with outcome, including RVSD. A composite of heart failure hospitalization and/or cardiovascular death was selected as primary study endpoint.

Results

145 consecutive patients (80.5±7.6 years; 51.7% female) were prospectively included, 25 (17.2%) of which had RVSD defined as RV ejection fraction (RVEF) <40%. RVSD was significantly associated with male sex, atrial fibrillation, reduced left ventricular (LV) EF (<50%) and RV endsystolic volume on CMR (all p<0.05). Serum NT-proBNP (14065±12042 vs. 3203±4615 ng/ml; p<0.001) and creatinine levels (1.59±0.96 vs. 1.29±1.03 mg/dl; p=0.201) were elevated in patients with RVSD. A total of 27 events occurred during follow-up (29±13 weeks). While LVSD was not significantly associated with outcome (p=0.654), RVSD showed a strong and independent association with event-free survival in the multivariate Cox-regression analysis [hazard ratio 3.836 (95% confidence interval 1.670–8.810); p=0.002], which included all relevant CMR parameters, cardiovascular risk factors and routine biomarkers.

Conclusions

RVSD rather than LVSD, as determined by CMR, is an important predictor of outcome in patients undergoing TAVR. RV function might thus add useful prognostic information on top of established risk factors.

Early Clinical Experience with Double Ring Implantation for Aortic and Mitral Valve Repair

Reconstruction of cardiac valves is associated with reduced mortality, including in multiple valve surgery. However, multiple valve repair is still considered a challenge, even with established techniques. Recently, internal aortic ring annuloplasty has been introduced and could simplify multiple valve reconstruction. This study reports early results with double ring aortic and mitral valve repair. Three patients with bivalvular degenerative regurgitation were managed with combined aortic and mitral valve repair using double rings. Mean (±SD) age was 41 ± 21 years, preoperative left ventricular end-diastolic volume was 119 ± 53 mL/m², and ejection fraction was 0.50 ± 0.07. Mean aortic ring diameter was 21 mm, and mitral rings averaged 32 mm. No operative mortalities or major complications were observed. No valve-related events occurred. Postoperative echo showed complete resolution of mitral and aortic regurgitation. Postoperative left ventricular end-diastolic volume decreased to 98 ± 10 mL/m²; no left ventricular outflow tract obstruction or significant transvalvular gradients were observed. Postoperative cardiac CTs showed an optimal three-dimensional configuration of aortic and mitral annuloplasty devices. This initial series demonstrated the feasibility and safety of combined aortic and mitral repair with double rings. Clinical and hemodynamic results were promising. Increasing application and more clinical experience with combined aortic and mitral double ring repair seems indicated.

A rare case of obstructive right atrial lipoma

Benign cardiac tumours are rare and cardiac lipomas account only for a small fraction among those. Most of these tumours differ in terms of clinical manifestation, diagnosis, morphology and size, and are therefore not diagnosed easily unless they become symptomatic. We report the case of a 71-year-old Caucasian woman with recurrent episodes of shortness of breath presenting with an acute exacerbation of dyspnoea and hypertensive crisis. Diagnosis of a right atrial lipoma with a coexisting patent foramen ovale was established on echocardiography and computed tomography, and the patient was evaluated for elective surgery. Comprising the entire free wall of the right atrium, the tumour was removed during open heart surgery on cardiopulmonary bypass. The right atrium and the orifices of both the superior and inferior vena cava were reconstructed with bovine pericardium. No evidence of tumour relapse was observed during successive follow-up visits.

Haem arginate infusion stimulates haem oxygenase-1 expression in healthy subjects

BACKGROUND AND PURPOSE

Haem oxygenase 1 (HO-1) is an inducible protein that plays a major protective role in conditions such as ischaemia-reperfusion injury and inflammation. In this study, we have investigated the role of haem arginate (HA) in human male subjects in the modulation of HO-1 expression and its correlation with the GT length polymorphism (GT(n)) in the promoter of the HO-1 gene.

EXPERIMENTAL APPROACH

In a dose-escalation, randomized, placebo-controlled trial, seven healthy male subjects with a homozygous short (S/S) and eight with a long (L/L) GT(n) genotype received intravenous HA. HO-1 protein expression and mRNA levels in peripheral blood monocytes, bilirubin, haptoglobin, haemopexin and haem levels were analysed over a 48 h observation period.

KEY RESULTS

We found that the baseline mRNA levels of HO-1 were higher in L/L subjects, while protein levels were higher in S/S subjects. HA induced a dose-dependent increase in the baseline corrected area under the curve values of HO-1 mRNA and protein over 48 h. The response of HO-1 mRNA was more pronounced in L/L subjects but the protein level was similar across the groups.

CONCLUSIONS AND IMPLICATION

HA is an effective inducer of HO-1 in humans irrespective of the GT(n) genotype. The potential therapeutic application of HA needs to be evaluated in clinical trials.