Development and internal validation of a clinical score to predict neonatal hypoglycaemia in women with gestational diabetes

INTRODUCTION

Gestational diabetes (GD) is a risk factor for neonatal hypoglycaemia (NH), but other factors can increase this risk.

OBJECTIVES

To create a score to predict NH in women with GD.

METHODS

Retrospective study of women with GD with a live singleton birth between 2012 and 2017 from the Portuguese GD registry. Pregnancies with and without NH were compared. A logistic regression was used to study NH predictors. Variables independently associated with NH were used to score derivation. The model's internal validation was performed by a bootstrapping. The association between the score and NH was assessed by logistic regression.

RESULTS

We studied 10216 pregnancies, 410 (4.0%) with NH. The model's AUC was 0.628 (95%CI: 0.599-0.657). Optimism-corrected c-index: 0.626. Points were assigned to variables associated with NH in proportion to the model's lowest regression coefficient: insulin-treatment 1, preeclampsia 3, preterm delivery 2, male sex 1, and small-for-gestational-age 2, or large-for-gestational-age 3. NH prevalence by score category 0-1, 2, 3, 4, and ≥5 was 2.3%, 3.0%, 4.5%, 6.0%, 7.4%, and 11.5%, respectively. Per point, the OR for NH was 1.35 (95% CI: 1.27-1.42). A score of 2, 3, 4, 5 or ≥6 (versus ≤1) had a OR for NH of 1.67 (1.29-2.15), 2.24 (1.65-3.04), 2.83 (2.02-3.98), 3.08 (1.83-5.16), and 6.84 (4.34-10.77), respectively.

CONCLUSION

Per each score point, women with GD had 35% higher risk of NH. Those with ≥6 points had 6.8-fold higher risk of NH compared to a score ≤1. Our score may be useful for identifying women at a higher risk of NH.

Atrioventricular block secondary to transient causes and long-term recurrence after an index event

BACKGROUND

Atrioventricular block (AVB) secondary to transient causes can recover with its correction. However, studies assessing predictors of recovery and long-term recurrence are lacking.

METHODS

Patients with advanced or complete AVB who had a reversible cause admitted in a single expert center were retrospectively studied. Patients with AVB secondary to acute coronary syndromes were excluded from analysis.

RESULTS

In a population of 162 patients, the main factors associated with recovery of rhythm without a permanent pacemaker (PPM) implantation were the presence of chronic kidney disease (CKD) on dialysis (OR 7.6; CI 95% 1.2-47.5 (p = .03)); greater serum potassium levels (OR 2.3; CI 95% 1.28-4.0 (p < .01)), higher dosage of bradycardic drugs (OR 2.2; CI 95% 1.13-4.4 (p = .02)), the association between different bradycardic drugs (OR 9.0; CI 95% 2.02-40.3 (p < .01)) and between drug therapy and hyperkaliemia (OR 5.2; CI 95% 1.8-15.1 (p < .01)). There was an overall high burden of conductions abnormalities which did not correlate with recovery of rhythm (OR 0.5; CI 95% 0.19-1.5 (p = .23)). In 29 patients (17.9%) there was a correction of the AVB. During a maximum follow-up of 130 months, 24 patients (82.8%) had a recurrence which warranted a PPM. In the overall cohort only five patients (3%) had sustained recovery of rhythm.

CONCLUSIONS

Recovery of AVB was mainly observed with higher doses of drug therapy, higher serum potassium levels or a combination of factors and regardless of baseline conduction abnormalities. The high rate of recurrence during follow-up warrants a close follow-up or PPM implantation at index admission.

Association between foetal sex and adverse neonatal outcomes in women with gestational diabetes

AIMS

Foetal male sex is associated with adverse perinatal outcomes. However, studies evaluating the impact of foetal sex on perinatal outcomes in women with gestational diabetes (GDM) are scarce. We studied whether male new-born sex is associated with neonatal outcomes, in women with GDM.

METHODS

This is a retrospective study based on the national Portuguese register of GDM. All women with live-born singleton pregnancies between 2012 and 2017 were eligible for study inclusion. Primary endpoints under analysis were neonatal hypoglycaemia, neonatal macrosomia, respiratory distress syndrome (RDS) and neonatal intensive care unit (NICU) admission. We excluded women with missing data on the primary endpoint. Pregnancy data and neonatal outcomes between female and male new-borns were compared. Multivariate logistic regression models were built.

RESULTS

We studied 10,768 new-borns in mothers with GDM, 5635 (52.3%) male, 438 (4.1%) had neonatal hypoglycaemia, 406 (3.8%) were macrosomic, 671 (6.2%) had RDS, and 671 (6.2%) needed NICU admission. Male new-borns were more frequently small or large for gestational age. No differences were observed on maternal age, body mass index, glycated haemoglobin, anti-hyperglycaemic treatment, pregnancy complications or gestational age at delivery. In the multivariate regression analysis, male sex was independently associated with neonatal hypoglycaemia [OR 1.26 (IC 95%: 1.04-1.54), p = 0.02], neonatal macrosomia [1.94 (1.56-2.41), p < 0.001], NICU admission [1.29 (1.07-1.56), p = 0.009], and RDS [1.35 (1.05-1.73, p = 0.02].

CONCLUSIONS

Male new-borns have an independent 26% higher risk of neonatal hypoglycaemia, 29% higher risk of NICU admission, 35% higher risk of RDS, and almost twofold higher risk of macrosomia, compared to female new-borns.

Underuse of reperfusion therapy with systemic thrombolysis in high-risk acute pulmonary embolism in a Portuguese center

INTRODUCTION

Reperfusion therapy is generally recommended in acute high-risk pulmonary embolism (HR-PE), but several population-based studies report that it is underused. Data on epidemiology, management and outcomes of HR-PE in Portugal are scarce.

OBJECTIVE

To determine the reperfusion rate in HR-PE patients, the reasons for non-reperfusion, and how it influences outcomes.

METHODS

In this retrospective cohort study of consecutive HR-PE patients admitted to a thromboembolic disease referral center between 2008 and 2018, independent predictors for non-reperfusion were assessed by multivariate logistic regression. PE-related mortality and long-term MACE (cardiovascular mortality, PE recurrence and chronic thromboembolic disease) were calculated according to the Kaplan-Meier method. Differences stratified by reperfusion were assessed using the log-rank test.

RESULTS

Of 1955 acute PE patients, 3.8% presented with hemodynamic instability. The overall reperfusion rate was 50%: 35 patients underwent systemic thrombolysis, one received first-line percutaneous embolectomy and one rescue endovascular treatment. Independent predictors of non-reperfusion were: age, with >75 years representing 12 times the risk of non-treatment (OR 11.9, 95% CI 2.7-52.3, p=0.001); absolute contraindication for thrombolysis (31.1%), with recent major surgery and central nervous system disease as the most common reasons (OR 16.7, 95% CI 3.2-87.0, p<0.001); and being hospitalized (OR 7.7, 95% CI 1.4-42.9, p=0.020). At a mean follow-up of 2.5±3.3 years, the survival rate was 33.8%. Although not reaching statistical significance for hospital mortality, mortality in the reperfusion group was significantly lower at 30 days, 12 months and during follow-up (relative risk reduction of death of 64% at 12 months, p=0.013). Similar results were found for MACE.

CONCLUSIONS

In this population, the recommended reperfusion therapy was performed in only 50% of patients, with advanced age and absolute contraindications to fibrinolysis being the main predictors of non-reperfusion. In this study, thrombolysis underuse was associated with a significant increase in short- and long-term mortality and events.

The challenging approach of a young patient with a primary intimal sarcoma of the heart: a case report

Background

Primary intimal sarcomas of the heart are extremely rare and have a dismal prognosis. Their management represents a complex clinical challenge since complete surgical resection is the only reliable possibility of cure but is only possible in 50% of patients. In non-resectable disease, anthracycline-based therapy is the most effective treatment, but pazopanib may be used in patients unfit to receive anthracyclines.

Case summary

A 38-year-old man presented with acute right heart failure symptoms due to a primary intimal sarcoma of the heart. A definite diagnosis was made after cardiac surgery. Multi-modality cardiac imaging showed early recurrence of disease with mitral valve and pulmonary veins' invasion, and the patient was deemed inoperable. Due to chronic kidney disease and previous heart failure symptoms, he was started on first-line pazopanib palliative treatment. After 11 months of chemotherapy, there was good clinical tolerance and no evidence of disease progression, which occurred after 13 months.

Discussion

This case highlights the value of a multi-modality imaging approach for cardiac masses. Most importantly, it reports the successful treatment of a young patient with a primary intimal sarcoma of the heart who was started on palliative pazopanib, with a significantly higher progression-free survival than is reported in the literature. This finding may support pazopanib as a good alternative as first-line treatment when there is contraindication for anthracycline-based chemotherapy.

Prevalence and predictors of chronic thromboembolic pulmonary hypertension following severe forms of acute pulmonary embolism

INTRODUCTION AND OBJECTIVES

The true prevalence of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) in the Portuguese population remains unknown. We aimed to assess the prevalence and predictors of CTEPH two years after a symptomatic high- (HR) or intermediate-high risk (IHR) PE.

METHODS

We conducted a retrospective cohort study of patients admitted with PE between 2014 and 2019 to a Portuguese referral center for pulmonary hypertension.

RESULTS

In this single-center registry of 969 patients admitted with PE (annual incidence of 46/100000 population), 194 had HR (5.4%) and IHR (14.7%) PE. After excluding patients who died or had no follow-up in the first three months, 129 patients were included in the analysis. The overall prevalence of suspected CTEPH by clinical assessment, Doppler echocardiography and V/Q lung scan was 6.2% (eight patients). CTEPH was confirmed by right heart catheterization in four of these (3.1%). Increased pulmonary artery systolic pressure (PASP) at admission (OR 1.12; 95% CI 1.04-1.22; p=0.005) and the presence of varicose veins in the lower limbs (OR 7.47; 95% CI 1.53-36.41; p=0.013) were predictors of CTEPH. PASP >60 mmHg at admission identified patients with CTEPH at follow-up with sensitivity and specificity of 83.3% and 76.3%, respectively. All patients diagnosed with CTEPH had at least two radiological findings suggestive of CTEPH at the index event.

CONCLUSIONS

In our cohort, the prevalence of CTEPH in survivors of severe forms of acute PE was 6.2%. PASP above 60 mmHg and supporting radiological findings on the index computed tomography scan are highly suggestive of acute-on-chronic CTEPH.

Percutaneous versus surgical revascularization of unprotected left main coronary artery: Data from the Portuguese Registry of Acute Coronary Syndromes (ProACS)

BACKGROUND

In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary artery (ULMCA) culprit lesion has been under-investigated. Therefore, we compared clinical characteristics and short- and medium-term outcomes of percutaneous and surgical revascularization in ACS.

METHODS AND RESULTS

Of 31 886 patients enrolled in a multicenter, national, prospective registry study between October 2010 and December 2020, 246 (0.8%) had ULMCA as a culprit lesion and underwent percutaneous coronary intervention (PCI) alone (n=133, 54%) or coronary artery bypass grafting (CABG) alone (n=113, 46%). Patients undergoing PCI presented more frequently ongoing chest pain (68% versus 41%, p<0.001) and cardiogenic shock (25% versus 1%, p<0.001). Time from admission to revascularization was higher in surgical group with a median time to CABG of 4.5 days compared to 0 days to PCI (p<0.001). Angiographic success rate was 93.2% in patients who underwent PCI. Primary endpoint (all-cause death, non-fatal reinfarction and/or non-fatal stroke during hospitalization) occurred in 15.9% of patients and was more frequent in the PCI group (p<0.001). After adjustment, surgical revascularization was associated with better in-hospital prognosis (odds ratio (OR) 0.164; 95% confidence interval (CI), 0.04-0.64; p=0.009). Similar results were achieved after propensity score matching. No difference was found at one-year all-cause death.

CONCLUSION

Percutaneous coronary intervention was the most common revascularization strategy in the ACS with ULMCA culprit lesion. PCI was preferred in unstable patients and presented a high angiographic success. CABG was often delayed and preferred in low-risk patients. At one-year follow-up, PCI and CABG conferred a similar prognosis. The two approaches appear complementary in this high risk cohort.

Chronic management of pulmonary embolism in thromboangiitis obliterans

Thromboangiitis obliterans (TAO), also known as Buerger’s disease, is a rare small vessel vasculitis that is associated with an increased risk of arterial occlusion. Although venous thromboembolism has been described, the risk of its recurrence and the best long-term anticoagulation management is not known. Considering this, we would like to share our experience with two patients admitted to our hospital with recurrent pulmonary embolism and previous diagnosis of TAO, aiming to discuss the indication for indefinite anticoagulation in this population.

Oral Presentation No. 112 Treatment of pulmonary embolism after paradoxical stroke

Introduction

A patent foramen ovale (PFO) is often diagnosed in cryptogenic strokes and concurrent pulmonary embolism (PE) may be associated. Although often asymptomatic and with low recurrence risk, the best therapy is controversial.

Purpose

To study the results of oral anticogulation (OAC) in this population.

Methods

Retrospective single-centre study (2015–2020) of pts with asymptomatic PE diagnosed after a paradoxical stroke due to a PFO.

Results

Forty pts were included. Mean age was 56 ± 11 years and 55% were female. At diagnosis, 27.5%, 50.0%, 17.5% and 5.9% had none, weak, moderate and strong predisposing factors for PE, respectively. Most pts had peripheral events: 60.0% subsegmental, 37.5% segmental and 2.5% lobar.

Regarding treatment, 97.5% initiated OAC (90.0% direct OAC, 7.5% vitamin K antagonist); 1 pt single antiaggregation; 30% had percutaneous PFO closure.

Mean clinical follow-up (FUP) was 32 ± 22 months. There was 1 recurrent PE and 1 non-cardiovascular death. Mean time under OAC (TUOAC) was 27 ± 26 months. The only predictor of OAC suspension was PFO closure (17.9% vs. 50.0%, P = 0.037). Of these pts, 50.0% suspended OAC after the procedure (TUOAC 23.2 ± 17.9 months); the remaining had a TUOAC of 28.9 ± 29.9 months. Age or PE predisposing factors were not associated with OAC suspension or TUOAC. There were 3 clinically relevant haemorrhagic events (1 BARC3a,1 BARC3b, 1 BARC3c). TUOAC was neither associated with bleeding (P = 0.307) nor with perfusion defects resolution in FUP scintigraphy (55.5 vs. 16.0 months, P = 0.172).

Conclusions

TUOAC was not associated with perfusion defects resolution, ischemic or bleeding events. Management of these pts needs more evidence and consensus.

Poster No. 115 Switch the risk: from PDE5i to Riociguat in real world pulmonary hypertension

Introduction

Switching from phosphodiesterase-5 inhibitors (PDE5i) to Riociguat is associated with increased efficacy in pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH).

Objective

To show clinical efficacy of replacing PDE5i to Riociguat in a portuguese PH-dedicated centre.

Methods

Retrospective single-centre study of PAH and inoperable/persistent/recurrent CTEPH patients (pts) who switched vasodilator therapy. Parameters were stratified according to the 2022 PH guidelines and stratification as low/intermediate/high-risk PH followed the COMPERA registry, before switching, at 3–6 months of follow-up (FUP) and until the last clinical evaluation, balloon pulmonary angioplasty (BPA), heart transplant or death.

Results

Of 13 pts, 75.0% had CTEPH (4 pts had persistent disease after surgical endarterectomy), 16.7% had PAH and 1pt had mixed PAH/CTEPH. Mean age was 56.2 ± 16.3years and 83.3% were females. Mean time until switch was 33.5 ± 25.5 months. Previous therapy was: 33.3% Sildenafil, 41.7% Sildenafil/Bosentan and 25% Sildenafil/Bosentan/prostanoid. Before switching, 66.7% had intermediate and 33.3% low-risk PH; at a FUP of 4.4 ± 1.7 months, 8.3% had intermediate and 91.7% low-risk PH. There was a significant benefit in the COMPERA risk (1.50[1.33;1.62] vs. 1.22[1.09;1.40], P = 0.011). Long-term FUP was performed in 8 pts at 48.2 ± 35.6 months (death 1pt, transplant 1pt, BPA 3 pts). Medical treatment was Riociguat in 33.3%, Riociguat and Bosentan in 58.3%, and 1pt with Riociguat, Bosentan and Treprostinil. Clinical benefit was significant at long-term FUP when compared to the initial evaluation (1.22[1.09;1.40], P = 0.011), but not to the first FUP.

Conclusion

This study corroborates previous evidence regarding the vasodilator switch and also suggests that the treatment goal is maintained throughout long-term FUP.

Oral Presentation No. 114 Small-bore aspiration thrombectomy versus catheter-directed thrombolysis in intermediate-high risk acute Pulmonary Embolism

Introduction

Catheter-directed thrombolysis (CDT) and mechanical thrombectomy (MT) are treatment options in intermediate-high risk pulmonary embolism (IHRPE).

Purpose

Compare the efficacy and safety of CDT and MT in IHRPE.

Methods

Retrospective single-centre study of consecutive IHRPE patients (pts) since 2018, treated with CDT (5Fr Cragg-McNamara device) or MT (Indigo MT system, Penumbra 8Fr). Clinical success at 48h was defined as survival and haemodynamic (HD) stabilization, oxygenation improvement or decrease in pulmonary hypertension (PH)/right heart strain. MACE during follow-up (FUP) was a composite endpoint of cardiovascular mortality, PE recurrence, chronic thromboembolic PH and heart failure hospitalization. Safety endpoint was defined as Major bleeding (BARC3).

Results

Of 25 pts, 60% were submitted to MT and 40% to CDT. Age (68.6 ± 15.6 vs. 62.7 ± 16.4, P = 0.381), Charlson Comorbidity Index (4.2 ± 1.9 vs. 2.9 ± 2.0, P = 0.121) and PESI score (103.2 ± 40.6 vs. 119.8 ± 46.2, P = 0.410) were similar. MT had increased fluoroscopy time (43.0 ± 19.1 vs. 10.1 ± 6.2 min, P &lt; 0.001) and procedure time (115 ± 63 vs. 45 ± 18 min, P = 0.009). Success at 48 h was similar (80% MT vs. 90% CDT; P = 0.626). Severe adverse events related with the technique happened in 2 pts in MT (1 death, 1 macroembolization) and 1pt in CDT developed HD instability. Haemoglobin fall was higher in MT (1.8 ± 1.3 vs. 0.7 ± 0.8 g/dL, P = 0.018), but BARC3 and transfusion were identical. In-hospital mortality was 8% (2 pts in MT, P = 0.229). Mean FUP was 229 ± 147days, with higher MACE in MT (40% vs. 0%, P = 0.051).

Conclusions

Despite similar efficacy at short-term, adverse events related to the procedure seemed higher in MT group. CDT was less time consuming.

At the outer edge of STEMI time: even after 12 hours, the clock keeps ticking

Introduction

Although primary percutaneous coronary intervention (pPCI) is not a class I recommendation in all patients (pts) presenting within 12 to 48h of symptom onset (late ST-segment Elevation Myocardial Infarction, STEMI), there is increasing evidence supporting its routine use in this population. Data on long-term clinical outcomes is sparse.

Objective

To evaluate long-term MACE in late-STEMI pts submitted to pPCI and compare with clinical outcomes of early reperfusion groups.

Methods

Retrospective analysis of consecutive pts submitted to pPCI due to STEMI between 2010 and 2015 in a pPCI centre. Included pts were stratified in 5 groups according to symptom-to-balloon time (SBT): &lt;3h; 3–6h; 6–12h; 12–24h; 24–48h. Of a total of 903 pts, 19 pts were excluded due to SBT &gt;48h. Long-term events were established as 5y mortality and 5y-MACE (a composite endpoint of death, re-infarction, heart failure hospital admission and ischemic stroke). The cumulative incidence of long-term outcomes was calculated by the Cox regression analysis and presented according to the Kaplan-Meier method.

Results

Of the 884 pts included in the study, stratification according to SBT was: pPCI&lt;3h (47.4%), pPCI 3–6h (24.9%), pPCI 6–12h (16.5%), pPCI 12–24h (8.0%), and pPCI 24–48h (3.2%). These groups showed no significant difference in terms of demographic characteristics (age, CV risk factors, previous coronary disease or heart failure), clinical severity (systolic arterial pressure, Killip-Kimball class, left ventricle ejection fraction) and angiography findings (multivessel disease, complete revascularization and PCI success). After a median follow-up of 76 (56; 98) months, 5-year mortality was 20.6% (182 pts) and 5-year MACE was 23.3% (206 pts). MACE was associated with increased median SBT: 5.0 (2.0; 9.0) hours vs 4.0 (2.0; 6.5) hours, p&lt;0.001. Of the MACE components, the only that showed a significant association with higher median SBT was mortality: 5.0 (2.0; 10.0) hours vs 4.0 (2.0; 6.0), p&lt;0.001. Differences in long-term outcomes were significant when considering SBT stratified by revascularization time (Figure 1).

Conclusions

As expected, there is a clinical benefit of early reperfusion for long-term cardiovascular events. Within the late-STEMI group, there seems to be a clear distinction between pPCI&lt;24h and &gt;24h, although the clinical benefit of pPCI timing most probably acts a continuum.

Funding Acknowledgement

Type of funding sources: None.

What is there to EAARN with a CRT implantation? Predictive factors of mortality or clinical deterioration in patients receiving cardiac resynchronization therapy based on pre-implant factors

Introduction

Cardiac resynchronization therapy (CRT) in heart failure patients with reduced ejection fraction (HFrEF) and wide QRS complexes has been shown to improve both functional capacity and quality of life, and to decrease hospital admissions and mortality. Mortality in CRT patients has been associated with several pre-implant risk factors and some risk scores, like the EAARN score, have been developed to try and predict mortality and morbidity in this population.

Purpose

Our aim was to assess risk factors for a compositive end-point of admissions for heart failure or cardiovascular death at 5 years, particularly the EAARN SCORE (EF, Age, Atrial Fibrillation (AF), Renal dysfunction, New York Heart Association (NYHA) class IV), in patients with EF &lt;35% and QRS &gt;130ms submitted to CRT implantation.

Methods

We performed a retrospective analysis between 2012 and May of 2019 of all patients admitted for CRT implantation due to HFrEF with EF &lt;35% and QRS &gt;130ms in a single expert centre. Medical records were analysed for clinical, procedural data and outcomes. The predictive accuracy of the score was assessed using the area under curve (AUC) of receiver operating characteristics (ROC) curve. The association between EAARN and the composite end-point at 5-years was analyzed using a Cox regression model.

Results

Of the 134 patients assessed, 101 patients fulfilled all inclusion criteria. The mean age at implantation was 70.2±10 years with a male preponderance (67.2%).

This population was significantly symptomatic, with 35% in NYHA class II, 58% in NYHA class III and 5% in NYHA class IV. Most had an ischemic etiology (74.2%). 75% of patients were considered responders after implantation (NYHA improvement of at least 1 class and/or increase in 10% in EF). A primary composite end-point occurred in 17.8% of patients. The pre-procedure characteristics associated with an event were an ischemic etiology (OR 4.66; CI 95% 1.52–14.24, p&lt;0.05) and pre-procedure EF (OR 0.81; CI 95% 0.81–0.97, p&lt;0.05). The age, sex, NYHA class, presence of AF, renal function, bundle branch block morphology and responder status were non significant. The EAARN Score showed predictive power for the occurrence of an event (OR 1.95; CI 95% 1.13–3.36, p&lt;0.05) and a reasonable discriminative capacity with the ROC curve analysis (figure 1A) demonstrating an AUC of 0.70. The survival analysis (figure 1B) with a Hazard Ratio of 1.88 (CI 95% 1.158–3.058, p&lt;0.05) signifying an increased risk of an event of 88% per EAARN class increase, with the Kaplan Meier curves widening significantly in the different categories of the score.

Conclusions

In patients who implanted a CRT due to HFrEF with EF &lt;35% and QRS &gt;130ms the EAARN score demonstrated a good predictive power and discriminative capacity for admission for heart failure or cardiovascular death at 5 years although it does not account for the etiology which was also a significant factor.

Funding Acknowledgement

Type of funding sources: None.

What are the NEWS in pulmonary embolism risk stratification?

Introduction

The patients with Pulmonary Thromboembolism (PE) stratified as intermediate-high risk with the European Society of Cardiology classification represent an heterogenous population, with the majority having a benign outcome however some evolving in clinical deterioration. Several risk scores have been developed to try and refine the population most at risk but they are deemed sub-optimal.

Purpose

Our aim was to assess the capacity of the National Early Warning Score (NEWS) in predicting a composite end-point of 30-days cardiovascular mortality, rescue thombolysis and/or haemodynamic instability, in a population of intermediate-high risk PE, as compared with other risk evaluation scores as the PESI and SHIeLD scores.

Methods

We performed a retrospective analysis between 2014 and 2019 of all patients admitted for intermediate-high risk PE, in a single expert centre. The patients who underwent fibrinolysis as per clinician discretion (without haemodynamically instability or clinical evidence of clinical deterioration) were excluded. Medical records were analysed for clinical data and outcomes. The predictive accuracy of all scores were assessed using the area under curve (AUC) of receiver operating characteristics (ROC) curve. The association between NEWS and composite end-point at 30-days was analyzed using a Cox regression model.

Results

Of the 1132 patients assessed and admitted with PE, 116 patients fulfilled all inclusion criteria and none of the exclusion criteria and were analysed. The mean age was 69±16 years at time of diagnosis with a female preponderance (62.9%). Most patients were treated with anticoagulation (97.4%), 68% with low molecular weight heparin and the remaining with unfractionated heparin. The average NEWS score was 7±3, the average PESI score was 110±34 and the average SHIeLD score was 14±13. A primary composite end-point occurred in 18 patients (15.5%). The NEWS score showed the greatest predictive power for the occurrence of an event (OR 1.35; 95% CI 1.11–1.64, p=0.003) compared with the SHIeLD score (OR 1.0; 95% CI 1.00–1.07, p=0.035) and the PESI score (OR 1.02; 95% CI 1.00–1.03, p=0.03); it also showed a greatest discriminative capacity with the ROC curve analysis (Figure 1A) demonstrating an AUC of 0.70, vs 0.65 and 0.62 respectively. The survival analysis demonstrated a Hazard Ratio of 1.29 (95% CI 1.10–1.52; p=0.002) signifying a 29% increased risk of an event per each NEWS class increase, with the Kaplan Meier curves widening significantly in the different terciles of the score (Figure 1B).

Conclusions

In PE patients with intermediate-high risk the NEWS score demonstrated a greater predictive power and discriminative capacity than other commonly used risk scores. The NEWS score may help to identify patients in this risk category who might benefit from a reperfusion strategy, but larger studies are needed to confirm this hypothesis.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous coronary intervention in elderly patients with chronic kidney disease and non-ST segment elevation acute coronary syndrome – is it worth it?

 

ESC guidelines recommend revascularization in patients (pts) with chronic kidney disease (CKD) irrespective of age. However, elderly pts are usually underrepresented in the available data on percutaneous coronary intervention (PCI). Thus, the decision on whether to perform PCI in these pts is usually at the discretion of the cardiology team.

Aim

To evaluate the impact of PCI vs conservative approach (CA) in elderly pts (&gt;80 years) with CKD and unstable angina (UA)/non-ST segment elevation myocardial infarction (NSTEMI) who were enrolled in the Portuguese National Registry of Acute Coronary Syndromes. To determine impact of CKD in in-hospital (IH) and long-term outcomes, including MACE (myocardial infarction, stroke and death) and death at 1 year.

Study population

Elderly pts admitted with UA and NSTEMI, from 2010 until 2021. There were three different groups: Group 1 – eGFR ≥60 ml/min/1.73 m2; Group 2 – eGFR between 30 and 59 ml/min/1.73 m2 and Group 3 – eGFR &lt;30 ml/min/1.73 m2. Pts with ST-segment elevation myocardial infarction and cardiogenic shock were excluded.

Results

A total of 2443 pts, of which 921 (37,7%) were submitted to PCI. 50,2% (n=1126,) were from the group 1, 38,5% (n=941) from group 2 and 11.3% (n=276) from group 3.

Regarding overall population, pts submitted to PCI were mainly male (60,4%) with a mean age of 84±3 years old. They had previous history of PCI (21,6% vs 15,1% p&lt;0.001), less history of heart failure (HF), stroke or dementia (8,5% vs 16,5%; 8,1 vs 13.3% and 2,1 vs 5,9%, p&lt;0.001). At presentation they had more angina (88,8% vs 81,2% p&lt;0.001), less NT-proBNP levels (387 vs 561 p&lt;0.001) and were more frequently in KK class I (75,6% vs 70,2% p=0.004). They developed less HF (21% vs 27%, p&lt;0.001) and MACE (5,7% vs 9,1% p=0.003). Pts in the group 3 were less submitted to PCI (27,5% vs 38,2% vs 39,6% p&lt;0.001) and had more MACE and cardiovascular death when comparing to group 2 and 1 (16,1% vs 8,7% vs 5,3% and 10,5% vs 5,5% vs 2,6% p&lt;0.001 respectively).

Comparing PCI vs CA in each group, there was no difference in IH outcomes between both strategies in group 3. The same was not true for groups 1 and 2, in which PCI seemed to favor overall outcomes (p=0.001 and p=0.015 respectively).

The predictors of IH death and MACE were: age (OR 1.068 p=0.010), dementia (OR 2,376 p=0.015), KK class &gt;1 (OR 2,243, p&lt;0.001), atrial fibrilhation (OR 1.605, p=0.046), not having PCI (OR 0.309, p&lt;0.001), eGFR &lt;30 (OR 3.51, p&lt;0.001) and PCI in pts with eGFR &lt;30 (OR 2.923, p=0.019).

Interestingly, survival analysis showed that pts submitted to PCI in all 3 groups (including group 3) had a longer 1-year survival (p&lt;0.001, p&lt;0.001 and p&lt;0.004).

Conclusions

PCI performance in elderly pts with CKD should be individualized. In our population, especially in group 3, the performance of PCI is associated with a higher IH mortality, however, after surviving hospitalization, these pts seem to have a benefit in 1 year survival.

Funding Acknowledgement

Type of funding sources: None.

Should we stay or should we go: assessment of the need for the implantation of a definite pacemaker in a population of acute coronary syndrome that evolved in advanced atrioventricular block

Introduction

The incidence of advanced atrioventricular block (AVB) secondary to acute coronary syndrome (ACS) has been decreasing in the era of percutaneous revascularization and in most cases is transitory and does not require pacemaker (PM) implantation.

Purpose

Our aim was to assess the characteristics of patients with AVB as a consequence of the ACS and compare those with and without PM implantation, in what regards in-hospital and at 1 year outcomes.

Methods

We performed a retrospective analysis of all patients admitted with AVB secondary to ACS in Portugal between October of 2010 and August of 2021 with data from the Real World Portuguese Registry on Acute Coronary Syndromes (ProACS). Medical records were analysed for demographic, procedural data and outcomes.

Results

Sex hundred and seventy one (671) patients with AVB secondary to ACS were admitted, which corresponded to 2.2% of the total cohort. The mean age was 70±13 with a male preponderance (66%). The ACS was categorized as ST elevation Myocardial Infarction (STEMI) in 76.4%, non-STEMI (NSTEMI) in 22.1%, and unstable angina (UA) in 1.5%. Of the patients admitted with AVB, 8.6% implanted a permanent PM. The was no clinically relevant differences in both groups in what regards to medical priors or medication. Regarding the location of the infarction, an Anterior STEMI was the diagnosis of admission in 36.8% (vs 14.5%; OR 3.45, CI 95% 1.31–9.06, p&lt;0.05) of patients that implanted a PM, and the left descending artery was more frequently the culprit artery, and an Inferior STEMI was the diagnosis of 63.2% (vs 83.7%; OR 0.31, CI 95% 0.12–0.82, p&lt;0.05) of patients and a right coronary artery was more frequently the culprit artery.

The presence of cardiovascular shock and in-hospital death was significantly more frequent in the group that did not implant a PM (OR 0.40; CI 95% 0.17–0.95, p&lt;0.05 and OR 0.33; CI 0.12–0.92, p&lt;0.05 respectively) and the implantation of PM was a negative predictor of in-hospital death (OR 0.28; CI 95% 0.08–0.93, p&lt;0.05).

The follow up at 1 year was performed in two hundred and sixty three (263) patients, 10.6% with an implanted PM. The survival analysis demonstrated increased mortality and a combined end-point of death and readmissions in the population of AVB that did not implant PM compared with a population who did not present with AVB (p&lt;0.05) with the Kaplan Meier curves widening significantly (Figure 1). This difference was not observed compared with an AVB population that implanted PM.

Conclusions

In patients with AVB secondary to ACS, the implantation of a PM might have been withheld in more severe patients, accounting for the increased mortality observed, and this population has worse outcomes at 1 year, leaving open to the hypothesis if either due to a more severe clinical status or the recurrence of AVB.

Funding Acknowledgement

Type of funding sources: None.

Large free-floating right atrial mass presenting as intermediate-high risk pulmonary embolism: is reperfusion a better definite strategy?

We present a woman in her 60s diagnosed with an intermediate-high risk acute pulmonary embolism and a large, non-serpiginous right atrial (RA) mass. Conservative therapy with unfractionated heparin was started and further assessment of the mass with cardiac MRI suggested thrombus as the most likely diagnosis. Despite 1 month of anticoagulation, mass size remained stable and surgical RA embolectomy and left pulmonary endarterectomy was performed. Histopathology confirmed thrombus. The patient died 10 weeks after surgery.

High-risk acute pulmonary embolism in a Portuguese centre: are we doing enough?

Introduction

For high-risk acute Pulmonary Embolism patients (HR-PE pts), reperfusion treatment is imperative to improve mortality. Although systemic thrombolysis (ST) is generally an appropriate first-line therapy, several population-based studies report its underuse. Data on epidemiology, management and outcomes of HR-PE in Portugal is scarce.

Purpose

Estimate the reperfusion rate in HR-PE pts, the reasons for non-reperfusion (NR) and how it influences outcomes.

Methods

Retrospective single-centre registry of consecutive HR-PE pts between 2008–2018, defined by the 2019 ESC guidelines criteria. Independent predictors for NR were assessed by multivariate logistic regression. The cumulative incidence of PE-related mortality at 30 days was calculated according to the Kaplan-Meier method and differences stratified by reperfusion were assessed using the log-rank test.

Results

Of a total of 1955 pts admitted with acute PE, 74 (3.8%) had HD instability at admission (mean age 68±15 years). The majority of pts (68.5%) came from the emergency department while the remaining 31.5% were already hospitalized for other reasons. The total reperfusion rate was 50% - 35pts were submitted to systemic thrombolysis, 1pt to first-line percutaneous embolectomy and 1pt to rescue endovascular treatment. Age was an independent predictor of NR (63±17 vs 73±12, p=0.02) with &gt;75 years representing 15 times the risk of non-treatment (OR 15.5, 95% CI 3.23–74.25, p&lt;0.001). Absolute contraindication for thrombolysis was present in 29.7% (22pts), with recent major surgery (13pts) and recent cerebral event (8pts) as the most common reasons. The presence of an absolute contraindication for systemic thrombolysis was also an independent predictor of NR (66.7% vs 13.6%; OR 13.3, 95% CI 2.51–70.65, p=0.002). Being hospitalized was associated with the presence of absolute contraindications for thrombolysis (68.2% vs 14.0%, p&lt;0.001) and was also an independent predictor of NR (38% vs 77.3%; OR 8.49, 95% CI 1.56–46.11, p=0.013). PE-related death at 30 days was 28.4% (21pts), which was significantly lower in the reperfusion group (17.1% vs 38.9%, p=0.042). At a mean follow-up of 2.5±3.3 years, survival rate was 33.8% (figure 1).

Conclusions

Low reperfusion rate due to contraindications for thrombolysis was associated with high PE-related mortality. This data suggests that it is necessary to implement interventional alternative strategies, at a national level, to improve outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Survival rate according to reperfusion.

Left atrial appendage velocity as an instrument of predicting atrial fibrillation recurrence after successful catheter ablation – a useful tool?

Introduction

Catheter ablation for the treatment of Atrial Fibrillation (AF) is a modality of treatment in growing expansion. However the sustained long term response in preventing AF recurrence is poor for most patients, namely in those with a dilated left atrium.

Purpose

Our aim was to assess the utility of an echocardiographic parameter for left atrium function, the left atrial appendage velocity (LAAV), in predicting recurrences after catheter ablation.

Methods

We performed a 9 year retrospective analysis of all patients who underwent a successful catheter ablation for the treatment of atrial fibrillation and had a valid pre-procedural transesophagic echocardiogram in a single expert centre. Medical records were analysed for demographic, procedural data and outcomes.

Results

Seventy-three (73) patients fulfilled all inclusion criteria and were analysed. The mean age was 62±11 with a male preponderance (58,7%). The majority of patients (82,7%) had preserved left ventricle ejection fraction. Only 46% of patient had a volumetric assessment of the left atrium dimensions prior to ablation, with slight, moderate and severe dilation of the left atrium in 20%; 8,6% and 28,6% of patients. Of the patients subjected to an AF ablation the average LAAV was 50,6±19 cm/s, with 78% of patients with normal atrial appendage velocities.

Patients with low LAAV (&lt;40cm/s) had a higher proportion of AF recurrences at 3 and 6 months (58,3 vs 12,8% and 89% vs 21,7%; p&lt;0,05 for all) with a linear correlation between the presence of recurrences and LAAV (LAAV of 39,1 vs 57,5 cm/s; p&lt;0,05 OR 0,91 (CI 95% = 0,85–0,97); r2=0,34 at 3 months and LAAV of 43,5 vs 59 cm/s; p=0,01; OR 0,94 (CI 95% = 0,89–0,99); r2=0,24 at 6 months respectively). There was a trend towards association with recurrences at 1 year although it did not reach statistical significance. There was no significant difference in the use of antiarritmic drugs, either prior or post ablation, in both groups. It was not possible to assess the additive predictive value to the left atrium dimensions due to the low percentage of volumetric assessment of left atrium prior to AF ablation.

Conclusions

Patients with low left atrial appendage velocities had a lower long term success rate of catheter ablation, with higher rates of recurrence at 3 and 6 months and a trend towards higher recurrences at 1 year, with linear correlation which hypothesises the use of the left atrial appendage velocity as novel predictive parameter for an integrative model.

Funding Acknowledgement

Type of funding sources: None.

STEMI around-the-clock: how off-hours admissions impact door-to-balloon time and the long-term prognosis of ST-segment Elevation Myocardial Infarction

Introduction

The outcomes of reperfusion in ST-segment Elevation Myocardial Infarction (STEMI) are time-dependent, and percutaneous coronary intervention (PCI) should be performed within 60 minutes from hospital admission in PCI centers – door-to-balloon time (D2B). The association between Off-Hours Admission (OHA) and long-term outcomes is controversial when considering contemporary organized STEMI networks.

Purpose

This study aims to analyze how OHA influences D2B and long-term mortality.

Methods

Retrospective study of consecutive STEMI patients (pts), admitted in a PCI-centre with a local Emergency Department, between 2010 and 2015. Pts submitted to rescue-PCI were excluded. OHA was defined as admission at night (8p.m. to 8a.m), weekends and nonworking holidays. Predictors of OHA and D2B were studied by logistic regression analysis. Demographic, clinical, angiographic and procedural variables were evaluated using stepwise Cox regression analysis to determine independent predictors of 5-year all-cause mortality (5yM). The cumulative incidence of 5yM stratified by hours of admission was calculated according to the Kaplan-Meier method.

Results

Of 901 pts, 472pts (52.4%) were admitted during off-hours. These pts were younger (61±13 vs 64±12, p=0.002) and had a lower median patient-delay time (128min vs 157min, p=0.014). Clinical severity at presentation, defined by systolic arterial pressure and Killip-Kimball (KK) class, did not differ between groups. OHA did not impact D2B (89 min vs 88 min, p=0.550), which was in turn influenced by age ≥75y (OR 1.85, 95% CI 1.31–2.61, p&lt;0.001). Mean clinical follow-up (FUP) was 68±37 months, with 75.1% of pts achieving a FUP &gt;5 years. 5yM rate was 9.7%. After multivariate cox regression analysis, independent determinants of long-term mortality were age (HR 1.05, 95% CI 1.02–1.08, p&lt;0.001), previous history of heart failure (HR 6.76, 95% CI 1.32–34.72, p=0.022) and pulmonary disease (HR 3.79, 95% CI 1.16–12.33, p=0.027), presentation with KK ≥2 (HR 2.82, 95% CI 1.32–6.01, p=0.007) and radial artery access in catheterization (HR 0.39, 95% CI 0.18–0.83, p=0.014) – figure 1. Although there was an association between a higher D2B time and 5yM (87min vs 101min, p=0.024), neither OHA nor D2B were independent predictors of long-term mortality – figure 2.

Conclusion

OHA did not seem to influence D2B and long-term STEMI outcomes in our PCI-centre. 5yM was mostly influenced by patient characteristics and clinical severity at presentation.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Predictors of long-term mortalityFigure 2. 5-year survival stratified by OHA

Contrast-induced nephropathy after staged balloon pulmonary angioplasty: lower risk compared with left-sided cardiac procedures

Introduction

The risk of contrast-induced nephropathy (CIN) after left-sided cardiac procedures is reported as 10–15%. When the ratio of total contrast volume in ml to glomerular filtration rate (GFR) in mL/min (ratio V/GFR) exceeds 3.7, the risk increases significantly. However, there are few reports regarding the risk of CIN in patients (pts) with right-sided cardiac interventions such as balloon pulmonary angioplasty (BPA) and ratio V/GFR is not validated for use in this procedures.

Purpose

To assess the prevalence of CIN in pts with chronic thromboembolic pulmonary disease with or without hypertension (CTEPH/CTED) undergoing BPA.

Methods

Prospective single-centre study that included all BPA sessions performed from 2017 to 2020. Serum creatinine concentration (SC) was measured and the GFR was estimated using the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) before and 48 hours after each BPA procedure and 6 months after BPA treatment completion. CIN was defined as an increase of ≥25% and/or ≥0.5 mg/dL in SC from the baseline value within 48h of contrast administration.

Results

76 consecutive BPA sessions were performed in 15 CTEPH/CTED pts: mean age 63.2±14.0 years, 60% female, 86.7% CTEPH, mean of 5.3±1.9 sessions per patient with 4.3±1.9 vessels dilated per session. Mean value of GFR before BPA program was 73.5±26.3 mL/min. All the procedures were performed using low-osmolality contrast agent with a 1:1 dilution ratio with normal saline solution. Pts received 273.0±73.0 mL of contrast per session with a ratio V/GFR 3.7±1.7 mL. SC and GFR did not change significantly within 48h after BPA (+3.1%, p=0.07 and −3.0%, p=0.13, respectively). Ratio V/GFR &gt;3.7 occurred in 44.3% of cases (n=31), but CIN occurred in only 5.3% (n=4) with an increase in SC &lt;0.5 mg/dL but ≥25% in 3 cases (+33% in mean) and ≥0.5 mg/dL in 1 case. None of the pts required renal replacement therapy. Higher SC and lower GFR 48h after BPA were significantly correlated with greater rato V/GFR during procedure (r=0.75, p&lt;0.01 and r=−0.74, p&lt;0.01, respectively) – see figure. But neither higher values of ratio V/GFR (OR 1.43; CI95% 0.84–2.41; p=0.19) nor V/GFR &gt;3.7 (OR 1.28; CI95% 0.17–9.6; p=0.81) were predictors of CIN. GFR before procedure did not influence the contrast volume administered (p=0.901), number of vessels (p=0.63) and segments treated by session (p=0.45). At 6 months follow-up, there was a trend for SC (1.3±0.2 mg/dL vs 1.1±0.2 mg/dL, −15%, p=0.43) and GFR (44.5±8.3 mg/dL vs 53.0±12.6 mg/dL, +16%, p=0.34) improvement in pts with impaired renal function at baseline (GFR&lt;60 mL/min).

Conclusions

These findings suggested that the occurrence of CIN after BPA was low, raising the hypothesis that the influence of contrast agent on renal function could differ in right-sided cardiac interventions. Although the ratio V/GFR may be correlated with the risk of nephropathy, it is necessary to find a new cut-off to predict CIN in BPA pts.

Funding Acknowledgement

Type of funding sources: None.

Reperfusion in high-risk acute pulmonary embolism: can the PESI score predict outcomes?

Introduction

Acute pulmonary embolism (PE) is one of the leading causes of cardiovascular death worldwide. Haemodynamic (HD) instability defines high risk (HR) of early mortality and reperfusion treatment is the standard of care for rapid relieve of right ventricle (RV) overload in these situations. The impact of reperfusion in long-term outcomes is not well established. The PE Severity Index (PESI) score is used to stratify the risk of early death in HD stable patients (pts) and was not validated to predict outcomes in HR-PE.

Purpose

Estimate the prognostic performance of the PESI score in HR-PE and study its possible interaction in acute and long-term outcomes of reperfusion in HR-PE pts.

Methods

Retrospective single-centre study of consecutive HR-PE pts, defined by the 2019 ESC guidelines criteria, between 2008–2018. Logistic regression analysis was performed to test for an interaction between tertiles of the PESI score and reperfusion in early-mortality (during hospitalization and at 30 days) as well as 1-year MACE (a composite of cardiovascular mortality, PE recurrence or chronic thromboembolic pulmonary hypertension).

Results

Of a total of 1955 PE pts, 102 fulfilled the inclusion criteria (72.5% pts initially presented with HD instability with the remaining developing HR-PE after hospital admission). Mean age was 68±15 years and 60% were females. In-hospital and 30-day mortality were 39.6% and 43.0%, respectively. At one-year follow-up, MACE was 55.0%. Mean PESI at the time of HR-PE diagnosis was 200±39 and showed significant differences for in-hospital mortality (189±38 vs 217±34; OR 1.02, 95% CI 1.00–1.03, p&lt;0.001), 30-day mortality (191±38 vs 214±36; OR 1.02, 95% CI 1.00–1.03, p=0.004) and 1y-MACE (186±41 vs 214±32; OR 1.02, 95% CI 1.01–1.03, p&lt;0.001). Total reperfusion rate was 57.8% and was also associated with lower in-hospital mortality (OR 0.45, 95% CI 0.20–1.02; p=0.057), 30-day mortality (OR 0.35, 95% CI 0.15–0.80; p=0.012) and 1y-MACE (OR 0.35, 95% CI 0.15–0.80; p=0.014). The benefit of reperfusion was significantly influenced by the PESI score categorized by tertiles (figure 1).

Conclusions

Although the PESI score stratifies HD stable pts, in this population it was able to predict cardiovascular outcomes in HR-PE pts. Furthermore, it showed a significant interaction with the prognostic impact of reperfusion in early and late cardiovascular outcomes.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Interaction between PESI and reperfusion

Complications of balloon pulmonary angioplasty for chronic thromboembolic pulmonary disease according to the classification proposed by the 6th world symposium on pulmonary hypertension

Introduction

Balloon pulmonary angioplasty (BPA) is a complex procedure and not risk free. In an attempt to standardize reports of BPA complications in the several centers, a classification of complications was proposed by the task force on chronic thromboembolic hypertension (CTEPH) in the 6th World Symposium on Pulmonary Hypertension (WSPH).

Purpose

To determine the prevalence of BPA complications according to the classification of 6th WSPH and to identify its predictors.

Methods

Detailed procedural and technical aspects were collected for consecutive patients (pts) with inoperable, residual/recurrent chronic thromboembolic disease, undergoing BPA at a single institution from December/2017 to December/2020. Per procedure logistic regression analysis was used to evaluate the predictive variables for complications.

Results

A total of 76 BPA sessions in 15 pts were performed (mean age 63.2±14.0 years; 60.0% women; 86.7% CTEPH). Mean pulmonary artery pressure and pulmonary vascular resistance before the first BPA session were 33.1±13.3 mmHg and 4.8±3.2 woods unit, respectively (73.3% of pts under vasodilator therapy). Femoral access was used for all pts. Mean vessels treated per procedure were 4.3±1.9 (324 vessels in total). Webs, subtotal occlusions, ring-like stenosis and total occlusions were noted in 215 (66.4%), 58 (17.9%), 31 (9.6%) and 20 (6.2%) treated vessels, respectively. We performed 21 pressure-wire-guided sessions (27.6%). Intravascular imaging was used in 6 procedures (7.9%). Average time of fluoroscopy was 60.3±14.0 minutes and volume of contrast 273.0±73.0 mL per session. Procedure-related adverse events occurred in 25.0% of the interventions (27.6% in the first two years vs 16.7% in the last two). Pulmonary artery vascular injuries were noted in 6 BPA vessels (7.9% per procedure and 1.9% per treated vessel): haemoptysis in all, but perforation was only detected angiographically in 3 of them (balloon inflation was performed for 2 distal perforations, and 1 perforation sealed without any intervention). Vascular dissection in distal lesions occurred in 4 cases (5.3%) with no need of transcatheter or surgical procedures. We had 3 lung injuries, all grade 2. None of the pts required oral intubation or mechanical ventilation. Extra-pulmonary complications were illustrated in table. Importantly, there was no peri-procedural death. The occurrence of vascular or lung injuries was 0% in pressure-wire-guided BPA versus 14.5% in non-guided (p=0.098). Multivariate analysis revealed that age (OR 1.05; CI 1.01–1.10; p=0.030) was the only independent predictor of complications.

Conclusions

In our experience, BPA can be safely performed in inoperable, residual or recurrent CTEPH or CTED pts, with 25% minor procedural-related complications but no major adverse event. Age was the strongest factor related to the occurrence of complications.

Funding Acknowledgement

Type of funding sources: None.

Metformin combined with insulin in women with gestational diabetes mellitus: a propensity score-matched study

AIM

Metformin use in gestational diabetes (GDM) is a common practice. Although its use in combination with insulin might be advantageous, it was never formally tested. We studied whether combined treatment was associated with better obstetric or neonatal outcomes compared to insulin alone.

METHODS

This is a retrospective study, using the Portuguese National Registry of GDM (2012-2017), of women treated with insulin ± metformin. Primary endpoints were obstetric and neonatal complications. Secondary endpoints were gestational weight gain (GWG) and insulin dose. A propensity score-matched analysis was performed to balance the distribution of age, BMI, insulin treatment duration, HbA1c, first trimester diagnosis of GDM and previous GDM or macrosomia. Women treated with metformin plus insulin and insulin only were then compared.

RESULTS

A total of 4034 women were treated with insulin or insulin plus metformin (10.2%). After propensity score matching, we studied two groups of 386 patients. Obstetric and neonatal complications were similar. Women treated with metformin plus insulin had 201 (52.1%) obstetric complications versus 184 (47.7%) in insulin-only group, p = 0.22; and 112 (29.0%) neonatal complications versus 96 (24.9%), p = 0.19. Patients treated with metformin plus insulin had similar GWG, excessive weight gain and insulin dose compared to the insulin-only group.

CONCLUSIONS

Women with GDM treated with insulin plus metformin had similar obstetric and neonatal complications, weight gained and insulin dose compared to those only treated with insulin.

Predictors of the presence of septal late gadolinium enhancement in follow-up cardiac magnetic resonance imaging and its relation to acute myocarditis prognosis

Funding Acknowledgements

Type of funding sources: None.

Introduction

Acute myocarditis (AM) is generally a self-limited and benign disease. However, a minority of patients (pts) present or develop adverse outcomes. It has been proposed that the presence of late gadolinium enhancement (LGE) in the septum is associated with worse prognosis. Also, the presence of LGE without oedema in follow-up cardiac magnetic resonance imaging (CMR) seems to reflect more permanent lesions.

Purpose

The aim of this study was to determine if the presence of septal LGE in acute-phase CMR was associated with higher extent of disease in follow-up CMR and if initial laboratory tests help to predict the evolution to more permanent lesions.

Methods

Prospective single-centre study of pts admitted with AM diagnosed according to clinical findings, troponin T elevation and CMR criteria (Lake Louise), since 1/2013. Selection of those who underwent acute-phase (CMR-I) and follow-up CMR (CMR-II).

Results

Of 88 pts admitted with AM, 46 fulfilled our inclusion criteria: median age 31 ± 13 years, 85% males. CMR-I was performed at 6 ± 5days and LGE was present in 43 pts (93.5%). CMR-II was performed at 8 ± 4.3 months and 29 pts (63%) improved the number of LGE-positive segments, 10 pts (21.8%) had stable disease and 7 pts (15.2%) worsened CMR findings. Septal-LGE was detected in 10 pts (21.7%) in CMR-I and in 6 pts (13.0%) in CMR-II. Logistic regression analysis identified septal-LGE in CMR-I as a predictor of higher extent of LGE in CMR-II (OR 1.4, 95%CI 1.1-1.9, p = 0.020). Although median values of maximum high-sensitivity troponin and reactive-C protein (RCP) were not associated with septal LGE in CMR-I, increasing values of such tests were univariate predictors of a higher likelihood of septal involvement in CMR-II: maximum troponin (886 vs 1852ng/L; OR 1.00, 95%CI 1.00-1.00 p = 0.017) and RCP (4.2 vs 13.9mg/dL; OR 1.17, 95%CI 1.04-1.33, p = 0.012). After multivariate analysis, RCP was the independent predictor of septal LGE in CMR-II (AUC 80.8, 0.97-0.91, p = 0.012). RCP cut-off value &gt;10.2mg/dL identified patients with septal LGE in CMR-II with a sensitivity and specificity of 83.3% and 85.0%, respectively. The presence of cardiovascular risk factors, clinical presentation and B-type natriuretic peptide values were not predictors of septal LGE in either CMR. In a mean clinical follow-up of 757 ± 476days, no patient died, 3 pts (6.5%) developed new-onset heart failure (NYHA class II functional symptoms) and 2 pts (4.3%) developed ventricular arrhythmias. Due to a small number of adverse events, neither laboratory tests nor LGE septal pattern predicted adverse outcomes.

Conclusions

In this population, septal LGE pattern was able to predict higher extent of LGE in follow-up CMR. Increased cardiac biomarkers and inflammatory proteins in the acute setting were also associated with septal involvement in follow-up and can potentially help to establish the risk of adverse events for patients admitted with acute myocarditis.

Probing the dynamic properties of two sites simultaneously in a protein–protein interaction process: a SDSL-EPR study

Probing two sites simultaneously in a protein–protein interaction process combining spin labels of different EPR signatures.

SimLabel: a graphical user interface to simulate continuous wave EPR spectra from site-directed spin labeling experiments

Site-directed spin labeling (SDSL) combined with continuous wave electron paramagnetic resonance (cw EPR) spectroscopy is a powerful technique to reveal, at the residue level, structural transitions in proteins. SDSL-EPR is based on the selective grafting of a paramagnetic label on the protein under study, followed by cw EPR analysis. To extract valuable quantitative information from SDSL-EPR spectra and thus give reliable interpretation on biological system dynamics, numerical simulations of the spectra are required. Such spectral simulations can be carried out by coding in MATLAB using functions from the EasySpin toolbox. For non-expert users of MATLAB, this could be a complex task or even impede the use of such simulation tool. We developed a graphical user interface called SimLabel dedicated to run cw EPR spectra simulations particularly coming from SDSL-EPR experiments. Simlabel provides an intuitive way to visualize, simulate, and fit such cw EPR spectra. An example of SDSL-EPR spectra simulation concerning the study of an intrinsically disordered region undergoing a local induced folding is described and discussed. We believe that this new tool will help the users to rapidly obtain reliable simulated spectra and hence facilitate the interpretation of their results. Copyright © 2017 John Wiley & Sons, Ltd.

Posaconazole Pharmacokinetics, Safety, and Tolerability in Subjects With Varying Degrees of Chronic Renal Disease

Posaconazole is a triazole antifungal in development for the treatment of invasive fungal infections. The authors evaluated the pharmacokinetics and safety of posaconazole in healthy subjects and in those with mild (CL(CR) = 50-80 mL/min), moderate (CL(CR) = 20-49 mL/min), and severe chronic renal disease (CL(CR) <20 mL/min; receiving outpatient hemodialysis) (n = 6/group). Subjects received one 400-mg dose of posaconazole oral suspension with a standardized high-fat breakfast. For hemodialysis-dependent subjects, this dose was given on a nonhemodialysis day, and a second 400-mg dose was given 6 hours before hemodialysis. Blood samples were collected before dose and up to 120 hours postdose. For hemodialysis-dependent subjects following the second dose, additional samples (predialyzed and postdialyzed) were collected before, during, and after dialysis. There was no correlation between posaconazole pharmacokinetics and mild to moderate renal disease; the slopes of the linear regressions for creatinine clearance versus posaconazole AUC, C(max), CL/F, and t1/2 values were not significantly different from zero (P > .130). Mean CL/F values before and during hemodialysis were comparable. Furthermore, the difference in the predialyzed and postdialyzed posaconazole concentrations was only approximately 3%, supporting that posaconazole was not removed by hemodialysis. Protein binding was similar in all groups (approximately 98%) and was unaffected by hemodialysis. Posaconazole was generally well tolerated. One patient had elevated liver function test results that were not present at baseline and were thought to be possibly related to posaconazole. Results of this single-dose study indicate that dosage adjustments for patients with varying degrees of renal disease are not required.

A new solid oral tablet formulation of posaconazole: a randomized clinical trial to investigate rising single- and multiple-dose pharmacokinetics and safety in healthy volunteers

Objectives

Posaconazole is an extended-spectrum triazole with proven efficacy as antifungal treatment and prophylaxis. The marketed oral suspension should be taken with food to maximize systemic absorption. A new solid oral tablet has been developed with improved bioavailability that can be administered without regard to food. The aim of this study was to evaluate rising single- and multiple-dose pharmacokinetics, safety and tolerability of the new tablet.

Methods

This was a single-centre, randomized, placebo-controlled, Phase I, rising single- and multiple-dose study of healthy subjects aged 18–65 years who received a posaconazole tablet as 200 mg once daily, 200 mg twice daily or 400 mg once daily. The 24 subjects were studied in two cohorts of 12 subjects each (9 active and 3 placebo).

Results

After single or multiple oral dose administration of posaconazole tablets (200 and 400 mg), exposure increased in a dose-related manner. Peak posaconazole concentrations were attained at a median T_max of 4–5 h. Mean half-life was similar for 200 and 400 mg posaconazole doses (25 and 26 h). The accumulation ratio upon multiple doses over 8 days was ∼3 for 200 and 400 mg once daily and ∼5 for 200 mg twice daily. C_avg values exceeded 1300 ng/mL. The posaconazole oral tablet was safe and well tolerated, although mild, transient elevations in liver function were reported in some patients.

Conclusions

Posaconazole exposure increased in a dose-related manner. The pharmacokinetics of this new solid oral tablet of posaconazole supports the clinical evaluation of once-daily dosing regimens for fungal infections.

DNA translocation and unzipping through a nanopore: some geometrical effects

This article explores the role of some geometrical factors on the electrophoretically driven translocations of macromolecules through nanopores. In the case of asymmetric pores, we show how the entry requirements and the direction of translocation can modify the information content of the blocked ionic current as well as the transduction of the electrophoretic drive into a mechanical force. To address these effects we studied the translocation of single-stranded DNA through an asymmetric alpha-hemolysin pore. Depending on the direction of the translocation, we measure the capacity of the pore to discriminate between both DNA orientations. By unzipping DNA hairpins from both sides of the pores we show that the presence of single strand or double strand in the pore can be discriminated based on ionic current levels. We also show that the transduction of the electrophoretic drive into a denaturing mechanical force depends on the local geometry of the pore entrance. Eventually we discuss the application of this work to the measurement of energy barriers for DNA unzipping as well as for protein binding and unfolding.

Pharmacokinetics, safety, and efficacy of posaconazole in patients with persistent febrile neutropenia or refractory invasive fungal infection

The pharmacokinetic profiles, safety, and efficacies of different dosing schedules of posaconazole oral suspension in patients with possible, probable, and proven refractory invasive fungal infection (rIFI) or febrile neutropenia (FN) were evaluated in a multicenter, open-label, parallel-group study. Sixty-six patients with FN and 32 patients with rIFI were randomly assigned to one of three posaconazole regimens: 200 mg four times a day (q.i.d.) for nine doses, followed by 400 mg twice a day (b.i.d.); 400 mg q.i.d. for nine doses, followed by 600 mg b.i.d.; or 800 mg b.i.d. for five doses, followed by 800 mg once a day (q.d.). Therapy was continued for up to 6 months in patients with rIFI or until neutrophil recovery occurred in patients with FN. The 400-mg-b.i.d. dose provided the highest overall mean exposure, with 135% (P = 0.0004) and 182% (P < 0.0001) greater exposure than the 600-mg-b.i.d. and 800-mg-q.d. doses, respectively. However, exposure in allogeneic bone marrow transplant (BMT) recipients (n = 12) was 52% lower than in non-BMT patients. Treatment-related adverse events (occurring in 24% of patients) were mostly gastrointestinal in nature. Twenty-four percent of patients had adverse events leading to premature discontinuation (none were treatment related). In efficacy-evaluable patients, successful clinical response was observed in 43% with rIFI (56% of patients receiving 400 mg b.i.d., 17% receiving 600 mg b.i.d., and 50% receiving 800 mg q.d.) and 77% with FN (74% receiving 400 mg b.i.d., 78% receiving 600 mg b.i.d., and 81% receiving 800 mg q.d.). Posaconazole is well tolerated and absorbed. Divided doses of 800 mg (400 mg b.i.d.) provide the greatest posaconazole exposure.

Autoimmune progesterone urticaria

Autoimmune progesterone dermatitis is a rare cutaneous disorder characterized by recurrent and cyclic skin eruption with variable morphology, occurring during the luteal phase. A case of autoimmune progesterone urticaria in a 47-year-old woman is reported. An intradermal progestin test revealed a strong reactivity against this hormone. Treatment with tamoxifen and leuprolide acetate induced only a partial remission of urticaria. Bilateral oophorectomy was performed with absolute clearing of cutaneous lesions.