Open-Label, Single-Center, Single-Arm Study Evaluating the Efficacy and Safety of Elobixibat for Chronic Constipation in Patients With Heart Failure

Background: Neither the efficacy nor safety of elobixibat has been investigated in the treatment of chronic constipation in patients with heart failure (HF). Methods and Results: In this prospective, single-center, single-arm study elobixibat (10 mg/day) was administered for 12 weeks to 18 HF patients with chronic constipation defined according to the Rome IV criteria. Spontaneous bowel movement (SBM), stool consistency as measured by the Bristol Stool Form Scale, and degree of straining during defecation were recorded. In addition, biomarkers, blood pressure (BP) measured by ambulatory monitoring, and adverse events were assessed. Although there was no significant difference, the frequency of SBM increased by 2.0/week from baseline to Week 12. Both the degree of straining during defecation and low-density lipoprotein cholesterol (LDL-C) levels were significantly decreased at Week 12 (straining, -0.79 [95% confidence interval (CI), -1.40 to -0.17]; LDL-C, -10.4 mg/dL [95% CI, -17.9 to -2.9]). Although not significant, the difference in BP before and after defecation tended to decrease from baseline by approximately 10 mmHg at Week 12. Serious adverse events were not observed. Conclusions: Elobixibat reduced the degree of straining during defecation, and improved the lipid profile in HF patients with chronic constipation.

The empty pelvis syndrome: a core data set from the PelvEx collaborative

BACKGROUND

Empty pelvis syndrome (EPS) is a significant source of morbidity following pelvic exenteration (PE), but is undefined. EPS outcome reporting and descriptors of radicality of PE are inconsistent; therefore, the best approaches for prevention are unknown. To facilitate future research into EPS, the aim of this study is to define a measurable core outcome set, core descriptor set and written definition for EPS. Consensus on strategies to mitigate EPS was also explored.

METHOD

Three-stage consensus methodology was used: longlisting with systematic review, healthcare professional event, patient engagement, and Delphi-piloting; shortlisting with two rounds of modified Delphi; and a confirmatory stage using a modified nominal group technique. This included a selection of measurement instruments, and iterative generation of a written EPS definition.

RESULTS

One hundred and three and 119 participants took part in the modified Delphi and consensus meetings, respectively. This encompassed international patient and healthcare professional representation with multidisciplinary input. Seventy statements were longlisted, seven core outcomes (bowel obstruction, enteroperineal fistula, chronic perineal sinus, infected pelvic collection, bowel obstruction, morbidity from reconstruction, re-intervention, and quality of life), and four core descriptors (magnitude of surgery, radiotherapy-induced damage, methods of reconstruction, and changes in volume of pelvic dead space) reached consensus-where applicable, measurement of these outcomes and descriptors was defined. A written definition for EPS was agreed.

CONCLUSIONS

EPS is an area of unmet research and clinical need. This study provides an agreed definition and core data set for EPS to facilitate further research.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Prognostic impact of diabetes mellitus on in-hospital mortality in patients with acute myocardial infarction complicating renal dysfunction according to age and sex

BACKGROUND

Patients with acute myocardial infarction (AMI) complicating renal dysfunction (RD) are recognized as being at high risk. Although diabetes mellitus (DM) is a major cause of RD, the prognostic impact of coexisting DM on mortality in patients with AMI complicating RD is ill-defined. This study compared the prognostic impact of coexisting DM in patients with AMI complicating RD according to both age and sex.

METHODS

A multicenter retrospective study was conducted on 2988 consecutive patients with AMI complicating RD (estimated glomerular filtration rate <60 mL/min per 1.73 m2). Multivariable Cox regression analysis was performed to investigate the effects of DM on in-hospital mortality.

RESULTS

Statistically significant interactions between age and DM and between sex and DM for in-hospital mortality were revealed in the entire cohort. Coexisting DM was identified as an independent risk factor for in-hospital mortality (hazard ratio [HR], 2.543) in young (aged <65 years), but not old (aged ≥65 years), patients. DM was identified as an independent risk factor (HR, 1.469) in male, but not female, patients. Kaplan-Meier survival curves showed that DM correlated with significantly low survival rates in patients that were young or male as compared to those who were old or female.

CONCLUSIONS

There were significant differences in the prognostic impact of DM on in-hospital mortality between young and old as well as male and female patients with AMI complicating RD. These results have implications for future research and the management of patients with DM, RD, and AMI comorbidities.

Evaluation of an Integrin αvβ3 Radiotracer, [18F]F-FPP-RGD2, for Monitoring Pharmacological Effects of Integrin αv siRNA in the NASH Liver

Purpose

Integrin αv is a key regulator in the pathophysiology of hepatic fibrosis. In this study, we evaluated the potential utility of an integrin αvβ3 positron emission tomography (PET) radiotracer, 18F-labeled cyclic arginine-glycine-aspartic acid penta-peptide ([18F]F-FPP-RGD2), for detecting hepatic integrin αv and function in nonalcoholic steatohepatitis (NASH) model rats using integrin αv siRNA.

Methods

NASH model rats were produced by feeding a choline-deficient, low-methionine, high-fat diet for 8 weeks. PET/computerized tomography imaging and quantification of integrin αv protein, serum aspartate aminotransferase, and alanine aminotransferase were performed 1 week after single intravenous injection of integrin αv siRNA.

Results

Integrin αv siRNA (0.1 and 0.5 mg/kg) dose-dependently decreased hepatic integrin αv protein concentrations in control and NASH model rats. The hepatic mean standard uptake value of [18F]F-FPP-RGD2 was decreased dose-dependently by integrin αv siRNA. The mean standard uptake value was positively correlated with integrin αv protein levels in control and NASH model rats. Serum aspartate aminotransferase and alanine aminotransferase concentrations were also decreased by siRNA injection and correlated with liver integrin αv protein expression levels in NASH model rats.

Conclusion

This study suggests that [18F]F-FPP-RGD2 PET imaging is a promising radiotracer for monitoring hepatic integrin αv protein levels and hepatic function in NASH pathology.

Anti-Inflammatory Actions of Expectorants in a Rat Carrageenan-Induced Footpad Edema Model

S-Carboxymethyl-L-cysteine (SCMS) exhibits sputum-regulating and anti-inflammatory actions. Previous studies reported the anti-inflammatory effects of SCMS on chronic inflammatory diseases, but no study has examined these effects on acute inflammatory diseases. In this study, we investigated the anti-inflammatory effects of SCMS in a rat carrageenan-induced footpad edema model, which is routinely used as an acute inflammation model. Expectorants were administered to rats with footpad edema induced by subcutaneously administering 1%λ-carrageenan to the footpad of the left posterior limb, and the dose dependency of the anti-inflammatory effects was evaluated. As a result, even when the dose of SCMS was increased to 400 mg/kg, there were no inhibitory effects on edema. Furthermore, we examined the inhibitory effects of other expectorants (ambroxol hydrochloride, N-acetyl-L-cysteine, L-cysteine ethylester hydrochloride, and L-cysteine methylester hydrochloride), which were reported to exhibit anti-inflammatory effects on chronic inflammation, on edema. However, none of these expectorants inhibited edema.

Clinical, electrocardiographic, and echocardiographic parameters associated with the development of pacing and implantable cardioverter-defibrillator indication in patients with transthyretin amyloid cardiomyopathy

AIMS

This study aimed to identify factors for attention leading to future pacing device implantation (PDI) and reveal the necessity of prophylactic PDI or implantable cardioverter-defibrillator (ICD) implantation in transthyretin amyloid cardiomyopathy (ATTR-CM) patients.

METHODS AND RESULTS

This retrospective single-center observational study included consecutive 114 wild-type ATTR-CM (ATTRwt-CM) and 50 hereditary ATTR-CM (ATTRv-CM) patients, neither implanted with a pacing device nor fulfilling indications for PDI at diagnosis. As a study outcome, patient backgrounds were compared with and without future PDI, and the incidence of PDI in each conduction disturbance was examined. Furthermore, appropriate ICD therapies were investigated in all 19 patients with ICD implantation. PR-interval ≥220 msec, interventricular septum (IVS) thickness ≥16.9 mm, and bifascicular block were significantly associated with future PDI in ATTRwt-CM patients, and brain natriuretic peptide ≥35.7 pg/mL, IVS thickness ≥11.3 mm, and bifascicular block in ATTRv-CM patients. The incidence of subsequent PDI in patients with bifascicular block at diagnosis was significantly higher than that of normal atrioventricular (AV) conduction in both ATTRwt-CM [hazard ratio (HR): 13.70, P = 0.019] and ATTRv-CM (HR: 12.94, P = 0.002), whereas that of patients with first-degree AV block was neither (ATTRwt-CM: HR: 2.14, P = 0.511, ATTRv-CM: HR: 1.57, P = 0.701). Regarding ICD, only 2 of 16 ATTRwt-CM and 1 of 3 ATTRv-CM patients received appropriate anti-tachycardia pacing or shock therapy, under the number of intervals to detect for ventricular tachycardia of 16-32.

CONCLUSIONS

According to our retrospective single-center observational study, prophylactic PDI did not require first-degree AV block in both ATTRwt-CM and ATTRv-CM patients, and prophylactic ICD implantation was also controversial in both ATTR-CM. Larger prospective, multi-center studies are necessary to confirm these results.

A potent allele marker related to low bull conception rate in Japanese Black bulls

Over the years, there has been considerable variation in the bull conception rate (BCR) of Japanese Black cattle; moreover, several Japanese Black bulls with a low BCR of ≤10% have been identified. However, the alleles responsible for the low BCR are not determined yet. Therefore, in this study, we aimed to identify single-nucleotide polymorphisms (SNPs) for predicting low BCR. To this end, the genome of Japanese Black bulls was comprehensively examined by a genome-wide association study with whole-exome sequencing (WES), and the effect of the identified marker regions on BCR was determined. The WES analysis of six sub-fertile bulls with a BCR of ≤10% and 73 normal bulls with a BCR of ≥40% identified a homozygous genotype for low BCR in Bos taurus autosome 5 in the region between 116.2 and 117.9 Mb. The g.116408653G > A SNP in this region had the most significant effect on the BCR (P-value = 1.0 × 10^-23), and the GG (55.4 ± 11.2%) and AG (54.4 ± 9.4%) genotypes in the SNP had a higher phenotype than the AA (9.5 ± 6.1%) genotype for the BCR. The mixed model analysis revealed that g.116408653G > A was related to approximately 43% of the total genetic variance. In conclusion, the AA genotype of g.116408653G > A is a useful index for identifying sub-fertile Japanese Black bulls. Some positive and negative effects of SNP on the BCR were presumed to identify the causative mutations, which can help evaluate bull fertility.

Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline

This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.

Increasing the class of foundational medication for heart failure is associated with improved prognosis in hospitalized patients with heart failure with reduced or mildly reduced ejection fraction

Aim

To clarify the association between changes in the number of foundational medications for heart failure (FMHF) during hospitalization for worsening heart failure and post-discharge prognosis.

Methods and results

We retrospectively analyzed a combined dataset of three large-scale registries of hospitalized patients with heart failure in Japan (NARA-HF, WET-HF, and REALITY-AHF) and included patients already diagnosed with heart failure with reduced or mildly reduced left ventricular ejection fraction (HFr/mrEF) before admission. Patients were stratified by changes in the number of prescribed FMHF classes, namely angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, and mineralocorticoid receptor blockers, from admission to discharge. The primary endpoint was defined as the combined endpoint of heart failure rehospitalization and all-cause death within 1-year of discharge. The cohort consisted of 1,113 patients, and 482 combined endpoints were observed. In total, 413 (37.1%) patients were on increased FMHF (increased group), 607 (54.5%) remained unchanged (unchanged group), and 93 (8.4%) had a decreased number of FMHF (decreased group) at discharge compared to the time of admission. In multivariable analysis, the increased group was associated with a significantly lower incidence of the primary endpoint compared with the unchanged group (hazard ratio 0.56, 95% confidence interval 0.45–0.60; P&lt;0.001) and decreased group (hazard ratio 0.58, 95% confidence interval 0.40–0.84; P=0.004).

Conclusion

Increasing the number of FMHF cases during heart failure hospitalization is associated with a better prognosis in patients with HFr/mrEF.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): REALITY registry was funded by the Cardiovascular Research Fund of Japan.WET-HF registry was supported by a Grant-in-Aid for Young Scientists (Y.S. JSPS KAKENHI, 18K15860).

Aberrant interaction between TEAD1 and Lamin A/C causes cardiomyopathy

Background

Mutations in the LMNA gene encoding Lamin A/C, a major component of the nuclear lamina, cause laminopathies including dilated cardiomyopathy (DCM). DCM patients with LMNA mutations have particularly severe clinical courses such as heart transplantation and death due to heart failure. However, underlying mechanisms of LMNA-induced DCM remains elusive.

Methods and results

We identified LMNA Q353R mutation in a DCM family with severe heart failure. We generated Q353R heterozygous knock-in mice, which showed sarcomere dysplasia and perinatal lethality. Integrative single-cell analyses of the fetal murine hearts and patient-specific induced pluripotent stem cell-derived cardiomyocytes (iPSCMs) revealed that transcriptional regulation of cardiomyocyte maturation/development genes governed by TEAD1 was impaired in LMNA mutant cardiomyocytes. Protein array and immunostaining uncovered increased binding of TEAD1 to mutant Lamin A/C protein and abnormal localization of TEAD1 at the nuclear periphery. Furthermore, TT-10, a Hippo pathway inhibitor, rescued the dysregulation of cardiac developmental genes in LMNA mutant cardiomyocytes. Single-cell RNA-seq of cardiac tissues from DCM patients with the LMNA Q353R mutation confirmed the dysregulated expression of TEAD1 and its target genes. These results demonstrated abnormal interaction between TEAD1 and mutant Lamin A/C impairs structural maturation of cardiomyocytes and suggests that LMNA Q353R-related DCM can be treated through intervention in the Hippo pathway.

Conclusion

TEAD1 trapped by mutant Lamin A/C protein at the nuclear membrane perturbs transcriptional maturation in LMNA Q353R-related DCM.

Funding Acknowledgement

Type of funding sources: None.

Placement of catheters without magnetic sensors in the coronary sinus without fluoroscopic guidance: Feasibility and safety evaluation

Background

A three‐dimensional (3D) mapping system is essential to reduce radiation exposure during catheter ablation. When using the CARTO 3D mapping system, only the catheter with magnetic sensor can visualize its location. However, once target chamber matrix is created using the catheter, even the catheters without magnetic sensors (CWMS) can enable visualization. We aimed to investigate the feasibility and safety of placing a CWMS in the coronary sinus (CS) without fluoroscopic guidance.

Methods

The study group comprised 88 consecutive patients who underwent catheter ablation. CWMS placement was performed without fluoroscopic guidance in 47 patients and with fluoroscopic guidance in 41 patients. Placement without fluoroscopic guidance was performed after creating a visualization matrix of the CS, right atrium, and superior vena cava using a catheter with a magnetic sensor. Feasibility and safety were compared between the two groups.

Results

Successful catheter placement was achieved in all patients without fluoroscopic guidance, with no inter‐group difference in the median procedure time: with guidance, 120.0 [96.0–135.0] min, and without guidance, 110.0 [97.5–125.0] min; p = .22. However, radiation exposure was significantly shorter, and the effective dose was lower without fluoroscopic guidance (0 [0–17.5] s and 0 [0–0.004] mSv, respectively) than with fluoroscopic guidance (420.0 [270.0–644.0] s and 0.73 mSv [0.36–1.26], respectively); both p < .001.

Conclusions

CWMS placement without fluoroscopic guidance is feasible, safe to perform, and does not involve complications. Our technique provides an option to decrease radiation exposure during catheter ablation and electrophysiological testing.

O-006 Annotation-free embryo score calculated by iDAScore® correlated with live birth and has no correlation with neonatal outcomes after single vitrified-warmed blastocyst transfer

Study question

Does the embryo score calculated by annotation-free embryo scoring system based on deep learning and time-lapse sequence images correlate with live birth (LB) and neonatal outcomes?

Summary answer

Annotation-free embryo score calculated by iDAScore correlates with decreased miscarriage and increased LB and has no correlation with neonatal outcomes.

What is known already

Embryo ranking models have recently been developed based on artificial intelligence (AI) and deep learning to rank embryos according to their potential for pregnancy. The practicability and usability of such models have been reported. And the previous report suggested iDAScore which is one of the deep learning models for embryo scoring was superior to traditional morphological assessment methods and morphokinetic embryo assessment models. However, few studies have used independent datasets to analyze the correlation between the score calculated by AI models, LB, and neonatal outcomes.

Study design, size, duration

A total of 3,010 single vitrified-warmed blastocyst transfer (SVBT) cycles were analyzed retrospectively. The quality and scoring of embryos were assessed using iDAScore v1.0 (iDAScore, Vitrolife, Sweden). The cohort was divided into four groups based on the iDAScore according to the percentile (9.9-9.3, 9.2-8.7, 8.6-7.3 and, 7.2-1.0).

Participants/materials, setting, methods

Scores were calculated using the iDAScore software module in the Vitrolife Technology Hub (Vitrolife, Gothenburg, Sweden). The correlation between iDAScore, LB rates and total miscarriage (TM), including 1st and 2nd trimester miscarriage, were analysed using a trend-test and multivariable logistic regression analysis. Furthermore, similarly, correlation between the iDAScore and neonatal outcomes were analysed.

Main results and the role of chance

LB rates decreased as the iDAScore decreased (P &lt; 0.05), and a similar inverse trend was observed for the TM rates (P &lt; 0.05). Additionally, multivariate logistic regression analysis showed that iDAScore significantly correlated with increased LB (adjusted odds ratio: 1.742, 95% CI: 1.601–1.904, P &lt; 0.05) and decreased TM (adjusted odds ratio: 0.799, 95% CI: 0.706–0.905, P &lt; 0.05). There was no significant correlation between iDAScore and neonatal outcomes, including congenital malformations, sex, gestational age, and birth weight. Multivariate logistic regression analysis, which included maternal and paternal age, maternal body mass index, parity, smoking, and the presence or absence of caesarean section as confounding factors, revealed no significant difference in any neonatal characteristics (low birth weight, small for gestation, large for gestation, preterm birth, male sex rates, and major congenital malformation).

Limitations, reasons for caution

SVBT was performed following minimal stimulation and natural cycle in vitro fertilisation. Therefore, only a few cycles of elective blastocyst transfer were available. However, there was no bias in selecting embryos for SVBT.

Wider implications of the findings

Objective embryo assessment using a completely automatic and annotation-free model, like iDAScore, showed a good correlation with increased LB and decreased TM. Furthermore, it did not correlate with neonatal outcomes. Therefore, iDAScore may be an optimal LB prediction model after SVBT without affecting neonatal outcomes.

Trial registration number

not applicable

Laparoscopic and Robot-Assisted Hepatic Surgery: An Historical Review

Hepatic surgery is a rapidly expanding component of abdominal surgery and is performed for a wide range of indications. The introduction of laparoscopic cholecystectomy in 1987 was a major change in abdominal surgery. Laparoscopic surgery was widely and rapidly adopted throughout the world for cholecystectomy initially and then applied to a variety of other procedures. Laparoscopic surgery became regularly applied to hepatic surgery, including segmental and major resections as well as organ donation. Many operations progressed from open surgery to laparoscopy to robot-assisted surgery, including colon resection, pancreatectomy, splenectomy thyroidectomy, adrenalectomy, prostatectomy, gastrectomy, and others. It is difficult to prove a data-based benefit using robot-assisted surgery, although laparoscopic and robot-assisted surgery of the liver are not inferior regarding major outcomes. When laparoscopic surgery initially became popular, many had concerns about its use to treat malignancies. Robot-assisted surgery is being used to treat a variety of benign and malignant conditions, and studies have shown no deterioration in outcomes. Robot-assisted surgery for the treatment of malignancies has become accepted and is now being used at more centers. The outcomes after robot-assisted surgery depend on its use at specialized centers, the surgeon's personal experience backed up by extensive training and maintenance of international registries. Robot-assisted hepatic surgery has been shown to be associated with slightly less intraoperative blood loss and shorter hospital lengths of stay compared to open surgery. Oncologic outcomes have been maintained, and some studies show higher rates of R0 resections. Patients who need surgery for liver lesions should identify a surgeon they trust and should not be concerned with the specific operative approach used. The growth of robot-assisted surgery of the liver has occurred in a stepwise approach which is very different from the frenzy that was seen with the introduction of laparoscopic cholecystectomy. This approach allowed the identification of areas for improvement, many of which are at the nexus of engineering and medicine. Further improvements in robot-assisted surgery depend on the combined efforts of engineers and surgeons.

Malnutrition-associated high bleeding risk with low thrombogenicity in patients undergoing percutaneous coronary intervention

BACKGROUND AND AIMS

Although antithrombotic treatments are established for coronary artery disease (CAD), they increase the bleeding risk, especially in malnourished patients. The total thrombus-formation analysis system (T-TAS) is useful for the assessment of thrombogenicity in CAD patients. Here, we examined the relationships among malnutrition, thrombogenicity and 1-year bleeding events in patients undergoing percutaneous coronary intervention (PCI).

METHODS AND RESULTS

This was a retrospective analysis of 300 consecutive CAD patients undergoing PCI. Blood samples obtained on the day of PCI were used in the T-TAS to compute the thrombus formation area under the curve. We assigned patients to two groups based on the geriatric nutritional risk index (GNRI): 102 patients to the lower GNRI group (≤98), 198 patients to the higher GNRI group (98<). The primary endpoint was the incidence of 1-year bleeding events defined by Bleeding Academic Research Consortium criteria types 2, 3, or 5. The T-TAS levels were lower in the lower GNRI group than in the higher GNRI group. Kaplan-Meier analysis showed worse 1-year bleeding event-free survival in the lower GNRI group compared with the higher GNRI group. The combined model of the GNRI and the Academic Research Consortium for High Bleeding Risk (ARC-HBR) had good calibration and discrimination for bleeding risk prediction. In addition, having a lower GNRI and ARC-HBR positivity was associated with 1-year bleeding events.

CONCLUSION

A lower GNRI could reflect low thrombogenicity evaluated by the T-TAS and determine bleeding risk in combination with ARC-HBR positivity.

Analysis of the linear oscillation dynamics of Fluidyne engines

A Fluidyne engine is a liquid piston Stirling engine that uses thermally induced self-sustained oscillations of water and air that are filled in a looped tube and tuning column. It presents high potential for use as a low-temperature-difference Stirling engine with a simple structure. This study analyzes the linear oscillation dynamics of the Fluidyne from a thermoacoustic point of view, with particular emphasis on the local specific acoustic impedance of the working gas, which is given by the ratio of the complex amplitudes of the pressure and velocity oscillations in the regenerator of the Fluidyne. The frequency dependence of the specific acoustic impedance indicates that the gas in the regenerator region undergoes a thermodynamic cycle equivalent to the Stirling cycle when the oscillation frequency is equal to the natural oscillation frequency of the U-shaped liquid column in the Fluidyne. The analysis of the natural oscillation modes determined two key parameters for the desired specific acoustic impedance: the tuning column length and the connecting position to the loop. Experimental verification was achieved via measurements of the onset temperature ratio and acoustic field of a prototype Fluidyne engine.

HFA-PEFF scores: prognostic value in heart failure with preserved left ventricular ejection fraction

BACKGROUND/AIMS

The Heart Failure Association (HFA)-PEFF score is recognized as a simple method to diagnose heart failure (HF) with preserved ejection fraction (HFpEF). This study aimed to evaluate the relationship between HFA-PEFF scores and cardiovascular outcomes in HFpEF patients.

METHODS

A total of 502 consecutive HFpEF patients were prospectively observed for up to 1,500 days. Cardiovascular outcomes were compared between two groups of patients, defined by their HFA-PEFF scores: those who scored 2-4 (the intermediate-score group) and those who scored 5-6 group (the high-score group). Overall, 236 cardiovascular events were observed during the follow-up period (median, 1,159 days).

RESULTS

Kaplan-Meier analysis showed that there were significant differences in composite cardiovascular events and HF-related events between the intermediate-score group and the high-score group (p = 0.003 and p < 0.001, respectively). Multivariate Cox proportional hazards analysis showed that the HFA-PEFF scores significantly predicted future HF-related events (hazard ratio, 1.66; 95% confidence interval [CI], 1.11 to 2.50; p = 0.014); receiver operating characteristic analysis confirmed this relationship (area under the curve, 0.633; 95% CI, 0.574 to 0.692; p < 0.001). The cutoff HFA-PEFF score for the identification of HF-related events was 4.5. Decision curve analysis revealed that combining the HFA-PEFF score with conventional prognostic factors improved the prediction of HF-related events.

CONCLUSION

HFA-PEFF scores may be useful for predicting HF-related events in HFpEF patients.

Increased soluble programed cell death-ligand 1 is associated with acute coronary syndrome

BACKGROUND

Programmed cell death (PD)-1 and its ligand (PD-L1) plays crucial roles in T-cell tolerance as immune checkpoint. Previous studies reported that increased serum levels of soluble PD-L1 (sPD-L1) reflect myocardial and vascular inflammation. However, little is known about the clinical relationship between sPD-L1 and acute coronary syndrome (ACS). We investigated the relation of sPD-L1 and ACS.

METHODS

We prospectively measured serum levels of sPD-L1 using a commercially available enzyme-linked immunosorbent assay kit in patients with coronary artery disease (CAD) and continuous non-CAD admitted to Kumamoto University Hospital between December 2017 and June 2019. All malignant diseases, patients who underwent hemodialysis, active collagen diseases, and severe infectious diseases were excluded.

RESULTS

Totally, 446 CAD patients [ACS, n = 124; chronic coronary syndrome (CCS), n = 322] and 24 non-CAD patients were analyzed. The levels of sPD-L1 were significantly higher in patients with ACS than those both with non-CAD and CCS {ACS, 188.7 (111.0-260.8) pg/mL, p < 0.001 vs. non-CAD [83.5 (70.8-130.4) pg/mL]; and p = 0.009 vs. CCS [144.2 (94.8-215.5) pg/mL], respectively}. Univariate logistic regression analysis identified that sPD-L1 was significantly associated with ACS [odds ratio (OR): 1.459, 95% confidence interval (CI): 1.198-1.778, p < 0.001]. Multivariable logistic regression analysis with nine significant factors identified from the univariate analysis revealed that sPD-L1 was significantly and independently associated with ACS (OR: 1.561, 95% CI: 1.215-2.006, p < 0.001).

CONCLUSIONS

This is the first clinical study to demonstrate the increased level of sPD-L1 in patients with CAD, and the significant association with ACS.

Renocardiac protective effects of SGLT2 inhibitor combined with angiotensin receptor blocker in salt sensitive Dahl rats

Background

Kidney plays a central role in regulating salt-sensitivity of blood pressure (BP) to governs sodium excretion via several mechanisms including pressure natriuresis and the actions of renal sodium transporters.

Purpose

We clarified the effects of combination treatment of sodium-glucose cotransporter 2 (SGLT2) inhibitor and angiotensin receptor blocker (ARB) on BP and the pathogenesis of renocardiac injuries, and elucidated underlying molecular mechanisms involved in the regulation of renal sodium handling in the development of salt-sensitivity by comparing with each monotreatment in Dahl salt-sensitive (DSS) hypertensive rats.

Methods

DSS rats were treated orally for 8-weeks with normal salt diet (0.3% NaCl) (NS/Cont group), high salt diet (8% NaCl) (HS/Cont group), high salt diet with ipragliflozin (0.04%) (HS/Ipra group), high salt diet with losartan (0.05%) (HS/Los group), or high salt diet with combination of ipragliflozin and losartan (HS/Ipra+Los group).

Results

The combination group significantly reduced systolic BP compared with either high salt diet control group, losartan or ipragliflozin monotreatment groups (HS/Ipra+Los: 182.5±18.4mmHg vs HS/Cont: 227.7±26.1; HS/Ipra: 216.6±26.9; HS/Los: 208.6±21.6, at 8-weeks of treatment, P&lt;0.05, respectively) (Figure 1A). The slope of pressure-natriuresis curve was significantly increased in the HS/Ipra+Los group compared to that in the HS/Cont group (interaction P=0.024), HS/Ipra group (P=0.009), and HS/Los group (P=0.084) using the linear regression model (Figure 1B), which indicated that only the combination treatment of ipragliflozin and losartan improved salt-sensitivity. The combined treatment significantly improved creatinine clearance (HS/Ipra+Los: 3.3±0.9mL/min vs HS/Cont: 1.1±0.5; HS/Ipra: 1.7±0.6; HS/Los: 1.9±0.8, P&lt;0.05, respectively). The combination treatment also significantly ameliorated glomerulosclerosis, and improved cardiomyocyte hypertrophy and perivascular fibrosis (Figure 1C). Angiotensin II type 1 receptor (AT1R) protein expression level in the kidney was remarkably suppressed in the combination treatment group compared to the other high salt diet groups. The protein expression level of Na+/H+ exchanger isoform 3 (NHE3) and Na+-K+-Cl– cotransporter 2 (NKCC2), two of major sodium transports in the renal tubules, were significantly decreased with losartan monotreatment and combination treatment, but not with ipragliflozin monotreatment (Figure 2).

Conclusions

The dual inhibition of SGLT2 and AT1R effectively improved salt-sensitivity via reducing renal expression levels of the sodium transporters, which eventually lead to renocardiac protection. Thus, the combination treatment could be a novel and useful therapeutic strategy for treating salt-sensitive hypertension and renal injury in non-diabetic patients.

Funding Acknowledgement

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

A Randomized, Double-Blind Comparison Study of Royal Jelly to Augment Vascular Endothelial Function in Healthy Volunteers

Aims: Royal jelly, a creamy substance secreted by honeybees, has been reported to have beneficial effects against dyslipidemia and metabolic syndrome. However, the effects of royal jelly on atherogenesis remain unknown. Hence, we prospectively evaluated whether royal jelly augments vascular endothelial function, which can reflect early atherogenesis, in healthy volunteers.

Methods: This was a single-center, double-blind, 1:1 randomized placebo-controlled study conducted from October 2018 to December 2019. A total of 100 healthy volunteers were randomly assigned to receive either royal jelly 690 mg or placebo daily for 4 weeks. The primary endpoint was augmentation in vascular endothelial function as assessed using the change in the reactive hyperemia peripheral arterial tonometry index (RH-PAT) index, and the secondary endpoints were the changes in liver function and lipid profiles between baseline and 4 weeks after enrollment.

Results: The mean age of the participants was 35.0±9.3 years in the placebo group and 36.1±9.1 years in the royal jelly groups; 45% and 50% of the placebo and the royal jelly groups, respectively, were male. The percentage relative change in the RH-PAT index was significantly higher in the royal jelly group than in the placebo group (21.4%±53.1% vs. 0.05%±40.9%,P=0.037). The percentage relative changes in alanine aminotransferase and γ-glutamyl transpeptidase were significantly lower in the royal jelly group than in the placebo group (alanine aminotransferase: −6.06%±22.2% vs. 11.6%±46.5%,P=0.02; γ-glutamyl transpeptidase: −3.45%±17.8% vs. 4.62%±19.4%,P=0.045). Lipid profiles were not significantly different between the two groups.

Conclusions: Royal jelly might have antiatherogenic property by improving vascular endothelial function. It also augmented liver functions in healthy volunteers.

Improvement of Vascular Endothelial Function Reflects Nonrecurrence After Catheter Ablation for Atrial Fibrillation

Background The clinical implication of vascular endothelial dysfunction in patients with atrial fibrillation (AF) remains unclear. This study aimed to elucidate the correlation between changes in vascular endothelial function assessed by reactive hyperemia-peripheral arterial tonometry and the effect of sinus rhythm restoration after catheter ablation (CA) for AF. Methods and Results Consecutive 214 patients who underwent CA for AF were included in this single center, retrospective study. The natural logarithmic transformed reactive hyperemia-peripheral arterial tonometry index (LnRHI) of all patients was measured before CA as well as 3 and 6 months after CA. LnRHI in sinus rhythm was significantly higher than that in AF before CA. Multivariate logistic regression analysis revealed that the presence of AF was an independent risk factor for lowering of LnRHI (odds ratio, 4.092; P=0.002) before CA. The LnRHI was significantly improved 3 and 6 months after CA in patients without AF recurrence. Multivariate Cox hazard analysis revealed that changes in LnRHI from before to 3 months after CA independently correlated with recurrence of AF (hazard ratio, 0.106; P=0.001). Receiver operating characteristic analysis showed the decrease in LnRHI levels from before to 3 months after CA as a significant marker that suspects AF recurrence (area under the curve, 0.792; log-rank test, P<0.001). Conclusions The presence of AF was independently correlated with the impaired vascular endothelial function assessed by the reactive hyperemia-peripheral arterial tonometry. Long-term sinus rhythm restoration after CA for AF might contribute to the improvement of vascular endothelial function, which may reflect the nonrecurrence of AF.

O-220 An annotation-free embryo scoring system (iDAScore®) based on deep learning shows high performance for pregnancy prediction after single-vitrified blastocyst transfer

Study question

How is the performance of an automated embryo scoring system for pregnancy prediction after single-vitrified blastocyst transfer (SVBT) compared to other, annotation-dependent blastocyst grading systems?

Summary answer

Automatic embryo ranking by iDAScore shows a higher or equal performance, with regards to pregnancy prediction after SVBT, compared to manual, annotation-dependent grading systems.

What is known already

Blastocyst viability can be assessed by blastocyst morphology grades and/or morphokinetic parameters. However, morphological and morphokinetic embryo assessment is prone to both inter- and intra-observer variation. Recently, embryo ranking models have been developed based on artificial intelligence (AI) and deep learning. Such models rank embryos according to their potential for pregnancy only based on images and do not require any user-dependent annotation. So far, no study has independently assessed the performance of AI models compared to other embryo scoring models, including traditional morphological grading.

Study design, size, duration

A total of 3,014 SVBT cycles were retrospectively analysed. Embryos were stratified according to SART age groups. The quality and scoring of embryos were assessed by iDAScore v1.0 (iDAS, Vitrolife, Sweden), KIDScoreTM D5 v3 (KS; Vitrolife), and Gardner criteria. The performance of the pregnancy prediction for each embryo scoring model was compared using the area under curve (AUC) of the receiver operating characteristic curve for each maternal age group.

Participants/materials, setting, methods

Embryos were cultured in the EmbryoScope+ and EmbryoScopeFlex (Vitrolife). iDAS was automatically calculated using the iDAScore model running on the EmbryoViewer (Vitrolife). KS was calculated in EmbryoViewer after annotation of the required parameters. ICM and TE were annotated according to the Gardner criteria. The degree of expansion in all blastocysts was Grade 4 due to our freezing policy. Furthermore, Gardner’s scores were stratified into four grades (Excellent: AA, Good: AB BA, Fair: BB, Poor: others).

Main results and the role of chance

The AUCs of the &lt; 35 years age group (n = 389) for pregnancy prediction were 0.72 for iDAS, 0.66 for KS and 0.64 for Gardner criteria. The AUC of iDAS was significantly higher (P &lt; 0.05) compared to the other two models. For the 35–37 years age group (n = 514) the AUCs were 0.68, 0.68, and 0.65 for iDAS, KS and Gardner, respectively, and were not significantly different. The AUCs of the 38–40 years age group (n = 796) were 0.67 for iDAS, 0.65 for KS and 0.64 for Gardner criteria and where was not significantly different. The AUCs of the 41–42 years age group (n = 636) were 0.66, 0.66, and 0.63 for iDAS, KS and Gardner, respectively, and there was no significant difference among the pregnancy prediction models. For the &gt; 42 years age group (n = 389) AUCs were 0.76 for iDAS, 0.75 for KS and 0.75 for Gardner criteria and not significantly different. Thus, for all age groups, iDAS was either highest or equal to the highest AUC, although a significant difference was only observed for the youngest age group.

Limitations, reasons for caution

In this study, SVBT was performed after minimal stimulation and natural cycle in vitro fertilisation (IVF). Therefore, we had only few cycles with elective blastocyst transfer. However, there was also no bias in selecting the embryos for SVBT.

Wider implications of the findings

Our results showed that objective embryo assessment by a completely automatic and annotation-free model, iDAScore, does perform as good or even better than more traditional embryo assessment or an annotation-dependent ranking tool. iDAS could be an optimal pregnancy prediction model after SVBT, especially in young and advanced age patients.

Trial registration number

not applicable

Clinical benefits of precision medicine in treating solid cancers: European Society of Medical Oncology-Magnitude of Clinical Benefit Scale score-based analysis

Background

Precision and matched cancer medicine has the potential to complement the existing biomarker approaches in cancer treatment. However, despite their promising potential, certain negative results have highlighted their limitations in molecular biology-driven treatment strategies. This study aimed to evaluate the clinical benefits of precision therapies.

Materials and methods

Three reviewers independently identified and assessed precision and matched cancer treatment studies published between January 2015 and December 2020. Clinical benefits of the treatments included in our cohort were assessed using two established frameworks; the European Society of Medical Oncology-Magnitude of Clinical Benefit Scale version 1.1 (ESMO-MCBS) and the American Society of Clinical Oncology Value Framework.

Results

Of the 290 eligible studies, 130 were for lung cancer, 51 for solid tumors, 24 for melanoma, and 24 for breast cancer. The common targets were: epidermal growth factor receptor (N = 66), serine/threonine-protein kinase B-Raf (N = 40), anaplastic lymphoma kinase (ALK) (N = 34), breast cancer protein (N = 26), phosphatidylinositol-3 kinase/protein kinase B/phosphatase and tensin homolog (PI3K/AKT/PTEN) pathway (N = 19), receptor tyrosine-protein kinase erbB-2 (HER2) (N = 19), mitogen-activated protein kinase (RAS/RAF/MAPK) pathway (N = 18), programmed death-ligand 1 (N = 12), fibroblast growth factor receptor (N = 8), and others (N = 43). The ESMO-MCBS scales ranged from 0 to 4. Based on the clinical benefit values, tumor mutational burden/mismatch repair-deficient/microsatellite instability-high for immunotherapy, anaplastic lymphoma kinase, and neurotrophic receptor tyrosine kinase therapeutic targets were considered high, whereas RAS/RAF/MAPK and PI3K/AKT/PTEN were considered low. Additionally, we found a significant difference between each average score (P < 0.001).

Conclusions

This study showed that precision and matched cancer therapies require further improvement. This is consistent with the views of the tumor board and of clinicians that precision strategies need to be revised to improve their therapeutic effects.

•

Of the 290 eligible studies, 130 were for lung cancer, 51 for solid tumors, 24 for melanoma, and 24 for breast cancer.

•

Precision strategies need to be revised to improve their therapeutic effects.

•

Therapeutic targets need to be narrowed down to improve the efficacy of precision medicine in the clinical setting.

Impact of Reactive Oxidative Metabolites Among New Categories of Nonischemic Heart Failure

Background We investigated the clinical significance of derivatives of reactive oxygen metabolites (DROMs), a new marker of reactive oxygen species, in patients with nonischemic heart failure (HF) and compared them among new categories of HF. Methods and Results We recruited 201 consecutively hospitalized patients with HF and measured DROM under stable conditions. Then, we divided them according to new categories of HF (HF with reduced ejection fraction [EF], HF with midrangeEF, and HF with preserved EF) without coronary artery disease. In subgroup analysis, we followed EF changes in patients with HF with reduced EF and classified them into HF with recovered EF or nonrecovered EF according to whether EF had improved to >40%. DROMs are significantly and independently associated with HF-related events in patients with NIHF. There were no significant differences in DROM and the probability of HF-related events among HF categories in Kaplan-Meier analysis. However, patients with HF with reduced EF and HF with preserved EF but not HF with midrange EF with HF-related events had higher DROM than those without HF-related events. In subgroup analysis, Kaplan-Meier analysis demonstrated that the probabilities of HF-related events in HF with recovered EF were dramatically decreased. DROM were significantly higher in patients with HF with nonrecovered EF than in HF with recovered EF. In receiver operating characteristic analysis, the cutoff level of DROM for predicting improvements in HF with recovered EF was 347 Carratelli units. Furthermore, the C-statistic value for predicting EF improvement for the DROM levels was 0.703. In multivariable logistic regression analysis, DROM was independently and significantly associated with the prediction of HF with recovered EF. Conclusions DROM measurements can provide important prognostic information for risk stratification in any category of NIHF. Registration URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000035827.

Preclinical Verification of the Efficacy and Safety of Aqueous Plasma for Ovarian Cancer Therapy

Simple Summary

Ovarian cancer is among the most malignant gynecologic cancers, in part because intraperitoneal recurrence occurs with high frequency due to occult metastasis. We have demonstrated a metastasis-inhibitory effect of plasma-activated medium (PAM) in ovarian cancer cells. Here, we investigated whether PAM inhibits intraperitoneal metastasis. We observed that PAM induced macrophages’ infiltration into the disseminated lesion, which was co-localized with inducible nitric oxide synthase (iNOS)-positive signal, indicating that PAM might induce M1-type macrophages. We also observed that intraperitoneal washing with plasma-activated lactate Ringer’s solution (PAL) significantly improved the overall survival rate in an ovarian cancer mouse model. Intraperitoneal washing therapy might be effective to improve clinical outcomes of ovarian cancer.

Abstract

Epithelial ovarian cancer (EOC) is the most lethal gynecologic malignancy. The major cause of EOC’s lethality is that intraperitoneal recurrence occurs with high frequency due to occult metastasis. We had demonstrated that plasma-activated medium (PAM) exerts a metastasis-inhibitory effect on ovarian cancer in vitro and in vivo. Here we investigated how PAM inhibits intraperitoneal metastasis. We studied PAM’s inhibition of micro-dissemination onto the omentum by performing in vivo imaging in combination with a sequential histological analysis. The results revealed that PAM induced macrophage infiltration into the disseminated lesion. The iNOS-positive signal was co-localized at the macrophages in the existing lesion, indicating that PAM might induce M1-type macrophages. This may be another mechanism of the antitumor effect through a PAM-evoked immune response. Intraperitoneal lavage with plasma-activated lactate Ringer’s solution (PAL) significantly improved the overall survival rate in an ovarian cancer mouse model. Our results demonstrated the efficiency and practicality of aqueous plasma for clinical applications.

Hemodialysis-related low thrombogenicity measured by total thrombus-formation analysis system in patients undergoing percutaneous coronary intervention

BACKGROUND

Established antithrombotic therapies can increase bleeding risk, especially in hemodialysis (HD) patients. The Total Thrombus-formation Analysis System (T-TAS) is useful for evaluating thrombogenicity. The aim of this study was to examine the relationship between HD and thrombogenicity, or bleeding events in patients undergoing percutaneous coronary intervention (PCI).

METHODS

In this retrospective cohort study, 300 patients undergoing elective PCI were enrolled between April 2017 and March 2019. Blood samples obtained on the day of PCI were analyzed with T-TAS to compute the thrombus formation area under the curve (AUC; PL₁₈-AUC₁₀ for platelet chip; AR₁₀-AUC₃₀ for atheroma chip). The patients were divided into three groups according to estimated glomerular filtration rate (eGFR): 33 HD patients, 124 non-HD patients with eGFR <60 mL/min/1.73m², and 143 non-HD patients with eGFR ≥60. We examined the thrombogenicity and spontaneous bleeding events within 1-year post-PCI.

RESULTS

HD was significantly associated with both low PL₁₈-AUC₁₀ and AR₁₀-AUC₃₀ levels determined by T-TAS. Bleeding events defined by the Bleeding Academic Research Consortium criteria types 2, 3, or 5 occurred during follow-up in 27 patients (9.0%): 7 in HD, 10 in non-HD with eGFR <60, and 10 in non-HD with eGFR ≥60. Both T-TAS parameters in the patients with bleeding were lower compared with those in the patients without bleeding, and HD was significantly associated with 1-year bleeding events.

CONCLUSIONS

The results suggested that HD patients undergoing PCI might be a predictor for low thrombogenicity measured by T-TAS and 1-year bleeding risk.

Elevated C-reactive protein is significantly associated with left ventricular dysfunction in patients with aortic regurgitation and concomitant collagen disease

BACKGROUND

Collagen disease is an important cause of aortic regurgitation (AR). Although aortic valve surgery is recommended for patients with AR and depressed left ventricular (LV) function, there have been few reports about risk factors for LV dysfunction in patients with AR concomitant with collagen disease.

METHODS AND RESULTS

We conducted this study at Kumamoto University Hospital in Japan. A total of 41 patients who had moderate to severe AR and concomitant collagen disease between January 2014 and December 2019 were enrolled. With regard to baseline characteristics, there were no significant differences in the type of collagen disease or El Khoury class between patients with preserved LV function and those with reduced LV function. B-type natriuretic peptide (375.2 [257.9-3852.6]pg/ml vs. 64.0 [33.3-133.6]pg/ml, p < 0.01), C-reactive protein (CRP) levels (2.00 [1.24-9.14]mg/dl vs. 0.19 [0.06-0.52]mg/dl, p < 0.01) and neutrophil-to-lymphocyte ratio (7.94 [3.30-9.98] vs. 3.94 [1.83-5.58], p < 0.05) were significantly higher, and hemoglobin level (10.7 ± 1.6 g/dl vs. 12.2 ± 1.8 g/dl, p < 0.05) was significantly lower in patients with reduced LV function than in those with preserved LV function. There were no significant differences in any variables associated with severity and features of AR. Multivariable logistic regression analysis showed that high CRP levels (≥1.0 mg/dl) were independently and significantly associated with LV dysfunction in patients with AR and collagen disease, even after adjusting for the severity of AR (odds ratio: 95.7; 95% confidence interval: 4.6-1990.4, p < 0.01).

CONCLUSIONS

Uncontrolled inflammation, represented as high CRP levels, is an important marker for LV dysfunction in patients with AR and collagen disease.

Prognostic impacts of prehospital age shock index in patients with acute myocardial infarction

Introduction

Early identification of high-risk patients is the cornerstone of managing patients with acute myocardial infarction (AMI). Age Shock index (ASI; age multiplied by the ratio of heart rate/systolic blood pressure) has been reported to be similar to Global Registry of Acute Coronary Events (GRACE) risk score for predicting mortality in patients with AMI. However, prognostic impacts of prehospital ASI (pre-ASI) in patients with AMI remain unknown.

Methods

We analyzed of 2578 AMI patients who underwent emergency primary percutaneous coronary intervention (PCI) from January 2013 to March 2018, using data from Mie ACS Registry, a prospective and multicenter registry in Japan. Pre-ASI was recorded by emergency medical services at the first contact with the patient before admission, and in-hospital ASI (in-ASI) was recorded prior to PCI at admission. The primary end point was defined as all-cause death.

Results

Median follow-up duration was 753 days (497–838 days). All-cause death was observed in 230 (8.9%) patients. The ROC-AUC (Receiver operating characteristic-area under the curve) of pre-ASI for all- cause death was 0.76 (p&lt;0.001), which was similar to that of in-ASI (0.78, p&lt;0.001) (p=0.25 for pre-ASI versus in-ASI). The cut-off value for pre-ASI and in-ASI was for the prediction of all-cause death was both 45 with a sensitivity of 0.66 and a specificity of 0.78, with a sensitivity of 0.68 and a specificity of 0.76 respectively. According to the Kaplan-Meier survival analysis by combination of pre-ASI≥45 and in-ASI≥45, the patients with pre-ASI≥45 and in-ASI≥45 showed significantly higher all-cause mortality compared to the patients with pre-ASI≥45 and in-ASI&lt;45, the patients with pre-ASI&lt;45 and in-ASI≥45, and the patients with pre-ASI&lt;45 and in-ASI&lt;45 (p&lt;0.001) (Figure). The addition of pre-ASI≥45 to in-ASI≥45 (global chi-squared score: 205) resulted in a significantly increased global chi-squared score, suggesting the incremental prognostic value of pre-ASI (267; p&lt;0.001). Multivariate cox proportional hazard regression analysis for all-cause mortality demonstrated pre-ASI≥45 was a significant independent predictor (HR: 4.86; 95% CI: 3.36 to 7.02, p&lt;0.001). It was strongest predictor compared to left ventricular ejection fraction&lt;40% (HR: 2.45; 95% CI 1.67 to 3.58, p&lt;0.001), hemodialysis (HR: 3.45; 95% CI 1.66 to 7.17, p=0.001), door to balloon time&gt;90 minutes (HR: 1.66; 95% CI 1.18 to 2.34, p=0.004).

Conclusions

High pre-ASI predict increase mortality and assessment of both high pre-ASI and high in-ASI enhance risk stratification in patients with AMI. Early recognizing high pre-ASI may help us make better strategies and improve prognosis for high-risk AMI patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Premature acute coronary syndrome patients do not have a better prognosis for their age than mature ACS patients by propensity score match analysis

Background

Acute coronary syndrome (ACS) is the most important cardiovascular (CV) disease with a prevalence that increases with age. There is no data which compared the prognosis with premature ACS and mature ACS using propensity score matched analysis

Purpose

The purpose of this study was to compare the prognosis of premature ACS patients and mature ACS patients using propensity score matched analysis.

Methods

We analyzed of 4249 ACS patients (69.1±12.6, male 77%) including 773 premature ACS patients (50.1±6.8, male 78%) and 3476 mature ACS (73.3±9.3, male 77%) from January 2013 to December 2018, using data from Mie ACS Registry, a prospective and multicenter registry in Japan.

Premature onset of ACS was defined as younger than 65 years old in male and 55 years old in female.

Primary end point was as major adverse cardiac event (MACE) including cardiovascular death, non-fetal myocardial infarction, heart failure requiring admission and unstable angina.

Results

During median follow duration of 742 days ranging from409 to 828 days, 502 MACE were occurred. Premature ACS patients were younger and showed higher body mass index compared to mature ACS patients (50.1±6.8 vs 73.3±9.3 y.o., 25.5 vs 23.0, P&lt;0.001, respectively). However, premature ACS patients were more likely to be associated with ST elevation myocardial infarction, dyslipidemia, family history of coronary artery disease (CAD) and lower Killip classification compared to mature ACS patients (P&lt;0.01, respectively). Common CAD risk factors such as hypertension, diabetes mellitus and past history of CAD were less associated with premature ACS patients compared to mature ACS patients (P&lt;0.01, respectively). Unadjusted Kaplan-Meier survival curves demonstrated the favorable prognosis in premature ACS patients compared to mature ACS patients with hazard ratio of 0.57 (95% CI 0.45–0.71, P&lt;0.001, see Figure 1A). We compared a 1:1 propensity score-matched cohort of 1208 patients with or without premature onset of ACS adjusting the several factors mentioned above (n=604, respectively). Age could not be introduced as a factor of propensity score match when comparing premature and mature ACS patients. After propensity score-match, premature ACS patients is about 18 years younger than mature ACS patients (50.7±6.5 vs 68.5±8.2 y.o., P&lt;0.001). The average age of premature ACS was younger than that of mature ACS, but MACE by Kaplan-Meier survival analysis for premature ACS patients was equivalent to mature ACS patients (P=0.77, see Figure 1B).

Conclusion

Premature ACS patients are required very careful management because they might have factors with unfavorable prognosis, such as lifestyle habit and genetics, that may be beyond age.

Figure 1

Funding Acknowledgement

Type of funding source: None

Right coronary artery as a culprit artery for better prognosis in patients with acute myocardial infarction (AMI) with or without shock

Background

Although patients with acute myocardial infarction (AMI) complicated by cardiogenic shock, morbidity and mortality remain high even with early revascularization and modern intensive care.

Culprit artery and prognosis were associated in patients with acute myocardial infarction.

Purpose

Evaluation of short- and long-term prognosis of AMI with cardiogenic shock by right coronary artery (RCA) and left coronary artery (LCR)

Method

We investigated 3400 AMI patients (age 68.8±12.7 y.o.) were enrolled from Mie ACS registry. They were divided into 4 groups according to the culprit artery and presence or absence of cardiogenic shock: RCA without shock n=1114, RCA with shock n=74, LCA without shock n=2028, LCA with shock n=184. Primary endpoint was defined as all-cause mortality.

Results

During the median follow-up periods with 743 days, 12.6% of the patients experienced all-cause death. RCA and LAC with shock groups demonstrated significantly higher in-hospital mortality compared to groups without shock (p&lt;0.001, Figure 1A). Interestingly, after discharge, LCA with shock group showed significant higher all-cause mortality compared with other 3 groups. Surprisingly, RCA with shock group showed similar favorable prognosis to that of without shock groups (Figure 1B). Multivariate analyses for after discharge mortality showed that LCA with shock group was strongest independent poor prognostic factor with hazard ratio of 2.3 (95% CI 1.4–3.7), but RCA with shock group was not.

Conclusion

Association of cardiogenic shock is the hazardous risk factor for cases with AMI, especially LCA infarction. Surprisingly, RCA AMI cases with shock showed favorable prognosis as well as AMI without shock.

Kaplan-Meier survival curves

Funding Acknowledgement

Type of funding source: None