Sternohyoid or sternocleidomastoid muscle flap for tracheoesophageal puncture closure in irradiated patients: A CARE case series

INTRODUCTION

A novel technique for tracheoesophageal puncture (TEP) closure is described in which the sternohyoid muscles are rotated and interposed between the tracheal and esophageal walls. The results of this technique are reported, following CARE guidelines, and compared with those obtained using the sternocleidomastoid flap. A literature review on the techniques previously described for TEP closure in irradiated patients is presented.

CASE SERIES

The novel technique was performed in six patients in whom the infrahyoid muscles were preserved during total laryngectomy. All received adjuvant radiotherapy. Successful closure was achieved in three cases; in one case a small leak was noted after initial closure and was successfully managed with simple sutures; and the other two failures occurred in patients with diabetes. The sternocleidomastoid flap was performed in five patients (only one with previous radiation) and success was achieved in two patients. In another patient a micro-fistular orifice appeared six months after the operation.

DISCUSSION

The sternohyoid muscles pose a low morbidity alternative to be considered in surgical TEP closure. Patient selection is a key factor to surgical success, and this technique should be reserved for small to moderate size fistulas and in the absence of multiple impaired wound healing conditions.

Associations between self-reported sleep quality and cerebrospinal fluid biomarkers in mild cognitive impairment and Alzheimer's disease

Sleep disorders are very common in mild cognitive impairment (MCI) and Alzheimer's disease (AD). Several parameters of polysomnography seem to correlate with cognitive scores and amyloid biomarkers in the different stages of AD. However, there is limited evidence for the relationship between self-reported sleep impairment and disease biomarkers. In this study, we assessed the relationship between self-reported sleep complaints, with the Pittsburgh Sleep Quality Index, and both cognitive function and cerebrospinal fluid biomarkers in 70 patients with MCI and 78 patients with AD. Sleep duration and daytime dysfunction were higher in AD. Daytime dysfunction had a negative correlation with cognitive scores (Mini-Mental-State Examination and Montreal Cognitive Assessment) and with amyloid-beta1-42 protein, and a positive correlation with total tau protein. However, daytime dysfunction was an independent predictor only of t-tau values (F=57.162; 95% CI: [18.118; 96.207], P=0.004). These findings support a relationship between daytime dysfunction, cognitive scores and neurodegeneration, further expanding recent findings that it may signal a risk of dementia.

Tumour microenvironment and pituitary tumour behaviour

The pituitary tumour microenvironment encompasses a spectrum of non-tumoural cells, such as immune, stromal or endothelial cells, as well as enzymes and signalling peptides like cytokines, chemokines and growth factors, which surround the tumour cells and may influence pituitary tumour behaviour and tumourigenic mechanisms. Recently, there has been intensive research activity in this field describing various pituitary tumour-infiltrating immune and stromal cell subpopulations, and immune- and microenvironment-related pathways. Key changes in oncological therapeutic avenues resulted in the recognition of pituitary as a target of adverse events for patients treated with immune checkpoint regulators. However, these phenomena can be turned into therapeutic advantage in severe cases of pituitary tumours. Therefore, unravelling the pituitary tumour microenvironment will allow a better understanding of the biology and behaviour of pituitary tumours and may provide further developments in terms of diagnosis and management of patients with aggressively growing or recurrent pituitary tumours.

Hemostasis of the radial artery after coronary angiography: a scoping review

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Nowadays, most interventional cardiology procedures are made via radial artery. There is significant variability of haemostasis methods, devices, and protocols. All of them try to avoid radial artery occlusion while maintaining patent haemostasis. Summarizing the available evidence about haemostasis of the radial artery after coronary angiography will allow us to challenge our current practice.

Purpose

The focus of this scoping review is to map the literature on haemostasis of the radial artery after coronary angiography. To date, no previous reviews addressing this purpose have been found.

Methods

This review follows the Joanna Briggs Institute methodology for scoping reviews. Two reviewers will independently perform the study selection regarding their eligibility. Data extraction will be accomplished using a researcher's developed tool to address the objectives and reviews questions. Any disagreements arisen between the reviewers will be resolved by discussion or consulting a third reviewer. Data synthesis will be presented in tabular form and a narrative summary that align with the review's objective. Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension to scoping reviews guidelines will be used to report the results. A set of relevant electronic databases and grey literature will be searched.

Results

Twenty-four studies were included, of various types: randomized clinical trials, case-reports, case series, narrative reviews. Three methods were described: compression devices, compression band and haemostatic patch. Sometimes more than one method is used, and there are various protocols that vary according to the institutional practice.

Conclusion

There are multiple radial artery haemostasis methods and protocols currently in use after a coronary angiography with no method overwhelmingly predominant. Few were associated with clearly defined haemostasis protocols, even though these protocols exist, often associated with compression devices. The institutional practice plays a decisive role on the use and modification of these protocols, with no clear evidence to support it. Such variability in protocols might have a detrimental effect in having a standardized one that can be used across various institutions/countries, facilitating broader multicentric studies.

P-538 KATNAL1 polymorphisms confer susceptibility to severe phenotypes of male infertility in a large European cohort

Study question

What is the contribution of the common variation of KATNAL1 to the development of severe spermatogenic failure (SPGF) in a phenotypically well-characterized cohort?

Summary answer

An allelic combination of KATNAL1 single-nucleotide polymorphisms (SNPs) increases the risk to develop SPGF, likely by altering the expression and splicing pattern of the gene.

What is known already

Spermatogenesis is a process that requires an exhaustive control of gene expression, and subtle alterations of its molecular regulatory network can lead to male infertility. The aetiology of most SPGF cases remains unknown, and increasing evidence clearly suggests that the idiopathic form of SPGF represents a complex trait, in which genetic susceptibility is conferred by the accumulation of risk alleles in genetically predisposed men. In this regard, previous studies reported that rare genetic mutations and polymorphisms in the KATNAL1 locus lead to male infertility through the disruption of microtubule remodelling and premature germ cell exfoliation.

Study design, size, duration

We designed a case-control genetic association study including three SNPs (rs2077011, rs7338931, and rs2149971) in the 3' and 5' regulatory regions of KATNAL1, which tagged the common genetic variability in the region. The allele frequencies in the study population, composed of 715 infertile men diagnosed with idiopathic SPGF, were compared to those observed in a control group comprising 1058 fertile men from Spain and Portugal.

Participants/materials, setting, methods

The SPGF group comprised 210 men with severe oligospermia (SO) and 505 with non-obstructive azoospermia (NOA). The latter were phenotypically characterised according to the histological examination of testis biopsies and its outcome (Sertoli cell-only syndrome, SCO; maturation arrest, MA; hypospermatogenesis, HS; and testicular sperm extraction, TESE). After genotyping, case-control association analyses by logistic regression were conducted. In silico functional characterization of risk variants was also carried out using public multiomic databases and bioinformatic tools.

Main results and the role of chance

Significant genetic associations with different SPGF patterns and/or TESE outcome were observed even after correction for multiple testing when independent SNP models were tested. However, in all cases, the haplotype model including the three risk alleles (rs2077011*C | rs7338931*T | rs2149971*A) was the most informative. This haplotype was specifically over-represented in the SPGF group (P = 3.45E-02, OR = 2.33), which includes all infertile men, and in the NOA group (P = 8.22E-03, OR = 2.97). In addition, subtype-specific associations were observed with the most severe subgroups, namely MA (P = 2.44E-02, OR = 5.00), SCO (P = 4.03E-03, OR = 5.16), and unsuccessful TESE outcome (P = 2.22E-04, OR = 6.13), which indicates the relevant role of KATNAL1 in spermatogenesis development. We prioritized the most likely causal variant/s based on in silico analyses addressing the possible functional implication of the tagged variants. We observed that an alteration of the KATNAL1 splicing pattern, by favouring the overrepresentation of a short non-functional transcript isoform in the testis, might be the cause behind the observed genetic association. The analysis of the testis transcriptome at the single cell level showed that KATNAL1 transcripts were mostly presented in spermatocytes and early spermatids at puberty, which correlates with its effect of premature exfoliation and loss of the germ cells.

Limitations, reasons for caution

Although a previous low-powered study reported suggestive associations between KATNAL1 and SPGF, additional genetic association studies in independent populations should be conducted to confirm our findings. Moreover, the statistical power for the overall analysis was appropriate, but the subphenotype analyses were performed with reduced power due to smaller study groups.

Wider implications of the findings

Our results suggest a relevant role of the common genetic variation of KATNAL1 in the susceptibility to develop the most severe histological phenotypes of NOA (i.e., SCO and MA). Studies like the one presented here may definitively help to develop future non-invasive molecular markers of TESE success.

Trial registration number

Not Applicable

Apical versus septal pacing - can we chose the localization of ventricular lead in order to prevent upgrade to cardiac resynchronization therapy?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Right ventricular apical pacing (RVAp) may be deleterious to ventricular function and hemodynamics due to pacing induced dyssynchrony. In the last decades, some studies showed that RVAp has been associated with heart failure, deterioration of left ventricular function and high mortality. Some patients (pts) may need, during the follow up (FUP), an upgrade to cardiac resynchronizaon therapy (CRT). New techniques have emerged such as RV lead implantation in the high septum or outflow RV tract (RVOT) and, more recently, His bundle/LB pacing.

Purpose

To compare the need for upgrade to CRT in patients with RVAp versus septal/RVOT pacing.

Methods

Retrospective single-center study of consecutive pts that implanted pacemakers in a tertiary center between January 1995 and December 2020. We collected data regarding pacing indication, RV pacing site (apex versus septum/RVOT) and need for an upgrade to CRT during follow up (FUP).

Our primary endpoint was upgrade to CRT during the FU period. In the model, the impact of localization of the implanted lead on the survival free from upgrade was estimated assuming a neutral effect on mortality. Statistical analysis was performed using T-student test and logistic regression.

Results

We included 8761 pts, 60.2% (n=5275) were male, with a mean age of 76.5±10.7 years. The main indications for pacemaker implantation were (1) complete atrioventricular (AV) block (2239, 25.6%), (2) sick sinus syndrome (2211, 25.2%), (3) atrial fibrillation with AV block or bradycardia with significant pauses (17.4%) and (4) Mobitz II 2nd degree AV block (1467, 16.7%).

RVAp was performed in 1746 (20%) patients and RVOT/septal pacing in 6933 patients (80%; RVOT in 657 (9,5%)). During FUP, 26 (1,5%) RVAp pts and 52 (0,8%) RVOT/septal pacing pts underwent upgrade to CRT, in a total of 78 pts (CRT-P in 54 patients and CRT-D in 24 patients).

We observed that patients with RVAp had twice the risk of CRT upgrade during FUP (OR: 2,0 (IC 95% 1,25-3,21), p=0,004) when compared to patients with RVOT/septal pacing.

Conclusions

Patients with RVAp presented a 2-fold higher risk for upgrade to CRT when compared to patients with RVOT/septal pacing in our center. This retrospective analysis shows that lead implantation in the septum/RVOT should be preferred instead of the apex to reduce pacing induced dyssynchrony and need for CRT upgrade.

Upgrade pacemaker to CRT: predictors and the importance of LVEF

Funding Acknowledgements

Type of funding sources: None.

Introduction

Nowadays 10-15% of CRT implantaon is upgrading from paents (pts) with pacemaker (PMK) who develop reduced LVEF and worsening symptoms from HF. There are few retrospecve studies showing some predictors of pts with single or dual chamber PMK that may need upgrade to CRT, but it is not completely established which pts may benefit the most.

Purpose

To identify predictors at follow-up of upgrading pacemaker to CRT in a population with pacemaker implantation.

Methods

Single center case-control study of pts that performed upgrading to CRT-pacemaker (CRT-P) in our hospital. We excluded pts that performed upgrade to CRT-D. We compare to a PMK populaon matched to age at implantaon and cause of PMK implantaon. Demographic, clinic and electrocardiographic (ECG) data were considered at baseline. Echocardiographic evaluation was performed before pacemaker/CRT upgrading implantaon and at follow-up. Predictors of upgrading were evaluated by the Cox regression. Prognosc impact of LVEF was evaluated as upgrading to CRT-P by Kaplan-Meier curves.

Results

We included 71 pts that performed CRT-P upgrade (mean age 77±10; 49,6% male, mean LVEF before PMK 54.9±9.2%) and 71 pts with pacemaker implantaon (mean age 78 ± 11; 50,4% male; mean LVEF 60.9±7.2%). The clinical characteriscs, ECG and echocardiographic were similar between pacemaker and CRT-P-upgrade, except atrial fibrillaon being more prevalent in PMK group (57.5% vs 42.5% p=0.039). Mortality was not different duringfollow-up between the two groups. In univariate analysis, QRS duraon (PMK: 115ms vs upgrade CRT-P: 132 ms, p=0.038), LVEF (PMK: 60.9% vs upgrade CRT-P: 54.9%, p=0.002) and LV end-diastolic diameter (LVEDD) (PMK: 48.9.4 ± 6.6mm vs upgrade CRT-P: 56.4 ± 6.6mm, p=0.001), LV end-sistolic diameter (LVESD) (PMK: 29.5 ± 6.5mm vs upgrade CRT-P: 37.9 ± 9 mm, p=0.006) were associate to upgrading to CRT. In our population, the unique independent predictor was lower LVEF(Long Rank 6.108, p=0.013) – Figure 1. The best LVEF cut- off to predict upgradingto CRT was 55% (AUC 0.954, sensitivity 64%, specificity 84%) – Figure 2.

Conclusion

In our populaon of CRT upgrading pts, a broad QRS duraon, lower LVEF and a higher LVEDD and LVESD were associated to upgrade to CTR-P. We try to establish a new value for LVEF that could lead to upgradingto CRT-P, and maybe the classical cut-off of 50% should be reviewed.

SCREENER, an educational game for teaching the Drug Discovery and Development process

Although the use of games as an educational strategy is an important current trend, there is practically no option available for training people on the Drug Discovery and Development (DDD) process. To fill this gap, we designed “SCREENER”, a science game that is intended to be educational, but also challenging and interesting enough to ensure player engagement. Our main target audience is students of postgraduate programs in pharmacology, medicinal chemistry, pharmacy, and medicine. This game could also be of interest to the pharmaceutical industry and regulatory and patent agencies for training new employees. We discuss the creation of SCREENER, a hybrid of board and card games, and present its components with some examples of cards and resources, as well as the dynamics of the game. SCREENER mimics the process of drug discovery and development from validating a target to registering the new drug with the regulatory agency, and can be played individually (self-learning) or with the help of a monitor who assists up to six players/teams. Briefly, 29 task cards categorized in four major areas (efficacy, safety, pharmacokinetics, and pharmaceutical development) must be purchased sequentially. Classic characteristics of games such as decision making and challenge have been incorporated. More in-depth information on the tasks and technical terms is available through QR codes. The vagaries of the DDD process are mimicked by the bonus/setback cards. The evaluation of our first test with students is presented and supports the usefulness of this new tool.

Sociocultural factors of cervical cancer screening uptake among migrant women: a mixed methods study

 

Cervical cancer has a high mortality in Europe despite being preventable by cervical cancer screening (CCS). Migrant women have a lower CCS attendance compared to non-migrants. This study aims to describe CCS uptake among migrant women in Portugal and explore sociocultural influences. Within a mixed-methods approach, an online survey and focus group discussions (FGs) were conducted. The survey included 655 migrant women and collected data on sociodemographics, attendance and attitudes toward CCS. Four FGs with 12 healthcare workers and a FG with 5 community workers were conducted exploring perceptions on CCS attendance and barriers among migrant women. Quantitative data was analyzed using descriptive analysis and Chi-Square test and qualitative data through content analysis. Survey data shows that 24.9% of women never had CCS or had it over 5 years ago, more Asian and African women (51.3% and 36.7%, respectively) (p < 0.001). Non-attenders reported significantly more often embarrassment towards CCS (21.7% vs. 18.8% of CCS attenders, p = 0.002) and being unaware of their risk of cancer and the relevance of CCS (28.8% vs. 12.5%, p < 0.001). Around 24% of non-attenders reported concern with having a consultation with a male doctor. For FGs participants, CCS is a taboo in some communities, particularly African, Asian and Muslim. Lack of information about CCS along with feelings of embarrassment and discomfort related to pap smear and with being seen by a male doctor were referred as reasons for avoidance of CCS. Participants also stated that some women have low autonomy and often their husbands have a key role in deciding whether they should attend CCS. Lack of a preventive mindset was also stated as reason for low CCS attendance. The sociocultural background can influence migrant women's attendance to CCS. A culturally grounded approach is needed to provide tailored information on CCS and to create opportunities to engage migrant communities on CCS and improve their uptake.

Key messages

Lack of information, embarrassment and low autonomy hinder some migrant women’s attendance to CCS. The sociocultural influences on CCS uptake call for a culturally grounded approach to provide tailored information and engage migrant communities on CCS.

It is possible to predict mortality after ICD implantation?

Introduction

Implantable Cardioverter Defibrillators (ICD) therapy is not recommended in patients who do not have a reasonable expectation of survival for at least 1 year, although specific recommendations regarding clinical or functional status evaluation are lacking.

Purpose

To identify predictors of all-cause mortality in patients who implanted an ICD.

Methods

Prospective single-center study of patients who implanted ICD between 2015 and 2019. Clinical characteristics were evaluated at baseline and mortality was assessed using the national registry of citizens. We performed uni and multivariate analysis to compare clinical characteristics of patients who died and who survived using Cox regression and Kaplan-Meier methods. For the predictor creatinine, we assessed the discrimination power and the best cut-off using the area under the ROC curve (AUC) method.

Results

From 2015–2019, 414 ICDs were implanted (81% male, 62±12 years-old), and 50 (13%) of the patients died after a median follow-up of 23 [11–41] months. Patients who died during the follow-up were older (67±9 vs 61±12, p=0.002), had more diabetes (48% vs 33%, p=0.033) and a higher creatinine (1.23 [0.84–1.86] vs 1.00 [0.84–1.22], p<0.001). The remaining comorbidities were similar between groups (Fig. 1). Patients who died had more frequently an ICD implanted after complication associated with a previous device or as a pacemaker upgrade (6% vs 2%, p=0.030). They also had a higher frequency of ischaemic cardiomyopathy (i-CMP) (82% vs 56%, p=0.002) and of ejection fraction (EF) ≤50% (96% vs 82%, p=0.040). The best cut-off value of creatinine to predict mortality with a sensitivity of 65% and a specificity of 72% was 1.2mg/dl (AUC 0.650; CI95% 0.53–0.77). After adjusting for diabetes, i-CMP, EF ≤50% and upgrade/re-implantation after complication, we found that age (HR 1.033; 95% CI 1.00–1.06, p=0.041) and creatinine ≥1.2mg/dl (HR 2.134; 95% CI 1.09–4.19, p=0.028) were independent predictors of all-cause mortality.

Conclusion

In our cohort of patients who underwent ICD implantation for primary or secondary sudden cardiac death prevention, the all-cause mortality over a median follow-up period of 23 [11–41] months was 13%. We found that in addition to age, a baseline creatinine level ≥1.2mg/dl increases by 2-fold mortality in patients who undergo ICD implantation. Decisions regarding ICD candidacy should not be based on age alone but should also consider creatinine that predisposes to mortality despite ICD implantation.

Funding Acknowledgement

Type of funding sources: None. All cause mortality

A119 THE LOCATION-BASED RESECT AND DISCARD STRATEGY FOR DIMINUTIVE COLORECTAL POLYPS: A PROSPECTIVE CLINICAL STUDY

Background

Replacing histopathology evaluation of diminutive polyps with optical polyp diagnosis is considered a cost-effective approach. However, the widespread use of optical diagnosis is limited due to concerns about making incorrect optical diagnoses and the requirements of training, credentialing and auditing of performance.

Aims

This prospective study aimed to evaluate a simplified resect and discard strategy that is not operator dependent.

Methods

The study evaluated a resect and discard strategy that uses anatomical polyp location to classify colon polyps into non-neoplastic or low-risk neoplastic. All rectosigmoid diminutive polyps were considered hyperplastic and all polyps located proximally to the sigmoid colon were considered neoplastic. Surveillance interval assignments based on these a priori assumptions were compared with those based on actual pathology results and optical diagnosis, respectively. The primary outcome was ≥90% agreement with pathology in surveillance interval assignment.

Results

Overall, 1117 patients undergoing complete colonoscopy were included and 482 (43.1%) had at least one diminutive polyp. Surveillance interval agreement between the location-based resect and discard strategy and pathological findings using the 2020 US Multi-Society Task Force guideline was 97.0% (95% CI = 0.96 - 0.98), surpassing the ≥90% benchmark. Optical diagnoses using NICE and Sano classifications reached 89.1% and 90.01% agreement, respectively (p <0.0001), and were inferior to the location-based strategy. The location-based resect and discard strategy allowed a 69.7% (95% CI = 0.67 - 0.72) reduction in pathology examinations compared with 55.3% (95% CI = 0.52 - 0.58) (NICE and Sano) and 41.9% (95% CI = 0.39 - 0.45) (WASP) with optical diagnosis.

Conclusions

The location-based resect and discard strategy achieved very high surveillance interval agreement with pathology-based surveillance interval assignment, surpassing the ≥90% quality benchmark and outperforming optical diagnosis in surveillance interval agreement and the number of pathology examinations avoided.

Funding Agencies

None

Left atrial functional assessment and mortality in patients with severe aortic stenosis

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction: Aortic valve stenosis (AS) is the most common primary valvular heart disease leading to surgical or percutaneous aortic valve replacement (AVR) in Europe. Both symptoms and systolic dysfunction can appear late in the course of the disease, being often synonym of irreversible damage to the myocardium when found. Thus, there is a necessity to find other sensitive markers present at an earlier stage of the disease. 

Purpose

Our primary aim is to clarify the relationship between LA function measured at severe AS diagnosis (evaluated by means of volumetric assessment) and all-cause mortality during follow-up.

Methods

We retrospectively evaluated patients diagnosed with severe AS for the first time at our echocardiography laboratory. We evaluated all 3 left atrial (LA) functional phases (reservoir, conduit and pump) by measuring LA volumes at different timings of cardiac cycle. Treatment strategy was decided according to heart team consensus and own patient decision. We divided patients into groups according to terciles of LA reservoir, conduit and pump function. Primary outcome was defined by the occurrence of all-cause mortality during follow-up.

Results

After exclusion criteria, a total of 451 patients were included in the analysis (aged 74 ±11years, 54% male) and were followed during a median period of 73 months (interquartile range 44.5). A total of 55.8% of patients underwent AVR and 45,5% of patients registered the primary outcome. Left atrial emptying fraction (LAEF) was the best LA functional parameter in discriminating primary outcome (AUC 0.840, p < 0.001), even when compared to left ventricular ejection fraction, aortic valve area, aortic mean pressure gradient and aortic Vmax. Patients in the lower tercile of LAEF were older, had greater comorbidities, had greater AS severity, with greater degree of diastolic disfunction. After adjustment for clinical and demographic variables, cumulative survival of patients with LAEF <37% and LAEF 37 to 53% relative to patients with LAEF ≥54% remained significantly lower (adjusted HR 19.04, 95% CI 8.30-43.67, P < 0.001 and adjusted HR 4.09, 95% CI 1.85-9.06, P = 0.001). Survival was also higher in patients with LAEF 37 to 53% when compared to patients with LAEF <37% (adjusted HR 0.22, 95% CI 0.13-0.37, P < 0.001). All associations remained true after adjustment for AVR (LAEF <37% versus LAEF 37 to 53% and LAEF ≥54%, respectively, adjusted HR 3.97, 95% CI 1.80-8.78, P = 0.001 and adjusted HR 13.95, 95% CI 5.98-32.54, P < 0.001, respectively)

Conclusion(s) In patients with a first diagnosis of severe AS in hospital setting, LA function assessed by volumetric parameters is an independent predictor of all-cause mortality. Compared to classical severity parameters, different LA functional parameters were found to be more potent predictors of death. These data can be useful in clinical practice for risk stratification and therefore for decision of timing for AVR.

Abstract Figure. Survival of patients stratified by group

Fully automated contrast and non-contrast cardiac view detection in echocardiography a multi-centre, multi-vendor study

Background

Correctly identifying views acquired in a 2D echocardiographic examination is paramount to post-processing and quantification steps often performed as part of most clinical workflows. In many exams, particularly in stress echocardiography, microbubble contrast is used which greatly affects the appearance of the cardiac views. Here we present a bespoke, fully automated convolutional neural network (CNN) which identifies apical 2, 3, and 4 chamber, and short axis (SAX) views acquired with and without contrast. The CNN was tested in a completely independent, external dataset with the data acquired in a different country than that used to train the neural network.

Methods

Training data comprised of 2D echocardiograms was taken from 1014 subjects from a prospective multisite, multi-vendor, UK trial with the number of frames in each view greater than 17,500. Prior to view classification model training, images were processed using standard techniques to ensure homogenous and normalised image inputs to the training pipeline. A bespoke CNN was built using the minimum number of convolutional layers required with batch normalisation, and including dropout for reducing overfitting. Before processing, the data was split into 90% for model training (211,958 frames), and 10% used as a validation dataset (23,946 frames). Image frames from different subjects were separated out entirely amongst the training and validation datasets. Further, a separate trial dataset of 240 studies acquired in the USA was used as an independent test dataset (39,401 frames).

Results

Figure 1 shows the confusion matrices for both validation data (left) and independent test data (right), with an overall accuracy of 96% and 95% for the validation and test datasets respectively. The accuracy for the non-contrast cardiac views of >99% exceeds that seen in other works. The combined datasets included images acquired across ultrasound manufacturers and models from 12 clinical sites.

Conclusion

We have developed a CNN capable of automatically accurately identifying all relevant cardiac views used in “real world” echo exams, including views acquired with contrast. Use of the CNN in a routine clinical workflow could improve efficiency of quantification steps performed after image acquisition. This was tested on an independent dataset acquired in a different country to that used to train the model and was found to perform similarly thus indicating the generalisability of the model.

Figure 1. Confusion matrices

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Ultromics Ltd.

P1166Women as candidates for CRT: Are they less but better?

Introduction

 Women have been under-represented in trials of cardiac resynchronization therapy (CRT).  Most available data suggest that CRT has a greater clinical benefit in women than in men. However, further studies are needed to investigate the exact reasons for these results.

Purpose

To compare the prognostic impact and response rate of CRT in women and man.

Methods

Prospective study, single-center study that included pts undergoing CRT implant from 2015 to 2019. Clinical and echocardiographic evaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevations≥10% or LV end-systolic volume (ESV) reductions≥15% were classified as responders. Patients with EF elevations ≥ 20% or ESV reductions≥30% were classified as super-responders. All the parameters were compared between women and man. Prognostic impact of CRT was evaluated as total mortality by the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 561 patients were submitted to CRT implant with a follow-up duration of 18.9 ± 15.8 months. From these 148 (26.4%) were female (mean age 72.2 ± 10 years, 22.4% ischemic, LVEF < 30% in 70.2%). The cardiovascular risk factors and comorbidities were similar in both populations (women and men). In the female group, dilated cardiomyopathy was more frequent than in men (71% vs 50.8%, p < 0.01), with ischemic heart disease being the second most frequent etiology of heart failure.

The frequency of LBBB was similar in both groups (63.9% in women and 57.0% in men, p = NS) however the QRS duration was higher in women (164 ± 17 vs 160 ± 24, p = 0.017). The baseline mean EF was similar (30.5 ± 10.3ms in women and 30.3 ± 11.4ms in men) but the ESV was lower (109.7 ± 59.9 vs 138.4 ± 64.6, p < 0.001).

The prevalence of complications and need for surgical revision were similar in both groups.

The rate of CRT responders was similar in both groups, although tendentially higher in women (64.3% in women vs 55.2% in men, p = NS). On the other hand, super-responder rate was statistically significant (38% in women vs 25.1% in men, p = 0.004). The long-term survival was similar in both groups.

Conclusion

The rate of super-responders was higher in women than in men. This may be explained by the higher prevalence of dilated cardiomyopathy in this subgroup of patients and by the fact that women have smaller hearts and a larger QRS duration at baseline, most likely to have a real LBBB. Long-term mortality of CRT was not gender related

Abstract Figure. Long-term survival by gender

P1162Atrial fibrillation and Cardiac resynchronization therapy - is this combination truly bad?

Introduction

 

Cardiac resynchronization therapy (CRT) significantly reduces mortality and hospitalizations in patients with heart failure and reduced ejection fraction (EF). Atrial fibrillation (AF) is a very common comorbidity in these patients, however, CRT benefit in AF patients has been controversial.

Purpose

 

To compare the prognostic impact of CRT in patients (pts) with and without AF.

Methods

Prospective, single-center study that included pts undergoing CRT implantsince 2015. Clinical and echocardiographicevaluation were made before CRT implant and between 6-12 months post-implant. Pts with EF elevation ≥10% or LV end-systolic volume (ESV) reduction ≥15% were classified as responders. Patients with EF elevation ≥ 20% or ESV reduction ≥30% were classified as super-responders. All the parameters were compared between patients with and without AF.Prognostic impact of CRT was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 166 patients (31%) had AF (73.5% males, mean age 72.2 ± 10.2 years, 37.3% ischemic, LVEF < 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without AF), except for chronic kidney disease which was more frequent in AF pts(28% vs 17%, p = 0.012). 

The prevalence of complications and surgical revision were similar in both groups.

The CRT response rate was similar in both groups (50% in AF group vs 59.6%, p = NS) as was the super-response rate (22.4% in FA pts vs 31.5%, p = NS).

The 4-year survival rate of patients with AF was similar to non-AF (83.7% vs 84.3%). 

Conclusion

 

Despite the controversy about the efficacy of CRT in AF pts, in our population the long-term survival and CRT response rates were comparable between patients with and without AF.

Abstract Figure.

864A modified snare technique improves left ventricular lead implant success and response rate to cardiac resynchronization therapy

Introduction

Left ventricular (LV) lead placement is often the most challenging aspect of cardiac resynchronization therapy (CRT) device implantation, with a failure rate up to 10% due to complex coronary anatomies.

Purpose

To evaluate the efficacy of a modified snare technique in the LV lead implantation in cases of standard technique failure and to evaluate its impact in the response rate to CRT.

Methods

A prospective study was conducted of patients indicated for a CRT implant. When LV lead delivery to the target vessel failed using standard techniques, a modified snare technique was implemented, using a secondary coronary sinus delivery sheath introduced through the same venous puncture.  Patients were evaluated every 6 months. Efficacy was quantified by long-term surgical intervention rates. Patients were evaluated with transthoracic echocardiography before CRT implant and between 6-12 months post-implant. Patients with ejection fraction (EF) elevation ≥ 10% or LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated by the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). The standard LV implant technique failed in 94 cases (16.6%), of which the modified snare technique was successful in 92 (97.9%) with LV lead implant in a lateral vein in 94.7% of cases. Baseline clinical characteristics were similar between patients who implanted LV lead with snare vs standard technique (p = NS). The 4-year surgical intervention rate was lower with the modified snare implant technique than with the standard technique (3.2% vs. 10.2%, HR 0.26, 95% CI 0.08-0.84, p < 0.05), with a relative risk reduction of 74% and a number needed to treat to prevent one surgical intervention of 14. The intervention rate was also lower regarding LV lead implant failure or dislodgement rates (0% vs. 5.3%, p < 0.05). Major complications were similar between groups.

In addition, the response rate to CRT was higher in the modified snare technique than in the standard approach (71.1% vs 55.0%, p < 0.05). In patients who implanted the LV lead with the snare technique, EF increased from 28.1 ± 8.2% to 36.1 ± 11.1% (p < 0.05) and LV ESV decreased from 127.8 ± 64.0mL to 99.8 ± 61.1mL (p = 0.01).

The super-response rate was similar between groups (33.3% vs 27.8%, p = NS).

Conclusion

For challenging coronary sinus anatomies that preclude LV lead placement by standard methods, this modified snare alternative was effective, with significantly lower surgical intervention rates and a higher response rate to resynchronization therapy. This higher than expected response rate with the snare technique, evaluated by remodeling criteria, may be explained by the implant of LV lead in the desired target lateral vein.

Abstract Figure.

P541Cardiac resynchronization therapy: left or non-left bundle branch block? That is the question

Introduction

Cardiac resynchronization therapy (CRT) is associated with reduced mortality and improved quality of life in patients (pts) with low ejection fraction (EF) and conduction delays. Patients with left bundle branch block (LBBB) seem to be the ones who benefit the most from CRT and there is controversy about its efficacy in patients with non-LBBB.

Purpose

To compare the prognostic impact and the response rate to CRT in patients with LBBB and non-LBBB.

Methods

Prospective single-center study of patients who implanted CRT between 2015 and 2019. Clinical, electrocardiographic and echocardiographic evaluations were made before CRT implant and between 6-12 months post-implant. Patients with EF elevation ≥ 10% or left ventricle end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. All the parameters were compared between patients with or without LBBB. Prognostic impact of resynchronization therapy was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, 72 ± 10.2 years old, follow-up duration 18.9 ± 15.8 months). From these patients, 59% had LBBB (69% males, mean age 71.6 ± 10.8 years, 34.5% ischemic, EF < 30% in 65.5%). The cardiovascular risk factors and comorbidities were similar in both populations (with and without LBBB), except for diabetes which was more frequent in non-LBBB patients (33% vs 50.6%, p = 0.007). Mean duration of QRS was similar between LBBB vs non-LBBB patients (163 ± 19ms vs 160 ± 22ms, p = NS) and baseline ejection fraction was also equivalent (29.8 ± 13.6% vs 27.9 ± 8.9%).

The prevalence of complications and surgical revisions were similar in both groups.

The response rate according to left ventricle remodelling criteria was higher in LBBB pts (65.9% vs 49.1%, p < 0.05), but the super-responders were similar in both groups (32.5% vs 26.4% p = NS).

The 4-year survival rate of patients with LBBB and non-LBBB was similar (86.5% vs 85.3%).

Conclusion

In our population the response rate to CRT was higher in LBBB pts. However, and despite the actual controversy about the efficacy of CRT in non-LBBB, the long-term mortality was similar in patients with or without LBBB.

Abstract Figure. lon-term survival

P578Multipoint pacing in cardiac resynchronization therapy - how to improve remodeling criteria and its impact in quality of life

Background

Despite the reduction in mortality and hospitalization rates, resynchronization therapy still has 30-40% of non-responders. Several studies are ongoing to evaluate if novel programming techniques such as multipoint pacing (MPP) increase the conversion rate of non-responder to responder to CRT. However, there is still lack of information about conversion to super-responders and the impact in quality of life of MPP.

Purpose

To evaluate the impact of MPP in conversion to super-responders and its impact in the quality of life of patients.

Methods

Randomized clinical trial of non-AF patients with indication for CRT and who implanted the Quartet™ quadripolar left ventricle (LV) lead. After implant, CRTs were programmed on biventricular pacing according to the latest activated area for 6 months. After a 6-month follow-up, patients were randomized in a 1:1 fashion to MPP ON or MPP OFF. MPP was programmed with the two widest spaced LV electrodes and with a LV1-LV2 to LV2-RV delay of 5ms. Patients were followed-up for 12 months with a 6-month evaluation of NTproBNP, echocardiographic remodeling criteria (LV end systolic volume (ESV) and LV ejection fraction), and quality of life (QoL) evaluated by EQ-5D, Minnesota Living with Heart Failure (MLWHF) questionnaire and 6-minute walk test (6MWT).

Results

 76 patients were included in this trial, 62 with a completed 12-month follow-up (average age 67.2 ± 10.2 years old, 32.3% female gender, dilated cardiomyopathy in 77.4%). Among these patients, 24 were randomized to MPP ON, 28 to MPP OFF. Six patients died and 4 were lost to follow-up. Baseline clinical and echocardiographic characteristics were similar between groups (p = NS).

At 6 months, the overall response rate (reduction in ESV≥15%) was 75%. At twelve months, patients randomized to MPP ON had a super-response rate (reduction in ESV≥30%) higher than patients with MPP OFF (75% vs 39.3%, p = 0.01).

Between 6-12 months, patients assigned to MPP ON had a higher reduction in ESV (93.4 ± 52.3mL to 82.1 ± 40.5mL, p = 0.04) and an improvement in LVEF (38.3 ± 9.8% to 45.1 ± 11.1%, p < 0.01) compared to patients with MPP OFF (92.2 ± 47.3mL to 95.4 ± 47.5mL, p = NS; 37.1 ± 12.0% to 40.2 ± 9.2%, p = NS). Additionally, QoL of patients with MPP ON improved during follow up (EQ-5D 78.3% to 86.3%, p < 0.01; MLWHF 12.1 to 6.6, p = 0.03, 6MWT 316m to 239m, p = NS; NTproBNP 1608 ± 2450pg/mL to 775 ± 914pg/mL, p = NS) and was unchanged in MPP OFF patients (76.6% to 74.2%; MLWHF 12.7 to 12.7; 6MWT 338m to 299m, NTproBNP 1112 ± 1442pg/mL to 1383 ± 2118pg/mL, for all p = NS).

Conclusion

In our population, patients with CRT programmed with MPP ON, when compared to MPP OFF, had an improvement in the super-response rate and in quality of life. These results may be consequence from a more favorable reverse remodeling due to MPP, with a higher reduction in the LV end systolic volume.

Abstract Figure.

42When to implant CRT-P or CRT-D in the elderly?

Introduction

Cardiac resynchronization therapy (CRT) in elder patients is increasingly common. However, the decision to implant a device with defibrillator in these patients is often complex and it can be limited not only by the shorter life expectancy but also by a lower relative risk of arrhythmic compare to non-arrhythmic death due to other comorbidities. Thus, wether CRT is effective in an elderly population (≥75 years old), or if a defibrillator (CRT-D versus CRT-P) influences outcomes is a pivotal concern needing additional data.

Purpose

To compare the prognostic impact of CRT-P vs CRT-D in old patients (≥ 75 years old) and its impact in the response rate to CRT.

Methods

A prospective single-center study was conducted of patients indicated for a CRT implant since 2015. Demographic and clinical criteria were evaluated. Transthoracic echocardiography was performed before CRT implant and between 6-12 months post-implant. Patients with an ejection fraction (EF) elevation ≥ 10% or a LV end-systolic volume (ESV) reduction ≥ 15% were classified as responders. Patients with EF elevation ≥ 20% or LV ESV reduction ≥ 30% were classified as super-responders. Time to surgical revision and mortality were evaluated using the Cox regression and Kaplan-Meier methods. The decision to implant a CRT-P or CRT-D device was made according to clinical decision. Prognostic impact of CRT-P vs CRT-D was evaluated by comparing total mortality using the Cox regression and Kaplan-Meier methods.

Results

From 2015-2019, 566 CRTs were implanted (26.1% female, follow-up duration 18.9 ± 15.8 months). Among these patients, 53.5% had < 75 years old and 46.5% ≥ 75 years. Baseline clinical characteristics were similar, except for a higher prevalence of chronic kidney disease and atrial fibrillation in the elderly population. The proportion of CRT-D/CRT-P was different between these groups (p < 0.001): in the elderly group, more CRT-P were implanted (67.6% vs 32.4 CRT-D) and in the younger group more CRT-D were implanted (77.9% vs 22.1% CRT-P).

The prevalence of complications due to CRT implant was similar in the two groups (4.7% vs 4.2%, p = NS) but the need for surgical revision was less frequent in the elderly group (11.0% vs 5.7%, p = 0.03). The CRT response rate was equivalent in both groups (40.1% vs 59.9%, p = NS), as was the super-response rate (33% in young vs 26.5% in old patients, p = NS).

In the elderly population, the 4-year survival rate was similar between CRT-P and CRT-D patients (75.4% vs 79.8%).

Conclusion

Patients older than 75 years old have similar benefits from the CRT as patients < 75 years, with equivalent response rates to CRT. However, judging from the similar prognostic impact of CRT-P vs CRT-D in this elder population, the implant of a defibrillator should be personalized.

A76 INCOMPLETE RESECTION OF 1-20MM COLORECTAL POLYPS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Colonoscopy has been used as a screening or surveillance tool for colorectal cancer (CRC), however, a minority of patients develop post-colonoscopy interval CRC. Incomplete resection of colorectal polyps is thought to be a major cause of post-colonoscopy interval CRC.

Aims

We were interested in studying the incomplete resection rate (IRR) of colorectal polyps and factors associated with incomplete resection in a systematic review and meta-analysis.

Methods

We conducted a systematic review and meta-analysis using MEDLINE, EMBASE, EBM Reviews, and CINAHL of all studies reporting on IRR of polyps 1-20mm published until March 2019. Exclusion criteria were: Inclusion of IBD cohorts; referrals for difficult polypectomy; polyp size >20mm; endoscopic submucosal dissection; conference abstracts; non-english language. Primary outcome was histologic IRR for polypectomies. Secondary outcomes included IRR for all studies; IRR for polyps 1-10mm and 10-20mm; IRR with or without submucosal injection; IRR based on assessment method of completeness; IRR for different polypectomy methods.

Results

6148 records were identified through initial search and 37 studies with a total of 11962 polyps were included in our quantitative analysis. Histologic IRR for polypectomies (snare and forceps) was 10.54% (95%CI 8.56–12.53). IRR for all included studies was 9.05% (95%CI 7.54–10.56). IRR was lower for polyps 1-10mm than polyps 10-20mm; 8.85% (95%CI 7.27–10.44) vs 18.08% (95%CI 10.30–25.87). IRR was statistically significantly lower when only evaluated using imaging enhanced endoscopy (IEE) (0.69%; 95%CI 0.02–1.35) compared to post polypectomy margin biopsies (7.19%; 95%CI 5.39–8.99). Histologic IRR for snare polypectomy (8.79%; 95%CI 6.96–10.62) was lower than histologic IRR for forceps polypectomy (17.75; 95%CI 10.49–25.01).

Conclusions

Incomplete resection of 1-20mm colorectal polyps occurs in a significant proportion of polypectomies. Incomplete resection occurs more frequently in larger (10-20mm) polyps. Visual inspection with IEE after polypectomy underestimates IRR in comparison to post polypectomy biopsies. Snare polypectomy had lower IRR when compared with forceps.

Funding Agencies

None

A86 SUBMUCOSAL INJECTION FOR POLYPECTOMY AND INTERVENTIONAL ENDOSCOPY: AN INTERNATIONAL SURVEY

Background

Submucosal injection (SI) is used for standard polypectomies or during complex endoscopic interventions. SI helps to facilitate endoscopic resection and to prevent complications such as bleeding or perforation.

Aims

We were interested to evaluate endoscopists practice patterns of using SI during routine standard polypectomy and complex endotherapeutic procedures.

Methods

An online survey using the Google Form application was distributed through medical societies. Survey domains included training and practice characteristics of participating endoscopists as well as questions regarding the use of SI products for endoscopy procedures.

Results

A total of 236 endoscopists (mainly from the US, Canada, and Europe) participated in the survey. About half (48%) of endoscopists start using SI for routine polypectomies when polyps are larger than 10 mm, while 37% of endoscopist report having a size threshold larger than 15mm for using SI (22% report using SI starting at >15 mm, and 15% report using SI starting at >20 mm). Only a minority (11%) of endoscopists report using SI for polyps <10 mm and starting SI at 6 mm. However, 30,3% of endoscopists reported that their size threshold for using SI during polypectomies has decreased in recent years. 83% reported that using SI is beneficial for en-bloc resection, avoiding perforation (91,5%), avoiding thermic lesions (80%) and identifying dysplastic tissue (54,5%). Normal saline is the submucosal agent most commonly available for endoscopists (86,4%), followed by Eleview (66,8%), and ORISE Gel (20%). “Short lasting lift” and “cost” are reported concerns when opting for a specific SI solution. Methylene blue is the coloring agent that is most commonly used (68,9%). Excellent submucosal elevation, availability, and length of action are the most important features an SI should have according to endoscopists’ responses.

Conclusions

The use of SI is common during endoscopy procedures. For standard colorectal polypectomy procedures, most endoscopists start using SI only for polyps larger than 10mm. SI is used by endoscopists to prevent complications, improve endoscopic resection and to identify dysplastic tissue.

Funding Agencies

None

P3808iBox-CRT: Better response, less complicated, equally fast

Introduction

The optimization of the left ventricle (LV) pacing site guided by the electrical delay increases CRT response rate (RR), however it's necessary to develop technology that allows its universal use.

Purpose

The aim is automatically, and operator-independent, access the conduction delay between the right ventricular (RV) stimulus and the LV available veins in order to select the LV pacing site. It is further intended to compare the total procedure and radiation times in relation to an historical control group.

Methods

Prospective, single-center study that included patients undergoing CRT implant according to the current ESC Guidelines. All patients were submitted to a clinical, electrocardiographic and echocardiographic basal evaluation prior to CRT implantation and at 6 months of follow-up.

To evaluate conduction delays between the RV lead and the LV available veins (RV-LV delay), an external interface - intelligent Box for CRT (iBox-CRT) was used. Four measurements in at least two different tributary veins were made. The implant of all the LV leads was guided by the longest measured delay.

A positive response to CRT was defined as an improvement of >10% in left ventricle ejection fraction (LVEF) or a reduction of end-systolic volume (ESV)>15%. The results were compared to a control group (CG) of pts submitted to CRT implantation in the conventional way.

Results

60 patients were included (68.3% males, 38% ischemic, mean age 67.4±10.2 years) and submitted to CRT implant (37 CRT-P; 23 CRT-D). At basal evaluation, LVEF was 28±7%, end-diastolic volume (EDV) was 200±73ml and ESV 145±64ml. CG (n=51) had similar characteristics.

The RR was 85.7%, significantly higher compared to the CG (55.9%, p=0.003). The ESV reduced 38.2±3% in responders vs 5.7±2% in non-responders (NR) (p=0,005), EDV reduced 33.3±16% in responders vs 13.6±10% in NR (p=0.002), the mean LVEF improved 11% in responders vs −1% in NR (p=0.02).

At follow-up, the mean ESV in the study group (SG) was 89±44 ml vs 132±75ml in the CG (p=0.002) and the EDV 136±51 vs 190±78 (p=0.007).

In addition to a much better response rate, the responders in the study group had significantly higher mean LVEF at follow-up (39±11% vs 37±7%, p=0.032).

The mean intra-procedure RV-LV delay was 187±34mseg. In the responder group the baseline delay was usually higher (190±35 msec) vs NR group RV-LV delay (165±23 msec; p=NS).

Compared with CG, the automatic assessment of RV-LV delay with iBox-CRT did not increase fluoroscopy time (15±16min vs 18±16; p=NS) and shortened procedure time (65±34 vs 108±83min, p<0.005).

Conclusions

The iBox-CRT use enabled an automatic and operator independent RV-LV delays measurement, in order to implant the LV lead at the most delayed site. This technique translated into a major increase in CTR response rate, not compromising the procedure duration nor increasing the radiation exposure.

P987Dilated cardiomyopathy - a group that does not benefit from ICD?

Introduction

The prevalence of sudden death in patients with heart failure with reduced ejection fraction has been declining in the last decade, not only due to better optimization of pharmacological therapy, but also due to the high rate of cardiac resynchronization responders. Overall, based on recent studies demonstrating a lack of improvement in mortality in some patients with dilated cardiomyopathy, the CRT-P/CRT-D implantation ratio has been increasing across Europe.

Objective

To evaluate the evolution of the CRT-P/CRT-D implantation ratio and to evaluate the impact on mortality of dilated cardiomyopathy (DCM) patients who underwent resynchronization therapy.

Methods

A single-center prospective study of non-randomized patients who underwent CRT implantation since 2015. Demographic and clinical data from patients with dilated cardiomyopathy were assessed. The mortality of these patients and the predictors of mortality by the Cox and Kaplan-Meier regression method were evaluated.

Results

486 CRTs were implanted since 2015 (male 73.9%, age 72.06±9.9 years, median follow-up time of 487 days IIQ [175, 749].) During the last 3 years, occurred an increased in CRT-P/CRT-D ratio with the CRT-P implant rate increasing from 36% of the total devices in 2015 to 47% in 2018. Of the patients submitted to CRT implantation, 256 (55%) had dilated cardiomyopathy as the etiology of heart failure. In this population, by multivariate Cox analysis, age (HR 1.1, 95% CI 1.0–1.1, p=0.003) and GFR <60ml/min/1.73m2 (HR 1.8 IC 95% 1, 2–2.6, p=0.01) were independent predictors of mortality. In addition, CRT-D implantation in these patients was associated with a significant reduction in all-cause mortality (HR 0.33 95% CI 0.15–0.73, p<0.01) with a required number to treat only 10 patients. Similar results were obtained in the subgroup of patients aged ≥59 years.

Mortality in DMC – CRT-P vs CRT-D

Conclusion

The CRT-P implant rate has been increasing at the expense of the CRT-D implant after some studies suggest no benefit in the population aged ≥59 years. However, in our population of patients with DCM, CRT-D implantation demonstrated a 67% mortality reduction. These results may demonstrate a good selection of patients for this therapy, but should also motivate further studies in the evaluation of mortality in this subgroup of patients.

The dynamics of stress: a longitudinal MRI study of rat brain structure and connectome

Stress is a well-established trigger for a number of neuropsychiatric disorders, as it alters both structure and function of several brain regions and its networks. Herein, we conduct a longitudinal neuroimaging study to assess how a chronic unpredictable stress protocol impacts the structure of the rat brain and its functional connectome in both high and low responders to stress. Our results reveal the changes that stress triggers in the brain, with structural atrophy affecting key regions such as the prelimbic, cingulate, insular and retrosplenial, somatosensory, motor, auditory and perirhinal/entorhinal cortices, the hippocampus, the dorsomedial striatum, nucleus accumbens, the septum, the bed nucleus of the stria terminalis, the thalamus and several brain stem nuclei. These structural changes are associated with increasing functional connectivity within a network composed by these regions. Moreover, using a clustering based on endocrine and behavioural outcomes, animals were classified as high and low responders to stress. We reveal that susceptible animals (high responders) develop local atrophy of the ventral tegmental area and an increase in functional connectivity between this area and the thalamus, further spreading to other areas that link the cognitive system with the fight-or-flight system. Through a longitudinal approach we were able to establish two distinct patterns, with functional changes occurring during the exposure to stress, but with an inflection point after the first week of stress when more prominent changes were seen. Finally, our study revealed differences in functional connectivity in a brainstem-limbic network that distinguishes resistant and susceptible responders before any exposure to stress, providing the first potential imaging-based predictive biomarkers of an individual's resilience/vulnerability to stressful conditions.

The neural correlates of obsessive-compulsive disorder: a multimodal perspective

Obsessive-compulsive disorder (OCD) is one of the most debilitating psychiatric conditions. An extensive body of the literature has described some of the neurobiological mechanisms underlying the core manifestations of the disorder. Nevertheless, most reports have focused on individual modalities of structural/functional brain alterations, mainly through targeted approaches, thus possibly precluding the power of unbiased exploratory approaches. Eighty subjects (40 OCD and 40 healthy controls) participated in a multimodal magnetic resonance imaging (MRI) investigation, integrating structural and functional data. Voxel-based morphometry analysis was conducted to compare between-group volumetric differences. The whole-brain functional connectome, derived from resting-state functional connectivity (FC), was analyzed with the network-based statistic methodology. Results from structural and functional analysis were integrated in mediation models. OCD patients revealed volumetric reductions in the right superior temporal sulcus. Patients had significantly decreased FC in two distinct subnetworks: the first, involving the orbitofrontal cortex, temporal poles and the subgenual anterior cingulate cortex; the second, comprising the lingual and postcentral gyri. On the opposite, a network formed by connections between thalamic and occipital regions had significantly increased FC in patients. Integrative models revealed direct and indirect associations between volumetric alterations and FC networks. This study suggests that OCD patients display alterations in brain structure and FC, involving complex networks of brain regions. Furthermore, we provided evidence for direct and indirect associations between structural and functional alterations representing complex patterns of interactions between separate brain regions, which may be of upmost relevance for explaining the pathophysiology of the disorder.

White matter changes in microstructure associated with a maladaptive response to stress in rats

In today's society, every individual is subjected to stressful stimuli with different intensities and duration. This exposure can be a key trigger in several mental illnesses greatly affecting one's quality of life. Yet not all subjects respond equally to the same stimulus and some are able to better adapt to them delaying the onset of its negative consequences. The neural specificities of this adaptation can be essential to understand the true dynamics of stress as well as to design new approaches to reduce its consequences. In the current work, we employed ex vivo high field diffusion magnetic resonance imaging (MRI) to uncover the differences in white matter properties in the entire brain between Fisher 344 (F344) and Sprague-Dawley (SD) rats, known to present different responses to stress, and to examine the effects of a 2-week repeated inescapable stress paradigm. We applied a tract-based spatial statistics (TBSS) analysis approach to a total of 25 animals. After exposure to stress, SD rats were found to have lower values of corticosterone when compared with F344 rats. Overall, stress was found to lead to an overall increase in fractional anisotropy (FA), on top of a reduction in mean and radial diffusivity (MD and RD) in several white matter bundles of the brain. No effect of strain on the white matter diffusion properties was observed. The strain-by-stress interaction revealed an effect on SD rats in MD, RD and axial diffusivity (AD), with lower diffusion metric levels on stressed animals. These effects were localized on the left side of the brain on the external capsule, corpus callosum, deep cerebral white matter, anterior commissure, endopiriform nucleus, dorsal hippocampus and amygdala fibers. The results possibly reveal an adaptation of the SD strain to the stressful stimuli through synaptic and structural plasticity processes, possibly reflecting learning processes.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Clinico-biochemical characteristics of 229 Portuguese infertile women with polycystic ovary syndrome: clinical relevance and relationship with fertility treatment results

PURPOSE

Polycystic ovary syndrome (PCOS) affects 6-20% of reproductive-age women. The authors aimed to evaluate the characteristics of PCOS women and its relationship with fertility treatment outcomes.

MATERIALS AND METHODS

The authors reviewed records of PCOS women assisted at Hospital Santa Maria. Fertility treatment results were assessed as pregnancy rate, number of cycles, and miscarriage rate.

RESULTS

They identified 229 PCOS women, 179 (78.2%) had waist circumference > 80 cm, 72 (31.4%) had type 2 diabetes mellitus (T2DM) familial history and glucose abnormalities, hypertriglyceridemia and low cholesterol-HDL were detected in 23(10.1%), 15 (6.6%) and 103 (45.0%), respectively. Pregnancy was achieved in 164 women. The mean number of cycles to achieve pregnancy was 2.7 (±2.2). Statistical analysis identified factors associated with longer/higher number of treatments: primary infertility, T2DM familial history, hypertriglyceridemia, and low cholesterol-HDL. Waist circumference > 80 cm, older age, and increased LH level were associated with miscarriage.

CONCLUSIONS

Primary infertility, T2DM familial history, hypertriglyceridemia, low cholesterol-HDL, older age, waist circumference > 80 cm, and high LH may confer poorer fertility treatment results.