Prevalence, risk factors and evolution of diabetes mellitus after treatment in primary aldosteronism. Results from the SPAIN-ALDO registry

PURPOSE

To evaluate the prevalence, risk factors and evolution of diabetes mellitus (DM) after targeted treatment in patients with primary aldosteronism (PA).

METHODS

A retrospective multicenter study of PA patients in follow-up at 27 Spanish tertiary hospitals (SPAIN-ALDO Register).

RESULTS

Overall, 646 patients with PA were included. At diagnosis, 21.2% (n = 137) had DM and 67% of them had HbA1c levels < 7%. In multivariate analysis, family history of DM (OR 4.00 [1.68-9.53]), the coexistence of dyslipidemia (OR 3.57 [1.51-8.43]) and advanced age (OR 1.04 per year of increase [1.00-1.09]) were identified as independent predictive factors of DM. Diabetic patients were on beta blockers (46.7% (n = 64) vs. 27.5% (n = 140), P < 0.001) and diuretics (51.1% (n = 70) vs. 33.2% (n = 169), p < 0.001) more frequently than non-diabetics. After a median follow-up of 22 months [IQR 7.5-63.0], 6.9% of patients developed DM, with no difference between those undergoing adrenalectomy and those treated medically (HR 1.07 [0.49-2.36], p = 0.866). There was also no significant difference in the evolution of glycemic control between DM patients who underwent surgery and those medically treated (p > 0.05).

CONCLUSION

DM affects about one quarter of patients with PA and the risk factors for its development are common to those of the general population. Medical and surgical treatment provides similar benefit in glycemic control in patients with PA and DM.

Granular vortex spin-torque nano oscillator for reservoir computing

In this paper, we investigate the granularity in the free layer of the magnetic tunnel junctions (MTJ) and its potential to function as a reservoir for reservoir computing where grains act as oscillatory neurons while the device is in the vortex state. The input of the reservoir is applied in the form of a magnetic field which can pin the vortex core into different grains of the device in the magnetic vortex state. The oscillation frequency and MTJ resistance vary across different grains in a non-linear fashion making them great candidates to be served as the reservoir's outputs for classification objectives. Hence, we propose an experimentally validated area-efficient single granular vortex spin-torque nano oscillator (GV-STNO) device in which pinning sites work as random reservoirs that can emulate neuronal functions. We harness the nonlinear oscillation frequency and resistance exhibited by the vortex core granular pinning of the GV-STNO reservoir computing system to demonstrate waveform classification.

Multigene germline testing usefulness instead of BRCA1/2 single screening in triple negative breast cancer cases

Triple negative breast cancer is considered as the worst aggressive subtype with poor prognosis. Recent studies suggest a hereditary component is involved in TNBC development, especially in young patients. However, genetic spectrum remains unclear. Our purpose was to evaluate the usefulness of multigene panel testing in triple negative patients compared to overall breast cancer cases as well as contributing to elucidate which genes are most implicated in triple negative subtype development. Two breast cancer cohorts, comprising 100 triple negative breast cancer patients and 100 patients with other breast cancer subtypes, were analyzed by Next-Generation Sequencing using an On-Demand panel which included 35 predisposition cancer genes associated with inherited cancer susceptibility. The percentage of germline pathogenic variant carriers was higher in the triple negative cohort. ATM, PALB2, BRIP1 and TP53 were the most non-BRCA mutated genes. Moreover, triple negative breast cancer patients without family history related who were identified as carriers were diagnosed at significantly earlier age. As conclusion, our study reinforces the usefulness of multigene panel testing in breast cancer cases but specifically in those with triple negative subtype regardless family history.

Rapid deployment bioprostesis for aortic valve stenosis: single center short and long-term outcomes

Background

Despite recent advances, surgical aortic valve replacement (SAVR) remains the gold standard for most of the patients with aortic valve stenosis. The ageing population, with increased comorbidities and the rising of minimally invasive techniques, led to the development of new prosthetic devices of easier and faster implantation.

Purpose

This study aimed to analyse short and long-term outcomes of SAVR with rapid-deployment (RD) aortic bioprosthesis for isolated aortic valve stenosis

Method

Singe center, retrospective longitudinal cohort study of patients with isolated aortic valve stenosis who underwent elective aortic valve replacement using RD devices between 2014 and December 2021.

Continuous variables are presented with median (IQR) and were analyzed using Mann-Whitney test. Categorical variables are presented in percentage or frequency and were analyzed using chi-square test. Kaplan-Meyer survival curve was constructed base on collected data from national registry.

Results

A RD device was implanted in 358 patients with a median age of 75,8 years and Euroscore II of 2,3. Median cross clamp and extracorporeal circulation time were 27,4 and 36,7 min, respectively. No significant paravalvular leaks.

Intensive care unit (ICU) length of stay was 3 days with acute renal lesion (any stage-53,2%; Dialysis-2,5%), need for hemodynamic support (63,1%) and new onset atrial fibrillation (33,6%) being the most frequent post-operative complications. Stroke occurred in 0,6% of cases and mortality was 1,1%. Pacemaker implementation rate of 11%.

The mean follow-up time was 6,7 years with 90% 5-years survival rate. Mean gradients of 11,2±4,8 mmHg at 6 months

Conclusion

Surgical treatment of aortic valve stenosis using RD devices is safe, with a low mortality rate. ICU length of stay and hospital length of stay are reduced. Follow-up shows an excellent long-term survival and hemodynamic performance.

Funding Acknowledgement

Type of funding sources: None.

Impact of coronavirus disease 2019 on adult patients with congenital heart disease

Background

COVID-19 is responsible for a worldwide pandemic, causing more than 18,000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation.

Purpose

To study the impact of COVID-19 in a adult patients with CHD

Methods

Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to December 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records.

Results

We identified seventy-nine patients (pts) with COVID-19 infection. Symptoms were present in 67 (84%). The median age was 44 (15) years, 52% were females. Eight P (10%) had complex cyanotic disease; seven Tetralogy of Fallot; five (6%) transposition of great arteries; eight (10%) right ventricle obstacle; two (3%) atrioventricular canal defect; sixteen (20%) atrial septal defect; nine (11%) ventricular septal defect; eight (10%) aortic coarctation; two (3%) had Eisenmenger syndrome. 49% of P had previous surgery or percutaneous procedure. 63% of P were at New York Heart Association (NYHA) class of I and 30% at NYHA II. Mild symptoms were reported by 56 P (71%). Ten adults (7,9%) experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, none required mechanical ventilation. One death was reported in an 83-year-old patient with non-corrected interventricular communication and compromised biventricular function. There was a significant association between the gravity of CHD and hospitalizations (p=0.02).

Conclusion

Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome; the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.

Funding Acknowledgement

Type of funding sources: None.

Transcatheter aortic valve implantation outcomes in patients with low flow low gradient aortic stenosis

Background

There are limited data about the outcomes of transcatheter aortic valve implantation (TAVI) in patients with low flow – low gradient (LF-LG) aortic stenosis (AS), but some studies suggest that these patients may have worse results.

Purpose

To compare outcomes between LF-LG AS and high gradient AS patients submitted to TAVI.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteriscs and outcomes after the procedure were collected. LF-LG AS was considered in patients with mean gradient &lt;40mmHg, valve area &lt;1mm2, stroke volume index &lt;35mL/m2 and at least one other criteria of contractile reserve confirmed by stress echocardiography, with elevation of mean gradient to &gt;40mmHg, or high aortic calcium score in angio-CT.

Results

A total of 480P (56.9% female) were included, with a mean age of 82±7 years. Patients with LF-LG AS (81P, 16.9%) had worse baseline characteriscs, with higher new euroscore (10.4% vs 6.3%, p&lt;0.0001), and natriurec peptide B (11252 vs 3095 pg/mL, p=0.001), more frequent left ventricular ejection fraction (LVEF) &lt;40% (33.3% vs 8.8%, p&lt;0.0001), more coronary artery disease (58% vs 37.1%, p&lt;0.0001), including previous myocardial infarction (28.4% vs 14.1%, p=0.002) and coronary artery bypass graft (29.6% vs 12.3%, p&lt;0.0001). In univariable analysis, LF-LG AS was associated with worse 1 year and long-term functional class (NYHA 3–4 – 17.8% vs 3.8% p&lt;0.0001 and 20.5% vs 6.0%, p&lt;0.0001, respectively), 1 year mortality (21.3% vs 10.8%, p=0.012) and 1 year and long-term heart failure hospitalizations (16.6% vs 3.3%, p&lt;0.0001 and 24.3% vs 6.3%, p&lt;0.0001). When adjusted to the differences in baseline characteristics, in a mulvariable analysis, LF-LG AS was still associated with worse functional class at 1 year (p=0.023) and long-term (p=0.004) and with heart failure hospitalizations at 1 year and long-term (p=0.001 and p&lt;0.0001, respectively). In a sub-analysis considering only the patients with LF-LG AS, those with LVEF &lt;40% have the worst outcomes, with more global, intra-hospital and 30 days mortality (48.1% vs 18.5%, p=0.005; 14.8% vs 1.9%, p=0.040; 18.5% vs 1.9%, p=0.014), global cardiovascular mortality (25.9% vs 7.4%, p=0.036), worse 1 year functional class (31.8% vs 11.8%, p=0.040) and more long-term heart failure hospitalizations (40.9% vs 17.3%, p=0.031).

Conclusion

Patients with LF-LG AS have worse short and long-term outcomes, even when adjusted for baseline characteriscs differences. The sub-group of patients with LVEF &lt;40% have the worst global outcomes.

Funding Acknowledgement

Type of funding sources: None.

Respiratory disturbance index as a predictor of atrial fibrillation

Background

Obstructive sleep apnea (OSA) is a risk factor for development of atrial fibrillation (AF). Recent pacemakers have specific algorithms for detecting of OSA based on impedance measurement.

Purpose

The aim was to determine the burden of AF in patients with high respiratory disturbance index (RDI). It was also intended to determine if the onset of continuous positive airway pressure (CPAP) reduced the AF burden.

Methods

Retrospective observational study carried out through the analysis of the patient records. It included patients with pacemakers evaluated in an outpatient clinic during the first 8 months of 2018. All had the RDI algorithm. AF burden was assessed according to automatic mode switch (AMS) duration. The percentage of nights with an RDI&gt;20/h was analysed to assess the risk of OSA.

Results

108 patients were included (mean age=70.3±9.0 years; 56.5% men). The most prevalent indication for cardiac pacing was atrioventricular node dysfunction (59.3%). The average percentage of nights with an RDI&gt;20/h was 44.2%. The average follow-up (FU) period was 4.1 years.

Of all cardiovascular risk factors, diabetes mellitus was the only one associated with a higher incidence of AF at FU (p=0.044).

Considering just the patients with an RDI &gt;20/h in more than 20% of nights (RDI20%), male gender was associated with higher rate of major adverse cardiovascular events [(acute myocardial infarction, stroke, acute heart failure and death) (p=0.019)].

Considering patients with AF prior to pacemaker implantation (n=34), 76% of patients had an RDI &gt;20/h in more than 20% of nights (mean of 58.1%). 23 of these patients had long standing persistent AF at the end of FU (vs 17 at the beginnig of FU).

Considering patients who developed AF after pacemaker implantation (n=24), 58% of patients had an RDI&gt;20/h in more than 20% of nights (mean of 45.3%). Most patients had paroxismal AF (83%).

Patients with prior paroxysmal AF or those who developed AF during FU (n=37) had a higher burden of AF at the end of FU when they had RDI &gt;20/h in more than 50% of nights (mean burden of 24.66% vs 14.69%, p=0.005).

There was no statistically significant correlation between the percentage of nights with RDI &gt;20/h and the Apnea Hypopnea Index (AHI) value. Patients who underwent polysomnography (n=30) had a mean AHI of 16/h (which corresponds to moderately severe OSA). 63% of patients who were referred from the pacemaker consultation to pneumology and performed polysomnography started CPAP.

CPAP use was not associated with a statistically significant reduction in any endpoints or AF burden.

Conclusion

A high RDI was associated with onset of de novo AF and higher AF burden in patients with paroxysmal AF. Thus, there is a rationale for early diagnosis and treatment of OSAS to prevent and reduce AF progression.

In this study, CPAP was not shown to significantly reduce this endpoint, probably due to reduced polysomnography and CPAP treatment.

Funding Acknowledgement

Type of funding sources: None.

Protective role of Portuguese natural mineral waters on skin aging: in vitro evaluation of anti-senescence and anti-oxidant properties

Natural mineral waters (NMWs) emerge from the earth as springs and their beneficial therapeutic effect has been empirically recognized in different countries. Portugal has diverse NMW resources that are sought for the relief of different afflictions including dermatological complications. However, there is a lack of scientific validation supporting this empiric knowledge. In this study, we aimed to screen the in vitro bioactivity of Portuguese NMWs with different chemical profiles, namely sulfurous/bicarbonate/sodic (SBS), bicarbonate/magnesium, sulfated/calcic, sulfurous/chlorinated/sodic, sulfurous/bicarbonate/fluoridated/sodic, and chlorinated/sodic, focusing on aging-related skin alterations. Mouse skin fibroblasts and macrophages were exposed to culture medium prepared in different NMWs. Cellular viability was evaluated by MTT assay and etoposide-induced senescence was analyzed through the beta-galactosidase staining kit. Wound healing was investigated by the scratch assay, and phototoxicity/photoprotection after UVA irradiation was evaluated using a neutral red solution. ROS production was quantified using the 2'7'-dichlorofluorescin diacetate dye, and the activity of superoxide dismutase (SOD) was analyzed by a commercial kit after lipopolysaccharide exposure. NMWs within the SBS profile demonstrated anti-senescence activity in skin fibroblasts, along with a variable effect on cellular viability. Among the tested NMWs, two decreased cellular senescence and preserved cell viability and were therefore selected for subsequent studies, together with a SBS NMW with therapeutic indications for dermatologic diseases. Overall, the selected NMW promoted wound healing in skin fibroblasts and activated SOD in macrophages, thus suggesting an anti-oxidant effect. None of the NMWs prevented phototoxicity after UV irradiation. Our results shed a light on the anti-aging potential of Portuguese NMW, supporting their putative application in cosmetic or medical products.

Predictors of pacemaker dependency after transcatheter aortic valve replacement

Funding Acknowledgements

Type of funding sources: None.

Background

Conduction disturbances after transcatheter aortic valve replacement (TAVR) are common with a variable risk of long-term pacemaker dependency (PD), being influenced by patient- and procedure-specific factors. As pacemaker (PM) implantation is associated with potential complications, our aim was to assess predictors of PD requirement after TAVR.

Methods

Retrospective analysis of consecutive patients (P) who underwent TAVR with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. Cumulative percentage of ventricular pacing (%Vp) was determined from stored PM data. P with a PM implanted previous to TAVR were excluded. PM implantation post-TAVR was defined as a device implant performed during hospital stay in the context of TAVR or during the first month after discharge. PD was defined as a %Vp &gt; 80% at one-year follow-up. Multivariate analysis for the prediction of PD was done using Cox regression.

Results

A total of 474 P (57% male, age 81.7±6.5 years, left ventricular ejection fraction 51.5±14.6%) were analysed. Mean follow-up was 18.7 months. Mean baseline gradient was 51.7 mmHg with a mean aortic valve area of 0.71 cm2. One hundred and four P (21.9%) required PM implantation after TAVR, with a mean %Vp of 65.3±43.4%, presenting PD in 60% of the cases at one-year follow-up. A glomerular filtration rate &gt; 60 ml/min (OR 0.87, CI 95% 0.74-0.96, p=0.021) and mean aortic annulus perimeter (OR 0.89, CI 95% 0.80-0.98, p=0.029) were independent predictors of a PD &lt; 5%. Arterial hypertension (OR 7.00, CI 95% 1.31-37.40, p=0.023), baseline right bundle branch block (OR 10.2, CI 95% 1.21-18.45, p=0.033), and the EUROSCORE II (OR 1.05, CI 95% 1.01-1.10, p=0.044) were predictors of PD &gt; 80%. Baseline left bundle branch block, implantation depth and aortic valve calcium score were not predictors of PD.

Conclusion

Predictors of PD after TAVR may influence PM implantation, as well as device selection and programming. P with a higher aortic annulus perimeter and preserved kidney function may undergo a more expectant management, as PD rates are low after 1 year follow-up.

Rhythm control in patients with atrial fibrillation admitted to outpatient clinic

Funding Acknowledgements

Type of funding sources: None.

Background

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice. Patients are often symptomatic leading to a reduction in quality of life. Recent studies suggests that early rhythm control therapy have a clinical benefit in patients with recently diagnosed AF.

Purpose

This study aims to evaluate outpatient with AF referred to an outpatient clinic to electrical Cardioversion. Besides that, the study aims to evaluate if outpatient referred from the emergency room had spontaneously reverted to sinus rhythm.

Material and Methods

Retrospective observational study carried out through the analysis of the clinical process. Clinical data were collected from AF patients evaluated in an outpatient clinic during the year of 2020. Statistical analysis was made using R software and RStudio.

Results

This study included 92 patients evaluated in an outpatient clinic and referred because paroxysmal, persistent and long standing AF to electrical cardioversion. Average age was 67.3 ± 10.1 years. 78 patients had atrial fibrillation and 14 patients had atrial flutter. Hypertension was the most prevalent risk factor (n=83; 79,3%), followed by dislipidemia (n=66; 71.7%), overweight (n=43; 46,7%), diabetes mellitus (n=27; 29.3%) and smoke (n=20; 21.7%). 15 patients had paroxysmal AF, 67 patients had persistent AF and 10 patients had long standing AF. CHA2DS2VASC median were 2,78 ± 1.66 and HASBLED median was 1,14 ± 0.94. The heart rate control were most frequently made with betablocker (n=78; 84.7%). 4 patients (4,3%) were medicated with digoxin and 3 patients with calcium channel blockers. 69 patients were forwarded from external consultant and 23 patients from the emergency room (ER). We verified that 12 patients (52,2%) were in sinus rhythm in admission of outpatient clinic and had spontaneously reversion to sinus rhythm. Mostly patients with paroxysmal AF were from the ER (80% of all patients, p&lt;.001) and mostly patients with persistent and long standing AF were from external consultant (respectively 82% p&lt;0.01 and 85% p&lt;0,01). Symptoms improvement were evaluated by EHRA classification. Mostly patients had clinical improvement after electrical or spontaneously cardioversion (63%, p.0.02). The median EHRA score previous to CVE were "2" and after cardioversion were "1".

Conclusions

Risk factor control is the cornerstone of AF prevention. Control rhythm is important to improve clinical symptons related to AF. However, we can delay cardioversion in a recent acute episode in the emergency room. In our sample, it seems that AF with short natural story presents more in emergency room and the more chronic comes to our consultation.

Evaluation of RV-arterial coupling in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

The ratio of echocardiography-derived tricuspid annular plane systolic excursion (TAPSE) and pulmonary arterial systolic pressure (PASP) - TAPSE/PASP ratio - is a noninvasive measure of RV-arterial coupling. TAPSE/PASP ratio is a potent independent predictor of prognosis in heart failure and pulmonary arterial hypertension, with a prognostic cutoff value of 0.36 mm/mmHg.

Objective

To assess the prognostic impact of TAPSE/PASP ratio in a population of advanced HF patients.

Methods

Prospective evaluation of adult patients with advanced HFrEF referred to our Institution for evaluation with HF team and possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 2 years for the primary endpoint of cardiac death and HT. Echocardiographically determined TAPSE/PASP ratio was used to assess RV-arterial coupling and a survival analysis was performed to evaluate the prognostic impact of the suggested cutoff of 0.36 mm/mmHg.

Results

A total of 450 Heart Failure with Reduced Ejection Fraction (HFrEF) patients with a mean age of 56 ± 12 years, of which 80% are male, and with a mean LVEF of 29 ± 4%, mean TAPSE of 19 ± 3 mm and PASP of 38 ± 11mmHg. The mean TAPSE/PASP was 0.80 ± 0.28. Fifty-four patients (12%) met the primary endpoint. Patients with RV-arterial uncoupling (TAPSE/PASP &lt; 0.36 mm/mmHg) were more likely to have a non-ischaemic etiology for HF (66.7% vs 40%, p = 0.047), had a lower prevalence of diabetes (53.3% vs 77.9%, p = 0.041), a higher prevalence of moderate-to-severe mitral regurgitation (33.3% vs 13.0%, p = 0.035), a lower LVEF (26.2 ± 6.1 vs 29.9 ± 5.9, p = 0.038), a higher prevalence of RV dysfunction (73.3% vs 26.7%, p &lt; 0.001) and worse cardiopulmonary fitness (pVO2: 12.7 ± 5.1 vs 15.8 ± 6.0 ml/kg/min, p = 0.047; VE/VCO2 slope: 49.5 ± 17.2 vs 37.6 ± 9.7, p &lt; 0.001; cardiorespiratory optimal point: 36.9 ± 11.3 vs 29.0 ± 6.4, p &lt; 0.001). More patients in the group of TAPSE/PASP &lt; 0.36 mm/mmHg met the primary endpoint (33.3% vs 9.6%, p = 0.034) and more patients underwent urgent HT (13.3% vs 1.4%, p = 0.44). RV-arterial coupling was associated with a lower survival free of events during follow-up (log-rank p = 0.010).

Conclusion

RV-arterial coupling predicts a worse prognosis in advanced HF patients, with those below a cutoff of 0.36 mm/mmHg having lower survival. This variable may improve risk stratification in this setting. Abstract Figure.

Three dimensional myocardial deformation parameters are associated with functional capacity in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Three-dimensional (3D) echocardiography is an emerging tool for assessment of left ventricular function, with a promising role in the evaluation of cardiomyopathies. Hypertrophic cardiomyopathy (HCM) is often associated with reduced exercise capacity. The aim of this study was to evaluate the importance of 3D myocardial deformation parameters as predictors of exercise capacity in HCM patients (P).

Methods

This prospective study enrolled P with HCM. Each P underwent a comprehensive transthoracic echocardiogram including 3D speckle-tracking to measure global longitudinal, radial and circumferential strain, twist, torsion and global area strain. Functional capacity was objectively assessed by treadmill cardiorespiratory exercise testing.

Results

83 patients with HCM, 50 (60%) male, mean left ventricular ejection fraction (LVEF) of 68 ± 7%, 27 (33%) with obstructive HCM (LV outflow tract [LVOT] gradient of 89 ± 60 mmHg). Impairment in LV myocardial deformation parameters was significantly correlated with lower peak VO2: global longitudinal 3D strain (r=-0.397, p &lt; 0.001), global radial 3D strain (r = 0.336, p = 0.003) and global circumferential 3D strain (r=-0.353, p = 0.002) (Figure 1).

Impaired LV twist was significantly correlated with inferior peak VO2 (r = 0.264, p = 0.033) (Fig.2) and peak circulatory power (r = 0.371, p = 0.003). Torsion impairment also significantly associated with lower peak VO2 (r = 0.285, p = 0.021), circulatory power (r = 0.380, p = 0.002), time to ventilatory anaerobic threshold (VAT) (r = 0.369, p = 0.003) and (VE/VCO2 slope)/peak VO2 ratio (r=-0.316, p = 0.012).

Furthermore, global area strain impairment showed significant relation with decreased peak VO2 (r=-0.368, p = 0.001), lower exercise duration (r=-0.384, p = 0.001), time to VAT (r=-0.404, p &lt; 0.001), circulatory power (r=-0.272, p = 0.032) and (VE/VCO2 slope)/peak VO2 ratio (r = 0.391, p = 0.002). LV twist (r=-0.135, p = 0.284), torsion (r=-0.120, p = 0.341) and global area strain (r = 0.152, p = 0.235) impairment did not correlate with VE/VCO2 slope. Exercise capacity was not associated with LV mass index (r = 0.209, p = 0.095), LV end-diastolic volume (r = 0.058, p = 0.639), maximum wall thickness (r = 0.041, p = 0.744), LVEF (r=-0.092, p = 0.458), 2D global longitudinal strain (r=-0.024, p = 0.848) or peak LVOT gradient (r=-0.006, p = 0.964). In a subanalysis examining only the nonobstructive (nHCM) P, we found that peak VO2 had a superior correlation with global longitudinal 3D strain (r=-0.420, p = 0.004), global radial 3D strain (r = 0.356, p = 0.016) and global circumferential 3D strain (r=-0.357, p = 0.016) as well as LV twist (r = 0.300, p = 0.046) and torsion (r = 0.336, p = 0.024).

Conclusion

Although P with HCM often have supranormal LVEF, 3D speckle-tracking echocardiographic imaging has the potential to demonstrate subclinical impairment of LV function. Impaired LV 3D strain, twist, torsion and global area strain were associated with reduced exercise capacity, particularly in nHCM P. Abstract Figure. Peak VO2 and 3D strain parameters  Abstract Figure. LV twist, torsion and global area strain

Microvascular dysfunction and myocardial fibrosis impact on left ventricular myocardial deformation in hypertrophic cardiomyopathy: per segment analysis by magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular hypertrophy (LVH) and microvascular dysfunction are hallmarks of hypertrophic cardiomyopathy (HCM). We hypothesized that microvascular dysfunction contributes to LV myocardial deformation impairment.

Methods

Prospective evaluation of adult patients with HCM (patients with "end-stage" HCM, prior septal reduction therapy or epicardial coronary artery disease were excluded). All underwent a cardiac magnetic resonance (CMR) protocol (1.5-T), from which the following parameters were analysed: maximal LV wall thickness (MLVWT), T1 and T2 mapping, extracellular volume, late gadolinium enhancement (LGE) and stress perfusion. Three-dimensional strain analysis was obtained by using feature-tracking from cine images. Results were stratified according to the 16 American Heart Association segments. Multivariate regression analyses for longitudinal, circumferential and radial strain were performed.

Results

A total of 1200 myocardial segments were analysed (Table 1) (75 patients, 63% male, age 54.6 ± 14.7 years) including 61% with asymmetric septal LVH, 29% with apical LVH, 8% with concentric LVH, 28% exhibiting LV outflow tract obstruction. The mean MLVWT was 20 ± 4.5mm.

Higher values of longitudinal strain (lower deformation) were found in segments with MLVWT ≥15mm (β-estimate: 2.31, 95% CI 0.91-3.70, p &lt; 0.001) and in patients with obstructive HCM (β-estimate: 2.44, 95% CI 1.15-3.72, p &lt; 0.001]) (Table 2). No association was found between perfusion defects, LGE and longitudinal strain.

Higher values of circumferential strain (lower deformation) were found in segments with MLVWT 12-14mm (β-estimate: 2.31, 95% CI 1.36-3.25, p &lt; 0.001), MLVWT ≥15mm (β-estimate: 5.29, 95% CI 4.47-6.12, p &lt; 0.001), with perfusion defects (β-estimate: 2.75, 95% CI 2.0-3.5, p &lt; 0.001), with LGE (β-estimate: 2.49, 95% CI 1.77-3.22, p &lt; 0.001) and in patients with obstructive HCM (β-estimate: 1.25, 95% CI 0.44-2.06, p = 0.003).

Lower radial strain values were found in segments with MLVWT 12-14mm (β-estimate: -10.64, 95% CI -13.95 to -7.33, p &lt; 0.001), with MLVWT ≥15mm (β-estimate: -20.67, 95% CI -23.36 to -17.97, p &lt; 0.001), with perfusion defects (β-estimate: -10.60, 95% CI -13.08 to -8.13, p &lt; 0.001), and with LGE (β-estimate: -10.49, 95% CI  -12.86 to -8.11) (table 2).

Diabetes, hypertension and BMI &gt; 25 kg/m2 were also associated with impaired myocardial deformation. Male gender correlated with worse radial and circumferential strain values.

No association was found between parametric mapping values and LV myocardial deformation.

Conclusion

In patients with HCM, three-dimensional speckle tracking parameters for LV systolic function were particularly impaired in segments with LVH, microvascular dysfunction or fibrosis. LVH was associated with abnormal longitudinal, circumferential and radial strain while perfusion defects and LGE correlated with impaired circumferential strain and radial strain. Abstract Table 1: Characteristics of AHA segments  Abstract Table 2: Multivariate analysis

Prognostic impact of right ventricular function in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

In patients with heart failure with reduced ejection fraction (HFrEF), the presence of coexistent right ventricular (RV) systolic dysfunction is associated with a worse functional capacity and outcome. However, the measurement of RV function is often overshadowed by its left counterpart.

Purpose

To assess the prognostic impact of RV dysfunction in a population of advanced HF patients.

Methods

Prospective evaluation of adult patients with advanced HFrEF referred to our Institution for evaluation with HF team for possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 1 year for the primary endpoint of cardiac death and HT. RV systolic dysfunction was defined by a tricuspid annular plane systolic excursion (TAPSE) &lt; 17 mm and/ or fractional area change (FAC) &lt; 35%. A survival analysis was performed to evaluate the prognostic impact of RV dysfunction and survival curves were compared using the log-rank test.

Results

A total of 450 HFrEF patients (mean age of 56 ± 12 years, 80% male, mean LVEF of 29 ± 4%, mean TAPSE of 19 ± 3 mm and RV FAC of 37 ± 6%), of which 30.4% had RV dysfunction. Thirty patients (6.7%) met the primary endpoint. Patients with RV dysfunction had a higher NT-proBNP value (3278.9 ± 296.7 pg/mL, p = 0.005) and a lower LVEF (26.7 ± 6.4 vs 31.4 ± 5.1, p &lt; 0.001), as well as a worse cardiopulmonary fitness (CPET duration: 7.2 ± 3.8 vs 8.6 ± 4.1, p = 0.019; pVO2: 13.6 ± 4.9 vs 16.2 ± 6.1 ml/kg/min, p = 0.006; VE/VCO2 slope: 41.8 ± 11.9 vs 37.0 ± 10.6, p = 0.015; cardiorespiratory optimal point: 33.0 ± 8.9 vs 28.4 ± 6.2, p &lt; 0.001). RV dysfunction was associated with a lower survival free of events during the first follow-up year (log-rank p = 0.046).

Conclusion

RV is associated with a poor survival in advanced HF patients and it may improve risk stratification in this population. Abstract Figure.

Functional mitral regurgitation in advanced heart failure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Moderate-to-severe functional mitral regurgitation (fMR) is present in about one-third of patients with heart failure (HF) with reduced left ventricular (LV) ejection fraction (HFrEF) and contributes to progression of the symptoms of HF and is and independent predictor of worse clinical outcomes.

Objective

To characterize the population of advanced HF patients with severe fMR and assess its prognostic impact.

Methods

Prospective evaluation of adult patients with advanced HFrEF were referred to our Institution for evaluation with HF team and possible indication for urgent heart transplantation (HT) or MCS. Patients were followed up for 1 year for the primary endpoint of cardiac death and HT. Severe fMR was defined by an EROA ≥ 20 mm2 and/or a regurgitant volume (RVol) ≥ 30 mL either taken from TTE or TOE. A survival analysis was performed to evaluate the prognostic impact of fMR and survival curves were compared using the log-rank test.

Results

A total of 450 HFrEF patients (mean age of 56 ± 12 years, 80% male, mean LVEF of 29 ± 4%) of which 14.4% had severe fMR, with a mean EROA of 29.2 ± 3.1 mm2 and a mean RVol of 43.6 ± 4.7 mL. Thirty patients (6.7%) met the primary endpoint. Patients with severe fMR were more likely to be female (69.2% vs 81.5%, p = 0.026) and to have atrial fibrillation (27.0% vs 14.1%, p = 0.028), had a higher NT-proBNP value (3625.8 ± 496.9 vs 1940 ± 212.4 pg/mL, p = 0.001), a lower LVEF (25.9 ± 6.8 vs 29.0 ± 6.7, p = 0.001), more dilated LV (LV end-diastolic diameter: 72.8 ± 13.3 vs 66.9 ± 9.0 P = 0.036), a lower HFSS value (8.1 ± 1.0 vs 8.6 ± 1.0). There was no difference regarding HF etiology, NYHA class or cardiopulmonary fitness (pVO2: 16.6 ± 5.6 vs 16.5 ± 6.3 ml/kg/min, p = 0.19; VE/VCO2 slope: 35.4 ± 9.9 vs 34.0 ± 9.7, p = 0.328). EROA was an independent predictor of the primary outcome (OR 1.23, 95% CI 1.08-1.54, p = 0.039) and patients with severe fMR had a lower survival free of events during the first follow-up year (log-rank p = 0.012).

Conclusion

Severe fMR was associated with worse clinical outcomes in advanced HF population. Abstract Figure.

Assessment of myocardial work: a promising tool in obstructive and nonobstructive hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Myocardial work is a novel dynamic non-invasive method for assessing myocardial deformation providing incremental information to left ventricular ejection fraction (LVEF) and strain imaging. The aim of this study was to assess left ventricular myocardial work in hypertrophic cardiomyopathy (HCM) and compare patients with obstructive HCM (oHCM) and nonobstructive HCM (nHCM).

Methods

Prospective assessment of HCM patients’ myocardial strain parameters with 2D speckle-tracking echocardiography, stratified according to LV segments (basal, midcavity and apical regions). Results were compared between oHCM and nHCM patients.

Results

83 patients with HCM, 60% male, 33% oHCM (with a LVOT gradient of 89 ± 60 mmHg). There was no significant difference between groups in mean age (56 ± 13 years vs. 55 ± 15 years, p = 0.719), LV mass index (186 ± 75 g/m2 vs. 158 ± 65 g/m2, p = 0.103), maximum wall thickness (21 ± 4 mm vs. 19 ± 5 mm, p = 0.425) or left ventricular ejection fraction (LVEF) (68 ± 8% vs. 67 ± 11%, p = 0.584).

Regarding global work index (GWI) there was no significant difference between oHCM and nHCM (1206 ± 431 mmHg% vs. 1384 ± 437 mmHg%, p = 0.090), although oHCM patients had a significantly inferior GWI in the basal (921 ± 383 mmHg% vs. 1364 ± 419 mmHg%, p &lt; 0.001) and midcavity (1049 ± 456 mmHg% vs. 1288 ± 492 mmHg%, p = 0.038) segments (Figure 1). No significant difference was noted in the apical segments (1680 ± 653 mmHg% vs. 1519 ± 770 mmHg%, p = 0.335). Myocardial work index in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.242, p = 0.032) and maximum provoked LVOT gradient (r=-0.291, p = 0.010). Furthermore, patients with septal hypertrophy pattern showed significantly impaired basal myocardial work index compared with apical hypertrophy patients (1090 ± 428 mmHg% vs 1537 ± 389 mmHg%, p &lt; 0.001).

Global constructive work (GCW) (1443 ± 449 mmHg% vs. 1604 ± 426 mmHg%, p = 0.123) and global wasted work (GWW) (197 ± 140 mmHg% vs. 154 ± 107 mmHg%, p = 0.137) were not significantly different between groups.

Global work efficiency (GWE) was significantly reduced in oHCM patients vs. nHCM (84.1 ± 7% vs. 88.3 ± 7.3%, p = 0.017), particularly in the basal (80.2 ± 11.2% vs. 88.3±.7.2%, p = 0.033) and midcavity segments (85.4 ± 9.2% vs. 90.0 ± 8.5%, p = 0.044) (Figure 2). No significant difference was noted in the apical segments (88.2 ± 9.9% vs. 87.0 ± 12%, p = 0.679). Myocardial work efficiency in the basal segments showed inverse correlation with resting LVOT gradient (r=-0.389, p = 0.002) and maximum provoked LVOT gradient (r=-0.446, p &lt; 0.001). Moreover, patients with septal hypertrophy pattern showed significantly reduced basal myocardial work efficiency versus apical hypertrophy patients (83 ± 9% vs 92 ± 3%, p &lt; 0.001).

Conclusion

Myocardial work is a promising tool to evaluate myocardial function in patients with oHCM and nHCM. oHCM patients had a significantly inferior GWI and GWE particularly in the basal and midcavity segments versus nHCM patients. Abstract Figure 1: Myocardial Work Index  Abstract Figure 2: Myocardial Work Efficiency

Segmental analysis of microvascular dysfunction and tissue characterization in hypertrophic cardiomyopathy by magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

Background

While left ventricular hypertrophy (LVH) and myocardial fibrosis are frequently evaluated in hypertrophic cardiomyopathy (HCM), microvascular dysfunction is often overlooked. The aim of this study was to assess the association between wall thickness, microvascular dysfunction and tissue characteristics in HCM patients (P), comparing individual myocardial segments.

Methods

Prospective evaluation of adult P with HCM (P with "end-stage" HCM, prior septal reduction therapy or epicardial coronary artery disease were excluded). All underwent a cardiac magnetic resonance (CMR) protocol (1.5-T), from which the following parameters were analysed: maximal LV wall thickness (MLVWT), T1 and T2 mapping, extracellular volume (ECV), late gadolinium enhancement (LGE) and stress perfusion. Results were stratified according to the 16 American Heart Association segments. Multivariate regression analyses for perfusion defects and tissue characteristics were performed.

Results

75 P (total of 1200 myocardial segments analysed), 63% male, mean age 55 ± 15 years, MLVWT of 20 ± 4.5mm (61% asymmetric septal LVH, 29% apical LVH and 8% concentric LVH). 28% presented LV outflow tract obstruction.

MLVWT was greater in the basal and mid septum (table 1). Among the 424 segments (35.3%) with a perfusion defect, 286 (23.8%) had a defect only in the endocardial layer and 138 (11.5%) in both endocardial and epicardial layers with defects more often detected in hypertrophied segments. This association was verified in segments with MLVWT 12-14mm and MLVWT ≥15mm (OR 7.83, 95% CI 5.75-10.67, p &lt; 0.001) (table 2). Among the 660 segments with normal MLVWT (≤11mm), 123 (19%) presented perfusion defects. A perfusion defect was more frequent in segments of obstructive HCM P (OR 1.48, 95% CI 1.13-1.92, p = 0.004).

Microvascular dysfunction was associated with changes in tissue characteristics. For the same thickness, segments with perfusion defects had a higher T1 mapping (β-estimate 20.91, 95% CI 16.87-24.96, p &lt; 0.001) and T2 mapping mean values than those without. Furthermore, regardless of MLVWT, segments with perfusion defects had LGE more often (OR 4.16, 95% CI 3.19-5.41, p &lt; 0.001) and a higher ECV. On the other hand, among the 424 segments with a perfusion defect, 115 (27%) did not present LGE.

MLVWT was associated with tissue characteristics. Comparing to non-hypertrophied segments, T1 mapping mean value was higher in segments with MLVWT 12-14mm and with ≥15mm (β-estimate 37.71, 95% CI 31.2-44.21, p &lt; 0.001). Segments with MLVWT ≥15mm showed a significantly superior ECV mean value comparing to non-hypertrophied segments. LGE was more frequent in the more hypertrophied segments: MLVWT 12-14mm and ≥15mm (OR 9.02, 95% CI 6.42-12.67, p &lt; 0.001) (Table 2).

Conclusion

Microvascular dysfunction is more prevalent in obstructive HCM, particularly in the more hypertrophied segments. The presence of microvascular dysfunction is associated with diffuse tissue abnormalities and replacement fibrosis. Abstract Table 1: Characteristics of AHA segments  Abstract Table 2: Multivariable analyses

Room temperature two terminal tunnel magnetoresistance in a lateral graphene transistor

We investigate the behavior of both pure spin and spin-polarized currents measured with four-probe non-local and two probe local configurations up to room temperature and under an external gate voltage in a lateral graphene transistor, produced using a standard large-scale microfabrication process. The high spin diffusion length of pristine graphene in the channel, measured both directly and by the Hanle effect, and the tuning of the relationship between the electrode resistance areas present in the device architecture allowed us to observe local tunnel magnetoresistance at room temperature, a new finding for this type of device. The results also indicate that while pure spin currents are less sensitive to temperature variations, spin-polarized current switching by an external voltage is more efficient, due to a combination of the Rashba effect and a change in carrier mobility by a Fermi level shift.

Non-vitamin K antagonist oral anticoagulants in adult congenital heart disease: a single-center study

Introduction

Adults with congenital heart disease (ACHD) are at an increased risk for thromboembolic events and atrial arrhythmias are common in this population. Non-vitamin K anatagonist oral anticoagulants (NOACs) prescription is increasing, however data on efficacy and safety in ACHD is unclear, particularly in patients (P) with complex CHD. The aim of the study was to review the use of NOACs in various types of ACHD and assess its safety and efficacy.

Methods

Evaluation of consecutive ACHD P started on NOAC therapy from 2014 to 2020. P were followed-up for bleeding or thromboembolic events and mortality. CHA2DS2-VASc and HASBLED scores were calculated and risk factors for bleeding were identified.

Results

93 ACHD P were included, mean age 52±15 years, 58% female, 44% with complex CHD (3.2% with Fontan circulation), with diagnosis of: 22.2% atrial septal defect, 20% tetralogy of Fallot, 11.1% transposition of the great arteries, 10% Ebstein's anomaly, 8.9% ventricular septal defect, 7.8% pulmonary stenosis, 5.6% ductus arteriosus, 4.4% AV septal defect, 3.4% univentricular heart, 3.4% coarctation of aorta, 2.2% supra-aortic stenosis and 1% with Uhl disease.

Most P were anticoagulated with rivaroxaban (43%), followed by edoxaban (24%), apixaban (20%), and dabigatran (13%). The indications for anticoagulation were: atrial arrhythmias (81%), pulmonary embolism (PE) (6.3%), atrial thrombi (4.3%), thromboprophylaxis in Fontan circulation (3.2%), deep vein thrombosis (3.2%) and stroke (2%). 66% of P had a CHA2DS2-VASc score ≥2 and 82% HASBLED score ≤2.

In a mean follow-up of 41±21 months (400.4 patient-years), there were embolic events in 2P (1 splenic infarction and 1 PE) albeit both were in the context of oral anticoagulation interruption. The cardiovascular mortality was 2% and allcause mortality 5%, however with no relation to thrombosis or bleeding events.

6 P (6.5%) suffered a minor and 3 P (3.2%) suffered a major bleeding, a median time of 12 (IQR 15) months after starting NOAC therapy. The annual risk for bleeding was 2.2%/patient/year. P with bleeding events showed no significant difference regarding age (55±16 vs 52±15 years, p=0.587), gender (13% female vs 5.1% male, p=0.295) or CHD type (p=0.582). 8.6% of P required dose reduction, mostly for bleeding (3.2%) or renal impairment (2.2%).

Renal disease was a strong risk factor for major bleeding (HR 14.6 [95% CI 1.23–73.6], p=0.033 and multivariate analysis showed that an increased HASBLED score was an independent predictor of minor (adjusted HR 3.44 [95% CI 1.13–10.52], p=0.030) and major (adjusted HR 5.29 [95% CI 1.14–24.45], p=0.033) bleeding complications.

Conclusion

Anticoagulation with NOACs is a safe and effective option for selected ACHD P, although bleeding complications were not negligible, particularly in P with renal disease. Larger scale research studies are required, especially regarding complex CHD such as P with Fontan circulation.

Funding Acknowledgement

Type of funding sources: None.

Left atrial strain imaging and integrated backscatter: predictors of recurrence in patients with paroxysmal, persistent and long-standing persistent atrial fibrillation undergoing catheter ablation

Introduction

Left atrial (LA) strain imaging by echocardiography (TTE) is a promising tool in the evaluation of LA mechanical function. The aim of this study was to compare LA longitudinal strain and integrated backscatter (IBS) between paroxysmal (PAF), persistent (PersAF) and long-standing persistent AF (LsAF) and evaluate its association with AF recurrence post-index catheter ablation.

Methods

Analysis of consecutive patients (P) with symptomatic PAF and PersAF who underwent index AF catheter ablation and had performed TTE in our centre prior to AF ablation. LA reservoir phase longitudinal strain (LASr) and strain rate was assessed by 2D speckle-tracking at baseline. LA volume index (LAVi) and IBS were analysed. AF recurrence was documented with 12-lead ECG, 24h Holter monitoring, external loop recorder or pacemaker analysis in a 12-month follow-up period.

Results

78 P, 69% PAF vs 31% PersAF (46% LsAF), 65% male, 40% with structural heart disease, who underwent pulmonary vein isolation were studied (cryoballoon ablation in 53% and radiofrequency ablation in 47%). P with PersAF had a higher LAVi (46±15 mL/m2 vs 36±13 mL/m2 p=0.004), particularly LsAF P (55±17 mL/m2) and impaired LASr (9.2±4.9% vs 23.9±9.3%, p&lt;0.001) (especially LsAF 5.61±3.08% vs 12.20±4.04%, p&lt;0.001) as well as strain rate (0.58±0.25 s–1 vs 1.08±0.40 s–1, p&lt;0.001). There was no significant difference between groups regarding IBS (116.6±36.1 dB vs 106.6±21.5 dB, p=0.134), including LsAF (128.8±21.5 dB vs 102.1±45.1 dB, p=0.071). During follow-up there was a 28% (22P) AF recurrence rate, higher in PersAF (50% vs PAF 20%, adjusted HR 3.44 [95% CI 1.44–7.69], p=0.005), particularly in LsAF (72% vs 31%, adjusted HR 3.24 [95% CI 0.98–10.9], p=0.048). P with AF recurrence showed significantly impaired baseline LASr both in PersAF (6.44±3.26% vs 11.93±4.79%, p=0.003), as well as PAF (13.86±5.65% vs 26.29±8.47%, p&lt;0.001). LsAF P with AF recurrence demonstrated a considerably impaired LASr (4.99±2.93% vs 9.34±1.40%, p=0.006) vs PersAF. Multivariate analysis showed that impaired baseline LASr was an independent predictor of AF recurrence both in PersAF (adjusted HR 0.82 [95% CI 0.68–0.98], p=0.028) and PAF (adjusted HR 0.78 [95% CI 0.68–0.88], p&lt;0.001). Kaplan-Meier analysis (Fig. 1) showed that both PAF and PersAF P with baseline LASr below the 18% cut-off had a significantly higher rate of AF recurrence, with earlier recurrence in PersAF. PAF P with AF recurrence had a higher baseline IBS (109.3±22.1 dB vs 94.7±14 dB, p=0.016) vs non-recurring P, in contrast to PersAF P (117.8±31.1 dB vs 115.4±42.1 dB, p=0.876), however IBS was not a significant predictor of AF recurrence in PAF (HR 1.03 [95% CI 0.99–1.07], p=0.060) or PersAF.

Conclusion

P with PersAF (and particularly LsAF) showed significantly impaired LASr, and PAF P with AF recurrence had superior baseline IBS vs non-recurring P. Reduced baseline LASr was an independent predictor of AF recurrence both in PAF and in PersAF P.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Malignant cardiac tumors: a single-centre 25-year review

Background

Primary cardiac tumors are extremely rare and are usually diagnosed late due to the nonspecific symptoms. Surgery is the main treatment option, and despite chemotherapy, the prognosis remains poor. Cardiac invasion by metastatic tumors, while more common, also entails an unsatisfactory outcome. The aim of this study was to review patients (P) with malignant cardiac tumors that were diagnosed by transthoracic echocardiogram (TTE) or transoesophageal echocardiogram (TOE) in a tertiary center between 1995 and 2020.

Methods

Retrospective analysis of clinical data, echocardiographic assessment of tumor location and morphology, histology results and survival outcomes.

Results

A total of 44 malignant cardiac tumors were diagnosed: 12 primary tumors (A) and 32 metastatic tumors (B). A: Regarding primary cardiac tumors, the most common types were angiosarcomas (6), undifferentiated pleomorphic sarcomas (2), fibrosarcomas (2), myxofibrosarcoma (1) and primary cardiac lymphoma (1). The mean age of P at time of diagnosis was 43±15 years, 50% male. The most frequent presentation was heart failure symptoms (50%) followed by arrhythmias (20%). 1 P presented with pruritus and polyarthralgias. On TTE, the most prevalent tumor location was in the right-heart chambers (70%) – mostly the right atrium (50%), with mean dimensions of 40±18x27±11 mm. 85% of P had preserved biventricular systolic function and there was severe pericardial effusion in 38%. The most frequent metastatic involvement at diagnosis was pulmonary (33%) and hepatic (33%). 50% of P were submitted to tumor resection and 40% to chemotherapy. Regarding angiosarcomas, the most common immunohistochemical markers were vimentin, CD31 and CD34. The authors found a mortality rate of 10P (83%) in P with primary cardiac tumors, with a median time to mortality of 5.5 (IQR 2–10) months (Figure 1), in a median follow-up of 6.2 (IQR 2.5–15) months (minimum of 20 days and maximum of 19 years). In the latter case, the P was submitted to heart transplantation after diagnosis of a fibrosarcoma and is still alive and well.

B: Regarding secondary cardiac invasion, there was a diagnosis of the following primary tumor sites: 12 lung carcinomas, 7 thymomas, 4 lymphomas, 3 hepatocellular carcinomas, 2 bladder carcinomas, 1 parathyroid carcinoma, 1 soft tissue sarcoma, 1 uterine sarcoma and 1 melanoma. The mean age of P was 57±19 years, 57% male. On TTE/TOE the authors found a right-sided chambers predominance (12 P, 38%) vs left-sided chambers in (8 P, 25%), with pericardial metastasis also present in 13 P (41%). Cardiac tamponade occurred in 6P (19%). The mortality rate was 75% (24P), with a median time to mortality of 1.1 (IQR 0.6–3.8) months (minimum of 7 days, maximum of 44 months), in a median follow-up of 2.3 (IQR 0.8–14) months.

Conclusion

Cardiac malignant tumors generally present in a late stage with a dismal prognosis. When possible, heart transplantation can be an option with a favourable outcome.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Kaplan-Meier analysis

Familial hypercholesterolemia in acute coronary syndrome patients: underdiagnosis in female and in young patients

Introduction

Familial hypercholesterolemia (FH) is often underdiagnosed, particularly in female patients (P), even during hospital admission for acute coronary syndromes (ACS). The aim of this study was to apply the Dutch Lipid Clinic Network (DLCN) Criteria in P admitted for ACS and evaluate gender and age differences.

Methods

Prospective evaluation of P with ACS admitted to a tertiary center from 2005 to 2019. Data including family history and laboratory tests was analysed for the application of the DLCN criteria and results were stratified according to ACS subtype, gender and age groups (20–39, 40–59, 60–79 and ≥80 years [y]). P were followed up for 30 days for hospitalization, recurring ACS and mortality.

Results

3811 P were evaluated, mean age 63±13 years, 28% female and mean LDL cholesterol of 125±43 mg/dL. The admission diagnosis was unstable angina (UA) in 5%, non-ST-segment elevation myocardial infarction (NSTEMI) in 27% and ST-segment elevation MI (STEMI) in 68%.

Applying the DLCN criteria, 3089 P (81%) had a score of &lt;3 (unlikely FH), 675P (17.7%) a score of 3 to 5 (possible FH), 41P (1.1%) a score of 6 to 8 (probable FH) and 1P (0.03%) a score of &gt;8 (definite FH). Stratifying according to ACS type: among UA, 31P (16%) had possible FH and 4P (2.1%) had probable FH. Among NSTEMI, 145P (14.2%) had possible FH, 9P (0.9%) probable FH and 1P (0.03%) definite FH. Finally, among STEMI P, 497P (19.1%) had possible FH and 28P (1.1%) probable FH. Regarding female P, 158P (14.7%) had possible FH and 16 P (1.5%) probable FH. Among male P, 517P (18.9%) had possible FH and 25P (0.9%) probable FH (p=0.016 for interaction).

According to age groups, among P aged 20–39 y (136P), 61P (44.9%) had possible FH and 6P (4.4%) had probable FH. Concerning P aged 40–59 y (1766P), 575P (32.6%) had possible FH, 31 P (1.8%) probable FH and 1P (0.1%) definite FH. With regard to P aged 60–80 y (2122P), 80P (3.8%) had possible FH and 4P (0.2%) probable FH. Among P aged ≥80 y (1837P), only 9P (0.5%) had possible FH and no P had probable FH.

In a 30-day follow-up, there was an hospitalization rate of 3.5% (134P) and recurring ACS in 1.7% (65P), while the all-cause mortality was 2% (78P) and cardiovascular (CV) death was 1.3% (49P). Female P had a significantly lower hospitalization rate (1.8% vs 3.2%, p=0.003) as well as fewer recurring ACS (0.6% vs 1.7%, p=0.001). There was no significant gender difference regarding all-cause mortality (female 1.7% vs 1.5%, p=0.552) or CV death (0.8% vs 1.1%, p=0.323). The DLCN criteria score was significantly correlated with admission for recurring ACS (OR 1.19 [95% CI 1.04–1.36], p=0.04).

Conclusion

Application of the DLCN criteria in female P admitted for ACS revealed 158P (14.7%) with possible FH and 16P (1.5%) with probable FH. Regarding younger ACS P (20–39y), 44.9% had criteria for possible FH and 4.4% for probable FH, prompting us to do not overlook these P subgroups in daily practice and routinely assess the likelihood of FH.

Funding Acknowledgement

Type of funding sources: None.

Acute myocardial infarction at an early age – importance of acute chest pain fast track in patient management

Background

Acute coronary syndrome (ACS) has a higher incidence in middle-aged and elderly patients but 2% to 6% of ACS cases occur in people younger than 45 years of age (Y). Younger patients have different clinical characteristics when compared to older patients. Acute chest pain fast track led to a reduction in the time required for the diagnosis of acute coronary syndromes, particularly those with ST segment elevation (STEMI).

Aim

This study aims to assess the differences in risk factors and clinical characteristics between young and older ACS patients. Besides that, we try to determine if the benefits of acute chest pain fast track have extended to this younger population.

Material and methods

Retrospective observational study carried out through the analysis of the clinical process. Clinical data were collected from ACS patients under 45Y from 2010 to 2019 and from ACS patients over 45Y from 2010 to 2012. Statistical analysis was made using R software and RStudio.

Results

This study included 93 patients with ACS under 45Y and 172 patients with ACS over 45Y. A total of 265 patients were included. The male gender was predominant in both groups but with a higher prevalence in the younger ones (88% vs 73%, p&lt;0,005). The prevalence of hypertension was higher in older ACS patients but the younger ones had more overweight (39.8% vs 17.4%, p&lt;0,001), smoking history (84.9% vs 38.4%, p&lt;0,001) and family history of sudden death (25.8% vs 5.8%, p&lt;0,01). Diabetes had no statistical difference. Dyslipidemia as previous known risk factor had no statistical difference but LDL was higher in patients with less than 45Y (147.2 vs 120.7 mg/dL, p&lt;0,001). STEMI were tendentially more prevalent in patients under 45Y (55.9% vs 44.8%, p 0.09). The anterior wall was the most frequently involved in both groups (52% vs 63%, p 0.28), followed by the inferior wall (42% vs 36%). Accordantly, anterior descending artery was the artery most frequently involved in both groups (44.1% vs 48.3%), followed by right coronary artery (24.7 vs 26.7%). STEMI patients under 45Y were submitted to an emergent coronary angiography in 89% of cases and STEMI patients over than 45Y were submitted in 70.1% of cases. Particularly for patients under 45Y, all STEMI patients were submitted to an emergent coronary angiography after 2014, which emphasis the importance of acute chest pain fast track in the emergency room. Finally, ACS patients under 45Y were less submitted to percutaneous coronary angiography compared to patients over 45Y (15.1% vs 4.7%, p&lt;0,001).

Conclusions

Cardiovascular risk factors differ accordingly the age of ACS patients. Younger patients had more overweight and smoking history. They probably have alternative pathophysiologic mechanisms that explain differences in percutaneous coronary angiography. Acute chest pain fast track had an important role reducing morbimortality related to ACS by reducing the time until STEMI diagnose.

Funding Acknowledgement

Type of funding sources: None.

Sutureless bioprosthesis as an alternative to conventional aortic valve replacement surgery

Background

Aortic valve stenosis is the most common adult valve disease in industrialized countries. The ageing population and the rising in comorbidities have urged the development of safer alternatives to the current gold standard surgical treatment. Sutureless bioprosthesis have shown promising results, especially in technically difficult procedures and as more and more patients need concomitant surgeries.

Purpose

Assess clinical and haemodynamic performance, safety and durability of the sutureless bioprosthesis implanted in patients with aortic valve disease, over a period of 5 years, both in isolated aortic valve replacement surgeries as well as in concomitant procedures.

Methods

Single centre retrospective longitudinal cohort study collected data of all adult patients with aortic valve disease who underwent valve replacement with a sutureless bioprosthesis between February 2015 and October 2020. Of the 196 patients analysed (mean age 77.20±5.08 years; 45.40% were female; mean logistic EuroSCORE 2.91±2.20%), the majority had aortic stenosis. To assess the comparative risk of adding concomitant procedures, patients were divided into two groups and compared: one comprised patients who underwent isolated valve implantation (n=132) and the other patients who had concomitant coronary artery bypass graftings (n=49). 15 patients had other heterogeneous concomitant procedures and were therefore not considered in this comparison.

Results

Overall mean cross-clamp and cardiopulmonary bypass times were 45.50±19.04 and 36.50±11.40 minutes, respectively. 4 valves were reimplanted due to misplacement. Mean transvalvular gradients were 7.82±3.62 mmHg. Mean ICU and total hospital stay were 3.32±3.20 and 7.70±5.82 days, respectively. Procedural success was 99%, as two explantations occurred. Pacemaker implantation occurred in 12.8% of patients, atrial fibrillation de novo in 21.9% and renal replacement support was necessary in 3.1%. Early mortality was 0.51%. We report no structural valve deterioration, strokes or endocarditis and one successfully treated valve thrombosis. By comparison, patients with concomitant procedures had worse left ventricular function (40.8 vs 79.5%; p=0.030), longer aortic clamping (43.33±11.60 vs 27.30±8.10 minutes; p&lt;0.001) and cardiopulmonary bypass times (59.98±17.60 vs 37.45±11.30 minutes; p&lt;0.001), as expected. ICU stay after surgery was also longer (3.96±3.20 vs 2.80±2.70 days; p=0.016). Apart from this, there were no other significant differences in postoperative complications and survival, even up to 5 years.

Conclusion

Our study confirms the excellent clinical and haemodynamic performance and safety of a truly sutureless aortic valve, even up to the 5-year follow-up. These results were consistent both in isolated and concomitant interventions, solidifying this device as a viable treatment of isolated aortic valve disease, and now also in patients needing concomitant procedures.

Funding Acknowledgement

Type of funding sources: None.

The impact of the cardiac rehabilitation program in patients with mid-range heart failure (40-50%) in improving cardio respiratory predictors

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Universitário Lisboa Central

Methods

We studied 30 patients (P) with ejection fraction (EF) 40-50%, in a number of 198 P that participated in cardiac rehabilitation program (CRP). Of these P, 24 (80%) male and 6 (20%) female, 20 P were diagnosed myocardial infarction with ST-segment elevation, 2 P myocardial infarction non ST and 8 P with myocardial hypertrophy non ischemic. Of these P 30% were diabetics, 56% hypertension, 70% dyslipidemia, 36% smokers previous to CRP and body mass index 26,3 medium.

All P were submitted to previous echocardiogram, cardiopulmonary exercise testing (CET) and a rehabilitation program minimum 4 sessions and maximum 52 sessions. At the end of the total sessions the echocardiogram and CET were repeated.

Results

Of the 30 P that participated in CRP only 20 completed the program, while the other 10 P dropped out because of social and economic problems. Of the P that completed the CRP, 70% got better on EF, 80% improved VE/VCO2 slope &lt; 33 therefore are classified VC-II in ventilatory classification (VC), 5% VE/VCO2 slope &gt; 40  VC-III classification, and 15% maintained the initial classification.  50% of the P increased at least one level metabolic equivalent of task (MET) from the first CET. Only 3 of the 20 patients came, once, to the hospital after the CRP with heart failure, and one died but did not fulfill the program.

Conclusion

Patients with mid-range heart failure submitted to a CRP can improve cardiorespiratory predictors, leading to a better quality of life. However, it is important to find solutions to minimize the causes that make patients to give up CRP.

POS1113 ANTIRESORPTIVE THERAPY AFTER TERIPARATIDE DISCONTINUATION – WHEN IS THE BEST TIME TO STARTING IT?

Background:

Treatment with teriparatide (TPTD) is associated with reduction of fracture risk in patients with severe osteoporosis. This drug can only be used for up to 2 years. After that a treatment course with antiresorptives should be considered, in order to prevent the rebound of bone turnover observed after TPTD discontinuation. In this regard, interest in sequential osteoporosis therapy has grown in recent years but the ideal timing for starting another treatment after TPTD is not well established.

Objectives:

The aim of this study is to assess if the timing of onset of antiresorptive therapy after TPTD discontinuation has implications in total hip bone mineral density (BMD) and in fracture risk.

Methods:

We performed a retrospective cohort study that included patients with severe osteoporosis treated with TPTD 20mcg/day for 24 months and followed for at least 2 more years in the rheumatology department of a tertiary university hospital. For analysis, demographic and clinical data and results of dual-energy X-ray absorptiometry (DXA) after cessation of teriparatide were used. For comparison between groups Mann-Whitney U test was used.

Results:

Fifty-five patients with osteoporosis, with a median age of 68 (32-85) years, were included. Forty-nine patients were female (89.1%). Nineteen patients (34.5%) had primary osteoporosis and 36 (65.5%) glucocorticoid-induced osteoporosis. The median time for initiating antiresorptive treatment was 7 (0-35) months after cessation of TPTD. Forty-three patients (78.2%) started a bisphosphonate, 6 denosumab (10.9%) and 6 patients did not receive any other treatment. The most prescribed bisphosphonate was zoledronate (69.8%). All patients received calcium and vitamin D supplementation. After completion of TPTD regimen 8 patients experienced at least one fragility fracture (14.5%). At follow-up, 37 (67.3%) of patients underwent DXA on average 30.0±15.4 months after starting antiresorptive agents. The median total hip BMD in patients who started antiresorptive therapy in the first 12 months (inclusive) after cessation of TPTD regime was 0,738 (0.587-0.993) g/cm2 and the median total hip BMD of patients who started therapy after one year of discontinuation of TPTD was 0.683 (0.390-0.813) g/cm2. This difference is marginally significant (p=0.067). The median time in starting antiresorptive treatment is higher in patients with new fragility fractures after TPTD than in patients without new fractures however this difference was not statistically significant (10.0 [2-35] vs 6.0 [0-35] months; p=0.393, respectively).

Conclusion:

Although this study is unable to show that anti-resorptive treatment should be started in the first year after discontinuation of TPTD, it is promising since the difference between the medians in the total hip BMD values obtained until one year and after one year are marginally significant. These results can be linked to the small sample size and highlight the need for further studies in this area.

References:

[1]Napoli N, Langdahl BL, Ljunggren Ö, Lespessailles E, Kapetanos G, Kocjan T, Nikolic T, Eiken P, Petto H, Moll T, Lindh E, Marin F. Effects of Teriparatide in Patients with Osteoporosis in Clinical Practice: 42-Month Results During and After Discontinuation of Treatment from the European Extended Forsteo® Observational Study (ExFOS). Calcif Tissue Int. 2018 Oct;103(4):359-371. doi: 10.1007/s00223-018-0437-x. Epub 2018 Jun 16. PMID: 29909449; PMCID: PMC6153867.

Disclosure of Interests:

None declared.

Left atrial strain imaging evaluation: a strong predictor of atrial fibrillation recurrence after single-procedure catheter ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Identification of predictors of arrhythmia recurrence after catheter ablation of atrial fibrillation (AF) is a clinically relevant issue. Transthoracic echocardiography (TTE) is a readily accessible exam that can be useful in estimating left atrial (LA) mechanical function. The aim of this study was to evaluate LA structure and LA strain imaging at baseline and its association with AF recurrence after an index AF catheter ablation. Methods: Analysis of patients with symptomatic paroxysmal and persistent AF who underwent a single-procedure for AF ablation between 2015 and 2019 and had performed TTE in our centre prior to AF ablation. LA parameters were assessed by 2D speckle-tracking at baseline. LA diameter index (LAVi), LA ejection fraction, LA phasic strain: reservoir (LASr), conduit (LAScd) and contraction phases (LASct), as well as integrated backscatter (IBS) values were analysed. AF recurrence was documented with 12-lead ECG, 24h Holter monitoring, external loop recorder or pacemaker analysis during a 12-month follow-up period. Results: Of a total of 106 patients, 28 patients were excluded due to poor image quality. We studied 78 patients who underwent pulmonary veins isolation (PVI) (age 59 ± 14 years, 65% male, 40% with structural heart disease, 69% paroxysmal AF) with cryoballoon ablation in 53% and radiofrequency ablation in 47%. In a 12-month follow-up there was a 28% (22 patients) AF recurrence rate. Patients with AF recurrence had a baseline significantly superior LAVi (47 ± 17 mL/m2 vs. 36 ± 12 mL/m2, adjusted HR 1.04 [95% CI 1.01-1.06], p = 0.002) and lower estimated LA ejection fraction (25 ± 19.7% vs. 45.4 ± 21%, adjusted HR 0.96 [95% CI 0.94-0.98], p = 0.001). Multivariate analysis showed that baseline LA strain parameters were independent predictors of AF recurrence, as patients with AF recurrence showed impaired LASr (9.81 ± 5.79% vs 22.94 ± 9.98%, adjusted HR 0.81 [95% CI 0.73-0.89], p &lt; 0.001) and LAScd (-6.74 ± 4.11% vs. -11.85 ± 7%, adjusted HR 1.11 [95% CI 1.03-1.19], p = 0.004). In patients in sinus rhythm during baseline TTE, LASct also correlated with AF recurrence, as patients with recurrence also showed impaired baseline LASct (-7.49 ± 3.65% vs -13.74 ± 5.4%, adjusted HR 1.39 [95% CI 1.11-1.75], p = 0.005). LASr &lt;18% showed a sensitivity of 86% and specificity of 70% to predict AF recurrence. Kaplan-Meier curves (figure 1) showed that patients with LASr below the 18% cut-off had a significantly higher rate of AF recurrence. Baseline IBS did not reveal significant differences in AF recurrence (111.2 ± 23.9 dB vs. 105.9 ± 33.5 dB, HR 1.007 [0.993-1.002], p = 0.349). Conclusion: Baseline LA strain imaging parameters, including reservoir phase LA strain, were demonstrated to be independent predictors of AF recurrence after PVI. A LASr &lt;18% showed good accuracy to predict AF recurrence. Abstract Figure. Kaplan-Meier curves - time to recurrence

Late gadolinium enhancement as a predictor of arrhythmias in patients with hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of arrhythmias and sudden cardiac death (SCD). The Late gadolinium enhancement (LGE) in cardiovascular magnetic resonance (CMR) has been associated with the occurrence of arrhythmic events.

Purpose

The aim was to analyze the association between LGE burden and location and arrhythmic events in HCM patients (P).

Methods

Retrospective analysis of P with HCM in a single tertiary center. Baseline clinical, echocardiographic and CMR characteristics were collected. On follow up arrhythmias (ventricular fibrillation (VF), sustained ventricular tachycardia (SVT), non-sustained ventricular tachycardia (NSVT), paroxysmal supraventricular tachycardia (PSVT), atrial fibrillation (AF) and atrial flutter (AFL)) were identified. LGE on CMR was compared between patients with and without arrhythmias.

Results

61P (59% male) were included, with a mean age of 58 ± 2 years. The HCM risk-SCD score was 3.35 ± 0.28%. On echocardiography mean left ventricle ejection fraction was 62.16 ± 1.36% and maximum wall thickness 20.59 ± 0.596mm. 31.1% had systolic anterior movement of mitral valve and 26.7% had left ventricle outflow tract obstruction. LGE was present in 88.5% P with a median number of 5 ± 7 segments involved. Interventricular septum (IVS) was involved in 78.7% P, anterior wall

in 57.4%, inferior wall in 54.1%, lateral wall in 52.5%, posterior wall in 9.8%, basal segments in 62.3%, median segments in 68.9% and apical segments in 63.9%. On follow up 3.3%P died, 45.8% had hospitalizations (22,2% because of an arrhythmia) and 75% had arrhythmias (1.6% VF, 6.6% SVT, 50% NSVT, 9.8% PSVT, 37.7% AF and 6.6% AFL). The number of segments with LGE correlated with arrhythmias (p = 0.05 for arrhythmias, p = 0.03 for SVT, p = 0.008 for NSVT and p = 0.042 for PSVT). A cut off of 5 segments involved was a good predictor of arrhythmias (p = 0.002), NSVT (p= 0.006), PSVT (p = 0.024) and AF (p = 0.0029). For SVT the best cut off was 9 (p = 0.003). Considering the LGE location, we found an association between the segments involved and the occurrence of different arrhythmias (table 1).

Conclusion

Supraventricular and ventricular Arrhythmias are frequent in patients with HCM, with the most frequents being NSVT and AF. The LGE burden (&gt;5 segments) and location (median inferior IVS, median anterior IVS, median anterior wall, basal anterior IVS, apical anterior wall, median inferior wall, apical anterior wall and basal inferior IVS) were correlated with arrhythmic events. Abstract Figure.

Effect of processing smoked salmon on contaminant contents

The influence of the type of smoking process (natural/liquid; hot/cold) and salt (NaCl or KCl) on the levels of polybrominated diphenyl ethers (PBDEs) and polycyclic aromatic hydrocarbons (PAHs) in smoked salmon was evaluated. One parent compound - BDE 47 - and two methoxylated forms - 2'-MeO-BDE-68 and 6-MeO-BDE-47 - were detected in all the samples. Among the 14 PAHs analysed, naphthalene was the most abundant followed by phenanthrene and fluorene. Only smoked salmon treated with NaCl presented quantifiable levels of chrysene and benzo[b]fluoranthene. Among the four smoking processes evaluated, natural smoke led to higher levels of PAHs. Risk characterization tools, such as hazard index (HI) and incremental lifetime cancer risk (ILCR), showed that the risk of both PBDEs and PAHs to human health through the consumption of smoked salmon was very low.

Cardiopulmonary exercise testing in repaired tetralogy of Fallot: a valuable tool for pulmonary regurgitation severity assessment

Funding Acknowledgements

Type of funding sources: None.

Introduction and purpose

The optimal timing for pulmonary valve replacement (PVR) in asymptomatic patients with repaired tetralogy of Fallot (TOF) and pulmonary regurgitation (PR) remains uncertain but is often guided by imaging characterization of the right ventricle. As cardiopulmonary exercise testing (CPET) performance is an accessible prognostic indicator, we assessed which CPET parameters best correlate with pulmonary regurgitation severity to potentially improve identification of high-risk patients.

Methods

A retrospective chart review was done from 2009 to 2018 on adult patients with repaired TOF who underwent maximal effort cardiopulmonary exercise testing with cycle ergometry and with concurrent pulmonary function testing. Demographics, standard measures of CPET interpretation, and major cardiovascular outcomes were collected.

Results

Cardiopulmonary exercise testing was performed in 54 adult repaired TOF patients (59% male), with a mean follow-up of 60 ± 33 months. The mean age was 34 ± 9 years. 30 patients (56%) had severe pulmonary regurgitation and 26 patients (48%) were submitted to PVR, with a 0% mortality rate. PVR was performed a mean 28 ± 7 years after TOF repair surgery. There was moderate to severe right ventricular dysfunction in 11 patients (20%). 12 patients (22%) had a hospitalization for heart failure. Arrhythmic events occurred in 9 patients (17%), mainly atrial fibrillation or atrial flutter (67%). 2 patients (4%) received an implantable cardioverter-defibrillator for secondary prevention of sudden cardiac death.

Peak VO2 consumption (pVO2) showed no statistically significant correlation with severity of pulmonary regurgitation (HR 0.26, 95% CI 0.879-1.036, p= 0.262) or PVR (HR 0.92, 95% CI 0.829-1.028, p = 0.914), while percent of predicted pVO2 significantly correlated with severity of pulmonary regurgitation (HR 0.95, 95% CI 0.918-0.993, p = 0.020) and PVR (HR 0.94, 95% CI 0.886-0.992, p = 0.025).

VE/VCO2 slope was not a significant predictor of severity of pulmonary regurgitation (HR 1.03, 95% CI 0.929-1.130, p = 0.622) or PVR (HR 1.04, 95% CI 0.952-1.128, p = 0.414) or) and neither cardiorespiratory optimal point (HR 0.94, 95% CI 0.786-1.120, p = 0.480) nor maximum end-tidal carbon dioxide pressure (PETCO2) (HR 0.93, 95% CI 0.846-1.037, p = 0.213) correlated with severity of pulmonary regurgitation or PVR.

Conclusion

Percent of predicted peak VO2 had the highest predictive power of all CPET parameters analysed in adult repaired TOF patients. Preoperative CPET could be an accessible way to identify high-risk patients earlier for PVR and should therefore be included in the routine assessment of these patients.

Effect of exercise training on amyloid-like protein aggregates among patients with heart failure

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): MG and CS were supported by a PhD FCT grant (SFRH/BD/128893/2017) and by an individual grant from CAPES [BEX 0554/14-6], respectively. This work was financially supported by the project POCI-01-0145-FEDER-030011, funded by FEDER, through COMPETE2020-POCI, and by national funds, through FCT/MCTES (PTDC/MEC-CAR/30011/2017). iBiMED is a research unit supported by the Portuguese Foundation for Science and Technology (REF: UID/BIM/04501/2020) and FEDER/Compete2020 funds).

Introduction

Amyloid-like protein aggregates play a decisive role in the pathology of heart failure. Alterations in protein homeostasis, in particular, the clearance of toxic amyloid-like aggregates are emerging therapeutic targets in cardiovascular medicine. The clinical benefits of cardiac rehabilitation and exercise training are widely accepted in heart failure; however, little is known about the potential benefit of exercise training in amyloid-like protein aggregates.

Purpose

To assess the effects of a moderate-intensity exercise training program on amyloid-like protein aggregates levels among patients with heart failure with reduced ejection fraction.

Methods

Eighteen subjects participated in the study; eight patients (age: 66.6 ± 5.9 years; FEVE: 38.4 ± 8.9%) with heart failure with reduced ejection fraction participated in a 3-month exercise training program (2 x 60 min sessions per week of moderate-intensity aerobic and resistance exercise). Ten healthy subjects (age: 68. 4 ± 3.1 years) were recruited to an age-matched reference group.  Amyloid-like protein aggregates were assessed before and after 3 months of exercise training. Clinical data, medication, anthropometrics, and cardiorespiratory fitness were also assessed. Thioflavin T (ThT) dye fluorescence was used to quantify the plasma levels of amyloid-like aggregates and the Fourier transform infrared spectroscopy (FTIR) was applied to evaluate the conformation of cross-β-sheet structures characteristic of amyloid protein aggregates.

Results

Exercise program improved cardiorespiratory fitness by 14.0 ± 17.1% (17.4 ± 3.2 to 19.7 ± 2.9 ml/kg/min) and reduced NT-proBNP levels by 16.5% (34.2) (median concentration of 632 pg/mL (720.8) to 517.5 pg/mL (707.0)) in the heart failure patients. A slight decrease of amyloid-like aggregates levels was observed in post-exercise training samples (a reduction of 3.1%); interestingly, after the exercise training program, the heart failure patients showed levels of amyloid-like aggregates similar to the reference group (1132.0 ± 114.2 vs. 1094.8 ± 132.9 a.u.). Additionally, the PLS-R multivariate analysis of the amide I region of the FTIR spectra revealed enrichment of antiparallel β-sheets (1693 cm-1) assigned to amyloid-like oligomers in the samples of heart failure patients before, but not after, the exercise program. Of note, oligomeric species, as intermediates of amyloid assembly, can contribute to the increase of amyloid burden, but also, some have been reported to be highly reactive and toxic to cells, being key elements of amyloid pathogenesis.

Conclusions

 Our preliminary results indicate that 3 months of exercise training may have significant effects on amyloid-like oligomers, and start hindering the formation of the larger ThT-positive aggregates among patients with heart failure.

Abstract Figure.

The influence of Castanea sativa Mill. flower extract on hormonally and chemically induced prostate cancer in a rat model

Prostate cancer (PCa) is one of the most common cancers in men, with a huge impact on their health. The use of Castanea sativa Mill. flowers (CFs) in beverages has been reported, through ancestral claims, as having health benefits. In vitro research has evidenced the properties of CFs, such as antitumor and antioxidant activities. This study aimed to evaluate the effects of CF extract in an animal model of PCa. Forty male Wistar Unilever rats were randomly assigned to four groups: control, induced, control + CF, and induced + CF groups. Animals from the induced groups were exposed to a multistep protocol for PCa induction. The CF extract, rich in trigalloyl-HHDP-glucoside and obtained via decoction, was administered to the CF groups in drinking water (3 mg per animal per day) for 49 weeks. Animals were sacrificed at 61 weeks of age. Regarding the effects of CFs on dorsolateral prostate tumorigenesis, no significant differences were observed between the induced and induced + CF groups. However, animals exposed to the CF extract showed fewer inflammation areas on the dorsolateral prostate lobe than those not exposed to CF. Moreover, the CF extract alleviated the hepatic oxidative stress associated with the multistep protocol, resulting in lower levels of lipid peroxidation. These results suggest that CF extract has antioxidant and anti-inflammatory properties.

Right atrial strain by speckle-tracking echocardiography as a prognostic predictor in a pulmonary hypertension cohort

Funding Acknowledgements

Type of funding sources: None.

Background

Right atrial (RA) strain is as a promising technique for assessment of RA function and several studies have suggested it is a powerful prognostic marker in pulmonary hypertension (PH) patients (pts). Our aim was to assess the prognostic power of RA strain in Pulmonary Arterial Hypertension (PAH) and Chronic Thromboembolic Pulmonary Hypertension (CTEPH) pts.

Methods

Pts with PH were prospectively studied and several clinical/demographic/echocardiographic were retrieved as well as data from six-minute walk test (6MWT) and brain natriuretic peptide (BNP). Correlation between RA strain and other variables was tested with Pearson"s correlation analysis. Regression and survival analysis were performed to assess the combined endpoint of all-cause mortality or hospitalization in the first follow-up year (MH1).

Results

A total of 51 PH pts (mean age 54 ± 46 years, 33.3% male, baseline BNP of 342.4 ± 439.9pg/mL and baseline pulmonary artery systolic pressure – PASP - of 78 ± 26mmHg), of which 64.7% had PAH and 35.3% presented CTEPH. 19 ots (37.3%) met the primary endpoint. The mean RA strain was -21.9 ± -4.9%, with no significant difference between groups (-23.4% vs -17.8%, p = 0.150), however male pts had a significantly lower RA strain (-15.9% vs -25.1%, p = 0.014). There was a statistically significant (p &lt; 0.05) correlation between RA strain and age (r = -0.287), indexed RA area (r = -0.539), index RA volume (r = -0.522) and right ventricular strain (r = -0.453). There was no correlation between RA strain and BNP value (p = 0.150), 6MWT distance (p = 0.145) or PASP (p = 0.072). RA strain was a predictor of MH1 (OR = 0.94, 95% CI: 0.894-0.998, p = 0.048). Pts who met the primary endpoint had a significantly worse RA strain (-17.0 vs -24.6%, p = 0.032). Those with a RA strain worse than -19% presented a significantly lower survival free of events during the first follow-up year (log rank p = 0.022).

Conclusion

RA strain is a powerful predictor of adverse events in a PH population and should be systematically assessed in order to improve risk stratification.

Abstract Figure.

Anti-inflammatory potential of Portuguese thermal waters

In light of Medical Hydrology, thermal waters (TW) are all-natural mineral waters that emerge inside a thermal resort and have therapeutic applications. Their beneficial effect has been empirically recognized for centuries, being indicated for symptom alleviation and/or treatment of several diseases, almost all associated with inflammation. Indeed, an anti-inflammatory effect has been attributed to many different Portuguese TW but there is no scientific validation supporting this empiric knowledge. In the present study, we aimed to investigate the anti-inflammatory properties of 14 TW pertaining to thermal centers located in the Central Region of Portugal, and grouped according to their ionic profile. Mouse macrophage cells stimulated with lipopolysaccharide (LPS), a Toll-like receptor 4 agonist, were exposed to culture medium prepared in TW. Metabolism, nitric oxide (NO) production, inducible nitric oxide synthase (iNOS) expression levels and the scavenging capacity of TW, were investigated in vitro. 11 out of 14 TW reduced NO production and/or iNOS expression, and/or scavenging activity, in macrophages exposed to LPS. The sulphated/calcic TW did not show any effect on at least one of the inflammatory parameters evaluated. Two sulphurous/bicarbonate/sodic TW and the sulphurous/chlorinated/sodic TW promoted an increase in NO production and/or iNOS expression. Our results validate, for the first time, the anti-inflammatory properties of Portuguese TW, supporting their therapeutic use in the treatment of inflammation-related diseases and promoting their putative application in cosmetic products and medical devices.

Predictors of atrial fibrillation occurrence in patients with hypertrophic cardiomyopathy

Introduction

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of dysrhythmias, especially atrial fibrillation (AF).

Purpose

The aim of this study was to evaluate the incidence of AF in HCM patients (P) and to determine predictors of AF.

Methods

Retrospective analysis of HCM P at a single tertiary center. Baseline clinical, echocardiographic and cardiovascular magnetic resonance (CMR) characteristics were collected. On follow up AF was identified by electrocardiogram and/or 24 hours Holter monitoring.

Results

61P (59% male) were included, with a mean age of 58±2 years. 27.9% had angina (all of them CCS 2), 34.4% were in NYHA II and 14.8% in NYHA III, 8.2% had syncope and 39.3% had palpitations. A family history of sudden cardiac death (SCD) or cardiomyopathy was present in 40.4% of the cases. The mean HCM risk SCD score was 3.35±0.28%. On echocardiography left atrium (LA) diameter was 44.86±0.87mm, LA volume (LAvol) was 89.97±5.39mL (indexed LAvol 46.05±2.55mL/m2), interventricular septum (IVS) was 16.83±0.663mm, left ventricle (LV) mass was 290.94±13.897g and maximum wall thickness (MWT) was 20.59±0.596mm. 77% P had LA enlargement. 88.5%P had late gadolinium enhancement (LGE) in CMR with a median number of 5±7 segments involved. AF developed in 23P (37.7%), with a mean age of 58±3 years. Predictors of AF development were NYHA III (p=0.007), risk score (p=0.007), LA diameter (p=0.007), LAvol (p=0.005) and indexed LAvol (p=0.002), MWT (p=0.0015), LGE in more than 5 segments (p=0.029) and LGE in the inferior basal and inferior median IVS (p=0.033 and p=0.042). The only independent predictor was LAvol (p=0.0012), with an area under the curve of 0.755 and a cut off of 85.9mL being the best predictor (p=0.004). Combining LAvol &gt;85.9mL with LGE involving &gt;5 segments and LAvol &gt;85.9mL with LGE in inferior basal IVS (IBIVS) a statistically significant difference between groups was achieved (p=0.009 in the combined predictor LAvol + LGE &gt;5 segments and p=0.002 in the combined predictor LAvol + LGE in IBIVS) (figure 1 and figure 2). In a multivariable analysis including these 2 combined predictors and LAvol alone the only independent predictor was the combination of LAvol + IBIVS involvement.

Conclusion

AF is frequent in patients with HCM and develops in younger ages than in general population. NYHA III, risk score, LA diameter, LAvol, MWT, LGE &gt;5 segments and LGE in IBIVS and in IMIVS were predictors of AF, with LAvol being the independent predictor. The combination of LAvol with LGE &gt;5 segments and LAvol with LGE in IBIVS presented stronger predictor value comparing with these characteristics alone.

Funding Acknowledgement

Type of funding source: None

Role of tilt-table testing in syncope diagnosis and management: analysis of patients referred to a syncope unit

Introduction

Head-up tilt-testing (HUT) enables the reproduction of reflex syncope in a laboratory setting. Despite being used to confirm the diagnosis of this syncope, there is some concerns regarding the best protocol to use and recent studies with implantable loop recorders have called the value of HUT into question.

Aim

To characterize the population undergoing HUT according to the modified Italian protocol, type of response to HUT and subsequent management at our center in the last 4 years.

Methods

Retrospective analysis of consecutive P who underwent HUT between 2015 and 2018. Descriptive analysis of patients (P) demographics and medical history, indication for HUT, type of response to HUT and management.

Results

A total of 419P (55.1% female) were included with a mean age of 62 years. The majority (n=302, 72.1%) had comorbidities (structural heart disease – 55%, cardiac dysrhythmias – 57.6%, hypertension – 48.3%, diabetes – 15.6%, depression – 15.9%, cerebrovascular disease –10.6%) or was under medication (n=220, 52.5%) with a potential hypotensive or bradycardic effect (44.1% ACEI/ARA, 29.1% beta-blocker, 27.7% diuretic, 23.6% antidepressant, 22.7% calcium channel blocker, 19.1% benzodiazepines). Syncope/presyncope episodes accounted for 56.1% of the HUT, with falls and disequilibrium accounting for 52%. In 21 cases (5%) suspected dysautonomia or other non-specified reasons were the indication for HUT. HUT were ordered according to the guidelines in 136P (84.6% – indication level I, 3.6% – level IIa, 11.8% – level IIb). HUT was positive in 292P (69.7%) – 77.1% after nitroglycerin administration (vasodepressor – 170P, cardioinhibitory – 53P, mixed – 62P and dysautonomic – 7P). Cardioinhibitory (CI) response predominated in the younger, and vasodepressor in the older P. Of the P with CI response, 41.5% had asystole (median of 41.4s, minimum 7.5s, maximum 115s). All P were instructed in the need to avoid triggering factors and perform counterpressure maneuvers. A pacemaker was implanted in 24P (5.7% of all population, due to long sinus pauses and asystole). Twenty-four P (5.7%) completed a tilt training program.

Conclusion

Most of the HUT were requested for syncope/presyncope, frequently according to the guidelines. There was a high rate of positive tests, with a predominance of vasodepressive response, particularly in the elderly.

Funding Acknowledgement

Type of funding source: None