Emission of coherent THz magnons in an antiferromagnetic insulator triggered by ultrafast spin-phonon interactions

Antiferromagnetic materials have been proposed as new types of narrowband THz spintronic devices owing to their ultrafast spin dynamics. Manipulating coherently their spin dynamics, however, remains a key challenge that is envisioned to be accomplished by spin-orbit torques or direct optical excitations. Here, we demonstrate the combined generation of broadband THz (incoherent) magnons and narrowband (coherent) magnons at 1 THz in low damping thin films of NiO/Pt. We evidence, experimentally and through modeling, two excitation processes of spin dynamics in NiO: an off-resonant instantaneous optical spin torque in (111) oriented films and a strain-wave-induced THz torque induced by ultrafast Pt excitation in (001) oriented films. Both phenomena lead to the emission of a THz signal through the inverse spin Hall effect in the adjacent heavy metal layer. We unravel the characteristic timescales of the two excitation processes found to be < 50 fs and > 300 fs, respectively, and thus open new routes towards the development of fast opto-spintronic devices based on antiferromagnetic materials.

Infection-specific PET imaging with 18F-fluorodeoxysorbitol and 2-[18F]F-ρ-aminobenzoic acid: An extended diagnostic tool for bacterial and fungal diseases

Introduction

Suspected infectious diseases located in difficult-to-access sites can be challenging due to the need for invasive procedures to isolate the etiological agent. Positron emission tomography (PET) is a non-invasive imaging technology that can help locate the infection site. The most widely used radiotracer for PET imaging (2-deoxy-2[¹⁸F] fluoro-D-glucose: [¹⁸F]FDG) shows uptake in both infected and sterile inflammation. Therefore, there is a need to develop new radiotracers able to specifically detect microorganisms.

Methods

We tested two specific radiotracers: 2-deoxy-2-[¹⁸F]-fluoro-D-sorbitol ([¹⁸F]FDS) and 2-[¹⁸F]F-ρ-aminobenzoic acid ([¹⁸F]FPABA), and also developed a simplified alternative of the latter for automated synthesis. Clinical and reference isolates of bacterial and yeast species (19 different strains in all) were tested in vitro and in an experimental mouse model of myositis infection.

Results and discussion

Non-lactose fermenters (Pseudomonas aeruginosa and Stenotrophomonas maltophilia) were unable to take up [¹⁸F]FDG in vitro. [¹⁸F]FDS PET was able to visualize Enterobacterales myositis infection (i.e., Escherichia coli) and to differentiate between yeasts with differential assimilation of sorbitol (i.e., Candida albicans vs. Candida glabrata). All bacteria and yeasts tested were detected in vitro by [¹⁸F]FPABA. Furthermore, [¹⁸F]FPABA was able to distinguish between inflammation and infection in the myositis mouse model (E. coli and Staphylococcus aureus) and could be used as a probe for a wide variety of bacterial and fungal species.

A phenomenological study on the migration trends of Filipino pharmacists who graduated from a university in Manila

Introduction

Migration trends and patterns differ in every country, and the current phenomena are happening at a particular time, whether in retrospect or prospect. In the Philippines, an influx of migration, especially among pharmaceutical healthcare providers, is seen due to the demands in the medical field even before the global COVID-19 pandemic.

Aim

This study determined the factors that influenced Filipino pharmacists' who graduated from a University in Manila; their motivation to work and migrate to other countries, as well as the responsibilities, competencies, and working conditions of pharmacists waiting for them abroad.

Methods

Following institutional ethical approval, snowball sampling was employed as the sampling method wherein the research participants were asked to help determine and recruit potential respondents. The sample size used to collate information for this study was 15 respondents from 3 different countries of origin, specifically Canada, Singapore, and the United States of America. Through a semi-structured interview, the participants elicited different responses with common themes analysed through thematic analysis. The respondents were not required to disclose any information they were not allowed to reveal. Hence, the researchers fully understood and did not force the respondents to get the information without the participant’s permission. In cases where participants shared information with another participant, this was their own doing, and researchers could not be responsible for this. The researchers safeguarded the information and identities of each participant as far as reasonably possible. Furthermore, each piece of data given is protected through the Philippine Data Privacy Act of 2012, and researchers are ensured to comply fully with what was written in the Informed Consent Form.

Results

All fifteen participants took their pharmacy undergraduate degree at a university in Manila before migrating or working abroad. Participants have at least a year of experience working abroad, covering the years 2010-2020, ranging from the completion of four-year pharmacy degrees to participants who graduated with five-year pharmacology degrees. Key themes which influenced the Filipino pharmacists included their chosen pharmacy degrees, including the University's curriculum reliability and relevance, turning point of migration decision, factors of their migration, ways migration was obtained, pharmacy work opportunities abroad, prior pharmacy working experience in the Philippines, work dynamics abroad, and their annual salary with benefits.

Discussion/Conclusion

There are numerous and limitless opportunities abroad, but most of them differ in the work setting in the Philippines, wherein they are more aligned with the clinical side of being a pharmacist. Moreover, the research field of the profession is still an emerging field with a wide array of opportunities. Overall, the study has collected varying and new insights into Filipino Pharmacists' migration, specifically their migration trends, competencies, responsibilities, and working conditions that may contribute to the betterment of the institution's curriculum and pharmacy practice in the Philippines. With the growing demand for pharmacists in the Philippines, the knowledge gained from a similar study would help improve conditions for healthcare workers to avert their desire or need to migrate.

References

1. Loquias, M. and Robles, Y. Issues and Concerns on Utilization of the Pharmacy Workforce in the Philippines. [Internet]. 2012 [cited 2021 Sept 10]; JAASP 2012;1(2):86-96. Available from https://www.aaspjournal.org/uploads/155/5955_pdf.pdf

2. Lorenzo, F., et. al. Migration of Health Workers: Country case study Philippines. ILO. [Internet] 2006. [cited 2021 Oct 15] Available from: https://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/publication/wcms_161163.pdf

3. Morii, Y., Furuta, S., Ishikawa, T., Fujiwara, K., Yamashina, H., & Ogasawara, K. Projecting supply and demand for pharmacists in pharmacies based on the number of prescriptions and system dynamics modeling. Human Resources for Health, 18(1). [Internet]. 2020 [cited 2021 Sept 27]; Available from: https://doi.org/10.1186/s12960-020-00524-5

Usefulness of telemedicine-based heart failure monitoring according to “eHealth literacy” domains: insights from the iCOR randomised controlled trial

Background/Introduction

The potential positive effect of electronic health (eHealth)-based heart failure (HF) monitoring remains uncertain, largely due to the heterogeneity of the studies published to date. A subgroup of patients in which its key role is particularly uncertain is in the “low literacy” or “computer or digital illiterate” patients mainly due to telemedicine (TM)-based strategies have been often discouraged on the basis of a foreseeable limited benefit in them.

Purpose

The aim of this study was to determine the effectiveness of a TM-based managed care solution across literacy levels and information and communications technology (ICT) skills.

Methods

We performed a sub-analysis on the basis of two literacy domains (traditional and computer literacy) encompassed in the definition of “eHealth literacy” to the HF-patients included in the “insuficiència Cardíaca Optimitzaciό Remota” (iCOR) randomised study comparing TM vs. usual care (UC) in HF-patients. The primary study endpoint was the incidence of a non-fatal HF event after 6 months of inclusion. The event rates of primary (the occurrence of non-fatal HF event) and secondary (all-cause hospitalization, all cause death and the composite endpoint combining of allcause death or non-fatal HF events) study endpoints were calculated for each literacy domains and its combination. Cox proportional-hazards regression models were used to evaluate the effect of “eHealth literacy” dimensions, treatment group and the interaction term “eHealth literacy” domains by treatment group on study endpoints, and p-value was used to compare the different curves.

Results

178 patients were analysed (81 TM vs 90 UC). As far as the “traditional literacy” analyses, 65% of patients had only elementary education and the 6% had no literacy qualifications, defining the low-educated subgroup as “lower literacy” (126 patients, 71%). All the other patients were classified in the “middle or higher literacy” (52 patients, 29%) subgroup. Moreover, concerning new technological management, 128 patients (72%) referred presenting moderate to high difficulties in its handling, constituting the “lower ICT skills” subgroup. The remaining 28% (50 patients) were allocated into the “middle or higher ICT skills” subgroup due to their minor handicap in their ICT use.

The beneficial effect of TM compared to UC strategy was consistent across all literacy domains (pvalue for interaction 0.207 and 0.117 respectively). The risk of experiencing a primary event was significantly lower in patients that underwent allocation to the TM arm compared to UC in both clustered in the “lower literacy” (p-value=0.001) (Picture 1) and those allocated to the “lower ICT skills” (p-value=0.001) (Picture 2) subgroup.

Conclusions

Non-invasive eHealth-based HF monitoring tools are effective compared to UC in preventing HF events in the early post-discharge period, regardless of two “eHealth literacy” domains (“traditional and computer literacy”).

Funding Acknowledgement

Type of funding sources: None.

Classic and genetic cardiovascular risk burden and case-fatality from SARS-CoV-2 virus infection. The CARGENCORS study

Background

The disease presentation of the severe acute respiratory syndrome coronavirus 2 infection (COVID-19) ranges from asymptomatic to fatal. COVID-19 patients with pre-existing coronary artery disease (CAD) risk factors or overt cardiovascular disease more often develop severe COVID-19, which are also related to thrombotic, inflammatory, and to viral infectivity response. We hypothesised that despite some genetic predisposition, especially in COVID-19 severity, the main determinants of fatal complications in COVID-19 patients are related to comorbidity.

Purpose

To determine the role of genetics and cardiovascular comorbidity in mortality from COVID-19.

Methods

We conducted a retrospective cohort study including 3,120 patients with positive COVID-19 test from several hospitals and primary care between February 2020 and June 2021. Among them 1,096 required hospitalization, and 121 died within 3 months after symptom onset. Standard parametric and non-parametric methods, as required, were used to compare patient characteristics by vital status. Individual genotypes for 32 CAD, 14 thrombosis, 19 inflammation, and 11 viral infectivity single nucleotide variants (SNV), as well as, 2 COVID-19 SNVs already published were tested for association with mortality with Cochran-Armitage statistics and p-values corrected for multiple comparisons. The mutually-adjusted odds ratio (OR) and 95% confidence interval (95% CI) of fatal COVID-19 was analysed for SNVs significantly associated to case-fatality, with their adverse alleles count (0, 1 or 2), and for comorbidity factors with logistic regression adjusted for age and sex. The discrimination of the models was also estimated by the area under the curve (AUC).

Results

Fatal and non-fatal cases' characteristics are compared in Table 1. Fatal cases had a more adverse cardiovascular and anthropometric risk profile. After correcting for multiple testing by Benjamini-Hochberg method, we observed the inflammation-related rs6993770 SNV to be significantly associated with COVID-19 fatality (p-value = 0.04). The CAD-related rs9982601 and rs2505083 SNVs, and the thrombosis-related rs7853989 SNV were moderately associated with COVID-19 fatality (p-value ≤0.1). On Figure 1 we show the adjusted OR for rs6993770 (OR: 1.02; 95% CI 1.01–1.03 per risk allele) and that for clinical factors related to COVID-19 case-fatality. The AUC of the model was 0.85 (95% CI 0.81–0.88), which not improved that of a model with clinical risk factors alone (AUC: 0.84; 95% CI 0.81–0.87).

Conclusion

The rs6993770 inflammation (interleukin measurement trait)-related SNV was independently associated to case fatality; however the outcome was mainly driven by age, male sex, diabetes, and glomerular filtration rate.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Carlos III Health Institute and the European Regional Development FundAgency for Management of University and Research GrantsCrue-CSIC-Santander FONDO SUPERA COVID-19

Significance and distribution of aortic valve calcium score before TAVI

Introduction

Aortic valve calcium scoring by multislice computed tomography (MSCT) is an alternative load independent assessment of aortic stenosis severity. Recent studies have further demonstrated that aortic valve calcification load is related to adverse outcomes during and after transcatheter aortic valve implantation (TAVI), however reference values in this population are uncertain. This study aimed to assess aortic valve calcium in P referred for TAVI.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2014 and 2020 in a tertiary care centre. Clinical and echocardiographic characteristics, along with MSCT-derived aortic valve calcium score were collected.

Results

A total of 467 P were included, 57% female, median age 83 (9) years (minimum 45 and maximum 95 years-old). The prevalence of hypertension, dyslipidemia and diabetes was 83%, 69% and 36%, respectively. Chronic renal failure was present in 51%, atrial fibrillation in 34% and peripheral artery disease in 14%.

Considering the 346 P with aortic valve calcification quantified by MSCT, median calcium score was 2161 (1761) AU. Age did not correlate with valvular calcification (r=0.043, p=0.422). Male gender showed significantly higher calcium score (2800 (2093) vs 1850 (1584), p&lt;0.001) (Figs. 1 and 2).

11P had bicuspid aortic valve disease, with this population being younger (75 (16) vs 83 (8) years, p=0.001), nonetheless displaying higher aortic valve calcium load (2800 (2599) vs 2112 (1788), p=0.025). A weak but statistically significant correlation between calcium score and maximum (r=0.366, p&lt;0.001) and mean gradients (r=0.387, p&lt;0.001) and aortic valve area (r=−0.120, p=0.047) was demonstrated. Valvular calcification was not significantly different in P with reduced ejection fraction (&lt;50%) (p=0.388).

Conclusion

There are significant differences in aortic valve calcium score between men and women referred for TAVI. Higher maximum and mean gradients were associated with increasing valvular calcification. Age and left ventricle ejection fraction were not related. P with bicuspid aortic valve have distinct calcification characteristics. As calcification burden may influence preprocedural planning, this parameter should be incorporated in the general work-up and reference values in this population should be known.

Funding Acknowledgement

Type of funding sources: None.

Artificial intelligence-enabled comprehensive coronary phenotyping in patients with suspected CAD

Introduction

The capabilities of artificial intelligence (AI) are rapidly progressing and the research community is getting increasingly interested in its possibilities. AI algorithms are able to work continuously and at high speed, reducing human workload and saving time that physicians can spend on more complex data or rarer cases. However, many clinical AI applications are currently only used in a research setting and lack proper testing and validation.

Objectives

This study aimed to determine the accuracy and performance of a novel AI-based software tool for CCTA analysis compared to conventional expert evaluation.

Methods

We evaluated 100 CCTA exams from a cohort of symptomatic patients with mild-to-moderately abnormal non-invasive ischemia test. Stenosis severity assessed by AI-based analysis (automatic evaluation, AEv) was compared with a level III expert CCTA interpretation (manual evaluation, MEv). AI-based analysis reported exact % stenosis and obstructive CAD was considered if maximal stenosis was ≥50%. Plaque phenotype was also estimated using AI algorithms.

Results

The study cohort was as follows: 52% male, mean age 68±10 years. The prevalence of hypertension, dyslipidemia and diabetes was 77%, 81% and 23%, respectively, and 10-year cardiovascular risk was 19±10% as predicted by Framingham risk score. Typical angina was present in 33%, of which 67% had a Canadian Cardiovascular Society angina grade ≥2.

Overall prevalence of obstructive CAD determined by MEv and AEv was 25% and 21%, respectively, with a significant association between both assessments (p&lt;0.001). When compared to MEv as reference, AEv method performed with a sensitivity, specificity, positive and negative predictive values of 0.56, 0.91, 0.58 and 0.86, respectively. Area under the curve was 0.871 (p&lt;0.001) demonstrating high accuracy.

AEv atherosclerosis quantification revealed significant differences between patients with and without obstructive CAD according to MEv: median total plaque volume (569 vs 115 mm3, p&lt;0.001), calcified plaque volume (297 vs 19 mm3, p&lt;0.001), non-calcified plaque volume (235 vs 71 mm, p&lt;0.001), low-density non-calcified plaque volume (2.8 vs 1.0 mm3, p=0.023) and percent atheroma volume (16.1 vs 3.8 mm3, p&lt;0.001).

Conclusion

In patients with suspected CAD and mild-to-moderately abnormal ischemia tests, a diagnostic strategy using AEv as a gatekeeper is effective, providing a quantitative stenosis evaluation with similar diagnostic performance for obstructive CAD when compared to MEv. AI-enabled approach additionally allows a fully automated quantification of coronary plaque volumes and composition, which would further enhance risk stratification.

Funding Acknowledgement

Type of funding sources: None.

Factors associated to renin-angiotensin-aldosterone system inhibitors discontinuation or down-titration due to hyperkalaemia in patients with chronic cardiovascular conditions

Background/Introduction

The renin-angiotensin-aldosterone system inhibitors (RAASI) are one of the keystones of the medical treatment in chronic cardiovascular disorders and have shown improvements in clinical outcomes in many clinical trials. Hyperkalaemia is a well-defined non-desirable effect of RAASI that occasionally forces to interrupt these medications. That enforced RAASI discontinuation or down-titration due to hyperkalaemia may have adverse prognostic consequences.

Purpose

Describe the demographical, clinical and pharmacological variables associated to a higher risk of RAASI discontinuation or down-titration due to hyperkalaemia among individuals with chronic cardiovascular conditions.

Methods

We used data from more than 375,000 individuals 55 years of age or older, included in the population-based healthcare database of a public Institute of Health between 2015 and 2017. We included participants with at least one relevant condition: chronic heart failure, chronic kidney disease, diabetes mellitus, ischemic heart disease or hypertension. They had to be under RAASI treatment as of January 1st, 2016, and with evidence of at least one episode of hyperkalaemia (serum potassium &gt;5.0 mmol/L) during 2016. Then, were classified in one of the two following profiles: RAASI treatment discontinuation or down-titration versus RAASI treatment unchanged or up-titrated. For the statistical analysis, we used logistic regression to calculate the multivariable-adjusted odds ratios of each study variable, comparing RAASI discontinuation or down-titration group to RAASI treatment unchanged or up-titrated controls (reference group).

Results

In the multivariable-adjusted model, the risk of RAASI treatment discontinuation or down-titration due to hyperkalaemia was significantly associated with the use of RAASI, very high comorbidity index, potassium derangements (both hypokalaemia and hyperkalaemia), prior hospitalizations and prior emergency visits. Among RAASI treatments, the use of Angiotensin receptor blockers (OR 2.518, 95% CI 2.317–2.735) and Angiotensin-converting enzyme inhibitors (OR 2.341, 95% CI 2.149–2.549) were associated with a higher risk of RAASI discontinuation or down-titration due to hyperkalaemia than Aldosterone inhibitors (1.428, 95% CI 1.285–1.584).

Conclusion

These results suggest that vulnerable populations such as those with very high comorbidity index, potassium derangements or prior emergency visits or hospitalizations have a higher risk of RAASI treatment discontinuation or down-titration due to hyperkalaemia.

A more careful and exhaustive management of RAASI should be advised in those patients.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Josep Comin-Colet has received speaker fees from Vifor Pharma.

Management of renin-angiotensin-aldosterone system inhibitors in patients with chronic cardiovascular conditions and its association with clinical outcomes

Background

In chronic cardiovascular diseases, the renin-angiotensin-aldosterone system inhibitors (RAASI) are one of the keystones of the medical treatment and have revealed improvements in clinical outcomes in many clinical trials. In contrast, is well defined as non-desirable effect of RAASI the development of hyperkalemia, which could force to interrupt these treatments. Hyperkalemia has been associated with worse outcomes in observational studies. Though, it is controversial if those negative outcomes in hyperkalemic patients could be because the potassium derangement itself or the circumstance that in these individuals could be enforced to discontinue RAASI medications with prognostic consequences at mid- to long-term.

Purpose

Assess associations between management of RAASI and clinical outcomes among individuals with chronic cardiovascular conditions and hyperkalemia.

Methods

Data from more than 375,000 individuals 55 years of age or older were analyzed, in a population-based healthcare database of a public Institute of Health between 2015 and 2017. We conducted a longitudinal analysis, in which participants with at least one relevant condition were included: chronic heart failure, chronic kidney disease, diabetes mellitus, ischemic heart disease or hypertension. They had to be under RAASI treatment as of January 1st, 2016, and with evidence of at least one episode of hyperkalemia (serum potassium &gt;5.0 mmol/L) during 2016. Then, were classified in one of the two following profiles: RAASI treatment discontinuation or down-titration versus RAASI treatment unchanged or up-titrated. Subsequently, all-cause death and hospitalization has been assessed in the follow-up period as clinical outcomes. For the statistical analysis, we calculated unadjusted incidence rate ratios and Cox Proportional Hazards Regression models to calculate the multivariable-adjusted risk ratios for the clinical endpoints comparing both groups.

Results

There was found an association with mortality and hospitalization for the RAASI treatment interruption/down-titration group when compared unadjusted incidence rate ratios of each clinical endpoints to RAASI treatment unchanged patients (reference group). We presented these results in a Kaplan-Meier survivor curves for endpoint mortality (Figure 1). In the multivariable-adjusted model, the risk of mortality and hospitalization was associated mainly with older age, hypokalemia and down-titration of RAASI treatments, achieving statistical significance (Table 1). The risk ratio for mortality associated with down-titration and with hyperkalemia compared with the reference group was 1.676 (95% CI 1.54–1.82) and 1.161 (95% CI 1.07–1.26) respectively.

Conclusion

These results suggest that the worse outcomes in hyperkalemia individuals could be influenced more for the discontinuation of RAASI prognostic drugs then for the hyperkalemia itself. It is necessary clinical randomized trials to confirm this observational hypothesis.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Josep Comin-Colet has received speaker fees from Vifor Pharma

3 year outcomes of permanent pacemaker implantation after alcoholic septal ablation

Introduction

Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete hear block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear.

Objectives

This study aims to evaluate the long-term clinical outcomes in patients who implant PPM after ASA.

Methods

In a tertiary center, patients who underwent ASA were consecutively enrolled prospectively. Patients with previous PPM or implantable cardio-defibrillator were from this analysis. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and 3-year primary and secondary endpoints.

Results

Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). At 3 years after ASA procedure, the primary endpoint (composite of all-cause mortality and all-cause re-hospitalization) showed a statistical tendency to a lower event rate in the group who implanted PPM (p-value 0.097, Graphic 1). The secondary endpoint (composite of all-cause mortality and cardiac cause re-hospitalization) did not show any significant statistical difference between the two groups (p-value 0.216, Graphic 2).

Conclusions

The long-term endpoint analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to a lower rate of the endpoint composite of all-cause mortality and all cause re-hospitalizations.

Funding Acknowledgement

Type of funding sources: None.

Coronary sinus reducer device for the treatment of refractory angina therapy. A multicentric initial experience

Introduction

The coronary sinus Reducer device (CSRD) emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSRD in a real-world setting.

Methods

Twenty-six patients with refractory angina (RA), evidence of myocardial ischemia attributable to the left coronary artery unsuitable for revascularization were treated with the CSRD at two centres between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at 6-month follow-up, were a reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7) and reduction in anti-anginal therapy.

Results

Twenty-three patients had end-stage CAD without revascularization targets and 3 patients had microvascular disease without epicardial stenosis. Procedural success was achieved 23 patients, with 2 device/procedural-related complications and one anatomically-related failure to deliver the device. Ultimately 25 patients implanted the device and entered the efficacy analysis. Eighteen patients (75.0%) had at least 1 reduction in CCS class, 41.7% had at least 2 class reductions, and 16.7% became asymptomatic, with a mean reduction of CCS class of 1.3±0.2 (p=0.001) at 6-month follow-up. All SAQ-7 domains improved, namely physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction of anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010).

Conclusion

In this real-world, multicentric experience, implantation of the CSRD was associated with improvement of angina and QoL in patients with RA.

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.

AB1393 RHEUMABUDDY4.0 LEADING THE PATH TO A PATIENT-DRIVEN ELECTRONIC SUPPORT AND MONITORING TOOL

Background

The use of health apps has become more popular in recent years, but it is still a small and rather unregulated market. Few apps have been designed in collaboration with patients and these mostly address patient reported symptoms. Some clinical registries have already developed patient apps to complete patient-reported outcome measures (PROMs) on smartphones, which normally would have been collected during an outpatient visit and have shown interchangeability. The next step would be providing a patient app offering possibilities not only of individual disease tracking, but to provide automated peer support, health information and behavioural advice.

Objectives

We aimed to further develop and validate RheumaBuddy, a health app for patients with rheumatoid arthritis (RA), from a standard monitoring app to an intelligent health app tailored to the needs of the user that provides transparency to all important stakeholders in Rheumatology care.

Methods

This is an international interdisciplinary project between Austrian and Danish partners funded by the EUREKA program. Rheumatologists, health scientists, digital data experts and patients with RA joined forces in a 4 phase-program, running from 2020 to 2023. Phase 1 continues to develop the app in a co-creation approach in several iterations with patients. Phase 2 concerns developing an automated learning algorithm based on user data to identify patient strata and connect these with helpful non-pharmacological interventions. Phase 3 connects healthcare system data on diagnosis, medication prescription, healthcare facility usage with a large clinical RA database. By that we develop patient pathways that correlate high granularity data with system resources to retrieve results on socioeconomic impact. In phase 4 a randomised clinical trial will evaluate the effect of the developed RB4.0 on clinical disease activity and quality of life.

Results

Currently, RB is regularly being used by more than 3100 patients in 35 countries and 8 languages throughout Europe. The current RheumaBuddy version offers logging of symptoms using Likert scale questions, a joint mannequin to mark painful body parts and a peer-support forum. Additionally, the user can anytime display his/her entries over time in a graphical report and also share data with the healthcare provider. This version is extended with tracking of sleep, working hours and other behaviours. A consultation compass function helps the patient to reflect on goals and issues before the rheumatologist visit.

Within this project, we already established a first version of a Recommender System (RS), which computes correlations between user entries (e.g. between a user’s mood and pain), thus providing individual feedback. Through integration of information obtained from the app with claims data and clinical data from a RA registry, patterns can be identified and translated into different case models that concern the impact of common RA symptoms. By mapping these scenarios with evidence based behaviour and lifestyle advice, the “virtual coach” (advanced RS) will be developed and integrated into the RB4.0 system. During continuous data collection on app users, similarities in user behaviour can be identified, and similar entry patterns can be grouped. This will allow users to exchange and learn from each other regarding certain difficult situations (ex. “life-hack”) etc.

We are creating a comprehensive system in providing feedback to both clinical and psychosocial aspects of coping and disease management, as well as everyday practicalities for living with a chronic disease. Figure 1 displays these aspects, contributing the empowerment of patients.

Figure 1.

RB4.0 shall support people living with RA in dealing with disease impact

Conclusion

RheumaBuddy4.0 will provide RA patients the means to improve their quality of life on an individual level, better understand their needs and therapy which could support overcoming barriers of successful shared decision making to achieve better outcomes.

Disclosure of Interests

Paul Studenic: None declared, Tanja Stamm Speakers bureau: AbbVie, Novartis, Roche, Sanofi, and Takeda, Consultant of: AbbVie and Sanofi Genzyme, Grant/research support from: AbbVie and Roche, Yuki Seidler: None declared, Andreas Dam Speakers bureau: Gilead, Galapagos, BMS, Roche, Takeda, Merck, Consultant of: Gilead, Galapagos, BMS, Roche, Takeda, Merck, Nadine Weibrecht: None declared, Günther Zauner: None declared, Thomas H Jakobsen: None declared, Rebekka L. Hansen: None declared, Nikolas Popper Speakers bureau: Roche, Consultant of: as CSO of dwh GmbH, Tanita-Christina Wilhelmer: None declared, Helga Radner Speakers bureau: Gilead, Merck Sharp, Pfizer, Abbvie, Consultant of: Gilead, Merck Sharp, Pfizer, Abbvie, Romualdo Ramos: None declared, James Rickmann: None declared, Christoph Urach: None declared, Lars Erik Kristensen Speakers bureau: AbbVie, Pfizer Janssen, Novartis, Galapagos, UCB, Biogen and Eli Lilly, Consultant of: AbbVie, Pfizer, Janssen, Novartis, Galapagos, UCB, Biogen and Eli Lilly, Grant/research support from: IIT grants from UCB, Biogen, Eli Lilly, Novartis, Tanja Schjødt Jørgensen Speakers bureau: AbbVie, Pfizer, Roche, Novartis, UCB, Biogen and Eli Lilly, Consultant of: AbbVie, Pfizer, Roche, Novartis, UCB, Biogen and Eli Lilly

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.

Permanent pacemaker implantation after Alcoholic Septal Ablation: long-term outcomes

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete heart block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear.

Objectives

This study aims to evaluate the long-term pacemaker dependency in patients with PPM after ASA and to assess the long-term impact of PPM in these patients.

Methods

In a tertiary center, patients who underwent ASA were retrospectively analyzed. Patients with previous PPM or implantable cardio-defibrillator were excluded. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and outcomes. In the group who implanted PPM, the long-term pacing rates were evaluated.

Results

Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding co-morbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). In the PPM group, the mean pacing rates at 1 month, 1 year and 2 years were 66.6±38.0, 50.4±44.1 and 50.8±42.5, respectively, with 2 patients (12.5%) having 1-5% pacing and none having pacing &lt;1% at 2 years. In the group without PPM, 5 patients (6.2%) required posteriorly PPM implantation during the follow-up. There were no statistically significant differences in the two groups regarding in-hospital mortality, 1 year mortality or 1 year re-hospitalization. Despite a lower mean follow-up period in the PPM group (2.3±1.5 years versus 3.5±2.2 years, p0.05), there were no differences in the groups regarding all-cause mortality, cardiac cause mortality and cardiac cause re-hospitalization, with a statistical tendency to a lower all cause re-hospitalization in the PPM group (19% versus 43%, p0.07).

Conclusions

The registered pacing rates shows that all devices were adequately implanted. The long-term impact analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to reduce all cause re-hospitalizations.

Relationship of 5-year changes in inflammatory, metabolic and oxidative biomarkers with cardiovascular diseases incidence at 10-years

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Carlos III Health Institute and the European Regional Development Fund Government of Catalonia through the Agency for Management of University and Research Grants

Background

Early stratification of cardiovascular (CV) risk saves thousands of lives every year. There is a debate about the value of determining genetic or plasma biochemical biomarkers, related to atherosclerosis process, to improve the prediction of an incident CV disease. While, single measurements of some of these biomarkers have been associated with an increased risk of CV disease, the change of the levels of these biomarkers over time could also improve the prediction of CV events and drive the identification of new biological pathways and therapeutic targets.

Purpose

This study aimed to examine the relationship between 5-year change in the levels of biomarkers of inflammation (TNF-α, IL-10, IL-6, MCP-1, and CRP), glucidic metabolism (adiponectin, leptin, and insulin) and oxidation (GHS-Px), and the incidence of CV events at 10 years in a population without previous CV disease.

Methods

This was a cohort study nested in a large population cohort. Participants were randomly selected from the REGICOR cohort (North-Eastern Spain) recruited in 2005 (6.352 participants). Biomarkers were measured at baseline and in a re-examination in 2010. Participants were followed until 2020 for a composite CV disease endpoint including fatal and non-fatal first occurrence of coronary artery disease, stroke and peripheral artery disease. Baseline characteristics were compared between participants with and without CV events with standard parametric and non-parametric methods, as required. We used Cox regression to analyse the effect of the 5-year change of the biomarker levels on the occurrence of the composite endpoint adjusted for age, sex, baseline levels of each biomarker and classical CV risk factors.

Results

We included 419 individuals aged 35 to 74 years. Overall, 6.2% developed an incident CV disease within the 10-year follow-up. Characteristics of participants, who had or not a CV event, are compared in Table 1. Cases had a more adverse CV and anthropometric risk profile. Compared to individuals with sustained IL-6 and insulin levels, those with increased IL-6 or insulin after five years were at higher independent risk of CV disease at ten years. After adjusting for potential confounders, an increased IL-6 and insulin at the 5-year follow-up were independently associated with CV disease at 10-years (Table 2). Each rise of IL-6 or insulin in 1pg/mL or 10pg/mL, respectively, increased 32% (IL-6) and 2% (insulin) the risk of developing a CV event at 10-years.

Conclusions

Increasing IL-6 and insulin levels over five years indicates a higher risk of CV disease ten years thereafter, independently of classical risk factors.

Genetic risk score for risk stratification of patients positive for SARS-CoV-2 virus. The CARGENCORS study

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Carlos III Health Institute and the European Regional Development Fund Government of Catalonia through the Agency for Management of University and Research Grants Crue-CSIC-Santander FONDO SUPERA COVID-19

Background

The disease presentation of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ranges from asymptomatic to fatal. COVID-19 patients with pre-existing coronary artery disease (CAD) risk factors or overt cardiovascular disease are at particular risk of severe disease. We hypothesised that a specific genetic risk score (GRS) based on single nucleotide polymorphisms (SNPs) allele count to score COVID-19 severity might include SNPs counts related to CAD incidence and to thrombosis, inflammation, and viral infectivity determinants involved in the severity of SARS-CoV-2. Such GRS could improve the early risk stratification of COVID-19 patients and optimize treatment strategies.

Purpose

To evaluate the capacity of a genetic risk score (GRS) with candidate genes to predict COVID-19 severity.

Methods

We conducted an age- and sex-matched case-control study with 1:2 ratio recruitment involving 2454 patients from Catalan hospitals and primary care. Cases were hospitalized severe (requiring at least oxygen treatment) or fatal COVID-19 patients; and controls were moderate-symptom and asymptomatic patients treated at home. Standard parametric and non-parametric methods, as required, were used to compare patient characteristics by severity. Individual genotypes for 33 CAD, 14 thrombosis, 22 inflammation, 15 viral infectivity SNPs and 2 COVID-19 SNPs already published were tested for association with severity with Cochran-Armitage statistics and p-values corrected for multiple comparisons. GRS was computed as the unweighted count of adverse alleles (0, 1 or 2). The odds ratio of severe COVID-19 was analysed for GRS (and its component SNPs) with logistic regression models adjusted for potential confounding factors. Area under the curve (AUC) improvement and net reclassification index (NRI) for GRS was estimated from a basic model including CAD and COVID-19 severity risk factors. Models’ performance was measured with the Akaike information criterion.

Results

SNPs identifications are not shown to prevent patent conflict. Cases and control characteristics are compared in Table 1. Cases had a more adverse cardiovascular and anthropometric risk profile. After correcting for multiple testing by Benjamini-Hochberg criteria, we observed 13 SNPs to be significantly associated with severity. After excluding the close SNPs in linkage disequilibrium, 7 were retained in the GRS model, which yielded the discrimination and reclassification characteristics described in Table 2.

Conclusion

A GRS with 7 SNPs related to CAD, thrombosis and inflammation significantly improves the severe COVID-19 risk assessment done with age, sex, comorbidity, and anthropometry alone.

ROR2 increases the chemoresistance of melanoma by regulating p53 and Bcl2-family proteins via ERK hyperactivation

Background

ROR2 is a tyrosine-kinase receptor whose expression is dysregulated in many human diseases. In cancer, ROR2 stimulates proliferation, survival, migration, and metastasis, and is associated with more aggressive tumor stages. The purpose of this work is to study the role of ROR2 in the chemoresistance of melanoma.

Methods

Gain- and loss-of-function experiments were used to study the biological function of ROR2 in melanoma. Cell death induced by chemotherapeutic drugs and BH-3 mimetics was evaluated using crystal violet cytotoxicity assays and annexin V/propidium iodide staining. Western blots were used to evaluate the expression of proteins implicated in cell death. The differences observed between cells with manipulation of ROR2 levels and control cells were evaluated using both Student’s t-test and ANOVA.

Results

We describe that ROR2 contributes to tumor progression by enhancing the resistance of melanoma cells to both chemotherapeutic drugs and BH-3 mimetics. We demonstrate that ROR2 reduced cell death upon treatment with cisplatin, dacarbazine, lomustine, camptothecin, paclitaxel, ABT-737, TW-37, and venetoclax. This effect was mediated by the inhibition of apoptosis. In addition, we investigated the molecular mechanisms implicated in this role of ROR2. We identified the MDM2/p53 pathway as a novel target of ROR2 since ROR2 positively regulates MDM2 levels, thus leading to p53 downregulation. We also showed that ROR2 also upregulates Mcl-1 and Bcl2-xL while it negatively regulates Bax and Bid expression. The effect of ROR2 on the expression of these proteins is mediated by the hyperactivation of ERK.

Conclusions

These results demonstrate that ROR2 contributes to melanoma progression by inhibiting apoptosis and increasing chemoresistance. These results not only position ROR2 as a marker of chemoresistance but also support its use as a novel therapeutic target in cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11658-022-00327-7.

Ecocardiographic comprehensive evaluation of OHCM patients treated with percutaneous ASA

Funding Acknowledgements

Type of funding sources: None.

Introduction

Alcohol septal ablation (ASA) has been widely accepted as an alternative to surgical myectomy in patients with symptomatic obstructive hypertrophic cardiomyopathy (OHCM) despite optimal medical treatment.

The aim of this study was to analyse the effect of ASA on anatomical and functional features analysed by echocardiography, as well as its clinical impact. We further evaluated the safety of procedure.

Methods and results

Retrospective analysis of consecutive patients submitted to ASA (2009 – 2019) in a single tertiary centre. A dedicated echocardiogram was performed at 3 and 6 months after procedure. Echocardiographic primary endpoint was a &gt; 50% reduction in left ventricular outflow tract (LVOT) gradient (the definition used for successful procedure). Echocardiographic secondary endpoint was improvement in mitral regurgitation. Clinical primary endpoint was defined as a combined endpoint of cardiac death or hospitalization during follow-up (FU).

110 patients were included, 66.4% women, mean age 65.1 ± 12.2 years. Functional class NHYA class III/IV, angina CCS class II/III and syncope were present in 87.3%, 52.7% and 10.0%, respectively.

Baseline LVOT gradients at rest and at Valsalva manoeuvre were 93.6 ± 39.8 mmHg and 118.9 ± 44.2 mmHg. Maximum septal thickness was 21.0 ± 3.3 mm, 24.5% had moderate mitral regurgitation and 52.7% showed systolic anterior motion of mitral valve.

During hospitalization for ASA, peak creatine kinase after procedure was 1306 ± 816 U/l. 17 (17.1%) patients required permanent PM due to induction of permanent complete heart block. There was one case of inferior myocardial infarction and one case of cardiac tamponade. 

Echocardiographic primary endpoint was achieved by 83.6% of patients. At 3 and 6-months follow up, LVOT gradients was significantly decreased in successful comparing with unsuccessful procedure group (24.6 ± 23.9 vs 82.0 ± 28.7 mmHg, p = 0.003 and 31.8 ± 34.5 vs 68.6 ± 27.8 mmHg, p = 0.027, respectively). There was no difference in baseline clinical or echocardiographic parameters between both groups. Regarding the echocardiographic secondary endpoint, among patients with moderate mitral regurgitation, 80% improved to mild regurgitation. A significant reduction in basal septal thickness was achieved in most patients, from 21.0 ± 3.3mm to 16.4 ± 2.7 mm after ASA (p = 0.001). 

During mean FU of 3.4 ± 2.1 years, clinical primary endpoint occurred in 25.5%, mainly in unsuccessful procedure group (50.0% vs 20.7%, p = 0.013). Reintervention was performed for recurrence of symptoms in 14 (12.7%) patients, surgical myectomy in 3 (3.6%) and repeated ASA in 10 (9.1%). 

Conclusion

ASA allows a significant reduction in LVOT gradient and improvement of mitral regurgitation in the majority of patients with OHCM. Systematic and comprehensive echocardiographic evaluation assumes a paramount importance for the evaluation of procedural success. Abstract Figure.

Epicardial fat volume improves prediction of adverse clinical events

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recent studies have demonstrated the potential of epicardial fat volume (EFV) to predict obstructive coronary artery disease (CAD), however its impact in clinical outcomes remains elusive.

Objectives

To assess the association between EFV and demo­graphic and morphometric data, coronary atherosclerotic burden and adverse events in a population of patients (pts) referred for coronary computed tomography angiography (CTA).

­Methods: Retrospective analysis of pts without known CAD referred for coronary CTA in a single tertiary care centre. A standardized protocol for quantification of EFV, thoracic fat volume (TFV), coronary artery calcification (CAC) and coronary angiography was performed. Endpoint was composite of cardiovascular death, nonfatal myocardial infarction and urgent hospitalization leading to revascularization at 12 months.

Results

72 pts were included, 58% male, mean age 67 ± 9 years. The prevalence of hypertension, dyslipidemia and diabetes was 75%, 82% and 24%, respectively. Median EFV was 101 (68) ml and total TFV 1504 (694) ml. EFV was directly related with age (rs= 0.42, p &lt;0.001), male sex (135 ± 50 vs 78 ± 30, p &lt;0.001), body mass index (rs= 0.32, p= 0.008) and TFV (rs= 0.27, p= 0.025). A positive correlation with CAC (rs= 0.47, p &lt;0.001) and a significant association with CAD (116 ± 50 vs 90 ± 37, p= 0.029) and obstructive CAD (141 ± 60 vs 97 ± 39, p= 0.031) were demonstrated. Composite endpoint was observed in 13 pts (18%). After adjusting for all considered confounders, EFV remained an independent predictor of adverse events (OR: 1.015, 95%CI: 1.003-1.027, p= 0.041). ROC analysis of EFV (AUC 0.751, p = 0.005) allowed to estimate that EFV &gt;124 ml had a sensibility and specificity to predict clinical outcomes of 69% and 71%, respectively.

Conclusion

EFV positively relates to coronary atherosclerotic burden. This study also advocates that EFV may improve risk stratification for clinical outcomes. Larger studies are required to evaluate these results. Abstract Figure 1

[The effect of age and sex on factors associated with dementia]

INTRODUCTION

There is currently no cure for dementia and its prevention is considered to be crucial. The aim is to analyse the association between risk factors and dementia, and how this varies according to age and sex.

PATIENTS AND METHODS

This cross-sectional study includes 1,048,956 people aged 65 and over. Data were obtained from the SIDIAP pseudonymised clinical database. The response variable was dementia and cases were identified using a validated algorithm. Exposure to the following risk factors was assessed: smoking, coronary heart disease, cerebrovascular disease, heart failure, peripheral arterial disease, alcoholism, high blood pressure, hyperlipidaemia, diabetes, hyperthyroidism, Parkinson's disease, depressive disorder and rurality. Logistic regression models were estimated to assess the association between risk factors and dementia, and they were stratified by age, sex and both jointly.

RESULTS

The association between a medical history of cerebrovascular disease, Parkinson, depressive disorder or hyperthyroidism and dementia was more pronounced in men. The inverse association between coronary heart disease, heart failure or smoking and dementia was significant only in women. A stronger association was observed in younger age groups for most risk factors, but hypertension, coronary heart disease, heart failure or smoking were negatively associated among the older age groups.

CONCLUSION

Sex and age both condition the association between risk factors and dementia. We recommend promoting effective control of cardiovascular risk factors in order to prevent dementia.

Periprocedural and short-term stroke after transcatheter aortic valve implantation – what are the outcomes and how can we predict it

Background

Stroke is a known complication after transcatheter aortic valve implantation (TAVI). Although risk factors for its occurrence are being suggested, we still don't have clear tools to predict which patients will most probably have it and how to prevent it.

Purpose

To identify possible clinical and procedural predictors of early post-TAVI stroke.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteristics, procedural information and stroke in first 30 days after TAVIwere collected.

Results

A total of 494P (56,1% female) were included, with a mean age of 82±6 years (minimum 45 and maximum 95 years- old). The majority (98,4%) had at least one cardiovascular risk factor (83,2% hypertension, 67,6% dyslipidemia, 64% excess weight, 36,8% diabetes, 11,9% smoking). Half patients had chronic kidney disease, 34,8% atrial fibrillation, 16,4% peripheral artery disease, 15,4% porcelain aorta, and 12,3% a previous stroke. The procedure was done via transfemoral access in 460P (93,1%), subclavian artery in 16P (3,2%), transcava in 10P (2%) and transaortic in 7P (1,4%). Aortic valve pre-dilation was done in 35,6% and post-dilation in 31,2%. In the first 30 days after TAVI 19P (3,8%) had a stroke (11P with a major and 8P with a minor stroke). Patients with stroke had more hypertension (100% vs 82,4%, p=0.045), higher BMI (29 vs 27, p=0.039) and more frequently porcelain aorta (36,8% vs 15,5%, p=0,014). They also tended to have more peripheral artery disease (31,6% vs 15,7%, p=0,066). There weren't other differences in baseline characteristics between the two groups. Considering the aspects related to the procedure, post-dilation was the only predictor of events (58,8% vs 32%, p=0,021). In a multivariable analysis including clinical and procedural predictors, porcelain aorta (p=0,048, OR = 2,895) and post-dilation (p=0,042, OR = 2,844) were the independent predictors. Stroke after TAVI was associated with longer hospital stay (36 vs 15days, p&lt;0,001) and intensive care unit stay (12 vs 3 days, p&lt;0,001), higher intra-hospital mortality (14,8% vs 3,2%, p=0,002), global 30-day mortality (12,1% vs 3,3%, p=0,0011) and cardiovascular 30-day mortality (11,5% vs 3,4%, p=0,038).

Conclusion

Periprocedural and 30-day stroke is a relatively uncommon but potentially devastating complication after TAVI. There are clinical and procedural characteristics that are associated with a higher risk and should be considered when selecting patients for treatment and strategies to prevent events.

Funding Acknowledgement

Type of funding sources: None.

Virtual fractional flow reserve derived from coronary angiography – artery and lesion specific correlations

Introduction

Virtual Fractional flow reserve (vFFR) from standard non-hyperaemic invasive coronary angiography (ICA) has emerged as a promising non-invasive test to assess hemodynamic severity of coronary artery disease (CAD).

Purpose

To investigate the difference in vFFR analysis between vessels and specific lesions.

Methods

Retrospective analysis of consecutive patients (pts) who underwent invasive functional assessment (iFA) in a tertiary center between 2019 and 2020. vFFR was calculated using dedicated software (CAAS Workstation 8.4) based on coronary angiograms of the acquired in ≥2 different projections, by operators blinded to iFA results. Diagnostic performance of vFFR was evaluated and correlated with iFA, according to coronary vessel, vessel diameter at stenosis, diameter stenosis and area stenosis at lesion. vFFR was considered positive when &lt;0.80. FFR &lt;0.8 and iFR/RFR &lt;0.90 were classified as positive according to current clinical standards.

Results

106 coronary arteries of 95 pts (78% male, mean age 67.8±9.7 years) underwent vFFR evaluation. ICA indications were chronic coronary syndrome in 63% or acute coronary syndrome (non-culprit lesion) in the remaining pts. VFFR accuracy was good (AUC 0.839 (p&lt;0.001) and Pearson's correlation coefficient 0.533 (p&lt;0.001) when vFFR was measured in the distal vessel segment. The correlation improved when vFFR were assessed at lesion site (r=0.631, p&lt;0.001) or up to 1cm below the stenosis (0.610, p&lt;0.001). Binary concordance of 89% were observed in RCA and LAD (Sensibility -S 68%, Specificity-Sp 96%, False positive -FP 3.8%, False negative - FN 31%, predictive positive value-PPV 87%, predictive negative value- PNV 89%), while in the circumflex coronary artery binary concordance were of 77% (S 50%; Sp 82%; FP 18%; FN 50%; PPV 33% and PNV 90%). Correlation between vFFR and iFA was higher in vessels ≥2mm (r=0.730, p&lt;0.001). and in lesions in the extremes of the severity spectrum (Table 1).

Conclusion

vFFR has a moderate to high linear correlation to iFA, depending on the artery and type of lesion studied. The higher correlation was found when vFFR were measured at lesion site, in non-circumflex artery stenosis, in vessels ≥2mm and in vessels with mild or severe stenosis.

Funding Acknowledgement

Type of funding sources: None.

Quantification of epicardial fat with cardiac CT and association with cardiovascular risk factors and obstructive coronary disease

Introduction

Recent studies advocate epicardial fat (EF) as a biologically active organ that influence coronary atherosclerosis development through endocrine and paracrine pathways. We aim to study the relations between EF, thoracic adipose tissue (TAT), cardiovascular risk factors (CRF) and obstructive coronary disease (OCD).

Methods

Retrospective analysis of patients (pts) referred to 64-multislice cardiac computed tomography (CT) in one center. The authors underwent a standardized protocol for quantification of EAT, TAT (subcutaneous and visceral), abdominal visceral fat, coronary calcium score and angiography.

Results

Total of 178 pts: male 99 (56%), mean age 65.9±12.9 years. Indications for performing CT were coronary disease (76%), valvular heart disease (15%), atrial fibrillation (6%) and congenital heart disease (2%). Regarding CRF, EF was only significant higher in patients with diabetes (115±60 vs 95±47, p=0.018), in male gender (114±60 vs 91±42, p=0.04) and was linear correlated with age (p=0.004). The authors also found that EF volume is significant higher in patients with typical angina (p=0.02) and with coronary atherosclerosis: non-obstructive (p=0.0049) and OCD (p=0.001) – Graphic 1. ROC analysis of EF (AUC 0.659, p=0.0039) and EF/TAT relation (AUC 0.704, p=0.003) allowed to estimate that EF&gt;100 ml and EF/TAT &gt;0.06 had a sensibility to predict OCD of 53% and 58%, respectively, and specificity of 66% and 60%. We did not find a correlation between EF, EF/TAT or TAT and coronary calcium score.

Conclusion

EF is higher in patients with diabetes and coronary atherosclerosis. EF and EF/TAT relation had moderate sensibility and specificity to predict OCD, irrespective of calcium score. EF and EF/TAT are promising atherosclerotic markers that could be routinely use in the near future.

Funding Acknowledgement

Type of funding sources: None.

Urgent vs non-urgent transcatheter aortic valve implantation outcomes

Background

There are limited data about the outcomes of non-elective transcatheter aortic valve implantation (TAVI), but some studies suggest that these patients have worst results.

Purpose

To compare outcomes in patients submitted to urgent versus elective TAVI.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2018 and 2020 in a tertiary center. Baseline characteristics and outcomes after the procedure were collected. Urgent TAVIwas considered when patients were not electively admitted for the procedure but required the intervention on the current admission for medical reasons and could not be sent home without a definitive procedure.

Results

A total of 208P (55,3% female) were included, with a mean age of 82±7 years. Patients submitted to urgent TAVI (57P, 27,4%) had worse baseline characteristics, with higher EuroScore risk (10,7% vs 5,4%, p&lt;0,001), STS score (7,3% vs 4,4%, p&lt;0,001), and natriuretic peptide B (1350 vs 728 pg/mL, p=0,021), lower left ventricle ejection fraction (44% vs 50%, p&lt;0,001), more diabetes (49,1% vs 33,1%, p=0,033), peripheral artery disease (22,8% vs 4,6%, p&lt;0,001) and worse accesses (21,2% vs 5%, p=0,002). In univariable analysis, urgent TAVI was associated with higher intra-hospital mortality (14% vs 4%, p=0,01), 30-days mortality (17,5% vs 4%, p=0,001) and 30-days cardiovascular mortality (17,5% vs 3,3%, p&lt;0,001), life- threatening bleeding (17,9% vs 4%, p=0,001), acute kidney injury (16,1% vs 4,7%, p=0,007), vascular complications (16,1 vs 4%, p=0,003) and longer hospital and intensive care unit stay (30 vs 12 days, p&lt;0,001 and 6 vs 4 days, p=0,025 respectively), but not with post-TAVI hospital stay (12 vs 10 days, p=0,37). When adjusted to the differences in baseline characteristics, in a multivariable analysis, urgent TAVI was only associated with longer hospital stay (p&lt;0,0001). There were no differences in outcomes between groups beyond the first 30 days after the procedure, including mortality and hospital admissions.

Conclusion

Patients submitted to urgent TAVI tend to have worse short-term outcomes, but this seems to be attributable to the worse baseline characteristics of these cases instead of the urgent nature of the procedure. Even with the adjustment for baseline differences, these patients have longer global hospital stays, but they don't have latter post-TAVI discharge.

Funding Acknowledgement

Type of funding sources: None.

Can we simplify or improve long-term risk stratification for patients with ST-segment elevation myocardial infarction undergoing primary intervention?

Background

Various scores have been developed to predict early to mid-term prognosis after ST-elevation myocardial infarction (STEMI). The aim of this study was to compare the predictive value of 7 popular risks scores for the long-term outcome of STEMI patients undergoing primary intervention, and to find an easy model with similar or superior predictive and discriminative ability.

Methods

Patients who underwent primary PCI from January 2003 through August 2007 in a single tertiary-center were analysed (n=665) using a dedicated prospective registry. Global Registry for Acute Coronary Events (GRACE), GRACE 6 months, Thrombolysis In Myocardial Infarction (TIMI) STEMI, dynamic TIMI, TIMI risk index, Primary Angioplasty in Myocardial Infarction (PAMI) and Zwolle primary percutaneous coronary intervention (PCI) index were calculated for each patient. We assessed, through the C statistic in receiver-operating characteristic analysis, the predictive accuracy of these scores using all-cause mortality at 5 year as an endpoint. With multivariate regression analysis the variables with highest predictive ability were applied to build a model.

Results

All-cause mortality at 5 years after primary PCI was 22.1%. The risk scores showed moderate predictive ability, GRACE (0.759, 95% confidence interval (CI) 0.712–0.805), GRACE 6 months (0.802, 95% CI 0.759–0.845), TIMI STEMI (0.744, 95% CI 0.696–0.791), dynamic TIMI (0.774, 95% CI 0.727–0.820), TIMI risk index (0.757, 95% CI 0.710–0.803), PAMI (0.753, 95% CI 0.707–0.800) and Zwolle index (0.749, 95% CI 0.703–0.795). Six independent predictors of 5-year mortality were identified (age &gt;70 years, history of MI, history of stroke, heart tare above 85 beats per min, 3-vessel disease and in-hospital adverse events) and the model built had similar discriminative performance in estimation of probabilities of death (0.804, 95% CI 0.762–0.846, p=0.953 for difference with GRACE score).

Conclusions

The prediction values of currently recommended risk scores are moderate for long-term perspective (5-year). The simplified risk stratification score for STEMI and primary angioplasty using only six variables demonstrates accuracy similar to the more advanced risk scores.

Funding Acknowledgement

Type of funding sources: None.

Transesophageal echocardiography versus intracardiac echocardiography-guided left atrial appendage occlusion: a comparative analysis

Introduction

The left atrial appendage occlusion (LAAO) procedure is a therapeutic option for stroke prevention in patients with atrial fibrillation (AF) which have contraindication to oral anticoagulants or still develop embolic events despite therapeutic anticoagulation. Transesophageal echocardiography (TEE) has been the gold standard to guide this procedure, with the intracardiac echocardiography (ICE) emerging as an alternative because of the advantage of reducing the general anesthesia burden compared to TEE.

Objectives

This study aims to compare the safety, procedure-related parameters and outcomes between TEE-guided LAAO and ICE-guided LAAO.

Methods

In a tertiary center, patients who underwent TEE-guided LAAO and ICE-guided LAAO were compared retrospectively regarding technical success, procedure-related events, procedure-related parameters (fluoroscopy time, dose of radiation and contrast volume), 45 days-transthoracic echocardiography (TTE) and 1-year outcomes (mortality, stroke and major bleeding).

Results

88 patients underwent LAAO between 2009 and 2020 (n=43 with TEE, n=45 with ICE). Baseline characteristics were similar. Success was achieved in 95.3% (n=41) and 95.6% (n=43) of the patients in the TEE and ICE groups, respectively (OR 0.95, p=0.96). Procedure-related complications (major vascular complications, perforation, device embolization) didn't show significant differences (14.0% vs 8.9%, OR 1.66, p=0.46) in the TEE and ICE groups, respectively. Fluoroscopy time was inferior in the TEE group (29.1±13.6 vs 44.1±17.4 minutes, p=0.001), while radiation dose (2761±1555 vs 3397±2118 mGy, p=0.113) and contrast volume (220.3±104.1 vs 204.0±100.9mL, p=0.469) showed no significant differences. 45 days-TTE showed no significant differences between the TEE and ICE groups regarding peri-device leaks (14.0% vs 24.4%, p=0.212), device thrombus (2.3% vs 0%, p=0.990) and iatrogenic atrial septal defects, all mild (4.7% vs 13.3%, p=0.174). 1-year outcomes showed no significant differences regarding stroke (9.3% vs 4.4%, p=0.186), major bleeding (9.3% vs 2.2%, p=0.78) and all-cause mortality (9.3% vs 11.1%, p=0.38) between the TEE and ICE groups, respectively.

Conclusions

ICE-guided LAAO is associated with similar results, procedure-related events, procedure related-parameters (fluoroscopy time being the only exception) and 1-year outcomes, compared with TEE-guided LAAO.

Funding Acknowledgement

Type of funding sources: None.

Feasibility of virtual fractional flow reserve derived from coronary angiography and its correlation with invasive functional assessment

Introduction

Invasive functional assessment (iFA) of coronary artery disease (CAD) needs expensive devices, has potential procedure-related complications and is still underutilized. Virtual Fractional Flow Reserve (vFFR) derived from invasive coronary angiography (ICA) has the potential to overcome these limitations.

Purpose

To investigate the feasibility of vFFR analysis and its correlation with iFA (iFR, RFR or FFR).

Methods

Retrospective analysis of consecutive patients (pts) who underwent iFA in a tertiary center between 2019 and 2020. vFFR was calculated using a dedicated software (CAAS Workstation 8.4) based on standard non-hyperaemic coronary angiograms acquired in ≥2 different projections, by operators blinded to iFA results. Diagnostic performance and accuracy of vFFR were evaluated. vFFR was considered positive when &lt;0.80. FFR &lt;0.8 and iFR/RFR &lt;0.90 were classified as positive according to current clinical standards.

Results

Out of 113 coronary arteries of 102 pts, vFFR was successfully analysed in 106 (94%). Reasons for vFFR analysis failure were: vessel projection overlap (48%), &lt;2 angiographic projections (28%) and table movement while acquisition (24%). From 106 coronary arteries of 95 pts with analysable vFFR (78% male, mean age 67.8±9.7 years), 90 (85%) showed agreement with the respective iFA result. The vFFR predicted which lesions were physiologically significant and which were not with accuracy, sensitivity, specificity, positive and negative predictive values of 73%, 73%, 83%, 53%, and 92% respectively. The mean difference between vFFR and iFA were −0.0484±0.096 and Pearson's correlation coefficient was 0.533 (p&lt;0.001). The ROC area under the curve was 0.839 (0.751–0.928, p&lt;0.001).

Conclusion

FFR were feasible in 94% of cases analysed retrospectively. As compared to gold-standard iFA, vFFR had an overall moderate accuracy in detecting ischemia-producing lesions and a negative predictive value &gt;90%. vFFR has the potential to substantially simplify physiological coronary lesion assessment and thus improve its current uptake.

Funding Acknowledgement

Type of funding sources: None. Bland-Altman plot between vFFR and IFA

Real world experience with coronary sinus reducer implantation for the treatment of refractory angina: a single-centre experience

Background

Coronary sinus Reducer device (CSF) implantation is a novel therapeutic option to relieve symptoms in patients with refractory angina (RA). There is limited real-world data describing its use outside of clinical trials.

Aim

To assess the safety and efficacy of this procedure in a real-world setting.

Methods

This is a report of a single centre prospective registry of consecutive patients with RA (CCS II-IV) deemed unsuitable for revascularization. Between May 2017 and August 2019, 17 patients were referred to CSF implantation. Baseline and follow-up evaluation consisted of clinical assessment, including completion of the short version of the Seattle Angina Questionnaire (SAQ-7) and CCS class evaluation and objective evaluation by transthoracic echocardiography and cardiopulmonary exercise test (CPET).

Results

A total of 13 patients (70,6±6,5 years, 76,9% male) underwent CSF implantation with a procedural success of 84.6%. No cases of periprocedural serious adverse events were reported. At 12-month follow-up, any reduction in CCS Class was achieved in 72.7% of cases, with 27.2% reducing 2 CCS classes. Baseline CCS score was reduced from 2.8±0.4 to 1.7±0.8 (p=0.009). Quality of life (QoL) was significantly improved as assessed by the improvement seen in all items of SAQ-7 (p&lt;0.017 for all). CPET duration was significantly increased (p=0.034), but no change was noted in the remainder CPET variables. During follow-up, 3 patients suffered myocardial infarction, resulting in 1 death.

Conclusion

CSF implantation in patients with RA was safe and led to a significant reduction of the angina burden and improvement of QoL at 12-month follow-up.

Funding Acknowledgement

Type of funding sources: None.

Prognostic impact of percentage of ventricular pacing in patients requiring pacemaker implantation after transcatheter aortic valve replacement

Background

Despite the continuous developments of transcatheter aortic valve implantation (TAVI), around 15% of the patients (P) who undergo this procedure require permanent pacemaker (PM). Right ventricular pacing (RVP), particularly with a cumulative percentage of ventricular pacing (CVp) above 40%, has been associated with detrimental effects on ventricular function and an increased risk of cardiovascular events in non-TAVI patients.

Aim

To evaluate the long-term prognostic significance of RVP, regarding overall mortality and the combined endpoint of overall mortality/heart failure hospitalization in P requiring a PM after TAVI.

Methods

We retrospectively examined P who underwent TAVI 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. CVp was determined from stored PM data. P with previous PM were excluded. Post-TAVI PM implantation was defined as a device implantation during hospital stay or during the first month after discharge.

Results

474P, 57% male, mean age 81.7±6.5 years with a mean left ventricular ejection fraction of 51.5±14.6% were analysed. Mean follow-up was 18.7 months. Mean STS score and mean Euroscore II were, respectively, 6.89% and 5.76%. Mean gradient was 51.67 mmHg and mean aortic valve area 0.71 cm2. After TAVI, 104P (21.9%) required PM implantation, with a mean CVp of 65.3±43.4%. Post-TAVI PM was not associated with a worse outcome - overall mortality: HR 1.13, 95% CI 0.72 – 1.78, p=0.57; combined mortality/heart failure hospitalization: HR 1.22, 95% CI 0.87 – 1.70, p=0.24. The follow-up Kaplan-Meier curves according to the need for PM post-TAVI were similar: log rank p=0.24. A CVp cut-off of 40% was not associated with any of the study endpoints - overall mortality: HR 1.72, 95% CI 0.38–7.86, p=0.48; combined mortality/heart failure hospitalization: HR 1.32, 95% CI 0.45–3.91, p=0.61. Also, a CVp cut-off of 40% did not provide an accurate risk stratification as survival free of events was similar between these P and those below this cut-off (log rank p=0.11) and in comparison, with P without PM (log rank p=0.65).

Conclusions

In P submitted to TAVI with a self-expanding valve, the need for PM implantation is common, but not associated with increased risk of total mortality or heart failure hospitalization during a 18 months follow-up period. A CVp cut-off of 40% showed poor discriminative ability regarding long-term events in this population.

Funding Acknowledgement

Type of funding sources: None.

Biological effectiveness of He-3 and He-4 ion beams for cancer hadrontherapy: a study based on the BIANCA biophysical model

While cancer therapy with protons and C-ions is continuously spreading, in the near future patients will be also treated with He-ions which, in comparison to photons, combine the higher precision of protons with the higher relative biological effectiveness (RBE) of C-ions. Similarly to C-ions, also for He-ions the RBE variation along the beam must be known as precisely as possible, especially for active beam delivery systems. In this framework the BIANCA biophysical model, which has already been applied to calculate the RBE along proton and C-ion beams, was extended to⁴He-ions and, following interface with the FLUKA code, was benchmarked against cell survival data on CHO normal cells and Renca tumour cells irradiated at different positions along therapeutic-like⁴He-ion beams at the Heidelberg Ion-beam Therapy centre, where the first He-ion patient will be treated soon. Very good agreement between simulations and data was obtained, showing that BIANCA can now be used to predict RBE following irradiation with all ion types that are currently used, or will be used soon, for hadrontherapy. Thanks to the development of a reference simulation database describing V79 cell survival for ion and photon irradiation, these predictions can be cell-type specific because analogous databases can be produced, in principle, for any cell line. Furthermore, survival data on CHO cells irradiated by a He-3 beam were reproduced to compare the biophysical properties of He-4 and He-3 beams, which is currently an open question. This comparison showed that, at the same depth, He-4 beams tend to have a higher RBE with respect to He-3 beams, and that this difference is also modulated by the considered physical dose, as well as the cell radiosensitivity. However, at least for the considered cases, no significant difference was found for the ratio between the RBE-weighted dose in the SOBP and that in the entrance plateau.

OPEN RYGB LONG-TERM COMPLICATIONS: VENTRAL HERNIA - REPORT ON A 10-YEAR SINGLE-CENTER EXPERIENCE

Aim of Study - we hypothesize if there are any apparent risk stratifications to the abdominal wall compromise after open Roux-en-Y gastric bypass (RYGB) surgery and if the outcomes of retromuscular sublay mesh repair using Rives/Stoppa's technique were different from the literature. Description of a 10-year experience of a single center using sublay retromuscular mesh hernia repair in patients with ventral hernia after RYGB, including a total of 189 patients. 149 (78.8%) patients were women. Mean age of 47.3±10.9 years. 171 (90.48%) patients had at least one comorbidity, being systemic arterial hypertension the most prevalent (74.26%). The most frequent location of hernias was in the epigastric region with 125 cases (66.1%), followed by umbilical, inferior and subcostal (28.4%; 3.6%; 1.8%). The mean BMI of patients undergoing bariatric surgery was 50.2±6.6 kg/m². 112 (59.26%) patients within the ventral hernia sample had a BMI higher than 50 kg/m² before the bariatric surgery. The average length-of-stay at the hospital was 2.6 days. There were 17 (9%) cases of hernia recurrence. BMI>50 kg/m² and female sex may be risk factor to incisional ventral hernia in patients after open Roux-en-Y gastric bypass. Retromuscular sublay mesh appliance using Rives/Stoppa's technique had low length-of-stay of hospitalization and hernia recurrence compared to the literature.

Validity and trends of myocardial infarction incidence and case-fatality estimated from linked administrative databases

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): CIBERCV of cardiovascular diseases; CIBERESP.

OnBehalf

REGICOR investigators

Background

Although myocardial infarction (MI) severity trends are systematically measured with mortality rates, MI incidence trends and the precision of its estimation by linkage of anonymized electronic databases are relatively untested. We validated a linked-data method (LDM) to estimate a population MI incidence and case-fatality, and to analyse the 1990-2016 trends in North-Eastern Spain. 

Methods

LDM consisted of linking MI hospital discharges (n = 4,533,981) and mortality registry data (n = 40,676) for 2008-2016, selecting key MI diagnostic codes. The prospective REGICOR study, including all MI cases in Girona, 1990-2009, was used as the gold standard for validation purposes. Standardized MI cumulated incidence and 28-day case fatality for population aged 35-74 years was calculated, 1990-2016 trends were analysed by linear and joinpoint regression and annual percentage change (APC).

Results

LDM and REGICOR MI incidence and case-fatality estimates were similar for 2008-09 (Table). LDM MI incidence and case-fatality significantly decreased: APC 1990-2016 [95% CI]) was -1.8 [-2.6;-0.9] in women, and APC 2002-2016  -2.8 [-3.8;-1.8] in men; case-fatality APC 1990-2016 was -4.7% [-5.7;-3.8] in women and APC 1995-2005 -6.5%[-8.5;-4.5] in men. 

Conclusions

LDM in population aged 35-74 reliably estimated MI incidence and case-fatality. MI incidence and case-fatality significantly decreased after 1990.

Comparative analysis of REGICOR vs LDM REGICOR 2008-2009 LDM 2008-2009 Estimate 95% CI Estimate 95% CI P-Value Cumulated incidence Men 245.4 228.3; 262.5 239.7 222.5; 256.3 0.626 Women 61.1 52.6; 69.6 58.2 49.9; 66.4 0.626 Overall 28-day case-fatality Men 23.5% 19.7; 27.2 21.3% 17.8; 24.9 0.422 Women 19.3% 6.7; 31.9 17.7% 6.3; 29.1 0.855 In-hospital case-fatality Men 6.9% 4.8; 9.0 5.7% 3.8; 7.6 0.394 Women 5.0% 1.9; 8.2 3.7% 1.0; 6.5 0.540 Pre-hospital case-fatality Men 16.5% 11.8; 21.3 15.6% 11.2; 20.1 0.791 Women 14.2 % 6.6; 21.9 14.0% 6.3; 21.7 0.961 CI Confidence Interval

[Recommendations for psychology and youth sports. A consensus document]

Sports organisations involved in grassroots sports have trainers, managers and referees whose attitudes, work and dedication show that many of them are volunteers with little knowledge of psychology as a working method. This document, promoted by the Programa Talento Deportivo of the University of Navarra and the Official Association of Psychologists of Navarra, considers the role of psychology in children's and adolescents' sport and the benefits it can offer to sports players, parents, trainers, referees and managers. It also establishes a consensus in the form of a set of guidelines and twenty-seven recommendations. The aim of this consensus is to recognise the benefits of including psychology in the profiles involved in grassroots sport, to enable those involved to acquire skills that can help to improve performance and psychological states, promoting directives to be used when managing and training young sports players.

Clinical implications of the morphological features of left ventricular intracavitary thrombi after anterior ST elevation myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular thrombi (LVT) after an anterior ST elevation myocardial infarction (STEMI) are usually classified as protruding or laminar according to their morphological characteristics. However, it is unknown whether this morphology has any clinical implication.

Purpose

Determine prognostic between laminar or protruding LVT in the community of anterior STEMI.

Methods

An observational cohort study on patients with LVT after anterior STEMI detected by echocardiography between 2008 and 2019 was conducted. Laminar LVT was defined as those protruding &lt;5mm inside the cavity.

Results

Of 1.215 anterior STEMI patients, 121 (10%) cases presented LVT: 86 (71%) were protruding and 35 (29%) laminar. Mean follow-up was 323 ± 116 days. No differences in baseline clinical and echocardiographic characteristics were detected between both groups. However, protruding LVT patients were more frequently treated with triple therapy (71% vs 40%; p &lt; 0.001). Laminar LVT patients presented a lower stroke rate (3% vs 16%; P = 0.042) and embolism-related rate (3% vs 19%; p = 0.024) than protruding LVT cases (see Figure). Laminar LVT was associated with lower embolism-related events during follow-up independently than left ventricular ejection fraction (LVEF) and age (OR = 0.11; 95% CI,0.12-0.94; p = 0.045). No differences were observed in laminar LVT patients in embolism-related events during follow-up between those treated with or without triple therapy (7% vs 0%; p = 0.400).

Conclusions

Laminar LVT after anterior STEMI presented a lower rate of embolism-related complications during follow-up compared with protruding LVT regardless of LVEF, age and even with a lower rate of triple therapy.

Abstract Figure.

Left ventricular remodelling patterns after MitraClip implantation: Do ischemic patients have the same benefit?

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Percutaneous mitral valve repair has shown to prevent and even reverse adverse LV remodelling in most patients with moderate to severe mitral regurgitation (MR). This effect is, however, highly variable and may differ according to the MR etiology.

Objectives

 The aim of the present study is to evaluate cardiac remodelling patterns and clinical outcomes after MitraClip implantation (MI) in ischemic and non-ischemic patients (P).

Methods

 A standardized registry was prospectively performed between 2013 and 2019 for all P who underwent MitraClip insertion in a single terciary care centre. Transthoracic echocardiographic information was assessed at baseline and 1, 6, 12 and 18 months after MI. Student’s t-test was used to assess the procedure’s effect on several variables. Clinical outcomes were compared with the use of Fisher’s exact test or the chi-square test, as appropriate.

Results

 46 P, 61% male, mean age 65 ± 14 years. 39% had ischemic MR. Dyslipidemia was more frequent in ischemic P (52% versus 93%, p= 0.002) as well as history of smoking (32% versus 67%, p= 0.022). Atrial fibrillation was significantly associated with non-ischemic etiology (75% versus 44%, p= 0.036). MI success rate was 87% (proper placement and reduction in MR to grade 2 or less), with an average of 1.5 clips. Considering the 37 P that completed 18 months of follow-up (FU), the echocardiographic parameters at baseline were: left ventricular ejection fraction (LVEF) 36 ± 12%, LV end-diastolic dimeter (LVEDD) 68.2 ± 10.2mm, LV end-systolic diameter (LVESD) 52.2 ± 13.5mm and left atrial diameter (LAD) 53.1 ± 6.7mm; there were no significant differences between groups. After MI, a compelling difference in LVEDD was noticeable early in the first month, with significant lower dimensions in non-ischemic P (66.6 ± 11.4 versus 72.8 ± 5.4, p= 0.039). Sustained differences in LVEDD were consistent at 6, 12 and 18 months (62.4 ± 12.3 versus 73.5 ± 7.4, p= 0.025). There was also a reduction in LVESD that became apparent in the sixth month (45.5 ± 15.1 versus 55.3 ± 9.8mm, p= 0.047) and that was sustained after 18 months from MI (45.4 ± 11.7 versus 58.3± 8.9, p= 0.012). No significant differences in LVEF or LAD were noticed over time. Regarding clinical outcomes at 18 months, overall mortality (M) was 24% (9P) and 51% (19P) died or were hospitalized due to heart failure (MH).  No difference was found between groups: M (p= 0.119), MH (p= 0.091).

Conclusion

 This study reports better LV reshape effects after MI in P with non-ischemic etiology, with sustained improvement over time. However, no differences regarding mortality or hospitalization due to HF were apparent at the 18-month FU. Larger long-term studies are required to evaluate these results.

Abstract Figure. LV remodelling pattern

Optimizing diagnosis of obstructive coronary artery disease by CT angiography: RCT's final results and 12-months follow-up

Aim

In patients (pts) with suspected coronary artery disease (CAD), computed tomographic angiography (CTA) may improve pt selection for invasive coronary angiography (ICA) as alternative to functional testing. However. the role of CTA in symptomatic pts after abnormal functional test (FT) is incompletely defined.

Methods and results

This randomized clinical trial conducted in single academic tertiary center selected 218 symptomatic pts with mild to moderately abnormal FT referred to ICA to receive either the originally intended ICA (n=103) or CTA (n=115). CTA interpretation and subsequent care decisions were made by the clinical team. Pts with high risk features on FT, previous acute coronary syndrome, previously documented CAD, chronic kidney disease (GFR&lt;60ml/min/1.73m2) or persistent atrial fibrillation were excluded. The primary endpoint was the percentage of ICA with no significant obstructive CAD (no stenosis ≥50%) in each group. Diagnostic (DY) and revascularization (RY) yields of ICA in either group were also assessed. Pts were followed up for at least 1 year for the primary safety endpoint of all cause death/ nonfatal myocardial infarction/ stroke. Unplanned revascularization

(UP) and symptomatic status (SS) were also evaluated. Pts averaged 68±9 years of age, 60% were male, 29% were diabetic. Nuclear perfusion stress test was used in 33.9% in CTA group and 31.1% in control group (p=0.655). Mean post (functional) test probability of obstructive CAD was 34%. Overall prevalence of obstructive CAD was 32.1%. In the CTA group, ICA was cancelled by referring physicians in 83 of the pts (72.2%) after receiving CTA results. For those undergoing ICA, non-obstructive

CAD was found in 5 pts (15.6%) in the CTA-guided arm and 60 (58.3%) in the usual care arm (p&lt;0.001 Mean cumulative radiation exposure related to diagnostic work up was similar in both groups (6±14 vs 5±14mSv, p=0.152). Both DY (84.4% vs 41.7, p&lt;0.001) and RY (71.9% vs 38.8%, p=0.001) yields were significantly higher for CTA-guided ICA as compared to standard FT-guided ICA. The rate of the primary safety endpoint was similar between both groups (1.9% vs 0%, p=0.244), as well as the rates of UP (0.9% vs 0.9%, p=1.000) and SS (persistent angina: 29.6% vs 24.8%, p=0.425).

Conclusions

In pts with suspected CAD and mild to moderately abnormal ischemia test, a diagnostic strategy including CTA as gatekeeper is safe, effective and significantly improves diagnostic and revascularization yields of ICA.

Funding Acknowledgement

Type of funding source: None

Clinical implications of the morphological features of left ventricular intracavitary thrombi after anterior ST elevation myocardial infarction

Background

Left ventricular thrombi (LVT) after an anterior ST elevation myocardial infarction (STEMI) are usually classified as protruding or laminar according to their morphological characteristics. However, it is unknown whether this morphology has any clinical implication.

Purpose

Determine prognostic between laminar or protruding LVT in the community of anterior STEMI.

Methods

An observational cohort study on patients with LVT after anterior STEMI detected by echocardiography between 2008 and 2019 was conducted. Laminar LVT was defined as those protruding &lt;5mm inside the cavity.

Results

Of 1.215 anterior STEMI patients, 121 (10%) cases presented a LVT: 86 (71%) were protruding and 35 (29%) laminar. Mean follow-up was 323±116 days. No differences in baseline clinical and echocardiographic characteristics were detected between laminar or protruding LVT groups. However, protruding LVT patients were more frequently treated with triple therapy (71% vs 40%; p&lt;0.001). Laminar LVT patients presented a lower stroke rate (3% vs 16%; P=0.042) and embolism-related rate (3% vs 19%; p=0.024) than protruding LVT cases. Kaplan-Meier analysis demonstrated significant differences in embolism-related event rate between the 2 groups (p=0.003) during the follow-up period. Laminar LVT was associated with lower embolism-related events during follow-up independently than left ventricular ejection fraction (LVEF) and age (HR=0.17; 95% CI,0.10–0.29; p&lt;0.001). No differences were observed in laminar LVT patients in embolism-related events during follow-up between those treated with or without triple therapy (7% vs 0%; p=0.400).

Conclusions

Laminar LVT after anterior STEMI presented a lower rate of embolism-related complications during follow-up compared with protruding LVT regardless of LVEF, age and even with a lower rate of triple therapy.

Figure 1. Kaplan-Meier curve showing cumulative probability of embolism-related event rate after anterior STEMI according to LVT morphology at 1 year.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of suspected cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)&gt;12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull's eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2±5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57±15% and 26.6% presented EF&lt;50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS &gt;1 was identified in 22 P (23.4%). An EF/GLS ratio &gt;4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4±25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p=0.002) and MACE (48.7% vs 22.2%, p=0.01). RALS&gt;1 correlated also with all-cause mortality (31.8% vs. 12.5%, p=0.04) and with new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p=0.05). P with GLS&gt;−14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p=0.003) and MACE (p=0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR=4.49, p=0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Funding Acknowledgement

Type of funding source: None

Efficient Spin Torques in Antiferromagnetic CoO/Pt Quantified by Comparing Field- and Current-Induced Switching

We achieve current-induced switching in collinear insulating antiferromagnetic CoO/Pt, with fourfold in-plane magnetic anisotropy. This is measured electrically by spin Hall magnetoresistance and confirmed by the magnetic field-induced spin-flop transition of the CoO layer. By applying current pulses and magnetic fields, we quantify the efficiency of the acting current-induced torques and estimate a current-field equivalence ratio of 4×10^{-11}  T A^{-1} m^{2}. The Néel vector final state (n⊥j) is in line with a thermomagnetoelastic switching mechanism for a negative magnetoelastic constant of the CoO.

A cost-utility analysis of increasing percutaneous coronary intervention use in elderly patients with acute coronary syndromes in six European countries

AIMS

Percutaneous coronary intervention reduces mortality in acute coronary syndrome patients but the cost-utility of increasing its use in elderly acute coronary syndrome patients is unknown.

METHODS

We assessed the efficiency of increased percutaneous coronary intervention use compared to current practice in patients aged ≥75 years admitted for acute coronary syndrome in France, Germany, Greece, Italy, Portugal and Spain with a semi-Markov state transition model. In-hospital mortality reduction estimates by percutaneous coronary intervention use and costs were derived from the EUROpean Treatment & Reduction of Acute Coronary Syndromes cost analysis EU project (n = 28,600). Risk of recurrence and out-of-hospital all-cause mortality were obtained from the Information System for the Development of Research in Primary Care (SIDIAP) database from North-Eastern Spain (n = 55,564). In-hospital mortality was modelled using stratified propensity score analysis. The 8-year acute coronary syndrome recurrence risk and out-of-hospital mortality were estimated with a multistate survival model. The scenarios analysed were to increase percutaneous coronary intervention use among patients with the highest, moderate and lowest probability of receiving percutaneous coronary intervention based on the propensity score analysis.

RESULTS

France, Greece and Portugal showed similar total costs/1000 individuals (7.29-11.05 m €); while in Germany, Italy and Spain, costs were higher (13.53-22.57 m €). Incremental cost-utility ratios of providing percutaneous coronary intervention to all patients ranged from 2262.8 €/quality adjusted life year gained for German males to 6324.3 €/quality adjusted life year gained for Italian females. Increasing percutaneous coronary intervention use was cost-effective at a willingness-to-pay threshold of 10,000 €/quality adjusted life year gained for all scenarios in the six countries, in males and females.

CONCLUSION

Compared to current clinical practice, broadening percutaneous coronary intervention use in elderly acute coronary syndrome patients would be cost-effective across different healthcare systems in Europe, regardless of the selected strategy.

P1136Is there a negative impact of permanent pacemaker implantation in long-term outcomes after transcatheter aortic valve implantation?

Introduction

Transcatheter aortic valve implantation (TAVI) is an established treatment in patients (P) with aortic stenosis. Despite the continuous developments of this procedure, high-grade conduction disturbances requiring permanent pacemaker (PPM) implantation is still a major and common complication of TAVI. Furthermore, long-term chronic right ventricular pacing has been associated with negative effects on ventricular function and heart failure (HF).

Aim

  to evaluate the long-term impact of PPM after TAVI focusing on mortality and HF hospitalization.

Methods

 We retrospectively examined P who underwent TAVI with a self-expanding valve from 2009 to 2018 at our institution. All P had pre-procedural clinical evaluation, including ECG, cardiac computed tomographic angiography and transthoracic echocardiography. P with previous PPM were excluded.

Results

 265P (57% male, mean age 81.4 years, 20% with left ventricular ejection fraction &lt;40%) were analysed. Mean STS score and mean Euroscore II were 6.33% and 7.07%, respectively. Mean transvalvular gradient was 52.78 mmHg and mean aortic valve area 0.67 cm2. Forty-seven P (17%) underwent PPM implantation during the first 30 days after TAVI. P requiring PPM had higher prevalence of diabetes mellitus, chronic renal disease, atrial fibrillation and right bundle branch block. During a mean follow-up of 20.3 months, post-TAVI PPM was associated with similar mortality rate (29.8% vs. 25.6%, HR 1.28, 95% CI 0.72-2.29, p = 0.42) and similar cardiovascular mortality (9.8% vs. 6.4%, HR 0.72, 95% CI 0.21-2.4, p = 0.59) compared to P without PPM. There were no significant differences in HF hospitalization (4.9% vs. 2.4%, p = 0.47). Kaplan-Meier curves of total mortality and cardiovascular mortality according to the need for PPM post-TAVI were similar. 

Conclusions

 In P submitted to TAVI, PPM implantation is a relatively common finding, not associated with higher risk of total mortality, cardiovascular mortality or HF hospitalization in a long-term follow-up.

1226 Prognostic impact of concomitant cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)&gt;12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull’s eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2 ± 5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57 ± 15% and 26.6% presented EF &lt; 50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS &gt; 1 was identified in 22 P (23.4%). An EF/GLS ratio &gt; 4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4 ± 25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p = 0.002), new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p = 0.05) and MACE (48.7% vs 22.2%, p = 0.01). All-cause mortality was also higher in P with RALS (31.8% vs. 12.5%, p = 0.04). P with GLS&gt;-14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p = 0.003) and MACE (p = 0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR = 4.49, p = 0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Abstract 1226 Figure. Kaplan–Meier curves and ASPB

P715 When "wait and see" is the best option: a case report of a spontaneous coronary artery dissection

Introduction

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and is now being identified more frequently, in part because of increased awareness.

Case report

We present the case of a 63-year-old female, without cardiovascular risk factors or relevant past medical history. She complained of atypical chest pain in the last year. The patient was admitted due to acute chest pain at rest, hemodynamically stable, with unremarkable physical examination, including absence of heart failure signs. The EKG revealed a dynamic ST depression in leads V4-V6. The peak of high sensitivity troponin I was 13744pg/mL (ULN&lt; 15.6) and CK 874U/l (ULN &lt;168). The echocardiogram showed preserved left ventricular ejection fraction and hypokinesia of mid-apical segments of anterior wall. Considering the diagnosis of NSTEMI the patient underwent coronary angiography that revealed luminal narrowing of 70% in left main artery, 70% in proximal anterior descending artery (LAD) and 99% in first obtuse marginal. Given the absence of cardiovascular risk factors, the smooth angiographic appearance of coronary lesions and absence of calcium, we suspected of spontaneous dissection or vasculitis. Considering the absence of angina revascularization was delayed. A first coronary angio-CT confirmed the luminal narrowing and suggested a spontaneous dissection. Two weeks later the coronariography and the angio-CT were repeated with a significant improvement, showing only intermediate stenosis of proximal LAD. The additional imaging study revealed a 45mm ascending aortic dilation and a left primitive carotid stenosis without other vascular territory alterations, excluding fibromuscular dysplasia. The auto-immune study was unremarkable. With all these results it was assumed the diagnosis of a spontaneous coronary artery dissection and the patient was discharged asymptomatic under single antiplatelet therapy and Rivaroxaban. Three months later a new coronary angio-CT showed no significant coronary artery stenosis and the patient was asymptomatic.

Discussion and conclusion

The recognition of spontaneous coronary artery dissection is essential to the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in these patients are suboptimal and conservative management is probably the best option.

Abstract P715 Figure. angio-CT

P182 Bleeding complications in a rendu-osler-weber syndrome patient with atrial fibrillation - challenging serial transoesophageal echocardiography

Rendu-Osler-Weber (ROW) syndrome or hereditary hemorrhagic telangiectasia is a rare autossomic dominant disease characterized by vascular dysplasia involving multiple systems and associated with an increased bleeding risk. The presence of atrial fibrillation in this population becomes a challenge, regarding the evaluation of bleeding and thrombotic risks and the best approach for the patient management.

A 72 years-old female with ROW syndrome, atrial fibrillation and a CHA2DS2-VASc risk score of four, was admitted to our hospital for left atrial appendage (LAA) closure after a period of novel oral anticoagulation crowed with multiple haemorrhagic events and blood transfusions. After the implantation of a Watchman LAA number 33 closure device (Image 1A), and because of the concomitant diagnose of chronic pulmonary embolism, she was restarted on anticoagulation therapy in lower doses, with initial tolerance. For evaluation of LAA closure device during follow-up, after an unsuccessful attempt of transoesophageal echocardiography (TEE) because of severe epistaxis subsequent to oropharyngeal anaesthesia, the patient underwent a Cardiac Computed Tomography (CT) that showed a moderate peri-device leak (4.4x11mm, 0.73cm2) – (Image 1B). For better characterization, the patient underwent a new attempt of TEE with the support of an anaesthesiologist and the need of local vasoconstrictor agents and tranexamic acid for epistaxis and oropharyngeal bleeding control. TEE confirmed a moderate posterior device-leak (7.1mm) with absence of cavitary thrombus (Image 1C). After a year of anticoagulation with new significant bleeding events, TEE was repeated with the anaesthetic and pharmacologic preparation. This TEE showed a decrease in peri-device leak (&lt;5mm wide – Image 1D), which was fundamental for supporting the multidisciplinary team decision of interruption of anticoagulation therapy. With this case we want to highlight the challenging decisions regarding patients with ROW syndrome and atrial fibrillation. Specifically, we must be alert about possible complications in trying to perform TEE in this population, once the frequent occurrence of telangiectasias in the oropharynges that may occur, as in this patient.

Abstract P182 Figure. Image 1