Chagas disease deaths detected among garbage codes registered in mortality statistics in Brazil: a study from the buRden of ChAgas dISEase in the contemporary world (RAISE) project

OBJECTIVES

The objective of this study was to identify Brazil's most critical garbage codes (GCs) reclassified to Chagas disease (ChD) in mortality data and their proportions. We also estimated the potential impact of misclassification on the number of deaths attributed to ChD.

STUDY DESIGN

Population-based descriptive study.

METHODS

We used the Mortality Information System (SIM; in Portuguese) data before and after routine GC investigation in 2015-2019 to evaluate ChD deaths detected among them. We identified priority GCs, which contributed more than 0.1 % to the percentage of total ChD deaths registered. Spearman's correlation was used to evaluate the association between the reclassification of priority GCs and ChD prevalence. Then, we applied the GC correction factors to estimate the number of deaths attributed to ChD.

RESULTS

22,154 deaths were reported as ChD in the study period. Among them, 1004 deaths originally listed as priority GCs were deaths reclassified to ChD after an investigation in the SIM final database. Unspecific cardiomyopathy (10.2 %), unspecific heart diseases (4.7 %), and heart failure (2.8 %) were GCs with the highest proportions of reclassification to ChD in Brazil. Higher ChD prevalence at the state level was associated with a higher proportion of GC deaths reclassified as ChD. When applying correction factors identified after investigation, we estimated an increase of 26.4 % in registered ChD deaths, mostly in states with higher endemicity.

CONCLUSIONS

GCs might conceal deaths due to ChD, particularly in Brazil's states with higher endemicity. The approach suggested in this study may offer an alternative method for estimating ChD-related deaths in endemic countries.

Gastrointestinal Parasites Affecting Non-Human Primates That Are Kept Ex Situ and Their Handlers in Different Brazilian Institutions: Diagnosis and Analysis of Risk Factors

AIM

Determining gastrointestinal parasites' frequency in non-human primates (NHPs) and handlers in different Brazilian institutions, and associate it with management information.

METHODS

Different institutions in São Paulo (A), Brasília (B), Rio de Janeiro (C), Pará (D) and Santa Catarina (E) were included in the study. Fecal samples were processed by using coproparasitological techniques; information about NHP handling and professionals' routine were collected through the use of questionnaires.

RESULTS

In total, 33.1% of 511 NHP samples were positive for parasites; the Entamoebidae Group and Strongyloides sp.-compatible eggs were the most detected protozoa and helminths, respectively. The Entamoebidae Group was mainly diagnosed in Alouatta from Institutions E and D, and was also the only parasite detected in handlers. Strongyloides-compatible eggs were mostly evident in fecal samples collected from Cebidae from Institutions B and D. Some risk factors associated with parasite infection were a high number of animals in the same enclosure and their use for research protocol purposes, whereas quarantine, a post-infection vacant period in enclosures and antiparasitic supply were categorized as protective factors against these agents' infection.

CONCLUSIONS

Parasites showing different transmission routes but concomitantly circulating in NHP institutions located in different Brazilian regions were identified in the current study, with an emphasis on those presenting zoonotic potential.

Vertical and sagittal changes produced by an expander with differential opening and fan-type expander: A post-hoc analysis of a randomised controlled trial

OBJECTIVE

To compare the sagittal and vertical cephalometric effects in participants treated with an expander with differential opening (EDO) versus the fan-type expander (FE).

DESIGN

Two-arm parallel randomised clinical trial (RCT).

METHODS

This study comprised cone-beam computed tomography-derived cephalometric images from 48 participants from a RCT. The sample was randomly allocated into two groups. The study was single-blinded. In total, 24 participants were treated with rapid maxillary expansion (RME) using EDO and 24 participants underwent RME using FE. The primary outcomes were the dentoskeletal vertical changes produced by RME. The secondary outcomes were the dentoskeletal sagittal changes. A cephalometric analysis was performed before treatment and 1 or 6 months after the active phase of RME using Dolphin Imaging Software. Intergroup comparisons of interphase changes were performed using the t-test and Mann-Whitney U test (P < 0.05).

RESULTS

The final sample comprised 24 patients (11 men, 13 women; mean age = 7.6 ± 0.9 years) in the EDO group and 24 patients (10 men, 14 women; mean age = 7.8 ± 0.9 years) in the FE group. Both expanders produced a similar clockwise rotation of the mandible (FMA; mean difference [MD] = 0.09°, 95% confidence interval [CI] = -1.01 to 0.84). In the FE group, a greater increase of the SNA angle was observed after expansion compared to the EDO group (MD = 1.04°, 95% CI = -1.90 to -1.58). A greater palatal torque of maxillary incisors was observed in the FE group (MD = 1.32°, 95% CI = 0.05-2.56). Of the participants, 54% reported a little discomfort during the active phase of treatment and 46% of the participants did not report any discomfort.

CONCLUSION

Both expanders produced similar vertical cephalometric changes. FEs caused slightly more maxillary anterior displacement after expansion with a compensatory palatal torque of the maxillary incisors compared to the EDOs. However, the amount of sagittal difference was not clinically relevant.

TRIAL REGISTRATION

The trial was registered at ClinicalTrials.gov, under the identifier NCT03705871.

Comparison of nasal cavity changes between the expander with differential opening and the fan-type expander: a secondary data analysis from an RCT

INTRODUCTION

The aim of this study was to compare the nasal cavity skeletal changes between the expander with differential opening (EDO) and the fan-type expander (FE).

METHODS

This study was a secondary analysis of a previous randomized clinical trial. Forty-eight patients with posterior crossbite were randomly allocated into two study groups. Twenty-four patients (11 male, 13 female) with a mean initial age of 7.6 ± 0.9 years were treated with rapid maxillary expansion (RME) using the EDO. Twenty-four patients (10 male, 14 female) with a mean initial age of 7.8 ± 0.9 years were treated with the FE. Cone-beam computed tomography (CBCT) was performed before treatment and 1 to 6 months after the active phase of RME. Using frontal CBCT slices passing at the level of maxillary permanent first molars and maxillary deciduous canines, the width of the nasal cavity was measured in the lower, middle and upper thirds. Nasal cavity height was also evaluated in both slices. Intergroup comparisons of interphase changes were performed using t or Mann-Whitney tests (P < 0.05).

RESULTS

The two groups were similar regarding baseline data. EDO showed a greater transverse increase in the lower third of the nasal cavity in both canine (P = 0.007) and molar regions (P < 0.001). No intergroup difference was observed for changes in middle and upper widths and height of the nasal cavity.

CONCLUSIONS

Both expanders are effective in promoting an increase of the nasal cavity skeletal dimensions. The expander with differential opening produced a greater transverse increase in the lower third of the nasal cavity compared to the fan-type expander, both at the anterior and posterior regions of the maxilla.

CLINICAL RELEVANCE

EDO might be more beneficial to pediatric patients with oral breathing and obstructive sleep apnea compared to FE.

Closure of maxillary lateral incisor agenesis space in unilateral cleft lip and palate: a digital model assessment

OBJECTIVE

To compare dental positional and gingival parameters of maxillary anterior teeth in unilateral cleft lip and palate (UCLP) after orthodontic treatment with canine substitution due to lateral incisor agenesis.

METHODS

This split-mouth study comprised 57 subjects with UCLP (31 male, 26 female) and agenesis of maxillary lateral incisor at the cleft side, from a single center. Canine substitution was completed after the secondary alveolar bone graft. Dental models were taken between 2 to 6 months after debonding (mean age: 20.4 years). The following variables were measured in the maxillary anterior teeth: crown height, width, proportion, and symmetry, as well as steps between incisal edges, gingival margins, tooth mesiodistal angulation and labiolingual inclination. Paired t-tests with Bonferroni post-hoc correction was used for comparisons between cleft and non-cleft sides (p<0.05).

RESULTS

At the cleft side, canines replacing missing lateral incisors had a higher crown height (0.77mm) and an increased width (0.67mm), and first premolars showed a shorter crown height (1.39mm). Asymmetries were observed in the gingival level of central and lateral incisors, with a greater clinical crown at the cleft side (0.61 and 0.81mm, respectively). Cleft side central incisors were more upright than their contralaterals (2.12º).

CONCLUSIONS

Maxillary anterior teeth demonstrated positional, size and gingival height differences between cleft and non-cleft side after space closure of maxillary lateral incisor agenesis. Slight asymmetries in tooth position and gingival margin in the maxillary anterior teeth should be expected after orthodontic treatment in UCLP patients.

Medical therapy for secondary prevention in patients with myocardial infarction with non-obstructive coronary artery disease: long-term outcome of a Portuguese centre

Background

The outcomes of dual anti-platelet therapy (DAPT), β-blocker, renin-angiotensin-aldosterone system (RAAS) inhibitor and statin therapy are unknown in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA). The aim of this study was to examine the effects of secondary prevention therapy at discharge on long-term outcomes in MINOCA.

Methods

Patients with MINOCA undergoing early coronary angiography between 2009 and 2016 were extracted from a clinical database. Patients were followed until 2018 for outcome events. All patients with a MINOCA diagnosis and without history of atrial fibrillation were included. A total of 646 consecutive patients were enrolled. The primary end point was major adverse cardiac events (MACE) defined as all-cause mortality, myocardial infarction (MI), stroke, and heart failure (HF). Secondary endpoints comprised all individual endpoints for the composite end-point. The relationship between treatments and outcomes was evaluated by using Kaplan-Meier survival analysis and Cox regression models.

Results

Mean age was 67.9±13.4 years and 31.6% were women. No patient was lost to follow-up. Mean left ventricular ejection fraction was 47.8±13.1%. At discharge, 87.2%, 82.5% and 79.5% of the patients were on statins, RAAS inhibitors and β-blockers, respectively. The majority (72.8%) were discharged on DAPT. During follow-up (Mdn 59 months), 303 (46.9%) patients experienced a MACE and 208 (33.4%) died. MI occurred in 98 patients (17.8%) and stroke in 31 patients (5.6%). HF admissions were also common (82, 14.9%). The hazard ratio (HR) for major adverse cardiac events was 0.31 (0.23–0.41) in patients on statins, RAAS inhibitors and β-blockers. For patients on DAPT the HR was 0.61 (0.48–0.78). In univariate Cox regression analyses, a reduced risk of MACE was found in patients using combined secondary prevention therapies (HR 0.58, 0.46–0.74). Regarding the individual endpoints, combined secondary prevention therapy reduced the risk of stroke (HR 0.45, 0.22–0.99, P=0.04) but not risk of future MI nor HF admissions. Patients in the combined therapy group had a higher median survival (66 months, IQR 27–82 months) than the group without secondary prevention (34.5 months, IQR 6.8–74 months; P&lt;0.001 of Log Rank test for equality of survivor functions). In a multiple Cox regression analysis including RAAS inhibitors, statins, DAPT and β-blockers in the model, none of these drugs was associated with lower MACE, except for RAAS inhibitors.

Conclusions

The results indicate long-term beneficial effects of treatment with secondary prevention medical therapies in patients with MINOCA. Properly powered randomized clinical trials are warranted.

Funding Acknowledgement

Type of funding sources: None.

Predictors of AF recurrence in patients with paroxysmal AF undergoing catheter ablation: new predictors coming?

Introduction

Recurrence of atrial fibrillation (AF) after catheter ablation (CA) is estimated to be between 20% and 45% and the prediction of recurrence AF in patients (pts) with paroxysmal AF undergoing CA remains challenging.

Purpose

To determine the clinical and procedural predictors of recurrence AF after CA in pts with paroxysmal AF.

Methods

Single-centre retrospective study that included all pts with paroxysmal AF who underwent AF CA between 2017 and 2019. Ablation procedures included radiofrequency and second-generation cryoballoon CA. All pts underwent cardiac computed tomography prior the procedure. AF recurrence was defined as any recurrence of AF, atrial flutter or atrial tachycardia &gt;30 seconds (recorded in 12-lead electrocardiogram or Holter) after 90 days of CA. The independent association between clinical and procedural variables and AF recurrence was evaluated with Cox regression analysis.

Results

We included 351 pts, 63,5% male and with a mean age of 57,1±11,4 years. CHADSVASCscore ≥2 points were present in 43,7% of the pts, median duration of AF prior the intervention was 3 years (IQR 1–6) and most pts were treated with some antiarrhythmic drug at the time of CA (56,9%). Overall, median follow-up was 27 months (IQR 19–39).

AF recurrence was present in 96 pts (27,4%), on average, 15,2±10,4 months after CA.

Univariate logistic regression identified female gender, thyroid disease, left atrium (LA) enlargement (defined as LA indexed volume &gt;34 mL/m2 or LA diameter &gt;38mm for female or &gt;40mm for male), coronary calcium score &gt;100, epicardial adipose tissue volume, number of previous electric cardioversions, treatment with antiarrhythmic drugs prior CA and the extent of CA (only pulmonary vein isolation (PVI) or PVI and ablation of other lesions) as predictors of recurrence AF after CA in pts with paroxysmal AF (p&lt;0,05 for all).

Cox regression analysis identified female gender (OR 1,615, 95% CI 1,005–2,597; p=0,008), LA enlargement (OR 2,084, 95% CI 1,207–3,596; p=0,008) and coronary calcium score &gt;100 (OR 1,958, 95% CI 1,133–3,385; p=0,016) as independent predictors of AF recurrence.

Conclusions

In our cohort, AF recurrence was significantly higher in pts with LA enlargement, with coronary calcium score &gt;100 and female gender pts.

Funding Acknowledgement

Type of funding sources: None.

Early aortic valve replacement in asymptomatic severe aortic stenosis with preserved ejection fraction

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. Specific timing of intervention for asymptomatic patients with severe aortic stenosis and preserved ejection fraction remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic AS patients with preserved ejection.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both interventional or observational studies comparing early-AVR with WW in the treatment of asymptomatic severeAS with preserved ejection fraction criteria. Random-effects meta-analysis was performed.

Results

Eight studies were included in which two were randomized clinical trials. A total of 2672 patients were included, providing a 642 pooled death events (327 in early-AVR and 941 in watchful waiting). In our meta-analysis, early-AVR revealed a significant lower all-cause mortality (pooled OR, 0.39; 95% CI [0.30, 0.51], P&lt;0.01; I2=47%). Additionally, the early-AVR group presented a lower rate of cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P&lt;0.01; I2=64%). Both strategies had similar rate of stroke (pooled OR, 1.30; 95% CI [0.39, 4.27], P=0.67; I2=0%) and myocardial infarction (pooled OR, 0.49; 95% CI [0.14, 1.78], P=0.28; I2=0%). Heart Failure hospitalizations presented a lower trend early-AVR group (pooled OR, 0.22; 95% CI [0.05, 1.08], P=0.36; I2=36%).

Conclusion

Our pooled data suggests that early-AVR strategy is preferable for asymptomatic severe AS patients with preserved ejection fraction.

Funding Acknowledgement

Type of funding sources: None.

Predictors for NYHA recovery and 1-year mortality after mitral TEER

Background

Mitral regurgitation (MR) is the second-most frequent valvular heart disease in Europe and frequently aggravates heart failure (HF) symptoms. Mitral transcatheter-edge-to-edge repair (TEER) can be considered in eligible patients, for both primary (in inoperable cases) or secondary severe MR. However, intervention is not advised in severe comorbid patients in whom it is not expected to prolong survival for over 1 year.

Purpose

Evaluate characteristics associated with HF New York Heart Association (NYHA) class recovery, and one-year all-cause mortality after mitral TEER for severe MR.

Methods

All mitral TEER procedures for primary and secondary MR conducted in a single-centre between 2014 and 2020 were retrospectively analyzed. The primary endpoint was defined as a reduction of at least one NYHA class in the first month after intervention, and a secondary endpoint considered a recovery of at least two NYHA classes. Survival status 12 months after mitral TEER was also consulted. Clinical, echocardiographic and blood-analysis data were explored as characteristics associated with the endpoints defined, using Pearson's Chi-squared test, Wilcoxon rank sum test and Fisher's exact test, as appropriate. A p&lt;0.05 was considered statistically significant.

Results

From 103 mitral TEER procedures, 86 (83%) had full information about pre- and post-intervention NYHA class, as well as survival status at 12 months. There was a higher proportion of primary MR among NYHA non-responders (47% versus 25%, p=0.034), but no differences for secondary MR. Higher surgical risk patients (EuroSCORE II) tended to have exhibit more NYHA recovery, though not reaching statistical significance (p=0.068). Both a more advanced NYHA class at baseline and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels were linked to a higher symptomatic recovery (2048 versus 5676pg/ml, p&lt;0.001). Also, persisting MR after TEER of at least grade 3/4 was more frequent in non-NYHA responders. Regarding NYHA improvement of at least two classes, it was observed in 13% patients, and these also had a more advanced NYHA class at baseline and lower NTproBNP basal levels, and exhibited a lower estimated systolic pulmonary artery pressure and inferior vena cava (IVC) diameter. Finally, 10 (11.6%) of mitral TEER patients died in the first 12 months, and no statistically significant associations were found regarding pre-intervention characteristics and survival.

Conclusions

This study suggests that three-fifths of severe MR improve their NYHA class after TEER, but only one-fourth for primary MR. Earlier intervention – with lower NTproBNP levels, less severe pulmonary hypertension, and lower IVC diameters – is associated with more symptomatic HF improvement. All-cause mortality in the first year is still significant, exposing a need for better patient selection. However, these findings represent exploratory deductions of a relatively low number, single-centre, patients.

Funding Acknowledgement

Type of funding sources: None.

Early intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

Background

Aortic stenosis (AS) is the most common valvular disease in developed countries. However, the specific timing of intervention for asymptomatic patients with severe AS remains controversial.

Purpose

To compare the outcomes of early aortic valve replacement (AVR) versus watchful waiting (WW) in asymptomatic patients with AS.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for both interventional or observational studies comparing early AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis was performed.

Results

Thirteen studies were included in which two were randomised clinical trials. A total of 4,679 patients were included, providing a 1,268 pooled death events (327 in early AVR and 941 in WW). Our meta-analysis showed a significantly lower all-cause mortality for the early-AVR compared with WW group, although with a moderate amount of heterogeneity between studies in the magnitude of the effect (pooled odds ratio [OR], 0.41; 95% confidence interval [CI] 0.34, 0.50, P&lt;0.01; I2=60%). An early surgery strategy displayed a significantly lower cardiovascular mortality (pooled OR, 0.33; 95% CI [0.19, 0.56], P&lt;0.01; I 2=64%) and heart failure hospitalisations (pooled OR 0.19; 95% CI [0.10, 0.39], P&lt;0.01, I2=7%). However, both groups had similar rates of stroke (pooled OR 1.30; 95% CI [0.73, 2.29], P=0.36, I2=0%) and myocardial infarction (pooled OR 0.49; 95% CI [0.19, 1.27], P=0.14, I2=0%).

Conclusions

Our pooled data suggest that an early-AVR strategy is preferable for asymptomatic patients with severe AS.

Funding Acknowledgement

Type of funding sources: None.

Meta-analysis comparing outcomes in patients undergoing transcatheter aortic valve implantation with versus without percutaneous coronary intervention

Background

Patients having transcatheter aortic valve implantation (TAVI) routinely undergo coronary angiography before the procedure to define the coronary anatomy and to evaluate the extend of coronary artery disease (CAD). Whether percutaneous coronary intervention (PCI) prior/concomitant with TAVI confers any additional clinical benefit in patients with CAD remains unclear.

Purpose

To compare the outcomes of PCI prior to TAVI in patients with significant coronary artery disease and severe aortic stenosis.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in November 2021, for both retrospective and prospective studies comparing TAVI with PCI versus TAVI alone. Random-effects meta-analysis was performed.

Results

Eleven studies were included in which one was a randomized clinical trial. A total of 2530 patients were included, providing a 145 pooled death events (64 in TAVI with PCI and 81 in TAVI only). In terms of 30-day clinical outcomes, our pooled analysis revealed a similar all-cause mortality (pooled OR, 1.24; 95% CI [0.80, 1.93], P=0.34; I2=27% - Figure), cardiovascular mortality (pooled OR, 1.44; 95% CI [0.56, 3.75], P=0.45; I2=57%) and stroke (pooled OR, 1.07; 95% CI [0.53, 2.13], P=0.86; I2=0%). However, our analysis revealed a higher rate of myocardial infarction (pooled OR, 4.28; 95% CI [1.56, 11.69], P&lt;0.01; I2=0%) and major bleeding events (pooled OR, 1.40; 95% CI [1.02, 1.93], P=0.04; I2=0%) in the TAVI with PCI group. A 1-year clinical outcomes analysis revealed a trend for lower all-cause mortality in TAVI only group (pooled OR, 1.37; 95% CI [0.98, 1.91], P=0.06; I2=0%), similar cardiovascular death rate (pooled OR, 1.15; 95% CI [0.70, 1.89], P=0.59; I2=6%) and major bleeding events (pooled OR, 1.62; 95% CI [0.95, 2.76], P=0.07; I2=0%).

Conclusion

Our pooled data suggests that PCI with TAVI in patients with severe aortic stenosis and concomitant CAD grants no additional clinical advantage.

Funding Acknowledgement

Type of funding sources: None.

Modeling aortic stenosis progression: impact on follow-up, treatment and survival

Background

Aortic stenosis (AS) is one of the main valvular heart diseases in developed countries. Degenerative fibrocalcific aortic stenosis is a progressive disease of the valve and ultimately of the myocardium, which can be fatal when symptomatic. There is no medical treatment that can halt or delay its progression. AS does not evolve linearly over time, and not every patient has the same progression rate.

Aims

The aim of this study is to 1) compare different mathematical models of aortic stenosis progression, 2) cluster patients into rapid and slow progressors and explore possible predictors, 4) evaluate the impact of different progression rates on cardiac structure and function, and 5) evaluate survival and optimal timing for follow-up and treatment.

Methods

We retrospectively studied consecutive patients with aortic peak velocities from 2012 to 2020. Follow-up echocardiograms, seriated biomarker assessment, and clinical records were consulted, providing a multiparametric data frame for longitudinal and dynamic modeling of aortic stenosis progression and its consequences.

Results

This study included 9583 studies from 752 patients with a median total follow-up of 4.26 years (interquartile range: 1.28 to 7.24 years). A logistic model was selected with the best accuracy to predict the rate of AS progression. Patients were categorized into slow and rapid progressors in a ratio of 5:1. Multiparametric analysis showed no association between these profiles and clinical variables. However, anti-hypertensive drugs before and after adjustment for blood pressure control (Calcium Channel Blockers, p=0.013, OR 0.50) were associated with slower progression. Meanwhile, elevated inflammatory markers (erythrocyte sedimentation rate, p=0.01) were associated with faster AS progression. Despite no survival difference between these groups, higher rates of valvular intervention were registered in rapid progressors (p&lt;0.001). Moreover, faster progressors were associated with earlier cardiac damage (as demonstrated by early onset of moderate mitral and tricuspid valve regurgitation, left auricle dilation, and left ventricle hypertrophy, p&lt;0.05).

Conclusions

These results can potentially modify follow-up times and deliver more personalized and individualized health care to different AS patients, thereby optimizing resources.

Funding Acknowledgement

Type of funding sources: None.

Concomitant tricuspid repair in mitral regurgitation surgery: a systematic review and meta-analysis

Background

Tricuspid Regurgitation (TR) is common in patients with severe mitral disease. However, the evidence is insufficient to inform a decision about whether to perform prophylactic tricuspid-valve repair during mitral-valve surgery in patients who have moderate TR or less-than-moderate regurgitation.

Purpose

To compare the outcomes of concomitant tricuspid repair in mitral valve surgery versus no concomitant tricuspid repair in less-than-severe TR patients.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in December 2021, for interventional studies comparing concomitant tricuspid repair in mitral valve surgery versus no tricuspid intervention. Random-effects meta-analysis was performed.

Results

Four randomised trials were included, providing a total of 651 patients (323 in prophylactic tricuspid intervention group and 328 patients in conservative group). Our meta-analysis showed a similar all-cause mortality for concomitant prophylactic tricuspid repair compared with no tricuspid intervention (pooled OR, 0.54; 95% CI [0.25, 1.15], P=0.11; I2=0%). Additionally, there is a similar New York Heart Association (NYHA) III–IV classes in both groups, despite a lower trend in the tricuspid intervention group (pooled OR, 0.63; 95% CI [0.38, 1.06], P=0.08; I2=0%) (Figure 3). However, there was a significant lower progression of TR (pooled OR, 0.06; 95% CI [0.02, 0.24], P&lt;0.01; I2=0%) and moderate-severe TR (pooled OR, 0.23; 95% CI [0.11, 0.46], P&lt;0.01; I2=27%).

Conclusions

Our pooled analysis suggests that a tricuspid-valve repair at the time of mitral-valve surgery in patients with moderate or less-than-moderate TR does not impact perioperative or postoperative all-cause mortality, despite reducing TR severity and progression of TR following intervention.

Funding Acknowledgement

Type of funding sources: None.

POS0564 SHOULD WE USE PHYSICIAN’S GLOBAL TO DEFINE REMISSION IN RHEUMATOID ARTHRITIS AND CONSIDER A SEPARATE PATIENT-CENTRED TARGET?

Background

The definitions of remission play a crucial role in the treat-to-target strategy in rheumatoid arthritis.The patient’s and physician’s global assessment (PGA|PhGA) of disease activity are considered in current definitions, but PGA has been criticized for its poor relationship with actual disease activity. This leads to a considerable risk of overtreatment in patients who are otherwise in remission but fail this target solely because of PGA: PGA-near-remission. A dual-target strategy, excluding PGA from the definition of biological remission and the creation of a second target focused on disease impact has been proposed.1 Another proposal is to substitute PGA by PhGA with the purpose of strengthening the definition with a fourth variable capable of conveying relevant unaccounted factors, such as comorbidity.2

Objectives

To assess the relationship of PGA and PhGA with objective measures of disease activity (DAS3v) and their impact upon near-remission and risk of overtreatment.

Methods

This is a cross-sectional analysis of data from RAID.PT, an observational, prospective and multicenter study, including adult patients fulfilling RA classification criteria. Tender (TJC28) and swollen (SJC28) 28 joint counts, C-Reactive Protein (CRP), Pain score, Health Assessment Questionnaire (HAQ), the Rheumatoid Arthritis Impact of Disease (RAID) total score, Hospital Anxiety and Depression Scale (HADS) scores, PGA and PhGA were collected. Disease Activity Score (DAS28-3v-CRP) was calculated and taken as the reference measure of current disease activity. Correlation between PGA and PhGA with other continuous variables was evaluated through Pearson´s Correlation Coefficient and variables with p<0.10 in univariate analysis were included in multivariable linear regression models.

Results

We included 299 patients, 81.3% women, mean age of 57.4±12.0 years and disease duration 9.4±9.5 years. Average DAS28-3v-PCR 2.4 (±1.9).

DAS3v-CRP is the strongest factor associated with PhGA, explaining 45% of its variance. Inversely, it only explains 2% of the variance of PGA, which is more affected by disease impact.

In this clinical cohort, 13% of patients were in full Boolean remission and 41% in PGA-near-remission. Only 49 of 123 patients in the latter group had a PhGA >1.

Considering PhGA instead of PGA in the Boolean definition of remission would increase the proportion of remission from 13 to 37.5% of the whole cohort.

Table 1.

Factors Associated with PGA and PhGA in multivariate regression analysis

PGAPhGA(β, 95% CI)(β, 95% CI)(β, 95% CI)ΔR2ΔR2DAS28-3v-CRP3.7 (1.9-5.5)10.9 (9.4 to12.5)0.020.45RAID7.7 (6.7-8.8)3.4 (2.5 to 4.3)0.610.09HAQ5.6 (1.0-8.1)-3.4 (-6.4 to -0.4)0.010.01R20.64*0.55*

DAS28-3v-CRP: Disease Activity Score-3 variables C-Reactive Protein. PGA: Patient global assessment; PhGA: Physician Global Assessment; HAQ (health assessment questionnaire); RAID: Rheumatoid Arthritis Impact Disease score. ΔR2 change of R2associated with the inclusion of the variable in the model. *p<0,01

Conclusion

PhGA is a closer representation of actual disease activity than PGA, thus providing a more valid basis for treatment decisions aimed at disease activity. These observations support the substitution of PGA by PhGA in the Boolean definition of remission as it would strengthen the representation of disease activity and significantly reduce the risk of overtreatment in comparison to current definitions. The consequences of this change upon the prediction of long-term function and structural stability warrant evaluation. The patient’s perspective will remain central to disease management in the form of a distinct target.

References

[1]Ferreira et al. Ann Rheum Dis 2019 Oct;78(10):e109.doi: 10.1136/annrheumdis-2018-214199

[2]Pazmino et al. J Rheumatol. 2021 Feb;48(2):174-178.doi: 10.3899/jrheum.200758

Disclosure of Interests

None declared.

Inflammation in acute coronary syndrome: prognostic significance

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with acute coronary syndrome (ACS) the acute phase reactant, C-reactive protein (CRP), might be significantly elevated. Several reports suggest that CRP may play a direct pathophysiological role on the development and progression of atherosclerosis, and CRP values correlate with infarct size when measured by magnetic resonance imaging.

Purpose

The aim of the present study was to evaluate the prognostic value of CRP in patients presenting with an ACS.

Methods

Retrospective analysis of 635 consecutively admitted patients due to ACS in a single coronary intensive care unit. CRP levels were measured at admission. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether CRP was an independent predictor of outcome.

Results

In the studied sample, 75% were male. Median age was 69 [interquartile range (IQR) 57–78]. ST-elevation myocardial infarction (STEMI) occurred in 39.6%, non-ST segment elevation myocardial infarction in 44.9% and unstable angina in 15.5% of the patients. Median left ventricular ejection fraction (LVEF) was 48% (IQR 40–55%) and median CRP level at admission 0.7 mg/dL (IQR 0.5–1.9 mg/dL). Regarding important comorbidities and past medical history, 75.9% had hypertension (HTN), 34.0% diabetes, 20.3% chronic kidney disease (CKD), 68.6% dyslipidaemia and 17.3% heart failure (HF). The median follow-up was 34 months (IQR 22–72). In univariate analysis, CRP was significantly associated with all-cause mortality (HR 1.06 per 1 mg/dL increase, 95% CI 1.04–1.08, p&lt;0.001), as was gender, age, LVEF, STEMI and previous history of diabetes, HTN, CKD or HF. In multivariate analysis, CRP remained significantly associated with the primary endpoint (HR 1.02, 95% CI 1.00–1.05, p=0.033), as did age, LVEF and previous history of HF.

Conclusions

In our study, CRP at admission was an independent risk factor for all-cause mortality following an ACS. This finding indicates that inflammation associated with the acute event has a significant impact in the long-term prognosis. More evidence is needed to determine if treating inflammation (and when, in the course of the disease) could result in better outcomes.

Peri-Operative Desensitization for Highly Sensitized Lung Transplant Recipients Following COVID-19 Acute Respiratory Distress Syndrome (ARDS) - Report of Two Cases

Introduction

Sensitized lung transplant (LTx) candidates have longer waiting times, decreased likelihood of transplant, and increased risk of death while on the waitlist. Patients with SARS-Cov-2 ARDS on ECMO support due to end-stage lung disease have a short window of opportunity for LTx. We report two cases in which the Toronto LTx peri-operative strategy was performed with good outcomes in highly sensitized Covid-19 patients.

Case Report

Case 1: 31-yo female patient with Covid-19 ARDS, transferred for LTx evaluation after 46 days on VV-ECMO. She was pregnant when she presented with Covid -19 acute respiratory failure, and underwent an urgent C-section due to fetal distress. She required blood transfusions during ICU stay. At LTx assessment: PRA class I: 95%; class II: 0%. A decision to proceed with LTx with perioperative desensitization was made considering the low probability of finding a suitable donor. After seven days on the waiting list, she underwent bilateral LTx. Virtual crossmatch (XM) positive (B35); CDC-XM negative. Desensitization protocol was performed with perioperative plasma exchange (PLEX) without basiliximab induction, followed by five sessions of PLEX and intravenous immunoglobulin 1 mg/kg. Due to postoperative acute cholecystitis with positive cultures after biliary drainage, anti thymocyte globulin (ATG) infusion (3 mg/kg) was held, and infusion postponed until four weeks post LTx. Tacrolimus, mycophenolate, and prednisone were used as maintenance immunosuppression. The patient was discharged home on PO day 53 with excellent graft function. Case 2: 35-yo female patient with Covid-19 ARDS, transferred for LTx after 69 days on VV-ECMO. History of 3 previous pregnancies and multiple blood transfusions due to transitory coagulopathy during her ICU stay. PRA class I: 83%; class II: 94%. VCM positive (B7, Cw7, DRB1*11:01, DR52, DQA1*05/DQB1*03). Desensitization protocol was performed, but ATG infusion was held due to C. albicans bloodstream infection and colonization with pan-resistant K. pneumoniae. DSAs at six weeks were negative. She remains hospitalized for mechanical ventilation withdrawal and inpatient rehabilitation.

Summary

In selected cases, peri-operative desensitization is feasible and can be safely implemented in highly sensitized patients with Covid-19 ARDS.

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

Introduction

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

Methods

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

Results

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

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

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

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

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

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.

Predictors of early and late recurrence of atrial fibrillation after catheter ablation: two sides of the same coin?

Background

Recurrence of atrial fibrillation (AF) after catheter ablation (CA) is estimated to be between 20% and 45%. Recurrent AF early after ablation is generally classified as benign as a part of a blanking period, but recently has been associated with later recurrent AF. The prediction of early and late AF recurrence after CA remains challenging as well as the predictive value of early AF recurrence in the blanking period.

Purpose

We aimed to determine the clinical and procedural factors associated with early and late recurrence of AF after CA.

Methods

Single-centre retrospective study that included all patients who underwent AF CA between January 2017 and October 2019. Ablation procedures included radiofrequency and second-generation cryoballoon CA. Early recurrence of AF (ERAF) was defined as any recurrence of AF &gt;30 seconds within 90 days after CA and late recurrence (LR) was defined as any recurrence of AF &gt;30 seconds after 90 days of CA. The independent association between clinical and procedural variables and AF recurrence was evaluated with logistic regression analysis.

Results

We included 399 patients, 64,7% male, with a mean age of 56,8±11,6 years, most of them had paroxysmal AF with a mean duration until CA of 3,5±3,4 years.

Early recurrence of AF occurred in 51 patients (12,8%). After multivariate logistic regression, we identify left atrium (LA) diameter [odds ratio (OR) 1,1, 95% confidence interval (CI) 1,03–1,18; p=0,007] as the only independent predictor associated with recurrent AF.

Late recurrence of AF was observed in 104 patients (26,1%), on average, 12,8±8,7 months after CA. After multivariable adjustment, LA diameter (OR 1,1, 95% CI 1,01–1,12; p=0,032) and intraprocedural electric cardioversion (OR 1,8, 95% CI 1,03–3,12; p=0,040) were independently associated with recurrent AF.

Regarding patients with ERAF, most of them also had late recurrent AF (64,7%), whereas in patients without ERAF, only 20,4% had LR (p&lt;0,001). After including ERAF in the multivariate logistic regression, we identify ERAF as the only independent predictor of late recurrence of AF (OR 5,23, 95% CI 2,56–10,72; p&lt;0,001).

Conclusions

In our cohort, late recurrence of AF after catheter ablation was significantly higher in patients with recurrence within the blanking period, which was the only independent predictor of AF late recurrence.

Funding Acknowledgement

Type of funding sources: None.

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

Introduction

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

Methods

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

Results

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

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

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

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

Conclusion

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

Funding Acknowledgement

Type of funding sources: None.

Prognostic significance of percutaneous coronary intervention associated blood loss in acute coronary syndrome

Background

Antiplatelet and anticoagulants are one of the mainstay treatment of acute coronary syndrome (ACS), however they are associated with a significant increase of bleeding risk. While anaemia is a recognized predictor of adverse outcomes, it is unknown if a variation of haemoglobin (HB) levels, even without associated anaemia, has the same impact.

Purpose

The aim of this study was to determine the prognostic impact of HB variation after percutaneous coronary intervention (PCI) in ACS patients.

Methods

Retrospective analysis of 822 consecutive patients admitted due to ACS and treated with PCI, in a single coronary intensive care unit. Delta HB – ΔHB – (HB at admission – HB 24 hours after PCI) was calculated. Clinical variables and therapeutic strategies were examined. The primary endpoint analysed during follow-up was all-cause mortality. Possible predictors for all-cause mortality were assessed by Cox regression models. When statistically significant values were found in univariate analysis, multivariate analysis was used to determine whether ΔHB was independent from other known factors in predicting the outcome.

Results

In the studied sample, 75.4% were male. Mean age was 66.4±13.1. ST-elevation myocardial infarction (STEMI) occurred in 45.5%, non-ST segment elevation myocardial infarction in 42.6% and unstable angina in 11 9% of the studied population. Moderate to severe systolic dysfunction was present in 23.5% of the cases. Regarding comorbidities and past medical history, 76% had hypertension (HTN), 30.3% diabetes, 16.4% chronic kidney disease (CKD), 62.2% dyslipidaemia and 10.5% heart failure (HF). Mean HB at admission was 13.8±1.8 g/dL, mean HB after PCI was 12.9±1.9 g/dL and mean ΔHB was 0.9±1.1 g/dL. The mean follow-up was 51.6±30.6 months. In univariate analysis, ΔHB was significantly associated with all-cause mortality (HR 1.15 per 1 g/dL loss, 95% CI 1.01–1.30, p=0.04), as was HB at admission, HB after PCI, age, sex, diabetes, HTN, dyslipidaemia, CKD and moderate to severe systolic dysfunction. In multivariate analysis, ΔHB remained significantly associated with the endpoint and gained even more statistical power (HR 1.25, 95% CI 1.10–1.43, p&lt;0.01). HB at admission and after PCI, age, CKD and moderate to severe systolic dysfunction were also independent predictors of this outcome.

Conclusions

In our study, irrespective of the admission and discharge HB, ΔHB was associated with more adverse outcomes in patients submitted to PCI. Hence, even patients with a normal HB after PCI have a worse long-term prognosis if a negative variation of HB occurs. This highlights the importance of identifying and optimising all the correctable factors that might lead to an increased bleeding risk.

Funding Acknowledgement

Type of funding sources: None.

Efficacy and safety of direct oral anticoagulants with diabetes and nonvalvular atrial fibrillation: a systematic review and meta-analysis

Background

Diabetes Mellitus (DM) is an independent risk factor for stroke and atrial fibrillation (AF). Therefore, the risk/benefit profile of the direct oral anticoagulants (DOAC) is of clinical interest.

Purpose

To compare efficacy and safety outcomes of DOAC for nonvalvular AF in patients with DM versus without DM.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in January 2020, for interventional studies comparing DOAC efficacy and safety in patients with AF and diabetes versus without diabetes.

Results

Four randomized clinical trials were included, providing a total of 63987 patients, 18860 with DM and 45127 without DM. In terms of efficacy, our meta-analysis revealed a similar rate of stroke/systemic embolism (pooled OR 1.02 [0.79, 1.31], P=0.87, I2=83%), stroke (pooled OR 1.98 [0.68, 1.40], P=0.90, I2=90%) and all-cause mortality (pooled OR 1.18 [0.97, 1.43], P=0.10, I2=87%), albeit with a significant heterogeneity. However, in direct factor Xa inhibitors sub analysis, diabetic patients had a lower trend of systemic embolism/stroke (pooled OR 0.90 [0.79, 1.02], P=0.09, I2=18%), significantly lower stroke rate (pooled OR 0.82 [0.73, 0.93], P&lt;0.01, I2=0%), but a higher all-cause mortality (pooled OR 1.08 [1.00, 1.16], P&lt;0.01, I2=0%). In terms of safety, the diabetic patients receiving DOAC had higher rates of major bleeding events (pooled OR 1.28 [1.14, 1.45], P&lt;0.01, I2=50%), although with significant heterogeneity. Direct factor Xa inhibitors sub analysis also revealed a higher rate of major bleeding events (pooled OR 1.22 [1.08, 1.38], P&lt;0.01, I2=24%), but a similar intracranial bleeding events (pooled OR 1.03 [0.86, 1.24], P=0.72, I2=0%).

Conclusion

Our pooled analysis suggests that diabetic patients on DOAC have an higher bleeding risk on DOAC, although with a superior embolic protection.

Funding Acknowledgement

Type of funding sources: None. Systemic Embolism/Stroke in DM vs. NonDM

Direct oral anticoagulants compared with vitamin K antagonists for left ventricular thrombi systematic review and meta-analysis

Background

Left ventricular thrombus (LVT) is a serious complication primarily occurring in patients with LV dysfunction following large myocardial infarction. The role of direct oral anticoagulants in this clinical setting remains controversial.

Purpose

To compare DOACs versus vitamin K antagonists (VKA) in LVT treatment.

Methods

We systematically searched PubMed, Embase and Cochrane databases, in February 2020, for interventional or observational studies comparing DOAC with VKA on LVT treatment.

Results

Fourteen publications were included, nine published studies and five conference abstracts, providing 1899 patients, 490 patients on DOACs and 1409 subjects on VKA. In terms of efficacy, DOAC had a lower LVT resolution for all studies included which reported LVT resolution (pooled OR, 0.73; 95% CI, 0.55–0.98; P=0.04; I2=52%), but sensitivity analysis revealed no difference between anticoagulant strategy (pooled OR, 0.78; 95% CI, 0.57–1.05; P=0.10; I2=59%). In terms of systemic embolism or stroke, DOAC had a similar efficacy (pooled OR, 1.06; 95% CI, 0.69–1.63; P=0.78; I2=30%) compared to VKA. In clinically relevant bleeding events analysis, the anticoagulation strategy did not differ in the odds of bleeding (pooled OR, 0.65; 95% CI, 0.37–1.15 P=0.14; I2=0%), with similar findings in net adverse clinical events analysis (pooled OR, 0.66; 95% CI, 0.35–1.25; I2=54%; P=0.20).

Conclusion

Our pooled data suggests DOACs as a safe approach to LVT, despite inconsistent efficacy on LVT resolution.

Funding Acknowledgement

Type of funding sources: None.

Cryoballoon versus radiofrequency guided by ablation index for atrial fibrillation ablation: a retrospective propensity-matched study

Background/Introduction

Radiofrequency (RF) and cryoballoon (CB) ablation are established techniques for the treatment of atrial fibrillation (AF). Randomized trials comparing both techniques show similar levels of success; however, studies comparing CB with RF guided by ablation index (AI) are lacking.

Purpose

To compare the treatment success of CB with RF guided by AI, in patients with paroxysmal or persistent AF undergoing their first ablation procedure.

Methods

Patients undergoing AF ablation between 2017 and 2019 were retrospectively analysed. Primary success outcome was freedom from recurrence (defined as any episode of AF, atrial flutter or atrial tachycardia lasting &gt;30 seconds and occurring after 91 days from ablation, or need for antiarrhythmic drugs (AAD), cardioversion or redo procedure). Secondary end-point was a composite of adverse cardiovascular outcomes (stroke/TIA, emergency room visit for AF, hospitalization for AF or cardiovascular death). Analysis was done before and after propensity score matching.

Results

A total of 316 patients were included. Mean age was 56.9±11.7 years. Sixty-two percent were male (n=196). Paroxysmal AF was present in 80.7% (n=255), with no difference between groups. RF was used in 57.9% (n=183) and CB in 42.1% (n=133), with isolation of all pulmonary veins accomplished in 95.9% (n=302), without differences between groups. Mean CHA2DS2-VASc score was 1.5±1.3, being higher in the RF group (1.7±1.3 vs 1.2±1.1; p=0.03); these patients were also older (mean age 58.1±12.0 vs. 55.17±11.0 years; p=0.007) and more likely to be in AF at the ablation (26.7% vs. 16.5%; p=0.006), have chronic kidney disease (40.2% vs. 23.2%; p=0.002), anaemia (11.8% vs. 2.7%; p&lt;0.001), moderate/severe mitral disease (17.5% vs. 7.4%; p=0.012) or history of atrial flutter (17.7% vs. 3.1%; p&lt;0.001). Patients in the CB group had a longer history of AF (3.8±3.5 vs. 3.0±2.9 years; p=0.041), received treatment with AAD more often (60.9% vs. 55.9%; p=0.049) and had longer follow-up time (889±397 vs. 601±239 days; p&lt;0.001). Mean freedom from recurrence was not significantly different between groups (1106 days for CB vs. 889 days for RF; p=0.793), and recurrence rates were also similar (27.8% for CB vs. 23.5% for RF; p=0.291); however, patients treated with CB were more likely to need a redo procedure (38.3% vs. 17.4%; p=0.025). There were no differences in the composite of adverse cardiovascular events or in individual outcomes. Propensity score matching was done, and 154 patients were matched 1:1 for each treatment group. Survival free from recurrence showed no differences (1060 days for CB vs. 864 days for RF; p=0.912), and neither did the recurrence rate. CB patients with recurrence were still more likely to need a redo procedure (37.9% vs. 11.1%; p=0.021).

Conclusion

RF and CB result in similar survival free from AF and AF recurrence; however, recurrence in CB seems more significant, leading to higher rates of redo procedures.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar de Vila Nova de Gaia/Espinho

Conquering stroke epidemiological statistics in Brazil an innovative initiative from the Brazilian Society of Cardiology

Background

Stroke has been the second major cause of death in Brazil in the last decades. A better understanding on epidemiological statistics as well as on the diseases burden is crucial for enabling stakeholders to better tackle the disease.

Purpose

This project aims to continuously monitor and evaluate the data sources on heart disease and stroke in Brazil to provide the most up-to-date information on the epidemiology of these diseases to Brazilian society annually.

Methods

This initiative is based on the Heart Disease & Stroke Statistics Update methodology of the American Heart Association, with the support of the Brazilian Society of Cardiology, the Global Burden of Diseases Brazil network and an international committee. The project incorporates official statistics provided by the Brazilian Ministry of Health and other government agencies, as well as data generated by other sources and scientific studies on heart disease, stroke, and other CVD, including GBD/IHME data.

Results

The age-standardized prevalence rates per 100.000 for ischemic stroke in 1990 was 1327,6 (1151.2 to 1516) and 870.1 (761.1 to 992.8) in 2019 representing a percent change of −34.5 (−36.7 to −0.3). The age-standardized prevalence rates for intracerebral hemorrhage in 1990 was 507.5 (438.9 to584.1) and 315.9 (275 to 361.4) in 2019 representing a percent change of −37.7 (−40.5 to −0.3). The age-standardized incidence rates for stroke in 1990 was 224.6 (201.6 to 251.8) and 127 (113.8 to 142.1) in 2019 representing a percent change of −43.5 (−44.7 to −0.4). the age-standardized mortality rates for stroke in 1990 was 137.8 (127.8 to 144) and 58.1 (52.6 to 61.8) in 2019 representing a percent change of −57.8 (−60.4 to −0.6). The age-standardized DALY rates for stroke in 1990 was 2959 (2829.6 to 3063) and 1219.6 (1142 to 1285.5) in 2019 representing a percent change of −58.8 (−61 to −0.6).

Conclusion

This project represents a fundamental step on a better understanding on the stroke epidemiology in Brazil. While we observed a significant decrease in mortality rates from 1990 to 2019, we also raise a concern on a possible shift for a plateau curve or even increased rates in the next years.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Brazilian Society of Cardiology

The burden of ischaemic heart disease in Brazil from 1990 to 2019 and the association between temporal changes and socioeconomic level

Introduction

The burden of ischaemic heart disease (IHD) has declined in several countries, although IHD remains the leading cause of death globally. Brazil is a large country with high inequality in income distribution across different regions.

Purpose

This study sought to evaluate the burden of IHD in Brazil from 1990 to 2019, as well as the relationship between temporal changes and socioeconomic level of the Federative Units.

Methods

Estimates of prevalence, mortality, and disability-adjusted life-years (DALYs) due to IHD were retrieved from the Global Burden of Disease Study 2019. We used databases from the Ministry of Health of Brazil to obtain the number of hospitalisations from acute coronary syndrome (ACS) and acute myocardial infarction (AMI) in the context of the public service. The Socio-demographic Index (SDI), a composite indicator of income per capita, average educational attainment, and fertility rate in females younger than 25 years, was used as a measure of socioeconomic status. Rates with 95% uncertainty intervals are reported.

Results

In 2019, the age-standardised prevalence rate of IHD was 1,709 (1,466–1,994) per 100,000 inhabitants. This rate remained stable from 1990 to 2019 (percent change: −1.1 [−2.6–0.5]). The estimate of deaths from IHD in 2019 was 171,246 (156,180–180,511), corresponding to 12% (11%-13%) of total deaths in the country (the leading cause) and 43% of all cardiovascular deaths. In 2019, the age-standardised mortality rate due to IHD was 75 (68–79) per 100,000. The unadjusted mortality rate due to IHD mildly increased from 2005 to 2019, while the age-standardised rate continuously decreased from 1990 to 2019 (cumulative percent change: −53 (−55 to −50, Figure 1). A negative correlation was observed between the change in age-standardised mortality rate from IHD in the period and the 2019 SDI (Figure 2). In 2019, the age-standardised DALY rate due to IHD was 1,563 (1,472–1,636) per 100,000. This DALY rate was equivalent to 5.7% (5.1%-6.3%) of total DALYs, meaning that IHD was the second most common cause of DALYs in Brazil in females and males. From 1990 to 2019, the crude DALY rate per 100,000 remained fairly stable, and the age- standardised DALY rate per 100,000 gradually declined (−50% [−52% to −48%]). There was a negative correlation between the change in age-standardised DALY rate from IHD in the period and the SDI (r2 0.59, p-value &lt;0.01). The number of hospital admissions for ACS remained stable from 2008 to 2019 (33 per 100,000 in 2019). The number of hospitalisations due to AMI increased from 25 per 100,000 in 2008 to 39 per 100,000 in 2019 (percent change: 52%).

Conclusions

While age-standardised mortality, DALY rates continuously decreased from 1990 to 2019, the burden of IHD in Brazil remains high, probably due to ageing and population growth. Reductions in age-standardised mortality, DALY rates over time tend to be more pronounced in more developed regions.

Funding Acknowledgement

Type of funding sources: None. Mortality rate (per 100,000)Change in mortality rate and SDI

Evaluation of Crizotinib Treatment in a Patient With Unresectable GOPC-ROS1 Fusion Agminated Spitz Nevi

Importance

Spitz nevi are benign melanocytic neoplasms that classically present in childhood. Isolated Spitz nevi have been associated with oncogenic gene fusions in approximately 50% of cases. The rare agminated variant of Spitz nevi, thought to arise from cutaneous genetic mosaicism, is characterized by development of clusters of multiple lesions in a segmental distribution, which can complicate surgical removal. Somatic single-nucleotide variants in the HRAS oncogene have been described in agminated Spitz nevi, most of which were associated with an underlying nevus spilus. The use of targeted medical therapy for agminated Spitz nevi is not well understood.

Observations

A girl aged 30 months presented with facial agminated Spitz nevi that recurred rapidly and extensively after surgery. Owing to the morbidity of further surgery, referral was made to a molecular tumor board. The patient's archival nevus tissue was submitted for extended immunohistochemical analysis and genetic sequencing. Strong ROS1 protein expression was identified by immunohistochemistry. Consistent with this, analysis of whole-genome sequencing data revealed GOPC-ROS1 fusions. These results indicated likely benefit from the oral tyrosine kinase inhibitor crizotinib, which was administered at a dosage of 280 mg/m2 twice daily. An excellent response was observed in all lesions within 5 weeks, with complete flattening after 20 weeks.

Conclusions and Relevance

Given the response following crizotinib treatment observed in this case, the kinase fusion was believed to be functionally consequential in the patient's agminated Spitz nevi and likely the driver mutational event for growth of her nevi. The repurposing of crizotinib for GOPC-ROS1 Spitz nevi defines a new treatment option for these lesions, particularly in cases for which surgery is relatively contraindicated.

Prevalence and predictor factors of persistent pulmonary vein isolation in redo AF ablation procedure

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial fibrillation (AF) catheter ablation is a well-established procedure for the treatment of AF. The cornerstone of AF ablation is the complete isolation of pulmonary veins (PV). However, persistent PV isolation (PVI) is difficult to accomplish, with PV reconnection rates of &gt; 70%. The factors associated with persistent PVI are still uncertain.

Purpose

To assess the PVI status in patients (pts) undergoing a redo ablation and to determinate the predictors associated with persistent PVI.

Methods

Consecutive pts who underwent a redo ablation between 2016 and 2020 were identified in a single-centre retrospective study. PVI status was assessed during electrophysiologic study with electroanatomic mapping system. Index procedures included second generation cryoballoon (CB), conventional radiofrequency (RF) before 2018 and CLOSE protocol guided RF ablation after 2018. Persistent PVI was defined by the absence of reconnection of all pulmonary veins.

Results

We included 83 pts with a mean age of 55,9 ± 11,9 years; 71,1% (n = 59) were male with a mean CHA2DS2-VASc score of 1,14 ±1,0. Seventy-five percent had paroxysmal AF and undergone a redo 35,0 months (±30,9) after the index PVI.

Seventeen pts (20,5%) had persistent PVI whereas 66 pts (79,5%) had at least one PV reconnected after the index procedure, with a reconnection rate of 51,8% for right superior and inferior PV, 47,0% for left superior PV and 36,1% for left inferior PV.

No statistically significant differences were noticed between pts with persistent and non-persistent PVI in baseline (clinical and echocardiographic) characteristics.

Regarding index ablation procedure, persistent PVI occurred more frequently in patients who underwent a "CLOSE" protocol-guided index PVI compared to RF pre-2018 and CB (45,5% vs 16,7%; p = 0,043).

Twenty-nine percent of pts with persistent PVI had a "CLOSE" protocol-guided index PVI whereas only 9,1% of non-persistent PVI pts had a "CLOSE" protocol-guided index PVI (p = 0,043).

In this cohort, "CLOSE" protocol-guided index PVI was the only predictor of persistent PVI (odds ratio 4.2, 95% confidence interval 1.1-15.9; p = 0.037).

Conclusions

In patients undergoing redo AF ablation procedures, only 20,5% had persistent PVI. "CLOSE" protocol-guided index PVI presented significantly higher rates of persistent PVI.  "CLOSE" protocol-guided index PVI was the only predictor for persistent PVI in patients with AF recurrence requiring a redo procedure.

Impact of pulmonary veins anatomy on outcome of cryoablation or radiofrequency catheter ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Pulmonary vein isolation is the cornerstone of interventional treatment of atrial fibrillation (AF). Pulmonary veins frequently display anatomic variants. If this influences the recurrence of AF after catheter ablation is still a matter of debate.

PURPOSE

Our aim was to determine if pulmonary vein anatomy variants influences the recurrence of AF after catheter ablation with radiofrequency or cryoablation.

METHODS

Retrospective analysis of patients with paroxysmal or persistent atrial fibrillation who underwent pulmonary vein isolation by radiofrequency (RF) or cryoablation (CA) in a single center between January 2017 and September 2019. All patients underwent computed tomography before AF ablation. Within each treatment group (RF or CA), patients were stratified according to their PV anatomy in: regular (2 left PVs and 2 right PVs) or variant (left common trunk, right common trunk, bilateral common trunk, right intermediate branch or other). The primary end-point was 1-year recurrence of AF. Recurrence was defined as electrical documented AF.

RESULTS

A total of 425 patients (RF = 300 and CA = 125), aged 56.6 ± 11.7 years, 277 men (65.0%) were enrolled. The majority of patients had paroxysmal AF (n = 343, 81.5%). Mean CHA2DS2-VASc score was 1.12 ± 1.28. Regular PV anatomy was identified in 357 patients (84.0%), a left common trunk in 53 patients (12.5%), a bilateral common trunk in 5 patients (1.2%), a right intermediate branch in 3 patients (0.7%) and other mixed variants in 7 patients (1.6%). There were no significant differences in the baseline clinical and echocardiographic characteristics between groups.

At 1-year follow-up, patients with atypical PV anatomy had more AF recurrence (regular 8.1% vs variant 16.2%; p = 0.037). Analyzing according to the ablation technique there was no difference in AF recurrence between PV anatomy groups in patients submitted to radiofrequency (regular 8.3% vs variant 13.0%; p = 0.224). On the other hand, in cryoablation group, patients with PV anatomic variant had significantly higher rates of 1-year AF recurrence (regular 7.8% vs variant 22.8%; p= 0.033).

CONCLUSION

The presence of atypical PVs anatomy seems to be associated with higher rates of AF recurrence at 1-year in patients undergoing cryoablation. Further prospective studies are needed to confirm the PV anatomy impact in the success of the procedure and if this needs to be accounted in the choice of ablation technique. Abstract Figure. Recurrence in AF after cryoablation

Redo ablation for atrial fibrillation recurrence post radiofrequency or cryoballoon ablation: a high volume single-centre experience

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial fibrillation (AF) ablation is a well-established procedure for the treatment of AF. The cornerstone of AF ablation is the complete and durable isolation of pulmonary veins (PV) through radiofrequency (RF) or cryoballoon (CB) ablation. However, PVI durability between RF or CB was not yet established, as reablation strategy and outcomes in patients (pt) undergoing a redo ablation.

Purpose

To compare RF versus CB regarding PVI status, reablation procedure and outcomes in pts undergoing a second procedure.

Methods

Single-centre retrospective study of consecutive pts who underwent a redo between 2016 and 2020. PVI status was assessed during electrophysiologic study with electroanatomic mapping system. Index procedures included second generation CB, conventional RF before 2018 and CLOSE protocol guided RF ablation after 2018. We assessed time-to-redo, number and location of reconnected PVs, procedural characteristics, acute and long-term outcomes between RF and CB index PVI.

Results

Seventy-four (55 RF and 19 CB) pts were included, 68,9% were male, most pts had paroxysmal AF (71,6%) and a mean CHA2DS2-VASc score of 1,14 ± 1,0.

No statistically significant differences were noticed in clinical and echocardiographic characteristics between pts within RF or CB cohorts.

Median time to reablation was significantly longer in the RF cohort (38,6 months ±33,6) compared to CB (17,0 months ±9,5) (p = 0,014). The number of reconnected PV was higher in CB than the RF cohort, although not significant (2,37 ±1,2 vs 1,75 ±1,4;p = 0,080). Right inferior PV was significantly more reconnected in pts within the CB compared to RF group (73,7% vs 45,6%;p = 0,034), without differences in the other PV reconnection rates.

Regarding reablation procedure, all pts were submitted to RF-redo. Fluoroscopy time was shorter for CB than RF cohort (7,4 ±2,9 vs 13,3 ±8,4;p = 0,002). There were no significant differences between the type of reablation (PVI only vs PVI plus other lesions or cavotricuspid isthmus ablation), with no difference in overall acute success.

After the redo procedure, no differences were observed in recurrence rate in the blanking period and after 91 days from reablation. Nevertheless, time-to-recurrence (&gt;91 days) was longer for RF than CB group (13,4 months ±10,7 vs 4,3 months ±1,5;p = 0,016). There were 2 pts in the RF group that were submitted to a third ablation procedure (p = 0,725). There were no differences between groups in the composite of adverse cardiovascular (CV) outcomes (stroke/transient ischemic attack, emergency room visit for AF, hospitalization for AF or CV death); p = 0,715.

Conclusions

After the index procedure, reablation occur later in RF than CB cohort.  Although the number of reconnected PV were similar between groups, right inferior PV was significantly more reconnected in pts originally treated with CB. After redo, time-to-recurrence was shorter for CB cohort. Recurrence and composite of adverse CV outcomes were similar.

Clinical outcomes and trans-syndesmotic screw frequency after posterior malleolar fracture osteosynthesis

AIM

This study aimed to evaluate the clinical outcomes and the trans-syndesmotic screw frequency after trimalleolar ankle fractures with a posterior malleolus fracture involving <25% of the articular surface.

MATERIAL AND METHODS

Retrospective comparative study. Patients with trimalleolar ankle fracture who underwent surgery between January 2011 and January 2018 were identified within the departments' fracture database. General demographics, treatment details, and fracture specific details (CT-scans) were assessed. Patients were grouped per the posterior malleolus fragment treatment: osteosynthesis (group 1) and non-osteosynthesis (group 2).

RESULTS

64 patients, 58.6 ± 17.8 years (range: 23-75), 68.8% female were eligible and follow up time was 43.1 ± 22.2 (range 24-96) months. The mean size of the posterior malleolus fragment was 14.7 ± 5.3% (range: 5-24). Posterior malleolus fragment treatment distribution: osteosynthesis (group 1) 31.2% and non- osteosynthesis (group 2) 68.8%. Group 1 showed significantly better clinical outcomes (p<0.05), AOOS (93.9 ± 5.79 (range: 73-99), AOFAS (91.5 ± 6.22 (range: 72-100) and VAS (0.8 ± 1.22 (range: 0-5) compared to Group 2, AOOS (84.25±8.34 (range: 63-100); AOFAS (84.75±8.05 (range: 58-100) and VAS (1.7 ± 1.38 (range: 0-6). Osteosynthesis of the posterior malleolus fragment significantly reduced the frequency of trans-syndesmotic screw (0%) compared to non-osteosynthesis posterior malleolus fragment (15.9%) (p < 0.05). The EQ-5D score was better in group 1 (1.08±0.27 (range: 1-2.2) compared to group 2 (1.27 ± 0.27 (range: 1-2.4) but with no statistical significance (p> 0.15).

CONCLUSION

Posterior malleolus fragments (<25% of the articular surface) have significantly better clinical outcomes and significant decrease in trans-syndesmotic screw need following osteosynthesis.

Coronary computed tomography angiography vs functional testing for stable coronary artery disease: long-term outcomes meta-analysis

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND  The emerging role of coronary computed tomography angiography (CCTA) has been acknowledged in the 2019 Guidelines of the European Society of Cardiology recommending it’s as the initial diagnostic strategy for most patients with suspected stable coronary artery disease (CAD). However, it is unclear how CCTA performs compared with the standard approach of functional testing (FT). We performed an updated meta-analysis to clarify the question, analyzing outcomes beyond one year of follow-up.

METHODS We searched PubMed for studies comparing clinical outcomes with ≥1 year of  follow-up between initial CCTA vs FT strategy in patients with suspected stable CAD. Occurrence of all-cause mortality and non-fatal acute coronary syndrome (ACS) was the combined primary outcome. Secondary outcomes included non-fatal myocardial infarction (MI), the use of longer-term investigations, revascularization procedures and new medication use.

RESULTS A total of 29,579 patients underwent either CCTA (n = 14,457) or FT (n = 15,122) and were followed for a mean of 1.75 years. CCTA was associated with a comparable all-cause mortality and non-fatal ACS to FT (2.64% vs 2.65%; risk ratio [RR], 0.97; 95% CI, 0.76-1.22). However, a 41% reduction in non-fatal MI was evident after CCTA testing (RR 0.59, 95% CI 0.41-0.83; P = 0.003). Compared with FT, patients undergoing CCTA were less likely to downstream additional testing (28.85% vs 33.86%; odds ratio [OR], 0.47, 95%CI 0.21-1.01; P = 0.05) and more prone to pursue coronary revascularization (OR 1.72; 95%CI 1.11-2.66; P = 0.01). Significant heterogeneity for invasive coronary angiography and revascularization was noted. CCTA patients had a non significant increase in new medication use, namely aspirin or statin therapy.

CONCLUSIONS In patients with suspected stable CAD, initial evaluation with CCTA was associated with a long-term 41% decrease in non-fatal MI and 53% reduction in downstream testing. Despite these differences, CCTA strategy was associated with a similar risk of long-term all-cause mortality and non-fatal ACS.

Abstract Figure.

Direct oral anticoagulants versus vitamin-K antagonists for left ventricular thrombus - a systemic review and meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Left ventricular (LV) thrombus is a current clinical problem. The incidence of systemic embolism (SE) is up to 16% in these patients and international guidelines recommend anticoagulation with vitamin-K antagonists (VKAs). Data on direct oral anticoagulants (DOACs) for LV thrombus is increasing but still with conflicting results.

Methods

We performed a systematic review and meta-analysis of studies assessing the efficacy of DOACs versus VKAs in LV thrombus resolution, SE events and/or stroke and bleedings events. We systematically searched PubMed and Cochrane database for studies comparing DOACs versus VKAs as anticoagulant strategy for LV thrombus. Random-effects meta-analysis was performed.

Results

Four studies were included: n= 727 patients (DOACs group – 243 patients vs VKAs group – 484 patients).  There is a 40% reduction in the odds for achieving thrombus resolution in the group of patients treated with DOACs (pooled OR 0.60; 95% CI 0.43-0.85; I2 =0%; P = 0.003) - Figure 1A. No difference between groups for the odds of SE and/or stroke was observed during follow-up (pooled OR 1.75; 95% CI 0.92-3.35; I2 =0%; P = 0.09) - Figure 1B. Bleedings events were not different between both anticoagulant strategies (pooled OR 0.65; 95% CI 0.30-1.39; I2= 0%, P = 0.26) - Figure 1C.

Conclusion

Although probably with less efficacy for thrombus resolution, the use of DOAC for LV thrombus does not seem to increase the risk of SE and/or stroke or bleedings events compared to VKAs.

Abstract Figure 1 - Pooled analysis (DOAC vs VKA)

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

Funding Acknowledgements

Type of funding sources: None.

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

Purpose

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

Methods

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

Results

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

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

Abstract Figure. Survival of patients stratified by group

Cardiac arrest after a cerebral gas embolism. Case report

Cerebral arterial gas embolism is a serious and often iatrogenic fatal event associated with invasive procedures. It is a possible cause of a cardiac arrest and the diagnosis is challenging. We report a case of a cardiac arrest after a cerebral arterial gas embolism, in a 63-year-old male subjected to a Computed Tomography-guided Transthoracic Needle Aspiration Biopsy, which was successfully managed with hyperbaric oxygen therapy.

Acute coronary syndromes in chronic kidney disease patients: the good, the bad or the ugly?

Background

Patients with chronic kidney disease (CKD) are at increased risk of composite cardiovascular (CV) events and all-cause mortality. However, current aggressiveness of therapeutic strategies may minimize the course of the disease.

Aim

To assess the prognostic impact of optimized medical treatment in a CKD population with acute coronary syndrome (ACS).

Methods

355 ACS patients admitted to a single coronary care with CKD who were discharged from hospital were included. Those with end-stage renal disease were excluded. Three groups were created based on the KDIGO classification: Group A (Stage 3A, eGFR [estimated glomerular filtration rate] 45–59mL/min/1.73 m2) N=190; Group B (Stage 3B, eGFR 30–44mL/min/1.73 m2) N=113; and Group C (Stage 3B, eGFR 15–29mL/min/1.73 m2) N=52. The primary endpoint was long-term all-cause mortality. Kaplan-Meyer survival curves and Cox regression were done. The median of follow-up was 32 (IQ 15–70) months.

Results

Groups were similar regarding demographics, CV risk factors, ACS type, heart failure diagnosis, left ventricular (LV) systolic function, peak troponin, multivessel disease, treatment option (PCI, CABG or OMT) and medical therapy at discharge. More advance renal failure patients had a higher prevalence of diabetes mellitus (DM), a lower haemoglobin, a higher NT-proBNP and were less likely to receive ACE inhibitors/angiotensin II antagonist at discharge. 170 patients met the primary outcome. Kaplan-Meyer curves showed decreased survival with worse renal function (Group A 68% vs Group B 57% vs Group C 37%, Log Rank P=0.006 – Figure 1). After adjustment for age, DM, haemoglobin, NT-proBNP, LV systolic function and ACE inhibitors/angiotensin II antagonist at discharge, eGFR was not associated with increased death (HR 1.00, 95% CI 0.98–1.01). In this model, only age (HR 1.04, 95% CI 1.01–1.07), haemoglobin (HR 0.86, 95% CI 0.979–0.94), Nt-proBNP (HR 1.00, 95% CI 1.00–1.00) and impaired LV function (LV ejection fraction 40–49%: HR 2.95, 95% CI 1.89–4.81; LV ejection fraction &lt;40%: HR 2.15, 95% CI 1.44–3.21) remained associated with the outcome.

Conclusion

The worse outcome attributed to CKD after an ACS seems to be related not the eGFR itself but to associated comorbidities such as age, anaemia, fluid overload and impaired LV function. The fact that some of these comorbidities may be altered by intensive therapy indicates that CKD patients should also be candidates to optimized medical treatment.

Funding Acknowledgement

Type of funding source: None

Meta-analysis and meta-regression of early aortic valve replacement versus watchful waiting in asymptomatic severe aortic stenosis: a 2020 boost of evidence

Background

Current guidelines recommend aortic-valve replacement (AVR) as the only effective therapy for severe symptomatic aortic stenosis (AS) patients. Nevertheless, management and timing of intervention in asymptomatic AS remains a controversial topic, with sparse evidence to support the recommendations (level C).

Purpose

To assess an early-AVR strategy in asymptomatic severe AS, comparing it with a watchful waiting (WW) strategy

Methods

We systematically searched PubMed, Embase and Cochrane databases, in February 2020, for both interventional or observational studies comparing early-AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis for early-AVR and WW were performed. Meta-regression was used to assess the influence of study characteristics on the outcome.

Results

Eight studies were included (seven registry-based or unrandomized studies and one randomized clinical trial) providing a total of 3985 patients, and 1232 pooled all-cause deaths (172 in early-AVR and 1060 in watchful waiting). Meta-analysis showed a significantly lower all-cause mortality for the early-AVR compared with WW group (pooled OR 0.24 [0.17, 0.32], P&lt;0.01) although with a moderate amount of heterogeneity between studies in the magnitude of effect (I2=57%, P=0.02). The early-AVR patients also displayed a lower cardiovascular mortality (pooled OR 0.27 [0.15, 0.48], P&lt;0.01) plus a lower heart failure hospitalization rate (pooled OR 0.27 [0.06, 0.65], P&lt;0.007). No difference in clinical thromboembolic event rate (stroke or myocardial infarction) was noted.

The meta-regression for all cause mortality based on possible confounders such as time of follow-up, age, gender, diabetes mellitus, coronary artery disease, left ventricular ejection fraction, and mean peak aortic jet velocity showed that effect sizes reported by the individual studies seem to be independent from the covariates considered (P&gt;0.05).

Conclusions

Our 2020 pooled data reinforces the previous evidence suggesting the benefit of early-AVR in asymptomatic patients with severe AS.

Early AVR vs WW, All-cause death

Funding Acknowledgement

Type of funding source: None

Non Type-1 Brugada pattern, diagnostic yield of 5 ECG criteria in a young adult cohort

Introduction

Distinguishing between non-Type 1 Brugada pattern (non-T1BrP) and an athlete's ECG remains challenging and may have important prognostic implications. We aimed to study prevalence and the diagnostic yield of experts and non-experts for the electrocardiographic non-T1BrP criteria in the young adults from the Sudden Cardiac Death-Screening Of risk factorS (SCD-SOS) cohort.

Methods

We performed a cross-sectional study in which we reviewed 14662 ECGs of SCD-SOS survey participants and selected 2494 that presented a rSr'-pattern in V1-V2. Among these, 98 were classified by experts in hereditary arrhythmic syndromes for the presence of non-T1BrP and by non-experts who performed manual measurements of the diagnostic criteria based on triangle formed by r'-wave. We estimated intra and interobserver concordance for each criterion, and used logistic regression and receiver operating characteristics (ROC) analysis and C-statistics for diagnostic accuracy and definition of the most appropriate cut-off values.

Results

We detected a rSr'-pattern in V1-V2 in 17% of the individuals and found that it was associated with higher PQ and QTc intervals, male gender and lower BMI. The manual measurements of non-T1BrP criteria were reproducible: we had high intraobserver concordance coefficients (CC) ranging from 0.90 to 0.94 (except for d(B) that had 0.66), but interobserver CC were lower (0.45–0.68). The measurements performed were highly correlated with non-T1BrP diagnosis and the criteria with higher discriminatory capacity were the distance d(B) (AUC 0.77; 95% CI0.69–0.84) and the degree of ST-ascent (AUC 0.79; 95% CI 0.72–0.86). The cut-offs defined by other authors had very low sensitivity (8–12%), despite high specificity (98%), so we defined new cut-offs: d(A) ≥2mm, d(B) ≥1.25mm, d(B)/h ≥0.38, β-angle ≥19° and ST-ascent ≥1mm. The addition of the degree of ST-ascent to a model with these 4 parameters presented an increase in C-statistics from 0.77 (95% CI: 0.68–0.86) to 0.83 (95% CI: 0.75–0.91) for the diagnosis of non-T1BrP by an expert in Sudden Arrhythmic Death and Channelopathies.

Conclusion

A rSr'-pattern in precordial leads V1-V2 is a frequent finding and the detection of non-T1BrP by using the aforementioned 5 measurements is reproducible and accurate. In this study, we describe new cut-off values that may help untrained clinicians to identify young individuals who should be referred for provocative drug testing for Brugada Syndrome.

Accuracy of non-T1 BrP criteria

Funding Acknowledgement

Type of funding source: None

Cardiovascular Risk estimates in ten years in the Brazilian population, a population-based study

Background

Cardiovascular diseases are the leading cause of morbidity and mortality, high health costs and significant economic losses. The Framingham score has been widely used to stratify the risk of the evaluated individuals, identifying those at higher risk for the implementation of prevention measures directed to this group.

Objective

Estimate the cardiovascular risk of developing cardiovascular event in 10 years, in the adult Brazilian population.

Methods

Cross-sectional study using laboratory data from da National Health Survey, 2014 and 2015, were used to calculate cardiovascular risk (CVR). Algorithms proposed by D`Agostino (2008) were used, based on the Framingham study, stratified by sex, was used. According to the guidelines of the Brazilian cardiology society, the following cutoff points for cardiovascular risk in 10 years were used: a) low CVR &lt;5%, medium CVR (5 to &lt; 20%) and high CVR (≥ 20%). The study estimated the general cardio vascular risk and the respective confidence intervals (95% CI).

Results

Most women 58.4% had low cardiovascular risk, 32.9% medium risk and 8.7% high risk. Among men, 36.5% had low cardiovascular risk, 41.9% medium risk and 21.6% high risk. The risk increased with age. The difference in CVR according to years of schooling was about five times, between high schooling (12 years of schooling and more) and (&lt;8 years of schooling) (3.2%: 95% CI 2.4 - 4.4 versus 15, 7%: 95% CI 13.5-18.3). Black women had a higher proportion in the highest risk group ( &gt; = 20%), 14.4% (95% CI 9.7-20.9), than white women, 7.3 (95% CI 5.8 - 9.1). The poor self-rated health showed the greatest difference, the population that self-rated with very good health 2.9% (95% CI 1.3-3.6) and very poor health 25.6% (12.7-45, 0).

Conclusions

The risk score is useful to support the prevention practices of these diseases, considering the clinical and epidemiological context.

Key messages

This is the first national population-based study to estimate RCV for the Brazilian adult population using laboratory data, being useful to identify the priority population for public health. Population with less education has a higher risk cardiovascular, and should be a priority for prevention actions in public health.

Garbage codes as causes of death and quality of mortality statistics in Belo Horizonte, Brazil

Background

Quality of cause-of-death information is fundamental for health planning. Traditionally, this quality has been assessed by the analysis of ill-defined causes from chapter XVIII of the International Classification of Diseases - 10th revision (ICD-10). However, studies have considered other useless diagnoses for public health purposes, defined, in conjunction with ill-defined causes, as garbage codes (GC). In Brazil, despite the high completeness of the Mortality Information System, approximately 30% of deaths are attributable to GCs. This study aims to analyze the frequency of GCs in Belo Horizonte municipality, the capital of Minas Gerais state, Brazil.

Methods

Data of deaths from 2011 to 2013 in Belo Horizonte were analyzed. GCs were classified according to the GBD 2015 study list. These codes were classified in: a) GCs from chapter XVIII of ICD-10 (GC-R), and b) GC from other chapters of ICD-10 (GC-nonR). Proportions of GC were calculated by sex, age, and place of occurrence.

Results

In Belo Horizonte, from the total of 44,123 deaths, 5.5% were classified as GC-R. The majority of GCs were GC-nonR (25% of total deaths). We observed a higher proportion of GC in children (1 to 4 years) and in people aged over 60 years. GC proportion was also higher in females, except in the age-groups under 1 year and 30-59 years. Home deaths (n = 7,760) had higher proportions of GCs compared with hospital deaths (n = 30,182), 36.9% and 28.7%, respectively. The leading GCs were the GC-R other ill-defined and unspecified causes of death (ICD-10 code R99)), and the GCs-nonR unspecified pneumonia (J18.9), unspecified stroke (I64), and unspecified septicemia (A41.9).

Conclusions

Analysis of GCs is essential to evaluate the quality of mortality information.

Key messages

Analysis of ill-defined causes (GC-R) is not sufficient to evaluate the quality of information on causes of death. Causes of death analysis should consider the total GC, in order to advance the discussion and promote adequate intervention on the quality of mortality statistics.

Trends in mortality due to noncommunicable diseases in Brazil and the sustainable development targets

Background

Monitoring premature mortality due to noncommunicable diseases (NCDs) is a global priority, as part of the Agenda 2030.

Objective

The current study aims to describe the mortality trends and disability-adjusted life years (DALYs) lost due to NCDs between 1990 and 2017 for Brazil and states, projections for 2030.

Methods

We analyzed the following NCDs: cardiovascular diseases, chronic respiratory diseases, neoplasms, diabetes mellitus, comparing deaths and mortality rates between 1990 and 2017, for Brazil and states. The study used the concept of premature mortality used by the World Health Organization (30 to 69 years). The absolute number of deaths, mortality rates, DALYs, years of life lost (YLL), were used, comparing 1990 and 2017. We also analyzed the premature death fraction (YLL) for NCDs attributable to risk factors.

Results

There was a reduction of 35,3% from 509.1 deaths/100,000 inhabitants (1990) to 329.6 deaths/100,000 inhabitants due to NCD in 2017. DALYs rate decreased by 33.6% and the YLL rate by 36.0% in the same period. There was a reduction in the NCD rates in all 27 states. The main risk factors related to premature deaths by NCDs in 2017 among women were - high body mass index, diet risks, high systolic blood pressure, tobacco, and among men, diet risks, high systolic blood pressure, tobacco, high body mass index. Trends in mortality rates due to NCDs were declining in the period, however, after 2015, the curve reversed and fluctuation and tendency to increase rates were observed.

Conclusions

Trends of mortality rates by NCD were declining in the period, however, after 2015, the curve was inverted and the fluctuation and trend of increasing rates was observed, which can compromise the SDG goals in 2030.

Key messages

The austerity policies adopted and the economic crisis in Brazil after 2015, resulted in increased poverty and worsening NCD mortality indicators. With the NCD indicators worsening in 2015, SDG targets may not be achieved.

Investigation of hospital deaths declared as garbage codes in Belo Horizonte, Brazil, in 2017

Background

Improving the quality of causes of death (COD) is vital for defining adequate public policies. In Brazil, one third of deaths are reported as having a cause that is not useful for public health analysis of cause-of-death data, the so-called garbage codes (GC). The investigation of these deaths is one of the strategies that could improve the quality of mortality statistics in the country.

Methods

For all GCs identified in 2017 in the routine mortality information system from Belo Horizonte city, Brazil, municipal health professionals collected information about the final disease obtained from hospital records or autopsies in a standardized form. A trained physician analyzed this information and filled in a new death certificate (DC). The DC that originally showed a GC as an underlying COD was categorized into GC reclassified when the garbage cause changed to a specific cause after investigation. Causes of death derived from the reclassified GCs were analyzed to assess the impact on the mortality profile before and after the investigation.

Results

In Belo Horizonte, 1,395 deaths out of 3,038 registered as garbage codes were investigated, with a 35% reduction in deaths due to these causes. There was an increase in deaths from ischemic heart diseases, Alzheimer's disease, chronic obstructive pulmonary disease, hemorrhagic and ischemic stroke, and violence.

Conclusions

The investigation of deaths from garbage codes modified the mortality profile and improved its quality, providing direction for more assertive public health policies. Strategies for training physicians to report specific causes of death is another strategy that could improve the quality of mortality data.

Key messages

This study proved to be a feasible strategy in improving the quality of causes of death in mortality statistics and should be incorporated into the surveillance routine activities in Brazil. The evaluation of the GC investigation is an important instrument in helping management of health interventions aiming at better quality of information and more qualified health services.

Improving the usefulness of mortality data in Brazil: reclassification of ill-defined causes of death

Background

Garbage codes (GC) among registered causes of death can bias mortality analysis. In Brazil, more than one million deaths occurred annually in 2006-2017 and around 100,000 deaths per year were originally attributed to GC ill-defined causes of death (IDCD) in the Mortality Information System (SIM - Sistema de Informação sobre Mortalidade). To provide more accurate cause-of-death analysis, routine investigations of IDCD in the health surveillance system have been implemented in the country since 2005. The objective of this study was to analyze specific underlying causes for deaths originally assigned as IDCD in the SIM in 2006-2017.

Methods

For all IDCD (ICD codes from chapter 18, or R-codes) identified in the SIM, municipal health professionals collected information about the final disease obtained from hospital records, autopsies, forms of family health teams, and home investigation. Proportions of reclassified deaths by cause-specific mortality fractions (CSMF) derived from the reclassified IDCD by age and four calendar periods were analyzed to assess specific causes detected after investigation.

Results

A high proportion of deaths due to IDCD was investigated in 2006-2017 (32%). From a total of 257,367 IDCD reclassified, chronic diseases (56.6%), injuries (7.2%), and infectious (5.2%) or neonatal, maternal, malnutrition (1.7%) were the underlying causes detected among IDCD. Neonatal-related conditions, interpersonal violence, ischemic heart disease and stroke were the leading causes detected in the age groups 0-9 years, 10-29 years, 30-69 years, 70 years and over, respectively.

Conclusions

High proportions of IDCD reassigned to more informative causes after review indicate the success of this approach to correct misclassification in the SIM, an initiative that should be maintained. Training physicians on death certification along with better quality of medical care and access to health services would lead to further improvement.

Key messages

Investigation of IDCD as part of routine data collection on a large scale as had occurred in Brazil in 2006-2017 is an innovative approach to strengthen population-level mortality statistics. In addition to reducing the proportions of IDCD by their reclassification into specific causes, this initiative opens up the prospect of using these results for redistributing remaining cases of IDCD.

P1433Prevalence and location of residual leaks following percutaneous left atrial appendage occlusion: the importance of 3D transesophageal echocardiography

Background

The left atrial appendage (LAA) shape and size are very variable, and incomplete appendage closure or persistent leaks around the device are common following device placement. Limited studies reported the rate of peri-device leaks (PDL) after percutaneous left atrial appendage closure, and the impact of 3D transesophageal echocardiography (3D-TEE) on the detection of those leaks.

Aim

To describe the rate and location of leaks 1 month after percutaneous closure of the LAA, with and without the use of 3D-TEE.

Methods

A cohort study of consecutive patients (P) who were submitted to a percutaneous LAA closure with success in one interventional cardiology centre, between May 2010 and October 2018, were included. Clinical and echocardiography data were recorded and analysed. Two groups were created: Group A (GA) included patients until August 2015 submitted to 2D TEE on follow up (N= 48) versus Group B (GB), which was composed of patients submitted to 3D-TEE after August 2015 (N= 76).

Results

A total of 124 P had an in-hospital admission for LAA closure, with control TEE 1 month after the procedure. Mean age was 73 ± 7 years old, with 62.9% male patients. The procedure was guided by TEE (52%) or intra cardiac echocardiography (ICE) (48%).Transeptal puncture was preferred (95% of the procedures). The most used device was Amulet (62%) vs ACP (23%) and Watchman (15%).

In the follow up TEE, 20% of patients had only 1 leak and 2% had 2 leaks. Of the detected leaks,31% were considered minor (&lt; 1 mm), 35% moderate (1-3 mm) and 34% major (&gt; 3 mm). Patients with leaks had a larger LAA diameter (22 ± 4 mm vs. 17 ± 3 mm, P = 0.01).

Of the detected leaks, 50% were located in the superior portion of the device, 23% were located in the inferior portion, 8% in the posterior portion and 8% in the lateral portion.

In GA the rate of leaks was 14% vs 24.5% in GB, with differences also when specified the size of the leak –  minor (GA 2% vs GB 8.8%), moderate (GA 8% vs GB 8.1%) and major (GA 4% vs GB 7.6%).

Conclusion

The use of 3D echocardiography, 1 month after successful percutaneous LAA closure, augmented the rate of detection of device leaks. It remains to be studied the clinical impact of this finding.

P1391 Global longitudinal strain in chronic asymptomatic aortic regurgitation: a meta-analysis

OBJECTIVES

To assess GLS impact on mortality and need for aortic valve replacement (AVR) or symptom development in chronic asymptomatic AR patients and preserved left ventricular ejection fraction (LVEF).

METHODS A literature search was performed according with these key terms "aortic regurgitation" and "longitudinal strain." The primary endpoint was all-cause mortality. Secondary end-points were: a composite of all-cause mortality, need for AVR or symptom development; and only AVR plus symptom development. Data was pooled using random-effects meta-analysis models. Pooled Hazard Ratio (HR) was performed using its log transformation and inverse variances as weights were then calculated for each study .

RESULTS Six studies were included, with a total of 1,571 asymptomatic patients with at least moderate AR and preserved LVEF. There were 996 events (death, AVR, symptom development) reported during follow-up. Pooled adjusted mortality HR tended to be higher for patients with worse GLS (1.14 [0.96–1.35], P = 0.13, I2 51%). GLS performed better in predicting AVR or symptom development (mean difference -0.72 [-1.29, -0.15], P = 0.01, I2 88%), with an estimated HR of 1.36 ([1.01–1.84], P = 0.04, I2 65%).

CONCLUSIONS In asymptomatic chronic moderate to severe AR patients, impaired GLS was associated with adverse cardiac outcomes. Left ventricular GLS may offer incremental value on risk stratification as well as on decision-making.

Abstract P1391 Figure 1

P714 Contradicting the most basic tenet of black holes: light can, indeed, escape

A 69-year-old man with history of non-insulin-treated type 2 diabetes mellitus, arterial hypertension and mixed dyslipidemia presented to the emergency department with chest pain lasting for four days. Immediate twelve-lead electrocardiogram unveiled an inferior ST-segment elevation myocardial infarction (STEMI), prompting emergent coronary angiography, which, in turn, revealed two-vessel disease, specifically proximal ramus intermedius 60-70% stenosis and proximal right coronary artery acute occlusion. Culprit lesion was successfully managed with balloon angioplasty and a single drug-eluting stent implantation. Still, clinical course was noticeable for deterioration, under the form of cardiogenic shock, which required invasive ventilation and intravenous vasopressor support with norepinephrine. Despite biventricular systolic function relative preservation, transthoracic echocardiography disclosed inferior akinesis, right ventricle dilation, mild circumferential pericardial effusion and, particularly, a 2.3cm posteroinferior ventricular septal defect (VSD), in the setting of a 4.4cm2 pseudoaneurism, resulting in left-to-right shunting, quantified through maximal/mean trans-VSD pressure gradients of 84/44mmHg. Further imaging with transesophageal echocardiography and cardiac computed tomography angiography allowing the conception of a 3D-printed model was performed. Surgical correction of the defect followed, achieving partial anatomic success, namely with residual shunting, as of a left ventricular systolic pressure of 80mmHg and a right ventricular systolic pressure of 25mmHg. Patient survived, recovered and got discharged three weeks later. At one-year follow-up, he was hospitalized for acute decompensated heart failure (hemodynamic profile C) twice, with medication non-adherence reported as the main precipitating factor. In addition to a significant remaining left-to-right shunt (maximal velocity 3m/s), adverse cardiac remodeling was recognized, featuring left ventricular ejection fraction of 30-35%, severe functional mitral regurgitation, severe postcapillary pulmonary hypertension and de novo left bundle branch block (QRS duration of 197ms). Having been deemed clinically unsuitable for another surgical correction, patient underwent percutaneous VSD closure with both AmplatzerTM septal and muscular VSD occluders, with a suboptimal result. He is now on New York Heart Association class III heart failure and on the waiting list for both MitraClip and cardiac resynchronization therapy implantation.

Reflecting numerous breakthroughs in the management of acute myocardial infarction, incidence of mechanical complications is on the decline. Nevertheless, when they occur, morbidity and mortality remain high. Acquired ventricular septal defects are no exception, demanding the best care from a tertiary hospital heart team.

Abstract P714 Figure.