Listeria monocytogenes in ready-to-eat (RTE) delicatessen foods: Prevalence, genomic characterization of isolates and growth potential

This study investigated Listeria monocytogenes prevalence and count in 132 ready-to-eat (RTE) delicatessen samples belonging to different categories (starters with/without mayonnaise pasta/rice-based courses, meat/fish-based main courses) produced by an Italian industry. Whole Genome Sequencing characterized the isolates to map the pathogen circulation. Moreover, the growth potential of L. monocytogenes in the most contaminated product was investigated by a challenge test. L. monocytogenes was detected in 23 samples, giving an estimated prevalence of 17.4 %. Starters with mayonnaise showed a very high prevalence (56.7 %), showing the role of the sauce in the diffusion of the pathogen within the plant. A total of 49 isolates were obtained; they belonged to two different serogroups, IIb and IIa, and were related to two clonal complexes (CCs) and sequence types (STs) (CC288-ST330 and CC121-ST717), suggesting the possible persistence and circulation of the pathogen within the plant. The results of the challenge test showed a limited ability to grow in the selected product thanks to the presence of lactic microflora.

Hospitalization and Housing: A Qualitative Study Exploring the Perspectives of Hospitalized Patients Experiencing Housing Insecurity

Although housing insecurity has clear negative impacts on health, little is known about how it impacts patients' experience of hospitalization. In this qualitative study, we interviewed 22 hospitalized patients experiencing housing insecurity. The following three major themes emerged: 1) adverse social and environmental factors directly contribute to hospitalization, 2) lack of tailored care during hospitalization leaves patients unprepared for discharge, and 3) patients have difficulty recuperating after a hospital stay, leading to the risk of rehospitalization. Within these themes, participants described the roles of extreme physical and psychological hardship, chaotic interpersonal relationships, substance use, and stigma affecting participants' experiences before, during, and following hospitalization. Our results, based directly on the patient experience, suggest a need for hospital systems to invest in universal in-hospital screening for housing insecurity, incorporation of trauma-informed care, and robust partnerships with community organizations. Future research should explore the feasibility and impact of these interventions.

The long-term clinical course of moderate tricuspid regurgitation

Background

Moderate TR is a frequent condition, worsening mid and long-term survival, particularly in patients >75 years old, and in those suffering from left ventricular systolic dysfunction. As TR is often clinically unsuspected until an advanced stage of congestive heart failure (HF), there is a great need of early diagnosis and long-term appropriate follow-up. However, data focusing on the clinical and echocardiographic course of a cohort of patients with moderate TR is lacking, and the most appropriate type and time of management of these patients is still heavily debated.

Purpose

To evaluate the evolution and the long-term clinical outcome of a cohort of patients suffering from moderate and moderate to severe TR, regardless of its etiology.

Methods

Clinical outcome and echocardiographic follow-up were assessed in 212 patients diagnosed with moderate and moderate to severe TR in our centre between January 2014 and December 2019. TR progression at follow-up was defined as TR grade increase to at least severe. The primary endpoint was all-cause death; secondary endpoints were cardiovascular (CV) death and HF hospitalization.

Results

After a median follow-up of 4.2 years, TR progression occurred in 76 patients (36%): patients with TR progression presented with more history of coronary artery disease (p=0.042), atrial fibrillation (AF, p=0.007) and chronic kidney disease (CKD, p=0.007) and with baseline larger right ventricle end-diastolic diameter (RVEDD, p<0.001) and worse left ventricular ejection fraction (LVEF, p=0.048). After univariate and multivariate analyses, a history of AF (HR 2.3, CI 1.2–4.5, p=0.011) and RVEDD (HR 2.4, CI 1.3–4.4, p=0.003) were independent predictors of TR progression. The primary endpoint occurred in 57 patients (27%) and was significantly more frequent (p=0.015) in the group of patients with TR progression compared to those without TR progression; multivariate analyses showed TR grade progression (HR 4.3, CI 2.1–9.1, p<0.001), CKD (HR 3.2, CI 1.5–7.1, p=0.002) and LVEF (HR 0.9, CI 0.93–0.99, p=0.007) as being independently associated with the primary outcome. Moreover, both CV death (p=0.003) and HF hospitalization (p=0.0139) were significantly more frequent in patients with TR progression.

Conclusions

Our results showed that moderate TR, by progressing in a relevant proportion of patients over a long-term follow-up, significantly increases the risk of mortality and HF hospitalization. We identified specific risk factors associated with TR progression, which could help to identify patients at risk before an advanced stage of this disease. We believe that this cohort of patients should be appropriately managed and closely followed-up to avoid adverse clinical events related to the natural course of this valvulopathy.

Funding Acknowledgement

Type of funding sources: None.

Feasibility and Impact of Trauma-Informed Care Training in Internal Medicine Residency: A Pilot Study

Introduction: Mounting evidence indicates that early life trauma is highly prevalent and associated with adverse health outcomes later in life. However, primary care providers report lacking the training to effectively address trauma encountered in daily practice. There is a paucity of research describing the implementation and evaluation of trauma-informed care (TIC) curricula within Graduate Medical Education.

Methods: We piloted a three-hour TIC workshop facilitated by a community-based psychologist expert to assess the feasibility and impact of TIC training on Internal Medicine (IM) residents’ knowledge, attitudes and skills related to TIC. Participants were a subset of IM residents in a health-equity-focused curricular pathway in the University of Colorado IM Residency. Residents completed anonymous surveys one week before and after the workshop, and a final survey 10 weeks later. Residents who did not participate in the workshop completed a similar baseline survey (control group). Data were analyzed using matched pair T-tests.

Results: Fourteen of 20 residents (70%) who participated in the pilot workshop completed the initial survey. Of these, 10 (71%) completed the first post-workshop survey, and seven (50%) completed the final survey. We observed significant improvements in residents’ self-reported knowledge, attitudes and skills related to TIC. The majority of residents in the control group reported a desire for TIC training.

Conclusions: TIC is an important curricular gap in IM training. A single, brief TIC workshop was feasible and was associated with improved self-reported knowledge, attitudes and skills among IM residents.

Right ventricular-arterial coupling in severe tricuspid regurgitation: prognostic relevance of longitudinal strain

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND. Right ventricular-to-pulmonary artery (RV-PA) coupling integrates RV systolic function at a given afterload and has been shown to have a prognostic impact in different clinical settings. In the context of severe functional TR, it reflects RV adaptation to both volume and pressure overload. However, its prognostic relevance has not been extensively  examined in patients suffering from severe TR, and available data evaluated RV-PA coupling using the TAPSE/PASP ratio, with its intrinsic limitation especially in the setting of concomitant severe TR. In patients with severe TR, right ventricular free-wall longitudinal strain (RVFWLS) has been demonstrated to be more senstie in evaluation of subtle RV systolic dysfunction and to reclassify patients with impaired RV systolic function although conventional echocardiographic parameters within normal limits.

PURPOSE.  To analyze whether the noninvasive evaluation of RV-PA coupling with the use of the RVFWLS/PASP ratio could improve risk stratification in patients with severe TR.

METHODS. Baseline clinical and echcardiographic parameters and correlation with long-term outcome were assessed in 250 consecutive patients with severe TR referred at our center from December 2015 to December 2018.

RESULTS. Patients were predominantly female, with severe cardiovascular risk factors and major comorbidities, history of heart failure (HF) and atrial fibrillation.

RVFWLS/PASP ratio ≤ 0.32 (AUC 0.72, p < 0.001, sensitivity 70%, specificity 67%) marginally predicted the presence of baseline clinical RV HF (p = 0.05). After univariate and multivariate analyses, RV-PA coupling as assessed by RVFWLS/PASP ratio, but not by TAPSE/PASP, was independently associated with all-cause mortality (OR 0.007, p = 0.03) and, at follow-up, "RV-PA coupled patients", defined by RVFWLS/PASP ratio >0.26 (AUC 0.74, p < 0.001, sensitivity 77%, specificity 52%) showed higher surival rates (p = 0.02).

CONCLUSIONS. RVFWLS/PASP ratio was systematically measured to possibly evaluate RV-PA coupling as a novel echocardiographic parameter in the context of patients with severe TR: it is independently associated with poor long-term prognosis and different values seem to improve irsk stratification in this cohort of patients.

Accuracy and reliability of left atrial appendage morphology assessment by new 3D transesophageal echocardiographic rendering modalities: a comparative study with computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction. Left atrial appendage (LAA) morphology assessed by contrast-enhanced computed tomography (CT) has been associated to the risk of cardioembolic stroke in non-valvular atrial fibrillation. Subsequent studies with the traditional LAA classification system (CS) into 4 morphologies (Chicken wing, Cauliflower, Cactus and Windsock) yielded mixed results in terms of reliability and stroke risk association. Recently, a simple LAA morphology CS (new-LAAcs) based on the LAA bend angle measurement has been suggested. Three-dimensional transesophageal echocardiography (3D TOE) quality imaging has been improved and new volume rendering modalities developed.

Purpose. Aim of this study was to evaluate the accuracy and reliability of 2D and new 3D TOE rendering modalities compared to CT in assessing LAA morphology. We used and validated a new simple LAA morphology classification system (new-LAAcs) based on the LAA bend angle in contrast to the traditional CS.

Methods. 50 consecutive patients who underwent both cardiac CT and TOE were enrolled. LAA morphology was assessed by three different TEE modalities: (1) 2D TOE inspective evaluation (2D TOE), (2) 3D TOE multiplanar reconstruction (3D TOE MPR) and (3) 3D TOE Philips TrueVue Glass rendering (3D TOE GLASS). We assessed TOE accuracy compared to CT by sensitivity, specificity, accuracy, and Cohen’s kappa. Two trained readers independently adjudicated LAA morphologies in the new-LAAcs and the inter-rater reliability was obtained by percentage agreement and Cohen’s kappa. The reliability of the new- vs. traditional-LAAcs was assessed by CT in terms of reliability rates and influence on LAA morphology prevalence.

Results. CT and TOE imaging analyses were feasible in all patients. 2D TOE was fairly accurate in identifying LAA morphology (κ 0.38, p = 0.022) and had only moderate inter-rater (κ 0.46, p = 0.027) and substantial intra-rater (κ 0.62, p = 0.003) reliability rates. 3D TOE showed high validity: 3D TOE MPR had an almost perfect accuracy (κ 0.84, p < 0.001) and substantial (κ 0.77, p < 0.001) inter-rater reliability; 3D TOE GLASS substantial accuracy (κ 0.67, p < 0.001) and almost perfect (κ 0.82, p < 0.001) inter-rater reliability. Intra-rater agreement was almost perfect for both 3D TOE modalities (κ 0.84, p < 0.001). In the comparison among CS the traditional-LAAcs inter-rater reliability was moderate (κ 0.47, p < 0.001) and the intra-rater reliability substantial (κ 0.68, p < 0.001) while the new-LAAcs yielded an almost perfect reliability level (inter-rater κ 0.84, p < 0.001 and intra-rater κ 0.93, p < 0.001). With the traditional-LAAcs, the prevalence of CW LAA was 30 (60%), while with the new-LAAcs the prevalence of low-risk-LAA was 13 (26%), leading to classify 17 (57%) CW morphologies as high-risk-LAA.

Conclusions. 3D TOE is an accurate, reliable, and feasible alternative to CT in assessing LAA morphology with the new-LAAcs. The new-LAAcs shows higher reliability rates than the traditional one. Abstract Figure.  Abstract Figure.

Multiparametric assessment of the intraprocedural result after transcatheter mitral valve edge-to-edge repair proceduret

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Research grant

OnBehalf

n/a

Background. Quantification of residual mitral regurgitation (MR) after transcatheter edge-to-edge mitral valve repair (TMVr) is challenging.

Objectives.  To evaluate the feasibility and the performance of an intraprocedural multiparametric approach based on echocardiographic and invasive hemodynamic parameters and to develop a multiparametric scoring system for MR grading after TMVr, and to compare this approach against currently recommended methods. 

Methods. Ninety-three consecutive patients treated with MitraClip (April 2019-July 2020) were enrolled. The protocol of MR evaluation included: 2D and 3D color-Doppler (3D-vena contracta area- 3D-VCA), pulsed-wave Doppler (pulmonary vein- PV flow, stroke volume), continuous-wave Doppler (jet density), morphological parameters (spontaneous echocontrast) and invasive hemodynamic (mean left atrial pressure-LAP, V-wave) at baseline and after clip implantation. A multiparametric score (M-score) was calculated by including the significant predictors (3D-VCA, dense jet on CWD, final LAP, final V wave) of primary endpoint (CV death or HF related hospitalization) at one year follow-up, weighted according to the corresponding odds ratio, to predict the clinical outcome at one-month and one-year follow-up. 

Results. The final study population included 86 pts (mean age 78.3 +8.9yrs, 54.6% primary MR). Procedural success was achieved in 78 pts (90.7%). 3D-VCA (AUC 0.808) and current method for MR grading (AUC 0.801) were comparable predictors of lack of symptom improvement (<5 point change in KCCQ-OS score) at one-month (p = 0.398, DeLong’s test). The M-score performed similarly as predictor of one-month follow-up but was a better predictor of primary endpoint at 1-year (AUC 0.919) compared to single parameters (p = 0.005 vs 3D-VCA DeLong"s test) and currently recommended methods for MR grading (p = 0.006 DeLong"s test). The optimal cut-off was 2 points with 86.7% sensitivity and 83.1% specificity.

Conclusion. We evaluated intraprocedural TMVr result in a multiparametric approach showing that 3D-VCA alone is comparable to current recommended method for MR grading. However, the integration of echocardiographic and invasive hemodynamic parameters into a multiparametric score provided a further added value for predicting clinical outcome  at one-year compared to currently recommended methods for MR grading and to 3D-VCA.

Impact on outcome of different etiologies, baseline degree and improvement of mitral regurgitation in patients with aortic stenosis who underwent transcatheter aortic valve replacement

Funding Acknowledgements

Type of funding sources: None.

Background -  Mitral regurgitation (MR) is a frequent finding in patients with aortic stenosis (AS). Moderate or severe MR is present in up to one-third of pts undergoing TAVR and it is a negative prognostic factor as well as the presence of residual MR after TAVR. However, whether different etiologies/mechanisms of MR have different effects on outcome and MR degree changes after TAVR is yet unknown.

Aim – The aim of the study is to evaluate the prognostic impact of baseline MR degree and its changes after TAVR procedures according to different etiologies of MR in patients who underwent TAVR.

Methods - We performed a retrospective observational study on a cohort of patients who underwent TAVR between January 2015 and December 2019. During the index period 947 pts underwent TAVR. To better characterize the mechanism of MR only pts with pre-procedural 3D transesophageal echocardiographic and at least one follow-up available study were included. The final study population consisted of 224 pts. MR severity was evaluated by multiparametric approach and classified in 4 degrees.

The study population was further divided in 4 groups: Group I: fibro-calcific degeneration of the leaflets (78.6% pts); 2. Group II: prolapse or flail (4.4% pts); Group III: functional MR (FMR) due to leaflets tethering (5.6% pts); Group IV: FMR due to annular dysfunction or dilatation (11.3% pts). Primary outcome was all-cause of death.

Results and Discussion – MR was absent in 15 pts (6.7%), mild in 79 pts (35.7%), mild-to-moderate in 109 in pts (49.3%), moderate-to-severe in 7 pts (3.1%) and severe in 11 pts (4.9%). Patients with > moderate MR degree at baseline had a worse outcome than patients with < moderate MR degree (p log rank = 0.029). FMR (groups III and IV) was associated with better outcome than organic MR (groups I and II) (p log rank = 0.035). Moreover, group IV showed a better outcome compared groups I (p log rank = 0.047) and II (p log rank = 0.038). Patients who showed improvement of MR of at least 1 degree post TAVR showed better outcome compared to patients without improvement (p log rank = 0.04). At multivariate analysis, including pre procedural MR > 2+, pre procedural TR > 2+, organic vs functional etiology and MR improvement after TAVR as covariates, only baseline MR > moderate was an independent predictor of mortality (HR 6.3; 95% CI 1.4 -27.0; p < 0.001).

Conclusion - This study confirms the prognostic role of the baseline degree of MR in patients with AS undergoing TAVR. Moreover, this is the first study demonstrating that FMR due to annular dilatation but not due to leaflet tethering is associated with better outcome compared to organic etiologies.

Improving Atraumatic Chest Pain Evaluation in an Urban, Safety-net Hospital Through Incorporation of a Modified HEART Score

Atraumatic chest pain is a common emergency department (ED) presentation and the American College of Cardiology and American Heart Association recommends stress testing within 72 hours. The HEART score predicts major adverse cardiac events (MACE) in ED populations and does not require universal stress testing. An evaluation based solely on history, electrocardiography, and biomarkers, therefore, is an attractive approach to risk stratification in resource-limited settings. The HEART score has not been previously evaluated in a safety net hospital setting. We therefore implemented an interdisciplinary clinical care guideline utilizing the HEART score to stratify patients presenting to our inner-city hospital. During a 6-month study period, 1170 patients were evaluated (521 before and 649 after implementation). Among the 998 patients with confirmed follow-up 6-weeks after the index ED encounter, the prevalence of MACE (all-cause mortality, acute myocardial infarction, or coronary revascularization) was 0% [95% confidence interval (CI), 0%-1%] for low, 9% (95% CI, 7%-12%) for moderate, and 52% (95% CI, 39%-65%) for high-risk groups. Guideline implementation significantly increased admissions (+12%, 95% CI, 7%-17%) primarily in the moderate risk group (+38%, 95% CI, 29%-47%), but significantly decreased median ED length of stay (-37 minutes, 95% CI, 17-58). It also led to an increase in stress testing among moderate and high-risk patients (+10%, 95% CI, 0%-19%). In conclusion, the HEART score effectively stratified risk of MACE in a safety net population, improved evaluation consistency, and decreased ED length of stay. However, implementation was associated with an increase in hospitalizations and stress testing. Although the American Heart Association/American College of Cardiology guideline regarding atraumatic chest pain in the ED recommends universal noninvasive testing, the value of this approach, particularly in conjunction with the HEART score is uncertain in safety net hospitals. Further evaluation of the costs and clinical advantages of this approach are warranted.

Use of MitraClip system for severe mitral regurgitation in cardiogenic shock: results from a multicentre observational Italian experience (the MITRA-SHOCK study)

Background/Introduction

Cardiogenic shock (CS) is a medical emergency and a frequent cause of death. CS can be complicated by mitral regurgitation (MR). The presence of at least moderate MR in the setting of shock was associated with about three-times higher odds of 1-year mortality. In the setting of refractory CS, percutaneous mitral valve repair (PMVR) can be a potential therapeutic option.

Purpose

The aim of the study was to evaluate the efficacy of percutaneous approach of severe MR in patients with CS assessing short-term clinical outcomes.

Methods

In this study we retrospectively included patients with CS and concomitant severe MR treated with Mitraclip system. We enrolled 28 patients from 5 Italian centers between 2012 and 2019. MitraClip implantation was performed according to each hospital standard care. CS was defined utilizing the Diagnostic Criteria of Cardiogenic Shock used in the SHOCK trial. Procedural success was defined as the presence of moderate or less MR after MitraClip implantation.

Results

All patients presented at least severe MR. All treated patients were at high surgical risk (STS mortality score 36.4±11.7%). Procedural success was obtained in 24 patients (86%). A mean of 1.71±0.76 clips per patients were implanted. In-hospital complications occurred in 13 patients (46%): 7 minor bleedings (25% of patients), 7 major bleedings (25%), 8 acute kidney injuries (28%). In-hospital mortality was 25% and the reported causes of death were cardiovascular in all patients. At Cox multivariate analysis procedural success was a strong predictor of in-hospital survival (HR 0.11, CI 95% 0.02–0.67, p=0.017).

Conclusions

PMVR with Mitraclip system in patients with CS and concomitant MR demonstrated high procedural success and acceptable safety. It can be considered a bailout option in this setting of patients with high short-term mortality. Larger prospective studies are needed.

In-hospital mortality predictors

Funding Acknowledgement

Type of funding source: None

P271 Hypoplastic posterior mitral leaflet associated with Marfan syndrome

Picture legend

(A) Mid-esophageal 4-chamber view shows severe hypoplasia of PML (red arrow) and the posterior ventricular myocardial shelf (green arrow). (B) Mid-esophageal commissural view shows a large central MR jet. (C) 3D ventricular perspective of the mitral valve: an almost complete absence of the PML can be appreciated in the central and lateral scallops (grey arrows). (D) CT 3 chamber view shows the myocardial shelf which takes the role of the posterior mitral annulus (blue arrow) and direct PML chordal insertion into the ventricular wall (yellow arrow). (E) CT reconstruction of the mitral valve shows a virtually absent P1 (< 1mm), a P2 length of 4.1 mm, and a P3 length of 5 mm.

Abstract P271 Figure. Hypoplastic posterior mitral leaflet

1183 Three-dimensional echocardiographic paramenters for mitral valve quantification: a feasibility and validation study

Introduction

Mitral regurgitation (MR) severity affects prognosis and a correct quantification is key for surgical indication. A multiparametric approach (MPA) is recommended, as singular parameters suffer pitfalls. Recently suggested three-dimensional echocardiographic (3DE) parameters lack clear reference values. No studies have assessed the feasibility of regurgitant volume (RV) and fraction (RF) using the 3D planimetric area of the mitral annulus (MAA) and of the left ventricular outflow tract (LVOTA).

Purpose

To assess the feasibility and reliability of 3DE, RV and RF obtained by doppler volumetric method using MAA and LVOTA, compare results with 2DE and 3D vena contracta area (VCA) and propose cut-offs for these parameters using MPA as gold standard.

Methods

Patients referred to our Department for MR assessment were enrolled from September 2018 to February 2019 without more than mild aortic regurgitation or severe stenosis, mitral stenosis and previous valvular surgery. Transthoracic 2DE was used to calculate a multiparametric index of MR severity including: jet area/left atrium (LA) area, CW characteristics, 2D vena contracta, PISA, pulmonary vein flow, LA volume and systolic pulmonary artery pressure. Transoesophageal 3DE was used to assess MAA and LVOTA from a 3D dataset. RV and RF were calculated by Doppler volumetric method using the planimetric areas instead of diameters. VCA 3D was calculated from a 3D color dataset as the cross-sectional area of the regurgitant jet. We compared the results between 2DE and 3DE and between functional and organic MR. ROC curves were analyzed to assess diagnostic performance and identify cut-offs for severity prediction. Intraclass correlation coefficient was calculated to assess variability in measurements.

Results

Population was composed by 87 patients (56 male, 65 ± 13 years), 72% organic MR. MAA was larger in 2DE (10.4 ± 3.2 vs 9.8 ± 2.9 cm2,) as was the RV (76.6 ± 36.1 vs 66.4 ± 31.9 ml) and RF (55.4 ± 12.4 vs 50.4 vs 10.9%, all p < 0.0001), while LVOTA was smaller (3.9 ± 0.98 vs 4.1 ± 1.0 cm2, p < 0.0001). RV 2D and RF 2D were larger in the organic MR group (p < 0.0001), meanwhile VCA 3D, RV 3D and RF 3D did not show a significant difference (all p > 0.1). VCA 3D had a good correlation with RV 3D (r = 0.593, p < 0.0001) and RF 3D (r = 0.576, p < 0.0001).

We proposed a cut-off value of 41.5 mm2 for VCA 3D (94% sens, 96% spec, AUC 0.978), 52 ml for RV 3D (84% sens, 78% spec, AUC 0.901) and 47.6% for RF 3D (91% sens, 90% spec, AUC 0.966) to predict MR severity as assessed by MPA.

Intraclass correlation coefficient was 0.980 for MAA and 0.985 for LVOTA for intra-observer variability, while for inter-observer variability it was 0.951 for MAA and 0.962 for LVOTA.

Conclusion

2DE overestimates MA dimensions and underestimates LVOT dimensions thus overestimating RV and RF. 3DE measures are relatively simple and reproducible. Proposed cut-offs for RV, RF and VCA 3D have a good diagnostic power.

P218 Accuracy and reproducibility of aortic root assessment by eSie Valves in patients candidate to transcatheter aortic valve implantation: a comparative study with computed tomography

Background

Accurate imaging assessment of the aortic root (AR) is critical for prosthesis sizing in transcatheter aortic valve implantation. Multislice computed tomography (MSCT) is the gold standard for this purpose. 3D transesophageal (3D-TOE) reconstruction tools have recently been introduced, which automatically configures a geometric model of AR from 3D-TOE dataset and perform quantitative analyses of the AR.

Purpose

The aim of the study was to compare semi-automated measurements of AR obtained by eSie Valves (EV) (Siemens Medical Solution, California, USA) tool with MSCT.

Methods

We prospectively enrolled 26 consecutive patients (mean age 79.5 ± 7.5 years; 38% men) with severe symptomatic aortic stenosis (mean gradient 48.8± 13.6 mmHg) who underwent both 3D-TOE and MSCT as part of TAVI evaluation protocol. Volumetric datasets of the AR, acquired with 3D-TOE in mid-esophageal view, were analyzed with EV tool. EV tool automatically detected AR landmarks and, after user validation, created 3D model of AR providing values of area, perimeter, diameters of aortic annulus (AA) and coronary ostia heights (Fig 1).

Results

EV tool analysis on 3D-TOE volumetric data sets was feasible in all patients.

Strong correlation between EV tool and MSCT assessment for AA major diameter (r = 0.79), AA minor diameter (r = 0.81), AA perimeter (r = 0.89) and AA area (r = 0.89) (all p< 0.0001) was found. On average EV tool underestimated MSCT measurements of AA major diameter (1.2 mm, 4.5%), AA minor diameter (2.6 mm, 11.3%), AA perimeter (4 mm, 5.2%) and AA area (65.3 mmq, 13.6%).

Moderate correlation between the two methods, already in this initial sample, for right coronary artery ostium height (r = 0.53, p = 0.007) was discovered. Finally, weak correlation for left coronary artery ostium height (r = 0.33, p = 0.1) was revealed.

EV tool measurements from two different volumetric datasets of the same patient showed an excellent reproducibility

intraclass correlation coefficient (ICC) for AA area 0.94 and ICC for right coronary height 0.98.

Conclusion

With these initial results EV tool could be used in clinical practice for quick and reliable assessment of AA area, perimeter and diameters. A larger group of patients will be needed to assess the consistency of coronary ostia height evaluation by EV tool.

Abstract P218 Figure. eSie Valve landmarks and 3D model of AR

P300 Reappraisal of aortic stenosis severity grading inconsistencies using 3D aortic valve area

Funding Acknowledgements

no fundings

Background

Different 3D imaging modalities have been proposed to overcome the limitations in aortic stenosis (AS) grading derived from underestimation of left ventricular outflow tract (LVOT) area by 2D transthoracic echocardiography (2D-TTE). Transesophageal echocardiography manual and software measurements (3D-TEEm and 3D-TEEs) and multidetector computed tomography (MDCT) have been recently been shown as valuable tools for AS grading using a combined approach incorporating 3D LVOT measurements and 2D Doppler parameters in the continuity equation (CE). This approach results particularly useful in cases of 2D-TTE grading inconsistence. As all these 3D imaging modalities provide larger AVA compared to 2D-TTE, we have recently proposed a 1.2 cm2 AVA cut-off could to define AS severity with 3D-TEE and MDCT.

Purpose

To compare AVA measurements with 3D-TEEm and 3D-TEEs using MDCT as gold standard in order to assess inconsistencies and evaluate the impact of a 1.2 cm2 AVA cut-off on AS severity grading.

Methods

288 patients (80 ± 11 years, 52.4% male) with symptomatic AS underwent 2D-TTE, 3D-TTEm, 3D-TEEs and MDCT within the same hospitalization. 3D-TEE LVOT reconstruction was performed manually and with semi-automated software (EchoPAC version 201). 3D-TEEm, 3D-TEEs and MDCT LVOT areas were combined with 2D-TTE Doppler parameters to calculate AVA by CE. The grading of AS was reassessed in patients with low flow-low gradient AS using a 1.2 cm2 cut-off for severity.

Results

Patients were classified according to flow state (stroke volume index ≥35 ml/m2 or <35 ml/m2) and mean pressure gradient (MPG ≥40 mmHg or <40 mmHg) into 4 groups: normal flow-high gradient (NF-HG; n 173, 60%), normal flow-low gradient (NF-LG; n 45, 15.5%), low flow-high gradient (LF-HG; n 39, 13.5%), and low flow-low gradient (LF-LG; n 31, 11%) AS. Among patients classified as LF-LG AS, 95%, 55%, 29% and 55% of cases were classified as severe by 2D-TTE, 3D-TEEm, 3D-TEEs and MDCT respectively using a 1.0 cm2 AVA cut-off. When the proposed severity AVA cut-off of 1.2 cm2 was applied using 3D imaging modalities, the proportion of severe AS significantly increased to 84% (p = 0.012) (3D-TEEm), 52% (p = 0.046) (3D-TEEs) and 71% (p < 0.001) (MDCT) respectively.

Conclusion

The use of a 1.2 cm2 AVA cut-off for 3D-TEE and MDCT significantly reduces the number of cases of inconsistently graded AS, increasing the proportion of patients with severe AS.

428 Prognostic implications of the relationship between effective regurgitant orifice area and left ventricle end diastolic volume in patients with functional mitral regurgitation treated with MitraClip

Funding Acknowledgements

none

Background

The distinction between proportionate and disproportionate functional mitral regurgitation (FMR), based on the relationship between effective regurgitant orifice area (EROA) and left ventricle end diastolic volume (LVEDV), has recently been proposed as a possible new clinical and physiopathological framework to identify patients that could likely benefit from transcatheter mitral repair.

Purpose The aim of our study was to explore the possible prognostic implications of the EROA/LVEDV ratio in patients with FMR treated with MitraClip.

Methods – Baseline EROA/LVEDV was calculated in 137 patients with at least moderate-to-severe, symptomatic FMR treated with MitraClip. All patients underwent clinical, biochemichal and echocardiographic evaluation before MitraClip. EROA was calculated using PISA method. The primary outcome was a composite end-point of all-cause death or re-hospitalization for heart failure (HF).

Results – The median follow-up was 1.1 years. The primary outcome occurred in 59 patients (43 %). Population study showed a LVEDVi 113.52± 32.16 mL/m2, LVEF 29.75± 10.06% and EROA 39.45± 15.43 mm2.. The cut-off value of EROA/LVEDV ratio for primary outcome, identified by receiver operating characteristic curve, was 0.15 (AUC 0,65, p = 0.002) with a sensitivity and specificity of 78% and 52%, respectively. Patients were divided in two groups according to the identified cut-off. Patients with higher ratio (Group I, n = 88) presented a less dilated LV (LVEDVi: 105.1 ± 29.6 mL/m2 vs 128.2 ± 31.9 mL/m2, p < 0.001; LVESVi: 73.1 ± 27.7 mL/m2 vs 94.9 ± 29.05 mL/m2, p < 0.001), and a more severe MR (EROA: 47.9 ± 12.1 mm2 vs 25.1 ± 8.3 mm2, p < 0.001; vena contracta: 7.2 ± 1.3 mm vs 6.5 ± 1.3 mm, p = 0.008). There were no significant differences of left ventricle ejection fraction, right ventricle systolic function and systolic pulmonary pressure between the groups. At univariate analysis, EROA/LVEDV ratio >0.15 (HR = 2.223, 95% CI 1.121-4.411, p = 0.022), baseline evidence of atrial fibrillation (HR = 1.949, 95% CI 1.156-3.283, p = 0.012) and baseline pro-BNP (HR= 1.000, 95% CI 1.000-1.000, p = 0,001) were associated with a worse clinical outcome. At multivariate Cox-regression analysis, both EROA/LVEDV ratio >0.15 and baseline pro-BNP values were identified as independent predictors (HR 2.941, 95% CI 1.035-8.353, p = 0.043; HR = 1.000, 95% CI 1.000-1.000, p = 0.002, respectively). At Kaplan-Meier survival analysis, patients with EROA/LVEDV >0.15 had a significant lower freedom from composite endpoint (log-rank χ2 =5.517, p= 0.019; Fig. 1).

Conclusion

Our data show that EROA/LVEDV ratio was an independent predictor of adverse clinical outcome in FMR patients treated with MitraClip. This preliminary experience shows that this index could help to identify subgroups of patients with potential different clinical benefits from Mitraclip therapy. However, further and extended data are needed to provide more precise evidence.

Abstract 428 Figure. Fig. 1

P1251 Percutaneous closure of two mitral perivalvular leaks: when the imaging guides the hands during threatening complications

With the contemporary development of structural interventional cardiology the prevalence of perivalvular leaks (PVL) is expected to grow. Advanced multimodality imaging is necessary for the guidance of transcatheter closure of PVL. We describe the case of a 57 year-old woman who underwent transcatheter mitral PVL closure. Past clinical history included a lymphoma treated with chemio and radiotherapy. Six months before she underwent a surgical replacement of the aortic and mitral valves with two mechanical prosthesis for severe aortic and mitral stenosis. Because of the calcium burden in both the annuluses, undersized mitral valve prosthesis was implanted leading to the presence of two moderate mitral PVL. The patient subsequently required hospitalization for acute HF and hemolytic anemia and received multiple blood transfusions. TEE confirmed the presence of a large antero-lateral PVL and a small medial PVL (3D VCA 0,32 cm2 and 0,2 cm2 respectively, associated with reverse flow in the pulmonary veins) with an extension of 33% of the circumference of the prosthesis. The regurgitation was considered severe and a percutaneous closure was planned with 3D-TEE and fluoroscopy image fusion guidance. Under general anesthesia a transeptal puncture was performed and the medial leak was closed with two vascular plugs (6mm each). During the deployment of the plugs an intermittent blockage of the medial disk of the prosthesis was noticed, which resolved completely after the removal of the wires previously positioned for the engagement of the leak. The lateral leak was then engaged and a second plug (10mm) was advanced causing a discontinuous interference with the two disks. The direct interference with the lateral disk caused a blockage in the closing position (leading to moderate stenosis, medium gradient 7mmHg) and in the opening position (leading to a massive regurgitation). The medial disk was intermittently blocked in the closing position due to the bulky effect of the devices provoking a traction and displacement of the prosthesis towards the medial region of the valve. To avoid this interference the plug was released with a marked atrial protrusion. Notably, after the removal of the wires no malfunctioning of the disks was noticed and the mild residual shunts appeared further decreased. The procedure was considered successful and at follow-up no residual leak was found. The percutaneous closure of PVL is a safe and effective intervention. Multimodality imaging is essential for the diagnosis, planning and procedural guidance. The knowledge of possible complications is warranted for the achievement of an optimal result. This case clearly show the possibility of interference with the prosthesis and overestimation of residual leaks.

Abstract P1251 Figure. PVL closure:procedure and complications

P755 Aortic valve area calculation by 3D transesophageal echocardiography: new insights in severity grading of aortic stenosis

Background

Aortic stenosis (AS) grading is mainly based on aortic valve area (AVA) calculation by 2D transthoracic echocardiography (2D-TTE), using continuity equation (CE). However, 2D-TTE shows several limits, mainly due to left ventricular outflow tract (LOVT) underestimation. Different 3D imaging modalities have been proposed to overcome 2D-TTE limitations, including 3D transesophageal echocardiography manual and software measurements (3D-TEEm and 3D-TEEs) and multidetector computed tomography (MDCT). The AVA cut-off value generally used to define severe AS has been established and validated by outcome studies in which AVA was measured by 2D-TTE. This cut-off value cannot be directly extrapolated to the 3D-TEE combined approach that systematically measures larger LVOT compared with 2D-TTE.

Purpose.To evaluate the diagnostic accuracy of 3D transesophageal echocardiography manual and software measurements (3D-TEEm and 3D-TEEs) in AS grading, compared with multidetector computed tomography (MDCT) as gold standard, and to identify a new cut-off for AS severity assessment.

Methods

218 patients (81 ± 5.4 years, 54% male) with symptomatic normal-flow AS underwent 2D-TTE, 3D-TTEm, 3D-TEEs and MDCT within the same hospitalization. 3D-TEE LVOT reconstruction was performed manually and with semi-automated software (EchoPAC version 201). 3D-TEEm, 3D-TEEs and MDCT LVOT areas were combined with 2D-TTE Doppler parameters to calculate AVA by CE. Using Doppler parameters (Vmax >4 m/s and MPG >40 mmHg) to define AS severity, a receiving-operating curve (ROC) was calculated for AVA obtained with different 3D imaging modalities.

Results

There was a good correlation between both 3D-TEEm and 3D-TEEs and MDCT measurements (r = 0.800 and r = 0.814, respectively) and excellent agreement between 3D-TEEm and 3D-TEEs with minimum bias. 2D-TTE significantly underestimated AVA compared to 3D-TEEm, 3D-TEEs and MDCT. On the other hand, both 3D-TEEm and 3D-TEEs underestimated AVA compared to MDCT (mean AVA difference = 0.13 and =0.06 cm2, respectively). ROC curve analysis demonstrated 91% sensibility and 34% specificity for 2D-TTE AVA using a cut-off of 1 cm2 (AUC 0.732). For 3D-TEEm and 3D-TEEs, a 1 cm2cut-off resulted in 74% sensibility and 59% specificity, while a 1.2 cm2cut-off resulted in 91% sensibility and 31% specificity (AUC 0.715). MDCT showed 59% sensibility and 70% specificity using a 1 cm2 cut-off and 83% sensibility and 45% specificity using a 1.2 cm2 cut-off (AUC 0.708).

Conclusion

3D-TEE represents a valuable tool for AS grading using a combined approach incorporating 3D LVOT measurements and 2D Doppler parameters in the CE. Both 3D-TEEm and 3D-TEEs AVA measurements demonstrated good correlation with MDCT and excellent reproducibility. 3D-TEE measurements underestimate AVA compared to MDCT. Given the multiparametric assessment of AS severity, a 1.2 cm2 AVA cut-off could be considered to define AS severity with emerging 3D imaging modalities.

P43673D analysis of mitral annular reshape with third generation MitraClip XTr in functional and degenerative mitral regurgitation

The 3rd generation Mitraclip XTr was recently introduced to improve device performance, through longer clip arms that should allow better grasping of the mitral leaflets, thus improving coaptation and results eventually. Several studies have demonstrated additional effects such as the reshape of the mitral annulus immediately after clip implantation.

The aim of our study was to evaluate the mitral valve (MV) annular remodelling with MitraClip XTr.

Between March 2018 and November 2018, 75 consecutive patients were enrolled. The population was divided in two groups: functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR).

The 3D MV datasets at baseline and immediately after the procedure were acquired and then analysed with semiautomatic MVQ software (QLAB Cardiac 3DQ v.10.0; Philips Medical Systems).

The software provides the following parameters: annular diameters (antero-posterior, AP, and inter-commissural, IC), circumference, area, height and ellipsicity (IC/AP ratio as percentage); saddle-index, defined as annular height to IC diameter ratio was derived.

The 3D post-processing was feasible in 54 patients (108 3D datasets): 28 had FMR (52%) and 26 had DMR (48%).

An average of 1.8 clips per patient were implanted: 2 clips in 38 (70%), 1 clip in 14 (26%) and 3 clips in 2 (4%) patients. The position was central in 93% of the procedures.

Results are reported in table 1. In the FMR group, a reduction in the AP diameter (p=0.001), an increase in both IC diameter (p=0.001) and annular ellipsicity (p<0.001) were observed.

In the DMR group, an increase in annular ellipsicity (p=0,008) and in saddle-index (p<0.05) were observed.

Table 1 Functional mitral regurgitation (N=28) Degenerative mitral regurgitation (N=26) Pre-clip Post-clip P-value Pre-clip Post-clip P-value IC diameter (mm) 39.3±4.2 41.9±4.1 0.001 40.9±6.5 41.8±5.8 0.257 AP diameter (mm) 32.8±4.6 30.4±3.2 0.001 32.6±4.8 31.7±4.5 0.199 Annular Height (mm) 5.1±1.8 5.4±1.8 0.336 4.8±1.9 5.7±2.2 0.026 3D circumference (mm) 122.7±15.1 123.5±11 0.718 123.5±19.0 124.0±17.1 0.812 3D area (mmq) 1128.0±280 1113.7±206 0.752 1160±346.7 1156.8±318.0 0.926 Annular ellipsicity (%) 121.5±12.2 138.5±11.8 0.0005 125.9±9.6 132.4±10.7 0.008 Saddle index 13.0±4 13.0±4 0.957 11.8±4.2 13.6±4.2 0.048

Our study demonstrates that the XTr implantation produces a MV annular remodelling both in FMR and DMR probably with different mechanisms. In FMR the MV annulus resulted more elliptical, wheras in DMR the geometrical modifications involve both the ellipsicity and the saddle-shape morphology.

P4728Prognostic implications of the relationship between effective regurgitant orifice area and left ventricle end diastolic volume in patients with functional mitral regurgitation treated with MitraClip

Background

The distinction between proportionate and disproportionate functional mitral regurgitation (FMR), based on the relationship between effective regurgitant orifice area (EROA) and left ventricle end diastolic volume (LVEDV), has recently been proposed as a possible new clinical and physiopathological concept to identify patients that could likely benefit from transcatheter mitral repair.

Purpose

The aim of our study was to explore the possible prognostic implications of the EROA/LVEDV ratio in patients with FMR treated with MitraClip.

Methods

Baseline EROA/LVEDV ratio was calculated in 72 patients with moderate-to-severe, symptomatic FMR treated with MitraClip. All patients underwent clinical, biochemichal and echocardiographic evaluation before MitraClip. EROA was calculated using PISA method. The primary outcome was a composite end-point of all-cause death or re-hospitalization for heart failure (HF).

Results

The median follow-up was 1 year. The primary outcome occurred in 25 patients (34.7%). The cut-off value of EROA/LVEDV ratio for primary outcome, identified by receiver operating characteristic curve, was 0.15 (p=0.007) with a sensitivity and specificity of 72 and 68%, respectively. Patients were divided in two groups according to the identified cut-off. Patients with higher ratio (Group I, n=35) presented a less dilated LV (LVEDVi: 113.2±33.4 mL vs 129.3±29.3 mL, p=0.033; LVESV: 140.7±49.0 mL vs 171.1±47.4 mL, p=0.010), a better LV systolic function (LVEF: 31.9±9.5% vs 27.8±5.8%, p=0.028) and a more severe MR (EROA: 44.5±12.9 mm2 vs 24.5±6.8 mm2, p<0.001; vena contracta: 7.4±1.5 mm vs 6.7±1.0 mm, p=0.045). Patients with lower ratio (Group II, n=37) showed a reduced prevalence of MV annular dilation (57.1% vs 91.7%, p=0.005) and a worse RV function (s'TDI: 9.2±2.2 cm/s vs 10.5±2.9 cm/s, p=0.039). At univariate analysis, EROA/LVEDV ratio >0.15 (HR = 2.467, 95% CI 1.017–5.982, p=0.046) and severe pulmonary hypertension (HR = 2.481, 95% CI 1.030–5.976, p=0.043) were associated with a worse clinical outcome. At multivariate Cox-regression analysis, both EROA/LVEDV ratio >0.15 and severe pulmonary hypertension were identified as independent predictors (HR 3.203, 95% CI 1–310–7.832, p=0.011; HR = 3.280, 95% CI 1.326–8.116, p=0.010, respectively).

Figure 1

Conclusion

Our data show that EROA/LVEDV ratio was an independent predictor of adverse clinical outcome in FMR patients treated with MitraClip. This preliminary experience shows that this index could help to identify subgroups of patients with potential different clinical benefits from MitraClip therapy. However, further and extended data are needed to provide more precise evidence.

Acknowledgement/Funding

None

Intra-procedural monitoring protocol using routine transthoracic echocardiography with backup trans-oesophageal probe in transcatheter aortic valve replacement: a single centre experience

Aim

The aim of this study is to describe our 9-year experience in transcatheter aortic valve replacement (TAVR) using transthoracic echocardiography (TTE) as a routine intra-procedural imaging modality with trans-oesophageal echocardiography (TEE) as a backup.

Methods and results

From January 2008 to December 2017, 1218 patients underwent transfemoral TAVR at our Institution. Except the first 20 cases, all procedures have been performed under conscious sedation, with fluoroscopic guidance and TTE imaging monitoring. Once the TTE resulted suboptimal for final result assessment or a complication was either suspected or identified on TTE, TEE evaluation was promptly performed under general anaesthesia. Only 24 (1.9%) cases required a switch to TEE: 6 cases for suboptimal TTE prosthetic valve leak (PVL) quantification; 12 cases for haemodynamic instability; 2 cases for pericardial effusion without haemodynamic instability; 4 cases for urgent TAVR. The 30-days and 1-year all-cause mortality were 2.1% and 10.2%, respectively. Cardiac mortality at 30-days and 1-year follow-up were 0.6% and 4.1%, respectively. Intra-procedural and pre-discharge TT evaluation showed good agreement for PVL quantification (k agreement: 0.827, P = 0.005).

Conclusion

TTE monitoring seems a reasonable imaging tool for TAVR intra-procedural monitoring without delay in diagnosis of complications and a reliable paravalvular leak assessment. However, TEE is undoubtedly essential in identifying the exact mechanism in most of the complications.

Clinical Use of an Imaging Probe in Breast Cancer Surgery

Aim

Portable cameras allow easy transfer of the detector, and thus of radioisotope imaging, to the operating room. In this paper we describe our preliminary experience in radionuclide imaging of breast cancer with a 22.8 × 22.8 mm2 field-of-view minicamera called “Imaging Probe” (IP).

Methods

Breast cancer detection by IP was performed to guide biopsy, in particular open biopsy, or help fine-needle or core-needle positioning when the main guidance method was ultrasonography or digital radiography. 99mTc Sestamibi (MIBI) was injected 1 h before imaging and biopsy to 14 patients with suspected or known breast cancer. Scintigraphic images were acquired before and after biopsy in each patient. The surgeon was allowed to take into account scintigraphic images as well as previously performed mammograms and ultrasonography.

Results

High-resolution IP images were able to guide biopsy toward cancer or toward washout zones of cancer, which are thought to be chemoresistant, in seven patients out of 10. Four patients in whom IP and MIBI were unable to guide biopsy were found not to have cancer.

Conclusions

Our study confirms the ability of IP to guide breast biopsy even when our minicamera has to be handled manually by trained physicians during surgery.

New Localization Technique for Breast Cancer Biopsy: Mammotome Guidance with Imaging Probe

Aims and Background

The “Imaging probe” (IP) is a small, portable, high-resolution gamma camera to be used in radioguided surgery. The present work discusses a special prototype designed for guiding biopsies. The IP was mounted to a Fischer digital X-ray stereotactic core biopsy system in such a way that biopsy could be guided simultaneously by X-ray stereotaxis and 99mTc-Sestamibi (MIBI) images from IP.

Methods

The IP field of view was 22.8 × 22.8 mm2, with a spatial resolution of approx. 2.5 mm. We used off-line software for image fusion on a dedicated Pentium III portable PC. It was matched with a Fischer digital X-ray stereotactic biopsy system dedicated to direct the mammotome towards breast opacities. The operator was allowed to slightly correct the direction of the mammotome needle taking into account stereotactic X-ray, scintigraphic and fused images. Biopsy samples were counted by IP before they were sent to the pathologist.

Results

High-resolution IP scintigraphy showed substantial, though not exact, matching between MIBI hot spots and X-ray opacities. More than one hot spot was detected even in the smallest (0.6 cm) lesion. Post-biopsy scintigraphy showed absence of significant hot spots in two patients, whereas in the third patient one of the three hot spots was still partially present. All lesions showed cancer on histological examination.

Conclusions

Measurement of radioactivity in biopsy specimens confirmed the heterogeneous distribution of radioactivity within cancers that IP had detected before biopsy.

Intraoperative Sentinel Node Detection by an Innovative Imaging Probe

Intraoperative tumor detection has been used in many applications, and today the sentinel node technique is a widely employed surgical procedure in breast cancer. Different detector systems are employed but several problems have been reported in clinical practice, in particular the difficulty to accurately detect the sentinel node within the axillary soft tissue. The problem is even greater for abdominal and thoracic tumors. We propose an innovative Imaging Probe (IP) able to visualize on a monitor the primary tumor and secondary lesions, if appropriately radiolabeled. The IP can be optimally applied for minimally invasive surgery in breast cancer treatment, and a preliminary experience related to 15 patients and 20 sentinel nodes is reported here. We compared the results obtained with the IP to those obtained with an Anger camera and a traditional scintillation detector, and found them to be very promising. In particular the surgeon's work is greatly facilitated by direct visual guidance instead of a generic acoustic signal.

Detection of Sentinel Node in Breast Cancer: Pilot Study with the Imaging Probe

The commonly used gamma probes are easy to use but also give rough information when employed in radioisotope-guided surgery. When images are required for exact localization, a gamma camera as well as a probe have to be used. Position-sensitive photomultipliers have contemporaneously allowed high-resolution scintigraphy and miniaturization of gamma cameras. We have assembled a miniature gamma camera with a 1-square-inch field of view and an intrinsic resolution of about 1 mm. When the minicamera is collimated with a large-holed, highly sensitive collimator, it acquires a spatial resolution of 3 mm. This prototype has been tested in the detection of difficult-to-image breast cancer sentinel nodes. Five nodes that had not been found with the usual technique of an Anger camera plus conventional probe were checked with the miniature camera that we named imaging probe: it actually is small enough to be used as a probe and large enough to give an image. One of the five nodes was found and imaged. It was small, disease-free, close to the tumor and probably hidden by the Compton halo around the peritumoral injection site. Our pilot study shows that the imaging probe, although still a prototype, has certain advantages over conventional methods when lymph node localization is required during surgery.

Slaughter performance and meat quality of Milanino chickens reared according to a specific free-range program

The study aimed to characterize meat quality traits of Milanino chickens reared according to a specific free-range farming program. A total of 120 birds was reared straight-run in outdoor pens (8 m2/bird) from 35 d of life and fed ad libitum a low (16%) protein diet. At 180 d of age, 20 birds (10 birds/sex) were slaughtered, and carcass weight data were recorded. After processing, carcasses were refrigerated at 4°C for 24 hours. Then, the right breast and thigh with skin were collected and color parameters, pH, water-holding capacity (WHC), and chemical composition were determined. The left breast and thigh were stored at -20°C until cooking loss and tenderness evaluation. Milanino was confirmed to be a heavy breed with a sexual dimorphism in relation to adult body weight. A high general carcass yield was recorded. Milanino meat was characterized by high protein and low fat contents compared with the standard broiler meat. Differences in meat composition were recorded according to the sex: females presented higher values of dry matter (breast and thigh), protein (breast), and fat (breast and thigh) contents. The meat with skin presented an intense luminosity, and this trait was higher in the females. The muscle color was characterized by high redness and yellowness indices with differences according to the sex: Higher yellowness index was observed in female carcasses, while higher redness index was detected in male breast samples. The pH muscle values were similar to those reported in other autochthonous breeds. WHC values did not show variation between sexes. In contrast, cooking loss values recorded in thigh samples were lower in males compared to females. The degree of tenderness of Milanino meat was not affected by the sex. However, the potential loss of water and the toughness in Milanino meat were low compared to other local chicken breed meat. The present results support the breeding of Milanino chickens for meat production according to its specific straight-run free-range system.

Effects of antioxidant mixtures in the diet of finishing pigs on the oxidative status and shelf life of longissimus dorsi muscle packaged under modified atmosphere

The effect of pig dietary supplementation with an antioxidant mixture (AOX), containing vitamin E and verbascoside, on animal oxidative status, meat quality parameters, and shelf life of the longissimus dorsi (LD) muscle was examined. Seventy pigs with an average live weight of 95.2 ± 1.2 kg were selected and assigned to 2 dietary treatments. The control (CTR) group was fed a commercial diet, and the AOX group was fed the same diet supplemented with the AOX, containing vitamin E and verbascoside from Verbenaceae extract, for 45 d before slaughter. At the beginning and at the end of the trial, blood samples were collected to determine oxidative status, using the Kit Radicaux Libres test. At slaughter, carcass weight was recorded and LD muscles from 10 pigs per treatment were sampled. Physical, chemical, microbiological, and sensory parameters and oxidative stability of LD muscle were assessed for up to 21 d of storage at 4°C under modified atmosphere packaging. Dietary AOX positively affected ( < 0.05) oxidative status and carcass dressing percentage. The oxidative and color stability of the LD muscle were improved ( < 0.05) in the AOX group compared with the control. The sensory shelf life revealed that at 15 d of storage, meat from the AOX group was comparable ( < 0.05) to the fresh meat in appearance and aroma. A lower ( < 0.05) spp. load was observed in the AOX samples than in the control samples. No other microbiological parameters were affected by dietary treatment. Overall, the present data showed that dietary AOX supplementation in pigs improved in vivo antioxidant status and exerted antioxidant and antimicrobial effects, thus enhancing the shelf life of raw pork under commercial conditions.

Electronic Hand Hygiene Monitoring: A Tool to Drive Improvement and Measure Impact

Background

Hand hygiene (HH) is a basic principle of infection control, yet national HH adherence rates are only 40%. Challenges to improving HH rates include finding effective ways to promote and sustain change and collecting unbiased observations to measure the success of interventions. Our institution implemented an electronic HH (eHH) monitoring system on select hospital units with the goal of using this technology to both improve and measure HH rates.

Methods

In Apr 2016, Denver Health installed the HillRom Hand Hygiene Compliance Solution in 4 inpatient units (2 adult wards, 1 intensive care unit, and 1 progressive care unit). Sensors were installed on all HH dispensers and at the thresholds of patient rooms on the units. Registered nurses and certified nursing assistants wear badges that track HH upon entry and exit from the room. Appropriate eHH was defined as the use of waterless hand sanitizer or soap within 60 seconds before or after entering or exiting a room. Baseline data was collected for 2 months; a series of interventions, including public recognition of top performers, private individualized feedback, and posters emphasizing social pressures, were undertaken beginning in June 2016 (Figure 1). Descriptive statistics, chi-squared tests, and interrupted time series analyses were used to analyze the data.

Results

The median number of total daily observations was 4083 (IQR 3801–4437). The mean eHH adherence rate in the baseline period (Apr/May 2016) was 46% (IQR 44%-49%) and increased to 76% (IQR 75%-78%) in Mar 2017. Over the study period, there was a significant decreasing trend in the proportion of nurses with eHH rates <50% (P < 0.0001, Figure 2) and a significant increasing trend in the proportion of nurses with eHH rates ≥80% on all units (P < 0.0001, Figure 3).

Conclusion

eHH provides thousands of objective observations per day. eHH rates improved over the study period both due to an increase in nurses with eHH ≥80% and a decrease in the proportion of nurses with eHH <50%.

Disclosures

All authors: No reported disclosures.

P1246Age-, body size-, and sex-specific reference values for tricuspid valve apparatus parameters by real-time three-dimensional transthoracic echocardiography

Background

and Purpose-Tricuspid valve (TV) apparatus parameters can vary significantly with demographic and anthropometric factors and could be useful for clinical decision making. Our aim was to (1) establish the reference values for TV apparatus parameters using transthoracic three-dimensional (3D) echocardiography; (2) investigate the influence of age, sex, and body size on TV anatomy.

Methods-A total of 180 healthy subjects referred in 2015 to our institution for a screening transthoracic echocardiography were enrolled (mean age 49.7+17.4 years, range 20 to 80 years: 30 subjects per age decade were included in the study, 15 for each gender). A real-time zoom 3D image of the TV and full volume 3D data set were collected from an apical window including TV using Philips iE33 and GE Vivid E9 Ultrasound Machines. After acquisition, the 3D data sets were analysed using 3D Qlab and EchoPAC PC softwares. The volumetric data set was analysed with multiplanar reformatting function to obtain three simultaneous orthogonal 2D slices (sagittal, coronal and axial planes). The following TV parameters were obtained and measured: 1. the 3D diastolic annular diameters (Major and Minor diameters); 2. the 3D diastolic annular area (TDAA); 3. the Tricuspid annular fractional area changes (TAFAC). Results are presented as mean ± SD. Differences between and among groups were tested for significance using the independent samples t-test and ANOVA test for continuous variables. Univariate Pearson correlation was used to assess the relation between these parameters and age, and body size. A p <0.05 was considered significant.

Results- Minor and major diastolic diameters in overall population were 26.1±3.9 and 32.3±4.1 mm, respectively. Minor diastolic diameter (mDD) (26.9±4.2 vs 25.1±3.4 mm, p <0.05) and major diastolic diameter (MDD) (33.4±4.0 vs 30.9±3.8, p <0.05) were significantly different between males and females. After normalization for BSA, mDD and MDD in overall population were 14.6±2.2 and 18.3±2.3 mm/m2. Normalized mDD (14.3±2.3 vs 14.9±2.2 mm/m2, p >0.05) and normalized MDD (18.1±2.4 vs 18.4±2.3 mm/m2, p>0.05) did not differ significantly between males and females. TTDAA and TAFAC in overall population were 76.7±17.3 mm2 and 29.6±8.6%. TDAA was significantly different between males and females (82.5±18.3 vs 69.7±13.0 mm2, respectively; p < 0.05); whereas TAFAC did not differ (28.8±8.2% vs 30.7±8.9%, p>0.05). After normalization for BSA, TDAA in overall population was 43.3±9.0 mm2/m2. Also normalized TDAA was significantly different between males and females (44.4±9.4 vs 42.0±8.4 mm2/m2, p < 0.05). mDD, MDD, TDAA and TAFAC showed no correlation with age (r = 0.16, p 0.04; r = 0.028, p 0.7; r = 0.17, p 0.27; r = 0.16, p 0.16; respectively).

Conclusion- This study can provide normal reference values for TV anatomic parameters that may be useful in the clinical practice, considering the effects of age, sex, and body size.