Cardiac implantable electronic devices and bloodstream infections: management and outcomes

BACKGROUND AND AIMS

Bloodstream infection (BSI) of any cause may lead to device infection in cardiac implantable electronic device (CIED) patients. Aiming for a better understanding of the diagnostic approach, treatment, and outcome, patients with an implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy and defibrillator (CRT-D) hospitalized with BSI were investigated.

METHODS

This is a single-centre, retrospective, cohort analysis including consecutive ICD/CRT-D patients implanted between 2012 and 2021. These patients were screened against a list of all hospitalized patients having positive blood cultures consistent with diagnosed infection in any department of a local public hospital.

RESULTS

The total cohort consisted of 515 patients. Over a median follow-up of 59 months (interquartile range 31-87 months), there were 47 BSI episodes in 36 patients. The majority of patients with BSI (92%) was admitted to non-cardiology units, and in 25 episodes (53%), no cardiac imaging was performed. Nearly all patients (85%) were treated with short-term antibiotics, whereas chronic antibiotic suppression therapy (n = 4) and system extraction (n = 3) were less frequent. Patients with BSI had a nearly seven-fold higher rate (hazard ratio 6.7, 95% confidence interval 3.9-11.2; P < .001) of all-cause mortality.

CONCLUSIONS

Diagnostic workup of defibrillator patients with BSI admitted to a non-cardiology unit is often insufficient to characterize lead-related endocarditis. The high mortality rate in these patients with BSI may relate to underdiagnosis and consequently late/absence of system removal. Efforts to increase an interdisciplinary approach and greater use of cardiac imaging are necessary for timely diagnosis and adequate treatment.

Beneficial Effects of IABP in Anterior Myocardial Infarction Complicated by Cardiogenic Shock

Background and Objectives. Recent guidelines have downgraded the routine use of the intra-aortic balloon pump (IABP) in patients with cardiogenic shock (CS) due to ST-elevation myocardial infarction (STEMI). Despite this, its use in clinical practice remains high. The aim of this study was to evaluate the prognostic impact of the IABP in patients with STEMI complicated by CS undergoing primary PCI (pPCI), focusing on patients with anterior MI in whom a major benefit has been previously hypothesized. Materials and Methods. We enrolled 2958 consecutive patients undergoing pPCI for STEMI in our department from 2005 to 2018. Propensity score matching and mortality analysis were performed. Results. CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. In the propensity-matched analysis, the use of the IABP was associated with a lower 30-day mortality (39.3% vs. 60.9%, p = 0.032) in the subgroup of patients with anterior STEMI. Conversely, in the whole group of CS patients and in the subgroup of patients with non-anterior STEMI, IABP use did not have a significant impact on mortality. Conclusions. The use of the IABP in cases of STEMI complicated by CS was found to improve survival in patients with anterior infarction. Prospective studies are needed before abandoning or markedly limiting the use of the IABP in this clinical setting.

Peri-Procedural Management of Direct-Acting Oral Anticoagulants (DOACs) in Transcatheter Miniaturized Leadless Pacemaker Implantation

INTRODUCTION

Data on peri-operative management of direct-acting oral anticoagulants (DOACs) during transcatheter pacing leadless system (TPS) implantations remain limited. This study aimed to evaluate a standardized DOAC management regime consisting of interruption of a single dose prior to implantation and reinitiation within 6-24 h; also, patient clinical characteristics associated with this approach were identified.

METHOD

Consecutive patients undergoing standard TPS implantation procedures from two Swiss tertiary centers were included. DOAC peri-operative management included the standardized approach (Group 1A) or other approaches (Group 1B).

RESULTS

Three hundred and ninety-two pts (mean age 81.4 ± 7.3 years, 66.3% male, left ventricular ejection fraction 55.5 ± 9.6%) underwent TPS implantation. Two hundred and eighty-two pts (71.9%) were under anticoagulation therapy; 192 pts were treated with DOAC; 90 pts were under vitamin-K antagonist. Patients treated with DOAC less often had structural heart disease, diabetes mellitus, and advanced renal failure. The rate of major peri-procedural complications did not differ between groups 1A (n = 115) and 1B (n = 77) (2.6% and 3.8%, p = 0.685). Compared to 1B, 1A patients were implanted with TPS for slow ventricular rate atrial fibrillation (AF) (p = 0.002), in a better overall clinical status, and implanted electively (<0.001).

CONCLUSIONS

Standardized peri-procedural DOAC management was more often implemented for elective TPS procedures and did not seem to increase bleeding or thromboembolic adverse events.

Role of genetic testing in young patients with idiopathic atrioventricular conduction disease

AIMS

To investigate the role of genetic testing in patients with idiopathic atrioventricular conduction disease requiring pacemaker (PM) implantation before the age of 50 years.

METHODS AND RESULTS

All consecutive PM implantations in Southern Switzerland between 2010 and 2019 were evaluated. Inclusion criteria were: (i) age at the time of PM implantation: < 50 years; (ii) atrioventricular block (AVB) of unknown aetiology. Study population was investigated by ajmaline challenge and echocardiographic assessment over time. Genetic testing was performed using next-generation sequencing panel, containing 174 genes associated to inherited cardiac diseases, and Sanger sequencing confirmation of suspected variants with clinical implication. Of 2510 patients who underwent PM implantation, 15 (0.6%) were young adults (median age: 44 years, male predominance) presenting with advanced AVB of unknown origin. The average incidence of idiopathic AVB computed over the 2010-2019 time window was 0.7 per 100 000 persons per year (95% CI 0.4-1.2). Most of patients (67%) presented with specific genetic findings (pathogenic variant) or variants of uncertain significance (VUS). A pathogenic variant of PKP2 gene was found in one patient (6.7%) with no overt structural cardiac abnormalities. A VUS of TRPM4, MYBPC3, SCN5A, KCNE1, LMNA, GJA5 genes was found in other nine cases (60%). Of these, three unrelated patients (20%) presented the same heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene. Diagnostic re-assessment over time led to a diagnosis of Brugada syndrome and long-QT syndrome in two patients (13%). No cardiac events occurred during a median follow-up of 72 months.

CONCLUSION

Idiopathic AVB in adults younger than 50 years is a very rare condition with an incidence of 0.7 per 100 000 persons/year. Systematic investigations, including genetic testing and ajmaline challenge, can lead to the achievement of a specific diagnosis in up to 20% of patients. Heterozygous missense variant c.2531G > A p.(Gly844Asp) in TRPM4 gene was found in an additional 20% of unrelated patients, suggesting possible association of the variant with the disease.

Serum uric acid in patients with ST-segment elevation myocardial infarction: An innocent bystander or leading actor?

Elevated serum uric acid (SUA) levels have been associated with several cardiovascular risk factors and the progression of coronary artery disease. In the setting of acute myocardial infarction, increasing evidence suggests that high SUA levels could be related to adverse outcomes. Interestingly elevated SUA levels have been linked to endothelial dysfunction, inflammation and oxidative stress. The aim of this review is to discuss the potential negative effects of SUA in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention, analyzing the possible underlying pathophysiological mechanisms.

Impact of SMART Pass filter in patients with ajmaline-induced Brugada syndrome and subcutaneous implantable cardioverter-defibrillator eligibility failure: results from a prospective multicentre study

AIMS

Ajmaline challenge can unmask subcutaneous implantable cardioverter-defibrillator (S-ICD) screening failure in patients with Brugada syndrome (BrS) and non-diagnostic baseline electrocardiogram (ECG). The efficacy of the SMART Pass (SP) filter, a high-pass filter designed to reduce cardiac oversensing (while maintaining an appropriate sensing margin), has not yet been assessed in patients with BrS. The aim of this prospective multicentre study was to investigate the effect of the SP filter on dynamic Brugada ECG changes evoked by ajmaline and to assess its value in reducing S-ICD screening failure in patients with drug-induced Brugada ECGs.

METHODS AND RESULTS

The S-ICD screening with conventional automated screening tool (AST) was performed during ajmaline challenge in subjects with suspected BrS. The S-ICD recordings were obtained before, during and after ajmaline administration and evaluated by the means of a simulation model that emulates the AST behaviour with and without SP filter. A patient was considered suitable for S-ICD if at least one sensing vector was acceptable in all tested postures. A sensing vector was considered acceptable in the presence of QRS amplitude >0.5 mV, QRS/T-wave ratio >3.5, and sense vector score >100. Of the 126 subjects (mean age: 42 ± 14 years, males: 61%, sensing vectors: 6786), 46 (36%) presented with an ajmaline-induced Brugada type 1 ECG. Up to 30% of subjects and 40% of vectors failed the screening during the appearance of Brugada type 1 ECG evoked by ajmaline. The S-ICD screening failure rate was not significantly reduced in patients with Brugada ECGs when SP filter was enabled (30% vs. 24%). Similarly, there was only a trend in reduction of vector-failure rate attributable to the SP filter (from 40% to 36%). The most frequent reason for screening failure was low QRS amplitude or low QRS/T-wave ratio. None of these patients was implanted with an S-ICD.

CONCLUSION

Patients who pass the sensing screening during ajmaline can be considered good candidates for S-ICD implantation, while those who fail might be susceptible to sensing issues. Although there was a trend towards reduction of vector sensing failure rate when SP filter was enabled, the reduction in S-ICD screening failure in patients with Brugada ECGs did not reach statistical significance.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov Unique Identifier NCT04504591.

Catheter Ablation of Atrial Fibrillation in Patients with Previous Lobectomy or Partial Lung Resection: Long-Term Results of an International Multicenter Study

INTRODUCTION

Data regarding the efficacy of catheter ablation in patients with atrial fibrillation (AF) and patients' previous history of pulmonary lobectomy/pneumonectomy are scanty. We sought to evaluate the efficacy and long-term follow-up of catheter ablation in this highly selected group of patients.

MATERIAL AND METHODS

Twenty consecutive patients (8 females, 40%; median age 65.2 years old) with a history of pneumonectomy/lobectomy and paroxysmal or persistent AF, treated by means of pulmonary vein isolation (PVI) at ten participating centers were included. Procedural success, intra-procedural complications, and AF recurrences were considered.

RESULTS

Fifteen patients had a previous lobectomy and five patients had a complete pneumonectomy. A large proportion (65%) of PV stumps were electrically active and represented a source of firing in 20% of cases. PVI was performed by radiofrequency ablation in 13 patients (65%) and by cryoablation in the remaining 7 cases. Over a median follow up of 29.7 months, a total of 7 (33%) AF recurrences were recorded with neither a difference between patients treated with cryoablation or radiofrequency ablation or between the two genders.

CONCLUSIONS

Catheter ablation by radiofrequency ablation or cryoablation in patients with pulmonary stumps is feasible and safe. Long-term outcomes are favorable, and a similar efficacy of catheter ablation has been noticed in both males and females.

Extracorporeal veno-venous ultrafiltration in patients with acute heart failure

Hospitalization for congestive heart failure represents a growing burden for health care systems. Heart failure is characterized by extracellular fluid overload and loop diuretics have been for decades the cornerstone of therapy in these patients. However, extensive use of intra-venous diuretics is characterised by several limitations: risk of worsening renal function and electrolyte imbalance, symptomatic hypotension and development of diuretic resistance. Extracorporealveno-venous ultrafiltration (UF) represents an interesting adjunctive therapy to target congestion in patients with heart failure and fluid overload. UF consists of the mechanical removal of iso-tonic plasma water from the blood through a semipermeable membrane using a pressure gradient generated by a pump. Fluid removal through UF presents several advantages such as removal of higher amount of sodium, predictable effect, limited neuro-hormonal activation, and enhanced spontaneous diuresis and diuretic response. After twenty years of "early" studies, since 2000 some pilot studies and randomized clinical trials with modern devices have been carried out with somehow conflicting results, as discussed in this review. In addition, some practical aspects of UF are addressed.

Long-term outcome of catheter ablation for atrial fibrillation in patients with severe left atrial enlargement and reduced left ventricular ejection fraction

AIMS

Data regarding the efficacy of catheter ablation in heart failure patients with severely dilated left atrium and reduced left ventricular ejection fraction (LVEF) are scanty. We sought to assess the efficacy of catheter ablation in patients with reduced LVEF and severe left atrial (LA) enlargement, and to compare it to those patients with preserved left ventricular function and equally dilated left atrium.

METHODS AND RESULTS

Three patient groups with paroxysmal or persistent atrial fibrillation (AF) undergoing a first pulmonary vein isolation (PVI) were considered: Group 1 included patients with normal or mildly abnormal LA volume (≤41 mL/m2) and normal LVEF; Group 2 included patients with severe LA enlargement (>48 mL/m2) and normal LVEF; and Group 3 included patients with severe LA enlargement and reduced LVEF. Time to event analysis was used to investigate AF recurrences. The study cohort includes 439 patients; Group 3 had a higher prevalence of cardiovascular risk factors. LA enlargement was associated with a two-fold in risk of AF recurrence, on the contrary only a smaller non-significant increase of 30% was shown with the further addition of LVEF reduction.

CONCLUSIONS

The long-term outcome of patients with severe LA dilatation and reduced LVEF is comparable to those with severe LA enlargement but preserved LVEF. Long-term efficacy of PVI is certainly affected by the enlargement of the left atrium, but less so by the addition of a reduced LVEF. CA remains the best strategy for rhythm control both in paroxysmal and persistent AF in this subgroup of patients.

New Drugs and Interventional Strategies for the Management of Hypertension

Essential hypertension is an important cause of cardiovascular morbidity and mortality worldwide with significant clinical and economic implications. The field of antihypertensive treatment already numbers numerous agents and classes of drugs. However, patients are still developing uncontrolled hypertension. Hence there is a continuous need for novel agents with good tolerability. Advances in this field are focusing both on pharmacotherapy, with the developments in traditional and non-traditional targets, as well as interventional techniques such as renal denervation and baroreflex activation therapy. It is likely that future strategies may involve a tailored approach to the individual patient, with genetic modulation playing a key role.

Elevated serum uric acid is a predictor of contrast associated acute kidney injury in patient with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

Contrast associated-acute kidney injury (CA-AKI) has been associated with adverse outcomes after ST-segment elevation myocardial infarction (STEMI). However, early markers of CA-AKI are still needed to improve risk stratification. We investigated the association between elevated serum uric acid (eSUA) and CA-AKI in patients with STEMI treated with primary percutaneous coronary intervention (pPCI).

METHODS AND RESULTS

Serum creatinine (Scr) was measured at admission and 24, 48 and 72 h after pPCI. CA-AKI was defined as an increase of 25% (CA-AKI 25%) or 0.5 mg/dl (CA-AKI 0.5) of Scr level above the baseline after 48 h following contrast administration. Multivariable analyses to investigate CA-AKI predictors were performed by binary logistic regression and multivariable backward logistic regression model. In the 3023 patients considered, CA-AKI was more frequent among patients with eSUA as compared with patients with normal SUA levels, considering both CA-AKI definitions (CA-AKI25%: 20.8% vs 16.2%, p < 0.012; CA-AKI 0.5: 10.1% vs 5.8%, p < 0.001). The association between eSUA and CA-AKI was confirmed at multivariable analyses (CA-AKI 25%: odd ratio 1.32, 95% CI 1.03-1.69, p = 0.027; CA-AKI 0.5: odd ratio 1.76, 95% CI 1.11-2.79, p = 0.016).

CONCLUSION

Elevated serum uric acid is associated with CA-AKI after reperfusion in patients with STEMI treated with pPCI.

ST-Segment Elevation Acute Myocardial Infarction Complicated by Cardiogenic Shock: Early Predictors of Very Long-Term Mortality

BACKGROUND

Cardiogenic shock (CS) is the leading cause of in-hospital mortality in ST-segment elevation myocardial infarction (STEMI). Only limited data are available on the long-term outcome of STEMI patients with CS undergoing contemporary treatment. We aimed to investigate long-term mortality and its predictors in STEMI patients with CS and to develop a risk score for long-term mortality prediction.

METHODS AND RESULTS

We retrospectively included 465 patients with STEMI complicated by CS and treated with primary angioplasty and intra-aortic balloon pump between 2005 and 2018. Long-term mortality, including both in-hospital mortality and all-cause mortality following discharge from the index hospitalization, was the primary endpoint. The long-term mortality (median follow-up 4 (2.0-5.2) years) was 60%, including in-hospital mortality (34%). At multivariate analysis, independent predictors of long-term mortality were age (HR 1.41, each 10-year increase), admission left ventricular ejection fraction (HR 1.51, each 10%-unit decrease) and creatinine (HR 1.28, each mg/dl increase), and acute kidney injury (HR 1.81). When these predictors were pooled together, the area under the curve (AUC) for long-term mortality was 0.80 (95% CI 0.75-0.84). Using the four variables, we developed a risk score with a mean (cross-validation analysis) AUC of 0.79. When the score was applied to in-hospital mortality, its AUC was 0.79, and 0.76 when the score was applied to all-cause mortality following discharge.

CONCLUSIONS

In STEMI patients with CS, the risk of death is still substantial in the years following the index event. A simple clinical score at the time of the index event accurately predicts long-term mortality risk.

De Winter Pattern Caused by a Large Diagonal Branch Culprit Lesion

A 70-year-old man was referred to the emergency department for an episode of ongoing chest pain during physical activity. Urgent coronary angiogram revealed a 75% stenosis in the left anterior descending coronary artery and a total occlusion of a large diagonal branch. Both stenoses were treated successfully with percutaneous coronary intervention. After reperfusion, the ECG showed a "De Winter" pattern, which was the ECG expression of a culprit lesion located in a large diagonal branch rather than in the left anterior descending.

Has hyperglycemia a different prognostic role in STEMI patients with or without diabetes?

BACKGROUND AND AIMS

Hyperglycemia at hospital admission is a common finding in patients with STEMI. However, whether elevated acute glycemia in these patients may have a direct impact on worsening prognosis or is just a marker of a greater neurohormonal activation in response to the infarction is still unsettled. We sought to investigate the prognostic impact of hyperglycemia at hospital admission in patients undergoing primary PCI (pPCI) for STEMI, and the influence of the presence of diabetes mellitus (DM) on its prognostic impact.

METHODS

and Results, We enrolled 2958 consecutive STEMI patients treated by pPCI. Hyperglycemia was defined as plasma glucose >198 mg/dL (or >11 mmol/L). Patients with hyperglycemia showed a greater risk-profile; they also experienced a higher mortality both at univariable (17.6% vs 5.2%, p < 0.001) and multivariable (HR 1.9, 95%IC 1.5-2.9, p = 0.001) analysis. However, after stratification for DM presence, hyperglycemia resulted as an independent predictor of mortality only in patients without DM (HR 2, 95%IC 1.2-3.4, p = 0.01).

CONCLUSION

Hyperglycemia in the setting of myocardial infarction treated with primary PCI in an independent predictor of all-cause mortality in patients without diabetes; in patients with diabetes, its prognostic impact seems attenuated.

Elevated serum uric acid is associated with a greater inflammatory response and with short- and long-term mortality in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND AND AIMS

Despite elevated serum uric acid (eSUA) has been identified as independent risk factor for cardiovascular diseases, its prognostic value in the setting of ST-segment elevation myocardial infarction (STEMI) is still controversial. Although the mechanisms of this possible relationship are unsettled it has been suggested that eSUA could trigger the inflammatory response. This study sought to investigate the association between eSUA with short- and long-term mortality and with inflammatory response in patients with STEMI treated with primary percutaneous coronary intervention (pPCI).

METHODS AND RESULTS

Blood samples were collected on admission and at 24 and 48 h after pPCI: the inflammatory biomarkers C-reactive protein (CRP), neutrophil count and neutrophil to lymphocytes ratio (NLR) were considered. Baseline eSUA was defined as ≥6.8 mg/dl. Cumulative 30-days and 1-year mortalities were estimated using the Kaplan-Meyer analysis. Multivariable analyses were performed by Cox proportional hazard models. In the 2369 patients with STEMI considered, 30-day mortality was 5.8% among patients with eSUA and 2% among patient with normal SUA level (p < 0.001); 1-year mortality was 8.5% vs 4%, respectively (p < 0.001). At multivariable analyses eSUA was an independent predictor of 30-day mortality (HR 1.196, 95%CI 1.006-1.321, p = 0.042) and 1-year mortality (HR 1.178, 95%CI 1.052-1.320, p = 0.005). eSUA patients presented higher values in on admission CRP (p < 0.001) and in neutrophil count and NLR at 24 h (respectively, p = 0.020 and p < 0.001) and at 48 h (p = 0.018 and p < 0.001) compared to patients with normal SUA levels.

CONCLUSIONS

Elevated serum uric acid is associated with higher short- and long-term mortality and with a greater inflammatory response after reperfusion in patients with STEMI treated with primary PCI.

Incidence of Ventricular Arrhythmias and 1-Year Predictors of Mortality in Patients Treated With Implantable Cardioverter-Defibrillator Undergoing Generator Replacement

Background

When implantable cardioverter defibrillator (ICD) battery is depleted most patients undergo generator replacement (GR) even in the absence of persistent ICD indication. The aim of this study was to assess the incidence of ventricular arrhythmias and the overall prognosis of patients with and without persistent ICD indication undergoing GR. Predictors of 1‐year mortality were also analyzed.

Methods and Results

Patients with structural heart disease implanted with primary prevention ICD undergoing GR were included. Patients were stratified based on the presence/absence of persistent ICD indication (left ventricular ejection fraction ≤35% at the time of GR and/or history of appropriate ICD therapies during the first generator's life). The study included 371 patients (82% male, 40% with ischemic heart disease). One third of patients (n=121) no longer met ICD indication at the time of GR. During a median follow‐up of 34 months after GR patients without persistent ICD indication showed a significantly lower incidence of appropriate ICD shocks (1.9% versus 16.2%, P<0.001) and ICD therapies. 1‐year mortality was also significantly lower in patients without persistent ICD indication (1% versus 8.3%, P=0.009). At multivariable analysis permanent atrial fibrillation, chronic advanced renal impairment, age >80, and persistent ICD indication were found to be significant predictors of 1‐year mortality.

Conclusions

Patients without persistent ICD indication at the time of GR show a low incidence of appropriate ICD therapies after GR. Persistent ICD indication, atrial fibrillation, advanced chronic renal disease, and age >80 are significant predictors of 1‐year mortality. Our findings enlighten the need of performing a comprehensive clinical reevaluation of ICD patients at the time of GR.

Short P-Wave Duration is a Marker of Higher Rate of Atrial Fibrillation Recurrences after Pulmonary Vein Isolation: New Insights into the Pathophysiological Mechanisms Through Computer Simulations

Background Short ECG P-wave duration has recently been demonstrated to be associated with higher risk of atrial fibrillation (AF). The aim of this study was to assess the rate of AF recurrence after pulmonary vein isolation in patients with a short P wave, and to mechanistically elucidate the observation by computer modeling. Methods and Results A total of 282 consecutive patients undergoing a first single-pulmonary vein isolation procedure for paroxysmal or persistent AF were included. Computational models studied the effect of adenosine and sodium conductance on action potential duration and P-wave duration (PWD). About 16% of the patients had a PWD of 110 ms or shorter (median PWD 126 ms, interquartile range, 115 ms-138 ms; range, 71 ms-180 ms). At Cox regression, PWD was significantly associated with AF recurrence (P=0.012). Patients with a PWD <110 ms (hazard ratio [HR], 2.20; 95% CI, 1.24-3.88; P=0.007) and patients with a PWD ≥140 (HR, 1.87, 95% CI, 1.06-3.30; P=0.031) had a nearly 2-fold increase in risk with respect to the other group. In the computational model, adenosine yielded a significant reduction of action potential duration 90 (52%) and PWD (7%). An increased sodium conductance (up to 200%) was robustly accompanied by an increase in conduction velocity (26%), a reduction in action potential duration 90 (28%), and PWD (22%). Conclusions One out of 5 patients referred for pulmonary vein isolation has a short PWD which was associated with a higher rate of AF after the index procedure. Computer simulations suggest that shortening of atrial action potential duration leading to a faster atrial conduction may be the cause of this clinical observation.

Transcatheter mitral valve repair with MitraClip in patients with pulmonary hypertension: hemodynamic and prognostic perspectives

Transcatheter mitral valve repair with MitraClip has emerged as a possible therapeutic option for patients with severe mitral regurgitation (MR) with high risk for surgical valve repair. MitraClip intervention has demonstrated to improve haemodynamics and clinical outcomes in selected patients in observational and randomized studies. Preoperative pulmonary hypertension (PH) is known to affect prognosis in patients undergoing surgical mitral valve intervention. The aim of the present review is to discuss the available literature focused on the haemodynamic and clinical effects of MitraClip in patients with severe MR and PH.

Challenges in activation of remote monitoring in patients with cardiac rhythm devices during the coronavirus (COVID-19) pandemic

Background

Remote monitoring (RM) technology embedded in cardiac rhythm devices permits continuous monitoring of device function, and recording of selected cardiac physiological parameters and cardiac arrhythmias and may be of utmost utility during Coronavirus (COVID-19) pandemic, when in-person office visit for regular follow-up were postponed. However, patients not alredy followed-up via RM represent a challenging group of patients to be managed during the lockdown.

Methods

We reviewed patient files scheduled for an outpatient visit between January 1, 2020 and May 11th, 2020 to assess the proportion of patients in whom RM activation was possible without office visit, and compared them to those scheduled for visit before the lockdown.

Results

During COVID-19 pandemic, RM activation was feasible in a minority of patients (7.8% of patients) expected at outpatient clinic for a follow-up visit and device check-up. This was possible in a good proportion of complex implantable devices such as cardiac resynchronization therapy and implantable cardioverter defibrillator but only in a minority of patients with a pacemaker the RM function could be activated during the period of restricted access to hospital.

Conclusions

Our experience strongly suggest to consider the systematic activation of RM function at the time of implantation or – by default programming - in all cardiac rhythm management devices.

Long-term effects of intensive B cell depletion therapy in severe cases of IgG4-related disease with renal involvement

IgG4-related disease (IgG4-RD) is an immune-mediated disorder often showing elevated serum IgG4 concentrations, dense T and B lymphocyte infiltration, and IgG4-positive plasma cells and storiform fibrosis. We prospectively evaluated for 4 years 5 patients with histologically proven IgG4-RD of whom 3 had tubulointerstitial nephritis (TIN) and 2 had retroperitoneal fibrosis (RPF). They received an intensive B depletion therapy with rituximab. The estimated glomerular filtration rate of TIN patients after 1 year increased from 9 to 24 ml/min per 1.73 m2. IgG/IgG4 dropped from 3236/665 to 706/51 mg/dl, C3/C4 went up from 49/6 to 99/27 mg/dl, and the IgG4-RD responder index fell from 10 to 1. CD20+ B cells decreased from 8.7 to 0.5%. A striking drop in interstitial plasma cell infiltrate as well as normalization of IgG4/IgG-positive plasma cells was observed at repeat biopsy. Both clinical and immunological improvement persisted over a 4-year follow-up. Treating these patients who were affected by aggressive IgG4-RD with renal involvement in an effort to induce a prolonged B cells depletion with IgG4 and cytokine production decrease resulted in a considerable rise in eGFR, with IgG4-RD RI normalization and a noteworthy improvement in clinical and histological features. Furthermore, the TIN subgroup was shown not to need for any maintenance therapy.

Peripheral Artery Disease in Diabetes Mellitus: Focus on Novel Treatment Options

Diabetes mellitus (DM) and peripheral artery disease (PAD) are two clinical entities closely associated. They share many pathophysiological pathways such as inflammation, endothelial dysfunction, oxidative stress and pro-coagulative unbalance. Emerging data focusing on agents targeting these pathways may be promising. Moreover, due to the increased cardiovascular risk, there is a growing interest in cardiovascular and "pleiotropic" effects of novel glucose lowering drugs. This review summarizes the main clinical features of PAD in patients, the diagnostic process and current medical/interventional approaches, ranging from "classical treatment" to novel agents.

A Primary Prevention Clinical Risk Score Model for Patients With Brugada Syndrome (BRUGADA-RISK)

OBJECTIVES

The goal of this study was to develop a risk score model for patients with Brugada syndrome (BrS).

BACKGROUND

Risk stratification in BrS is a significant challenge due to the low event rates and conflicting evidence.

METHODS

A multicenter international cohort of patients with BrS and no previous cardiac arrest was used to evaluate the role of 16 proposed clinical or electrocardiogram (ECG) markers in predicting ventricular arrhythmias (VAs)/sudden cardiac death (SCD) during follow-up. Predictive markers were incorporated into a risk score model, and this model was validated by using out-of-sample cross-validation.

RESULTS

A total of 1,110 patients with BrS from 16 centers in 8 countries were included (mean age 51.8 ± 13.6 years; 71.8% male). Median follow-up was 5.33 years; 114 patients had VA/SCD (10.3%) with an annual event rate of 1.5%. Of the 16 proposed risk factors, probable arrhythmia-related syncope (hazard ratio [HR]: 3.71; p < 0.001), spontaneous type 1 ECG (HR: 3.80; p < 0.001), early repolarization (HR: 3.42; p < 0.001), and a type 1 Brugada ECG pattern in peripheral leads (HR: 2.33; p < 0.001) were associated with a higher risk of VA/SCD. A risk score model incorporating these factors revealed a sensitivity of 71.2% (95% confidence interval: 61.5% to 84.6%) and a specificity of 80.2% (95% confidence interval: 75.7% to 82.3%) in predicting VA/SCD at 5 years. Calibration plots showed a mean prediction error of 1.2%. The model was effectively validated by using out-of-sample cross-validation according to country.

CONCLUSIONS

This multicenter study identified 4 risk factors for VA/SCD in a primary prevention BrS population. A risk score model was generated to quantify risk of VA/SCD in BrS and inform implantable cardioverter-defibrillator prescription.

Very late stent expansion with intracoronary lithotripsy: a case report

Background

Underexpanded stent in heavily calcified coronary lesion is common and persists over years. It is related to long-term failure and negative outcomes. Treatment of this situation after many years with intracoronary lithotripsy (ICL-Shockwave^®) could be an option.

Case summary

We report a case of a man with underexpanded coronary stent implanted 11 years earlier. Optical coherence tomography highlighted the mechanism of stent underexpansion showing the presence of calcium stones under the old struts. Intracoronary lithotripsy crushed calcium under the stent struts causing its geometric change (from elliptical to round shape) and a consequent better transmission of the true radial force of the old stent.

Discussion

Heavily calcified coronary lesions lead to stent underexpansion which persists over years. Intracoronary lithotripsy could be a very late option to manage this unfavourable common result.

Leptin affects the inflammatory response after STEMI

Leptin is an adipose tissue-derived hormone primarily involved in the regulation of food intake. Leptine has been shown to have a much broader role than just regulating body weight and appetite in response to food intake: among the others, it has been associated with increased ROS production and inflammation, factors involved in the restoration of an effective myocardial reperfusion after myocardial revascularization. Our study, to our best knowledge, is the first showing a direct relationship between leptin serum levels, inflammatory mediators of the ischemia reperfusion damage and effective myocardial reperfusion in patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention. Our findings suggest that leptin serum levels are directly associated with the inflammatory response during an acute myocardial infarction and may have a role in risk stratification in this clinical setting.

P523Incidence of anti tachycardia therapies and mortality at one and two years in patients with and without persistent ICD indication at the time of generator replacement

BACKGROUND ICD implantation with or without resynchronization is an established therapy for the prevention of sudden cardiac death in patients with LV dysfunction. However, when elective replacement interval (ERI) approaches most patients undergo generator replacement (GR) even in the absence of persistent indication to ICD therapy- Moreover, at the time of GR patients are usually older and with more comorbidities as compared to the time of first implantation.

AIM The aim of our work was to evaluate the rate and predictors of mortality and to analyze.the incidence of appropriate ICD therapies after GR.

METHODS Our registry includes 323 patients with structural heart disease (SHD) implanted with ICD in primary prevention who underwent GR. Our population was stratified based on the presence or absence of persistent indication to ICD at the time of GR, which was defined as: LVEF ≤ 35% and/o history of appropriate ICD therapies during the first generator"s life. In each group the incidence of appropriate ICD therapies after GR, 1 and 2 years mortality after GR and multivariate predictors of 1 year mortality. Were analyzed. Comparisons between categorical variables were made using χ2 or Fisher Exact test when required and continuous variables were compared using Mann Whitney test.  Kaplan-Meier curves with Log Rank test were used to investigate 1 and 2 years mortality.

RESULTS In our population, 81% were male, 41% had ischemic heart disease, 60% had CRT-D. Median LVEF at the time of first implantation was 30%  (25-35), whereas at the time of GR was 35% (25-45); median age at GR was 64 (56-73) years. Notably 33.6% of our population no longer met ICD indication at the time of GR; this subgroup showed a significantly lower mortality at one and two years as compared to patients with persistent ICD indication: 1% vs 9% and 2.1% vs 13.5% respectively (figure 1 and 2). At multivariable analysis permanent AF (HR: 3.6; 95% CI 1.9-8.6) chronic renal disease (HR 4; 2.3-8.9), and persistent ICD indication  were independent predictors of 1-year mortality. When survival analysis was limited to patients implanted with single-chamber and dual-chamber devices only AF an renal insufficiency remained significantly predictors of mortality. Nevertheless, in this subgroup, the absence of persistent indication was associated with a significantly lower rate of appropriate ICD therapies after GR (0% vs 14.8%, p = 0.02). 

CONCLUSION The absence of persistent indication at the time of generator replacement was associated with a significantly better prognosis and a lower incidence of appropriate therapies after GR. Atrial fibrillation, renal insufficiency and persistent ICD indication significantly predicted 1 year mortality in our population. Our data suggest the importance of an arrhythmic vs. non-arrhythmic risk evaluation in the individual patient at the time of ICD generator replacement

Abstract Figure.

P376Prognostic impact of atrial fibrillation in STEMI patients treated by primary percutaneous coronary intervention: a focus on cardiogenic shock

Background

Atrial fibrillation (AF) is a common finding in patients with ST elevation myocardial infarction (STEMI). However, its prognostic influence in MI remains controversial. Almost all previous studies were performed before the era of primary percutaneous coronary intervention (pPCI), and there is a lack of data in patients with  STEMI complicated by cardiogenic shock (CS). The aim of our study was to evaluate the prognostic impact of AF in a large real-world population of STEMI undergoing pPCI stratified by the presence of CS.

Methods

Our registry included 3017 consecutive patients with STEMI undergoing pPCI in our department in 2005-2017. The presence of a persistent (&gt;30 min) systolic blood pressure &lt; 90 mmHg associated with signs of pulmonary congestion/impaired end organ perfusion needing catecholamine infusion or mechanical support devices qualified for CS. Firstly we performed mortality analysis in all patients with AF during hospitalization; secondly, we compared patients with the first episode of AF and patients with AF during hospitalization but known AF in anamnesis.  The analysis was stratified for the presence of CS. Univariate (cross-tables and Kaplan-Meier curves with log-rank test) and multivariate mortality analysis (Cox regressions) were performed. In STEMI patients without CS we also performed a propensity-matched analysis including all variables known before STEMI that could influence the occurrence of a first episode of AF.

Results

AF was present in 337 (11.3%) patients during hospitalization; in 193 (57.3%) of them was the first episode. CS occurred in 250 patients (8.4%), 27.2% of whom were affected by an AF episode (86.5% as the first episode). Among patients without CS, AF occurred in 269 patients (9.7%) and for the 77.5% was the first episode. In CS patients, AF was not associated with increased mortality, neither at 30 days (43.5% vs 43.7%, p = 0.867) nor at 1 year (47.5% vs 53.1%, p = 0.633). In the population without CS, AF was an independent predictor of mortality both at 30 days (HR 2.25 (1.05; 4.82), p = 0.037) and at 1 year (HR 1.87 (1.094; 3.18), p = 0.022); only new-onset AF was an independent predictor of mortality.  We successfully matched 175 pairs of patients with similar propension to experience the first episode of AF. Among them the first episode of AF was confirmed to be an indipendent predictor of mortality (figure).

Conclusion

In the present large real-world cohort of unselected patients with STEMI, the presence of an episode of AF during hospitalization was an independent predictor of mortality in patients not complicated by cardiogenic shock. Conversely, AF did not show a significant prognostic impact in patients with STEMI complicated by CS.  Furthermore, the presence of a first episode of AF was confirmed to be an independent predictor of mortality, while an AF episode in patients with known AF was not found to have prognostic impact.

Abstract Figure

Bail-out unexpanded stent implantation in acute left main dissection treated with intra coronary lithotripsy: a case report

Background

The percutaneous treatment of heavily calcified coronary lesions is challenging and presents high rate of complications. Unexpandable stent is one of the most serious complication. Both of these conditions may benefit from the intracoronary lithotripsy (ICL-Shockwave^®), a new coronary percutaneous technique.

Case summary

This case report describes a man treated with percutaneous coronary intervention (PCI) for a left main (LM) severe calcified lesion. The PCI was complicated by a huge dissection of LM in a not completely expandable lesion. A bail-out stent implantation was performed with residual unexpansion. The ICL permitted to expand acutely the stent and obtain an optimal final result.

Discussion

Familiarity with dedicated techniques and devices to treat calcified coronary lesions is fundamental to perform high-risk complex PCI. This case emphasizes the potential usefulness of the new ICL technique to treat calcified lesions or related complications like unexpandable stent.

P5640How to decide to implant an ICD in out-of-hospital cardiac arrest survivors with bad neurological outcome. CPC is an option?

Background

According to the European Society of Cardiology guidelines secondary prevention ICD implantation is a class I indication only for those patients with an estimated survival >1 year with a good functional status. However, it is not specified how to assess the functional status and its evaluation could be quite difficult in the case of Out-of-Hospital Cardiac Arrest (OHCA) survivors. Cerebral Performance Category (CPC) scale is the most widespread scale to define the neurological and functional outcome, but it is not known if it can be used to guide ICD implantation.

Purpose

To evaluate whether the presence of a bad neurological outcome (CPC >2) in OHCA survivors at discharged could be used as a prognostic index in order to evaluate the implantation of an ICD.

Methods

We considered all the patients enrolled in the Cardiac Arrest Registry of our Province (55ehz746.0583 inhabitants in northern Italy) from the 1 October 2014 to the 31 January 2018 presenting a CPC >2 at discharge. We evaluated the survival and the neurological status variation at 1-year.

Results

In the study period CPR was attempted in 1565 confirmed OHCA (60.2% males, 73.4±15.8 years). Of these, 119 (7.6%) were discharged and 26 of them (21.8%) showed a CPC more than 2 (13 CPC = 3, 11 CPC = 4 and 2 CPC A). 1-year survival of CPC>2 patients was significantly lower than those with a CPC≤2 (46.1% vs 92.5% p<0.001). Only 12/26 patients discharged with a CPC >2 survived at 1 year; a good cerebral performance (CPC 1) was recovered in 2 of them, whilst a moderate cerebral disability (CPC 2) was present in 1 of them. A severe cerebral disability (CPC 3 or 4) persisted in the other 9 patients. The neurological prognosis of patients based on CPC at hospital discharge is presented in Figure 1.

Figure 1

Conclusions

Our results highlight that 1-year survival is quite low in patients with a CPC >2 at discharge and an improvement in cerebral performance occur in a minority of them. The prognosis of the patients was very variable and unpredictable for all the CPC scale values at hospital discharge. This evidence suggest that an ICD implantation should carefully evaluated in this kind of patients and a clinical and neurological re-evaluation can be reasonable some time after the event to decide if implant an ICD.

P1763Derivation and validation of a risk score to predict incomplete ST segment resolution in STEMI patients undergoing primary PCI: association with the benefit of Glycoprotein IIb-IIIa inhibitors Use

Incomplete ST segment resolution (iSTR) is a well-known marker of poor outcome in patients undergoing primary percutaneous coronary intervention (pPCI) for ST elevation myocardial infarction (STEMI). The use of glycoprotein IIbIIIa inhibitors (GPIs) was suggested to be associated with a survival benefit in high-risk patients. A simple score to predict the risk for developing iSTR could help early identification of these patients and could allow a tailored use of pharmacological tools, such as GPIs.

The aim of this study was to create and validate a numerical score to predict iSTR occurrence in STEMI patients undergoing pPCI and to assess its association with the potential benefit of GPIs use.

We prospectively enrolled all STEMI patients undergoing pPCI in our University Hospital (2005–2017). iSTR was defined as a <70% resolution of initial ST segment shift in the lead with maximal ST deviation 60 min after reperfusion. Our population was randomly divided in two group: a derivation cohort (60%) and a validation cohort (40%). Potential predictors of iSTR were selected at univariate analysis and were then inserted in a multivariate binary stepwise-backward logistic regression. To create a risk score, numerical values were obtained considering the odds ratio of each independent predictor rounding to the nearest unit or half. A ROC curve with its c-statistic was then used to test the discrimination power of the score both in the derivation and in the validation cohort.

Out of a total of 2959 patients, 1774 were included in the derivation: 480 (27%) of them presented iSTR. All-cause mortality at 30 days was significantly higher in patients with iSTR (OR 3.2, 95% CI 2.1–4.9, p<0.001). Anterior MI (OR 2.46, 95% CI 1.90–3.14, p<0.001, score 2.5), anemia at admission (OR 1.76, 95% CI 1.29–2.4, p<0.001, score 2), blood glucose >198 mg/dl at admission (OR 1.77, 95% CI 1.29–2.49, p<0.001, score 2), age >75 years (OR 1.54, 95% CI 1.15–2.10, p=0.004, score 1.5), female sex (OR 1.41, 95% CI 1.06–1.88, p=0.02, score 1.5) and Killip class >2 (OR 1.44, 95% CI 1.05–1.98, p=0.024, score 1.5) were identified as independent predictors of iSTR, creating a ISTR-score that ranged from 0 to 11. The validation cohort consisted in 1185 patients, with 31% showing iSTR. The c-statistic was 0.67 and 0.66 in the derivation and validation cohorts. Patients with score ≥4 versus <4 showed present a worst prognosys but a similar GPI use. Notably, GPIs were associated with a significant survival benefit among patients≥4 but not among patients <4 (Figure). The use of GPIs was not associated to any clinically relevant difference, the increase in bleeding risk appeared similar.

P2825ICD implantation in secondary prevention after an out-of-hospital cardiac arrest. Does age really matter?

Background

The implantation of an implantable cardioverter defibrillator (ICD) in secondary prevention is a class I indication for patients with an estimated survival more than 1 year with a good functional status. However, in the elderly population, it is often difficult to estimate the expected survival, especially after an acute event such as an out-of-hospital cardiac arrest (OHCA).

Purpose

To evaluate 1-year survival after OHCA of patients older than 80 compared to those younger than 80.

Methods

We considered all the patients who suffered an OHCA in our Province (55ehz748.1135 inhabitants in northern Italy) from October 1st 2014 to November 30th 2017 stratified in two groups accordingly to their age at the moment of OHCA: elderly group (≥80 years old) and non-elderly group (<80 years old).

Results

In the period analysis resuscitation was attempted in 1464 OHCA patients: 632 of the elderly group (mean age of 86.4±4.4 years) and 832 of the non-elderly group (mean age of 63.4±13.8 years). The two groups were different at baseline. In the non-elderly group there were more males (74.5% vs 42.4%, p<0.001), more cases of medical etiology (95.9% vs 91.2%, p<0.001), a higher rate of bystander CPR (39.4% vs 23.4%, p<0.001) and more shockable rhythms at presentation (25.5% vs 7.9%, p<0.001), whilst a home location of the event was more frequent in the elderly group (81.3% vs 77%, p=0.048). No differences were found regarding both the percentage of not witnessed cardiac arrest (27.5% in elderly and 26% in non-elderly, p=0.57) and the time of EMS arrival (11:36 mins in elderly and 11:23 mins in young, p=0.64). Non-elderly patients showed a significantly higher rate of survival both to hospital admission (25.2% vs 6.8%, p<0.001), to hospital discharge (12.1% vs 1.7%, p<0.001) and at 1 year after the event (10.2% vs 1.6%, p<0.001, Figure 1 - left) as compared to older ones. However, when considering only those patients discharged alive we found a non-significant difference in one-year survival (84.2% vs 90.9%, p=0.64, Figure 1 – right).

Conclusions

Elderly patients have a worst prognosis in the acute phase after an OHCA. However, after hospital discharge, older and younger patients showed a similar 1-year survival. This result highlights how age should not be considered alone to decide whether an ICD in secondary prevention could be indicated or not in older OHCA survivors.

6118Mid- and long-term percentage of ventricular pacing in patients implanted with a pacemaker after a transcatheter aortic valve replacement procedure: potential clinical implications

Background

Cardiac conduction disturbances frequently occur following transcatheter aortic valve replacement (TAVR). As this procedure is getting more and more common, more research efforts should focus on post procedural rhythm disturbances and their evolution over time

Purpose

To evaluate the percentage of pacing in patients who underwent a TAVR procedure and developed a conduction disturbance requiring a transvenous pacemaker (PM) implantation

Methods

We considered all the patients who underwent a TAVR procedure between march 2009 and november 2018 in our centre. Patients implanted with a PM or an ICD before the TAVR procedure or 30 days after the TAVR were not considered eligible for our analysis, because likely not related to TAVR. The percentage of effective right ventricular pacing was assessed both at mid- and long-term follow-up

Results

265 patients underwent TAVR in the study period (45% males, 81±6 years). 20 patients already had a PM and were excluded. 39 of the 245 patients (16%) were implanted with a PM after TAVR, 26 of them were implanted within 30 days (median time TAVR-PM implant: 8±7 days). The rate of PM implant within 30 days after TAVR was 8% (20/246) for patients implanted with an Edward Sapien valve, 25% (4/16) for patients with an Evolute Pro valve and 66% (2/3) in patients with a Lotus Edge valve. The indication for PM implant was a permanent 3rd degree A-V block in 12 patients, a paroxysmal A-V block in 4, a bifascicular A-V block with an infra-hisian disease in 5, a II degree Mobitz II A-V block in 2, an atrial fibrillation with slow A-V conduction in 2 and a 2:1 A-V block with infra-hisian disease in 1. The first follow-up after the PM implantation was available in 24 patients (mean 78±87 days after PM implant) and the second in 15 patients (372±267 days after PM implant). The patients were divided into two groups based on the presence/absence of permanent 3rd degree AV block at the time of implantation. At the first follow-up the percentage of pacing was significantly higher in patients implanted with vs. without a permanent 3rd degree AV block (98.5% vs 11%, p<0.001). Notably, in none of the patients without a permanent 3rd AV block at baseline conduction disturbances progressed toward a permanent AV block during long-term follow-up. Accordingly, at the second follow-up patients without permanent 3rd AV block at baseline showed a significantly lower percentage of pacing (1% vs 100%; p<0.01)

Conclusion

Patients implanted with a PM after TAVR in the absence of a permanent 3rd AV block have a very low likelihood of progression to a permanent AV conduction disturbance and show a negligible percentage of pacing during follow-up. Our results may impact the choice of the correct timing of PM implantation after TAVR and the potential indication for a leadless PM.

P6395Elevated serum uric acid is associated with a greater inflammatory response and with short- and long-term mortality in patients with ST-segment elevation myocardial infarction undergoing primary percu

Introduction

Elevated serum uric acid (eSUA) has been identified as independent risk factors for cardiovascular diseases, including coronary artery disease, and it has been associated with increased mortality in the general population. However, whether eSUA is associated with adverse outcomes in the setting of ST-segment elevation myocardial infarction (STEMI) is still controversial. Although the mechanisms of this possible relationship is similarly unsettled it has been suggested that eSUA could trigger oxidative stress and inflammatory response.

Aim

This study sought to investigate the association between eSUA with short- and long-term mortality and with inflammatory response in patients with STEMI treated with primary percutaneous coronary intervention (pPCI).

Methods

We prospectively enrolled all STEMI patients undergoing pPCI in our hospital between 2005 and 2017. Blood samples were collected on admission and at 24 and 48 hours after pPCI: SUA and the inflammatory biomarkers C-reactive protein (CRP), neutrophil count and neutrophil to lymphocytes ratio (NLR) were parameter of interest. NLR was obtained by dividing the total count of neutrophil by the total count of lymphocyte. eSUA was defined as >6.8 mg/dl. Cumulative 30-days and 1-year mortalities were estimated using the Kaplan-Meyer analysis and compared with the long-rank test. Landmark analysis was set at 365 days. Multivariable analyses were performed by Cox proportional hazard models.

Results

Out of the dataset of 2959 STEMI patients treated with pPCI, we analyzed 2369 patients who had SUA data. Overall age was 63 (p25-p75: 54–73) years, men were 2295 (75.5%), anterior MI 1390 (45.8%). eSUA was present in 563 patients (23.8%). 30-day mortality was 5.8% (n=31) among patients with eSUA and 2% (n=34) among patient with normal SUA level (p<0.001); 1-year mortality was 8.5% (n=46) vs 4% (n=70), respectively (p<0.001). Landmark analysis is shown in Figure 1. At multivariable analyses eSUA was an independent predictor after adjusting for age, female gender, BMI, diabetes, previous MI, serum creatinine, Hb, acute glycemia, Killip class >2 (30-day mortality HR 1.196, 95% CI 1.006–1.321, p=0.042; 1-year mortality HR 1.178, 95% CI 1.052–1.320, p=0.005). On admission CRP was higher in the group with eSUA as compared with the group with normal SUA levels (respectively, 1.27 [0.57–3.37] mg/dl vs 0.72 [0.30–1.8] mg/dl, p<0.001). On admission neutrophil count and NLR did not differ among the groups (respectively, p=0.205 and p=0.399), but eSUA patients presented higher values in neutrophil count and NLR at 24 hours (respectively, p=0.020 and p<0.001) and at 48 hours (p=0.018 and both p<0.001).

Figure 1

Conclusions

Elevated serum uric acid is associated with higher short- and long-term mortality and with a greater inflammatory response after reperfusion in patients with STEMI treated with primary PCI.

P5733IABP use in patients with STEMI complicated by cardiogenic shock: time for rehabilitation?

Background

Evidence from a large randomized clinical trial has led international guidelines to downgrade to Class III the recommendation level for the routine use of intra-aortic balloon pump (IABP) in patients with STEMI complicated by cardiogenic shock (CS). Despite this, its use in clinical practice remains high.

Purpose

The aim of our study was to evaluate whether IABP use could provide a prognostic benefit in a large real-world population of STEMI patients undergoing primary PCI (pPCI).

Methods

Our registry included 2958 consecutive patients undergoing primary pPCI for STEMI in our department from 2005 to 2017. The presence of a persistent (>30 min) systolic blood pressure <90 mmHg and signs of pulmonary congestion or impaired end organ perfusion needing catecholamine infusion qualified for CS. Among patients with CS we compared mortality between those with and those without IABP in the whole population and in the pre-specified subgroup with anterior STEMI. Univariate (cross-tables and Kaplan-Meier curves with log-rank test) and multivariate mortality analysis (Cox regressions) were performed.

Results

CS occurred in 246 patients (8.3%); among these patients, 145 (60%) had anterior AMI. Mortality at 30 days was 3.7 in inferior vs 7.1% in anterior STEMI (p<0.001). In these two groups of patients, IABP was used in 32% and 66.7% of cases, respectively. In the whole CS group, IABP use was associated with a lower 30-day mortality (39% vs 53%, p=0.020 – see figure panel A); this figure was confirmed at multivariable analysis (HR 0.49, 95% CI 0.27–0.87, p=0.016) after adjusting for age, CK peak, triple-vessel disease, eGFR and all-TIMI bleeding during hospital stay. IABP use in CS patients was not associated with major complications or an increased rate of Hb drop (>3 mg/dL) during hospital stay. In the subgroup of patients with anterior STEMI, there was a marked survival benefit at univariate analysis (30-day mortality 41% vs 61%, p=0.013 – see figure panel B), confirmed at multivariable analysis (HR 0.40, 95% CI 0.19–0.88, p=0.023) after adjusting for the same variables of the previous model. In the subgroup of patients with inferior STEMI, IABP use was not significantly associated with a lower 30-day mortality (32% vs 41%, p=0.380).

Figure 1

Conclusion

In the present large real-world cohort of unselected patients with STEMI, the use of IABP in case of CS was found to improve survival. This finding suggests that IABP could still play a role in patient with STEMI complicated by CS, especially when additional risk features are present, such as anterior MI. We suggest that additional careful prospective studies are needed before abandoning or markedly limiting the use of IABP in this clinical setting.

Reduced Cardio-Renal Function Accounts for Most of the In-Hospital Morbidity and Mortality Risk Among Patients With Type 2 Diabetes Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

OBJECTIVE

ST-segment elevation myocardial infarction (STEMI) patients with type 2 diabetes mellitus (DM) have higher in-hospital mortality than those without. Since cardiac and renal functions are the main variables associated with outcome in STEMI, we hypothesized that this prognostic disparity may depend on a higher rate of cardiac and renal dysfunction in DM patients.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed 5,152 STEMI patients treated with primary angioplasty. Left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate (eGFR) were evaluated at hospital admission. The primary end point was in-hospital mortality. A composite of in-hospital mortality, cardiogenic shock, and acute kidney injury was the secondary end point.

RESULTS

There were 879 patients (17%) with DM. The incidence of LVEF ≤40% (30% vs. 22%), eGFR ≤60 mL/min/1.73 m² (27% vs. 18%), or both (12% vs. 6%) was higher (P < 0.001 for all comparisons) in DM patients. In-hospital mortality was higher in DM patients than in non-DM patients (6.1% vs. 3.5%; P = 0.002), with an unadjusted odds ratio (OR) of 1.81 (95% CI 1.31-2.49; P < 0.001). However, DM was no longer associated with an increased mortality risk after adjustment for cardiac and renal function (OR 1.03, 95% CI 0.68-1.56; P = 0.89). A similar behavior was observed for the secondary end point, with an unadjusted OR for DM of 1.52 (95% CI 1.25-1.85; P < 0.001) and an OR after adjustment for cardiac and renal function of 1.07 (95% CI 0.85-1.36; P = 0.53).

CONCLUSIONS

The study indicates that the increased in-hospital mortality and morbidity of DM patients with STEMI is mainly driven by their underlying cardio-renal dysfunction.

[Bleeding risk in patients with acute coronary syndromes treated with antiplatelet agents: incidence, prognosis and clinical evaluation. From research to clinical practice]

Dual antiplatelet therapy (DAPT) including aspirin and a P2Y12 inhibitor is the cornerstone for the treatment of patients with acute coronary syndrome (ACS). The introduction of more potent drugs significantly reduced ischemic events, but with an associated increased risk of bleeding. Although appropriate estimation of bleeding risk by comparing the single drugs is challenging, mainly because of differences in definitions, it has been consistently shown that bleeding events are associated with an adverse outcome, both at short and long-term follow-up.Current guidelines recommend a short DAPT in patients at high bleeding risk, making appropriate risk estimation of crucial importance. Several numerical scores have been proposed for use in daily clinical practice. Although an objective risk assessment provides superior risk discrimination compared to physician's estimation, none of these scores appear free from limitations, nor have been obtained from cohorts of patients on short-tern treatment with prasugrel or ticagrelor. In the present review, we report the rates of major bleeding observed in the main randomized clinical trials and registries, their association with mortality, differences in definitions when used as safety endpoint, and finally the scores currently used for evaluation in daily clinical practice.

IgG4-related kidney disease: the effects of a Rituximab-based immunosuppressive therapy

IgG4-related disease (IgG4-RD) is a recently recognized disorder, characterized by elevated serum IgG4 concentrations, dense tissue infiltration of IgG4-positive plasma cells and storiform fibrosis. Treatment is usually based on steroids, however, relapses and long-term adverse effects are frequent. We prospectively studied 5 consecutive patients with histologically-proven IgG4-RD and renal involvement, treated with an extended Rituximab protocol combined with steroids. Two doses of intravenous cyclophosphamide were added in 4 patients. Five patients with IgG-RD were investigated: three had tubulointerstitial nephritis (TIN), while two had retroperitoneal fibrosis (RPF). In the patients with TIN, renal biospy was repeated after 1 year. In the patients with TIN, estimated glomerular filtration rate (eGFR) at 12 months increased from 9 to 24 ml/min per 1.73 m²; IgG/IgG4 decreased from 3,236/665 to 706/51 mg/dl; C3/C4 increased from 49/6 to 99/27 mg/dl; CD20⁺ B-cells decreased from 8.7% to 0.5%; Regulatory T-cells decreased from 7.2% to 2.5%. These functional and immunologic changes persisted at 24 months and in two patients at 36 months. A repeat renal biopsy in the patients with TIN showed a dramatic decrease in interstitial plasma cell infiltrate with normalization of IgG4/IgG positive plasma cells. The patients with RPF showed a huge regression of retroperitoneal tissue. In this sample of patients with aggressive IgG4-RD and renal involvement, treatment aimed at depleting B cells and decreasing antibody and cytokine production was associated with a substantial, persistent increase in eGFR, and a definite improvement in immunologic, radiologic and histological parameters.