A proof-of-principle for decontamination of transplantation kidney through UV-C exposition of the perfusate solution

Kidney transplantation is a common yet highly demanding medical procedure worldwide, enhancing the quality of life for patients with chronic kidney disease. Despite its prevalence, the procedure faces a shortage of available organs, partly due to contamination by microorganisms, leading to significant organ disposal. This study proposes utilizing photonic techniques associated with organ support machines to prevent patient contamination during kidney transplantation. We implemented a decontamination system using ultraviolet-C (UV-C) irradiation on the preservation solution circulating through pigs' kidneys between harvest and implant. UV-C irradiation, alone or combined with ultrasound (US) and Ps80 detergent during ex-vivo swine organ perfusion in a Lifeport® Kidney Transporter machine, aimed to reduce microbiological load in both fluid and organ. Results show rapid fluid decontamination compared to microorganism release from the organ, with notable retention. By including Ps80 detergent at 0.5% during UV-C irradiation 3 log10 (CFU mL-1) of Staphylococcus aureus bacteria previously retained in the organ were successfully removed, indicating the technique's feasibility and effectiveness.

Effects of sunflower oil infusions of Asparagopsis taxiformis on in vitro ruminal methane production and biohydrogenation of polyunsaturated fatty acids

Asparagopsis taxiformis inhibits ruminal methane (CH4) production due to its bromoform (CHBr3) content. The immersion of A. taxiformis in edible vegetable oils allows the extraction and stabilization of the highly volatile CHBr3 in the oil phase. The objectives of this study were to explore the effects of adding sunflower oils with increasing concentrations of CHBr3 on in vitro ruminal methanogenesis and biohydrogenation. Five batches of 48-h in vitro incubations were performed in 14 fermentation bottles, using rumen inocula collected shortly after the slaughter of young crossbred bulls and 1 g of dry matter (DM) from a total diet of mixed feed without added oil (control) or with 60 μL of sunflower oil per gram of DM as the substrate. The treatments were the CHBr3 content in the oil added: 0 μg (B0), 25 μg (B25), 50 μg (B50), 75 μg (B75), 100 μg (B100), and 150 μg (B150) of CHBr3 per gram of substrate DM. Organic matter (OM) degradability, total gas, CH4, volatile fatty acids (VFA), long-chain fatty acids, and dimethyl acetals (DMA) were analyzed at the end of each incubation. Data were analyzed with a model considering the treatments as the fixed effect and the run as a random block and using orthogonal contrasts. Degradability of OM was higher in the control group and was unaffected by CHBr3 concentration. Total gas production per gram of degraded OM was unaffected by treatments and averaged 205 ± 29.8 mL/g. Methane (mL) production decreased linearly with increasing CHBr3 concentrations, with 33%, 47%, and 87% reductions for B75, B100, and B150, respectively. Total VFA concentration was unaffected by oil inclusion but was reduced by 20% in CHBr3-containing treatments, although without any dose-response pattern. The molar percentage of acetate decreased linearly, whereas propionate and butyrate increased linearly with the increasing CHBr3 dosage. Including oil in the diet decreased the branched-chain fatty acids and DMA content. Increasing CHBr3 concentrations did not affect branched-chain fatty acids, but linearly increased most of the identified DMA. Adding oil to the control diet increased the 18:2n-6, whereas increasing the concentration of CHBr3 had no effect on 18:2n-6 but decreased linearly the 18:0 and increased the trans-18:1 isomers. The results obtained provide evidence that oil immersions of A. taxiformis can successfully inhibit ruminal production of CH4 in vitro at doses of 100 and 150 μg/g DM, and simultaneously modulate biohydrogenation.

Clinical predictors of NEDA-3 one year after diagnosis of pediatric multiple sclerosis: an exploratory single-center study

Introduction

Multiple sclerosis (MS) is an inflammatory and demyelinating disorder of central nervous system that can be diagnosed in pediatric age (<18 years) in 3-5% of the cases. This early onset is associated with higher relapse rates and earlier progression to neurological disability. By using NEDA-3 (No Evidence of Disease Activity-3) criteria, we aimed to identify clinical predictors associated with absence of disease activity and control of disease progression 12 months after the diagnosis, in a cohort of pediatric-onset MS (POMS) patients regularly followed-up in our center.

Methods

We analyzed demographic, clinical, laboratorial and imaging variables of patients with POMS identified in our center, between 2010 and 2021, in two moments: at the diagnosis and 12 months after it. Statistical tests were applied to compare the distribution of those variables between groups defined by NEDA-3 status and by each one of its three variable components.

Results

We included 27 patients in the study (18 female), with a mean age of 14.8 years (± 2.8), being all diagnosed with relapsing-remitting MS and with a median score of 1.5 at the Expanded Disability Status Scale (EDSS). The use of natalizumab (p = 0.017) and the negativity for anti-EBV IgG antibodies (p = 0.018) at diagnosis were associated with a higher achievement of NEDA-3 status 12 months after, in our cohort. Prescribed treatment was also associated with statistically significant differences in the "absence of MRI activity" component of NEDA-3 (p = 0.006): patients under treatment with natalizumab had a higher probability of achieving this status, and the opposite was observed in glatiramer acetate-treated children.

Discussion and conclusion

Our exploratory results underline the pivotal importance that an early and more effective therapeutical approach may have in the control of disease activity, in POMS. Additionally, they also seem to suggest that the presence of anti-EBV antibodies is not innocent, as it can be related to a less favorable evolution of the disease, even at a very early stage. Further studies are needed to confirm the applicability of these variables as prognostic and personalized tools in this clinical setting.

X-Linked Myotubular Myopathy: A Novel Mutation Expanding the Genotypic Spectrum of a Phenotypically Heterogeneous Myopathy

X-linked myotubular myopathy (XLMTM), a centronuclear congenital myopathy secondary to pathogenic variants in the MTM1 gene encoding myotubularin, is typically recognized for its classic and severe phenotype which includes neonatal hypotonia, severe muscle weakness, long-term ventilator dependence, markedly delayed gross motor milestones with inability to independently ambulate, and a high neonatal and childhood mortality. However, milder congenital forms of the condition and other phenotypes are recognized. We describe a 6-year-old boy with a mild XLMTM phenotype with independent gait and no respiratory insufficiency even in the neonatal period. The child has a hemizygous novel splice site variant in the MTM1 gene (c.232-25A > T) whose pathogenicity was confirmed by cDNA studies (exon 5 skipping) and muscle biopsy findings. We also compared the phenotype of our patient with the few reported cases that presented a mild XLMTM phenotype and no respiratory distress at birth, and discussed the potential mechanisms underlying this phenotype such as the presence of residual expression of the normal myotubularin transcript.

Noninvasive drug adherence monitoring of antipsychotic patients via finger sweat testing

Collection of finger sweat is explored here as a rapid and convenient way of monitoring patient adherence to antipsychotic drugs. Finger sweat samples (n = 426) collected from patients receiving treatment with clozapine, quetiapine and olanzapine were analysed by liquid chromatography mass spectrometry, including a subgroup of patients with paired plasma samples. Finger sweat samples were also analysed from a negative control group and patients who had handled antipsychotic medication only. The finger sweat test (based on the detection of parent drug in one donated sample) was 100% effective in monitoring adherence within commonly prescribed dosing ranges. In comparison to participants who handled the medication only, the test could distinguish between contact and administration through monitoring of the drug metabolite, or the level of parent drug. Additionally, in a subgroup of patients prescribed clozapine, a statistically significant correlation was observed between the mass of parent drug in finger sweat and plasma concentration. The finger sweat technology shows promise as a dignified, noninvasive method to monitor treatment adherence in patients taking antipsychotics.

Does endodontics influence radiological detection of external root resorption? an in vitro study

BACKGROUND

External root resorption (ERR) has a multifactorial etiology and is difficult to diagnose, which means that is continues to be of research interest. This work mainly aims to determine whether external root resorption can be differentially detected in root-filled versus non-endodontically treated teeth using digital periapical radiography (DPR) and cone-beam computed tomography (CBCT).

METHODS

The Checklist for Reporting In-vitro Studies (CRIS) guidelines were followed throughout this study. This experiment highlights the preparation and generation of standardized synthetic teeth measured on three-dimensional records converted into Digital Imaging and Communication on Medicine (DICOM) file format. Twelve replicate maxillary incisors were randomized into two groups: (G1) six non-endodontically treated, and (G2) six endodontically treated teeth. In both groups, actual tooth lengths of all specimens were measured and compared with measurements obtained using DPR and CBCT. Simulated ERR lesions [0.12, 0.18, 0.20 mm × 0.5 mm depth in the mesial, distal and palatal apical regions] were created progressively, radiographic images were recorded, and 24 DPRs and 96 CBCTs were obtained in total. Eight blinded, previously calibrated researchers made a total of 1920 measurements (using Horos Software). Data were analyzed using the Shapiro-Wilk, ANOVA, Kruskal-Wallis and Wilcoxon rank post-hoc tests [Bonferroni correction in multiple comparison tests (p < 0.05)].

RESULTS

ICC values for intra- and inter-examiner agreement were appropriate. DPR overestimated ERR detection compared to the actual and CBCT measurements [Mean diff = 0.765 and 0.768, respectively]. CBCT diagnosis of ERR lesions in specimens without root canal treatment was significantly more accurate than DPR diagnoses on both non-endodontically and endodontically-treated specimens [p = 0.044; p = 0.037, respectively]. There was an 18.5% reduction in sensitivity in all DPR diagnoses made on endodontic teeth versus those made on non-endodontically treated teeth. For the smallest ERR lesions, this sensitivity was even more marked, with 27.8 and 25% less sensitivity, respectively.

CONCLUSIONS

The results of this study highlight that both CBCT and DPR are good diagnostic methods for ERR. Nevertheless, root canal filling material influences diagnostic capability in ERR. The clinical significance was that the presence of intracanal material reduces the detection and diagnosis of ERR by DPR in teeth with root canal treatment.

A real-world characterization of a cohort with eosinophilic esophagitis: looking for severity biomarkers

Summary

Background. Eosinophilic esophagitis (EoE) is an immune-mediated chronic esophageal disease, with frequent association with atopy. A validated non/minimally invasive biomarker of disease severity has not been identified. We aimed to determine if sensitization to airborne and food allergens correlates with disease severity, and to evaluate the association between clinical and laboratory characteristics with the severity of EoE. Methods. Retrospective study of EoE patients observed in a differentiated center, 2009-2021. The association between patients' diagnosis age, disease duration before diagnosis, sensitization to airborne/food allergens, serum total IgE and peripheral blood eosinophil values and severe clinical disease (presence of symptoms with a significant impact on quality of life and/or ≥ 1 hospital admission due to EoE complications, namely severe dysphagia, food impaction or esophageal perforation) and histological severe disease (≥ 55 eos/hpf and/or microabscesses in esophageal biopsies) was evaluated. Results. 92 patients were observed, 83% male, 87% atopic. There was a mean delay in diagnosis of 4 years (range 0-31). 84% had aeroallergen sensitization and 71% food sensitization. Food impaction and dysphagia were the most frequent symptoms, and severe clinical disease was observed in 55%. Histologically, 37% had severity criteria. Patients with severe clinical disease had a significantly longer mean disease duration before diagnosis than patients without severe clinical disease (79 vs 15 months, p = 0.021). Patients who described food impaction were significantly older at time of diagnosis than those who have never had impaction (18 vs 9 years, p less than 0.001). There was no significant association (p less than 0.05) between sensitization, serum total IgE and peripheral blood eosinophil values and clinical or histological severity. Conclusions. An older age at diagnosis and a longer disease duration before diagnosis appear to be useful for predicting EoE clinical severity. Despite having been demonstrated a high prevalence of allergic disease, the presence of sensitization to airborne and/or food allergens do not seem to be useful for predicting clinical or histological severity.

Carcass, meat quality traits, and economic analysis of Nellore bulls fed with finishing feedlot diets containing mechanically processed corn silage

Effects of mechanical processing (MP) of corn silage and its inclusion in feedlot diets on carcass and meat quality traits of Nellore (Bos indicus) were analyzed. Seventy-two bulls aged approximately 18 months and with an initial average body weight of 392.8 ± 22.3 kg were used. The experimental design was a 2 × 2 factorial arrangement, considering the concentrate-roughage (C:R) ratio (40:60 or 20:80), MP of silage and their interactions. After slaughter, hot carcass weight (HCW), pH, temperature, backfat thickness (BFT), and ribeye area (REA), yields of meat cuts (tenderloin, striploin, ribeye steak, neck steak, and sirloin cap), meat quality traits and economic analysis were evaluated. A lower final pH was found in the carcasses of animals consuming diets containing MP versus unprocessed silage (pH = 5.81 versus 5.93). Carcass variables (HCW, BFT, and REA) and meat cut yields were not affected by treatments. The C:R 20:80 increased the intramuscular fat (IMF) content by approximately 1%, without affecting moisture, ash, and protein contents. Meat/fat color (L*, a* and b*) and Warner-Bratzler shear force (WBSF) were similar among treatments. The results indicated that the MP of corn silage in finishing diets can provide better carcass pH results in Nellore bulls, without negatively influencing carcass weight, fatness, and meat tenderness (WBSF). The IMF content of meat was slightly improved using a C:R 20:80 and lower total costs per arroba produced (3.5%), daily costs per animal/day (4.2%), and cost per ton of feeds (5.15%) were found with MP silage.

Service provision of genetics health care in Portugal

In recent decades, genetics has undergone important technological advances. The rapid shift to genomics has made a strong impact on health systems around the world. In Portugal, this huge increase in consultations and typologies of genetic tests has joined the serious limitations of the few existing genetics services. The following study aims to characterize the current state of the network of genetics services in Portugal regarding its functioning, main challenges, and opportunities. Five semi-structured interviews were conducted, corresponding to 83.33% of the directors of the public genetics services of the National Health Service. Four thematic categories emerged from the analysis: (1) specialty and technical developments, (2) structural difficulties, (3) potentialities, and (4) future directions. The developments are due to the emergence of more comprehensive genetic applications, specific protocols and patient referral standards, and accreditation of services. The main difficulties encountered in the functioning of the services were difficulty in obtaining funding, lack of human resources, service overload, and lack of exclusive time for training and research. The potentialities mentioned were the establishment of multidisciplinary teams and the best articulation with specialists from other areas. Among the various future directions pointed out, better management of patients' waiting lists, the importance of research, the simplification of test request procedures, and the creation of specialized units inside the genetic services, were reported. The results showed several gaps in the practice of medical genetics that should be addressed with the development of public policies for the recognition and restructuring of medical genetics in health care.

1200 EFFECT OF BALANCE TRAINING AFTER HIP FRACTURE SURGERY: A SYSTEMATIC REVIEW OF RANDOMISED CONTROLLED STUDIES

Introduction

Hip Fracture Surgery (HFS) can result in balance impairment which is associated with an increased risk of falls in the elderly as well as limitations in their mobility. Balanced Training (BT) is a rehabilitation method used aiming to minimize the balance impairments post HFS. BT options include stepping, balance task-specific exercise, standing on one leg, yoga. Our main outcome is to evaluate the effect of BT on the physical functioning of elderly patients post an HFS.

Methods

We conducted a systematic review using the PubMed-Medline, Cochrane Library and Embase databases to locate randomized controlled trials which compared BT with standard care post HFS. The Cochrane’ Library Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was used as our template for the review.

Results

Overall, nine randomised controlled trials were selected, comprising a total of 712 patients, all aged 65 years of age and older. With regards to the type of BT rehabilitation: four trials used step-ups (n=500), three trials used balance task-specific exercise (n=170) and two studies used standing on one leg (n=42). The BT group demonstrated improvement in physical functioning post HFS compared to the control group (Standardised Mean Difference (SMD) = 0.410). Moreover, all functional parameters which include, lower limb strength, performance task and health related quality of life, were also improved in the BT group.

Conclusion

Evidently, the results demonstrate an improvement of physical functioning by BT post HFS. Furthermore, the positive effects on all functioning parameters were apparent. As a result, the implementation of BT in postoperative rehabilitation programs in elderly patients with hip fractures should be considered.

Reference

[1] Monticone M, Ambrosini E, Brunati R, et al. How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture: a randomized controlled trial. Clin Rehabil. 2018;32:340–351.

1199 PREVENTION AND TREATMENT OF CRITICAL ILLNESS ACQUIRED WEAKNESS IN THE ELDERLY

Introduction

Critical Illness Acquired weakness (ICU-Acquired Weakness (ICU-AW)) is an umbrella term used to describe Critical Illness Myopathy (CIM) and Critical Illness Polyneuropathy (CIP). The condition exerts high prevalence in the elderly admitted in the ICU and is associated with deteriorating patient outcomes, namely mortality and morbidity. The prevalence of the syndrome is highly variable in the current literature hindering our ability to objectively quantify the scale of the problem. Moreover, several preventative methods and treatment for ICU-AW as a result of sarcopenia have been proposed in literature with some of them providing favourable outcomes.

Objectives

1. Evaluate the prevalence of ICU-AW in the elderly through a systematic review; and 2. Explore the treatment options currently available.

Methods

We conducted a systematic review using the PubMed, Embase and Cochrane databases to explore the current studies available on the diagnosis of ICU-AW syndromes. Cochrane’s Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was our template.

Results

Overall, twenty-one studies (1544 patients) were included. The minimum reported prevalence is 20%, whereas the maximum is 76%. The overall median prevalence was 52% (Q1: 32% and Q3: 61%) with an interquartile range (IQR) of 29%. The highest IQR was found in studies using clinical examination (IQR=37%) whereas the lowest in studies using electrophysiological assessment (IQR= 21%). Moreover, several preventative measures for ICU-AW were identified and analyzed namely: nutritional alterations (high protein dies), glucose control, early mobilization, neuromuscular electrical stimulation and the ABCDEF bundle.

Conclusion

The variability in the diagnostic modalities used to measure the syndrome as well as the inconsistency in the diagnostic parameters within each modality prevent us from objectively quantifying the prevalence of ICU-AW. With regards to treatment early mobilization protocols offer promising evidence.

Reference

Vanhorebeek, Latronico, Van den Berghe G. ICU-acquired weakness. Intensive Care Med. 2020;46(4):637-53.

Clinical experience of a specialized urticaria outpatient clinic from a Portuguese UCARE

Summary

Background. Chronic urticaria (CU) is a frequent disease, with a prevalence of at least 1%. It is characterized by pruritic wheals, angioedema or both for a period longer than 6 weeks. Objective. Identify the demographic, clinical, laboratory and therapeutic profile of patients treated in a Portuguese Urticaria Center of Reference and Excellence (UCARE) and compare it with international series. Methods. Retrospective analysis of database of patients observed in a specialized urticaria outpatient clinic, from January 2017 through September 2019, of a UCARE center in Portugal. Demographic and clinical features, laboratory findings and pharmacological treatment were obtained from the records. Descriptive analyses were performed for all variables. Chi square and fisher's exact tests were applied to analyze the independence of variables and the fit of distribution. P less than 0.05 was considered significant. Results. During this period, 477 patients were observed, of whom 429 (90%) were diagnosed with chronic urticaria. Mean age (years) at the onset of symptoms was 43.7 (standard deviation (SD) 17.6, range 6-88) and at diagnosis 46.7 (SD 17.8, range 6-88) resulting in an average diagnostic delay of 3 years (range 0-25). Median follow-up period since first attendance in the specialized outpatient clinic was 1.7 years (interquartile range (IQR) 0.79, range 0.1-2.75) . Concerning the whole group of CU patients, 347 (81%) had chronic spontaneous urticaria (CSU) - 79% female, 39 (9%) had isolated chronic inducible urticaria (CIndU) and 43 (10%) had CSU with CIndU. Autologous serum skin test (ASST) was done in 76 patients (positive in 24 (32%)) and basophil activation test (BAT) was done in 38 (positive in 13 (34%)). At the moment of study, 204 (48%) of CU patients were medicated with a second-generation H1-antihistamine (sgAH) daily (first-line therapy), 99 (23%) with sgAH up to four times the standard dose (second-line therapy) and 126 (29%) with omalizumab (third-line therapy). Additionally, 7 (2%) patients were completing a short course of systemic corticosteroids for management of disease exacerbation. Disease control was achieved in 316 of CSU patients (81%). Conclusions. Referral to a specialized urticaria outpatient clinic is important for a proper assessment of the disease and adequately symptom control.

Hereditary angioedema: 24 years of experience in a Portuguese Reference Center

Summary

Hereditary angioedema (HAE) poses a high burden of disease, being its epidemiological and clinical data heterogeneous among countries, with no recent published studies concerning Portuguese patients. Therefore, we aimed to raise awareness of HAE and to contribute to clinical knowledge. An observational, descriptive, retrospective, and cross-sectional study was performed, that included a cohort of 126 patients followed in a single Portuguese Center. We observed a high prevalence of HAE-C1-INH type II (45.2% of patients). Most HAE patients (67.4%) presented the initial manifestations of the disease before adulthood, at a mean age of 12.6 ± 8.4 years. However, we found a long delay in HAE diagnosis, especially in those without family history (mean 20.7 ± 17.3 years). Stress was the most common trigger, followed by trauma and infection. Symptoms involving different systems were increasingly reported with increased disease duration. Cutaneous symptoms (95.0%) were more frequent, followed by gastrointestinal (80.7%), and respiratory symptoms (50.4%). HAE symptoms led to abdominal surgery in 22 (17.5%) patients and induced laryngeal edema requiring intubation/tracheostomy in 8 (6.3%) patients. Most patients were under long-term prophylaxis, mainly with attenuated androgens (62.7% of patients).The correct distinction between HAE and other common causes of angioedema is critical, allowing reduction of diagnostic delay, improvement of adequate management, and ultimately improving outcomes and quality of life of HAE patients.

Acute total occlusion of the unprotected left main coronary artery – patient characteristics and outcomes

Background

Acute total occlusion of the unprotected left main coronary artery (ATOLMCA) is a dramatic entity with very high mortality. Owing to its infrequency, there is limited and inconsistent data regarding this population.

Purpose

To describe the clinical presentation, short- and long-term outcomes of patients with ATOLMCA.

Methods

This retrospective multicentric cohort study included all patients presenting with acute (&lt;12h) myocardial infarction (MI) due to ATOLMCA (Thrombolysis In Myocardial Infarction - TIMI=0) between January 2008 and December 2020 in three tertiary hospitals.

Results

In the period of the study, 11,036 emergent coronary angiographies were performed in the participating centers, 59 of which were ATOLMCA (0.5%). Mean age of patients at the time of the event was 61.2 (±12.2) years. Seventy-three percent were male. At presentation, 72.9% of patients were in cardiogenic shock, and aborted cardiac arrest occurred in 27.1%. Right dominance was present in all patients except one, who had a balanced dominance. Primary percutaneous coronary intervention (PCI) was performed in 89.8% of the patients, with angiographic success being achieved in 55.6% of the procedures. Overall, the in-hospital mortality rate was 57.6%. Mortality was significantly higher in patients without angiographic criteria for PCI success (87.5 vs 36.7%, p&lt;0.001). Among survivors, 91.7% were still alive at 1-year and 66.7% at 5 years of follow-up.

Conclusion

Patients with ATOLMCA have a dismal prognosis. Most patients present with cardiogenic shock, and a significant number develop cardiac arrest during the acute phase. Despite medical care, in-hospital mortality is high. Patients with left dominance may not even reach the hospital. Among survivors, long term outcomes are reasonable. Further studies are needed in order to improve the management and outcomes of patients with ATOLMCA.

Funding Acknowledgement

Type of funding sources: None.

Does my TAVR patient have cardiac amyloidosis?

Introduction

Aortic stenosis (AS) is highly age-related, and its prevalence is increasing rapidly in high-income countries. There are 2 major types of amyloid protein responsible for cardiac amyloidosis (CA) - transthyretin (TTR) and immunoglobulin lightchain (AL). Previous cohorts report an incidence ranging from 9 to 16% for the presence of CA in patients with AS referred for TAVR. These patients appear to have a similar prognosis to those with lone AS when undergoing TAVR, but a trend toward worse prognosis if left treated. We aimed to investigate the prevalence of CA in patients with severe AS referred for TAVR in the Portuguese population.

Methods

We prospectively recruited 60 consecutive patients referred for TAVR at our tertiary center between November 2020 and May 2021. 59 patients agreed to participate and signed an informed consent, approved by the local Ethics Commission. All patients performed coronary angiogram, echocardiogram, thoracic abdominal pelvic CT scan, ECG, bone scintigraphy (99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid [DPD]) and blood and urine monoclonal immunoglobulin testing. (Figure 1).

Results

About half (54.2%) of patients were male, average age was 82 years and the prevalence of ischemic heart disease and cardiovascular risk factors was high. About one third of patients had atrial fibrillation and 27.1% were pacemaker carriers. Echocardiographic baseline findings were: maximum aortic valve gradient 72.77±18.18 mmHg; mean aortic valve gradient 43.49±11.60; aortic valve area 0.65±0.15 cm2; interventricular septum thickness 1.30±0.23 cm; left ventricular ejection fraction (LVEF) 52.06±11.35%; E/E' 14.63±7.5; tricuspid annular plane systolic excursion 19.2±4mm; right ventricle/ right atrial gradient 38.1±14.32mmHg.

CA was diagnosed in 6 (10.2%) patients. Perugini grade was 1 (n=3) and 3 (n=3). One patient (Perugini grade = 3) was found to have plasma cell dyscrasia, producing monoclonal IgG Kappa protein. CA patients were all male, older (86.5 vs 81.30 years, p=0.049), more frequently pacemaker carriers (66.7 vs 22.6%, p=0.041) and had a tendency to have a thicker interventricular septum (1.48 vs 1.28 cm, p=0.065).

Conclusions

We show that in the Portuguese population, the prevalence of CA in severe AS patients referred for TAVI is in line with what is observed in other countries. This has important consequences regarding the diagnosis and management of these patients.

Funding Acknowledgement

Type of funding sources: None.

Percutaneous valve commissurotomy in mitral stenosis patients: a 20 years follow-up

Background

Percutaneous valve commissurotomy (PMC) is a viable alternative to mitral valve surgery in the treatment of patients with clinically significant mitral stenosis (MS). Although rheumatic MS incidence has decreased in developed countries, it remains a prevalent healthcare problem in Cardiology clinics

Purpose

To evaluate the early and long-term results of PMC in patients with rheumatic MS and to compare long-term events between patients with and without pulmonary hypertension (PH).

Methods

We retrospectively analysed all consecutive patients between 1991 and 2008 with clinically significant rheumatic MS undergoing PMC. Clinical and echocardiographic data were collected at baseline and during long-term follow-up. MACE was a composite of adverse events defined as all-cause mortality, mitral valve re-intervention or hospitalization for a cardiovascular cause.

Results

A total of 124 patients were enrolled: 87% were female, with a mean age at the time of repair of 46±11 year-old and a mean follow-up of 20±6 years. Before the procedure, 34% were in NYHA class ≥ III and 81% had a Wilkins score ≤8; all patients had preserved biventricular systolic function, 83% presented PH, mean transvalvular gradient (TVG) and mitral valve area (MVA) were 12.8 mmHg and 1.0 cm2, respectively. Most of the procedures were successful (91%) and without complications (94%), with a mean MVA improvement of 0.9 cm2 and reduction of 8.5 mmHg in TVG and 9.7 mmHg in pulmonary artery systolic pressure (PASP) after PMC.

During long-term follow-up, 42% of patients were submitted to re-intervention (most of them surgically) and 24% died. In patients non-submitted to re-intervention, TVG and PASP remained similar with early post-procedure evaluation (p=0.109 and p=0.777, respectively), while MVA reduced over time, yet still statistically superior to baseline MVA (1.6 cm2 vs 1.0 cm2, p&lt;0.001). Concerning time-to-event analysis, approximately 80% of patients kept uneventful after 10 years; after 30 years, more than 20% continued MACE-free and approximately 50% were alive. Regarding PH presence at time of PMC, there was no significant difference in MACE events and all-cause mortality between the two groups (Log Rank, p=0,846 and p=0.661, respectively).

Conclusion

PMC was safe and effective in clinically significant rheumatic MS. After a long-term follow-up patients maintained the reduction in TVG and PASP and a smaller but significative improvement in MVA. Most of the patients were free from adverse events after 10 years and half were alive after 30 years. There was no difference in all-cause mortality and in a composite of all-cause death, mitral valve re-intervention or cardiovascular hospitalization concerning PH presence.

Funding Acknowledgement

Type of funding sources: None.

Patient delay in acute myocardial infarction: a long journey still ahead

Background

It is overly known that time delays in acute myocardial infarction (AMI) strongly influence its outcomes. Patient delay (PD) is repeatedly pointed out as the longer one in this context, as well as it is the less modifiable one by organizational measures. Therefore, it is crucial to understand the reasons for longer PD in our population, to define proper strategies to improve PD and, ultimately, AMI-outcomes.

Methods

In this six-month prospective study of patients (pts) admitted in a tertiary hospital due to type-1 AMI, 194 pts were consecutively enrolled between May and October 2021. Data was based on a pts well-structured interview within 48h after admission and review of medical records.

Results

Our work spotted several aspects significantly influencing PD in AMI context (Figure 1). Concerning pts cardiovascular background, a trend towards a shorter PD was found in pts with at least one cardiovascular risk factor (CVRF) (p=0,08) and with a previous history of AMI (p=0,08). Regarding clinical presentation, a significantly shorter PD was found in pts presenting with associated symptoms (p=0,02), higher chest pain intensity (chest pain intensity ≥7 vs &lt;7 in a 0–10 scale; p=0,03) and symptoms onset on weekdays rather than weekends (p=0,003). Regarding pts knowledge, significant differences were found when pts recognized their symptoms as AMI, presenting a shorter PD in this context (p=0,006). Curiously, pts ability to correctly identify AMI symptoms, when asked, or to acknowledge their CVRF (when present), did not influence PD. Considering sociodemographic factors, higher incomes (p=0,03) and non-rural residence (p=0,03) significantly translated into shorter PD. No differences were found in PD according to pts age, gender or educational level. After this initial univariate analysis, multiple linear regression was performed to identify possible predictors of PD. Four variables were identified: pts ability to recognize their symptoms as AMI (β −0.199; 95% CI: −277 to −34,87; p=0.012), living in a non-rural residence (β 0.154; 95% CI: 0.12–161.44; p=0.05), presenting associated symptoms (β −0.194; 95% CI: −257.43 to −28.84; p=0.014) and occurrence of symptoms on weekdays (β 0.170; 95% CI: 12.73–259.49; p=0.031) predicted shorter patient delays.

Conclusion

Our study clearly points to the need for increasing public awareness and educational measures, mainly in pts living in rural areas, in order to: 1) Improve pts knowledge about AMI symptoms, clarifying that atypical symptoms can happen; 2) Reinforce the importance of shortening AMI time delays, clearly explaining the concept “time is muscle”.

Funding Acknowledgement

Type of funding sources: None.

Management of fulminant myocarditis: peripheral venoarterial extracorporeal membranous oxygenation and associated complications

Background

Fulminant Myocarditis (FM) leads to cardiogenic shock with multi-organic dysfunction, being peripheral venoarterial extracorporeal membranous oxygenation (VA-ECMO) a rescue technique. Despite growing experience, it is still related with several complications. We aim to appraise the management of patients with FM and the adverse events associated to VA-ECMO.

Methods

We conducted a retrospective study in a ECMO centre in Portugal, which included 15 patients diagnosed with FM and managed on VA-ECMO from 2008 to 2018. Hemorrhage or infection on cardiac device site, cardiac tamponade, limb ischemia, ischemic stroke, cerebral hemorrhage, severe hemolysis and accidental decannulation were considered major complications.

Results

For sample characteristics and resumed complications, see Table. Inotropic and mechanical ventilation support were transversal to all, with only one patient extubated before decannulation. Six patients received renal replacement therapy, whom half recovered renal function and the remaining died. VA-ECMO operated on average for 8,5 days (range, 1 to 20 days). 3 patients had concomitant Impella heart pump and one of them had a third assistance device with Intra-Aortic Ballon pump.

Major complications were observed in 9 patients (60%), being ischemic stroke the most common. Limb ischemia, observed in 5 patients, related with longer duration of VA-ECMO support (limb ischemia vs non-limb ischemia; 12,8±4,9 vs. 6,8±6,5 days). Two patients presented hemorrhage on cardiac assistance device site, and 1 patient had a cardiac tamponade, all with fatal outcome. Infection on cardiac site, cerebral hemorrhage, severe hemolysis and accidental decannulation were not observed.

Conclusion

The most common complications were ischemic stroke and limb ischemia, both not apparently related with mortality. Differently, hemorrhage on cardiac site and cardiac tamponade were less frequent but presented ominous outcome. Overall, adverse events can be serious and hinder recovery and discharge.

Funding Acknowledgement

Type of funding sources: None.

Thyrotropin-secreting microadenoma and the importance of a prompt diagnosis: A case report

Background

The prevalence of thyrotropin-secreting pituitary adenomas, most being macroadenomas, is one to two cases per million inhabitants. Their differential diagnosis may be challenging, especially for microadenomas.

Case description

We present the case of a 50-year-old male with progressive neck enlargement, hot sudorific hands, anorexia, diarrhea, and weight loss over the preceding three months. Laboratory evaluation revealed high thyroid hormones, predominantly high free triiodothyronine of 7.74 pg/mL (reference range 2.3-4.2), with a non-suppressed thyroid stimulating hormone (TSH) of 1.73 µIU/mL (reference range 0.55-4.78). A high level of suspicion directed additional evaluation that revealed a high total alpha-subunit of glycoprotein hormones (αGS) and αGS/TSH ratio. Magnetic resonance imaging revealed a six mm pituitary lesion. A microthyrotropinoma was diagnosed, and long-acting octreotide was initiated before surgery for symptomatic control. Endoscopic transnasal transsphenoidal tumor resection was performed months later. The patient was in remission one year after surgery with no pituitary deficits.

Conclusions

Reaching an accurate diagnosis on time is crucial for deciding the optimal therapeutic approach and preventing and decreasing the frequency of endocrine and neurological complications. HIPPOKRATIA 2022, 26 (4):157-160.

POS0901 INTERSTITIAL LUNG DISEASE IN MIXED CONNECTIVE TISSUE DISEASE: CLINICAL AND SEROLOGICAL ASSOCIATIONS

Background

Mixed connective tissue disease (MCTD) is a rare systemic rheumatic disease characterized by the expression of autoantibodies targeting the U1-ribonucleoprotein and overlapping clinical features of systemic sclerosis, systemic lupus erythematosus, and inflammatory myopathies. Interstitial lung disease (ILD) is present in 47% to 78% of patients and has been associated with higher mortality rates. Associations of ILD with Raynaud’s phenomenon, dysphagia, anti-Ro52 antibodies, and a scleroderma pattern on nailfold capillaroscopy have been reported in MCTD patients.

Objectives

This study aims to identify clinical and serological associations and independent predictors of ILD for patients with MCTD.

Methods

Multicenter retrospective study using data collected from clinical records. Adult patients who underwent lung computed tomography (CT) and met at least one of four MCTD diagnostic criteria (Sharp, Alarcón-Segovia, Kasukawa, or Kahn criteria) were included. Univariate analysis was performed using Chi-Square, Fischer’s Exact, and Mann-Whitney tests, as appropriate. Multivariate analysis was performed using binary logistic regression modelling. The linearity of the continuous variables concerning the logit of the dependent variable was assessed via the Box-Tidwell procedure. Cases with missing information and outliers were excluded from the multivariate analysis to fulfil all assumptions necessary to assure the validity of the regression.

Results

Fifty-seven patients, of whom 37 were Caucasian (64.9%) and 48 were females (84.2%), with a mean age of 39.4±14.0 years, were included. Twenty-seven patients had ILD (47.4%), of whom 22 had nonspecific interstitial pneumonia (81.5%), 4 had usual interstitial pneumonia (14.8%), and 1 had lymphoid interstitial pneumonia (3.7%) pattern on CT. Among patients with ILD, 13 were asymptomatic (48.1%), while 14 had respiratory symptoms (51.9%), including dyspnea (N=13, 48.1%), cough (N=7, 25.9%), and pleuritic chest pain (N=1, 3.7%). Pulmonary function tests were performed in 22 patients (81.5%), 20 of whom had a restrictive pattern (90.9%).

In the univariate analysis, lymphadenopathy at disease onset (22.2% vs 3.3%, p=0.045) and esophageal involvement at any time point (40.7% vs 16.7%, p=0.043), were associated with ILD.

The binary logistic regression model predicting ILD included 56 patients, and the model explained 36.5% (Nagelkerke R2) of the variance in ILD and correctly classified 75% of all cases. Older age at diagnosis (OR 1.10/year, 95%CI: 1.00-1.12, p=0.046) and lymphadenopathy at disease onset (OR 19.65, 95%CI: 1.91-201.75, p=0.012) were identified as predictors of ILD in MCTD patients, irrespective of sex and esophageal involvement.

Conclusion

Older age at diagnosis and lymphadenopathy at disease onset were independent predictors of ILD in MCTD. Therefore, these factors should be considered when evaluating MCTD patients, especially at the time of diagnosis. To the best of our knowledge, this is the largest study ever describing predictors of ILD for MCTD patients.

References

[1]Fagundes MN, Caleiro MT, Navarro-Rodriguez T, Baldi BG, Kavakama J, Salge JM, Kairalla R, Carvalho CR. Esophageal involvement and interstitial lung disease in mixed connective tissue disease. Respir Med. 2009 Jun;103(6):854-60. doi: 10.1016/j.rmed.2008.12.018. Epub 2009 Feb 6. PMID: 19201182.

[2]Gunnarsson R, Aaløkken TM, Molberg Ø, Lund MB, Mynarek GK, Lexberg AS, Time K, Dhainaut AS, Bertelsen LT, Palm O, Irgens K, Becker-Merok A, Nordeide JL, Johnsen V, Pedersen S, Prøven A, Garabet LS, Gran JT. Prevalence and severity of interstitial lung disease in mixed connective tissue disease: a nationwide, cross-sectional study. Ann Rheum Dis. 2012 Dec;71(12):1966-72. doi: 10.1136/annrheumdis-2011-201253. Epub 2012 May 1. PMID: 22550317

Disclosure of Interests

None declared

AB0655 Clinical and immunological features of a Portuguese cohort of Mixed Connective Tissue Disease

Background

Various nationwide studies have been already published to better understand Mixed Connective Tissue Disease (MCTD) (1,2). However, Portuguese data is not available.

Objectives

To characterize clinical and immunological features of a Portuguese cohort of patients with MCTD.

Methods

Retrospective, multicenter study including adult-onset patients with clinical diagnosis of MCTD and fulfilling at least one of the following classification criteria: Sharp, Kasukawa, Alarcón-Segovia or the Kahn’s criteria. Positivity to other autoantibodies besides anti-U1-RNP were allowed. SPSS was used for statistical analysis and significance level was defined as 2-sided p<.05.

Results

A total of 98 patients were included, with a mean age at diagnosis and disease duration of 40.5±13.7 and 7.0±6.5 years, respectively. Most patients were female (87.8%) and Caucasian (70.4%). Raynaud’s phenomenon (96.9%), arthralgia/arthritis (94.9/74.5%) and puffy fingers (60.2%) were the most common and early manifestations. Gastroesophageal (GE), respiratory and muscular involvement were also prevalent, mostly during the follow up, affecting 30.6%, 34.7% and 43.9% of the patients, respectively. Clinical and immunological characteristics are described in Table 1. Males were older at symptom’s onset (65.0 VS 46.7, p=.035), having more respiratory involvement (OR=4.5, 95% CI 1.3-16.4), and positivity to anti-ACPA (OR=20.0, 95% CI: 3.1-129.4). GE involvement occurred more often in Caucasian patients (OR=3.8; 95% CI: 1.0-14.1), while anemia of chronic diseases (OR=2.7; 95% CI: 1.0-7.2), myositis (OR=3.6; 95% CI: 1.3-9.9) and constitutional symptoms (OR=3.2; 95% CI: 1.2-8.3) were more frequent in Afro-American patients, whose were also younger at disease (34.1 VS 50.6, p=.01). After a median follow-up time of 4 (IQR 8) years, 4 deaths occurred (4.1%), mostly (75%) due to infectious complications.

Table 1.

Clinical and immunological characteristics

Clinical ManifestationsAt presentationFollow-upMucocutaneous systemRaynaud’s phenomenon, n (%)85 (86.7)95 (96.9)Puffy hands, n (%)48 (49.0)59 (60.2)SSc-like, n (%)43 (44.8)59 (60.8)SLE-like, n (%)28 (28.9)35 (35.7)Musculoskeletal systemArthralgia/Arthritis, n (%)/n (%)81 (82.7) / 56 (57.1)93 (94.9) / 73 (74.5)Myositis, n (%)26 (25.6)43 (43.9)Hematological system, n (%)46 (46.9)70 (71.4)Respiratory system, n (%)14 (14.3)34 (34.7)Cardiovascular system3 (3.1)4 (4.1)Pulmonary hypertension*2 (2.0)15 (15.3)Gastroesophageal involvement, n (%)11 (11.2)30 (30.6)Renal involvement, n (%)2 (2.0)10 (10.2)Neurological involvement, n (%)6 (6.3)14 (14.3)Constitutional symptoms, n (%)26 (26.5)30 (30.6)Immunological characteristicsAnti-dsDNA, n (%)21 (21.4)Anti-smith antibody, n (%)21 (21.4)Anti-Ro/SSA, n (%)31 (31.6)Anti-La/SSB, n (%)7 (7.1)Anti-centromere, n (%)3 (4.1)Rheumatoid Factor, n (%)39 (39.8)Anti- anti-citrullinated protein antibodies, n (%)6 (6.1)Antiphospholipid antibodies, n (%)7 (7.1)Myositis antibodies, n (%)9 (9.2)Complement activation, n (%)27 (27.6)Hypergammaglobulinemia, n (%)51 (52.0)

Legend: Anti-dsDNA: anti-double stranded deoxyribonucleic acid antibody; SLE: systemic lupus erythematosus, SSc: systemic sclerosis. *No information regarding cardiac catheterism, then compatible alterations in the echocardiogram.

Conclusion

Raynaud’s phenomenon, puffy fingers and arthritis were the most common manifestations in Portuguese patients, with similar proportions found in literature (1,2). However, we reported some differences in mucocutaneous, renal and serosa involvement and higher prevalence of probable pulmonary hypertension (1,2), which may be explained by the heterogeneity of the inclusion criteria. Except for respiratory, myositis, GE and constitutional symptoms, there were no differences regarding gender and ethnicity.

Here, we characterize the largest cohort of MCTD in Portugal.

References

[1]Cappelli S, et al. Semin Arthritis Rheum. 2012 Feb;41(4):589–98.

[2]Alves MR et al. Clin Exp Med. 2020 May;20(2):159–66.

Disclosure of Interests

None declared

AB0688 Predictors of muscle involvement in Portuguese patients with mixed connective tissue disease

Background

Mixed connective tissue disease (MCTD) is a rare heterogeneous disease, characterized by overlapping features of classic connective tissue diseases. Myositis may be present in up to two-thirds of patients with MCTD and it is included in all diagnostic criteria available. Although some possible associations have been reported, to the best of our knowledge, no independent predictors of MCTD-related myositis have been described.

Objectives

To identify clinical and laboratorial predictors for muscular involvement in a cohort of Portuguese patients with MCTD.

Methods

Multicentre retrospective cohort study including adult-onset patients with a clinical diagnosis of MCTD and fulfilling at least one of the following diagnostic criteria: Sharp, Kasukawa, Alarcón-Segovia or Kahn criteria. Myositis was defined as proximal muscle weakness, creatine kinase elevation, electromyography (EMG) suggestive changes or a positive muscular biopsy. Univariate analysis was performed using Chi-Square, Fischer’s Exact Test and Mann-Whitney Test, as appropriate. Multivariate analysis was performed using binary logistic regression modelling. The linearity of the continuous variables concerning the logit of the dependent variable was assessed via the Box-Tidwell procedure. Cases with missing information and outliers were excluded from the multivariate analysis to fulfil all assumptions necessary to assure the validity of the regression.

Results

A total of 98 patients were included, 43 (44.3%) of whom had muscular involvement at any time of the disease course. Concerning patients with MCTD-related myositis, the mean age at diagnosis was 34.8±12.5 years and the mean disease duration of 4.1±4.9 years. The majority of patients were female (90.7%) and of European ancestry (66.7%).

EMG was performed in 24 patients, of whom 10 (41.7%) had a myopathic pattern. Seventeen patients were submitted to a muscular biopsy, of whom 8 (47.1%) had histological myositis features. Capillaroscopy was performed in 24 patients and 12 (50%) had a scleroderma pattern.

African ancestry and leukopenia were positively associated with myositis at disease onset. Furthermore, fever at the onset of disease, younger age at diagnosis and shorter disease duration were positively associated with the occurrence of myositis at any phase of the disease.

The multivariate analyses predicting myositis at diagnosis included 54 patients and at any time of the disease included 90 patients. These models explained 37.8% and 26.9% (Nagelkerke R2) of the variance in myositis and correctly classified 79.6% and 73.3% of all cases, respectively.

African ancestry (OR 8.39, 95%CI: 1.43-49.37, p=0.019), leukopenia (OR 6.24, 95%CI: 1.32-29.48, p=0.021) and younger age at diagnosis (OR 1.07/year, 95%CI: 1.01-1.14, p=0.035) were identified as independent predictors of myositis at diagnosis. Fever (OR 6.51, 95%CI: 1.23-34.37, p=0.027) was an independent predictor of muscular involvement at any time of the disease in MCDT patients.

Conclusion

African ancestry, leukopenia and younger age at diagnosis are independent predictors of myositis at presentation in MCTD patients, while fever is an independent predictor of myositis at any time of the disease. While evaluating patients with MCTD, these predictive factors should be considered.

References

[1]Ciang NCO, Pereira N, Isenberg DA. Mixed connective tissue disease-enigma variations? Rheumatol. 2017 Mar 1;56(3):326–33.

[2]Hall S, Hanrahan P. Muscle involvement in mixed connective tissue disease. Rheum Dis Clin North Am. 2005 Aug;31(3):509–17, vii.

Disclosure of Interests

None declared

Breast cancer patients presenting with cardiotoxicity - risk factors and role of cardioprotective drugs

Funding Acknowledgements

Type of funding sources: None.

Introduction

Recent advances in cancer treatment have led to improved survival, albeit with cardiovascular adverse effects being some of the most frequent and feared consequences. Patient’s risk stratification, prevention and treatment are still to be fully elucidated. Our aim was to evaluate the risk and therapy of cardiotoxicity (CT) secondary to cancer treatment in a subset of patients with breast cancer (BC).

Methods

We collected a retrospective cohort of female with BC treated with conventional chemotherapy (CHT) and/or anti-HER2-targeted therapies (AHT) referred to Cardio-oncology consultation from January 2017 to March 2020. All patients were evaluated before CHT and at least at 3, 6 and 12-months with echocardiogram and cardiac biomarkers, namely high sensitivity troponin I (hs-cTnI) and brain natriuretic peptide (BNP). CT was defined as left ventricle ejection fraction (LVEF) under 50% or decline of at least 10% in LVEF during follow-up. As cardioprotective drugs (CPD) we considered renin-angiotensin-aldosterone system inhibitors and beta-blockers.

Results

A total of 203 women were enrolled, with mean age 50.9 ± 10.9 year-old. As for the cardiovascular risk factors, 23.5% had hypertension, 32.4% dyslipidaemia, 9.8% diabetes and 33.0% were smokers or previous smokers. The majority of patients had a high or very-high CT risk score (98.5% with score ≥ 5) and 35.5% were already on CPD before CHT. All patients were submitted to CHT: anthracyclines (AC) and AHT were applied to 83.8% and 41.7% of patients, respectively, with 27.9% of patients on both therapies; 81.4% were submitted to radiotherapy (RT). At presentation, all patients had normal cardiac function with mean LVEF of 62.9% and mean global longitudinal strain (GLS) of -19.4; mean hs-cTnI and BNP were 3.3 ng/L and 33.4 pg/mL, respectively. During a median follow-up of 16 months, 8.5% of patients developed CT, leading to initiation or titration of CPD in 76.9% and treatment interruption in 23.5%; most of them recovered (88.2%). During treatment there was a significantly increase of hs-cTnI (mean 19.7 ng/L at 3 months, p &lt; 0.001) and a decrease of GLS and LVEF at 12 months (decrease of 1.1 and 2.2%, respectively, both p &lt; 0.001). Both AHT and AHT plus AC were significantly associated with CT (p = 0.002 and p &lt; 0.001, respectively), with an extremely high prevalence in the latter group (19.6%). Nor CVRF neither RT raised the risk of CT. Although patients on CPD did not had lower prevalence of CT (5.6% vs 10.2%, p = 0.268), its initiation was associated with a higher rate of cardiac function recovery (100.0% vs 66.7%, p = 0.057).

Conclusion

Patients submitted to AHT or AHT plus AC were at higher risk of developing CT. This and the significant LVEF decline during follow-up highlight the importance of long-term-monitoring of these patients. CPD seemed to be associated with cardiac recovery, although this finding needs further validation.

Impact of severe mitral annular calcification on mitral regurgitation after transcatheter aortic valve implantation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter aortic valve implantation (TAVI) has become the standard of care treatment in patients with severe aortic stenosis who are at intermediate or high risk for surgical aortic valve replacement. Mitral annular calcification (MAC) is frequent in patients with aortic stenosis, and its presence is associated with increased cardiovascular morbidity and mortality. Not infrequently, it is associated with significant morphologic and functional abnormalities of the mitral valve apparatus.

Purpose

 The aim of this work is to evaluate the relationship between severe MAC and the presence and development of significant mitral regurgitation after TAVI.

Methods

 We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019. Clinical, echocardiographic and procedure-related data were collected until a follow-up of 6 months. Statistical analysis was conducted on IBM SPSS® Statistics software. Descriptive statistics were calculated for all variables. Sample T-test, Chi-square and Wilcoxon sign test were used. A p-value &lt; 0.05 was considered significant. The presence and severity of MAC was defined according to echocardiographic data. Severe MAC was defined by the presence of calcification of more than half of the mitral annular circumference.

Results

 A total of 343 patients were enrolled in the study. The mean age of the population was 80 ± 8 years, 45% were male. Mean functional area was 0.75 ± 0.18 cm2, mean transvalvular pressure gradient was 48 ± 15 mmHg and the mean left ventricular ejection fraction (LVEF) was 54 ± 14%.  MAC was detected in 231 (67%) patients. In 44 (19%) of these patients, MAC was graded as severe. Patients with severe MAC tended to have higher prevalence of moderate (27.3 vs 20.4%, p = 0.30) as well as severe (4.5 vs 1.8%, p = 0.24) mitral regurgitation at baseline. After TAVI, the prevalence of moderate mitral regurgitation at 6 months was similar between both groups (22.5 vs 20.4%, p = 0.76). Although not reaching statistical significance, patients with severe MAC had higher prevalence of severe mitral regurgitation at 6 months post-procedure (12.2 VS 5.0%, p = 0.07) as well as higher incidence of worsening of mitral regurgitation (34.2 vs 23.7%, p = 0.16). The proportion of patients that had improvement (13.2 vs 15.0%, p = 0.76) or no change (52.6 vs 61.3%, p = 0.31) in the degree of mitral regurgitation was similar in both groups. 

Conclusion

 The presence of severe MAC at baseline echocardiography in patients undergoing TAVI may be associated with worsening of mitral regurgitation after the procedure. These patients tend to have higher prevalence of severe mitral regurgitation post-TAVI. Further studies are needed in order to further elucidate this association.

Can aortic calcium score predict new conduction disturbances in pos-transcatheter aortic valve implantation?

Funding Acknowledgements

Type of funding sources: None.

Background

Transcatheter aortic valve implantation (TAVI) may be the first line treatment for severe aortic stenosis according to overall patient characteristics. Semi-quantitative Agatston score (AS), which quantifies aortic calcium by cardiac computed tomography (CCT), has knowledgeable practical and clinical implications, and is performed in TAVI diagnostic workup. Since conduction disturbances continue to be the most frequent complication, further refinements are required to predict high-risk patients.

Purpose

To access if aortic AS relates with new conduction disturbances and permanent pacemaker (PPM) implantation in patients undergoing TAVI.

Methods

We retrospectively analyzed all patients who underwent TAVI at a tertiary center from October 2014 to November 2019; patients with previous permanent pacemaker (PPM) or had no aortic AS were excluded. Clinical and electrocardiogram (ECG) data were collected at admission and after the procedure. All categorical variables are reported as numbers and percentages. Continuous variables were analyzed using the two-tailed unpaired Student’s t-test and are reported as mean values and the standard deviation. Statistical analysis was performed using the IBM SPSS.

Results

172 patients with a mean age 79 ± 9.1 years old were included (see table 1 for baseline characteristics). AS was on average 3008 ± 2262 (see table 2 for remaining diagnostic workup and procedure characteristics).

Comparing AS with new conduction disturbances, no statistically significant difference was found for new complete left branch block (LBBB) (no vs new LBBB, AS: 3179 ± 2555 vs 2637 ± 1388, p= 0,15) and with new complete atrioventricular block (AVB) (no vs new AVB, AS: 2834 ± 1520 vs 4485 ± 5285, p = 0.2). Considering PPM implantation after TAVI, there was a tendency for higher AS and PPM implantation (no vs PPM implantation, AS: 2756 ± 1451 vs 4242 ± 4310, p = 0.07).

In patients who had pre-ballooning, there was no difference relating to AS; however, in patients who had no pre-ballooning there was a trend to higher AS and PPM implantation (no vs PPM implantation, AS: 2417 ± 1301 vs 4616 ± 4969, p = 0.06). No statistically significant difference was found when comparing earlier (Portico, CoreValve Evolut R) vs newer valves (CoreValve Evolut Pro; Edward Sapiens 3; Accurate Neo).

Conclusion

Aortic calcium measured by Agatston score did not show a correlation with new LBBB or new AVB after TAVI. Nevertheless, it seems to be a trend for higher AS and PPM implantation; this was more noticeable when pre-ballooning was not performed. Further studies are needed in order to further elucidate this association. Abstract Figure. Patients baseline characteristics  Abstract Figure. TAVI diagnostic workup and procedure

The importance of smoking cessation during pregnancy and its association with perinatal outcomes

 

In utero exposure to tobacco smoke is associated with an increased risk of multiple adverse perinatal outcomes. Smoking cessation during pregnancy has been related to the improvement of these outcomes, but often relies on self-reporting, impairing an accurate assessment of smoking cessation impact on newborńs health. Building on data obtained in the frame of the NEOGENE project, this work aimed to estimate the association between smoking cessation among pregnant women, confirmed by maternal urinary cotinine concentrations, and perinatal outcomes. The study population included 595 pregnant women who sought prenatal care in a public hospital in Porto (Portugal), from April 2017 to July 2018. Data on tobacco consumption and cessation was obtained in a face-to-face interview, during the hospital stay. Perinatal outcomes, namely birth weight (BW), length (BL) and head circumference (HC) were retrieved from the hospital medical records. Maternal self-reported tobacco use was validated by urinary cotinine concentrations, using the solid-phase competitive ELISA technique. Maternal active smoking was associated with a significant decrease in BW, BL and HC of 157.66 g (p &lt; 0.001), 0.78 cm (p = 0.001) and 0.39 cm (p = 0.016). Notably, maternal smoking cessation led to a significant increase in BW of approximately 172 g (p = 0.006), when compared to mothers who have not ceased. Increases in BL and HC did not reach significance. This study upholds that tobacco consumption is still an important public health threat in Portugal and that smoking cessation during pregnancy reverses smoking-associated deficits in perinatal outcomes, emphasizing the crucial need for awareness campaigns to promote smoking cessation during pregnancy.

Acknowledgments: This work was supported by FCT and FAPESP (FAPESP/19914/2014). AIS, JM and CC also acknowledge FCT for individual funding (SFRH/BD/145101/2019, SFRH/BPD/115112/2016 and SFRH/BPD/96196/2013 grants, respectively).

Key messages

Maternal active smoking was significantly associated with lower birth weight, length and head circumference. Maternal smoking cessation reverses the smoking-associated deficits in birth weight.

Catheter ablation supported by extracorporeal membrane oxygenation -last resort treatment of arrhythmic storm?

Introduction

Arrhythmic storm (AS) is associated with high mortality, even with best medical care and hemodynamic support. If medical therapeutic failure, electrophysiological mapping and ablation are potential lifesaving therapies. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary mechanical circulatory support and can be used as a salvage intervention in patients with cardiogenic shock. Considering the seriousness of AS and the technical complexity involved, catheter ablation supported by VA-ECMO is infrequently performed. We sought to assess the safety and effectiveness of emergent catheter ablation procedures performed in patients on VA-ECMO at our hospital.

Methods

Retrospective study of all ventricular tachycardia (VT) catheter ablation procedures performed with VA-ECMO support at a tertiary centre between 2016 and 2020. Follow-up data was obtained from review of electronical records.

Results

Five patients underwent 6 emergent VT ablation procedures due to AS. The median age was 62 years (range, 52) and 4 patients were men. Three patients had VT at admission, while 2 were admitted with an acute coronary syndrome and developed VT during the hospitalization. Four patients had ischemic heart disease, though only 1 had previous history of VT; the remaining patient presented no structural heart disease. Median left ventricle ejection fraction was 11% (range 30).

All patients had incomplete response to amiodarone, lidocaine or overdrive pacing, before being proposed to catheter ablation. Four patients were on ECMO support before ablation, while 1 was cannulated during the procedure due to hemodynamic instability. Ablation was performed using a retrograde approach in 3 patients, and combined retrograde and transeptal access in 2; one patient had epicardial ablation after unsuccessful endovascular approach. Three patients had left ventricle substrate ablation and the remaining 2 of the right ventricle. No major complications were seen directly related to the procedures.

The median length of stay in intensive care unit was 22 days (range 41 days). Weaning of VA-ECMO was accomplished in all patients. Two patient died during the same hospitalization (one due to uncontrolled arrhythmic events). At a median 23 months (range 31) of follow-up of the surviving patients, two had recurrence of VT but no one had return of AS.

Conclusion

In our sample VT ablation on VA-ECMO support was a safe procedure, with no immediate complications. However, as reported in the literature, a high mortality rate was observed both in-hospital and during follow-up, mostly related to advanced structural heart disease. Also, considerable VT recurrence rates were seen, but with no re-hospitalization. Our experience shows that catheter ablation is a life-saving procedure in otherwise uncontrollable AS and allowed absolute success in weaning VA-ECMO.

Funding Acknowledgement

Type of funding sources: None.

STEMI with mid-range ejection fraction: a group of intermediate risk not to be forgotten

Background

Reduced left ventricular ejection fraction (LVEF) &lt;40% is an important negative prognostic factor in the setting of ST-elevation acute myocardial infarction (STEMI). On the other hand, data concerning mid-range LVEF (mrEF) post-STEMI are scarce. Consequently, recommendations regarding reassessment of LVEF or administration of neurohormonal medication in this group of patients (pts) are also lacking.

Purpose

To assess the current treatment and prognosis of STEMI with mrEF.

Methods

Retrospective study including all consecutive pts hospitalized for STEMI and submitted to primary percutaneous coronary intervention in a Cardiology centre in 2018. Pts were divided into 3 groups according to LVEF assessed before hospital discharge: preserved EF (pEF: LVEF ≥50%), mid-range EF (mrEF: LVEF 40–49%) and reduced EF (rEF: LVEF &lt;40%). We analysed clinical characteristics, treatment, evolution of LVEF post-STEMI and clinical outcomes - death, myocardial infarction (MI) and hospitalization for heart failure (HF) – of the mrEF group and compared it with pEF.

Results

188 pts with a mean age of 61 years were admitted for STEMI in 2018. The majority (58%, n=109) had pEF; 29% (n=55) had mrEF and 13% (n=24) were in the rEF group. Pts in the mrEF group had similar baseline characteristics to the others. However, compared with pEF, culprit-lesion was more often located in left main or left anterior descending arteries (80% vs 35%, p&lt;0.001) and NT-proBNP levels were higher in mrEF pts (2270 vs 881 pg/mL, p&lt;0.001).

At discharge, all mrEF patients were medicated with a renin-angiotensin-aldosterone blocker and 91% with a beta-blocker.

After a median of 8 months, LVEF improved a mean of 4% (± 9%) in the mrEF group. However, in 12.5% LVEF worsened to &lt;40% (vs 0 in the pEF group, p=0.006).

At a median follow-up of 2.6 years, there was an increase in mortality according to the EF group (pEF 4% vs mrEF 13% vs rEF 48%, log-rank: p&lt;0.001 – fig. 1) with a hazard ratio (adjusted for age) of 3.75 (95% CI 1.1–12.8, p=0.035) for mrEF vs pEF. There was also a non-significant tendency to higher rates of the composite endpoint of MI and hospitalization for HF in the mrEF group vs pEF (8.2% vs 2.9%, p=0.213).

Conclusions

This study confirms previous reports of the worse prognosis of STEMI with mrEF and suggests the existence of a continuum of risk of adverse clinical outcomes according to LVEF. Therefore, this group of intermediate risk might also benefit from neurohormonal medication, which is only specifically recommended for rEF in current STEMI guidelines. It also highlights the importance of a closer follow-up (with reassessment of LVEF) of mrEF pts since a non negligeable proportion ultimately progress to rEF and may require additional medical treatment or even an implantable cardioverter defibrillator. Further research with larger samples is required to identify predictors of worsening LVEF and assess the impact of neurohormonal modulation in this population.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier Survival Analysis

The role of coronary collateral circulation in patients presenting with acute left main coronary artery occlusion

Introduction

Acute occlusion of the unprotected left main coronary artery (LMCA) is an uncommon occurrence associated with a dismal prognosis. Whereas the role of early recruited coronary collateral circulation (CC) in prognosis of ST-segment elevation acute myocardial infarction (STEMI) patients is still controversial, it seems to be important in patients with acute LMCA occlusion. This study aimed to evaluate the coronary CC in patients with acute LMCA occlusion and its impact in short and long-term outcomes.

Methods

In a retrospective two-center study, we identified 7630 patients with STEMI or high-risk non-ST segment elevation myocardial infarction who underwent emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analyzed 83 patients who presented with unprotected LMCA acute occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and classified them in 2 groups based on the degree of CC through the right coronary artery as seen in the emergent angiography: patients with no filling of collateral vessels or filling of collateral vessels without any epicardial filling of the occluded vessel [Rentrop class 0–1 (71 patients)]; and patients with partial or complete epicardial filling by collateral vessels [CC Rentrop class 2–3 (12 patients)].

Results

Compared to patients with CC Rentrop 0–1, patients with CC Rentrop 2–3 presented significantly later to medical attention (symptom to coronary angiography time 8.7 vs 4.3 hours, p=0.02). Despite that, patients with CC Rentrop 2–3 had a significantly lower prevalence of cardiogenic shock at admission (16.7 vs 57.7%, p=0.01). During hospitalization, Killip class III-IV presentation (33.3 vs 88.7%, p&lt;0.001) and inotropic/vasopressor therapy use (25.0 vs 69.0%, p=0.01) were less frequent in CC Rentrop 2–3 patients. The CC Rentrop 2–3 group had a significantly lower in-hospital (16.7 vs 53.5%, p=0.02) and 30-day mortality (9.1 vs 52.2%, p=0.01). In patients surviving hospitalization there was no significant difference in 1-year (30.0 vs 19.4%, p=0.48) and 5-year mortality (70.0 vs 77.4%, p=0.68).

Conclusion

A well-developed coronary CC was associated to lower short-term mortality in patients presenting with acute occlusion of the unprotected LMCA. Nevertheless, in patients surviving index-event, there was no difference in the long-term outcomes. Further studies are needed to clarify if clinical approach (eg. early short-term mechanical circulatory support) of patients with CC Rentrop 0–1 should be different from those with CC Rentrop 2–3 in order to improve the outcomes of the former patients.

Funding Acknowledgement

Type of funding sources: None.

The world upside down – after 20 years follow-up of dextro-transposition of the great arteries

Introduction

Congenital Heart Disease (CHD) affects under 1% of newborns and thanks to its prognosis improvement, most patients survive until adulthood. Dextro-transposition of the great arteries (dTGA) is a CHD classically palliated with atrial switch (ATS) procedure and nowadays corrected with an arterial switch (ARS), with better clinical outcomes. Nevertheless, several post-ATS patients remain alive and questions persist regarding their long-term prognosis.

Purpose

To observe a group of dTGA patients followed in an Adult CHD outpatients clinic, access their comorbidities, surgical interventions, complications and clinical outcomes.

Methods

We retrospectively analyzed a group of dTGA patients born between 1974 and 2001. Clinical features were collected and time-to-event statistics were analyzed. Adverse event was defined as at least one of the follows: death, stroke, myocardial infarction or coronary revascularization, arrhythmia and ventricular, valvular or conduct dysfunction.

Results

A total of 80 patients were enrolled with a mean follow-up of 26 years after surgery: 46% were female, median age 27 (19–57) year-old. Concerning other concomitant defects, 25% had ventricular septal defect, 12% pulmonary stenosis, 3% aortic coarctation and 1% single coronary ostium. ATS palliation was performed in 54% of patients (Senning procedure in 95%) and ARS (Jatene procedure) in 45% of patients; median age at procedure was 13 months and 10 days, respectively. During follow-up, almost all patients submitted to ARS remained in sinus rhythm (97%) versus 64% of ATS patients (p=0.037). The latter group had higher incidence of arrythmias (40% vs 3%, p=0.013), mostly atrial flutter or fibrillation (present in 28%), followed by bradyarrhythmia (10%); median time from surgery to first arrhythmic event in these patients was 23 years. Also, systemic ventricle systolic dysfunction (SVSD) and chronotropic incompetence were significantly higher in ATS (41% vs 3%, p&lt;0.001 and 46% vs 9%, p=0.005, respectively); mean time to SVSD was 29 years. In respect to long-term outcomes in ARS, the most frequent complications were moderate to severe aortic regurgitation, pulmonary stenosis and regurgitation, occurring in 21%, 7% and 3%, respectively. Concerning both groups, mean time to first adverse-event was 21 years. Regarding gender and demographic features, there were no differences in time-to-adverse-event, comparing patients living in urban versus rural neighbourhoods and female versus male (Log Rank, p=0.368 and p=0.693). Only one patient died, submitted to ATS, at 46 years-old, from chronic heart failure.

Conclusion

After a long-term free of events, ATS patients experienced more arrhythmic complications and SVSD. ARS complications were anastomosis related. This report highlights the efforts that should be made to identify late complication is this particular population. Of note, no demographic or gender differences were observed.

Funding Acknowledgement

Type of funding sources: None. Gender analysis

Sex disparities in lipid-lowering therapy and dyslipidemia control in a coronary rehabilitation program

Introduction

Lipid control is one of the most important secondary cardiovascular prevention targets. Although cardiovascular disease is the most common cause of death for both genders, several studies have consistently shown that women are less likely to receive guideline-recommended secondary prevention medications after an acute coronary syndrome (ACS).

Purpose

To compare sex disparities in dyslipidemia control in a secondary prevention population with ACS in light of the ESC Dyslipidemia Guidelines.

Methods

We retrospectively analysed all patients who participated in a Coronary Rehabilitation Program (CRP) after an ACS from January 2011 to October 2019. Clinical data was collected at presentation and during 12 months follow-up. Doses of atorvastatin ≥40 mg, rosuvastatin ≥20 mg or a combination of a statin and ezetimibe were considered high-intensity LDL-lowering therapy (HIT).

Results

Of a total of 881 patients enrolled, mean age 55.0±10.0 year-old, 16.1% were female. At baseline there were no differences respecting clinical features between genders. At admission, 51.4% of patients had ST-elevation myocardial infarction and, concerning to cardiovascular risk factors, 63% patients had dyslipidemia, 46% had hypertension, 19% were diabetic, 76% were smokers or previous smokers, 27% had family history of coronary disease and 12% had previous coronary disease (ACS or &gt;50% coronary artery stenosis). At hospital admission, females and males had similar mean LDL-levels [120.7 vs 118.1 mg/dL, t(708)=0.691, p=0.496]. The vast majority of patients from both genders were prescribed with statins on hospital discharge (99.5%) and maintain it during follow-up (99.3%). Female patients received more HIT during follow-up (67.8% vs 53.9% at baseline, p=0.015; 75.6% vs 59.0% after CRP, p=0.003; and 79.8% vs 65.1% at 1-year-follow-up, p=0.007). During follow-up, at the end of the CRP (about 3 months after event), male patients exhibit a better control of LDL [82.0 vs 75.6 mg/dL, t(597)=2.4, p=0.016)] with 12.8% vs 16.4% below 55 mg/dL and 29.8% vs 44.5% below 70 mg/dL (p=0.008). At 1-year follow-up, both genders exhibited similar LDL-control due to a worsening control of the male population (81.9 vs 80.6 mg/dL, t(540)=0.52, p=0.605). Only 13.3% of females had LDL below 55 mg/dL (vs 12.9%, p=0.921) and 32.5% below 70 mg/dL (vs 37.0%, p=0.432).

Conclusion

This real-life study showed that guideline recommended LDL target is not achieved in the majority of patients, even under a structured CRP. Unlike other reports, there were more women receiving potent anti-dyslipidemic therapy. Nevertheless, women showed a poor control of LDL-concentration after three months of ACS and a similar control after 1-year; this highlights the uncertainties concerning the efficacy of lipid-lowering therapy in women, an underrepresented population in clinical trials.

Funding Acknowledgement

Type of funding sources: None.

HER2 positive breast cancer: is there a preventive role of cardioprotective drugs?

Introduction

In patients with breast cancer, anti-HER2-targeted therapies (AHT) are highly associated with cardiotoxicity (CT), being the main reason for treatment interruption in patients receiving adjuvant trastuzumab. Guidelines recommend regular left ventricular ejection fraction (LVEF) assessments and CT's management with cardioprotective drugs (CPD). However, while secondary prevention has already entered clinical practice, primary prevention is still in the research domain. Our aim was to evaluate risk of CT and the role of CPD in a subset of breast cancer patients treated with AHT.

Methods

We retrospectively analyzed a population of breast cancer female patients treated with AHT referred to Cardio-oncology consultation at a tertiary center from January 2017 to March 2020. All patients were evaluated with echocardiogram before treatment initiation and at least at 3, 6, 9 and 12-months. CT was defined as LVEF under 50% or decline of at least 10% in LVEF during follow-up. As CPD we considered renin-angiotensin-aldosterone system inhibitors and beta-blockers.

Results

A total of 85 patients were included with mean age of 52.4±10.2 year-old. Concerning cardiovascular risk factors 11.8% had diabetes, 32.9% dyslipidaemia, 29.4% hypertension and 22.4% were smokers or previous smokers; most patients had a high or very-high CT risk score (98.8% with score ≥5). Besides AHT, 68.2% and 80% were also on anthracyclines and radiotherapy, respectively. Patients were followed for a median follow-up of 16 months. At baseline, mean high sensitivity troponin I was 3.9 ng/L, mean LVEF was 63.1% and mean global longitudinal strain was −19.7, with all patients having normal cardiac function. During follow-up, 15.7% developed CT with a higher prevalence in patients concomitantly on anthracyclines (19.6% vs 7.4%, p=0.151). CPD was initiated or titrated in 84.6% of patients and 30.8% needed to suspend AHT; overall 92.3% of CT patients recovered. Unlike AHT suspension, CPD initiation after CT was associated with a higher rate of cardiac function recovery (100.0% vs 50.0%, p=0.020). When comparing patients already medicated with CPD before cancer treatment (41.7%) to those naïve of CPD, the first group presented a significative lower incidence of CT [2.9% vs 25.0%, p=0.006, OR=0.09 (95% CI 0.01 – 0.72)]. When analysed all sample (with or without CT), patients already on CPD also presented a higher LVEF at 6 months follow-up (62.5% vs 59.2%, t(69)=−2.4, p=0.017 at 6 months), despite a non-significative lower LVEF at baseline (62.3% vs 63.6%, p=0.139). Medication with statins before chemotherapy didn't reduce the risk of CT.

Conclusion

Pre-treatment with CPD was significantly associated with a lower prevalence of CT and a higher LVEF at 6-months follow-up. CPD initiation after CT was associated with cardiac function recovery. These results highlights the importance of cardiac evaluation in HER2+ patients and strengthen the primary prevention field in these patients.

Funding Acknowledgement

Type of funding sources: None.

Emergent coronary angiography in a 90-plus population – outcomes at 5-years follow-up

Introduction

Elderly people represents a vulnerable and increasing population presenting with acute coronary syndrome (ACS). Several data suggest the benefit of an early revascularization in ST-elevation (STE)-ACS or non-STE-ACS with positive troponin. However questions persist considering the unavoidable adverse prognosis, patient's functional and cognitive status, comorbidities and preferences.

Purpose

To evaluate a group of very old patients who underwent emergent coronary angiography (CA).

Methods

We retrospectively analyzed a group of very old patients (≥90 year-old) who underwent emergent CA from January 2008 to September 2020. Clinical features were collected; survival and MACE were compared with an aged-matched control population with ACS not submitted to emergent CA. MACE was defined as a composite of all-cause death, ischemic stroke, ACS or hospitalization for acute heart failure.

Results

A total of 34 patients were enrolled: 56% female, with mean age 92±2 year-old. As for the cardiovascular risk factors, 88% had hypertension, 49% dyslipidaemia, 12% diabetes and 15% were previous smokers. Concerning other comorbidities, 27% had atrial fibrillation, 21% chronic kidney disease, 12% had cerebrovascular disease and median modified Rankin scale for neurologic disability was 2. Almost all patients had STE-ACS, 68% anterior and 29% inferior, inferolateral or inferoposterior infarction; 3% had infarction of indeterminate location. In CA, 65% had multivessel disease, 14% of them involving left main coronary artery; coronary intervention was performed in 71% of patients (mostly stent implantation), the remaining 29% had no invasive treatment. Concerning to clinical status, median troponin was 131 517 ng/L and median BNP 496 pg/mL; 36% of patients evolved in Killip class III or IV and only 32% of patients had normal left ventricular systolic function. Regarding mortality, 38% of patients died in the index-event versus 25% in the aged-matched control group (p=0.319). During five years of follow-up, there was no significant difference in mortality between the two groups (Log Rank, p=0.403) and more than 50% of patients died in two years. Comparing MACE occurrence, both groups were similar (Log Rank, p=0,662), with more than 80% having at least one event in five years.

Conclusion

Very old patients submitted to emergent CA had a high percentage of multivessel disease, left ventricular dysfunction and mortality during hospitalization. Compared to an aged-matched control group, they showed no survival or MACE benefit of emergent CA strategy during a five-years follow-up. Although this is a small study, these findings highlight the efforts that should be made to optimize care in this vulnerable population, under-represented in the clinical trials. Special caution should be given to avoid possible unnecessary discomfort in this setting.

Funding Acknowledgement

Type of funding sources: None. MACE analysis

P14.81 Brain metastases of lung adenocarcinoma - Clinicopathological profile and outcomes of a single-centre

BACKGROUND

Brain metastases (BM) in patients with non-small cell lung cancer (NSCLC) are considered a major determinant of overall survival (OS). Historically, surgical resection (SR), stereotactic radiosurgery (SRS), or/and whole-brain radiation therapy (WBRT) followed by chemotherapy has been the treatment modalities for BM from lung adenocarcinoma. Recent insights into the biology of adenocarcinoma have led to a wealth of novel therapies, including tyrosine kinase inhibitors (TKIs). Here, we review the pattern of brain metastasis in lung adenocarcinoma patients and management strategies in our centre.

MATERIAL AND METHODS

We performed a single-centre retrospective analysis of patients with lung adenocarcinoma and BM between 2017–2020. Data were collected from electronic medical records, including clinical and histopathological features and outcomes. Survival curves were estimated with the Kaplan-Meier method and compared using the log-rank test.

RESULTS

We identified 29 patients, 65% male, median age 65 years (range 38–84); 55% ECOG PS 0–1; 59% smokers; 55% had extracranial metastases (ECM) and 66% were symptomatic, 24% were EGFR mutated, the frequency of ALK rearrangement was 14%, in 14% the molecular testing was not performed. We treated 59% with WBRT, 12% with SRS, 11% with SR+WBRT and 4% with SR+SRS; 14% were referred for palliative care. Clinical deterioration during local therapy was observed in 32% of the patients and, consequently, they haven’t undergone systemic treatment. After local treatment, 26% received chemotherapy (CT) and 28% received TKIs therapy. Median OS (mOS) was 11.3 months (95% CI 2.4–20.3) for the CT subgroup; mOS for the TKIs subgroup was not reached, but the 1-year survival rate was 67%.

CONCLUSION

BM confers a worse prognosis in lung adenocarcinoma patients. Currently, targeted systemic treatments in patients with driver mutations improve survival and have demonstrated efficacy in lung adenocarcinoma metastatic to the brain. Further research is needed to find better treatments for BM in NSCLC patients with no driver mutations.

Spinal cord ischaemic injury while playing in a playground

Spinal cord ischaemia is a rare condition in children in which imaging diagnosis can be difficult and treatment guidelines are not well established. We describe a case of a previously healthy 13-year-old girl admitted to the emergency department with an acute flaccid paralysis of the lower limbs, abdominal and dorsal pain, and bladder dysfunction. A few hours earlier, she had been playing on a swing with hyperextension and an arched back position. Spinal cord MRI was normal in the first hours, but ischaemic signs were described in a second examination performed some hours later. We discuss the extensive investigation for differential diagnosis and the management of this case.

Imaging mass spectrometry: a new way to distinguish dermal contact from administration of cocaine, using a single fingerprint

Here we show a new and significant application area for mass spectrometry imaging. The potential for fingerprints to reveal drug use has been widely reported, with potential applications in forensics and workplace drug testing. However, one unsolved issue is the inability to distinguish between drug administration and contamination by contact. Previous work using bulk mass spectrometry analysis has shown that this distinction can only be definitively made if the hands are washed prior to sample collection. Here, we illustrate how three mass spectrometry imaging approaches, desorption electrospray ionisation (DESI), matrix assisted laser desorption ionisation (MALDI) and time of flight secondary ion mass spectrometry (ToF-SIMS) can be used to visualise fingerprints at different pixel sizes, ranging from the whole fingerprint down to the pore structure. We show how each of these magnification scales can be used to distinguish between cocaine use and contact. We also demonstrate the first application of water cluster SIMS to a fingerprint sample, which was the sole method tested here that was capable of detecting excreted drug metabolites in fingerprints, while providing spatial resolution sufficient to resolve individual pore structure. We show that after administration of cocaine, lipids and salts in the fingerprint ridges spatially correlate with the cocaine metabolite, benzoylecgonine. In contrast after contact, we have observed that cocaine and its metabolite show a poor spatial correlation with the flow of the ridges.

OP0264-HPR “I LITERALLY CONVINCED MYSELF I WAS GOING TO CATCH IT AND DIE”: LIVED EXPERIENCES OF THE COVID-19 PANDEMIC BY PEOPLE WITH RHEUMATIC DISEASES FROM FOUR EUROPEAN COUNTRIES

Background:

The COVID-19 pandemic has resulted in unforeseen challenges for humanity, taking a significant toll, especially the immune-suppressed individuals. In this regard, the health and general well-being of people with rheumatic diseases, the great majority users of immunosuppressives, have been at stake.

Objectives:

To explore the impact of the COVID-19 pandemic on people with rheumatic diseases on immunosuppression during the first wave, concerning a) (self-)management of their disease; b) interaction with the health care team; c) emotional well-being and d) overall health.

Methods:

A qualitative study was conducted following a phenomenological approach. Adults (>18 years) with a rheumatic disease from four European countries (Cyprus, England, Greece, Portugal). Patients were recruited through patient’s associations and social media and were invited to participate in semi-structured, audio-recorded interview or focus groups, between July - August 2020. Following a pilot study the information provided was transcribed verbatim, anonymized and translated into English where necessary. An inductive approach was adopted to carry out a thematic framework analysis with the assistance of ATLAS.ti to identify key themes and subthemes. Data validation strategies were employed, and Ethical approval and informed consent were obtained.

Results:

Participants were 24 patients (21 women, age range 33 to 74 years) divided by 7 focus-groups and 1 individual interview. Most frequent diagnoses were rheumatoid arthritis (n=7), lupus (n=4), juvenile idiopathic arthritis (n=3).

Three key themes with 3-7 subthemes were identified within the analytical framework, centred around the impact of the Covid-19 on patients’ lives (Figure 1): i) individual person (e.g. fear for myself and family, social isolation and lack of personal freedom, more time with family) ii) health settings (e.g. (un)clear information about risks of contamination, fear or risk of shortages of medication, remote consultations), and iii) work and community (e.g. persistent stress due to mass media exposure, lack of awareness by others about patients’ rheumatic disease and its disclosure, hope and suspicion about new vaccine development: “I hear that they will ask vulnerable groups to have the vaccine first (...) Why is that? we will be again the innocent victims”). Findings were similar across countries, except for spirituality (i.e. the pandemic as “the hand of God”), a coping subtheme particular to Portugal. These main themes resonated well with the social ecological model and Walsh’s Family Resilience Process [1,2].

Conclusion:

When experiencing a significant life-event people require some time to process the different lived experiences. This study provides insights on how patients from four countries coped with the new challenges. Such insights are invaluable for health care providers and policy makers, in guiding more meaningful support tailored to individual needs, especially at times of crisis. The study highlights the impact of COVID-19 on the lives of people with rheumatic disease. A follow-up study is currently underway to examine the effect of subsequent waves of the pandemic.

References:

[1]Golden SD, Earp JA. Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions. Health Educ Behav. 2012;39(3):364-72. doi: 10.1177/1090198111418634.

[2]Walsh F. Family resilience: a framework for clinical practice. Fam Process. 2003;42(1):1-18. doi: 10.1111/j.1545-5300.2003.00001.

Acknowledgements:

We thank the participants of this study.

Disclosure of Interests:

None declared

Cold Urticaria. Characterizing the population from an urticaria outpatient clinic

INTRODUCTION

Cold Urticaria (ColdU) is a type of chronic inducible urticaria (CIndU) where recurrent pruritic wheals and/or angioedema occur after exposure to cold stimulus. Although it usually only affects exposed areas, systemic reactions can occur in severe cases. In this study, we seek to characterize the ColdU cases within our Centre's population of patients.

MATERIAL AND METHODS

Retrospective study based on clinical files of patients diagnosed with ColdU followed in an urticaria outpatient clinic in Portugal prior to October 2020.

RESULTS

We included 52 patients total (40 women) with median age of 35 years, 19 patients with symptom onset before 18 years-old. ColdU was classified as acquired in all patients. Cold provocation tests were negative in 9 patients and these were classified as atypical ColdU. No significant differences were found between those with pediatric or adult onset of disease. Most of the patients had a localized form of the disease (52%). Despite not being statistically significant, it was found that patient's temperature threshold, assessed with TempTest® 4.0, was higher and stimulation time was shorter in more severe groups. All patients were treated with non-sedating antihistamines (daily or on-demand), finding that those controlled with standard dosages had lower temperature thresholds than those needing higher dosages (p < 0.01). One patient was under treatment with omalizumab.

CONCLUSION

ColdU is an heterogenous disease that can have life-threatening event consequences. Cold provocation tests and threshold assessment can be an important tool in the management treatment and in identifying severity groups.

Rapid atrial fibrillation increases cardiac biomarkers: decision to perform coronary angiography based on novel high-sensitivity Troponin I peak

Funding Acknowledgements

Type of funding sources: None.

Background

Since January 2018 the availability of high sensitivity Troponin I (hsTnI) has improved ischemia diagnosis. In patients with rapid atrial fibrillation (AF), the decision to undergo coronary angiography is usually due to elevated cardiac biomarkers. However, evidence to support the rentability of this approach is sparse.

Purpose

Evaluate if hsTnI in patients with rapid AF and elevated cardiac biomarkers has a good discriminative power to predict a positive coronary angiography.

Methods

We retrospectively studied consecutive patients admitted to the emergency department (ED) between January 2018 and December 2019 with rapid AF that underwent coronary angiography and had multiple hsTnI values obtained. We analysed risk factors, initial and peak hsTnI, time from ED admission to peak hsTnI and ST-T segment abnormalities (ST depression and/or T wave inversion). We evaluated the presence of significant coronary artery stenosis with the need of revascularization at coronary angiography. Univariable and multivariable analysis was performed to obtain the Odds Ratio (OR, 95% CI, p-value) for significant coronary artery disease (CAD).

Receiver operator characteristics (ROC) curve and area under the curve (AUC) were obtained to determine the discriminative power of peak hsTnI as predictor of a positive coronary angiography. Optimal cut-point value was obtained (Youden index) and patients were divided according to this value.

Results

From 1407 patients admitted to the ED with rapid AF, 30 patients, 60% male, median age 74 (IQR 61.25-80.75) years, were submitted to coronary angiography. Significant coronary artery stenosis was present in 17 (57%) patients.

Age, ST-T segment abnormalities and peak hsTnI were predictors of significant CAD, respectively 1.203, 1.064-1.361, 0.003; 25.00, 3.522-177.477, 0.001; and 1.000, 1.000-1.001, 0.015.

Optimal cut-point value for predicting the presence of significant coronary artery stenosis at coronary angiography was a peak hsTnI of 359 pg/mL (AUC 0.869, p-value 0.001, 95% CI 0.742-0.995). The two groups with hsTnI &lt; 359 and hsTnI &gt;359 differed in age and ST-T segment abnormalities (see Table).

After adjustment, peak hsTnI &gt;359 pg/mL was the only independent predictor of significant CAD (23.894, 1.310-435.669, 0.032).

Conclusion

In this group of patients with rapid AF, peak hsTnI &gt;359 pg/mL was the only independent predictor of significant coronary artery disease. Therefore, those patients should undergo coronary angiography. Abstract Figure.