Characterization and prognostic impact of ACTBL2-positive tumor-infiltrating leukocytes in epithelial ovarian cancer

Actin beta-like 2 (ACTBL2) was recently identified as a new mediator of migration in ovarian cancer cells. Yet, its impact on tumor-infiltrating and thus migrating leukocytes (TILs) remains to date unknown. This study characterizes the subset of ACTBL2-expressing TILs in epithelial ovarian cancer (EOC) and elucidates their prognostic influence on the overall survival of EOC patients with special regard to different histological subtypes. Comprehensive immunohistochemical analyses of Tissue-Microarrays of 156 ovarian cancer patients revealed, that a tumor infiltration by ACTBL2-positive leukocytes was significantly associated with an improved overall survival (OS) (61.2 vs. 34.4 months; p = 0.006) and was identified as an independent prognostic factor (HR = 0.556; p = 0.038). This significant survival benefit was particularly evident in patients with low-grade serous carcinoma (OS: median not reached vs. 15.6 months, p < 0.001; HR = 0.058, p = 0.018). In the present cohort, ACTBL2-positive TILs were mainly composed of CD44-positive cytotoxic T-cells (CD8+) and macrophages (CD68+), as depicted by double-immunofluorescence and various immunohistochemical serial staining. Our results provide significant evidence of the prognostic impact and cellular composition of ACTBL2-expressing TILs in EOC. Complementary studies are required to analyze the underlying molecular mechanisms of ACTBL2 as a marker for activated migrating leukocytes and to further characterize its immunological impact on ovarian carcinogenesis.

The critical isthmus of left atrial anterior wall flutter is mostly circumscribed into a small area immediately behind the aortic root. Implications for catheter ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial flutters (LAFL) are typically observed in patients with previous ablation lines or surgery in the left atrium (LA). Less frequently, scar-related left atrial anterior wall (LAAW) flutters may occur. Although the presence of low-voltage areas (LVAs, a surrogate of scar) in the LA is considered an arrhythmogenic substrate and a marker of atrial cardiomyopathy, the pathophysiologic factors responsible for its formation remain unclear. We hypothesized that compression of the LAAW by the aortic root could be responsible of LVAs found in the LAAW, and therefore, be the substrate for the development of LAAW flutter.

Purpose

We aimed to describe: 1) the relationship between the aortic root and the presence of LVAs in the LAAW, which is the substrate for reentry; and 2) the clinical and electrophysiological characteristics of LAAW atrial flutter.

Methods

Consecutive patients referred for LAFL ablation between April 2019 and September 2022 in a single center were retrospectively collected. Among 55 patients with LAFL, 10 (18%) demonstrated a macroreentrant circuit with a critical isthmus identified in the LAAW, in the absence of previous ablation lines or surgery, and were included in the analysis. Previous pulmonary vein isolation (PVI) was not an exclusion criterion. All patients underwent a multidetector computerized tomography (MDCT) prior to the procedure and the images were analyzed using ADAS 3DTM imaging platform. Activation mapping was performed in all patients using a multielectrode mapping catheter and CARTO 3 navigation system.

Results

9 of 10 patients were male (mean age 74,3 ± 6,3 years). LA enlargement was present in all patients (48,3 ± 4,7 mm) and the mean aortic root diameter was 34,8 ± 3,4 mm. The mean LAAW flutter cycle length was 293,4 ± 68,3 ms. In 9 of the patients (90%), the LAAW flutter critical isthmus was just behind the aortic root, separated by &lt; 1 mm according to the LA-aortic root fingerprinted isodistance map (mean fingerprinted isodistance area was 5,8 ± 2,5 cm2). The remaining patient had the critical isthmus just below the aortic root, between the area in contact with the latter and the mitral annulus. Furthermore, in all cases, the critical isthmus was immersed in LVAs. All but 1 LAAW flutter terminated during radiofrequency (RF) energy applications and rendered it non-inducible. After a median follow-up of 13,6 months (IQ range 5,3-21,6), 7 patients (70%) remained without recurrences.

Conclusion

In patients with LAAW atrial flutter, the presence of LVAs and the critical isthmus of the tachycardia are mostly circumscribed into small areas immediately behind the aortic root. Knowledge of this close relationship and the use of the isodistance map could be useful when mapping and ablating LAAW flutter, helping to straightforward the ablation procedure.

"Ten euros now" temporal discounting in Huntington disease

BACKGROUND

When making decisions, one often faces a trade-off between immediate and long-term rewards. In these situations, people may prefer immediate over later rewards, even if immediate rewards are smaller than later ones; a phenomenon known as temporal discounting. In this study, we, for the first time, assessed temporal discounting in three populations: participants with manifest Huntington disease (HD), participants with premanifest HD, and control participants.

METHODS

Using the temporal discounting task, we invited participants to choose between small immediate amount of money vs. delayed, but larger amount of money (e.g., "Which do you prefer: you get 10 euros right now or 50 euros in a month?"). We also measured inhibition in order to test if it impacts discounting performance.

RESULTS

Analysis demonstrated higher temporal discounting (i.e., a preference for the immediate rewards) in participants with manifest HD compared to those with premanifest HD or control participants, but no significant differences were observed in participants with premanifest HD and control participants. Analysis also demonstrated significant correlations between temporal discounting and scores on an inhibition test in participants with manifest HD, but not in those with premanifest HD or in control participants.

DISCUSSION

We suggest that, when making decisions, patients with manifest HD may have difficulties with suppressing the temptation of smaller, but immediate, rewards.

Implementation of a clinical trial recruitment support system based on fast healthcare interoperability resources (FHIR) in a cardiology department

Background

Clinical Trial Recruitment Support Systems can booster patient inclusion of clinical trials by automatically analyzing eligibility criteria based on electronic health records. However, missing interoperability has hindered introduction of those systems on a broader scale.

Purpose

Our aim was to develop a recruitment support system based on FHIR R4 and evaluate its usage and features in a cardiology department.

Methods/Implementation

Clinical conditions, anamnesis, examinations, allergies, medication, laboratory data and echocardiography results were imported as FHIR resources. Trial study nurses and physicians were enabled to add new and edit trial information and input inclusion and exclusion criteria using a web-browser user interface in the hospital intranet. All information were recorded on the server side as the FHIR resources “ResearchStudy” and “Group”. Eligibility criteria linked by the logical operation “OR” were represented by using multiple FHIR Group resources for enrollment. On the client side, eligibility criteria were transformed to a tree-like structure (see Figure 1). Upon user demand, all hospitalized and ambulatory patients in the cardiology department were instantly screened for trial eligibility using the FHIR eligibility criteria on the existing patients' FHIR resources. Furthermore, study personal was able to manually edit trial status (i.e. ineligible, on-study, ...) of patients, which was implemented using the FHIR resource “ResearchSubject”.

Results

This implementation of a CTRSS based on FHIR R4 was evaluated in clinical practice: Beginning from 1st April 2021 the application was used as an additional patient screening tool for the four trials CLOSURE-AF, FAIR-HF2, SPRIRIT-HF and TORCH-PLUS of the German Centre for Cardiovascular Research. As the COVID-19 pandemic is prohibiting any proper comparison of patient inclusion rates, efficacy of the recruitment support system was tested by comparing the numbers of patients identified by the recruitment support system and enrolled in a trial to the actual number of enrolled patients irrespective of the screening method from 1st April 2021 to 23rd November 2021. The system was able to identify 52 of 55 patients included in those four clinical trials.

Conclusion

Use of FHIR for defining eligibility criteria of clinical trials may facilitate interoperability and allow automatic screening for eligible patients at multiple sites of different healthcare providers in the future. Upcoming changes in FHIR should allow easier description of “OR”-linked eligibility criteria.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft

Suture-based vs. pure plug-based vascular closure devices for VA-ECMO decannulation

Background

VA-ECMO is a valuable treatment option for patients in cardiogenic shock, but complications during decannulation may worsen the overall outcome. To date, no larger study has ever compared suture-based to pure plug-based vessel closure devices for VA-ECMO decannulation.

Purpose

The aim of the study was to compare the efficacy and safety of suture-based to pure plug-based vascular closure devices for veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation for patients with cardiogenic shock.

Methods

In this retrospective study, the outcome of 33 patients with suture-based closure devices implanted between 02/2019 to 05/2020 were compared to 38 patients with plug-based closured device implanted between 06/2020 to 11/2021.

Results

Closure device success rate was 88% in the suture-based group versus 97% in the plug-based group (Figure 1, p=0.27). Median number of devices used was two for patients with suture-based closure device and 1 for patients with plug-based closure device (p&lt;0.01). Severe bleeding was more frequent in the suture-based (21%) compared to the plug-based group (3%) (Figure 2, p=0.04). Ischemic complications occurred in 6% with suture-based and 5% with plug-based device (p=1.00). Pseudoaneurysm formation was detected in 3% in both groups (p=1.00). Application of the femoral compression system was required in 27% of patient with suture-based closure device and 11% of patients with plug-based closure device (p=0.13). No switch to open vascular surgery due to closure device failure occurred in both groups.

Conclusions

Based on our retrospective analysis, we propose that plug-based vascular closure should be the preferred option for VA-ECMO decannulation. This hypothesis should be further tested in a randomized trial.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft

Propofol versus midazolam sedation in patients with cardiogenic shock – an observational propensity-matched study

Introduction

Benzodiazepines are recommended as first line sedative agent in ventilated cardiogenic shock patients, although data regarding the optimal sedation strategy are sparse. On our cardiac ICU, midazolam was used as first line sedation until 2016, whereas soybean oil formulated propofol was used preferentially since 2017.

Purpose

The aim of this study was to investigate the hemodynamic effects of propofol versus midazolam sedation in our cardiogenic shock registry.

Methods

Mechanically ventilated patients suffering from cardiogenic shock were retrospectively enrolled from a cardiogenic shock registry. 174 patients treated predominantly with propofol were matched by propensity-score to 174 patients treated predominantly with midazolam.

Results

Catecholamine doses were similar on admission but significantly lower in the propofol group on days 1–4 of ICU stay (Figure 1). Mortality rate was 38% in the propofol and 52% in the midazolam group after 30 days (p=0.002, Figure 2). Rate of ≥BARC3 bleeding was significantly lower in the propofol group compared to the midazolam group (p=0.008). Age, gender, first lactate measured on ICU, first GFR measured on ICU, cardiac arrest, coaxial left ventricular assist device and sedation with midazolam were significantly associated with ICU mortality.

Conclusion

In this observational cohort study, sedation with propofol in comparison to midazolam was linked to a reduced dose of catecholamines, decreased mortality and bleeding rates for patients with cardiogenic shock. Based on this study and in contrast to current recommendations, propofol should be given consideration for sedation in cardiogenic shock patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Deutsche Forschungsgemeinschaft

Multidetector computed tomography identification of previous ablation lines: insights for left atrial flutter ablation

Funding Acknowledgements

Type of funding sources: None.

Background

Left atrial flutter (LAFL) frequently occurs in patients with history of previous left atrial (LA) ablation. LAFL ablation is still considered a challenging and time-consuming procedure (1). Conduction gaps on ablation lines are frequently due to non-transmural or non-contiguous lesions. It was recently demonstrated that aiding AF ablation procedures with the integration of multidetector computed tomography (MDCT)-derived left atrial wall thickness (LAWT) maps into the navigation system allowed decreasing radiofrequency (RF) delivery, fluoroscopy, and procedure time while obtaining a high rate of first-pass isolation (2).

Purpose

We hypothesized that MDCT-derived 3D-LAWT map could be useful to aid LAFL ablation procedure in patients with previous LA ablation lines.

Methods

Consecutive patients with history of previous LA ablation who underwent LAFL ablation were prospectively enrolled from a single referral center. LAWT three-dimensional maps were obtained from MDCT and integrated into the navigation system. LAWT information was used to focus mapping in the areas of the probable crucial isthmus: the presence of previous ablation lines was searched at the level of linear segments with reduced parietal thickness at the LAWT-maps (LAWT &lt;1mm), while the search for conduction gaps was started at the level of the thicker areas of these lines. Conduction gap was defined as the presence of peak-to-peak bipolar potentials &gt; 0.5 mV at the level of the previous ablation line or as the presence during arrhythmia of a LAT delay &lt;30 ms between contiguous points lying in the same axial plane at the two sides of the line. Ablation was performed transecting the crucial isthmus with the documentation of bidirectional block; ablation first-attempt was guided by color-coded maps by connecting the parts of identified previous ablation lines with reduced LAWT. Finally, RF delivery was adapted to the local LAWT.

Results

Five patients [4 (80%) male, age 62 years (57-73)] were included. LAWT-aided LAFL ablation procedures had a median procedure time of 78 minutes (75-114) and a RF time of 5.9 minutes (4.7-8.5); fluoroscopy time was 3.2 minutes (1.5-3.6) with a fluoroscopy dose of 6.1 Gy*cm2 (2.8-8.2). Mean wall thickness of the gap zone was significantly higher with respect to the thickness of the zones of previous ablation lines (1.8 ± 0.5 mm vs. 1.0 ± 0.4 mm, p=0.047). All patients presented sinus rhythm at the end of the procedure and no acute complication occurred. No patient reported arrhythmic recurrence at 1-year follow-up (Figure 2).

Conclusions

LAWT-aided approach for LAFL ablation can facilitate identifying the wall thinning produced by the previous RF ablation line and the gap (seen as relative wall thickening) acting as the isthmus for the reentry circuit. This, in turn might help analysis of reentry circuits and increase procedure efficacy and efficiency. Further data are needed to reproduce these findings in a larger study cohort.

Personalized persistent atrial fibrillation ablation guided by left atrial wall thickness: a multicenter study

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) has been proven to be effective in treating persistent atrial fibrillation (PeAF), although long-term ablation outcomes have been significantly less satisfactory than in paroxysmal AF (1). A recent personalized PVI approach, aiming for contiguous lesions with ablation index (AI) titration according to the local left atrial wall thickness (LAWT) as per multidetector cardiac tomography (MDCT), has demonstrated to achieve an arrhythmia-free survival &gt; 95% at 12 months in patients with paroxysmal AF (2).

Purpose

We sought to investigate the safety and clinical outcomes of this personalized PVI approach guided by LAWT in patients with PeAF.

Methods

Consecutive patients referred for PeAF first ablation were prospectively enrolled from three referral centers. PeAF was defined in the presence of at least one AF episode sustained beyond 7 days. LAWT three-dimensional maps were obtained from MDCT and integrated into the navigation system. LAWT was categorized into 1 mm layers and AI was titrated to the LAWT. The ablation line was personalized to avoid thicker regions (Figure 1) while encircling PV antrum. Follow-up was scheduled at 1, 3, 6, and every 12-months thereafter.

Results

One hundred twenty-seven patients [89 (70.6%) male, age 64 ± 10 years] were included. 68 (60.7%) patients were hypertensive, 10 (18%) patients suffered of type 2 diabetes, and mean CHA2DS2-VASc score was 2.3 ± 2.1. Mean procedure time was 61 ± 20 minutes and mean fluoroscopy time was 1.3 ± 2.2 minutes. Radiofrequency (RF) time was 9.0 ± 2.3 minutes for the right pulmonary veins with a first-pass isolation in 109 (85.8%) patients and 7.6 ± 1.9 minutes for the left pulmonary veins with first-pass in 110 (86.6%). No major complication occurred. The rate of survival free from AF recurrences at a mean follow-up of 12 ± 6 months was 82% (Figure 2).

Conclusions

Personalized Persistent AF ablation by wide circle PV isolation guided by LAWT, proved to be safe and highly efficient, requiring a low amount of RF delivery, procedure time, and fluoroscopy use, while obtaining a high rate of first-pass isolation and of freedom from AF recurrences.

A novel weighted hybrid clinical and electrocardiographic score to predict the origin of outflow tract ventricular arrhythmias: a multicenter study

Funding Acknowledgements

Type of funding sources: None.

Background

To correctly predict the outflow tract ventricular arrhythmia (OTVA) site of origin (SOO) before the ablation is still a procedural major step, having important implications for correct patient counseling, ablation planning, and periprocedural complication evaluation. Although multiple ECG criteria have been proposed for predicting OTVA SOO, their accuracy and usefulness are still limited as recently (1).

Purpose

The present study sought to prospectively evaluate the accuracy of a previously published Hybrid Score (HS) for prediction of OTVAs with LVOT origin. Besides, multiple ECG measurements of patients with V3 precordial transition (V3PT) OTVA were analyzed to identify potential variables useful to improve the accuracy of the HS (2).

Methods

Consecutive patients (n=105) referred for OTVA ablation were prospectively enrolled from three referral centers. Vascular access and first-mapped ventricle were decided based on the previously published HS, which includes ECG (R/S precordial transition) and clinical information (age, hypertension, and gender). Surface ECGs during the OTVA were analyzed by two independent electrophysiologists to compare the discriminative performance of HS and previous published ECG-alone criteria, to assess their inter-observer variability and to identify potential variables useful to improve the proposed model.

Results

Of the 105 VAs, 70.5% had an RVOT origin and 29.5% an LVOT origin. HS achieved a correct prediction in 90% patients. This rate dropped to 75% in the subgroup of patients with V3PT OTVA. The correct prediction rate of the other ECG-alone criteria in the whole population ranged from 74 to 82% and from 41 to 76% in V3PT patients, and their Cohen’s Kappa coefficient for inter-observer variability assessment ranged from 0.63 to 0.81. R-wave amplitude in V3 was the best ECG parameter for discriminating LVOT origin in V3PT patients. When this parameter was incorporated in the novel Weighted Hybrid Score (WHS) (Figure 1), it correctly classified 99 (94.2%) patients (90% sensitivity, 96% specificity, AUC: 0.97). The WHS discriminatory capacity was maintained in V3PT subgroup, (87% sensitivity, 91% specificity AUC: 0.95). WHS showed a Cohen’s kappa coefficient of 0,82. Finally, WHS was validated in an additional population of 97 patients with OTVAs referred for catheter ablation from three additional external centers; in this testing sample the WHS correctly predicted the SOO in 90% patients and proved to have 89% sensitivity and 90% specificity (AUC: 0.94) for a score ≥2 to predict a LVOT origin.

Conclusions

The novel simple-to-use WHS proved to accurately anticipate the PVC’s SOO and can be introduced in clinical practice for choosing the first chamber to map.

Prospective evaluation of a hybrid clinical and electrocardiographic algorithm to predict the origin of outflow tract PVCs. A prospective multicenter study

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): Beca de la Asociación del Ritmo Cardiaco para Formación en Investigación Post-Residencia en centros españoles.

Background

To predict the premature ventricular complex (PVC) site of origin (SOO) before the ablation procedure has important implications. 12 lead ECG information as well clinical characteristics are related with the PVC-SOO, but there is no prospective data validation.

Purpose

This prospective multicenter study sought to analyze the applicability and accuracy of a simple hybrid algorithm that includes electrocardiographic and clinical information in a consecutive patient population with outflow tract (OT) PVCs undergoing catheter ablation.

Methods

Consecutive patients with frequent OT-PVCs and indication for catheter ablation were prospectively included in 4 centers. The vascular access (femoral vein vs femoral artery) and the first outflow tract to be mapped were decided based on a two-steps hybrid algorithm (see Figure 1) including ECG information [R/S PVC precordial transition (PT): early PT if it occurs before V3; late PT if beyond V3) and clinical information [the following variables compute 1 point in a clinical score: age (&gt;59 y.o); presence of hypertension; and gender (man)].

Results

115 consecutive patients [42 (37%) man, 52 + 15 y.o] were included. Mean PVC burden at baseline was 20 ± 13% and mean LVEF was 59 ± 8%. Mean procedure time was 55 ± 26 min. Complete acute abolition of the PVC was achieved in 110 (96%) patients. 84 (73%) patients had the PVC’s SOO in the right ventricle OT (RVOT) whereas 31 (27%) in the left ventricular OT (LVOT). Compared with patients with a RVOT-SOO, those with a LVOT-SOO were more frequently man [18 (58%) vs 24 (29%), p = 0.004], more frequently suffered from hypertension [18 (58%) vs 15 (18%), p &lt; 0.001) and had an early R/S PVC transition [17 (55%) early PT, 3 (10%) late PT) in the case of LVOT-SOO vs 4 (5%) early PT, 55 (65%) late PT in the case of RVOT-SOO, p &lt; 0.001]. The hybrid algorithm accurately anticipated the PVC’s SOO in 101 (88%) patients. A reduction of at least 80% of PVC burden was achieved by 90% of patients at 6 months.

Conclusions

The hybrid algorithm, prospectively evaluated in an international multicenter study, has proved to permit to accurately anticipate the PVC’s SOO (right vs left) in a consultive population of patients with OT PVCs. Abstract Figure 1

Personalized atrial fibrillation ablation by tailoring ablation index to the left atrial wall thickness. the ablate by-law single center study

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Teres is funded by the research fellowship grant from the Swiss Heart Rhythm Foundation, Dr Carreno was funded was funded by a Scholarship from Sociedad Española de Cardiología (SEC).

Introduction

Left atrial wall thickness (LAWT) is a determinant of transmural lesion formation during atrial fibrillation (AF) ablation. The utility of ablation index (AI) to dose radiofrequency (RF) delivery for the reduction of AF recurrences has already been proven with a target AI ≥ 400 at the posterior wall and ≥550 at the anterior wall.

Objective

To determine if adapting AI to atrial wall thickness (AWT) is feasible, effective and safe during AF ablation.

Methods

Consecutive patients referred for a first PAF ablation. LAWT 3D-maps were obtained from multidetector computed tomography (MDCT) and integrated into the CARTO navigation system. LAWT maps were semi-automatically computed from the MDCT as the local distance between the LA endo and epicardium and categorized into 1mm-layers and AI was titrated to the LAWT, as follows: Thickness &lt; 1 mm (red): 300; 1-2 mm (yellow): 350; 2-3 mm (green): 400; 3-4 mm (blue): 450; &gt; 4 mm (purple): 450 (Figure). The ablation line was designed in a personalized fashion to avoid thicker regions. All ablation procedures were performed under general anesthesia with a high frequency low-volume ventilation. Primary endpoints were acute efficacy and safety, and freedom from AF recurrences. Follow-up (FU) was scheduled at 1, 3, 6, and every 6 months thereafter.

Results

90 patients [60 (67 %) male, age 58 ± 13 years] were included. Mean LAWT was 1.25 ± 0.62 mm. Mean AI was 366 ± 26 on the right pulmonary veins (RPVs) with a first-pass isolation in 84 (93%) patients and 380 ± 42 on the left pulmonary veins (LPVs) with first-pass in 87 (97%). Procedure time was 59 min [49-66]; RF time 14 min [12,5-16]; fluoroscopy time 0.7 min [0.5-1.4]. No major complication occurred. Eighty-six out of 90 (95.5%) patients were free of recurrence after a mean FU of 11 ± 4 months.

Conclusions

 Personalized AF ablation, adapting the AI to LAWT allowed decreasing RF delivery, fluoroscopy and procedure time while obtaining a high rate of first-pass isolation. Lesion durability as estimated by freedom from AF recurrences was as high as in more demanding ablation protocols. Abstract Figure. Personalized protocol and results

Cardiovascular magnetic resonance determinants of ventricular arrhythmic events after myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

Background

 Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) permits to identify the arrhythmogenic substrate in chronic post-myocardial infarction (MI) patients. It is unknown why a minority of chronic post-MI patients develop sustained ventricular tachycardias (VT) over follow-up, regardless of their left ventricular ejection fraction (LVEF).

Objectives

 To noninvasively characterize scar differences and potential predictors of VT occurrence in chronic post-MI patients.

Methods

 A case-control study was designed through retrospective LGE-CMR data analysis of chronic post-MI patients i) consecutively referred for VT substrate ablation after a first VT episode (n = 66), and ii) from a control group (n = 84) with no arrhythmia evidence. The myocardium was characterized differentiating core, border zone (BZ) and BZ channels (BZC) using the ADAS 3D post-processing imaging platform. Clinical and scar characteristics, including a novel parameter, the BZC mass, were compared between both groups.

Results

 150 post-MI patients were included for analysis. Four multivariate Cox proportional hazards regression models were created for total scar mass (model 1), BZ mass (model 2), core mass (model 3), and BZC mass (model 4, see table). All of them were adjusted by age, sex, and LVEF. In the corresponding models, only total scar mass, BZ mass, core mass, and BZC mass were independent variables associated with the development of VT. BZC mass showed the best performance: a cut-off of 5.15 g identified the cases with 92.4% sensitivity and 86.9% specificity  [AUC 0.93 (0.89–0.97); p &lt; 0.001], with a significant increase in the AUC compared to the other scar parameters (p &lt; 0.001 for all pairwise comparisons using the De Long’s test). By using BZC mass as a risk stratification parameter together with LVEF, the net reclassification improvement (NRI) was 33.3% for the cases, and 39.3% for the controls. The net proportion of patients reclassified correctly was 36.7%

Conclusions

 The mass of BZC, automatically obtained with a commercially available CMR post-processing software, is the strongest independent variable associated with the occurrence of clinical SMVT in post-MI patients after covariate adjustment for age, sex, and LVEF. The measurement of BZC mass could permit a more accurate arrhythmia risk stratification than LVEF in chronic post-MI patients (NRI 36.7%). Scar characteristics analyzed from LGE-CMR imaging should be taken into consideration to better stratify ventricular arrhythmia risk in chronic post-MI patients. Abstract Figure. ROC curves for predicting VT occurrence

Esophagus-to-posterior Atrial wall relationship: pre- and Intra-procedural three-dimensional multimodality imaging for esophageal position

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Teres was funded by the research fellowship grant of the Swiss Heart Rhythm Foundation. Dr Carreno-Lineros was funded by a Scholarship from Sociedad Española de Cardiología (SEC).

Introduction

  pulmonary vein isolation (PVI) approach implies unavoidable ablation  on the posterior atrial wall which is closely related to the esophagus. PVI may result in several complications.

Objective

the present study aims to analyze the stability of the esophageal position inside the mediastinum at the level of the posterior atrial wall from one procedure to another (Redo group) and during a single procedure (multi-image group).

Methods

the esophageal position was compared in two groups. First, pre-procedural multidetector computerized tomography (MDCTs) of the first PVI and the redo intervention (Redo group) were segmented with ADAS 3D™ software to compare the esophageal position and the atrio-esophageal distance prints (Figure A). Second, three imaging modalities were compared for the same procedure (multi-image group): i) preprocedural MDCT; ii) intraprocedural fluoroscopy obtained with the TEE probe in place in three projections with CARTOUNIVU™ (Biosense Webster); and iii) esophageal fast-anatomical map (FAM) obtained at the end of the procedure (Figure D). Ablation procedures were performed under general anesthesia. Exclusion criteria were unavailability or contraindication to obtain any of the techniques. The 3D correlation of the esophageal position acquired with different techniques, was computed in Matlab using semiautomatic segmentation analysis.

Results

35 patients were analyzed for the Redo group. Mean age 61 ± 10 years, 17 (65%) male, mean LVEF 57 ± 7%, mean LA diameter 43 ± 5 mm, median time since previous ablation (and therefore between MDCT acquisitions) was 6 months (IQR 3-9). Mean atrio-esophageal distance for both MDCTs was 1.2 ± 0.6 mm . The esophageal trajectory as related to the atrial posterior wall was left for 20 (57%) patients, central for 6 (18%) patients, and right for 3 (9%) patients, left-central for 4 (11%) patients, and right-central for 2 (5%) patients. There was a 91 ± 5% correlation on the esophageal position between the first procedure and the redo procedure MDCT. In 3 cases the position was clearly different with a correlation of only 40 ± 22%. The multi-imaging group was composed of 100 patients, mean age 61 ± 10 years, 17 (65%) male, mean LVEF 56 ± 7%, mean LA diameter 39 ± 6 mm. The esophageal trajectory as related to the atrial posterior wall was left for 55 (55%) patients, central for 23 (23%) patients, and right for 9 (9%) patients, left-central for 8 (8%) patients, and right-central for 5 (5%) patients. The correlation between MDCT and CARTOUNIVU™ was 82 ± 10% (Figure B); between MDCT and ESOFAM 80 ± 12% (Figure B); and between ESOFAM and CARTOUNIVU™ 83 ± 15% (Figure C).

Conclusions

There is a high stability of the esophageal position between procedures and from the beginning to the end of procedure. This observation needs to be tested for its clinical utility by designing studies that take into account the esophagus distance print to modulate RF delivery Abstract Figure. Multimodal Esophageal imaging

Effects of feed particle size on energy values for broiler chickens at various ages

The objective of this study was to evaluate the effects of various geometric mean diameters (GMDs) of particles of corn, pelleted soybean meal and a corn-soy mixture in the proportion of 70% and 30%, respectively, on the nutritional value of the feeds. The study evaluated energy consumption, the contents of apparent metabolizable energy (AME) and AME corrected for nitrogen balance (AMEn) and the metabolizability coefficients for broiler chickens at various ages. A total of 540 Cobb 500 male broilers were housed in metabolic cages (experimental units). Trials were performed separately with each feed. A completely randomized design was used with four treatments, namely corn with 573, 636, 851, and 1012 μm GMDs; pelleted soybean meal with 538, 550, 665, and 741 μm GMDs; and the corn-soy mixture with 627, 658, 893, and 1040 μm GMDs. Birds were evaluated on days 1 - 10, 11 - 20, 21 - 30, and 31 - 40. Larger GMDs resulted in lower energy consumption. From 1 to 10 days, birds consumed less metabolizable energy than older birds. Birds fed corn from days 1 to 10 had higher metabolizable energy (P <0.05) with increasing GMD up to 1042 μm. However, the results varied, depending on the feed and its combinations. The use of coarse particles could reduce the costs of grinding, and would have few effects on the metabolizable energy of broiler chickens.

Isoflurane sedation in patients undergoing VA-ECMO treatment for cardiogenic shock – an observational propensity-matched study

Introduction

The feasibility and hemodynamic effects of isoflurane sedation in cardiogenic shock in the presence of extracorporeal membrane oxygenation (VA-ECMO) treatment is currently unknown.

Methods

Thirty-two cardiogenic shock patients with VA-ECMO treatment under sedation with volatile isoflurane on a cardiac intensive care unit have been enrolled in this retrospective single-center study and were matched by propensity score in a 1:1 ratio with intravenously (IV) sedated patients.

Results

Administration of isoflurane was associated with lower IV sedative drug use during VA-ECMO treatment (86% vs. 32%, p=0.01). Mean systolic arterial pressure was similar (94.3±12.6 mmHg versus 92.9±10.5 mmHg, p=0.65), but mean heart rate was significantly higher in the conventional sedation group, when compared to the isoflurane group (85.2±20.5 / min vs. 74.7±15.0 /min; p=0.02). Catecholamine doses, VA-ECMO blood and gas flow, ventilation time (304±143 h vs. 398±272 h, p=0.16), bleeding complications BARC3a or higher (59.3% vs. 65.3%, p=0.76) and 30-day mortality (59.2% vs. 63.4%, p=0.80) were similar in both groups.

Conclusions

Volatile sedation with isoflurane is feasible in patients with cardiogenic shock and VA-ECMO treatment and was not associated with higher catecholamine dosage or ECMO flow rate compared to IV sedation.

Mortality and bleeding

Funding Acknowledgement

Type of funding source: None

Cyclosporine A does not prevent second-eye involvement in Leber's hereditary optic neuropathy

BACKRGROUND

Evaluation of the efficacy of oral cyclosporine A as a prophylactic agent in preventing second-eye involvement in Leber's hereditary optic neuropathy (LHON) in a prospective, open-label, non-randomized, multicenter pilot study. Only LHON patients aged 18 years or more, with confirmed primary mitochondrial DNA mutations and strictly unilateral optic neuropathy occurring within 6 months prior to enrolment, were included in the study. All these patients, receiving treatment with oral cyclosporine (Neoral®, Novartis) at 2.5 mg/kg/day, were examined at three-month intervals for a year. The primary endpoint was the best corrected visual acuity in the unaffected eye; the secondary endpoints were the best corrected visual acuity in the first eye affected, the mean visual field defect on automated perimetry, the thickness of the perifoveal retinal ganglion cell inner plexiform layer, and the thickness of the peripapillary retinal nerve fiber layer in both eyes.

RESULTS

Among the 24 patients referred to our institution with genetically confirmed LHON, between July 2011 and April 2014, only five patients, four males and one female, fulfilled the inclusion criteria. Age at enrolment ranged from 19 to 42 years (mean: 27.2 years; median: 26 years), four patients harbored the m.11778G > A pathogenic variant, and one the m.14484 T > C pathogenic variant. The time-interval between the onset of symptoms and inclusion in the study ranged from 7 to 17 weeks (mean: 11.8 weeks; median: 9 weeks). Despite treatment with oral cyclosporine A, all patients eventually experienced bilateral eye involvement, occurring within 11-65 weeks after the initiation of treatment. Over the study time period, the average best corrected visual acuity worsened in the first eye affected; by the end of the study, both eyes were equally affected.

CONCLUSIONS

Oral cyclosporine, at 2.5 mg/kg/day, did not prevent second-eye involvement in patients with strictly unilateral Leber's hereditary optic neuropathy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02176733 . Registrated June 25, 2014.

Dissociation between decision-making under risk and decision-making under ambiguity in premanifest and manifest Huntington's disease

We investigated decision-making under ambiguity (DM-UA) and decision making under risk (DM-UR) in individuals with premanifest and manifest Huntington's disease (HD). Twenty individuals with premanifest HD and 23 individuals with manifest HD, on one hand, and 39 healthy individuals divided into two control groups, on the other, undertook a modified version of the Iowa Gambling Task (IGT), an adaptation of a DM-UA task, and a modified version of the Game of Dice Task (GDT), an adaptation of a DM-UR task. Participants also filled in a questionnaire of impulsivity and responded to cognitive tests specifically designed to assess executive functions. Compared to controls, individuals with premanifest HD were unimpaired in performing executive tests as well as in decision-making tasks, except for the Stroop task. In contrast, individuals with manifest HD were impaired in both the IGT and executive tasks, but not in the GDT. No sign of impulsivity was observed in individuals with premanifest or manifest HD. Our results suggest that the progression of HD impairs DM-UA without affecting DM-UR, and indicate that decision-making abilities are preserved during the premanifest stage of HD.

Theory of mind and empathy in preclinical and clinical Huntington's disease

We investigated cognitive and affective Theory of Mind (ToM) and empathy in patients with premanifest and manifest Huntington's disease (HD). The relationship between ToM performance and executive skills was also examined. Sixteen preclinical and 23 clinical HD patients, and 39 healthy subjects divided into 2 control groups were given a French adaptation of the Yoni test (Shamay-Tsoory, S.G., Aharon-Peretz, J. (2007). Dissociable prefrontal networks for cognitive and affective theory of mind: a lesion study. Neuropsychologia, 45(3), 3054-67) that examines first- and second-order cognitive and affective ToM processing in separate conditions with a physical control condition. Participants were also given questionnaires of empathy and cognitive tests which mainly assessed executive functions (inhibition and mental flexibility). Clinical HD patients made significantly more errors than their controls in the first- and second-order cognitive and affective ToM conditions of the Yoni task, but exhibited no empathy deficits. However, there was no evidence that ToM impairment was related to cognitive deficits in these patients. Preclinical HD patients were unimpaired in ToM tasks and empathy measures compared with their controls. Our results are consistent with the idea that impaired affective and cognitive mentalizing emerges with the clinical manifestation of HD, but is not necessarily part of the preclinical stage. Furthermore, these impairments appear independent of executive dysfunction and empathy.

Contribution of the Torsional Modes to the Equilibrium Distribution of Vibrational States and to the Specific Heat of a Chain Molecule

The torsional modes of a chain molecule were studied recently under the assumption that it has a well defined spatial configuration at any time. Here we show how the averages over the possible configurations, for a distribution in thermal equilibrium, should be performed in the calculation of the thermodynamical properties. Our results show that the mean density of torsional states increases in the low frequency region with increasing temperature. The specific heat behaviour shows a considerable difference from the result obtained in the previous paper, where only the lowest energetic configuration was considered. The consequences of this result with respect to the configurational properties of polymer molecules near the θ temperature are discussed.

Association between caffeine intake and age at onset in Huntington's disease

Habitual consumption of caffeine, a non-selective adenosine receptor (AR) antagonist, has been suggested to be beneficial in Parkinson's and Alzheimer's diseases. Experimental evidence support that ARs play a role in Huntington's disease (HD) raising the hypothesis that caffeine may be a life-style modifier in HD. To determine a possible relationship between caffeine consumption and age at onset (AAO) in HD, we retrospectively assessed caffeine consumption in 80 HD patients using a dietary survey and determined relationship with AAO. Following adjustment for gender, smoking status and CAG repeat length, caffeine consumption greater than 190mg/day was significantly associated with an earlier AAO. These data support an association between habitual caffeine intake and AAO in HD patients, but further studies are warranted to understand the link between these variables.

Exigência de treonina digestível para codornas de corte no período de 15 a 35 dias de idade

Estimou-se a exigência de treonina digestível (ThrD) para codornas de corte (Coturnix coturnix sp.) em fase de crescimento no período de 15 a 35 dias de idade. Foram utilizadas 1020 codornas com 15 dias de idade, não sexadas, distribuídas em um delineamento experimental inteiramente ao acaso, com seis porcentagens de adição de treonina digestível - 0,93; 1,00; 1,07; 1,14; 1,21 e 1,28% na dieta - , cinco repetições e 34 codornas por unidade experimental. Não houve efeito sobre o desempenho, o rendimento e a composição química da carcaça e sobre o balanço de nitrogênio com o aumento da porcentagem de treonina digestível na dieta. Houve aumento linear no consumo de treonina e no custo da ração por quilograma de peso vivo ganho com o aumento da porcentagem de treonina digestível. Concluiu-se que o melhor nível de treonina digestível avaliado foi suficiente para atender as exigências de codornas de corte, no período de 15 a 35 dias de idade.

Avaliação de probiótico na alimentação de poedeiras comerciais no segundo ciclo de postura

Avaliou-se o efeito da inclusão de probiótico sobre o desempenho e a qualidade dos ovos de poedeiras semipesadas no segundo ciclo de postura. Foram utilizadas 450 aves com 69 semanas de idade, distribuídas aleatoriamente em um delineamento inteiramente ao acaso, em cinco tratamentos, seis repetições e 15 aves por unidade experimental. A ração experimental foi à base de milho e farelo de soja e suplementada com probiótico composto por Lactobacillus acidophilus, Streptococcus faecium e Bifidobacterium bifidum. O experimento teve a duração de 16 semanas e foi dividido em quatro períodos de 28 dias cada, nos quais as aves receberam cinco rações experimentais contendo diferentes porcentagens de inclusão de probiótico, 0; 0,05; 0,10; 0,15 e 0,20%. Não foi observado efeito (P>0,05) da inclusão de probiótico sobre o desempenho e a qualidade dos ovos de galinhas poedeiras no segundo ciclo de postura. A inclusão de 0,10% de probiótico influenciou negativamente a gravidade específica dos ovos. A utilização de probiótico para galinhas no segundo ciclo de postura não interfere na produção e na qualidade dos ovos.

Developing consistent scenarios to assess flood hazards in mountain streams

The characterizing feature of extreme events in steep mountain streams is the multiplicity of possible tipping process patterns such as those involving sudden morphological changes due to intense local erosion, aggradation as well as clogging of critical flow sections due to wood accumulations. Resolving a substantial part of the uncertainties underlying these hydrological cause-effect chains is a major challenge for flood risk management. Our contribution is from a methodological perspective based on an expert-based methodology to unfold natural hazard process scenarios in mountain streams to retrace their probabilistic structure. As a first step we set up a convenient system representation for natural hazard process routing. In this setting, as a second step, we proceed deriving the possible and thus consistent natural hazard process patterns by means of Formative Scenario Analysis. In a last step, hazard assessment is refined by providing, through expert elicitation, the spatial probabilistic structure of individual scenario trajectories. As complement to the theory the applicability of the method is shown through embedded examples. To conclude we discuss the major advantages of the presented methodological approach for hazard assessment compared to traditional approaches, and with respect to the risk governance process.

[Hereditary optic atrophies]

INTRODUCTION

Hereditary optic neuropathies, resulting from retinal ganglion cell degeneration, are a heterogeneous group of diseases ranging from asymptomatic forms to legal blindness.

STATE OF KNOWLEDGE

Two most frequent phenotypes are Kjer's disease, an autosomal dominant optic atrophy caused by OPA1 gene mutations, and Leber's disease due to maternally inherited mitochondrial DNA mutations.

PROSPECTS AND CONCLUSION

Both optic neuropathies usually isolated are sometimes associated with extraocular symptoms, especially neurological symptoms, thus justifying a systematic neurological evaluation and brain imaging.

Exon deletion in the non-catalytic domain of eIF2Bepsilon due to a splice site mutation leads to infantile forms of CACH/VWM with severe decrease of eIF2B GEF activity

The CACH/VWM syndrome is an autosomal recessive leukodystrophy characterized by a broad spectrum of clinical presentations and by diffuse cavitary degeneration of the white matter on MRI. Mutations responsible for this disorder are missense or frameshift mutations occurring in the five genes (EIF2B1-5) that encode the translation eukaryotic initiation factor eIF2B. We found that a patient with infantile CACH/VWM carries a mutation in the acceptor splice site of EIF2B5 exon 6. In lymphoblastoid cells of the patient, we detected an abnormal EIF2B5 transcript in which exon 6 was absent, however, the predicted protein product lacking part of the non-catalytic domain encoded by exon 6 was not detected. The eIF2B GEF activity was severely decreased. These data support the importance of the non-catalytic domain of the eIF2Bepsilon subunit in the eIF2B complex formation and activity.

Cognitive changes in asymptomatic carriers of the Huntington disease mutation gene

Huntington disease (HD) is a neurodegenerative disorder due to an excessive number of CAG repeats in the IT15 gene on chromosome 4. Studies of cognitive function in asymptomatic gene carriers have yielded contradictory results. This study compared cognitive performance in 44 subjects with the HD mutation (group of carriers) who had no clinical signs of HD and 39 at-risk individuals without HD mutation (group of non-carriers). Neuropsychological evaluation focused on global cognitive efficiency, psychomotor speed, attentional, executive and memory functions. Significant differences, with lower performances in the group of gene carriers, were detected for some measures of psychomotor speed, attention and executive functioning (all P < 0.01). More differences between groups were observed for memory measures, in particular on the California Verbal Memory Test. Complementing these observations, cognitive scores were correlated with age in the group of gene carriers, but not in the group of non-carriers. This suggests that the cognitive changes precede the appearance of the motor and psychiatric symptoms in HD and that tests proved to be sensitive to early HD deficiencies are better suited than global cognitive efficiency scales to observe them.

Crises épileptiques révélatrices d’une hyperglycémie sans cétose

In patients older than 50 years, a first seizure can reveal non-ketotic hyperglycemia, regardless of any previous history of diabetes mellitus. Partial motor seizures are observed in most cases, sometimes with epilepsia partialis continua. Plasma glucose levels are usually above 20 mmol/L, and serum osmolarity is normal or slightly elevated. The absence of ketoacidosis may promote the occurrence of seizures. EEG and neuroimaging between seizures are usually normal. Treatment involves correction of the hyperglycemia with insulin treatment and rehydration.