Basal characteristics of the prospective spanish immunotherapy registry of cardiovascular toxicity: SIR-CVT

Background

The immune checkpoint inhibitors (ICI) have improved the prognosis of many cancers in the last years but concerning cardiovascular toxicity (CVtox) have been reported. Nowadays, specific surveillance protocols are lacking, and early diagnosis of toxicity may be challenging.

Purpose

To characterize the cardiovascular (CV) effects of immunotherapy and to seek for the mechanisms of CVtox of ICI in a protocolize surveillance program of cardio-oncology.

Methods

A multicentre national registry was developed by a research consortium of scientific societies of Cardiology and Oncology (SEC and SEOM) and the cardiovascular research centre (CNIC) in Spain (Figure 1). A total of 18 hospitals participate in recruiting since Q4 2021. A follow-up protocol was stablished with clinical, electrocardiographic (EKG), echocardiography, cardiac magnetic resonance (CMR) and laboratory assessment, including cardiac biomarkers, inflammatory panel and the expression of miR-721, a specific myocarditis biomarker. Toxicity management is performed at each institution following international guidelines.

Results

53 patients were currently included. Median age was 68 [59, 75] years-old, 79% were male. 83% had at least 1 CV-risk factor (75% smoking history, 20% diabetes mellitus, 50% hyperlipemia, 57% hypertension, 19% chronic kidney injury) and up to34% had previous CV disease. 93% had at least one dose of COVID19 vaccine. Dyspnoea was referred by 23% of patients, 28% have abnormal EKG findings and one-third (33%) abnormal cardiac biomarkers (median Troponin I-hs 5.30 [2.60, 11.00]; NT-proBNP 199 [68, 736]). Mean LVEF (60% [56.15, 66.78]) and GLS (−18 [−19.75, −16]) were within the normal range but 26% showed LGE at baseline. Cancer characteristics are summarized in Table 1.

Conclusion

Real-world SIR-CVT patients show a high CV risk profile and frequent pre-existing CV diseases before ICI treatment. The prospective follow-up of this cohort will help to develop personalized surveillance protocols according to baseline CVtox risk and to define different grades of cardiotoxicity.

Funding Acknowledgement

Type of funding sources: None.

Role of three-dimensional imaging techniques in the management of transcatheter closure of complex atrial septal defects

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Reina Sofia. Instituto de investigación biomédica Maimonides

Introduction

Percutaneous closure is nowadays considered the treatment of choice of ostium secundum atrial septal defects (ASD) but complex defects may be a challenging. In the last years, the imaging techniques used for ASD assessment have improved considerably, allowing therapeutic approaches in patients with complex morphological features particularly in those with absence of rims. However, there are no studies about the impact of 3D imaging techniques on transcatheter closure of ASD as compared with 2D imaging along time .

Purpose

To compare the impact of real time 3D Transesophageal echocardiography (3D-RT TEE) and cardiac computed tomography (CCT) on the profile as well as on the success rate of transcatheter closure of complex ASD as compared to 2D imaging.

Methods

We selected 106 adults patients suffering from ASD of complex anatomy (large≥30 mm, multiple, multifenestrated, aneurysmal, or deficiency of posterior or inferior rims) from 1998 to 2020. Along this time, we compared closure success rate, morphological characteristics, and procedure complications after ASD transcatheter closure. We defined closure success rate as a complete closure without complications. In our study, ASD assessment and further intervention was performed by two-dimensional transesophageal echocardiography (2D-TEE) from 1998 to 2007 (n = 66), whereas 3D-RT TEE and CCT was performed from 2008 to 2020 (n= 40).

Results

The type of ASD complexity was different between the two diagnostic approaches. Thus, those patients management by 2D-TEE showed more number in large ASD (40,9%), multiple-ASD (34,8%), fenestrated (10,6%), aneurysmal (7,6%) and with lower ring deficiency (6,1%) as compared to those with 3D-RT TEE and CCT (10%, 25%, 15%, 15%, and 35%, respectively, p < 0,05). Although no significant differences were observed, patients from the 2D group needed a second surgical closure more frequently than those treated with 3D-RT TEE and CCT (12,1% vs 5%, p = 0.31). In our study, there were few complications (10 (9,4%), with no significant differences according to the imaging technic used (2D-TEE group: 3 device embolisms, 2 cardiac tamponade, 2 complications of the femoral access; 3D-RT TEE and CCT group: 2 device embolisms and 1 complication of the femoral access. All of them were resolved intraprocedure. Importantly, closure success was higher in those patients manage by 3D-RT TEE and CCT in comparison to 2D-TEE (88% vs. 67%, respectively, p <0.05).

Conclusion

Transcatheter closure of complex ASD is a secure procedure. However, the use of 3D TEE and cardiac CT improves the success rate of this approach as compared to 2D-TEE and changes the profile of complex ASD treated by transcatheter closure in favor of those with absence of some rims

Left ventricular global longitudinal strain as an early marker of the need for echocardiographic follow-up in patients with breast cancer: a real-life study

Funding Acknowledgements

Type of funding sources: None.

Introduction

The monitoring of the left ventricular ejection fraction (LVEF) is a common practice in patients with breast cancer undergoing chemotherapeutic treatment. Although indiscriminate follow-up is not very cost-effective, we don’t have enough data to determine which patients would benefit from it.

Purpose

To analyze if any baseline ventricular function echocardiographic parameter can help to identify the subsequent development of ventricular dysfunction secondary to cardiotoxic drugs (DV-CTOX).

Methods

Retrospective study of patients with breast cancer who have received treatment with anthracyclines with / without adjuvant treatment with immunotherapy and / or radiotherapy. We analyzed baseline and follow-up ventricular function parameters (LVEF estimated by 2D-3D automatic quantification and semi-automatic quantification of global longitudinal strain (GLS)).

Results

We included 93 patients (mean age 59 ± 11 years, 98.9% women). 67% received immunotherapy and 84% radiotherapy. Median follow-up was 6 months. 10 patients (11%) developed DV-CTOX. There were differences in baseline clinical characteristics between patients and those with no DV-CTOX. Regarding echocardiographic parameters we didn’t observe differences between both groups in basline 2D LVEF (65 ± 1% vs 62 ± 14%, p = 0.4), and 3D LVEF (60 ± 7% vs 57 ± 8%, p = 0.4), although the GLS was lower in patients who later developed DV CTOX (GLS 19 ± 3% vs 16 ± 3%, p = 0.03); At follow-up, patients who developed DV-CTOX had worse LVEF estimated by 2D-3D and maintained a worse GLS value (52 ± 7% vs 69 ± 8% p <0.001.49 ± 8% vs 61 ± 4%, p = 0.005 and 14 ± 3% vs 20 ± 4%, p = 0.04 respectively). We used the area under the curve for the use of baseline GLS as a diagnostic method for the early detection of DV-CTOX. It was 0.785 (CI 0.585-0.985 for a p value = 0.047). A baseline GLS cut-off point of 17.5% was determined with a sensitivity of 73% and a specificity of 80%.

Conclusion

The quantification of baseline GLS in patients with breast cancer who are going to start treatment with cardiotoxic drugs could help to discriminate which patients require a closer LVEF monitoring, improving efficiency in the Cardio-Onco-Hematology unit. A value greater than 17.5% in absolute terms of baseline GLS could be an optimal cut-off point that discriminates between patients who will develop DV-CTOX. Abstract Figure.  Abstract Figure.

Risk scores for predicting incident heart failure admission in patients with chronic coronary syndromes: validation in a prospective, monocentric, long-term, cohort study

Background

Heart failure (HF) admission is a serious event in the follow up of patients with chronic coronary syndromes (CCS). Stratification schemes have been described for predicting this end-point but none of them has been externally validated.

Purpose

To develop point-scores for predicting incident HF admission with data from previous studies, to perform an external validation in an independent prospective cohort study, and to compare their discriminative ability for this event.

Methods

We performed a literature review searching for prospective studies including patients with CCS, excluding patients with HF at baseline, with data on HF admission incidence in follow up and predictive variables. If undescribed previously, scores were developed including those variables independently associated with this outcome, and score points were assigned based in the relative magnitude of the coefficients of Cox regression models. The resulting scores were validated and their discriminative ability compared in a prospective, monocentric, 17-years cohort study, that included consecutive outpatients with CCS.

Results

Four studies were included: two post-hoc analysis of clinical trials (CARE and PEACE) and two observational registries (CORONOR and CLARIFY). The validation cohort included 1212 patients (mean age 67±11 years, 74% male) followed for up to 17 years (median 12 years, p25–75 5–15 years), with 171 patients suffering at least one HF admission in follow-up. The proportions of the variables needed for scores calculation available in the database of the study were 75% (6/8), 88% (15/17), 100% (8/8) and 85% (17/20) respectively, for each of these study-derived scores. Discriminative ability for predicting HF admission was statistically significant for all (C-statistic 0.72, 95% CI 0.68–0.75, p<0.0005; 0.72, 95% CI 0.68–0.76, p<0.0005; 0.73, 95% CI 0.69–0.76, p<0.0005; and 0.69, 95% CI 0.65–0.73, p<0.0005 for CARE, PEACE, CORONOR and CLARIFY scores, figure 1) and paired comparison among them were all non-significant except for CORONOR and CLARIFY scores (p=0.03). The CORONOR score (Age [each year] 2 points, ejection fraction [each percentage point] −1 point, hypertension 11 points, diabetes 10 points, atrial fibrillation 14 points, body mass index [each kg/m2 unit] 1 point, symptomatic angina 11 points and multivessel disease 7 points) identified subgroups of patients with 12 years-HF admission free survival probabilities of 97%, 87 and 62% (p<0.0005, first, second and third tertile of the score, figure 2).

Conclusions

All tested scores showed significant discriminative ability for predicting incident HF admission in this independent validation study. Their discriminative ability was similar, except that CORONOR score performed significantly better than CLARIFY score.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The work for this paper was funded by the Andalusian Society of Cardiology through anunconditional grant from Astra Zeneca. ROC curves for HF predictive scoresHF free survival by CORONOR score

Tissue Doppler velocities for ruling out rejection in heart transplant recipients in the daily routine of the echocardiography laboratory: a feasibility study

Funding Acknowledgements

Type of funding sources: None.

Background

The sum of systolic and early diastolic myocardial velocities at lateral mitral annulus, evaluated by tissue Doppler (in absolute values, s’+e’) in the apical four chambers view is a parameter whose value for ruling out acute cellular rejection (ACR) in heart transplant (HTx) recipients has been acknowledged by the European and Brazilian recommendations for the use of imaging in HTx. A recent study has shown its independent association with ACR in the context of classical and myocardial deformation variables, with a negative predictive value (NPV) of 98% for treatment requiring ACR (TR-ACR, grade ≥ 2R) for a cut-off point of ≥23 cm/s. This work was performed under experimental conditions (only one expert echocardiographer, only one high-end equipment).

Purpose

Our objective was to study the diagnostic utility of this parameter for ruling out rejection in HTx recipients in the daily routine of the echocardiography laboratory.

Methods

From October 2017 to May 2020, serial echocardiograms were performed to 33 consecutive HTx recipients, in the 3 hours after the routine surveillance endomyocardial biopsies (EMB), in the first year after HTx. Three sonographers, seven cardiology residents and six expert echocardiographers participated in the acquisition and interpretation of the images, with seven different echocardiographic machines in only one centre. We analysed the association of s’+e’ with the presence of ACR, and the NPV of s’+e’ ≥23 cm/s for ruling out TR-ACR was investigated.

Results

A total of 176 pairs of EMB and echocardiogram were obtained. The value of s’+e’ was significantly lower with higher severity of rejection: 25.6 ± 5.5 cm/s, 23.8 ± 5.1 cm/s and 21.6 ± 3.5 cm/s for ACR grade 0R (n = 91, 52%), 1R (n = 67, 38%) and ≥2R (n = 18, 10%), respectively, p = 0.005. It was also lower when comparing studies with (≥1R) and without rejection (23.4 ± 4.9 cm/s versus 25.6 ± 5.5 cm/s, p = 0.005), or TR-ACR versus the rest of series (21.6 ± 3.5 cm/s versus 24.8 ± 5.3 cm/s, p = 0.01). The area under curve for the detection of TR-ACR was 0.67 (CI95% 0.56-0.78), p = 0.02. A cut-off point of ≥23 cm/s, present in 57% of the studies, showed a NPV of 95% for TR-ACR.

Conclusion

Lateral mitral annulus velocities showed an excellent NPV of 95% for TR-ACR detection in HTx recipients when evaluated in the daily routine of an echocardiography laboratory with a wide variety of operators and echocardiographic equipment. This finding could be useful for reducing the number of EMB in selected cases.

Long-term echocardiographic assessment of descendants of gestational breast cancer patients exposed to anthracycline-based chemotherapy

Background

Breast cancer is the most common cancer in women and the leading cause of cancer death in women. Although gestational breast cancer (GBC) accounts only for a small amount of diagnosis, the incidence is increasing due to delayed childbearing.

Treating GBC is a significant challenge, having to maintain a balance between effective treatment for the patient and safety for the descendants.

Anthracycline-based chemotherapy (AC) remains to be the systemic treatment of choice in many GBC patients.

Although AC in GBC appears to be safe for the descendants, data on the long-term cardiotoxic effects of AC are scarce.

Purpose

To evaluate long-term cardiotoxicity on descendants of GBC patients exposed to AC during pregnancy or breastfeeding.

Methods

We retrospectively recruited descendants of GBC patients and classified them according to AC exposure (case group and non-exposed control group). We performed a thorough echocardiographic assessment.

Results

We identified 7 GBC patients that received AC during pregnancy (n=6) or breastfeeding (n=1). All of them were diagnosed during the second or third trimester. Median cumulative anthracycline dose was 508mg/m2.

A total of 8 cases and 5 controls were recruited. Median age at echocardiographic assessment was 10 years in cases and 8 years in controls. None of them had known prior cardiac disease. Echocardiographic parameters were within normal values in both groups (Table 1).

Conclusion

A long-term echocardiographic assessment showed no abnormalities in a series of descendants of GBC exposed to AC during pregnancy or breastfeeding. This study may contribute to a better understanding of the safety for the descendants of AC during pregnancy or breastfeeding.

Funding Acknowledgement

Type of funding source: None

Long term prognostic impact of gender in patients with stable coronary disease: an analysis of the CICCOR registry, a seventeen years, prospective, monocentric, cohort study

Purpose

Women and men with stable coronary artery disease (sCAD) have different clinical features and management, but 1-year prognosis has been reported to be similar in large observational registries. The objective of the present study was to investigate the impact of female sex in the prognosis of the disease in the very long-term.

Methods

The CICCOR registry (“Chronic ischaemic heart disease in Cordoba”) is a prospective, monocentric, cohort study. From February 1, 2000 to January 31, 2004, all consecutive patients with sCAD attended at two outpatient cardiology clinics in a city of the south of Spain were included in the study and prospectively followed. Differential clinical features of women and men were described and the impact of female sex in long term prognosis was investigated.

Results

The study sample included 1268 patients, 337 women (27%) and 931 men (73% male). Women were older than men (70±9 versus 65±11 years, p<0.0005), more likely to have hypertension (72% versus 49%, p<0.0005) and diabetes (45% versus 26%), and less likely to be ex-smoker/active smoker (5%/2% versus 49%/9%, p<0.0005). They had more frequently angina in functional class ≥II (22% versus 17%, p=0.04) and atrial fibrillation (8% versus 5%, p=0.04), but had received less frequently coronary revascularization (32% versus 44%, p<0.0005). Prescription of statins (64% versus 68%, p=0.22), antiplatelets (89% versus 93%, p=0.07) and betablockers (67% versus 63%, p=0.28) at first visit was similar than men, but women received more frequently nitrates (78% versus 64%, p<0.0005), angiotensin-conversing enzyme inhibitors or receptor antagonists (56% versus 47%, p=0.004) and diuretics (41% versus 22%, p<0.0005). After up to 17 years of follow-up (median 11 years, IQR 4–15 years, with a total of 12612 patients-years of observation), probabilities of acute myocardial infarction (12% versus 14%, p=0.55) or stroke (14% versus 12%, p=0.40) at median follow up were similar for women and men. However, the risks of hospital admission for heart failure (22% versus 13%, p<0.0005) or cardiovascular death (35% versus 24%, p<0.0005) were significantly higher for women, with a non-significant trend to higher overall mortality (45% versus 39%, p=0.07). After multivariate adjustment, the risks of most events were similar for women and men (Hazard Ratios [95% confidence intervals]: 0.79 [0.55–1.14], p=0.21 for acute myocardial infarction; 0.89 [0.61–1.29], p=0.54 for stroke; 1.13 [0.82–1.57], p=0.46 for admission for heart failure; and 0.92 [0.73–1.16], p=0.48 for cardiovascular death), with a non-significant trend to lower overall mortality (0.83 [0.67–1.02], p=0.08).

Conclusion

Although women and men with sCAD presents a different clinical profile, and crude rates of hospital admissions for heart failure and cardiovascular death were higher in women, female sex was not an independent prognostic factor in this observational study with up to 17 years of follow-up.

Funding Acknowledgement

Type of funding source: None

Potential eligibility for low dose rivaroxaban treatment in a “real world” population of Spanish patients with stable coronary artery disease: a subanalysis of the CICCOR registry

Background

In the COMPASS trial, low dose rivaroxaban (2.5 mg/12h) on top of aspirin showed a 26% reduction in major cardiovascular events in patients with stable coronary artery disease (sCAD). However, information about external applicability of these results is limited. Our objective was to assess potential eligibility for this treatment in a “real world” cohort of Spanish patients with sCAD and to evaluate the incidence of major events in the long-term follow up in this population.

Methods

The CICCOR registry (“Chronic ischemic heart disease in Cordoba”, in Spanish “Cardiopatía isquémica crόnica en Cordoba”) is a prospective, monocentric study. From February 1, 2000 to January 31, 2004, all consecutive patients with sCAD attended at two outpatient cardiology clinics in a city of the south of Spain were included in the study and prospectively followed. The COMPASS inclusion and exclusion criteria were applied to this cohort, and the proportion of patients potentially eligible for this trial was described. The rate of the main COMPASS end-point (the composite of acute myocardial infarction, stroke, or cardiovascular death), as well as mortality rates, were investigated in this subset of patients, and compared with those of sCAD patients included in the aspirin alone group of the COMPASS trial.

Results

From a total population of 1268 patients, 1246 subjects presented enough data to assess eligibility. Among these, 575 patients (46%) had exclusion criteria, and another 229 (18%) did not fulfill the inclusion criteria and were not eligible. The main reasons for exclusion were requirement for dual antiplatelet therapy within 1 year of an acute coronary syndrome or coronary stent implantation (70%), high-bleeding risk (33%), other non-aspirin antiplatelet therapy (13%), atrial fibrillation (12%), anticoagulant use (11%), history of ischemic stroke (5%) and heart failure with severe left ventricular dysfunction (4%). The reason for not fulfilling inclusion criteria was the absence of additional high risk factors in patients younger than 65 years. The potentially eligible population included 442 patients (35% of evaluable patients), with up to 17 years of follow-up (median 9 years, IQR 4–15 years, only 1 patient lost in follow-up, 4174 patients-years of observation). These patients experienced higher primary outcome event rates than coronary patients actually enrolled in the aspirin alone arm of COMPASS (5.1% versus 2.9% per year), and higher rates of cardiovascular (4.0% versus 1.1%) and all-cause mortality (6.3 versus 2.1%, p<0.00005 for all comparisons).

Conclusion

More than one third of “real world” patients with sCAD of this prospective Spanish registry could be potentially eligible for low dose rivaroxaban therapy, according to COMPASS inclusion and exclusion criteria. This population had a higher risk of cardiovascular events and mortality than COMPASS participants with sCAD in the reference aspirin group.

Funding Acknowledgement

Type of funding source: None

1158 Autograft degeneration, clinical outcomes and predictors after 21 years follow up in Ross procedure. A single center experience

Background

Autograft regurgitation and the need of autograft reintervention are possible complications of Ross procedure.

Purpose

Our Aim was to identify rates of autograft degeneration, reintervention and predictive

factors valvular disease in a prospective series of a reference cardiovascular surgery hospital.

Methods

Since November 1997 to July 2009, a total of 107 patients diagnosed of aortic valvular disease requiring surgical treatment underwent Ross surgery (mean age 30 ± 11 years, 69% male, 21 patients <18 years). In all of them, a comprehensive clinical and echocardiographic evaluation was performed before the intervention and at discharge, at 6, 12 months and annually after surgery.

Results

At the end of follow-up (21 years, median: 17 years, interquartile rank 12-19 years), echocardiographic and clinical data were available in 95 (89%) and 105 (98%) patients, respectively. 30 patients (32%) developed at least moderate aortic regurgitation and 18 of them (17%) required autograft reintervention. Probability of survival free from at least moderate autograft regurgitation and reintervention at the end of follow up was 71% and 83% respectively. Two patients died because of reintervention related complications. A larger native pulmonary annulus size was the only factor, associated to autograft reintervention (HR 1.24 95% [CI] 1.04-1.48, p = 0.01) and at least moderate autograft regurgitation (HR 1.19 95% [CI] 1.03-1.37, p = 0.02). Autograft reintervention was also associated to intervention in the learning curve period (first 12 cases, HR 3.78, [CI] 95% 1.42-10.08, p = 0.008). We found no significant association of these outcomes with previous cardiac surgery, age, sex, aetiology of aortic lesion or native aortic annulus diameter.

Conclusion

At long term follow-up after Ross procedure, 32% of patients developed at least moderate autograft regurgitation and 17% required autograft reintervention. A larger size of the native pulmonary annulus and intervention in the learning curve period were associated with the need of autograft surgery in the long term follow up.

P337 Edge-to-edge mitral valve repair in patients with secondary mitral regurgitation: impact of tethering pattern on clinical, echocardiographic and procedure-related characteristics

Edge-to-edge mitral valve repair (E2E-MVR) has emerged as a therapeutical option in patients with secondary mitral regurgitation (SMR). Two tethering patterns (TP) have been described in SMR: symmetric and asymmetric. However, information on the implications of these TP on E2E-MVR is limited.

Our aim was to assess the impact of mitral valve TP on clinical, echocardiographic and procedure-related characteristics in patients undergoing E2E-MVR.

We consecutively recruited 62 patients with at least moderate SMR who underwent E2E-MVR in our center between 2011 and 2019 and analysed clinical, echocardiographic and procedure-related characteristics according to TP, which we classified into symmetric and asymmetric considering jet direction and mitral valve leaflet position during systole by means of two-dimensional transesophageal echocardiography (Figure 1).

In our series, 43 patients (69.3%) had symmetric TP and 19 (30.7%) had asymmetric TP. Asymmetric TP was associated with ischemic aetiology (52.6% vs 23.3%, p = 0.02) and a non-significant trend to higher frequency of male sex (89.5% vs 67.4%, p = 0.07), diabetes mellitus (52.6% vs 27.9%, p = 0.06), massive regurgitation (78.9% vs 58.1%, p = 0.11) and higher values of left ventricular ejection fraction (LVEF) (34 ± 9% vs 28 ± 11%, p = 0.06).

There were no differences in procedure-related characteristic between groups, in particular in number of devices (1.63 [IQR 1-2] vs 1.52 [IQR 1-2], p = 0.27), number of graspings (3.21 [IQR 2-4] vs 2.78 [IQR 2-3], p = 0.16) and time of procedure (95 ± 38min vs 107 ± 43min, p = 0.29). Procedural success (defined as SMR severity reduction≥2) was high in both groups (89.5% vs 74.4%, p = 0.18).

At discharge, there was a significant reduction in effective regurgitant orifice area (EROA) in (0.36 ± 0.16cm² vs 0.15 ± 0.10cm², p < 0.001) and pulmonary artery systolic pressure (PASP) (46 ± 12mmHg vs 40 ± 12mmHg, p = 0.004). LVEF was impaired in patients with asymmetric TP but not in patients with symmetric TP (difference in LVEF after procedure: -5 ± 9% vs -0 ± 8%, p = 0.03).

In our study, asymmetric TP was related to the ischemic aetiology of left ventricular dysfunction. Procedural characteristics, and EROA and PASP reductions at discharge were similar regardless of TP. However, patients with asymmetric TP had a significantly impairment in LVEF, probably because of afterload mismatch phenomenon.

Abstract P337 Figure 1: example of tethering patterns

P368 Ross procedure: homograft deterioration, clinical outcomes and predictors after 21 years follow up. A single center experience

Background and purpose

Pulmonary homograft stenosis can appear in long-term follow-up after Ross

intervention. Our aim was to describe the incidence, clinical impact and predictors of homograft stenosis and reintervention after the Ross procedure in a prospective series in a tertiary referral hospital after 21 years followup.

Methods

From 1997 to 2009, 107 patients underwent the Ross procedure (mean age: 30 ± 11 years; 69% men; 21 aged <18 years). In all of them, a comprehensive clinical and echocardiographic evaluation was performed before the intervention and at discharge, at 6, 12 months and annually after surgery. We analyzed echocardiographic homograft stenosis (peak gradient > 36 mmHg) and surgical or percutaneous homograft reintervention.

Results

At the end of follow-up (21 years, median: 17 years, interquartile rank 12-19 years), echocardiographic and clinical data were available in 95 (89%) and 105 (98%) patients, respectively: 28/95 (29%) patients developed homograft stenosis and 13/105 (12%) patients underwent diferent homograft reintervention procedures (five patients underwent surgical replacement, four received a percutaneous pulmonary valve and one needed stent implantation). The other three patients underwent two or even three consecutive procedures in follow-up; two died because of complications after percutaneous pulmonary valve implantation and other one after surgical replacement. Rates of survival free from homograft stenosis and reintervention at the end of the follow-up were 71% and 88%, respectively. Younger age, and especially being part of paediatric group (<18 years) at surgical

time predicted worse survival free from homograft stenosis (hazard ratio [HR] 3.88, 95% confidence interval [CI]: 1.78-8,43; p = 0.001), although there were no significant differences regarding reintervention (HR 1.54, [CI] 95% 0.42-5.58, p = 0.52). We found no significant association of this outcome with previous cardiac surgery, donor age, donor or recipient sex, homograft size, time of freezing or congenital aetiology.

Conclusions

After 21 years follow-up, incidence of homograft stenosis and reintervention after the Ross procedure were 29% and 12%, respectively; three patients had a reintervention-related death. Younger recipient age at Ross procedure was associated with a higher rate of stenosis.

P1509 Obesity and diastolic function of the left ventricle by echocardiography in a Mediterranean child population

Background

The prevalence of overweight in childhood is 26% and obesity is 12.6% in Spain. Diastolic function assessed with echocardiography shows significant worsening in obese adults compared to non-obese adults. However, few studies describe the association between obesity and diastolic function in the pediatric population.

Aim

To investigate the relationship between obesity and diastolic function in a Mediterranean pediatric population.

Methods

A random sample of children and adolescents of primary and secondary education was selected, stratifying by age, gender and educational centers in a rural town of 2864 inhabitants of southern Spain. Children between 6 and 17 years old were included. A transthoracic echocardiogram was performed to evaluate diastolic function.

Results

A total of 212 children were studied (10.9 ± 3.0 years old and 51.9% males): 163 (76.9%) were not obese and 49 (23.1%) were obese. Age and sex were similar in both groups. Results are shown in the table. Obesity was related to a larger left atrial volume, a higher A-wave velocity, a lower lateral e "wave velocity, a higher average E/e ratio, and a higher pressure gradient between the atrium and the right ventricle.

Conclusions

Obesity in childhood is associated to worsening of diastolic function parameters commonly measured in echocardiography.

Obese Vs non-Obese non-obese obese p Age 10,8 ± 3,0 11,0 ± 2,8 0,63 Male (%) 50,1% 57,1% 0,4 A-wave velocity (cm/s) 58,7 ± 13,1 64,8 ± 13,8 0,005 E/A 1,89 ± 0,45 1,75 ± 0,41 0,05 lateral e" velocity (cm/s) 21,26 ± 4,61 19,58 ± 3,97 0,02 average E/e" 6,4 ± 1,1 7,0 ± 1,2 0,001 left atrial volume (mL) 20,8 ± 6,8 27,9 ± 7,4 <0,0005 pressure gradient (mmHg) 15,5 ± 4,5 18,0 ± 4,9 0,02

P1415 Obesity and epicardial fat in a Spanish infant population by echocardiography

Introduction

Childhood obesity is currently a mayor public health problem. There is a direct relationship between a high body mass index with a higher cardiovascular morbimortality. Among child population 4 out of 10 individuals are overweight, the prevalence of overweight is 26 per cent and the prevalence of obesity is 12,6 per cent. The epicardial fat is a heart visceral adiposity index, may play a role in the coronary atherosclerosis pathogenesis, a chronic inflammatory disease and in heart disease. The rise in the epicardial fat is considered as a target organ injure in child population.

Aims

To know the relationship between childhood obesity and echocardiographic parameters of epicardial fat, as a target organ injure among the child Mediterranean population.

Methods

Randomly, we selected a sample of children and adolescents of primary and secondary education, in a rural town of 2864 inhabitants of southern Spain. We include children between 6-17 years. We performed transthoracic echocardiography, with measurements of 2D epicardial fat, in systole in parasternal long axis (PLA) and parasternal short axis (PSA), taking the measure as the average of 3 measurements in consecutive beats.

Results

We studied a total of 212 children (10.9 ± 3.0 years and 51.9% males), 45 (21.3% were obese), of which 7.2% were diagnosed with hypertension (HBP), 5.1% with metabolic syndrome and 5.3% as prediabetic. The thickness of the epicardial fat in PLA was related to Obesity 2.2 ± 0.7 mm vs 1.75 ± 0.5 mm p (<0.001); HBP 2.16 ± 0.9 mm vs. 1.86 ± 0.5 mm (P <0.05); Metabolic syndrome 2.23 ± 0.8 mm vs 1.81 ± 0.5 mm (P <0.05), in PSA: Obesity 2.36 ± 0.7 mm vs 1.78 ± 0.6 mm p (<0.001); HBP 2.31 ± 0.6 mm vs 1.88 ± 0.6 mm (P <0.05); Metabolic syndrome 2.43 ± 0.8 mm vs 1.87 ± 0.6 mm (P <0.01) and overall combining PLA and PSA views: Obesity 2.27 ± 0.7 mm vs 1.76 ± 0.5 mm p (<0.001); HBP 2.23 ± 0.7 mm vs 1.85 ± 0.5 mm (P <0.05); Metabolic syndrome 2.23 ± 0.7 mm vs 1.84 ± 0.5 mm (P <0.01).

Conclusion

In a random Spanish pediatric population correlation is found by echocardiography of the thickness of epicardial fat with obesity, HBP and metabolic syndrome. Being this a rapid test, non-invasive and without ionizing radiation.

P3444Overweight and obesity in a Mediterranean pediatric population: impact in cardiac chambers morphology and systolic function

Background

Obesity is a major medical and public health problem. A high body mass index has been associated with increased mortality and cardiovascular disease morbidity. Obesity in adults is related to hypertrophy and left ventricular dilatation. Previous studies have shown that, in Spain, the prevalence of overweight and obesity in childhood is 26% and 12.6% respectively. The association between obesity and left ventricular morphology has been poorly studied in the pediatric population.

Aim

To investigate the relationship between childhood obesity and the dimensions of cardiac structures and systolic function in a Mediterranean pediatric population.

Methods

A random sample of children and adolescents in primary and secondary education was selected, stratified by age, gender and educational centers in a rural town of 2864 inhabitants in southern Spain. Children between 6 and 17 years old were included. A transthoracic echocardiogram was performed for the evaluation of cardiac chambers morphology and systolic function.

Results

A total of 212 children were studied (10.9±3.0 years old and 51.9% males): 106 (50%) were normal weight, 57 (26.9%) were overweight and 49 (23.1%) were obese. Results are shown in the table. Age and sex were similar in the three groups. Overweight and obesity were related to larger values of left ventricle end-diastolic diameter and volume, left atrial volume and right ventricle basal diameter, and lower values of left ventricle ejection fraction.

Normal weight Overweight Obese p Age 10.9±3.2 10.7±2.7 11.0±2.8 0.79 Male (%) 50.9% 49.1% 57.1% 0.69 End-diastolic left ventricle diameter (mm) 41.1±5.5 42.8±5.4 44.2±5.5 0.003 End-diastolic left ventricle volume (mm) 57.9±18.6 64.3±18.3 78.1±22.4 <0.0005 Interventricular septum (mm) 6.3±1.4 6.7±1.3 7.0±1.7 0.01 Left ventricle mass (g) 69.3±30.1 80.9±30.2 94.8±36.5 <0.0005 Left atrium volume (mm) 19.7±6.8 22.6±6.5 27.9±7.4 0.004 Basal right ventricle diameter (mm) 27.6±4.5 28.0±3.9 30.2±4.2 0.001 Left ventricle ejection fraction (%) 65.7±3.6 63.6±4.7 61.5±4.6 <0.0005

Conclusions

Overweight and obese children have larger cardiac chambers, higher left ventricular mass, and worse systolic function compared with normal weight children of similar age and sex.

P6448Major cardiovascular events free survival in the long term follow up of “real world” diabetic patients with stable coronary artery disease at the beginning of the 21st century. The CICCOR Registry

Background

Safety trials of antidiabetic drugs have included a main endpoint of cardiovascular morbidity and mortality. However, “real world” data on long term prognosis of diabetic patients with stable coronary artery disease (sCAD) are limited. This study aimed to assess long-term incidence of major cardiovascular events in this population and to identify clinical predictors of this end-point.

Methods

The CICCOR registry is a prospective, monocentric, cohort study. From February 1, 2000 to January 31, 2004, all consecutive patients with sCAD attended at two outpatient cardiology clinics in a city of the south of Spain were included in the study and prospectively followed. Patients with type 2 diabetes mellitus were selected for this analysis. None of these patients received sodium-glucose cotransporter-2 inhibitors at first visit, as they were not commercially available at that time. Survival free of major cardiovascular events (combined end-point: acute myocardial infarction, stroke, or cardiovascular death) and variables associated with this end-point were investigated.

Results

The study sample included 394 patients (mean age 68±9 years, 61% male). After up to 17 years of follow-up (median 9 years, IQR 4–14 years, only 2 patients lost in follow-up, with a total of 3517 patients-years of observation), 66 had an acute myocardial infarction, 55 had an stroke and 165 died for cardiovascular causes. Survival free of major cardiovascular events was 88%, 70%, 57%, 47% and 32% at 3, 6, 9, 12 and 15 years. Multivariate predictors of the combined end-point are shown in the table.

Predictors of major cardiovascular event Variable Hazard Ratio (95% CI) p value Age (year) 1.06 (1.04–1.08) <0.0005 Tobacco use 0.02 Never smoker 1 (reference) Ex-smoker 1.43 (1.02–1.99) 0.04 Active smoker 2.23 (1.16–4.30) 0.02 Functional Class ≥II (angina) 1.57 (1.14–2.16) 0.006 Resting heart rate (10 bpm increase) 1.12 (1.01–1.24) 0.04 Diuretic treatment at first visit 1.71 (1.26–2.30) 0.001

Conclusions

Probability of major event-free survival was only 47% at 12 years in this “real world” cohort of diabetic patients with sCAD followed in the first 17 years of this century in a single center in the south of Spain. Simple clinical variables can identify patients at higher risk of events.

Acknowledgement/Funding

This work has been partially financed by an investigational grant by Boehringher Ingelheim

Clinical pharmacokinetics of tacrolimus in heart transplantation: new strategies of monitoring

The aim of this study was to investigate the absorption profile of tacrolimus (TAC) in heart transplant patients in order to find the best sampling time to predict the total exposure and to explore the target range for optimal clinical immunosuppression. Twenty-five full pharmacokinetic studies were performed in 22 heart transplant patients (11 men and 7 women) at less than 1 year posttransplant. The immunosuppressive treatment was steroids plus azathioprine or mycophenolate mofetil and TAC. The mean age was 55 years (36-64 years) and the mean weight 70.49 kg (50-111 kg). After three days of receiving the same dose, eight blood samples were collected at 0.5, 1, 2, 4, 6, 8, and 12 hours postmorning dose. TAC concentrations were measured by microparticle enzyme immunoassay (IMx). Area under the concentration-time curve(AUC(0-12)) was calculated by the trapezoidal rule. Using 0-4 hours TAC blood concentrations, a projected 12 hours AUC (extrapolated AUC(0-4)) was calculated assuming C0 and C12 were comparable. A high interpatient TAC pharmacokinetics variability that was greater during the absorption phase was observed. A Cmax (30.5+/-13.8 ng/mL) was reached at 2.3+/-1.5 h. When target trough levels were achieved (10-20 ng/mL), the mean tacrolimus exposure was 230.6+/-59.2 ng h/mL (120.14-327.7) (n=19). Correlation between AUC(0-12) and C0 was relatively good (r2=0.74). Between individual time points, C4 showed the best correlation (r2=0.88). In any case the best strategy to monitor is to obtain the extrapolated AUC(0-4) (r2=0.98), as a good approach to patients with a poor response to treatment.

Comparing the well-being of post-caregivers and noncaregivers

Researchers who study family caregiving have begun to recognize the need to broaden the realm of inquiry to include the exploration of the positive aspects of caregiving as well as conceptualizing caregiving on a continuum from the pre-caregiving phase through the post-caregiving phase. Additionally, researchers are urged to use control groups in research. This study complements the current trends by examining the positive aspects of caregiving among former caregivers. Specifically, the well-being of post-caregivers is compared to that of noncaregivers. Bivariate analyses examine the factors that are significantly different between former caregivers and noncaregivers. Results show that former caregivers have higher well-being than noncaregivers. In the multivariate model, only one subscale of well-being (basic needs) is different between the two groups. Implications of this research are discussed.

The Caregiver Well-Being Scale revisited

The Caregiver Well-Being Scale measures caregiver well-being from a strengths-based perspective by assessing caregivers' basic human needs and satisfaction with activities of daily living. This article revisits the scale to examine further the scale's psychometric properties using a caregiver-only sample. Reliability is determined through internal consistency. Construct validity is supported through factorial validity with factor analysis. Criterion-related validity is established by examining the concurrent validity of the Well-Being Scale with a measure of depression. Using a sample of family caregivers, results suggest that the Well-Being Scale is a valid and reliable measure.

[Clinical features and prognosis of infective endocarditis in the elderly]

INTRODUCTION AND OBJECTIVES

In recent decades the mean age of patients with infective endocarditis has progressively increased. The objective of the present study was to describe the clinical features and prognoses of infective endocarditis in the elderly.

METHODS

A prospective study was performed of 125 non drug abuser patients over the age of 14 years and admitted from 1987 until 1997 in a single institution. Twenty-one patients were older than 65 years.

RESULTS

No significant differences were observed among the age groups with respect to delay in diagnosis, clinical signs, site of the infection and the rate of negative blood cultures. Prosthetic valve endocarditis was more frequent in elderly than in younger adults (41 and 33%, respectively). S. viridans and enterococcus were more frequent (47 compared with 29% in younger adults, p < 0.05). Elderly patients underwent surgery less frequently (46 versus 56%) and most surgery was performed on an emergency basis. The in hospital mortality was higher in the elderly (50 versus 15%), p < 0.05.

CONCLUSIONS

Prosthetic valve endocarditis and severe complications during the active phase are more frequent in the elderly and this is related to a worse prognosis in the short and intermediate term. A higher rate of elective surgery during the active phase could improve the prognosis of infective endocarditis in the elderly.

[Short and long-term prognosis of prosthetic valve endocarditis in non-drug addicts]

INTRODUCTION AND OBJECTIVES

Prosthetic valve infective endocarditis is a complication of valvular replacement surgery with a high morbimortality during the in-hospital phase and an important risk of complications during follow-up. The objective of the present study is to assess the clinical features and the short and long-term prognosis of this disease.

PATIENTS AND METHODS

A prospective study of 43 consecutive cases of prosthetic valve endocarditis in non-addict patients from January 1987 to March 1997.

RESULTS

The mean age was 51 +/-16 years. Eight patients (19%) had early prosthetic valve endocarditis (two months following heart surgery), fourteen patients (32%) had intermediate (between 2 and 12 months post surgery) and twenty-one (49%) had late prosthetic valve endocarditis (more than one year after heart surgery). Transesophageal echocardiography was performed in 32 patients with a sensibility of 81%. Complications occurred in 86% of patients and 53% of patients underwent surgery during the active phase (25% was emergency surgery). Inpatient mortality was 23% (50% in early prosthetic valve endocarditis). After a mean follow-up of 56 months there were 5 cases of recurrence, four patients required late surgery and 5 patients died. Survival (excluding early mortality) was 82% at 5 years with no significant differences among patients who received only medical treatment and those who underwent surgery in the active phase.

CONCLUSIONS

Early mortality of prosthetic valve endocarditis is, according to our experience of 20%. The prognosis of survivors to the active phase is favourable in the majority. Early prosthetic valve endocarditis still causes a high mortality rate despite the use of combined medical surgical treatment in most cases.

[The general characteristics and short- and long-term results of infective endocarditis in non-drug addicts]

INTRODUCTION AND OBJECTIVES

Infective endocarditis is a disease with a high morbimortality during the active phase and a considerable risk of complications during follow-up. The aim of our study is to describe the clinical and prognostic features of infective endocarditis in non-drug addict patients in short and long terms.

PATIENTS AND METHODS

A prospective study of 138 cases of infective endocarditis in non-drug addict patients through the parenteral pathway treated in our institution from 1987 to 1997.

RESULTS

The mean age was 44 +/- 20 years. Ninety-five patients (69%) had native valve infective endocarditis and forty-three (31%) had prosthetic valve endocarditis. Streptococci were the causal microorganism in 34% and staphylococci in 33%. 83% of patients developed some type of complications during hospital stay. 51% of patients were operated on during the active phase (22% were urgent). The in-hospital mortality rate was 21%. 10 patients (9%) needed late cardiac surgery and seven patients (5%) died during follow-up. Global survival at 10 years was 71%. There were no statistical differences in survival in as much as the type of treatment received during the hospital stay in the active phase (medical alone or combined medical-surgical).

CONCLUSIONS

A high early surgery rate in the active phase related to good long-term results and does not increase early in-hospital mortality. Medical treatment also offers good long-term results in cases of infectious endocarditis with absence of bad prognostic factors and good clinical outcome.

[Embolism in the right heart chambers: the diagnostic and therapeutic aspects]

Deep venus thrombosis may result in pulmonary embolism. In rare instances, embolization has occurred, not directly to the pulmonary arterial tree, but to the right heart chambers. Although the value of echocardiography in the diagnosis is well recognised, their is no consensus for the appropriate treatment. We report herein six cases of floating right atrial thrombi, diagnosed by echocardiography, in patients with pulmonary embolism, or unexplained shock or syncope. Surgical embolectomy was carried out in 4 patients, and thrombolytic therapy in 2, without in-hospital mortality. The high mortality associated to this entity may be improved by rapid echocardiographic recognition and emergency treatment with thrombolysis or surgery. Our data suggest the possible use of thrombolysis as a first-choice therapy in selected patients.

[Mobile thrombus in the right cardiac cavities in patients with severe pulmonary thromboembolism. Importance of echocardiography]

The pulmonary thromboembolism is a frequent and severe disease, usually difficult to recognize, specially in patients with thrombotic material trapped within right heart cavities. We present our experience in three patients with severe pulmonary thromboembolism where echocardiographic study demonstrated the presence of huge mobile thrombus in right heart cavities, which demanded urgent therapy with excellent results. We would like to stress that echocardiographic study in these patients could be elective diagnostic procedure, avoiding the realization of pulmonary arteriography, which could bring risk of possible thrombus mobilization.

Direction tuning of individual retinal inputs to the turtle accessory optic system

Neurons in turtle accessory optic system [basal optic nucleus (BON)] were recorded to study convergence of retinal afferents, using whole-cell patch electrodes in a reduced in vitro brainstem preparation with the eyes attached. BON cells primarily exhibit EPSPs from a contralateral retinal ganglion cell input and generate an output of action potentials. Visual responses were evoked by different directions of either full-field or local moving patterns. Direction tuning of action potentials was compared with that of EPSPs detected by passing the membrane voltage through an AC amplifier and window discriminator. This rough measure of retinal input indicated that the direction tuning of the full-field excitatory input from the retina matched that of the spike output for the same BON cell. Using local patterns within the receptive fields of the BON cells, it was estimated that one to four adjacent retinal inputs were being stimulated. The direction tuning of these inputs had preferred directions that were similar to that of the full-field spike output of the cell, irrespective of where the small window was placed within the receptive field. Because more than one retinal input may have been stimulated by the small stimulus window, subsets of those EPSPs that may represent responses of a single retinal afferent were identified based on their amplitude and rise time. Again, the preferred direction of those putative single retinal afferents matched the direction tuning of the spike output of the BON cell. These findings are discussed in terms of the formation of the retinal slip signal by the BON.

Triage services: a profile of high utilization

With challenges continuing to be presented to health care delivery, inappropriate out-patient service utilization is of utmost concern to all health care service providers. This study is an examination of the utilization patterns of 189 veterans in an urban Veterans Administration Medical Center (VAMC). Factors found to be related to high utilization of ambulatory care triage clinic services for veterans who had presented for at least two unscheduled visits in the past six months include: patient perception of health status; number of prescription medications; and social needs. Implications for social work practice, program development and research are discussed.

Is a history of alcohol problems or of psychiatric disorder associated with attrition at 11-year follow-up?

Although rarely available, detailed analyses of attrition in psychiatric surveys are important because surveys of this type might be more vulnerable to follow-up losses. In this report the demographic characteristics, as well as history of alcohol problems and psychiatric disorders of responders were compared to nonresponders in an 11-year follow-up study. Data revealed few differences between responders and nonresponders. Men, those less educated, and low users of medical care were more likely to be nonresponders, as were those reporting driving trouble when drinking or a history of barbiturate abuse or dependence. A history of other psychiatric disorders was not associated with nonresponse. Refusal conversion did not change the findings; those who were converted (25% of initial refusals) had demographic characteristics, symptoms of alcohol abuse, and psychiatric histories comparable to those who resisted conversion. These findings suggest that efforts to convert refusals to responders might not be necessary. The results also support community psychiatric research by providing evidence that those with a history of psychiatric disorder are not more difficult to recruit than their unaffected counterparts.