Transthyretin amyloid polyneuropathy in France: A cross-sectional study with 413 patients and real-world tafamidis meglumine use (2009-2019)

OBJECTIVE

We aimed to describe characteristics of patients with ATTR variant polyneuropathy (ATTRv-PN) and ATTRv-mixed and assess the real-world use and safety profile of tafamidis meglumine 20mg.

METHODS

Thirty-eight French hospitals were invited. Patient files were reviewed to identify clinical manifestations, diagnostic methods, and treatment compliance.

RESULTS

Four hundred and thirteen patients (296 ATTRv-PN, 117 ATTRv-mixed) were analyzed. Patients were predominantly male (68.0%) with a mean age of 57.2±17.2 years. Interval between first symptom(s) and diagnosis was 3.4±4.3 years. First symptoms included sensory complaints (85.9%), dysautonomia (38.5%), motor deficits (26.4%), carpal tunnel syndrome (31.5%), shortness of breath (13.3%), and unexplained weight loss (16.0%). Mini-invasive accessory salivary gland or punch skin and nerve biopsies were most common, with a performance of 78.8-100%. TTR genetic sequencing, performed in all patients, revealed 31 TTR variants. Tafamidis meglumine was initiated in 156/214 (72.9%) ATTRv-PN patients at an early disease stage. Median treatment duration was 6.00 years in ATTRv-PN and 3.42 years in ATTRv-mixed patients. Tafamidis was well tolerated, with 20 adverse events likely related to study drug among the 336 patients.

CONCLUSION

In France, ATTRv patients are usually identified early thanks to the national network and the help of diagnosis combining genetic testing and mini-invasive biopsies.

Wintertime aerosol properties of urban desert region of western India: Implications in regional climate assessment

This study assessed the inter-relation between physiochemical and optical characteristics of aerosols measured at a desert-urban region affected by anthropogenic sources and desert dust during October 2020 to January 2021. Based on horizontal visibility and measured PM_2.5 concentration, clear (37 %), light (33 %) and high (31 %) pollution periods were identified. Elemental and organic carbon (50 ± 15 μgm^-3_; 31 %) and secondary inorganics (53 ± 21 μgm^-3; 33 %) dominated the PM_2.5 mass (160 ± 4 μgm^-3) during high pollution period with low dust (14 ± 7 μgm^-3; 8 %) content. Interestingly, the clear pollution period was also influenced by carbonaceous fraction (19 ± 8 μgm^-3; 32 %) and secondary inorganics (19 ± 5 μgm^-3; 32 %), but the PM_2.5 concentrations (59 ± 9 μgm^-3) were ∼ one-third as compared to high pollution period. High scattering coefficients were observed which were comparable to highly polluted Indian city like Delhi. An exponential increase in non-absorbing material was observed and showed clear influence on light absorption capacity of EC and dust due to coating/mixing. High absorption Ångström exponent (AAE) >0.6 was observed for the ratio of non-absorbing to light absorbing components (LAC) in the range of 1-2.5 and EC/PM_2.5 fraction of 7-14 %. While further increase in non-absorbing to absorbing components ratio > 4 and low amount of EC (<4 %) tend to decrease AAE below 0.4. Higher mass absorption cross-section (>30 m²g^-1 of EC) was observed when 4-10 % EC fraction of PM_2.5 associated with 1.5-3.5 times non-absorbing components to total absorbing components. Likewise, absorption enhanced by three to five folds compared to uncoated EC for low EC fraction (3-6 %) in PM_2.5, but high non-absorbing to absorbing component ratio (>2.5). Interestingly, absorption was minimally amplified for nominal coating fraction associated with significant core materials or vice-versa. These findings have implications not only in regional climate assessment but also for other regions with comparable geography and source-mixes.

Size fraction of hazardous particulate matter governing the respiratory deposition and inhalation risk in the highly polluted city Delhi

Delhi has been identified as one of the highly polluted cities in the world and recently associated with the highest population weighted PM_2.5 concentration. However, the unavailability of the health risk estimations using long-term data for Indian cities has been pointed out as a hurdle in performing the correct assessment. The present work estimated deposition of particles in different regions of respiratory systems (head airway = 67% deposition for 2.5 µm particles; tracheo-bronchiolar (TB) = 73% deposition for 1.0 µm particles; alveolar (AL) = 17% deposition for 0.5 µm, 0.25 µm, and < 0.25 µm particles) using PM samples collected at a breathing height of 1.5 m near the major ring road in New Delhi (India). The calculated risk index (RI) varied considerably between winter (1.21 ± 0.26 to 1.33 ± 0.50) and pre-monsoon-southwest monsoon months (0.34 ± 0.08 to 0.96 ± 0.27). Respiratory deposition dose of nanosized particles (≤ 500 nm) in the alveoli region of the lung was found to be considerable (35%) indicating the need for understanding the role of these particles in posing health risk. Although the calculated values of risk metric for exposures of PM-associated metals indicated no risk to IIT Delhi population (hazard quotient < 1 and excess risk of getting cancer < 10^-6-10^-9), continuous monitoring for particles of different sizes at inhalation height are required for protecting human health.

Cutibacterium acnes endocarditis: a multicenter case series

Background

Infective endocarditis (IE) due to Cutibacterium acnes (C. acnes) (formerly known as Propionibacterium acnes) is challenging to diagnose. It is suggested that patients often present without fever nor inflammatory parameters. Meanwhile, cardiac abscesses and valve dysfunction are often reported, with a high percentage of patients requiring cardiac surgery [1–7]. No study has yet confirmed the atypical presentation of IE caused by C. acnes.

Purpose

To study clinical characteristics and outcomes of patients with C. acnes IE.

Methods

A multinational retrospective case series was conducted. Patients who were diagnosed with definite IE according to the modified Duke criteria between 2010 and 2020 were included. There were six participating hospitals. Cases were identified by positive blood cultures or positive valve/prosthesis cultures. Clinical data was retrieved from medical records.

Results

We identified 61 cases of C. acnes IE. Patients were predominantly male (n=58, 95%) and had previous cardiac surgery (n=56, 91.8%), which in most cases consisted of aortic valve replacement or Bentall procedures (n=34, 60.7% and n=13, 23.2% respectively). The median time between index surgery and presentation was 31 months (IQR 15.9–69.3). At presentation, fever was absent in 59% of patients (n=36). Most patients experienced symptoms for one to two weeks prior to hospital presentation (41%). At presentation, the median CRP level was 35.5 mg/L (IQR 10.0–70.8). Moreover, in 23% of patients (n=14), the median CRP level was not elevated (&lt;10.0 mg/L). The median leucocyte count at presentation was 9.8x109/L (IQR 8.0–12.3), and thus not exceeding the upper limit of the normal range (10.0x109/L). Approximately half of the blood cultures became positive. In addition, the median time to positivity of blood cultures was seven days (IQR 6–9) and 82.4% of patients had a time to positivity of more than five days. (Redo) surgery was performed in 40 patients (65.5%). Peroperatively, valve dehiscence was observed in 19 patients (47.5%) and vegetations and abscesses were present in 16 patients (40%). The 30-day and one-year mortality rates were 4.9% and 11.5% respectively. Eight patients experienced relapse IE during follow-up of which seven initially received conservative treatment.

Conclusion

IE due to C. acnes predominantly concerns males with prosthetic heart valves. The diagnostic process in C. acnes IE is difficult due to its atypical presentation, with frequent absence of fever and inflammatory parameters. Meanwhile, blood cultures remain negative in approximately half of the patients. Moreover, the time to positivity of blood cultures is one week, which further delays the diagnostic process. Redo surgery is required in a high percentage of patients.

Funding Acknowledgement

Type of funding sources: None.

Characteristics, management, and outcomes of patients with left-sided infective endocarditis complicated by heart failure: a substudy of the ESC-EORP EURO-ENDO (European infective endocarditis) regist

Background/Introduction

Congestive heart failure (CHF) is a strong prognostic factor in infective endocarditis (IE), but data are lacking regarding its current management and outcome in Europe.

Purpose

To evaluate the current management and survival of patients with left-sided IE complicated by CHF.

Methods

We used data of the ESC-EORP EURO-ENDO registry, which is a prospective multicentre observational study conducted between January 1, 2016 and March 31, 2018 in 156 centres in 40 countries. The primary endpoints were 30-day and one-year mortality.

Results

Among the 3116 patients enrolled in this prospective registry, 2449 (mean age: 60 years, 69% male) with left-sided (native or prosthetic) IE were included in this study. Patients with CHF (n=698, 28.5%) were older, with more comorbidity and more severe valvular damage (mitro-aortic involvement, vegetations &gt;10mm and severe regurgitation/new prosthesis dehiscence) than those without CHF (all p≤0.019). Patients with CHF experienced higher 30-day and one-year mortality than those without (20.5% vs. 9.0% and 36.1% vs. 19.3%, respectively) and CHF remained strongly associated with 30-day (OR [95% CI]: 2.37 [1.73–3.24]; p&lt;0.001) and one-year mortality (HR [95% CI]: 1.69 [1.40–2.05]; p&lt;0.001) after adjustment for established outcome predictors, including early surgery, or after propensity matching for age, sex, and comorbidity (n=618 [88.5%] for each group, both p&lt;0.001). Early surgery, performed on 49% of these patients with IE complicated by CHF, remained associated with a substantial reduction in 30-day mortality following multivariable analysis, after adjustment for age, sex, Charlson index, cerebrovascular accident, staphylococcus aureus IE, Streptococcal IE, uncontrolled infection, vegetation size &gt;10mm, severe valvular regurgitation and/or new prosthetic dehiscence, perivalvular complication, and prosthetic IE (OR [95% CI]: 0.22 [0.12–0.38]; p&lt;0.001) and in one-year mortality (HR [95% CI]: 0.29 [0.20–0.41]; p&lt;0.001).

Conclusion

CHF is common in left-sided IE and is associated with older age, greater comorbidity, more advanced lesions, and markedly higher 30-day and one-year mortality. Early surgery is strongly associated with lower mortality but is performed on only approximately half of patients with CHF, mainly because of a surgical risk considered prohibitive.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott Vascular Int. (2011–2014) Amgen Cardiovascular (2009–2018),

Risk calculator to predict 30-day mortality in left-sided infective endocarditis. The EURO-ENDO score

Background/Introduction

Infective endocarditis (IE) is associated with high in-hospital mortality, despite improvements in therapeutic strategies. Nonetheless, there is no prospective risk model to estimate IE mortality.

Purpose

We sought to develop and validate a calculator to predict 30-day mortality risk regarding to perform surgery or medical treatment alone in left-sided IE.

Methods

This is a prospective, multicenter registry that included patients between January 2016 and March 2018 with a diagnosis of IE based on ESC 2015 diagnostic criteria. Patients with possible or definite left-sided IE were included in the analyses. Clinical, biological, microbiological and imaging data were collected. The primary end point was 30-day mortality in patients with left-sided IE. The risk calculator was based on multivariable Cox regression models. The accuracy of the logistic regression models was assessed by discrimination and calibration using C-statistic and Hosmer-Lemeshow test.

Results

Among 3116 patients included, 2171 patients presented left-sided IE and 257 patients (11.8%) died during the first 30 days of IE diagnosis. After multivariable Logistic regression analysis, eleven variables were associated with 30-days mortality and were included in the calculator: previous cardiac surgery, previous stroke/TIA, creatinine &gt;2 mg/dL, S. aureus infection, embolic events on admission, heart failure or cardiogenic shock, vegetation size &gt;14 mm, presence of abscess, severe regurgitation, double left-sided IE and no left valve surgery. There was an excellent correlation between the predicted 30-days mortality in both models with or without performing left valve surgery (area under the receiver operator curve: 0.798 and 0.758, respectively). Moreover, calibration by Hosmer-Lemeshow were 0.085 and 0.09, respectively).

Conclusion(s)

Our risk score in patients with left-sided IE provides an accurate individualized estimation of 30-day mortality according to perform or not perform left-valve surgery. It allows medical professionals to determine whether submitting patients to surgery or not, and thus improve their prognosis.

Funding Acknowledgement

Type of funding sources: None.

Redo isolated tricuspid valve surgery: prediction of in-hospital mortality using the TRI-SCORE

Background

Redo isolated tricuspid valve surgery (ITVS) is rarely performed. The TRI-SCORE reliably predicts in-hospital mortality after ITVS on native valve but has not been tested in the setting of redo interventions.

Purpose

We aimed to compare the predictive value of the TRI-SCORE to other surgical risk scores for redo ITVS.

Methods

Using a mandatory administrative database, we identified all consecutive adult patients who underwent a redo ITVS at 12 French tertiary centers between 2007 and 2017. Baseline characteristics and outcomes were collected from chart review and the TRI-SCORE, Logistic EuroSCORE, EuroSCORE II and STS were calculated.

Results

We identified 70 patients who underwent a redo ITVS (mean age 54±15 years, 63% female). Prior intervention was a repair in 51% and a replacement in 49%. A tricuspid valve replacement was performed in all patients. In-hospital mortality was 10%. The TRI-SCORE was the only risk score associated with in-hospital mortality (p=0.01). Area under the receiver operating characteristic curve for the TRI-SCORE was 0.83, much higher than with logistic EuroSCORE (0.58), EuroSCORE II (0.61) or STS (0.59). The table presents the observed and predicted values of in-hospital mortality according to TRI-SCORE categories.

Conclusion

The TRI-SCORE accurately predicted in-hospital mortality after redo isolated tricuspid valve surgery and may guide the clinical decision-making process especially as transcatheter therapies are emerging.

Funding Acknowledgement

Type of funding sources: None.

Physical, chemical and optical properties of PM2.5 and gaseous emissions from cooking with biomass fuel in the Indo-Gangetic Plain

The current study was designed to capture real-world cooking process-wise emissions generated by the combustion of mixed biomass fuel in traditional mud cookstoves in rural kitchens of the north Indian state of Uttar-Pradesh during regular meal preparations. Combustion characteristics, including modified combustion efficiency, thermal efficiency and burn rate, were examined to understand their relationship with emissions. Variations were observed in emission factors (EFs) of PM_2.5, trace gases, namely CO, CO₂, NO_x and SO_2, for different cooking processes. While the highest emission of PM_2.5, CO and SO₂ were observed for boiling (7.0 ± 2.7, 68 ± 29.3, 1.0 ± 1.7 gkg^-1, respectively), CO₂ and NO_x recorded the highest EFs for frying (1537 ± 278.2 & 1.6 ± 0.9 gkg^-1 respectively). Although the study reported similar carbon content emissions for different processes, high EC emissions were observed for baking (1.1 ± 0.3 gkg^-1). A high concentration of K⁺ (indicating biomass burning) and toxic trace metals including Al, Cu, Sr, Ti, Mo & Cd has been reported in the present study. EFs of black carbon and brown carbon from mixed fuel burning during uncontrolled cooking have been discussed for different cooking processes which are critical inputs to emission inventories and radiative forcing calculation. The processes of frying and sautéing were found to be more consistent in emissions of pollutants than boiling and baking (variability- 13 %-167 %). Overall, this study emphasizes that a measurement of combustion characteristics and cooking method type should also be contemplated along with fuel and stove types during field emission studies.

A global perspective of the current state of heavy metal contamination in road dust

Heavy metals are persistent and bio-accumulative, and pose potential risk to human health and ecosystem. We reviewed the current state of heavy metal contamination, the ecotoxicological and human health risk of heavy metals reported in urban road dust from various cities in different continents (Asia, Europe, Africa, America, and Australia). We compared and synthesized the findings on the methods related to sample collection, extraction, analytical tools of heavy metals, their concentrations, level of contamination, ecological risk, non-carcinogenic risk, and carcinogenic risk in road dust. Concentrations of Pb, Zn, Cu, Ni, Cd, Cr, Mn, and Fe were found to be higher than their background values in soil. As expected, the contamination levels of the heavy metals varied extensively among cities, countries, continents, and periods. A high level of contamination is observed for Pb and Cd in road dust due to operating leaded gasoline and the old vehicle population. The highest Zn contamination was observed from road dust in Europe, followed by Asia, Africa, Australia, and America (North America and South America). Cu contamination and the pollution load index (PLI) is found to be the highest in Europe and lowest in Africa, with in-between values of PLI in American and African cities. The potential ecological risk on different continents was observed highest in Asia, followed by Europe, Australia, America, and Africa. A comparative assessment of non-carcinogenic risk for children indicated that Australia is the most susceptible country due to high heavy metal exposure in road dust, followed by Asia. However, there is no susceptible risk in European, African, and American cities. We did not observe any potential risk to adults due to non-carcinogenic metals. Carcinogenic risk to all age groups was within the threshold limit range for all the regions worldwide.

Factors associated with favorable outcomes in patients undergoing transcatheter edge-to-edge mitral valve repair (TEER) with the mitraclip device

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter edge-to-edge mitral valve repair (TEER) has over the years become a viable alternative to surgery in high-risk patients with severe symptomatic mitral regurgitation (MR). Selection of optimal candidates who will benefit from the procedure remains challenging.

Our study aims to determine clinical, echocardiographic and procedural factors associated with favorable outcomes after mitraclip implantation. 

Methods

We retrospectively analyzed the data concerning patients who underwent MitraClip implantation for symptomatic severe MR in our institution. 

All patients underwent a clinical evaluation and a transthoracic echocardiography before the procedure, and at follow up (between one and up to three months after the index procedure). 

A clinical endpoint combining absence of cardiovascular death, absence of rehospitalization for heart failure and improvement of at least 1 class New York Heart Association NYHA at three months, was used to define a good response.

Results

Among 109 patients referred to our institution for TEER since January 2018, 106 had a successful clip implantation and were included in our study. 76 of them had a primary MR and 30 others a secondary mitral regurgitation (SMR). The primary endpoint was achieved in 65% of those patients.  Reduction of MR severity to less than grade 2+ was achieved in 87% of the patients. 

A high body mass index (p = 0.03), a high level of NT-proBNP at admission (p = 0.02), the association with at least a moderate tricuspid regurgitation prior to mitraclip implantation (p = 0.02) and a severe residual mitral regurgitation (p = 0.01) were predictive of a worse outcome in all patients. In the group of secondary MR, patients who reached the primary endpoint had significantly a lower telediastolic diameter (p = 0.02). A post procedural transvalvular mitral gradient superior to 4.4 mmHg was associated with a worse prognosis in patients with primary mitral regurgitation (p = 0.004) but not in the group of secondary mitral regurgitation (p = 0.7). Furthermore, the ratios EROA/LVEDV and VR/LVEDV defining proportionate mitral regurgitation were not correlated to any benefit in the secondary MR group. 

Conclusion

Our study in real life patients found some elements supporting the results of former studies about predictors of outcomes after mitraclip treatment. Tricuspid regurgitation prior to the procedure and an elevated mitral valve pressure gradient after clip implantation are correlated with a worse prognosis. In accordance with recent literature, an elevate mean gradient seems to have less impact on prognosis in SMR, fostering to get optimal MR reduction in those patients. Identifying criteria that would predict insufficient benefit of Mitraclip implantation is necessary to avoid futility.

Multimodal imaging assessment of left atrial strain in cardiac amyloidosis and hypertrophic cardiomyopathies

Funding Acknowledgements

Type of funding sources: None.

Background

Despite the increasing number of studies concerning Left Atrial Strain (LAS), few data are available comparing LAS patients with cardiac amyloidosis (CA) and sarcomeric hypertrophic cardiomyopathies (HCM).

Purposes

We aimed to perform a comparative multimodal imaging analysis of LAS of a prospective cohort of patients with CA and HCM.

Methods

For each enrolled patient, we performed same-day two and three-dimension echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) to blindly measure the peak atrial longitudinal strain (PALS) and the peak atrial contraction strain (PACS). Patients with acute atrial fibrillation were excluded.

Results

  Between January 2020 and July 2021, 67 patients were included: 31 patients with CA (age 75.1 ± 10 years, left ventricular ejection fraction 60.6 ± 10.4%, maximum left ventricular thickness 17.8 ± 3.9 mm) and 36 with HCM (age 50.8 ± 15.5 years, left ventricular ejection fraction 66.1 ± 9.8%, maximum left ventricular thickness 20.7 ± 4.5 mm). Left atrial volume was similar in the 2 groups (42.5 ± 15.6 mL/m2 in HCM vs 47.9 ± 15 in CA, P = 0.1557).

Concerning PALS, its values for CA and for CMH were on 2D TTE manual (10.9 ± 5.8% vs 21.4 ± 9.4%, P &lt; 0.001), 2D TTE automatic (11.5 ± 7.3% vs 22.9 ± 10.2%, P &lt; 0.001), 3D TTE (10 ± 6.8% vs 18.1 ± 6.7%, P &lt; 0.001), and CMR (11.3 ± 8 vs 24.4 ± 17.1, P &lt; 0.001) respectively.

Concerning PACS, its values for CA and for CMH were on 2D TTE manual (5.2 ± 3.4% vs 10 ± 4%, P &lt; 0.001), 2D TTE automatic (4.9 ± 3.9% vs 10.2 ± 5.1%, P &lt; 0.001), 3D TTE (3.6 ± 3.8% vs 7.9 ± 4%, P = 0.001) and CMR (6.2 ± 5.8% vs 11.9 ± 9%, P = 0.004) respectively.

Multivariate analysis adjusted on main factors influencing LAS (left ventricular (LV) mass, LV ejection fraction, LV global longitudinal strain, renal function and history of hypertension) found that the differences between the two groups remained significant for PALS and PACS for almost all technics.

Furthermore, although concordance between the 3 echocardiographic technics was excellent (the interclass correlation coefficient (ICC) was higher than 0.80 between each TTE methods), ICC was poor between TTE and CMR technics: 0.40 (0.18-0.59) for manual 2D TTE and CMR, 0.46 (0.24-0.63) for auto 2D TTE and CMR, 0.40 (0.14-0.60) for 3D TTE and CMR.

Conclusion

Our study is the first to describe and compare, both on TTE and CMR, LAS on a prospective cohort of patients with CA and HCM. Although they have same mean left atrial volume, we found significant differences on PALS and PACS between these two groups of patients on all the studied technics. These findings may be used in future multi-modality imaging studies dealing with diagnosis or prognosis of these hypertrophic cardiopathies. Abstract Figure. LAS 2D TTE manual  Abstract Figure. LAS comparison between CA and HCM

Assessment of PM10 and PM2.5 over Ghaziabad, an industrial city in the Indo-Gangetic Plain: spatio-temporal variability and associated health effects

This study examined the PM₁₀ and PM_2.5 concentration, associated mortality, and transport pathways in Ghaziabad which is an industrial city in the Indo-Gangetic Plain. To achieve this, PM (both PM₁₀ and PM_2.5) and meteorological parameters were measured from June 2018 to May 2019 at 2 locations and analyzed together with data from a 3rd location in Ghaziabad. The highest daily average PM₁₀ and PM_2.5 concentrations were ~ 1000 µg m^-3 and ~ 450 µg m^-3, respectively. At each of the three locations, the annual mean PM₁₀ concentrations were ~ 260 ± 150 µg m^-3 while the PM_2.5 concentrations were 140 ± 90 µg m^-3. Nonparametric Spearman rank correlation analysis between meteorological parameters and PM concentrations indicated that ventilation coefficient was anti-correlated with PM concentration during the post-monsoon and winter seasons (the most polluted seasons) with rank correlation values of approximately - 0.50. Multiple linear regression (MLR) revealed that the variability in local meteorological parameters account for ~ 50% variability (maximum) in PM₁₀ mass during the monsoon and PM_2.5 during the post-monsoon season. For long-range sources, cluster and concentrated weighted trajectory (CWT) analyses utilizing regional meteorology showed the impact of transported PM from sources in Arabian sea through western India in monsoon and from parts of South Asia through Northwestern IGP and neighboring cities in Uttar Pradesh in other seasons. Finally, mortality estimates show that the number of deaths attributable to ambient PM_2.5 in Ghaziabad were ~ 873 per million individuals which was ~ 70% higher than Delhi.

Demographic characteristics of the 1902 transthyretin amyloid cardiomyopathy patients treated by tafamidis through the French early access program

Background

Transthyretin amyloidosis (ATTR) is a rare and serious, systemic disease characterized by deposits of amyloid fibrils in various tissues and organs. Tafamidis meglumine is a potent and selective stabilizer of TTR, indicated since 2011 in the treatment of neurological forms of the disease. The French “Agence Nationale de Sécurité du Médicament et des produits de santé” (ANSM) granted a temporary recommendation for use (RTU) on November 28th 2018, based on ATTR-ACT, the pivotal trial results, and designed to enable use of tafamidis meglumine in ATTR cardiomyopathy (ATTR-CM) patients with NYHA I, II and III before marketing authorization. This RTU has been a unique opportunity in France to collect real world data of ATTR-CM patients treated by tafamidis meglumine.

Objective

We aimed to describe the characteristics of ATTR-CM patient treated by tafamidis in the setting of the RTU, over 2 years from November 28th 2018 to November 27th 2020.

Methods

Demographic and clinical data about the diagnosis pathway of patients included in the RTU were prospectively collected using questionnaires, as requested by ANSM to be completed by physicians at the time of tafamidis prescription. A second version of the inclusion form, introduced in May 2020, has allowed collection of additional clinical information.

Results

Overall, 1902 ATTR-CM patients have been included by 189 physicians from 107 centers. Nine centers included each at least 50 patients, accounting for 1092, or 57.4% of all patients. The median age of the patients was 82 years (IQR=9 years), 82% were male, and, 12.4%, 58.8% and 28.7% of patients had a NYHA class of I, II and III, respectively. For almost all patients, the diagnosis of restrictive/infiltrative heart failure was based on heart MRI and/or echocardiography (98.5%; among the 601 patients included from May 2020 28.8% had both exams, 69.7% echo only and 1.6% MRI only), the infiltrative nature of the cardiomyopathy had been confirmed by bone scintigraphy (99.3%), and the absence of light chains had been confirmed by protein electrophoresis or Bence Jones proteinuria (96.6%). Genetic test was performed in 1205 patients (69.4%). Out of the 884 patients who had a genetic test result available at the time of initial prescription, 762 (86.2%) were affected with the wild-type form and 122 (13.8%) with the hereditary form. Among the 601 patients included from May 2020, a hospitalization for cardiovascular condition within the 6 months preceding tafamidis initiation was reported for 22.3% of them, and tafamidis was initiated within 12 months after diagnosis for 92% of them (only 8% initiated the treatment beyond that period).

Conclusion

The RTU program has provided 1902 ATTR-CM patients with early access to tafamidis over 24 months, in France. Overall, as compared to patients included in ATTR-ACT, the pivotal trial, RTU patients were older, the proportion of wild-type was slightly higher, and NYHA distributions were similar.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Early access program sponsored by Pfizer

Infective endocarditis in adult patients with congenital heart disease: results from the ESC EORP EURO-ENDO registry

Background

Congenital Heart Disease (CHD) predisposes to Infective Endocarditis (IE)

Purpose

To characterize and to determine the prognosis of IE in this specific population.

Methods

The ESC EORP EURO-ENDO study is a prospective international study in patients (n=3111) diagnosed with IE. In this pre-specified ancillary analysis, we aimed to describe adult patients with CHD (n=365, 11·7%) and compare them with patients without CHD (non-CHD, n=2746) in terms of baseline characteristics and 1-year outcome.

Results

CHD patients (73% men, age 44·8±16·6 years) were younger and had less comorbidities. Of the CHD patients, 14% had a dental procedure in the 6 months before hospitalization versus 7% in non-CHD patients (p&lt;0·001) and more often positive blood cultures for Streptococcus viridans (16·4% vs 8·8%, p&lt;0·001). As in non-CHD patients, IE affected most often the left-sided valves. For CHD patients, in-hospital mortality was 9·0% vs 18·1% in non-CHD patients (p&lt;0·001), and also 1-year outcome was more favourable (log-rank for all-cause mortality p&lt;0·0001), even after adjustment for age (Hazard Ratio (HR) 0·61; 95% CI 0·45–0·81). Within the CHD population, multivariable Cox regression revealed the following predictors for mortality: fistula (HR 6·97), cerebral embolus (HR 4·64), renal insufficiency (HR 3·44), Staphylococcus aureus as causative agent (HR 2·06) and failure to undertake surgery when indicated (HR 5·93).

Conclusion

CHD patients with IE have better outcome in terms of all-cause mortality. The observed high incidence of dental procedures prior to IE fuels the discussion about the need for antibiotic prophylaxis.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Since the start of EORP, the following companies have supported the program: Abbott Vascular Int. (2011–2021), Amgen Cardiovascular (2009–2018), AstraZeneca (2014–2021), Bayer AG (2009–2018), Boehringer Ingelheim (2009–2019), Boston Scientific (2009–2012), The Bristol Myers Squibb and Pfizer Alliance (2011–2019), Daiichi Sankyo Europe GmbH (2011–2020), The Alliance Daiichi Sankyo Europe GmbH and Eli Lilly and Company (2014–2017), Edwards (2016–2019), Gedeon Richter Plc. (2014–2016), Menarini Int. Op. (2009–2012), MSD-Merck & Co. (2011–2014), Novartis Pharma AG (2014–2020), ResMed (2014–2016), Sanofi (2009–2011), Servier (2009–2021), Vifor (2019–2022). Survival CHD vs non-CHD patients

Socio-economic variations in the clinical presentation, etiology and outcome of infective endocarditis in the ESC-EORP EURO-ENDO (European Infective Endocarditis) registry: a prospective cohort study

Background

Infective endocarditis (IE) is a life threatening disease associated with high mortality and morbidity worldwide. We sought to determine how socio-economic factors may influence variations in epidemiology, clinical presentation, investigation and management (and their consequence upon clinical outcomes) in a large international multi-centre registry.

Methods

The ESC-EORPEURO-ENDO registry comprises a prospective cohort of 3116 adult patients admitted to 156 hospitals in 40 countries with IE between January 2016 and March 2018. We analysed the complete dataset to assess potentially important determinants of variation according to World Bank economic stratification (high income (Group 1) [73.8%]; upper-middle income (Group 2) [17.1%]; lower-middle income (Group 3)[9.1%]).

Results

Patients in Group 3 were younger (median age [IQR]: Group 1 - 66 [54–75] years; Group 2 - 57 [40–68] years; Group 3 - 33 [26–43] years; p&lt;0.001) with a higher prevalence of smoking, intravenous drug use and human immunodeficiency virus (HIV) infection (all p&lt;0.001). Group 3 patients with IE presented later (median [IQR) days since symptom onset: Group 1 - 12 [3–35]; Group 2 - 20 [6–51]; Group 3 - 31 [12–62]; p&lt;0.001) and were more likely to develop congestive heart failure (13.6%; 11.3%; and 22.6%, respectively; p&lt;0.001), septic shock (8.3%; 11.1%; 13.4%; p=0.007), and persistent fever for greater than 7 days (9.6%; 14.4%; 27.9%; p&lt;0.001) following hospital admission. Surgery was performed less frequently in Group 3 (75.4%, 76.8% and 51.3% in Groups 1, 2 and 3, respectively; p&lt;0.001) and mortality was highest in the poorest countries (14.6%; 23.6% and 23.7%, respectively; p&lt;0.001).

Conclusion

Socio-economic factors influence the clinical profile of patients presenting with IE across the world. Despite being younger, patients from the poorest countries presented with more frequent complications and higher mortality associated with delayed diagnosis and less frequent use of surgery.

Funding Acknowledgement

Type of funding sources: None.

Ejection fraction basal strain ratio (EFBSR), a new accurate echocardiographic deformation parameter to screen cardiac amyloidosis among hypertrophic cardiopathies

Background

Early diagnosis of cardiac amyloidosis (CA) is challenging. Several echocardiographic (echo) parameters have been proposed to differentiate CA from hypertrophic cardiomyopathy (HCM), but their respective value is debated. CA is known to be characterized by a more severe decline in longitudinal deformation parameters as compared with radial function parameters (LVEF). This characteristic justified the use of the ejection fraction strain ratio (EFSR) in these patients. However, since longitudinal dysfunction usually predominates in basal segments (apical sparing), we postulated that a new parameter focusing on LVEF and basal LV deformation (EFBSR: ejection fraction basal strain ratio) will even better discriminate patients with CA from HCM than EFSR and other echo or strain parameters.

Purpose

To compare the accuracy of deformation-based echocardiographic parameters for detecting CA in a population with different causes of LV hypertrophy.

Methods and results

We included 237 subjects, of which 89 patients with CA (77±10.7 years, 72% male, EF: 56.2±12.8%, and mean interventricular septum: 18.3±3.5 mm), 137 patients with hypertrophic cardiomyopathies (HCM), 52 patients with severe aortic stenosis with myocardial remodeling, 20 patients with arterial hypertension, and 20 control patients. Conventional echocardiographic parameters and strain-derived ratios (Relative apical sparing (RELAPS), Ejection Fraction Strain Ratio (EFSR) and EFBSR) were analyzed.

EFBSR and RELAPS presented with the best performance to discriminate CA from other causes of hypertrophy (Area Under the Curve (AUC): 0.880; 95% CI: 0.830–0.929 and 0.903; 95% CI: 0.863–0.943 respectively) (p-value=0.3). In our study, among all the parameters, RELAPS had the best specificity (89.8% vs 88.3% for EFBSR), whereas EFBSR had the best sensitivity (78.7% vs 76.4% for RELAPS). EFBSR ranged from 35.25 to 1.83 and the cutoff value to differentiate CA from other hypertrophic cardiopathy was an EFBSR &gt;7.75.

Conclusions

Our study demonstrates that in patients with LV hypertrophy, a new deformation parameter, the ejection fraction basal strain ratio (EFBSR) can accurately differentiate CA from other causes of myocardial thickening and can be used in routine practice for screening.

Funding Acknowledgement

Type of funding sources: None.

Predictors of mortality in patients with left-side infective endocarditis, the ESC-EORP EURO-ENDO registry

Background/Introduction

Infective endocarditis (IE) is associated with high in-hospital mortality, ranging from 16% to 25%, despite improvement in diagnostic and therapeutic strategies, mainly due to complications and heterogeneity of the disease. Baseline risk stratification is essential, in order to focus an aggressive management toward high-risk patients.

Purpose

We sought to assess the association between surgery and 30-day mortality rate as related to vegetation size.

Methods

The ESC-EORP EURO-ENDO registry is a prospective multicentre observational study of patients presenting with definite or possible IE in Europe and ESC-affiliated/non-affiliated countries. Patients were included from January 2016 to 31 March 2018 in 156 centers from 40 countries. Clinical data, blood test analysis and multi-modality imaging tests (echocardiography, computed tomography, PET-CT, magnetic resonance) were collected. Primary endpoint was 30-day mortality. Multivariable logistic regression analysis was performed to assess variables associated with 30-day mortality. Besides, univariable analysis was performed to assess best vegetation size cut-off related to 30-day mortality.

Results

Among 2171 patients with left-side IE, 257 patients (11.8%) died during the first 30 days of IE diagnosis. Patient characteristics and univariable analysis are summarized in TABLE 1. Cut-off value for best vegetation size related to 30-day mortality was vegetation length &gt;14mm, with a HR =2.00 (95% CI 1.59–2.51, p&lt;0.0001) and a Harrell's Concordance of 0.58. After multivariable logistic regression analysis, factors associated with 30-day mortality risk were: vegetation size &gt;14mm (OR =2.68, 95% CI [1.96–3.67], p&lt;0.0001), previous stroke or transient ischemic attack (TIA) (OR =1.60, 95% CI [1.07–2.40], p=0.0235), creatinine &gt;2mg/dL (OR =2.45, 95% CI [1.73–3.47], p&lt;0.0001), presence of embolic events (OR =2.64, 95% CI [1.86–3.74], p&lt;0.0001), hemorrhagic stroke (OR=3.71, 95% CI [1.80–7.64], p=0.0004), presence of heart failure or cardiogenic shock (OR =3.50, 95% CI [2.57–4.77], p&lt;0.0001) and no cardiac surgery during the event (OR =4.07, 95% CI [2.93–5.67], p&lt;0.0001). The C-statistic of the logistic model to predict 30-day mortality was 0.795.

Conclusion

Left-side infective endocarditis had a high 30-day mortality rate (11.8%). Presence of a large vegetation size (&gt;14mm), embolic events, hemorrhagic stroke, renal failure, presence of heart failure or cardiogenic shock were associated with an increase in 30-day mortality. Performing cardiac surgery had a protective effect.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC-EORP EURO-ENDO project from the ESC society

Predictors of mortality in patients with right-side and cardiac device-related infective endocarditis, the esc-eorp euro-endo registry

Background/Introduction

Mortality in right-sided infective endocarditis (RSIE) and cardiac device-related IE (CDRIE) rates have increased mainly due derived complications and heterogeneity of the disease. A better understanding of associated risk factors to mortality in these entities are required in order to develop an efficient therapy.

Purpose

The aim of this study was to assess 30-day mortality rate and variables associated in RSIE and CDRIE.

Methods

The ESC-EORP EURO-ENDO registry is a prospective multicenter observational study of patients presenting with definite or possible IE in Europe and ESC-affiliated/non-affiliated countries. Patients were included from January 2016 to 31 March 2018 in 156 centers from 40 countries. Clinical data, blood test analysis and multi-modality imaging tests (echocardiography, computed tomography, PET-CT, magnetic resonance) were collected. Primary endpoint was 30-day mortality. Univariable analysis was performed to assess variables associated with 30-day mortality.

Results

Among 269 patients with RSIE, 24 patients (9.8%) died during the first 30-day of IE diagnosis. Cut-off value for best vegetation size related to 30-day mortality was vegetation length &gt;19mm, with a HR = 2.88 (95% CI 1.26–6.58, p=0.01) and a Harrell's Concordance of 0.632. Factors associated with 30-days mortality by univariable analysis were: vegetation size &gt;19mm (OR = 2.99, 95% CI [1.31–6.84], p=0.009), previous stroke or transient ischemic attack (OR = 5.10, 95% CI [1.19–21.88], p=0.029), HIV infection (OR = 3.52, 95% CI [1.03–12.10], p=0.046), chronic renal failure (OR = 2.66, 95% CI [1.06–6.71], p=0.038), congestive heart failure at admission (OR = 2.34, 95% CI [1.00–5.47], p=0.050) and severe regurgitation (OR = 3.77, 95% CI [1.56–9.09], p=0.003).

On the other side, among the 227 patients with CDRIE, 24 patients (8.8%) died during the first 30-day of IE diagnosis. Factors associated with an increase in 30-day mortality by univariate analysis were: age per 10 years (OR = 1.49, 95% CI [1.02–2.18], p=0.039), heart failure history (OR = 3.88, 95% CI [1.39–10.80], p=0.009), congestive heart failure on admission (OR = 5.80, 95% CI [2.31–14.55], p&lt;0.001) and cardiogenic shock on admission (OR = 13.37, 95% CI [3.75–47.64], p&lt;0.001). An increase in left ventricular ejection fraction (LVEF) per 10% was a protective factor (OR = 0.66, 95% CI [0.49–0.90], p=0.008).

Conclusions

Patients with RSIE and CDRIE had a not negligible 30-day mortality rate (9.8% and 8.8%, respectively). Factors associated with RSIE and CDRIE mortality are different; while in the right side location, the mortality was related with vegetation size and comorbidities, in the case of CDRIE, the mortality was mainly associated to the presence of heart failure.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Euro-Endo registry by European Society of Cardiology

Development and evaluation of air pollution-linked quality of life (AP-QOL) questionnaire: insight from two different cohorts

In this study, the air pollution-related quality of life (AP-QOL) questionnaire was carried out in two geographically and economically different groups including New Delhi (Megacity) and Hamirpur, Himachal Pradesh (town), and APE scores were linked with respiratory and cardiovascular illness. The APE-Score was developed by AP-QOL questionnaire responses using Delphi technique and further analyzed using principal component analysis (PCA). For reliability of APE-Score and AP-QOL questionnaire, α-Cronbach's test and basic statistics were performed. The linear mixed-effect model and odds ratios were used to evaluate air pollution exposure and health outcomes. Overall, 720 academicians and 276 security guards were invited to participate in the questionnaire. Cronbach's α coefficients ranged from 0.70 to 0.84 indicated significant reliability in the AP-QOL questionnaire conducted in this study. Substantial variation in respiratory symptoms and their medical history were found - 76.9% ([95% confidential interval (CI)]: (- 83.8, - 66.9) (p < 0.05)) and - 28.6% (95% CI: (- 37.8, - 18.0) (p < 0.05)), respectively, with interquartile range (IQR) increase of APE score. The odds ratios (ORs) of respiratory medical history (MH Res.) showed a significant increase from 1.01 to 1.35 for low to high air pollution exposure in the academic group of IIT Delhi. Interestingly, for an academic group of NITH, the ORs for medical history of cardiovascular (MH Card.) showed an increase from 1.08 to 1.13 for low to high APE which was not the case for IIT Delhi academicians.

Risk of atrial fibrillation in hypertrophic cardiomyopathy: a clustering analysis based on the French registry on hypertrophic cardiomyopathy (REMY)

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): CHU Rennes, Inserm, LTSI – UMR 1099, F-35000 Rennes, France Assistance Publique-Hôpitaux de Paris-Centre Université de Paris, University of Paris

onbehalf

REMY register

Paroxysmal or chronic atrial fibrillation (AF) is frequent in hypertrophic cardiomyopathy (HCM),(20%-25% of patients), and is often considered as an important disease turning point. The aim of this study is to determine HCM-phenogroups with different risk of AF-occurrence at 5-year.

We applied the Bayesian method to differentiate phenogroups of patients with different risks of AF across a French hospital registry of adult HCM(REMY). Data were prospectively recorded on 5 years follow-up. 1431 HCM patients were recruited, including 1275 analyzed.

The population included 412 women. AF-occurred in 167 (11.6%) patients. 3 phenogroups were defined according to their common characteristics. Patients at the highest risk were more often female, with more frequent comorbidities, greatest anteroposterior LA diameter, diastolic dysfunction, outflow-tract obstruction or mitral valve abnormality, and presented higher sPAP or right ventricular dysfunction. These also had a higher risk of all-cause hospitalizations and death.

Based on a clustering analysis, 3 phenogroups of HCM according to the risk of AF occurrence can be identified. It can indicate which patients should be more monitored.

3 different AF-risk groups Intermediate risk group n = 524 High-risk group n= 207 Low-risk group n = 544 P Gender = Males (%) 338 (64.5) 103 (49.8) 422 (77.6) &lt;0.001 Age (median [IQR]) 59.00 [47.00, 66.00] 63.00 [54.00, 74.00] 50.00 [38.00, 60.00] &lt;0.001 Stroke (%) 29 (5.5) 44 (21.3) 5 (0.9) &lt;0.001 Right ventricular failure (%) 10 (1.9) 41 (19.8) 0 (0.0) &lt;0.001 None Mitral regurgitation (%) 207 (42.2) 25 (12.6) 416 (81.2) &lt;0.001 Moderate to severe mitral regurgitation (%) 258 (52.6) 143 (72.3) 92 (18) &lt;0.001 Mitral Valve elongation (%) 113 (23.5) 48 (24.9) 62 (12.1) Abnormal insertion of a papillary muscle (%) 13 (2.7) 12 (6.2) 6 (1.2) Mitral valve SAM (%) 214 (40.8) 115 (55.6) 77 (14.2) &lt;0.001 Basal obstruction (%) 196 (37.4) 119 (57.5) 54 (9.9) &lt;0.001 Anteroposterior LA diameter (mm) (median [IQR]) 44.00 [38.00, 49.00] 47.00 [42.00, 51.00] 39.00 [33.00, 43.00] &lt;0.001 Mitral E/e’ Lateral (median [QR]) 10.00 [8.00, 13.53] 15.00 [10.11, 20.00] 7.50 [5.80, 10.00] &lt;0.001 Mitral E/e’ Septal (median [QR]) 15.00 [11.18, 19.55] 18.40 [14.20, 23.50] 10.50 [8.33, 13.88] &lt;0.001 Normal sPAP (%) 354 (82.1) 74 (39.6) 435 (98.0) &lt;0.001 Event AF (%) 80 (15.3) 60 (29.0) 27 (5.0) &lt;0.001 Any cause death (%) 29 (5.5) 36 (17.4) 7 (1.3) &lt;0.001 Any cause hospitalization (%) 174 (33.2) 113 (54.6) 56 (10.3) &lt;0.001 3 different groups on their caracteristics and AF-risk Abstract Figure.

Insights on the biological role of ultrafine particles of size PM<0.25: A prospective study from New Delhi

When the total ambient PM_2.5 levels are several-fold higher than the recommended limit, it may be important to study the distributions of different sizes of particulate matter (PM). Here, we assess the distributions of various sizes of total PM_2.5 for 12 months (on a monthly basis) in New Delhi, India. Importantly, we found that ultrafine particles (i.e., particles <0.5 μm) contribute significantly to total PM_2.5. PM_<0.25 were the most cytotoxic particles to human lung epithelial cells in all the 12 months. In addition, PM_<0.25 were associated with significantly higher cytotoxicity per unit mass compared to other size fractions constituting PM_2.5. For any given size of PM, the amount of reactive oxygen species (ROS) generated per unit mass is higher for the month of March as compared to that for the rest of the months in the year. The higher ROS generations for all sizes of PM collected in the month of March was not explained by differences in their metal content values. Our data suggests the lack of correlation between total PM_2.5 levels and the highly cytotoxic PM_<0.25. In summary, this work establishes the need for policy changes to routinely monitor PM_<0.25 and the necessity to establish exposure limits for PM_<0.25, especially when the total PM_2.5 levels are breached.

Reactive oxygen species production and inflammatory effects of ambient PM2.5 -associated metals on human lung epithelial A549 cells "one year-long study": The Delhi chapter

The fine particulate matter (PM_2.5) was collected at academic campus of Indian Institute of Technology, Delhi, India from January-December 2017. The PM_2.5 samples were analysed for carcinogenic (Cd, Cr, As, Ni, and Pb) and non-carcinogenic (V, Cu, Zn, Fe) trace metals and their elicited effects on carcinoma epithelial cell line A549. Toxicological testing was done with ELISA kit. Same analyses were repeated for standard reference material (NIST-1648a) represents urban particulate matter. The student-t test and spearman correlation were used for data analysis. The seasonality in PM_2.5 mass concentration and chemical composition showed effect on biological outcomes. The PM_2.5 in post-monsoon and winter had higher amount of trace metals compared to mass collected in pre-monsoon and monsoon. Following the trend in PM mass concentration significantly (p < 0.5) lower cell viability was observed in post-monsoon and winter compared to other two seasons. NIST UPM 1648(a) samples always had higher cytotoxicity compared to ambient PM_2.5 Delhi sample. Strong association of Chromium, Nickel, Cadmium, and Zinc was observed with cell viability and reactive oxygen species (ROS) production. In winter IL-6, IL-8 production were 2.8 and 3 times higher than values observed in post-monsoon and 53 and 9 times higher than control. In winter season trace metals As, Cu, Fe, in pre-monsoon Cr, Ni, As, Pb, V, and Fe, in post-monsoon Cd and V strongly correlated with ROS generation. ROS production in winter and pre-monsoon seasons found to be 2.6 and 1.3 times higher than extremely polluted post-monsoon season which had 2 to 3 times higher PM_2.5 concentration compared to winter and pre-monsoon. The result clearly indicated that the presence of Fe in winter and pre-monsoon seasons catalysed the ROS production, probably OH˙ radical caused high cytokines production which influenced the cell viability reduction, while in post-monsoon PM majorly composed of Pb, As, Fe and Cu and affected by photochemical smog formation showed significant association between ROS production with cell viability. Overall, in Delhi most toxic seasons for respiratory system are winter and post-monsoon and safest season is monsoon.

Estimating seasonal variations of realistic exposure doses and risks to organs due to ambient particulate matter -bound metals of Delhi

This study aims to calculate deposition of PM_2.5 -bound hazardous metals in different organs after inhalation of particulate matter for the Delhi (India), and to estimate risks to organs following inhalation. Bio-accessible fractions of three PM-associated carcinogenic metals (As, Pb &Cd) were calculated using the metal values in simulated lung fluids. Depositions of metals in different organs were calculated using an integrated model consists of HRT and PBPK models. The calculation indicates that the major or significant deposition of metal Pb occurs in tissues, such as bone, muscle and blood. Most of the depositions of Cd happens in lung whereas most of the depositions of As happens in lung, muscle and skin. Most of the deposition of studied metals was found in lung (45% for arsenic and 70% for cadmium of their bio -dissolved contents). The following order of depositions of metals in different tissues were found (from highest deposition to smallest deposition): As: Lung > muscle = liver; Pb: bone > blood > muscle; Cd: lung > intestine. The combined exposures of PM_2.5 and its associated metals were found to give interaction-based hazard index greater than 1 for several months of the year, indicating a chance of health risk. Hazard quotient (HQ) <1 was seen for ingestion and dermal pathways, indicating no cause of concern. Findings indicate the need for doing periodic monitoring and estimating deposition doses and exposure risks of PM-associated metals to lungs and other organs for protecting human health.

Age-related characteristics of infective endocarditis: prospective data from the Euro-Endo registry

Introduction

The profile of infective endocarditis (IE) is continuously evolving over time, and this may probably be partly due to increasing age of the patients.

Methods

All data were collected from the EURO-ENDO registry, which is a one-year prospective international multicentre observational survey on patients with definite or possible IE included between 2016 and 2018. Subjects were stratified into 3 groups according to their age at index hospitalization.

Results

Among the 3113 patients included, 1670 patients (54%, Young group) were &lt;65, 1068 (34%, Medium group) between 65 and 80 and 375 (12%, Old group) ≥80 years old. The most striking age-related differences were (old group vs others) (table 1) 1) the higher comorbidity burden and Charlson index; 2) the lower rate of embolic events on admission and under therapy; 3) the higher rate of Enterocci and digestive streptococci; 4) the lower rate of surgery during acute IE despite a theoretical indication; 5) the higher in-hospital and 1-year mortality. With regards to surgery, young and medium age were predictive of more frequent performance of surgery as compared to old age (Young: OR 4.33, 95% CI [3.09–6.06], Medium: 3.62, [2.57–5.10], p&lt;0.001). In multivariable analysis, age per se was not predictive of in-hospital and 1yr FU mortality, but lack of surgical procedures when indicated (27% of the old group), was strongly predictive.

Conclusion

This is the largest contemporary registry showing the strong influence of age on the demographic, clinical, therapeutic, and prognostic profile of IE. Non-performance of surgical procedures when indicated is frequent in old patients and is a strong predictor of mortality while age per se is not. Endocarditis Teams should take these results into account when considering surgery in elderly patients.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): EORP grant

The 3 noes right-sided infective endocarditis: a unrecognized type of right-sided endocarditis

Introduction

The “3 noes right-sided infective endocarditis” (3no-RSIE: no left-sided, no drug users, no cardiac devices) was depicted for the first time more than a decade ago. We describe the largest series to date to characterize its clinical, microbiological, echocardiographic and prognostic profile.

Methods

Eight tertiary centers with surgical facilities participated in this study. Patients with right-sided endocarditis without left involvement, absence of antecedents of drug use and no intracardiac electronic devices were retrospectively included in a multipurpose database. A total of 53 variables were analysed in every patient. We performed a univariate analysis of in-hospital mortality to determine variables associated with worse prognosis.

Results

A total of 100 patients (mean age 54.1±20 years, 65% male) with definite 3no-RSIE were included (16.7% of all the right-sided endocarditis of the series). Most of the episodes were community-acquired (72%), congenital cardiopathies were frequent, fever was the main manifestation at admission (85%). The microbiological profile is led by Staphylococci spp. Vegetations were detected in 92% of the patients. Global in-hospital mortality was 19% (5.7% in patients operated and 26% in patients who received only medical treatment, p&lt;0.001). Non community-acquired infection, diabetes mellitus, right heart failure, septic shock and acute renal failure were more common in patients who died.

Conclusions

The clinical profile of 3no-RSIE is closer to other types of RSIE than to LSIE, but mortality is higher than that reported on for other types of RSIE. Surgery plays an important role in improving outcome.

Funding Acknowledgement

Type of funding source: None

Correction to: Chemical characterization of PM1.0 aerosol in Delhi and source apportionment using positive matrix factorization

The correct 1st Author name is Jai Prakash.

18F-fluorodeoxyglucose positron emission tomography computed tomography (18F-PET/CT) for the diagnosis of native valve infective endocarditis (NVIE): a prospective study

Background and objectives

18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines. We and others have demonstrated that18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) / computed tomography (CT) was useful in patients with suspected prosthetic valve and cardiac device IE. However, the sensitivity and specificity of ESC classification is unknown in patients with native valve endocarditis (NVE) as well as the clinical impact of PET findings.

Purposes

1. Primary objective: To assess the value of the new ESC criteria including 18F-FDG PET/CT in native valve infective endocarditis (NVIE).

2. Secondary objectives:

– to determine the usefulness of PET/CT concerning embolic or neoplastic detection.

– to describe a new PET/CT feature, i.e. the diffuse splenic uptake.

Methods

Between 2012 and 2017, 75 patients with suspected NVIE were prospectively included, after exclusion of patients with uninterpretable or not feasible PET/CT. Using the expert consensus of the Endocarditis Team after a 3-month follow-up as gold standard, 63 IE were confirmed and 12 were rejected. Patients follow-up was scheduled at one and three months after hospitalization.

Results

Significant cardiac uptake by PET/CT (major criterion) was observed in 11 among 63 patients with definite NVIE and no patients with rejected IE (sensitivity 18%, specificity 100%). Among the 63 patients with a final diagnosis of NVE, a peripheral embolism or mycotic aneurysm was observed in 20 cases (32%). Considering this, the ESC 2015 classification increased the sensitivity of Duke criteria from 64 to 70% (p&lt;0.001) without no change on specificity (p&lt;0.001). Twenty-four patients (38%) were diagnosed with secondary infectious sites or infectious portal of entry. A diffuse splenic uptake was observed in 39 (52%) patients, including 37 (59%) of patients with a final diagnosis of NVE (specificity 83%).

Conclusion

1. The value of 18F-FDG PET/CT in NVE diagnosis is poor (18% sensitivity)

2. Usefulness of PET/CT remains high when concerning embolic or neoplastic detection.

3. Our study describes for the first time in NVE a new potential endocarditis criterion, i.e. the presence of a diffuse splenic uptake on 18F-FDG PET/CT

Diffuse splenic uptake

Funding Acknowledgement

Type of funding source: None

Comparative study of tissue adhesive therapy versus band ligation in control of actively bleeding esophageal varices

BACKGROUND AND STUDY AIMS

Bleeding esophageal varices is a common life-threatening emergency that carries a significant morbidity and mortality. Acute variceal bleeding is considered active when spurting and/or oozing varix is seen at the time of endoscopy, or inactive in the presence of large esophageal varices with blood in the stomach with no other bleeding source at the time of endoscopy. Aim: comparing endoscopic variceal ligation (EVL) versus cyanoacrylate injection (CI) in active esophageal variceal bleeding control.

PATIENTS AND METHODS

a retrospective single tertiary center study from April 2014 to February 2018, including 401 patients with active esophageal variceal bleeding.

RESULTS

Endoscopic hemostasis was achieved by both endoscopic variceal ligation in 182 patients (91.9%) and cyanoacrylate injection in 197 patients (97.05%) without significant difference (P value 0. 15). Re-bleeding occurred more frequently in EVL group 20 patients (10.1%) compared to 14 patients (6.9%) in CI (P value 0.01). Early six-week Mortality was higher among EVL group (20.7%) compared to CI (17.2%) without statistical significance (P value 0.3).

CONCLUSION

Both EVL and CI are almost as effective in achieving endoscopic hemostasis. CI is more effective, feasible, and could be used as a salvage therapy and/or spared for risky active bleeding esophageal varices.

P3666Spondylitis: a frequent and severe complication of infective endocarditis

Background

Spondylodiscitis (SP) is a rare, but severe complication of infective endocarditis (IE). The incidence, clinical features and prognosis of SP in IE are unknown.

Purpose

The primary objective of our study was to assess the incidence, epidemiology, clinical presentation, prognosis, and therapeutic implications of SP in patient with IE. The secondary objectives were to assess factors associated with occurrence of spondylitis and to assess the value of imaging techniques.

Methods

In a French bi-center prospective study of patients who presented in our endocarditis reference centers with a diagnosis of definite IE from 1990 to 2018 (n=1755), 150 (8.5%) presented with SP. Clinical, epidemiological, microbiological, and prognostic variables were prospectively recorded and compared between patients with (n=150) and without (n=1605) SP.

Results

Patients with SP were older (mean age 69.7±18 vs 66.2±14; p=0.004), had more arterial hypertension (48% vs 34,5%; p<0.001) and autoimmune disease (5% vs 2%; p=0.03) than patients without SP. The lumbar vertebrae were the most frequently involved (84 patients, 66%), especially L3-L4. Neurological symptoms were observed in 59% of patients. Enterococci et Gallolyticus streptococci were more frequent (24% vs 12% and 24% vs 11%; p<0,001, respectively) in the SP group. Observed sensitivities of full spine contrast-enhanced MRI and CT were 95% and 89%, respectively. PET/CT had a great power to differentiate infective to degenerative vertebral processes, and to find embolic foci with a sensitivity of 90%. Clinical outcome did not differ between patients with or without SP, including similar in-hospital mortality (16% vs 13,5%, p=0.38).

Conclusions

We describe the largest ever reported series of patients with spondylodiscitis complicating IE. Spondylodiscitis is a more frequent complication of IE than previously reported (8.5% of IE), is observed in older hypertensive patients with Enterococcal or Streptococcus gallolyticus IE and has a similar prognosis than other forms of IE. Since SP is associated with prolonged antibiotic therapy and may need specific surgical therapy, multimodality imaging including MRI, CT, and PET/CT should be used for early diagnosis of this IE complication.

333018F-Fluorodeoxyglucose Positron Emission Tomography Computed Tomography (PET/CT) for the diagnosis of prosthetic valve infective endocarditis (PVIE): a prospective multicenter study

Background and objectives

18F-FDG PET/CT has recently been added as a major criterion in the ESC 2015 infective endocarditis (IE) guidelines, but the value of this new diagnostic algorithm has never been prospectively assessed.

Purposes

1. Primary objective: to assess the value of the new ESC criteria including 18F-FDG PET/CT in prosthetic valve infective endocarditis (PVIE).

2. Secondary objectives: to determine the reproducibility of 18F-FDG PET/CT; to assess its ability to predict embolic events.

Methods

Between 2014 and 2017, 175 patients with suspected PVIE were prospectively included in 3 French centers. After exclusion of patients with uninterpretable or not feasible PET/CT,115 patients were finally included in the analysis, including 91 definite IE and 24 rejected IE, as defined by an expert Consensus of Endocarditis Team after 3-month follow-up as Gold Standard

Nuclear data were blindly analyzed by two independent nuclear medicine physicians.

Patients follow-up was scheduled at one and three months after hospitalization

Results

Significant cardiac uptake by PET/CT (major criterion) was observed in 67 among 91 patients with definite PVIE and 6 patients with rejected IE (sensitivity 73.6%, specificity 75%, positive predictive value 91%, negative predictive value 42%). Considering cardiac uptake as a major criterion, the ESC 2015 classification increased the sensitivity of Duke criteria from 57 to 84% (p<0.001) but decreased its specificity from 84 to 70% (p<0.001).

Intraobserver reproducibility of cardiac uptake evaluation was good (kappa = 0.84) but inter observer reproductibility was less satisfactory (kappa = 0.63).

Embolic events occurred in 31 patients (27%) and were correlated with vegetation size by ECHO (p<0.001), Staphylococcus infection (p=0.003), and PET/CT cardiac uptake (p=0.02).

Conclusion

1. the value of PET CT and ESC criteria is confirmed and may allow earlier diagnosis of PVIE

2. PET CT is associated with an increased risk of false positive results probably related to the technical improvements

3. Reproducibility of nuclear measurements seems unsatisfactory, justifying efforts to standardize PET studies interpretation

4. Our study describes for the first time a positive correlation between a positive PET/Ct and occurrence of embolic events, warranting additional studies.

P2760Prognostic value of 18-fluorodeoxyglucose positron emission tomography/computed tomography in infective endocarditis

Background

18-Fluorodeoxyglucose Positron emission tomography (18F-FDG PET/CT) has been shown to be useful for the diagnosis of IE, but its prognostic value is unknown.

Objectives

This study sought to assess the prognostic value of 18F-FDG PET/CT in prosthetic (PVE) and native valve endocarditis (NVE).

Methods

We prospectively studied 173 consecutive patients (109 PVE and 64 NVE) with definite IE who underwent a 18F-FDG PET/CT study and were follow-up for one year. Primary end-point was a composite of major cardiac events i.e. death, recurrence of IE, acute cardiac failure, non-scheduled hospitalization for cardiovascular reason, and new embolic event

Results

18F-FDG PET/CT was positive in 98 (57%) patients, 82% (n=88/109) in the PVE and 16% (n=10/64) in the NVE group. At a mean follow of 225±18 days, the primary end-point occurred in 94 (55%) patients, 63 (58%) in the PVE group and 31 (48%) in the NVE group. In the PVE group, positive 18F-FDG PET/CT was significantly associated with higher rate of primary end-point (OR=2.6, IC95%=1.04 to 6.6; p=0.04). Moderate to intense 18F-FDG valvular uptake was also associated with worse outcome (OR=2.1; IC95%=1.1 to 4.0; p=0.03) and to new embolic events, (OR: 8.8; IC95%= 1.1 to 69.5; p=0.02). In the NVE group, 18F-FDG PET/CT was not associated with occurrence of the primary end-point.

Conclusion

In addition to be an accurate diagnostic tool, 18F-FDG PET/CT is predictive of major cardiac events in PVE and to embolic events during the first year following IE episode

P4381Improvement of the PISA method in the setting of mitral regurgitation of complex geometry

Background

Doppler echocardiographic methods, such as proximal isovelocity surface area (PISA) are used to quantify mitral regurgitations. However, their accuracy and reproducibility are still discussed, especially in case of mitral regurgitations of complex geometry.

Purpose

The aim of this study was to test in-vitro the accuracy of the PISA method depending on the shape and number of regurgitant flows.

Methods

Several regurgitant volumes (RV) were produced through various regurgitation severities and shapes in a left heart double activation simulator. Circular mitral regurgitation (MR) was performed with a circular orifice in a rigid plate. Triangular and oblong MR were performed by suturing the extremity of a bioprosthesis leaflet to the annulus. Multiple jets regurgitation was performed by suturing centrally the two leaflets of an anatomically shaped mitral valve made of hydrogel. A transesophageal echocardiography probe was used to acquire the data. The RV was calculated with the classical PISA method (hemispheric assumption), or by considering the PISA as a hemicylinder or a double hemisphere. It was then compared to a reference value obtained from an electromagnetic flowmeter measurement (accuracy ± 2 ml/min).

Results

A central and circular orifice was correctly quantified, as expected, with the hemispheric assumption (bias 0.2±1.9 ml, p=0.46). For a triangular central jet, the hemispheric assumption best estimated the RV (−3.5±14.8 ml, p=0.10). An oblong MR was underestimated with the hemispheric assumption (−18.3±14.9 ml, p<0.01) whereas the hemicylindrical assumption was more accurate (−0.2±5.8 ml, p=0.85). In case of 2 regurgitant jets, considering only the largest jet led to an important underestimation (−10.9±5.6 ml, p<0.01), whereas adding the two RV was more accurate (−1.2±8.2 ml, p=0.50).

Conclusions

In case of a single central orifice, the hemispheric assumption correctly quantified the MR. In case of an oblong orifice, the hemicylindrical assumption provided a good quantification with simple measurements. In case of multiple jets of different sizes, it was more accurate to consider both jets for RV calculation.

Acknowledgement/Funding

Képhalios part of Affluent Medical

Ecological and human health risk assessment of heavy metal contamination in road dust in the National Capital Territory (NCT) of Delhi, India

The present study was carried out to determine the contamination levels of heavy metals in road dust of the National Capital Territory of Delhi (NCT), India and its consequent effect on human and environment. The levels of heavy metals (Pb, Zn, Cu, Cr, Ni, Mn, and Fe) in 9 districts (Z1-Z9) of NCT were monitored and the corresponding human health risk was estimated. District-wise evaluation of heavy metal pollution in the road dust was performed. The mean concentrations of Pb, Zn, Cu, Ni, Cr, Mn, and Fe in the road dust samples over the study area were 164.2 ± 53.2, 200.7 ± 45.3, 99.9 ± 64.8, 24.7 ± 5.7, 57.7 ± 25.9, 241.4 ± 39.8, and 11113.9 ± 1669.7 mg kg^-1, respectively. PLI showed a high pollution load in the monitored nine locations, indicating an alarming condition and the urgent need for immediate remedial actions. Ecological risk assessment depicted that a 74% risk was attributed to Pb. Hazard quotient (HQ) values indicated that ingestion was the major pathway of road dust heavy metal exposure to human beings. Hazard index values showed that there was no probable non-carcinogenic risk of the heavy metals present in the road dust of the area. Children were found vulnerable to the risks of road dust metals. The findings of this study showed the alarming status of heavy metal contamination to road dust in NCT and the associated risk to human health.