Predicting the future of our oceans-Evaluating genomic forecasting approaches in marine species

Climate change is restructuring biodiversity on multiple scales and there is a pressing need to understand the downstream ecological and genomic consequences of this change. Recent advancements in the field of eco-evolutionary genomics have sought to include evolutionary processes in forecasting species' responses to climate change (e.g., genomic offset), but to date, much of this work has focused on terrestrial species. Coastal and offshore species, and the fisheries they support, may be even more vulnerable to climate change than their terrestrial counterparts, warranting a critical appraisal of these approaches in marine systems. First, we synthesize knowledge about the genomic basis of adaptation in marine species, and then we discuss the few examples where genomic forecasting has been applied in marine systems. Next, we identify the key challenges in validating genomic offset estimates in marine species, and we advocate for the inclusion of historical sampling data and hindcasting in the validation phase. Lastly, we describe a workflow to guide marine managers in incorporating these predictions into the decision-making process.

Hospital context in surgical site infection following colorectal surgery: a multi-level logistic regression analysis

BACKGROUND

Surgical site infections (SSIs) are associated with poor health outcomes. Their incidence is highest after colorectal surgery, with little improvement in recent years. The role of hospital characteristics is undetermined.

AIM

To investigate whether SSI incidence after colorectal surgery varies between hospitals, and whether such variance may be explained by hospital characteristics.

METHODS

Data were retrieved from the electronic platform of the Directorate General of Health, from 2015 to 2019. Hospital characteristics were retrieved from publicly available data on the Portuguese public administration. Analysis considered a two-level hierarchical data structure, with individuals clustered in hospitals. To avoid overfitting, no models were built with more than one hospital characteristic. Cluster-level associations are presented through median odds ratio (MOR) and intraclass cluster coefficient (ICC). Beta coefficients were used to assess the contextual effects.

FINDINGS

A total of 11,219 procedures from 18 hospitals were included. The incidence of SSI was 16.8%. The ICC for the null model was 0.09. Procedural variables explained 25% of the variance, and hospital dimension explained another 17%. More than 50% of SSI variance remains unaccounted for. After adjustment, heterogeneity between hospitals (MOR: 1.51; ICC: 0.05) was still found. No hospital characteristic was significantly associated with SSI.

CONCLUSION

Procedural variables and hospital dimension explain almost half of SSI variance and should be taken into account when implementing prevention strategies. Future research should focus on compliance with preventive bundles and other process indicators in hospitals with significantly less SSI in colorectal surgery.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Flow-status and survival in severe aortic stenosis treated with TAVI – is flow rate superior to stroke volume index?

Background

Low-flow status, currently defined as a stroke volume index (SVi) <35 mL/m2, is an important prognostic predictor for mortality after Transcatheter Aortic Valve Implantation (TAVI) for severe aortic stenosis (SAS). However, transaortic flow rate (FR) – defined as stroke volume divided by left ventricle ejection time - has recently been suggested to be superior to SVi in defining low-flow states, as it reflects more closely valvular resistance, while being independent of body surface area. Low FR is most consistently defined as FR<200 mL/s.

Purpose

Determine the prognostic impact of FR and SVi before TAVI in survival after intervention for SAS.

Methods

A single-centre retrospective database of all TAVI performed between 2011 and 2019 was analyzed, and cases with pre-intervention echocardiograms available were included. Low-flow patients were identified according to basal FR (<200 mL/s) or SVi (<35 mL/m2), and compared with normal-flow cases. The primary endpoint was defined as time to all-cause death or last follow-up. The impact of flow-status (using FR or SVi) in survival was assessed using Kaplan-Meier curves and log-rank test, as well as Cox proportional hazard model adjusted for EuroSCORE II, using FR or SVi either as categorical or continuous variables. A subanalysis further compared patients with preserved and reduced ejection fraction (EF, <52%). p<0.05 was considered statistically significant.

Results

From 657 TAVI performed, 490 (74.6%) cases were included, with a median follow-up of 43 months. From those, 59.6% were defined as low-flow according to FR, and 43.3% using SVi. Low-flow patients, using each parameter, were of higher surgical risk (EuroSCORE II and STS scores), had more advanced NYHA classes, worse estimated creatinine clearance, and suffered more frequently from coronary artery disease. Low-FR patients were also older, and more predominantly female. Atrial fibrillation was more prevalent among low SVi cases. Functional aortic valve area was lower in low-flow patients using both assessments, but low-SVi was also associated with lower transaortic gradients, as well as lower EF before and after TAVI. Regarding all-cause mortality, low-SVi was associated with worse survival [p=0.02, hazard ratio (HR) 1.43 (1.05–1.94)], but not low-FR (p=0.4). However, low-SVi, when adjusted for EuroScore II, was no longer a predictor of all-cause mortality (p=0.08). When considering FR and SVi as continuous variables, a higher SVi (but not FR) was associated with better survival (HR 0.98, p=0.047) in multivariable analysis adjusted for EuroSCORE II. When stratifying according to preserved and reduced EF, both FR and SVi did not predict all-cause mortality.

Conclusions

Low-flow states are common in SAS population treated with TAVI, being frequently associated with worse symptoms and higher procedural risk. Low-SVi, but not low-FR, negatively impacts survival after intervention, representing a marker for prognosis after TAVI.

Funding Acknowledgement

Type of funding sources: None.

Predictors for NYHA recovery and 1-year mortality after mitral TEER

Background

Mitral regurgitation (MR) is the second-most frequent valvular heart disease in Europe and frequently aggravates heart failure (HF) symptoms. Mitral transcatheter-edge-to-edge repair (TEER) can be considered in eligible patients, for both primary (in inoperable cases) or secondary severe MR. However, intervention is not advised in severe comorbid patients in whom it is not expected to prolong survival for over 1 year.

Purpose

Evaluate characteristics associated with HF New York Heart Association (NYHA) class recovery, and one-year all-cause mortality after mitral TEER for severe MR.

Methods

All mitral TEER procedures for primary and secondary MR conducted in a single-centre between 2014 and 2020 were retrospectively analyzed. The primary endpoint was defined as a reduction of at least one NYHA class in the first month after intervention, and a secondary endpoint considered a recovery of at least two NYHA classes. Survival status 12 months after mitral TEER was also consulted. Clinical, echocardiographic and blood-analysis data were explored as characteristics associated with the endpoints defined, using Pearson's Chi-squared test, Wilcoxon rank sum test and Fisher's exact test, as appropriate. A p<0.05 was considered statistically significant.

Results

From 103 mitral TEER procedures, 86 (83%) had full information about pre- and post-intervention NYHA class, as well as survival status at 12 months. There was a higher proportion of primary MR among NYHA non-responders (47% versus 25%, p=0.034), but no differences for secondary MR. Higher surgical risk patients (EuroSCORE II) tended to have exhibit more NYHA recovery, though not reaching statistical significance (p=0.068). Both a more advanced NYHA class at baseline and lower N-terminal pro-brain natriuretic peptide (NTproBNP) levels were linked to a higher symptomatic recovery (2048 versus 5676pg/ml, p<0.001). Also, persisting MR after TEER of at least grade 3/4 was more frequent in non-NYHA responders. Regarding NYHA improvement of at least two classes, it was observed in 13% patients, and these also had a more advanced NYHA class at baseline and lower NTproBNP basal levels, and exhibited a lower estimated systolic pulmonary artery pressure and inferior vena cava (IVC) diameter. Finally, 10 (11.6%) of mitral TEER patients died in the first 12 months, and no statistically significant associations were found regarding pre-intervention characteristics and survival.

Conclusions

This study suggests that three-fifths of severe MR improve their NYHA class after TEER, but only one-fourth for primary MR. Earlier intervention – with lower NTproBNP levels, less severe pulmonary hypertension, and lower IVC diameters – is associated with more symptomatic HF improvement. All-cause mortality in the first year is still significant, exposing a need for better patient selection. However, these findings represent exploratory deductions of a relatively low number, single-centre, patients.

Funding Acknowledgement

Type of funding sources: None.

Modeling aortic stenosis progression: impact on follow-up, treatment and survival

Background

Aortic stenosis (AS) is one of the main valvular heart diseases in developed countries. Degenerative fibrocalcific aortic stenosis is a progressive disease of the valve and ultimately of the myocardium, which can be fatal when symptomatic. There is no medical treatment that can halt or delay its progression. AS does not evolve linearly over time, and not every patient has the same progression rate.

Aims

The aim of this study is to 1) compare different mathematical models of aortic stenosis progression, 2) cluster patients into rapid and slow progressors and explore possible predictors, 4) evaluate the impact of different progression rates on cardiac structure and function, and 5) evaluate survival and optimal timing for follow-up and treatment.

Methods

We retrospectively studied consecutive patients with aortic peak velocities from 2012 to 2020. Follow-up echocardiograms, seriated biomarker assessment, and clinical records were consulted, providing a multiparametric data frame for longitudinal and dynamic modeling of aortic stenosis progression and its consequences.

Results

This study included 9583 studies from 752 patients with a median total follow-up of 4.26 years (interquartile range: 1.28 to 7.24 years). A logistic model was selected with the best accuracy to predict the rate of AS progression. Patients were categorized into slow and rapid progressors in a ratio of 5:1. Multiparametric analysis showed no association between these profiles and clinical variables. However, anti-hypertensive drugs before and after adjustment for blood pressure control (Calcium Channel Blockers, p=0.013, OR 0.50) were associated with slower progression. Meanwhile, elevated inflammatory markers (erythrocyte sedimentation rate, p=0.01) were associated with faster AS progression. Despite no survival difference between these groups, higher rates of valvular intervention were registered in rapid progressors (p<0.001). Moreover, faster progressors were associated with earlier cardiac damage (as demonstrated by early onset of moderate mitral and tricuspid valve regurgitation, left auricle dilation, and left ventricle hypertrophy, p<0.05).

Conclusions

These results can potentially modify follow-up times and deliver more personalized and individualized health care to different AS patients, thereby optimizing resources.

Funding Acknowledgement

Type of funding sources: None.

Cardioneuroablation of severe neurally mediated reflex syncope: the experience of two Portuguese centres

Funding Acknowledgements

Type of funding sources: None.

Background

Neurocardiogenic syncope (NCS) is the most frequent aetiology of syncope in young people. Cardioinhibition with asystole and/or transitory atrio-ventricular block induced by a massive vagal reflex is commonly observed in severe cases. According to the current guidelines, cardiac pacing is indicated in patients > 40 years old with severe, recurrent syncope and documented cardioinhibitory reflex. In younger patients there is no recommendation. Although pacing therapy could be effective, complications after pacemaker implantation are commonly seen. Recently, cardioneuroablation (CNA), a technique based on radiofrequency ablation of vagal ganglia, was developed to treat NCS as an alternative to pacemaker implantation in younger patients. However, this method is still evolving, and existing data refer to a small number of patients in a limited number of centres.

Purpose

The aim of our study was to evaluate the efficacy and safety of CNA in patients with highly symptomatic neurocardiogenic syncope.

Methods and Results

A total of 15 patients (11 male; aged 40.0 ± 13.3 years) who underwent CNA in two Portuguese centres between January 2019 and September 2021 were included. All had recurrent syncope with documented pauses at head-up tilt test, Holter or implantable loop recorder. Radiofrequency energy was applied in ganglionated plexi (GP) 1 (between the right upper pulmonary vein and the right atrium) in 14 patients, GP2 (between the superior vena cava and aortic root just above the right upper pulmonary vein) in 9 patients, GP3 (between the inferior vena cava and the right and left atrium) in 5 patients and GP4 (at the insertion of the left pulmonary veins) in 9 patients. The end point of procedure was the inhibition of the vagal response at target sites. Ablation was successfully performed in all patients. One patient had a convulsive episode after the procedure, requiring admission to intensive care but without neurological sequelae. No other major complications occurred. At a mean follow-up of 17.1 ± 12.6 months (range 3-35 months), 13 patients remained free of syncope. Other 2 patients had spontaneous recurrence of syncope (both 9 months after CNA) and underwent a new procedure. These 2 patients had a new symptomatic recurrence and a pacemaker was implanted.

Conclusion

CNA appears to be an effective and safe treatment option for patients with refractory neurocardiogenic syncope and provide a new potential approach without pacemaker implantation.

Higher coronary calcium score is associated with increased risk of atrial fibrillation recurrence

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with atrial fibrillation (AF) referred for catheter ablation routinely undergo cardiac computed tomography (CCT) for procedure planning. An opportunistic evaluation of coronary artery calcium score (CACS) can be an important tool to improve clinical care. It is already known that CACS is associated with a high risk of AF development, particularly if values are above 100, but few data are available regarding the impact of CACS in AF recurrence after ablation.

Purpose

To assess the impact of CACS on atrial fibrillation recurrence following catheter ablation.

Methods

Retrospective, single-centre cohort study of consecutive patients with AF undergoing CCT for ablation procedure planning, from 2017 to 2019. Baseline clinical and demographical data were collected. Patients with known history of coronary artery disease (CAD) and moderate to severe valvular heart disease were excluded. CACS was assessed using the Agatston method. Recurrence was defined as any documented episode of AF, atrial flutter or atrial tachycardia after 3 months from procedure. Patients were stratified in CACS<100 and CACS≥100. Explorative analysis incorporated Kaplan-Meier survival curves and Cox regression.

Results

A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. More than half of the patients had a CACS>0 (n=185, 52%) and 63 patients (18%) had a CACS≥100. Patients with CACS≥100 were older (63 ± 7 vs 54 ± 12 years, p<0.001), had higher prevalence of hypertension (68% vs 43%, p<0.001) and diabetes mellitus (21% vs 10%, p=0.012) and higher left atrial volume (39 ± 9 vs 35 ± 9 ml/m2, p=0.018). After a median observation time of 34 months (IQR 24-43), 117 patients (33%) had AF recurrence.

CACS≥100 was associated with increased risk of AF recurrence (unadjusted Cox regression: hazard ratio [HR] 1.85; 95% confidence interval [CI], 1.23-2.79, p=0.003) (Fig. 1). After covariate adjustment (age, gender, hypertension, diabetes mellitus, obesity, thyroid disease, AF type and left atria enlargement) CACS≥100 remained an independent predictor of the risk of AF recurrence (HR, 1.68; 95% CI, 1.05-2.70, p=0.03) as well as persistent AF (HR, 1.91; 95% CI, 1.23-3.00, p=0.004) (Fig. 2).

Conclusion

In patients with AF undergoing catheter ablation, without previous history of CAD, a CACS≥100 was independently associated with a 68% increase in the risk of AF recurrence.

Epicardial mapping as first intention approach for structural ventricular tachycardia ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

In several structural arrhythmogenic diseases that comprise intricate endocardial, intramural and epicardial substrates, endocardial ablation of ventricular tachycardia (VT) is not sufficient and epicardial ablation has lately become a complementary and necessary tool.

Purpose

To evaluate the clinical characteristics of patients (pts) most suitable for first intention epicardial VT ablation.

Methods

Single-center prospective study of consecutive pts with structural heart disease undergoing first intention epicardial VT mapping between August 2015 and June 2021. Decision for epicardial approach was based on the etiology, VT electrocardiogram (ECG) and cardiac magnetic resonance (CMR) results. Under general anesthesia, subxiphoid access using a Tuhoy needle was done using fluoroscopic guidance and with high-density epicardial mapping was performed. Epicardial ablation was performed if relevant arrhythmogenic findings were locally confirmed.

Results

First intention epicardial VT ablation was attempted in 18 pts (mean age 59.8±12 years,94% male) of whom 16 had non-ischemic dilated cardiomyopathy (NICM,idiopathic:11; post-myocardis:4; hereditary:1) and 2 had right ventricular arrhythmogenic cardiomyopathy. Mean LVEF was 33% and 79% had a previous ICD (53% in primary prevenon). 69% were referred for ablation due to arrhythmic storm (1pt in cardiogenic shock). Epicardial access was achieved in 17 pts (94%), without acute complications. In 35% pts with NICM the decision for epicardial approach was based on the detection of subepicardial CMR delayed-hyperenhancement and relevant epicardial arrhythmic substrate was confirmed by mapping in all cases. In 3 pts radiofrequency (RF) applicaons were not performed at epicardium, as no abnormal electrograms were locally detected, and an addional endocardial approach was prosecuted. The mean overall procedure and fluoroscopic time were 123 and 28min, respectively, with a mean RF application me of 51min. After the procedure 1pt required pericardial drainage due to inflammatory pericardial effusion. No other acute complications occurred. During a mean follow-up of 2.8±1.8 years, only 3pts (17%) had VT recurrence; 5pts (28%) died due to end-stage heart failure and 2pts (11%) underwent heart transplantation.

Conclusion

In NICM a first intention epicardial VT ablation performed by experienced operators/centers is efficient, particularly if guided by CMR findings,and presents a safety profile.

Association of epicardial adipose tissue and coronary artery calcium score in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Both coronary artery calcium (CAC) and epicardial adipose tissue (EAT) had been implicated in coronary artery disease (CAD) and risk of future adverse cardiovascular events. There are scarce data regarding the assessment and association of EAT volume and CAC score (CACS) in atrial fibrillation (AF) patients.

Purpose

To assess the association between EAT volume and the presence and severity of CAC in patients with AF.

Methods

Retrospective and single-centre study including consecutive patients with AF undergoing contrast-enhanced cardiac computed tomography for catheter ablation planning, from 2017 to 2019. Patients with known history of CAD and moderate to severe valvular heart disease were excluded. Baseline clinical and demographical data were collected, as well as their cardiovascular risk, based on the SCORE (Systematic Coronary Risk Evaluation) system and cardiovascular risk categories. We assessed CACS (Agatston method) and EAT volume and analysed their association. EAT was defined as the adipose tissue accumulated between the visceral pericardium and the myocardium and was semi-automatically reconstructed by manually tracing the pericardium. Patients were split into three groups according to CACS: 0, 1-99 and ≥100. A logistic regression (LR) analysis was performed to explore the relationship between EAT volume and the presence of CAC (CACS>0), adjusted for age, gender, obesity, diabetes mellitus and hypertension.

Results

A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. A CHA2DS2-VASc score ≥2 was present in 130 (37%) patients and most patients had low to moderate cardiovascular risk (n=213, 82%). More than half of the patients had a CACS>0 (n=185, 52%), of which 63 patients (18%) had a CACS≥100. The mean EAT volume was 79 ± 39 ml. There was a significant association between EAT volume and the presence of CAC: CACS=0 69 ± 34 ml vs CACS 1-99 84 ± 38 ml vs CACS ≥100 95 ± 45 ml (p<0.001) (Fig. 1). After covariate adjustment (LR model R2 = 0.373, p <0.0001), the presence of CAC was not associated with EAT volume (OR 1.00, 95%CI 1.00 - 1.01, p=0.2) or obesity, and only with higher age, male gender, hypertension and diabetes mellitus (Fig. 2).

Conclusion

In our cohort of patients with AF undergoing catheter ablation we observed an association between EAT and CACS. Nevertheless, EAT volume was not an independent predictor of CACS and only the classical cardiovascular risk factors remained significant.

Staging cardiac damage in aortic valve disease: one size fits all?

Background

Nowadays, in patients with aortic regurgitation (AR), aortic valve surgery is indicated when severe and symptomatic or those with depressed LVEF. However, clinical outcomes of patients with significant aortic regurgitation are not influenced by these factors only. Recently, a new staging system for severe aortic stenosis has been proposed by Généreux on the basis of the extent of anatomic and functional cardiac damage. If this model could be applicable to an unselected significant AR population has not been tested.

Purpose

The aim of our study was to evaluate the prevalence of the different stages of extra-aortic valvular cardiac damage by the application of Généreux staging and its impact on prognosis in a large, real world cohort of significant AR patients.

Methods

This study retrospectively analysed the clinical, Doppler echocardiographic and outcome data in patients with grade III or greater AR between January 2014 and September 2019. According to the extent of cardiac damage on echocardiography, patients were classified as Stage 0 (no cardiac damage), Stage 1 (left ventricular damage), Stage 2 (mitral valve or left atrial damage), Stage 3 (tricuspid valve or pulmonary artery vasculature damage) or Stage 4 (right ventricular damage). Exclusion criteria were severe aortic stenosis and previous valve repair or replacement. The primary end-point was all-cause mortality.

Results

A total of 572 patients, aged 70.1±13.9 years, 294 (51.3%) men were enrolled. One third of patients were in NYHA I. Based on the proposed classification, 82 patients (14.3%) were classified in stage 0, 130 (22.7%) in stage 1, 276 (48.2%) in stage 2, 68 (11.8%) in stage 3 and 17 (3.0%) in stage 4. Median follow-up time was 3.3±1.9 years. There was a progressive increase in mortality rates according to staging: 8.5% in stage 0, 10.8% in stage 1, 24.9% in stage 2, 42.6% in stage 3 and 52.9% in stage 4 (p<0.001). On multivariable analysis, the extent of cardiac damage was independently associated with excess mortality (HR 1.69, 95% CI 1.29 to 2.21)

Conclusion

Our study demonstrated that this new staging system studied for aortic stenosis also provides increased prognostic value to patients with significant aortic regurgitation. This staging system can be helpful to identify the degree of extra-aortic valvular cardiac damage and to optimize the time of valvular intervention. Further prospective studies are needed to confirm the benefit of the applicability of this model in clinical practice.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho Distribution of stages of cardiac damageSurvival analysis according to stage

Cryoballoon versus radiofrequency guided by ablation index for atrial fibrillation ablation: a retrospective propensity-matched study

Background/Introduction

Radiofrequency (RF) and cryoballoon (CB) ablation are established techniques for the treatment of atrial fibrillation (AF). Randomized trials comparing both techniques show similar levels of success; however, studies comparing CB with RF guided by ablation index (AI) are lacking.

Purpose

To compare the treatment success of CB with RF guided by AI, in patients with paroxysmal or persistent AF undergoing their first ablation procedure.

Methods

Patients undergoing AF ablation between 2017 and 2019 were retrospectively analysed. Primary success outcome was freedom from recurrence (defined as any episode of AF, atrial flutter or atrial tachycardia lasting >30 seconds and occurring after 91 days from ablation, or need for antiarrhythmic drugs (AAD), cardioversion or redo procedure). Secondary end-point was a composite of adverse cardiovascular outcomes (stroke/TIA, emergency room visit for AF, hospitalization for AF or cardiovascular death). Analysis was done before and after propensity score matching.

Results

A total of 316 patients were included. Mean age was 56.9±11.7 years. Sixty-two percent were male (n=196). Paroxysmal AF was present in 80.7% (n=255), with no difference between groups. RF was used in 57.9% (n=183) and CB in 42.1% (n=133), with isolation of all pulmonary veins accomplished in 95.9% (n=302), without differences between groups. Mean CHA2DS2-VASc score was 1.5±1.3, being higher in the RF group (1.7±1.3 vs 1.2±1.1; p=0.03); these patients were also older (mean age 58.1±12.0 vs. 55.17±11.0 years; p=0.007) and more likely to be in AF at the ablation (26.7% vs. 16.5%; p=0.006), have chronic kidney disease (40.2% vs. 23.2%; p=0.002), anaemia (11.8% vs. 2.7%; p<0.001), moderate/severe mitral disease (17.5% vs. 7.4%; p=0.012) or history of atrial flutter (17.7% vs. 3.1%; p<0.001). Patients in the CB group had a longer history of AF (3.8±3.5 vs. 3.0±2.9 years; p=0.041), received treatment with AAD more often (60.9% vs. 55.9%; p=0.049) and had longer follow-up time (889±397 vs. 601±239 days; p<0.001). Mean freedom from recurrence was not significantly different between groups (1106 days for CB vs. 889 days for RF; p=0.793), and recurrence rates were also similar (27.8% for CB vs. 23.5% for RF; p=0.291); however, patients treated with CB were more likely to need a redo procedure (38.3% vs. 17.4%; p=0.025). There were no differences in the composite of adverse cardiovascular events or in individual outcomes. Propensity score matching was done, and 154 patients were matched 1:1 for each treatment group. Survival free from recurrence showed no differences (1060 days for CB vs. 864 days for RF; p=0.912), and neither did the recurrence rate. CB patients with recurrence were still more likely to need a redo procedure (37.9% vs. 11.1%; p=0.021).

Conclusion

RF and CB result in similar survival free from AF and AF recurrence; however, recurrence in CB seems more significant, leading to higher rates of redo procedures.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar de Vila Nova de Gaia/Espinho

Prognostic impact of coronary artery disease severity and revascularization in TAVI patients

Background

Coronary artery disease (CAD) is highly prevalent in patients with severe aortic stenosis. In patients who undergo surgical aortic valve replacement, the presence of CAD and the need for CABG adversely influences short- and long-term outcomes. However, the impact of concomitant CAD and its revascularization in patients undergoing transcatheter aortic valve implantation (TAVI) is still a matter of debate.

Purpose

The aim of this study was to evaluate the prognostic impact of CAD severity in 1-year all-cause mortality of patients undergoing TAVI and whether prior complete or incomplete reasonable revascularization can improve prognosis after TAVI.

Methods and results

Retrospective analysis of a total of 575 patients (51,3% female, mean age 79,7±7,7 years) who underwent TAVI from August 2007 to November 2018. 50,3% of patients had significant CAD (at least one stenosis >50%) which 54,2% of these had history of prior revascularization (64,8% complete or incomplete reasonable revascularization and 35,2% incomplete revascularization).

Pre-TAVI CAD severity was defined by the SYNTAX Score (SS) and reasonable revascularization by the residual SYNTAX Score (rSS). Patients without history of revascularization were stratified into 3 groups: no CAD (SS=0); nonsevere CAD (SS between 1 and 22); and severe CAD (SS ≥23); Patients who had undergone revascularization prior to TAVI were separated into 2 categories based on their residual SS: complete or incomplete reasonable revascularization (rSS<8) and incomplete revascularization (rSS≥8). The primary end point was an all-cause mortality. 1 year, patients with severe CAD had significantly higher rates of mortality (no CAD: 9,8%, nonsevere CAD: 12,6%, severe CAD: 38,9%; P=0.001) without significant differences between patients with no CAD and nonsevere CAD (p=1,00). Patients with high rSS had significantly higher rates of mortality comparing to no CAD or rSS<8 (no CAD: 9,8%, rSS<8: 8,6%; rSS≥8: 28,0%, p=0.001).

Conclusions

In our study, only the presence of severe CAD (SS≥23) prior to TAVI was associated with increased 1-year all-cause mortality. In patients with previous history of revascularization, a complete/reasonable revascularization (lower rSS) was associated with lower long-term mortality, which may attenuate the association of severe CAD and mortality and therefore improve the prognosis of these patients.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho Figure 1. Prognostic Impact of CAD severityFigure 2. Prognostic Impact of Revascularization

Feasibility of coronary angiography after TAVR

Background

The prevalence of coronary artery disease (CAD) is high among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR).

Indications for TAVR are now expanding to younger and lower risk patients. During their lifetime, these patients will be at risk of developing CAD and it is expected an increase in coronary angiography and percutaneous coronary intervention (PCI). Aortic prosthesis, particularly if in supra-annular position, may pose important technical difficulties in coronary re-engagement after TAVR.

Purpose

To evaluate the feasibility to reengage the coronary ostia after TAVR, describe complications and compare technical differences between coronary procedures performed before and after TAVR.

Methods

Retrospective analysis of 714 patients submitted to TAVR from August 2007 to December 2019. Patients who needed coronary angiography after TAVR were selected.

The primary endpoint was the rate of successful coronary ostia cannulation after TAVR, defined by the possibility to selectively cannulate and inject both coronary ostia.

Secondary endpoint was complications associated with coronary catheterization after TAVR.

Results

Among 714 patients, 25 (3.5%) patients were submitted to a total of 28 coronary angiography after TAVR. 14 patients were male (56%), mean age 78.2±6.2 years and 9 (36%) had history of previous coronary revascularization.

From the 28 coronary angiographies (balloon-expandable Edwards-Sapien n=11, 44%; self-expandable CoreValve n=10, 40%; Portico n=2, 8%; Symetis n=2, 8%), 25 (89%) met the primary endpoint. Only three was semiselective (Symetis, CoreValve Evolut R and CoreValve TAVR in TAVR), with impossibility to cannulate both coronary arteries, right coronary artery and left coronary artery, respectively. 13 (46%) patients had also indication for PCI and all were successfully performed (Edwards-Sapien n=4, 31%; CoreValve n=6, 46%; Portico n=2, 15%; Symetis n=1, 8%). The main indications for coronary angiography was chronic coronary syndrome (n=12, 43%) and acute coronary syndrome without ST segment elevation (n=7, 25%). Circumflex artery was the most frequently treated vessel (n=6), followed by left anterior descending artery (n=4), right coronary artery (n=3) and left main (n=2).

There were no complications reported during or post-procedure. Comparing coronary angiographies before and after TAVR, there were no significant differences regarding arterial access site, catheter diameter, fluoroscopy time and quantity of contrast used in coronary angiography.

Conclusion

Although the need for coronary angiography was rare in patients after TAVR, selective diagnostic coronary angiographies were possible in 89% (25/28) and PCI was feasible in all patients in whom it was indicated, without any reported complications.

Further prospective studies are needed to confirm the great feasibility of performing coronary angiography after TAVR.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho

Impact of pulmonary veins anatomy on outcome of cryoablation or radiofrequency catheter ablation for atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Pulmonary vein isolation is the cornerstone of interventional treatment of atrial fibrillation (AF). Pulmonary veins frequently display anatomic variants. If this influences the recurrence of AF after catheter ablation is still a matter of debate.

PURPOSE

Our aim was to determine if pulmonary vein anatomy variants influences the recurrence of AF after catheter ablation with radiofrequency or cryoablation.

METHODS

Retrospective analysis of patients with paroxysmal or persistent atrial fibrillation who underwent pulmonary vein isolation by radiofrequency (RF) or cryoablation (CA) in a single center between January 2017 and September 2019. All patients underwent computed tomography before AF ablation. Within each treatment group (RF or CA), patients were stratified according to their PV anatomy in: regular (2 left PVs and 2 right PVs) or variant (left common trunk, right common trunk, bilateral common trunk, right intermediate branch or other). The primary end-point was 1-year recurrence of AF. Recurrence was defined as electrical documented AF.

RESULTS

A total of 425 patients (RF = 300 and CA = 125), aged 56.6 ± 11.7 years, 277 men (65.0%) were enrolled. The majority of patients had paroxysmal AF (n = 343, 81.5%). Mean CHA2DS2-VASc score was 1.12 ± 1.28. Regular PV anatomy was identified in 357 patients (84.0%), a left common trunk in 53 patients (12.5%), a bilateral common trunk in 5 patients (1.2%), a right intermediate branch in 3 patients (0.7%) and other mixed variants in 7 patients (1.6%). There were no significant differences in the baseline clinical and echocardiographic characteristics between groups.

At 1-year follow-up, patients with atypical PV anatomy had more AF recurrence (regular 8.1% vs variant 16.2%; p = 0.037). Analyzing according to the ablation technique there was no difference in AF recurrence between PV anatomy groups in patients submitted to radiofrequency (regular 8.3% vs variant 13.0%; p = 0.224). On the other hand, in cryoablation group, patients with PV anatomic variant had significantly higher rates of 1-year AF recurrence (regular 7.8% vs variant 22.8%; p= 0.033).

CONCLUSION

The presence of atypical PVs anatomy seems to be associated with higher rates of AF recurrence at 1-year in patients undergoing cryoablation. Further prospective studies are needed to confirm the PV anatomy impact in the success of the procedure and if this needs to be accounted in the choice of ablation technique. Abstract Figure. Recurrence in AF after cryoablation

Comparing single approaches success in index atrial fibrillation ablation

Funding Acknowledgements

Type of funding sources: None.

Introduction

Atrial Fibrillation (AF) ablation can be performed by inducing pulmonary vein electrical isolation. There are two widely used approaches: point-by-point and single-shot.  Catheter AF ablation is effective in restoring and maintaining sinus rhythm. However, efficacy is limited by high rate of AF recurrence, after an initially successful procedure.

Purpose

To evaluate AF index ablation successfulness using single-shot techniques and compare them to conventional one (point-by-point using irrigated- tip ablation catheter).

Methods

We analyzed, from a single center, all patients submitted to an index AF ablation procedure and its successfulness. The last was defined as AF, atrial tachycardia or flutter recurrence (with a duration superior to 30seconds) event- free survival, determined by holter and/or event recorder. These exams were performed after 6 and 12months and then annually, until 5years post procedure were accomplished.

Results

From November 2004 to November 2020, 821patients were submitted to first AF ablation (male patients 67,2%(N = 552), mean age of 59 ± 12years old). Paroxysmal AF(PAF) was present in 62,9%(N = 516), with short-duration persistent AF in 21,8%(N = 179) and long-standing persistent in 15,3%(N = 126). Ablation techniques were irrigated tip catheter point-by-point (PbP)ablation in 266 patients (32,4%) and single-shot (SS)techniques on the remaining 555(67,6%), including PVAC in 294(35,8%),225(27,4%) submitted to cryoablation and 36(4,4%) to nMARQ.

Globally, AF ablation had one-year success rate of 72,5%, and 56,2% at 3 years. A significant difference between AF duration type was found: Arrhythmic recurrence risk was 58% higher in persistent AF(PeAF) (HR 1.58;95%IC 1,22-2,04; p < 0.001). In patients presenting with PAF prior to the procedure, success was significantly higher in those submitted to SS technique(HR:0.69;95%CI 0,47-0,90;p = 0.046), while those with PeAF had similar results.

Conclusion

In this single center analysis almost three-quarters had achieved one-year event-free survival, and more than a half reached long-term freedom from atrial arrhythmia. Patients with paroxysmal atrial fibrillation submitted to single-shot procedure presented with a higher success-rate. Moreover, our study confirmed previous data on the importance of atrial fibrillation classification to postprocedural outcomes. Abstract Figure. Survival Curves

The use of an electronic form to register play observation of a child with anxiety: A study case at a university clinical practice in Brazil

Introduction

The modality of assessment used at a University Clinical Practice in Brazil is interventive psychodiagnosis in which the active participation of children and families is considered. Orientation is given following the input provided by children and their parents.

Objectives

Evaluating the use of an electronic form to be fulfilled during the observation of a child’s play in psychological session.

Methods

A child at the age of 5yrs 4m was brought for psychological assessment with the complaint of aggressiveness and irritability. His parents answered the Child Behavior Checklist (CBCL -1 1/12 5 yrs) and the Psychology interns had to observe the child’s play and fulfill an electronic form in which the choice of toys and plays, motricity, creativity, symbolic abilities, frustration tolerance, adequation with reality were verified.

Results

The results of CBCL indicated that the child was within the clinical range regarding anxiety and depression along with somatic complaints. The indicators observed in the electronic form such as rigidity in the modality of play, the lack of adequate ability of impersonating in role-playing, the difficulty of using creativity during play unless he was guided by peers or the Psychology interns and the constant anguish of separating himself from his parents were crucial for parents’ orientation. The psychological treatment lasted five months and benefited from the information obtained through the form once the symptoms of irritability and aggressiveness were reduced.

Conclusions

This modality of assessment can be instructional for parents and may also reduce financial and time costs once provides specific indicators to observe during play.

P1457Does high density mapping increase the efficacy of ischemic ventricular tachycardia ablation?

Introduction

 The treatment of ventricular tachycardia (VT) in patients (pts) with ischemic heart disease (IHD) represents a challenge because of its high morbidity and mortality rates and low long-term success rates. In the VANISH clinical trial, 51% of pts undergoing the conventional ablation technique developed within 2 years the combined outcome of mortality or electrical storm (ES) or appropriate CDI shock. The use of high-density substrate maps can lead to greater precision in substrate evaluation and ideally to improved ablation success.

Objectives

 To assess the efficacy of substrate-guided ischemic VT ablation using high-density mapping.

Methods

 Single-center prospective study of consecutive IHD pts submitted to endocardial ablation of substrate-guided VT using multipolar catheters (PentaRayTM or HDGridTM) and three-dimensional mapping systems with automatic annotation software. The maps were evaluated in order to identify the intra-cicatricial channels (areas of bipolar voltage <1.5mV) in which sequential propagation of local abnormal ventricular activities (LAVAs) were observed, during or after QRS. The ablation strategy aimed at the abolition of all intra-cicatricial LAVAs, directing the radiofrequency applications primarily to the entrances of the channels. The success of ablation was assessed by the primary outcome (death by any cause or ES or appropriate CDI shock) at 2 years and compared to the population of the VANISH study undergoing conventional ablation, using Cox regression and Kaplan- Meier survival analysis.

Results

 We included 40 patients, 95% males, 70 ± 8 years, mean ejection fraction 34 ± 10%. 82% on previous amiodarone therapy and 72% were ICD carriers. 32% underwent ablation during hospitalization for ES and 20% had previously undergone VT ablation. The median duration of substrate mapping was 74 minutes, with a mean of 2290 collected points. Major complications were seen in 1 patient (aortic dissection). During a mean follow-up time of 17.3 ± 12.9 months, the long-term success rate of VT ablation was 75%. Additionally, there was a reduction in the proportion of patients receiving amiodarone before vs after ablation (82% vs. 45% respectively). The rate of events observed during follow-up was lower than expected, namely by comparison with the population of the VANISH study undergoing conventional ablation (25% vs 51% at 24 months, HR 0.42 CI 95% 0.2-0.88, p = 0.022), reflecting a relative risk reduction of 58%.

Conclusions

 High density mapping allows a detailed characterization of the dysrhythmic substrate in patients with VT in an IHD context. Our results suggest that these technological innovations may be improving the clinical success of VT ablation.

Abstract Figure.

P945What is the role of late-potentials determined by signal-averaged ECG in predicting flecainide provocative test in brugada pattern?

Introduction

The sudden cardiac death risk in Brugada Syndrome (BrS) is higher in patients with spontaneous type 1 pattern. Brugada diagnosis is also established in patients with induced type 1 morphology after provocative test with intravenous administration with a sodium blocker channel. Nevertheless, this group of patients is known to be at a lower risk of SCD, and their risk stratification is still a matter of discussion.  Late potentials (LP) detected on signal-averaged ECG (SAECG) on the RVOT have been previously proposed as a predictor factor for BrS, even though data is lacking on its value.

Purpose

To evaluate the association between positive LP (LMS40> 38ms) on SAECG with modified Brugada leads and a positive flecainide test in patients with non-type 1 BrS.

Methods

Retrospective single-center study of non-type 1 BrS patients referred for the performance of a flecainide provocative test. Patients presenting with spontaneous type 1 morphology were excluded from the study. Study of LP on SAECG with modified leads for Brugada were evaluated before administration of flecainide [2mg/kg (maximum150mg), for 10minutes] with determination of filtered QRS duration (fQRS), root mean square voltage of the last 40ms of the QRS complex (RMS40) and duration of low amplitude signals <40μV of the terminal QRS complex (LMS40).

Results

126 patients (47.3 ± 14.1 years, 61.9% males) underwent study with LP SAECG and flecainide test. Among these patients, 7.9% were symptomatic and 16.7% had familiar history of BrS. Flecainide test was positive in 46.8% of patients.

In patients with a positive flecainide test, 64.4% presented LMS40 > 38ms whereas LMS40 > 38ms was present in only 46% of those with a negative flecainide test (p = 0.031). The presence of positive LMS40 was a positive predictor for a positive flecainide test, associated with a two-fold increase likelihood in the induction of a Brugada pattern (OR: 2,12; IC95% 1,025-4,392; P = 0,043).

There was no association between fQRS or RMS40 and a positive flecainide test (p = NS). fQRS > 114ms and RMS40 <20uV was present in 22% and 61% of patients with a positive flecainide test, respectively.

Conclusion

In patient with non-type 1 Brugada syndrome, LMS40 > 38ms in SAECG was a predictor for a positive flecainide test, suggesting that this finding could be helpful on the risk stratification of patients undergoing diagnostic study for Brugada syndrome.

Abstract Figure. Effect of LMS 40 in flecainide test

P1402Isolation of pulmonary veins with duty-cycled circular multi-polar catheter: randomized controlled clinical trial

Introduction

Pulmonary vein isolation (PVI) is the central element in the ablation of atrial fibrillation (AF), and can be obtained with different ablation modalities. The duty-cycled circular multi-pole catheter PVAC® (Medtronic) allows linear application of radiofrequency energy, with the production of circumferential lesions. Conceptually, it can make ablation simpler and faster in patients with favorable anatomy.

Objectives

To evaluate the safety and efficacy of ablation with a PVAC® catheter and to compare it with the conventional technique point-by-point (PbP) with irrigated catheter.

Methods

Clinical trial with single-blinded patients with AF refractory to antiarrhythmic therapy, randomized (1: 1) for ablation with PVAC® or PbP. The ablation strategy consisted of PVI, complemented with ablation of the cavo-tricuspid isthmus in patients with history of concomitant flutter. Monitoring was performed with a 7-day event loop recorder at 3, 6 and 12 months and annually from the 2nd year. Success was defined by AF-free survival or any maintained supraventricular tachycardia (duration > 30seconds).

Results

354 patients (67.5% males, 58 ± 12 years, PbP: 175, PVAC: 179) were included, of which 59.1% had paroxysmal, 26.2% short-standing persistent and 14.7% had long-standing persistent AF. Baseline characteristics were similar between groups. Among patients treated with PVAC, 93.1% of the pulmonary veins were isolated (620/666), similar to the 98.3% immediate success of the PbP group (697/709). Although the complication rate was similar in both groups (PVAC: 4.9% vs. PbP: 7.8%; P = NS), the risk of hemopericardium was lower with PVAC (0% vs. 4.6%; P = 0.013). Two patients treated with PVAC developed stroke (1.13% vs. 0%; P = NS). The duration of the procedure was lower among the patients treated with PVAC [136 (100-180) vs. 230 (188-270) min; P <0.001], with no difference in fluoroscopy time [24.4 (14.5-36.8) vs. 27.1 (17.0-45.0) min]. The success rate after 1st ablation at 36 months was 68%, with no differences between groups. The success rate after multiple ablations increased to 85.8%, with no differences between groups.

Conclusion

The multipolar PVAC catheter can represent an added value in AF ablation, making the procedure simpler and faster, ensuring similar efficacy to the conventional technique and with a lower risk of cardiac tamponade. The present trial suggests the need for clinically manifested stroke risk surveillance, which may be increased with this technique.

Abstract Figure.

164 Gonadotrophin-releasing hormone injection and colour flow Doppler ultrasound of the preovulatory follicle as a tool to increase pregnancy outcome after timed AI in beef cows

The aims of this study were to determine (1) the association between Doppler vascularisation scores (DVS) of the preovulatory follicle (POF) and fertility of beef cows submitted to timed AI (TAI) and (2) whether cows with low DVS benefit from a gonadotrophin-releasing hormone (GnRH) treatment at TAI. Multiparous lactating Nelore cows (Bos indicus; n=69) from a commercial beef farm in the state of Rondônia, Brazil, were enrolled in this study. Cows received 2mg of oestradiol benzoate intramuscularly (Bioestrogen, Biogénesis Bagó) and an intravaginal progesterone-releasing device (1.9g of progesterone; controlled internal drug release, CIDR) to synchronise follicular wave emergence on Day 0. The CIDR device was removed and cows were treated with 150μg of D-cloprostenol intramuscularly (prostaglandin F2α analogue; Croniben), 1mg of oestradiol cypionate intramuscularly, and 300IU of equine chorionic gonadotrophin (Novormon) intramuscularly on Day 8. Cows were then painted with a tail chalk marker to identify those displaying oestrus. All cows were submitted to TAI 48h after CIDR removal. At TAI, occurrence of oestrus was recorded and all cows were examined using transrectal ultrasonography. Blood flow of the POF was evaluated using colour Doppler imaging. Colour Doppler signals present on the follicular wall were subjectively scored using a 1-to-4 scale (1=absence or very low blood flow, and 4=intense blood flow detected on most of the follicular wall surface) adapted from Ginther (2007Ultrasonic Imaging and Animal Reproduction: Color-Doppler Ultrasonography, pages 87-114). Then, cows were divided into three groups according their DVS of the POF: (1) high DVS (DVS ≥3; n=36), (2) low DVS (DVS <3; n=16), and (3) low DVS (DVS <3; n=17) plus a GnRH treatment at TAI. The diameter of the POF was analysed using analysis of variance (PROC GLIMMIX of SAS; SAS Institute Inc.), and the means were compared among groups using Tukey's test. The proportion of cows that displayed oestrus and pregnancy rates was analysed using chi-square test. Cows in the high-DVS group had a larger POF than cows in the low-DVS and low-DVS-GnRH groups (13.2±0.2, 11.7±0.5, and 12.2±0.4, respectively; P<0.05). The proportion of cows that displayed oestrus was greater (P<0.05) in the high-DVS group (72%, 26/36) than in the low-DVS (37.5%, 6/16) or low-DVS-GnRH (53%, 9/17) groups. Finally, greater (P<0.05) pregnancy rates were observed in cows from the high-DVS (47.2%; 17/36) and low-DVS-GnRH (52.9%; 9/17) groups than in cows from the low-DVS group (18.7%; 3/16). The preliminary results from this study demonstrated that diameter of POF is positively associated with DVS. Moreover, cows that presented POF with higher DVS are more likely to become pregnant, and the administration of GnRH to females with low DVS can increase the fertility of beef cows submitted to TAI protocols. This study received funding support from Embrapa (MP1/PC3 project no. 01.03.14.011.00.00) and from CNPq (universal project no. 407307/2016-8).

P1930Pharmacodynamic effects of vorapaxar as an add-on antiplatelet therapy in patients with and without diabetes mellitus: the optimizing anti-platelet therapy in diabetes mellitus (OPTIMUS)-5 study

Background

Vorapaxar (Vora) is a protease-activated receptor (PAR)-1 inhibitor which when added to dual antiplatelet therapy (DAPT) in patients with a history of myocardial infarction (MI) or with peripheral arterial (PAD) reduces thrombotic cardiovascular events at the expense of increased bleeding. The efficacy of Vora is enhanced in patients with diabetes mellitus (DM) compared to non-DM. However, the differential pharmacodynamic (PD) effects of Vora in DM vs non-DM patients are unknown. Moreover, although withdrawal of aspirin has emerged as a strategy to reduce bleeding when adjunctive antithrombotic therapies are used, the PD effects of Vora after stopping aspirin in DAPT treated patients is unknown.

Purpose

To assess the PD effects of Vora in addition to standard DAPT as well as in combination with clopidogrel following aspirin withdrawal in patients with and without DM.

Methods

This was a prospective parallel-design PD study conducted in post-MI or PAD patients with and without DM. Patients on DAPT with aspirin (81mg/qd) and clopidogrel (75mg/qd) were divided in two groups according to DM status. Each cohort was treated with Vora (2.5mg/qd) in addition to DAPT (i.e., triple therapy) for 30 days and afterwards stopped aspirin and maintained treatment with Vora plus clopidogrel (i.e., dual therapy) for other 30 days. PD testing using 5 different assays was conducted at 3 time-points: baseline (while on DAPT); after 30 days of triple therapy; after 30 days of dual therapy. The primary endpoint was the non-inferiority of CAT (Collagen-ADP-TRAP)-induced aggregation, a marker of global platelet reactivity, of Vora plus clopidogrel (dual therapy) vs Vora plus DAPT (triple therapy).

Results

The PD population was composed of a total of 64 patients (DM, n=30; non-DM, n=34). Although adding Vora to DAPT significantly reduced CAT-induced aggregation, stopping aspirin was associated with an increase in CAT-induced aggregation in both DM (mean difference=12; 95% CI: 3 to 21; p=0.010) and non-DM (mean difference=10; 95% CI: 4 to 16; p=0.003), thus not meeting the primary endpoint of non-inferiority (Figure). The magnitude of such increase was higher in DM compared with non-DM (p=0.036). Although Vora abolished TRAP-induced aggregation in both DM and non-DM patients, it did not affect markers of clot kinetics including speed of thrombin generation. Aspirin withdrawal was associated with a marked increase in makers sensitive to cyclooxygenase-1 (COX-1) blockade; markers of P2Y12 signaling were higher in DM compared to not DM after aspirin withdrawal.

CAT-induced aggregation

Conclusion

Adjunctive treatment with Vora reduces platelet-mediated thrombogenicity without affecting clot kinetics in both DM and non-DM patients while on DAPT. However, platelet-mediated thrombogenicity is increased after aspirin withdrawal, a phenomenon which is enhanced in DM patients underscoring the pivotal contribution of the COX-1 signaling pathway in these high risk patients.

Acknowledgement/Funding

The study was supported in part by an investigator initiated study grant from Merck

P1934Platelet inhibitory profiles of prasugrel versus ticagrelor in patients with CYP2C19 loss-of-function genotypes undergoing percutaneous coronary intervention: results of a randomized feasibility study

Background

Although clopidogrel is the most widely used P2Y12 inhibitor, loss-of-function (LOF) allelic variants located within the hepatic cytochrome P450 (CYP) 2C19 gene lead to attenuated bioactivation, increased rates of high platelet reactivity (HPR), and worse outcomes in patients undergoing percutaneous coronary intervention (PCI). Drug regulating authorities have suggested using alternative P2Y12 inhibitors (i.e., prasugrel or ticagrelor) in these patients. However, tailoring antiplatelet therapy in clinical practice according to results of genetic testing has been limited due to lack of access to promptly available results. Moreover, there are no head-to-head pharmacodynamic (PD) comparisons of prasugrel vs ticagrelor among patients with CYP2C19 LOF alleles.

Purpose

The aim of this study was to evaluate the feasibility of using rapid genetic testing in clinical practice and to compare the PD effects of prasugrel vs ticagrelor in patients undergoing PCI with CYP2C19 LOF alleles.

Methods

This was a prospective, randomized study conducted in patients with stable coronary artery disease and non-ST elevation acute coronary syndrome scheduled for left heart catheterization (LHC) with the intent to undergo PCI. Patients underwent rapid genetic testing using the Spartan RX assay, which defines CYP2C19 genetic status within 1 hour, allowing patients to be genotyped the same day of their LHC. Patients who were carriers of at least one LOF (*2 or *3) allele were randomized to receive either prasugrel [60mg loading dose (LD) - 10mg/day maintenance dose (MD)] or ticagrelor (180mg LD - 90mg b.i.d MD). Blood samples for PD analysis by VerifyNow were collected at 5 time points: baseline (prior to PCI), 30 minutes, 2 hours, 24 hours (or at hospital discharge whichever came first), and 1–4 weeks post-LD. All patients were treated with aspirin. The primary endpoint of our study was the non-inferiority in platelet reactivity, measured as PRU, at 24 hours of prasugrel vs ticagrelor in LOF allele carriers.

Results

A total of 781 consecutive patients scheduled for LHC were genotyped, of whom 223 (28.5%) were carriers of at least one LOF. Of these, 65 patients underwent PCI and randomized to prasugrel (n=32) vs ticagrelor (n=33). PRU levels at 24 hours were 33 vs 36 (prasugrel vs ticagrelor; mean difference = −3; 95% CI: −28 to 22; p=0.814) meeting the primary endpoint of non-inferiority. Both prasugrel and ticagrelor significantly reduced PRU to a similar extent with no differences between groups at all other time points (Figure). Accordingly, HPR rates were low and similar between groups.

PRU by VerifyNow

Conclusion

Rapid genetic testing using the Spartan assay is feasible providing results in a timely fashion in a real-world clinical practice of patients undergoing PCI. Among patients with CYP2C19 LOF carrier status, prasugrel and ticagrelor are associated with similar levels of platelet inhibition.

Acknowledgement/Funding

Genetic testing was provided by Spartan RX

P115 Subarachnoid haemorrhage with negative initial vascular imaging: a single unit experience

Objectives

To investigate the incidence of vascular abnormality and clinical outcomes in a group of patients presenting with spontaneous subarachnoid haemorrhage (SAH) and negative initial vascular investigation.

Design

Single centre prospective cohort study.

Subjects

All adult patients with SAH admitted to our unit over a 12 month period.

Methods

Prospective collection of data on secure electronic database. Information pertaining to gender, age, mode of initial and subsequent vascular investigations was acquired. Details regarding clinical outcomes at 30 days and complications were documented.

Results

118 consecutive patients with SAH were admitted to our unit over the 12 month study period. 37 patients had negative initial vascular imaging (37/118=31.4%). M:F=19:18, age range 26–76 years. 32 patients underwent a high quality CT angiogram as initial vascular investigation, 5 patients underwent catheter cerebral angiogram (DSA). The most common modality of further vascular imaging was DSA. 5 vascular abnormalities were detected on subsequent vascular imaging (5/37=13.5%). Hydrocephalus and vasospasm were the commonest complications. Clinical outcomes were very good; all patients had a GOS of 5 at 30 days.

Conclusions

Patients with SAH and negative initial vascular investigation are an important subset of patients with SAH. There is no uniformity in the type of subsequent vascular investigations selected. Our experience is consistent with previously published studies.

Overall Survival in Advanced Breast Cancer: Relevance of Progesterone Receptor Expression and DNA Ploidy in Fine-Needle Aspirates of 392 Patients

Fine-needle aspiration cytology (FNAC) is essential for making a diagnosis in advanced breast cancer. The determination of hormone receptors in the material obtained is useful for predicting patient response to endocrine therapy, but the prognostic value of hormone receptor expression as well as the clinical utility of DNA flow cytometry are controversial. The aim of this prospective study with long-term follow-up (median: 81 months) was to evaluate these biomarkers in relation to overall survival in a series of 392 patients with advanced breast cancer (stage IIB, n=106; IIIA, n=66; IIIB, n=174; and IV, n=46) using FNAC. Estrogen and progesterone receptor expression was found in 65.1% and 46.1% of the tumors, respectively. Hormone receptors were not found to be associated with clinical staging. DNA aneuploidy was present in 70.9% of the cases and the median S-phase fraction (SPF) was 9.4%. There was a significant correlation of aneuploidy and high SPF with lack of hormone receptors. In univariate analysis, advanced disease stage, absence of hormone receptors, DNA aneuploidy and high SPF showed a statistically significant correlation with poor clinical outcome. In multivariate analysis, disease stage, progesterone receptors and DNA ploidy retained independent prognostic significance in relation to overall survival. These data indicate that progesterone receptor expression and DNA ploidy are independent prognostic factors in advanced breast cancer.

Prognostic Biomarkers in Renal Cell Carcinoma: Relevance of DNA Ploidy in Predicting Disease-Related Survival

Objective

To investigate the prognostic value of DNA ploidy, Ki-67 index and p53 expression in relation to disease-related survival in a consecutive series of patients with renal cell carcinoma (RCC).

Material and methods

The study group consisted of 64 RCC patients treated by radical nephrectomy. Histological type, pathological staging and nuclear anaplasia were assessed according to the WHO classification, TNM system and Fuhrman grading criteria, respectively. Ploidy was determined by DNA flow cytometry using two sampling methods (frozen vs paraffin-embedded tissue). Ki-67 and p53 were evaluated by immunohistochemistry techniques using two cutoff points (10% vs mean value) for staining interpretation. Kaplan-Meier and Cox regression analyses were used for prognostic evaluation.

Results

Thirty-one tumors (48.4%) showed DNA diploidy and 33 (51.6%) were DNA aneuploid. Concordance between both ploidy measurement methods was found in 85.5% of cases (p=0.0455). The mean values for Ki-67 and p53 immunostaining were 3.65% (0–23.5%) and 5.90% (0–55.9%), respectively. DNA ploidy significantly correlated with staging, tumor size (pT), nuclear grading, and Ki-67 (mean value cutoff). Ki-67 (10% cutoff) correlated with staging and pT, while p53 (mean value cutoff) was associated with Ki-67 (mean value cutoff). There were significant differences between survival curves for pathological stage, pT, nuclear grade, ploidy, Ki-67 (both cutoffs), and p53 (10% cutoff). By univariate regression analysis, stage III and stage IV, pT3, aneuploidy, high Ki-67 (both cutoffs), and p53 overexpression (10% cutoff) showed significant correlations with worse disease-related survival. In addition, DNA aneuploidy significantly correlated with poor prognosis within stages I/II (p=0.0355) and stages III/IV (p=0.0138) of the disease.

Conclusion

The results indicate that DNA ploidy has relevant prognostic value in RCC, adding useful information to the classic histopathological indicators of clinical outcome.

St36 electroacupuncture activates nNOS, iNOS and ATP-sensitive potassium channels to promote orofacial antinociception in rats

Orofacial pain is pain perceived in the face and/or oral cavity, generally caused by diseases or disorders of regional structures, by dysfunction of the nervous system, or through referral from distant sources. Treatment of orofacial pain is mainly pharmacological, but it has increased the number of reports demonstrating great clinical results with the use of non-pharmacological therapies, among them electroacupuncture. However, the mechanisms involved in the electroacupuncture are not well elucidated. Thus, the present study investigate the involvement of the nitric oxide synthase (NOS) and ATP sensitive K⁺ channels (KATP) in the antinociception induced by electroacupuncture (EA) at acupoint St36. Thermal nociception was applied in the vibrissae region of rats, and latency time for face withdrawal was measured. Electrical stimulation of acupoint St36 for 20 minutes reversed the thermal withdrawal latency and this effect was maintained for 150 min. Intraperitoneal administration of specific inhibitors of neuronal nitric oxide synthase (nNOS), inducible nitric oxide synthase (iNOS) and a KATP channels blocker reversed the antinociception induced by EA. Furthermore, nitrite concentration in cerebrospinal fluid (CSF) and plasma, increased 4 and 3-fold higher, respectively, after EA. This study suggests that NO participates of antinociception induced by EA by nNOS, iNOS and ATP-sensitive K⁺ channels activation.