Safety and efficacy of cerebral embolic protection devices in transcatheter aortic valve implantation: a meta-analysis

Funding Acknowledgements

Type of funding sources: None.

Background

Stroke during Transcatheter Aortic Valve implantation (TAVI) is not an uncommon complication with potential devastating consequences. With the extension of TAVI to the low-risk patient, stroke prevention takes on increasing importance. The use of cerebral embolic protection device (EPD) reveals conflicting data. This meta-analysis aims to evaluate the clinical efficacy and safety of EPDs.

Methods

A comprehensive literature search for all studies till May 2022 reporting clinical safety and efficacy outcomes of the only EPD approved for use by the Food and Drug Administration (FDA) was performed. Study outcomes were divided based on time period - overall (up to 30 days and in-hospital) and short (≤7 days). Primary outcome was stroke - major and minor. Secondary outcomes included transient ischaemic attack (TIA), mortality, acute kidney injury (AKI), major vascular and bleeding complications.

Results

A total of 12 studies involving 288531 patients were analysed, which included 3 randomised controlled trials (RCTs), 7 propensity-matched and 2 cohort studies. Regarding overall outcomes, significant differences were noted for mortality (OR 0.59 [0.42-0.84], p=0.0036) and major stroke (OR 0.40 [0.18-0.91], p=0.028) (Fig 1). No significant differences were noted for all stroke (p=0.058), minor stroke (p=0.32), TIA (p=0.49), AKI (p=0.17), major vascular complications (p=0.40) and major bleeding complications (p=0.11). There was significant heterogeneity across the studies for mortality (p=0.032) and all stroke (p=0.009). In the subgroup analysis of studies reporting ≤7 days outcomes (n=5), EPDs showed significantly lower rates of all stroke (0.33 [95% CI 0.19-0.56], p=<0.0001), major stroke (0.19 [0.08-0.48], p=0.0004) and major bleeding complications (OR 0.29 [0.10-0.79], p=0.016), but no significant differences for mortality (p=0.67) and minor stroke (p=0.070). There was no significant heterogeneity across the studies (all p>0.05)

Conclusions

In this meta-analysis including non-randomised studies, the use of EPDs was associated with lower mortality and major stroke rates, although significant heterogeneity was noted for the studies reporting mortality. Further ongoing larger scale RCTs will further clarify these results.

Real-world outcomes of Selexipag for treatment of pulmonary hypertension in an Asian population

Funding Acknowledgements

Type of funding sources: None.

Introduction

Selexipag is an oral selective prostacyclin IP receptor agonist indicated for treatment of pulmonary arterial hypertension (PAH). Data on its real-world safety and efficacy in Asians is lacking.

Purpose

We sought to evaluate the clinical characteristics, treatment regimens and outcomes of patients initiated on selexipag in a tertiary cardiac centre in Asia.

Methods

This was a retrospective study on all patients initiated on selexipag from January 2017 to December 2020. Baseline and follow up characteristics including demographics, functional status and clinical data were collected. Clinical outcomes evaluated included hospitalisation for PH related complications and all-cause mortality. Patients were risk stratified using the COMPERA 2.0 risk scores.

Results

A total of 36 PAH patients were treated with selexipag. At baseline, most patients were WHO functional class II or III (36.4% and 51.5% respectively), with a NT-proBNP of 1335 pg/ml (557 – 2918) and 6 minute walk test (6MWT) duration of 327.5 ±126.4 meters. Selexipag was initiated at 200mcg twice daily dosage for all except one patient (started at 200mcg once daily) and the maximum tolerated dose ranged from 200mcg twice daily to 1400mcg twice daily, with majority tolerating up to a dose of 600mcg twice daily (58.3%). Side effects were reported in 23 patients (63.9%), of which headache (27.8%), diarrhea (30.6%) or musculoskeletal symptoms (27.8%) were predominant. After a median follow up duration of 25.9 ± 23.1 months, selexipag was stopped in 20 patients (55.6%), of which eight patients were due to PAH progression requiring alternative therapy, and 12 patients due to side effects from selexipag. At baseline, patients were classified into low (8.3%), intermediate-low (30.6%), intermediate-high (33.3%) and high risk (27.8%) respectively. Patients who continued on selexipag at follow up showed no change (46.2%), improvement (15.4%) and deterioration (38.5%) in risk score. In the overall cohort of 36 patients, majority (75%) had at least one hospitalisation for PAH related complications and 15 patients (41.7%) demised.

Conclusion

In this real-world study, while selexipag was associated with a stable or improved PAH risk scores in majority of patients, there was a subset of patients with disease progression or intolerance to the medication. Further studies are warranted to identify patients who will benefit most from this therapy.

Contemporary review of the management of left ventricular thrombus

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular thrombus (LVT) is a known complication of acute myocardial infarction (AMI) and other cardiomyopathies. LVT increases the risk of stroke and systemic embolism, hence treatment with oral anticoagulation is indicated. While the initial treatment options for LVT is clear, the management of patients after the initial duration of anticoagulation is more complex and varied.

Purpose

We aimed to undertake a comprehensive literature review to study the currently available evidence regarding not only the initial type and duration of anticoagulation for LVT, but also potential treatment options after the initial period of anticoagulation in the setting of both LVT persistence and resolution.

Methods

MEDLINE, EMBASE, Scopus, and Google Scholar were searched from inception to August 2022. Data from randomized controlled trials (RCTs), observational studies and case series discussing management of LVT were included in this summarized synthesis.

Results

Of 2050 studies screened, 30 studies (24 observational studies, 3 case series, 2 RCTs, 1 non-randomized, open-label trial) were included. A total of 17 studies compared warfarin with direct oral anticoagulants (DOACs) for the initial anticoagulation strategy, with the vast majority showing similar outcomes (Table 1). Half (n = 9/18) of the studies repeated imaging between 3-6 months. All studies (n=30) used transthoracic echo with or without contrast as the imaging modality of choice, with selected patients undergoing computed tomography (CT) or cardiac magnetic resonance (CMR). If the LVT persisted, most studies recommended continuing anticoagulation (n = 11/16, 69%) or switching to a different class of anticoagulants (n = 6/16, 38%). In the event of LVT non-resolution, high-risk features of embolization (protruding, mobile vs layered clot) may aid in the discussion of risk and benefit of long-term anticoagulation. Even upon resolution of the LVT, some studies (n=5) recommend continuing anticoagulation in the presence of high-risk features of recurrence (eg. persistently depressed left ventricle ejection fraction (LVEF) and/or apical wall dyskinesis). Regardless, medical management should be optimized together with the appropriate revascularization strategy as clinically indicated.

Conclusions

Current evidence on the management of LVT is limited. This updated review summarizes the available evidence for the management for LVT. Evidence-based recommendations on the management of these patients is warranted to appropriately guide clinicians.

Pathophysiologic mechanism for MYOcarditis in COVID-19 VAccinations ("MYOVAx" Study)

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NMRC COVID-19 Research Fund

Objective

This is the first prospective cohort study in Singapore to investigate the COVID-19 vaccine-associated myocarditis to understand its pathophysiology.

Introduction

Acute myocarditis and other cardiovascular symptoms have been observed to be associated with the two mRNA-based coronavirus disease 2019 (COVID-19) vaccines—namely Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273)—currently in-use in Singapore. The mechanisms through which myocarditis occurs are unknown, hence our study aims to understand the pathophysiology of myocarditis associated with COVID-19 vaccines.

Methods

Patients with onset of cardiac manifestations were recruited from multiple hospital outpatient clinics between November 2021 and September 2022. Clinical history and physical examination data was collected with blood sample collection, echocardiography, 12-lead electrocardiogram (ECG), coronary angiography and magnetic resonance imaging (MRI) at recruitment and 6-month follow-up. Analysis of biomarkers, genetic, serological and MRI data was conducted.

Results

As of 6 September 2022, a total of 5 patients have been enrolled (4 males, 1 female). The most commonly reported symptoms across all patients were chest pain/discomfort (80%), followed by palpitations (40%). MRI evidence of myocarditis has been detected in 2 (50%) of the male patients, of which both reported two or more symptoms occurring 1-2 days post-vaccination. Both patients have each received at least two doses of either the Pfizer-BioNTech BNT162b2 vaccine or Moderna mRNA-1273 vaccine. Their MRI findings were consistent with myocarditis. On late gadolinium enhancement (LGE) imaging, epicardial enhancement at the basal inferolateral segment and mid-wall enhancement at the apical anterior, lateral and inferior walls were observed in one patient. Patchy, mid-wall LGE in the basal inferior/inferolateral wall was observed in the other patient. No MRI evidence of myocarditis was available for the sole female patient.

Conclusion

While more data is needed to definitively prove the association of the two mRNA-based Pfizer-BioNTech BNT162b2 and Moderna mRNA-1273 COVID-19 vaccines with post-vaccination myocarditis, we believe our findings may support further investigations to enable risk stratification for vaccine-associated myocarditis and identify potential preventative strategies accordingly.

IL-37-a putative therapeutic agent in cardiovascular diseases

Although it is a member of the Interleukin (IL)-1 family, IL-37 is unique in that it has wide-ranging anti-inflammatory characteristics. It was originally thought to prevent IL-18-mediated inflammation by binding to the IL-18-binding protein. However, upon discovery that it binds to the orphan receptor, IL-1R8, further studies have revealed an expanded role of IL-37 to include several intracellular and extracellular pathways that affect various aspects of inflammation. Its potential role specifically in cardiovascular diseases (CVD) stemmed initially from the discovery of elevated plasma IL-37 levels in human patients with acute coronary syndrome and atrial fibrillation. Other studies using mouse models of ischemia/reperfusion injury, vascular calcification and myocardial infarction have revealed that IL-37 can have a beneficial role in these conditions. This review will explore recent research on the effects of IL-37 on the pathogenesis of CVD.

Intravenous epoprostenol therapy in the treatment of pulmonary arterial hypertension: the Singapore experience

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary arterial hypertension (PAH) is a progressive disease with significant morbidity and mortality. While intravenous (IV) Epoprostenol, a prostacyclin analogue, has been shown to improve exercise tolerance, symptoms, hemodynamics and survival, there are challenges with initiation and maintenance of this IV therapy.

Purpose

We aim to describe our local experience of the use of IV Epoprostenol in the treatment of PAH patients in Singapore, highlighting various issues and challenges.

Methods

From 2016, patients at a tertiary cardiac institution diagnosed with Group 1 PAH and remaining in intermediate to high risk class with progressive symptoms (despite being on maximum tolerable doses of PhosphoDiEsterase-5 inhibitors and Endothelin-1 receptor antagonists) were assessed and counselled for initiation of Epoprostenol therapy. With a fixed set of local protocols, comprehensive assessment and support of a multi-disciplinary team including physicians, specialist nurses and pharmacists, suitable patients were started on this treatment.

Results

A total of 12 patients (11 female, mean age 42.8 +/- 11.0 years) were included. The average New York Heart Association class of the patients initiated on Epoprostenol was II-III. The pulmonary artery pressures and pulmonary vascular resistance on right heart catheterization prior to initiation was 52.5 (IQR 47.0-54.0) mmHg and 12.6 (IQR 10.0-14.2) Woods respectively. The duration from diagnosis to time of initiating Epoprostenol was 89 (IQR 62-140) months. Epoprostenol was generally well tolerated. The most common side effect experienced was diarrhea (5/12 patients) followed by headache and musculoskeletal complains (3/12 patients each). Of the 12 patients, 6 passed away after 12 (IQR 10-16) months of Epoprostenol therapy. Of the remaining 6, PAH was diagnosed 110 (IQR 104-136) months ago and Epoprostenol therapy has been continued for 17 (IQR 14-27) months. Of those who survived, right ventricle size and PA pressures on echocardiography remained relatively stable as compared to those who passed on. 2 patients had line related infections requiring a line change 1 and 2 times respectively.

Conclusion

While not without its challenges, the establishment of concrete protocols with the support of a multidisciplinary team allows for the introduction of IV Epoprostenol as an additional potential line of effective therapy for PAH patients in Singapore.

Clinical characteristics and outcomes of myocardial infarction with nonobstructive coronary arteries

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is caused by a heterogenous group of conditions with clinically significant sequelae.

Purpose

This study aims to compare the clinical characteristics and prognosis of MINOCA with myocardial infarction with obstructive coronary artery disease (MICAD).

Methods

Data was obtained from the Singapore Cardiac Longitudinal Outcomes Database (SingCLOUD), a national multicenter registry of patients with cardiovascular disease. Patients with a first presentation of acute myocardial infarction who underwent coronary angiography between 1 January 2011 and 31 December 2014 were extracted from the database. Follow up was conducted until 31 December 2017. Subjects were classified as having either MICAD or MINOCA based on angiographic findings. The primary outcomes were all-cause mortality and major adverse cardiac events (MACE) defined as a composite of all-cause mortality, recurrent myocardial infarction, hospitalization for heart failure and ischemic stroke.

Results

All 4124 patients who met the inclusion criteria were included in this study, of which 159 (3.9%) were diagnosed with MINOCA. Patients with MINOCA were more likely to be female, present with a non-ST elevation myocardial infarction (NSTEMI), have a higher left ventricular ejection fraction and less likely to have diabetes mellitus, previous ischemic stroke or smoking history. Over a mean follow-up duration of 4.5 years, MINOCA patients had a lower incidence of all-cause mortality (10.1% vs. 16.5%, p=0.030) and MACE (20.8% vs. 35.5%, p<0.0001) compared to patients with MICAD. On multivariable analysis, patients with MINOCA had a significantly lower risk of all-cause mortality (HR 0.42; 95% CI 0.21–0.82; p=0.011), MACE (HR 0.42; 95% CI 0.26–0.69; p=0.001) and recurrent myocardial infarction (HR 0.35; 95% CI 0.15–0.85; p=0.021). Within the MINOCA group, older age, higher creatinine, a STEMI presentation and the absence of antiplatelet use predicted all-cause mortality and MACE.

Conclusions

While patients with MINOCA had better clinical outcomes compared to MICAD patients, MINOCA is not a benign entity with about one in five patients experiencing a major adverse cardiovascular event in the mid-term.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Medical Research Council Project Grant

POS0303 PREVENTION OF CHRONIC DISEASES DUE TO INFLAMMATION IN INFLAMMATORY ARTHRITIS: RESULTS OF A DELPHI PROCESS TO SELECT CARE RECOMMENDATIONS FOR AN ELECTRONIC MEDICAL RECORD (EMR) INTERVENTION

Background:

Inflammatory arthritis (IA) predisposes patients to several chronic conditions including cardiovascular diseases (CVD), diabetes (DM), osteoporosis (OP) and infections, likely due to systemic effects of inflammation. Studies have found that patients with IA often receive suboptimal care for screening and managing these conditions.

Objectives:

This is the first phase of a study which will develop and pilot test automated EMR reminders for family physicians. The reminders will prompt family physicians to screen for and address risk factors for these conditions. We conducted a Delphi process to select care recommendations to be addressed by the EMR reminders.

Methods:

We conducted a review of current BC, Canadian and international guidelines for screening and addressing risk factors for CVD, DM, OP and infection. A list of 22 care recommendations, including their level of evidence and risks/benefits of implementation, was reviewed by a panel of six family physicians, three rheumatologists and three IA patients, in a three-round online modified Delphi process. Panelists rated each care recommendation, using 9-point scales, on 1) their clinical importance, 2) their likelihood of improving outcomes, and 3) implementation feasibility. Results were discussed in an online forum. Panelists then rated slightly revised care recommendations, modified based on feedback from the discussion. Care recommendations were retained if the median rating was ≥7 with no disagreement as defined by the RAND/UCLA Method handbook.

Results:

A list of 15 care recommendations was selected by the Delphi process for EMR integration, including recommendations that address CVD risk assessment (1), hypertension screening (1), DM screening (2), fracture risk assessment (1), BMD testing (1), osteoporosis prevention (1) and treatment (1) with bisphosphonates, preventing infections through immunization (2), minimizing steroids (1) and hepatitis screening (1), screening for hydroxychloroquine retinal toxicity (1), and counselling for lifestyle modifications (2). We excluded 7 recommendations which addressed lipid testing (1), BMD testing in steroid users (1), immunizations (2), weight management (1), and DMARD laboratory test monitoring (2). Recommendations were excluded on the basis of importance (1) or feasibility (6).

Conclusion:

The results of the Delphi process will inform the development of reminders, integrated in EMRs, that will support family physicians in their efforts to engage IA patients in addressing risk factors for chronic diseases related to inflammation. We hope to improve the prevention of these diseases, which represent an important cause of morbidity and mortality for people with inflammatory arthritis.

Acknowledgements:

Iman Sheriff’s work on this project was funded by the CRA summer studentship programme. Dr. Lacaille is supported by the Mary Pack Chair in Arthritis Research from UBC and The Arthritis Society of Canada. Thank you to all who participated in the Delphi survey.

Disclosure of Interests:

None declared

Impact of age and sex on subclinical coronary atherosclerosis in a healthy asian population

Funding Acknowledgements

Type of funding sources: None.

Background and Aims

The influence of age and gender on clinical atherosclerotic cardiovascular disease is well reported, but literature remains sparse on whether these extend to the disease in its preclinical stage. We aim to report the prevalence, risk-factors and impact of age and gender on the burden of subclinical coronary atherosclerosis in a healthy Asian population.

Methods

Healthy subjects aged 30-69 years old, with no history of cardiovascular disease or diabetes were recruited from the general population. Subclinical coronary atherosclerosis was quantified via the Coronary Artery Calcium Score (CACS) with CACS of 0 indicating the absence of calcified plaque, 1 to 10 minimal plaque, 11 to 100 mild plaque, and >100 moderate to severe plaque.

Results

A total of 663 individuals (mean age 49.4 ± 9.2 years, 44.8% male) were included. The prevalence of any CAC was 29.3% with 9% having CAC > 100.  The prevalence was significantly higher in males than females (43.1 vs 18.0%, p < 0.001). These gender differences became increasingly pronounced with increasing age, especially in those with moderate-severe CAC. Multivariable analysis revealed significant associations between increasing age, male, higher blood pressure, increased glucose levels and higher LDL cholesterol levels with the presence of any CAC. LDL cholesterol was more significantly associated with CAC in females compared to males (Pinteraction = 0.022).

Conclusions

The prevalence of preclinical atherosclerosis increased with age, and was higher in males than females, with gender-specific differences in associated risk factors. These results will better inform individualised future risk management strategies to prevent the development and progression of coronary artery disease within healthy individuals.

Sinecatechins ointment as a potential novel treatment for usual type vulval intraepithelial neoplasia: a single-centre double-blind randomised control study

OBJECTIVE

To compare the safety and efficacy of 10% sinecatechins (Veregen® ) ointment against placebo in the treatment of usual type vulvar intraepithelial neoplasia (uVIN).

DESIGN

A Phase II double-blind randomised control trial.

SETTING

A tertiary gynaecological oncology referral centre.

POPULATION

All women diagnosed with primary and recurrent uVIN.

METHODS

Eligible patients were randomised 1:1 to receive either sinecatechins or placebo ointment (applied three times daily for 16 weeks) and were followed up at 2, 4, 8, 16, 32 and 52 weeks.

MAIN OUTCOME MEASURES

The primary outcome measure, recorded at 16 and 32 weeks, was histological response (HR). Secondary outcome measures included clinical (CR) response, toxicity, quality of life and pain scores.

RESULTS

There was no observed difference in HR between the two arms. However, of the 26 patients who were randomised, all 13 patients who received sinecatechins showed either complete (n = 5) or partial (n = 8) CR, when best CR was evaluated. In placebo group, three patients had complete CR, two had partial CR, six had stable disease and two were lost to follow up. Patients in the sinecatechins group showed a statistically significant improvement in best observed CR as compared with the placebo group (P = 0.002). There was no difference in toxicity reported in either group.

CONCLUSION

Although we did not observe a difference in HR between the two treatment arms, we found that 10% sinecatechins application is safe and shows promise in inducing clinical resolution of uVIN lesions and symptom improvement, thus warranting further investigation in a larger multicentre study.

TWEETABLE ABSTRACT

A randomised control study indicating that sinecatechins ointment may be a novel treatment for uVIN.

Atrial fibrillation and the prognostic performance of biomarkers in heart failure

Background

Consideration of circulating biomarkers for risk stratification in heart failure (HF) is recommended in authoritative international guidelines but the influence of atrial fibrillation (AF) on the prognostic performance of many markers is unclear. Therefore we investigated the interactions between AF and biomarkers in prediction of important clinical outcomes in HF.

Methods

NT-proBNP, pro-atrial natriuretic peptide (MR-proANP), C-type natriuretic peptide (CNP), NT-proCNP, high-sensitivity troponin-T, high-sensitivity troponin-I, mid-regional-propeptide adrenomedullin (MR-proADM), co-peptin (PAVP), growth differentiation factor-15 (GDF-15), sST2, Galectin-3 and procalcitonin levels were measured in a prospectively designed, multicenter, longitudinal study of adults with HF. AF was defined as a documented history of AF based on medical records, and/or presence of AF/atrial flutter on baseline 12-lead ECG. The primary outcome considered was the composite of HF-hospitalization or all-cause mortality on prospective follow-up at 2-years. Cox proportional-hazards models were used in the prognostic evaluation of biomarkers, and each was tested for interaction with AF.

Results

Among 1,099 patients with HF (mean age 62±12 years, 28% female, mean left ventricular ejection fraction 35±16%), 261 (24%) patients had AF. Median levels of NT-proBNP, GDF-15, ST2, MR-proADM, proANP and CNP were higher in AF (p<0.05). Above-median levels of all 12 biomarkers were independently associated with increased risk of the primary outcome. Significant interactions with AF were detected for Galectin-3 and sST2. Galectin-3 (>7.7ng/mL) was associated with increased HF-hospitalizations (adjusted hazard ratio [AHR] 1.75, 95% C.I. 1.10–2.77) and all-cause mortality (AHR 1.95, 95% C.I. 1.04–3.63) only among patients with AF. The prognostic performance of sST2 (>35.6ng/mL) was also stronger in AF especially for the primary outcome (AF: AHR 2.06 95% C.I. 1.32–3.21; non-AF: AHR 1.49 95% C.I. 1.18–1.88) and HF-hospitalization (AF: AHR 1.65, 95% C.I. 1.01–2.69; non-AF: AHR 1.32, 95% C.I. 1.02–1.71). The association of Galectin-3 with the composite outcome was not modified by HF type (HFpEF vs HFrEF) (p for 3-way interaction=0.61) except for sST2 (p for 3-way interaction=0.018) where the association appeared stronger in patients with HFpEF and AF (HR 3.12, 95% C.I. 1.26–7.78) compared to those with HFrEF and AF (HR 1.83, 95% C.I. 1.01–3.33) although numbers of events in each subgroup were small. Notably, no such interactions were observed for the most frequently measured prognostic markers in HF including NT-proBNP and the high-sensitivity cardiac troponins.

Conclusion

AF modified the prognostic utility of guideline-endorsed HF-biomarkers, wherein prognostic associations of Galectin-3 and ST2 were limited to, or stronger in, patients with AF. Application of markers for prognostic purposes in HF requires consideration of the presence or absence of AF.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): National Medical Research Council of Singapore

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Initial experience with the convergent procedure for longstanding persistent atrial fibrillation: A 5 year dataset

In patients with longstanding persistent atrial fibrillation (AF), outcomes from catheter ablation remain suboptimal. The convergent procedure combines minimally invasive surgical ablation with subsequent catheter ablation, and may contribute towards maintenance of sinus rhythm in this patient group. We performed the convergent procedure on 43 patients with longstanding persistent AF from 2013–2018. Patients underwent clinical review at 3, 6, and 12 months and thereafter as necessitated by their symptoms. Our dataset describes patients’ baseline characteristics and rhythm control protocols, as well as outcomes including arrhythmia recurrence, the need for antiarrhythmic drugs, requirement for repeat rhythm control procedures, and complications. These data provide a real world insight into the risks and benefits of the convergent procedure in patients with longstanding persistent AF.

P205 Effectiveness of a portable patient education video prior to coronary angiography and angioplasty

Introduction

 Coronary angiography and angioplasty is widely used in the diagnosis and treatment of coronary artery disease. Limited time to explain the procedure to patients in busy clinical settings may lead to increased adverse outcomes. 

Purpose

To evaluate the effectiveness of a portable patient education video in improving knowledge and allaying patient"s anxiety prior to coronary angiography and angioplasty.

Methods

 Consecutive patients undergoing coronary angiography and angioplasty were prospectively recruited over 1 year from June 2016 to May 2017 from a tertiary cardiac institution. We developed a 3 minute animated patient education video on the procedure. Patients were randomised 1:3 into a control group (receiving routine standard of care) and intervention group (watched video plus routine standard of care). Before the procedure, a self-administered written survey was conducted in the control group, pre-video in the intervention group, and post-video in the intervention group. Demographic data, knowledge and State Trait Anxiety Inventory (STAI) scores were gathered. Figure 1 shows excerpts of the video.

Results

We recruited 332 patients- 80 controls (80% males, mean age 59.6 ± 11.5, 51% previous procedures) and 252 intervention group (86% males, mean age 59.0 ± 9.4, 52% previous procedure). Compared to the control group, the intervention group had lower overall baseline knowledge scores (7.6vs8.5, p = 0.022) and similar anxiety scores (94vs92, p = 0.323); but significantly higher overall knowledge scores (10.3vs8.5, p= <0.001) and lower anxiety scores (75vs92, p= <0.001) after watching the video. Within the intervention group, there was a significant increase in overall knowledge scores (7.6vs10.3, p= <0.001) and reduction in anxiety scores (94vs 75, p= <0.001) before versus after watching the video. See Table 1. Subjectively, after watching the video, 98% of the patients reported benefit, 96% were more prepared and 85% less worried. There was significant improvement in knowledge scores and reduction in anxiety scores (p < 0.001) in the subset of patients who had previously underwent a similar procedure (n = 131).

Conclusion

The video improved knowledge and reduced anxiety in patients undergoing coronary angiography and angioplasty. This is a useful adjunct to incorporate into existing workflows to improve patient care.

Table 1 Total scores* Procedural events - Sedation Procedural events - Access site Procedural events-Contrast Procedural events-Stent Complications-General risk Complications-Bleeding Complications-Myocardial infarction Complications-Stroke Complications-Re-stenosis Anxiety-STAI# P-value comparing pre and post amongst cases (n = 252) <0.001 <0.001 <0.001 <0.001 <0.001 0.094 <0.001 <0.001 <0.001 <0.001 <0.001 P-value comparing cases (post) and controls (n = 80) <0.001 0.042 0.005 0.006 0.131 0.021 <0.001 <0.001 <0.001 <0.001 <0.001 * Range from 0-12 # State-Trait Anxiety Inventory (STAI), 40 questions, score range from 40-160

Abstract P205 Figure 1

P259 Adherence to optimal medical therapy in Asian patients with acute myocardial infarction treated with PCI

On Behalf

SingCLOUD collaborators

Background

 Notable regional differences have been observed worldwide in clinical characteristics and outcomes in patients experiencing acute myocardial infarction (AMI). Asian patients present younger and report higher adverse outcomes rates compared to Western cohorts. The reasons are multifactorial, but adherence to medication prescription guidelines is one of the modifiable factors.

Purpose

 Our aim was to study the effect of physician adherence to Optimal Medical Therapy (OMT) prescription guidelines on a MACE outcome in a high-risk group of Asian AMI patients over 1 year following percutaneous coronary intervention (PCI).

Method

 Data for this retrospective study was from the Singapore Cardiac Longitudinal Outcomes Database (SingCLOUD) pilot study involving AMI patients surviving primary PCI at two tertiary centers from 2012 to 2013. Guideline-directed OMT adherence was defined as concurrent prescription of at least one statin plus dual antiplatelet therapy (DAPT – aspirin plus P2Y12-I). Prescription of β-blockers and ACE-i/ARBs was also recorded. Prescription status and MACE (repeat MI, stroke, death) was recorded at discharge, 3, 6 and 9 months, and 1 year following the index discharge. The cumulative effect of OMT adherence at 3, 6, 9 months and 1 year post-discharge was studied by comparing risk of first MACE among patient groups with complete, partial and non-adherence to OMT prescription guidelines.

Results

 2,478 patients, 80.3% males, mean age 60.3 ± 11.7 years were studied. 1094 (44.1%) underwent primary PCI for STEMI. Single drug prescription at discharge for aspirin, P2Y12-I, and statins was 95, 97 and 95.8%, while prescription of β -blockers and ACE-inhibitors was 86.5 and 75.7%. Prescription of statins and aspirin declined gradually while P2Y12-I fell to 67.9% at 6mo and 47.6% at 1 year. Adherence to OMT declined from 92.3% at discharge to 82.1, 58.5, 56.1 and 40.3% at 3, 6, 9 months and 1 year, respectively. Of 342 (13.8%) occurrences of first MACE, 48.5% occurred within 3mo post-discharge. Complete adherence to OMT upon discharge significantly decreased risk of MACE at 3mo (OR = 0.066; 95% CI: 0.054-0.080; p < 0.001) and 12mo (OR = 0.017; 95% CI: 0.010-0.028; p < 0.001) relative to non-adherence.

Conclusion

 Over the course of a year in this high-risk group of PCI-treated AMI patients, there was a reduction in prescription adherence to the minimally essential OMT. Complete OMT adherence is beneficial in reducing MACE. Interventions targeting reasons for non-adherence are important in improving patient outcomes.

Abstract P259 Figure 1 - Medication over 1 year

Abstract P3-12-15: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Yap J, Tamimi M, Griffin M, Stanley T, Steinman J, Chen W, Catalfamo F. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-12-15.

Diagnostic accuracy of content-based dermatoscopic image retrieval with deep classification features

BACKGROUND

Automated classification of medical images through neural networks can reach high accuracy rates but lacks interpretability.

OBJECTIVES

To compare the diagnostic accuracy obtained by using content-based image retrieval (CBIR) to retrieve visually similar dermatoscopic images with corresponding disease labels against predictions made by a neural network.

METHODS

A neural network was trained to predict disease classes on dermatoscopic images from three retrospectively collected image datasets containing 888, 2750 and 16 691 images, respectively. Diagnosis predictions were made based on the most commonly occurring diagnosis in visually similar images, or based on the top-1 class prediction of the softmax output from the network. Outcome measures were area under the receiver operating characteristic curve (AUC) for predicting a malignant lesion, multiclass-accuracy and mean average precision (mAP), measured on unseen test images of the corresponding dataset.

RESULTS

In all three datasets the skin cancer predictions from CBIR (evaluating the 16 most similar images) showed AUC values similar to softmax predictions (0·842, 0·806 and 0·852 vs. 0·830, 0·810 and 0·847, respectively; P > 0·99 for all). Similarly, the multiclass-accuracy of CBIR was comparable with softmax predictions. Compared with softmax predictions, networks trained for detecting only three classes performed better on a dataset with eight classes when using CBIR (mAP 0·184 vs. 0·368 and 0·198 vs. 0·403, respectively).

CONCLUSIONS

Presenting visually similar images based on features from a neural network shows comparable accuracy with the softmax probability-based diagnoses of convolutional neural networks. CBIR may be more helpful than a softmax classifier in improving diagnostic accuracy of clinicians in a routine clinical setting.

Effects of branched chain amino acid supplementation on patient care outcomes in adults and children with liver cirrhosis: A systematic review

BACKGROUND & AIMS

Malnutrition is highly prevalent in chronic liver disease (CLD) due to alterations in nutrient utilization, malabsorption and poor intake. Low serum concentrations of branched chain amino acids (BCAA) in the presence of elevated aromatic acid concentrations is commonly observed in adult and children with liver cirrhosis and is associated with malnutrition and other adverse patient outcomes. The efficacy of BCAA supplementation has not been well established in adults and children with CLD. The purpose of this review was to critically evaluate the literature regarding the impact of BCAA supplementation related to changes in body composition, muscle strength, liver biomarkers, medical and hepatic complications (hepatic encephalopathy (HE), ascites, edema) and patient care outcomes (event free survival, health related quality of life, length of hospitalization).

METHODS

A total of 40 articles retrieved from PubMed or Web of Science databases (1989-2017) were included.

RESULTS

BCAA supplementation may be beneficial in improving muscle strength, ascites and edema with potential clinically significant improvements in HE in adult liver patients. In children, limited data have shown that BCAA supplementation may exert favourable effects on weight, fat mass, fat free mass and serum albumin level.

CONCLUSIONS

Heterogeneity of study findings attributed to variability in BCAA dose (total, relative proportions), duration, disease severity and lack of uniformity in tools used for assessing patient outcomes limit overall conclusions. Longitudinal studies examining the efficacy of BCAA supplementation as a therapeutic treatment of malnutrition in chronic liver disease is warranted.

The role of antimicrobial sutures in preventing surgical site infection

INTRODUCTION Healthcare associated infections (HCAIs) are falling following widespread and enforced introduction of guidelines, particularly those that have addressed antibiotic resistant pathogens such as methicillin resistant Staphylococcus aureus or emergent pathogens such as Clostridium difficile, but no such decline has been seen in the incidence of surgical site infection (SSI), either in the UK, the EU or the US. SSI is one of the HCAIs, which are all avoidable complications of a surgical patient's pathway through both nosocomial and community care. METHODS This report is based on a meeting held at The Royal College of Surgeons of England on 21 July 2016. Using PubMed, members of the panel reviewed the current use of antiseptics and antimicrobial sutures in their specialties to prevent SSI. FINDINGS The group agreed that wider use of antiseptics in surgical practice may help in reducing reliance on antibiotics in infection prevention and control, especially in the perioperative period of open elective colorectal, hepatobiliary and cardiac operative procedures. The wider use of antiseptics includes preoperative showering, promotion of hand hygiene, (including the appropriate use of surgical gloves), preoperative skin preparation (including management of hair removal), antimicrobial sutures and the management of dehisced surgical wounds after infection. The meeting placed emphasis on the level I evidence that supports the use of antimicrobial sutures, particularly in surgical procedures after which the SSI rate is high (colorectal and hepatobiliary surgery) or when a SSI can be life threatening even when the rate of SSI is low (cardiac surgery).

Interleukin-11 up-regulates endoplasmic reticulum stress induced target, PDIA4 in human first trimester placenta and in vivo in mice

Interleukin (IL)11 is a crucial factor for human trophoblast function and placentation. Elevated levels are associated with pregnancy complications including preeclampsia, intrauterine growth restriction (IUGR) and preterm birth. However, the regulation of IL11 in the placenta has not been investigated. We examined the effect of pro-inflammatory cytokines IL1β and TNFα, as well as low oxygen tension (2%) on IL11 levels in first trimester placental villous explants. IL1β upregulated IL11 mRNA and protein, while TNFα and low oxygen had no effect. Using mass spectrometry, we identified protein disulfide isomerase 4 (PDIA4) in IL11-treated first trimester human placental explants (100 ng/ml, 24 h, n = 3), but not PBS control tissues. PDIA4 is a member of the PDI family, also known as endoplasmic reticulum (ER) stress protein (ERP)72. We previously identified GRP78 (a master regulator for ER stress) in human placenta for the first time and demonstrated that IL11 up-regulates GRP78 in the placenta. In this report, we demonstrated that IL11 upregulates PDIA4 protein in human placental villous tissue, HTR8-SVneo trophoblasts (cell line) and in vivo in IL11-treated mouse placenta. We aimed to determine whether IL11 upregulates other ER stress proteins in human first trimester placental villous. IL11 stimulated ERP44, but not GRP94, or PDI. Placental endoplasmic reticulum stress has been postulated in the pathophysiology of preeclampsia and IUGR, but its activation remains elusive. Together, these data suggest that IL11 could trigger an ER stress response in the placenta, which may contribute to obstetric complications such as preeclampsia.

Long-term follow-up results of the multicenter phase II trial of regorafenib in patients with metastatic and/or unresectable GI stromal tumor after failure of standard tyrosine kinase inhibitor therapy

BACKGROUND

This investigator-initiated trial provided the justification for the phase III GRID study resulting in worldwide regulatory approval of regorafenib as a third-line therapy for patients with metastatic gastrointestinal stromal tumors (GIST). We report the genotype analyses, long-term safety, and activity results from this initial trial of regorafenib in GIST.

PATIENTS AND METHODS

The trial was conducted between February 2010 and January 2014, among adult patients with metastatic GIST, after failure of at least imatinib and sunitinib. Patients received regorafenib orally, 160 mg once daily, days 1-21 of a 28-day cycle. Clinical benefit rate (CBR), defined as complete or partial response (PR), or stable disease lasting ≥16 weeks per RECIST 1.1, progression-free survival (PFS), overall survival (OS), long-term safety data, and metabolic response by functional imaging were assessed.

RESULTS

Thirty-three patients received at least one dose of regorafenib. The median follow-up was 41 months. CBR was documented in 25 of 33 patients [76%; 95% confidence interval (CI) 58% to 89%], including six PRs. The median PFS was 13.2 months (95% CI 9.2-18.3 months) including four patients who remained progression-free at study closure, each achieving clinical benefit for more than 3 years (range 36.8-43.5 months). The median OS was 25 months (95% CI 13.2-39.1 months). Patients whose tumors harbored a KIT exon 11 mutation demonstrated the longest median PFS (13.4 months), whereas patients with KIT/PDGFRA wild-type, non-SDH-deficient tumors experienced a median 1.6 months PFS (P < 0.0001). Long-term safety profile is consistent with previous reports; hand-foot skin reaction and hypertension were the most common reasons for dose reduction. Notably, regorafenib induced objective responses and durable benefit in SDH-deficient GIST.

CONCLUSIONS

Long-term follow-up of patients with metastatic GIST treated with regorafenib suggests particular benefit among patients with primary KIT exon 11 mutations and those with SDH-deficient GIST. Dose modifications are frequently required to manage treatment-related toxicities.

CLINICAL TRIAL NUMBER

NCT01068769.

Pediatric intestinal transplant listing criteria - a call for a change in the new era of intestinal failure outcomes

Current listing indications used for intestinal transplantation (IT) were proposed in 2001. We undertook the present single center study to see if these criteria are still valid. The 2001 criteria (advanced cholestasis, loss of >50% central venous catheter (CVC) sites, ≥2 sepsis/year, ultrashort bowel) were compared in children with intestinal failure in old era-1998-2005 (N = 99) to current era-2006-2012 (N = 91) to predict the need for IT using sensitivity, specificity, NPV and PPV. Two 2001 criteria had poorer predictive value in the current era: Advanced cholestasis (PPV 64% old vs. 40% current era; sensitivity 84% vs. 65%, respectively) and ultrashort bowel (PPV 100% old vs. 9% current era; sensitivity 10% vs. 4%, respectively). Three newly proposed criteria had high predictive value: ≥2 ICU admissions (p = 0.0001, OR 23.6, 95% CI 2.7-209.8), persistent bilirubin >75 mmol/L despite lipid strategies (p = 0.0005, OR 24.0, 95% CI 3.2-177.4), and loss of ≥3 CVC sites (p = 0.0003, OR 33.3, 95% CI 18.8-54.0). There was 98% probability of needing IT when two of these new criteria were present. The 2001 IT criteria have limited predictive ability in the current era and should be revised. A multicenter study is required to validate the findings of this single center experience.

Clinical features, microbiology and surgical outcomes of infective endocarditis: a 13-year study from a UK tertiary cardiothoracic referral centre

BACKGROUND

Infective endocarditis (IE) causes substantial morbidity and mortality. Patient and pathogen profiles, as well as microbiological and operative strategies, continue to evolve. The impact of these changes requires evaluation to inform optimum management and identify individuals at high risk of early mortality.

AIM

Identification of clinical and microbiological features, and surgical outcomes, among patients presenting to a UK tertiary cardiothoracic centre for surgical management of IE between 1998 and 2010.

DESIGN

Retrospective observational cohort study.

METHODS

Clinical, biochemical, microbiological and echocardiographic data were identified from clinical records. Principal outcomes were all-cause 28-day mortality and duration of post-operative admission.

RESULTS

Patients (n = 336) were predominantly male (75.0%); median age 52 years (IQR = 41-67). Most cases involved the aortic (56.0%) or mitral (53.9%) valves. Microbiological diagnoses, obtained in 288 (85.7%) patients, included streptococci (45.2%); staphylococci (34.5%); Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella (HACEK) organisms (3.0%); and fungi (1.8%); 11.3% had polymicrobial infection. Valve replacement in 308 (91.7%) patients included mechanical prostheses (69.8%), xenografts (24.0%) and homografts (6.2%). Early mortality was 12.2%, but fell progressively during the study (P = 0.02), as did median duration of post-operative admission (33.5 to 10.5 days; P = 0.0003). Multivariable analysis showed previous cardiothoracic surgery (OR = 3.85, P = 0.03), neutrophil count (OR = 2.27, P = 0.05), albumin (OR = 0.94, P = 0.04) and urea (OR = 2.63, P < 0.001) predicted early mortality.

CONCLUSIONS

This study demonstrates reduced post-operative early mortality and duration of hospital admission for IE patients over the past 13 years. Biomarkers (previous cardiothoracic surgery, neutrophil count, albumin and urea), predictive of early post-operative mortality, require prospective evaluation to refine algorithms, further improve outcomes and reduce healthcare costs associated with IE.

Parental perceptions regarding lifestyle interventions for obese children and adolescents with nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) affects 30% of obese children globally. The main treatment for NAFLD is to promote gradual weight loss through lifestyle modification. Very little is known regarding parental perspectives about the barriers and facilitators that influence the ability to promote healthy lifestyle behaviours in children with NAFLD.

OBJECTIVES

To explore and describe parental perspectives regarding barriers to and facilitators of implementing lifestyle modification in children with NAFLD.

METHODS

A mixed-methods approach, including qualitative methodology (focus groups) and validated questionnaires (Lifestyle Behaviour Checklist), was used to assess parental perceptions regarding barriers to and facilitators of lifestyle change in parents of children with healthy body weights (control parents) and in parents of children with NAFLD (NAFLD parents).

RESULTS

NAFLD parents identified more problem behaviours related to food portion size and time spent in nonsedentary physical activity, and lower parental self-efficacy than parents of controls (P<0.05). Major barriers to lifestyle change cited by NAFLD parents were lack of time, self-motivation and role modelling of healthy lifestyle behaviours. In contrast, control parents used a variety of strategies to elicit healthy lifestyle behaviours in their children including positive role modelling, and inclusion of the child in food preparation and meal purchasing decisions, and perceived few barriers to promoting healthy lifestyles. Internet sources were the main form of nutrition information used by parents.

CONCLUSIONS

Lifestyle modification strategies focused on promoting increased parental self-efficacy and parental motivation to promote healthy lifestyle behaviour are important components in the treatment of obese children with NAFLD.

Basiliximab with delayed introduction of calcineurin inhibitors as a renal-sparing protocol following liver transplantation in children with renal impairment

Renal impairment is frequently compromised in patients with end-stage liver disease and is associated with increased long-term mortality post-LT. In contrast to CNI, basiliximab is an immunosuppressive agent with minimal nephrotoxic potential. This study reviews the experience of a single pediatric liver transplant center's renal-sparing approach with the use of basiliximab and MMF to compensate for delayed entry of CNI in children with renal impairment at the time of organ availability. There were no differences in renal function between pediatric patients with and without pre-LT renal impairment within the first year (cGFR: 135 mL/min/1.73 m2 vs. 144 mL/min/1.73 m2 ; p = 0.56) or at 5-8 yr following LT, (129 mL/min/1.73 m2 vs. 130 mL/min/1.73 m2 ; p = 0.97). In addition, there was no difference in ACR rates (50% vs. 43%, p = 0.62) between patients in the basiliximab group and those patients receiving standard CNI and steroid strategies. The utilization of a renal-sparing approach with basiliximab alongside delayed entry and lower early target trough levels of CNI in children with renal impairment at the time of LT is safe and maintains excellent long-term kidney function.

Small intestinal transplant mucosal necrosis associated with enteral sodium polystyrene sulfonate administration

Diarrhea is a common manifestation of disease in recipients of intestinal transplants. Sodium Polystyrene Sulfonate administration has been associated with significant bowel injury. Recognizing the diagnosis requires clinical awareness and comprehensive review of intestinal biopsies. We present an illustrative case and discussion. It is the first reported case in a pediatric intestinal transplant patient with serial intestinal biopsies documenting the evolution of disease.