Environment and Health in Children Day Care Centres (ENVIRH) - Study rationale and protocol

BACKGROUND

Indoor air quality (IAQ) is considered an important determinant of human health. The association between exposure to volatile organic compounds, particulate matter, house dust mite, molds and bacteria in day care centers (DCC) is not completely clear. The aim of this project was to study these effects.

METHODS - STUDY DESIGN

This study comprised two phases. Phase I included an evaluation of 45 DCCs (25 from Lisbon and 20 from Oporto, targeting 5161 children). In this phase, building characteristics, indoor CO2 and air temperature/relative humidity, were assessed. A children's respiratory health questionnaire derived from the ISAAC (International Study on Asthma and Allergies in Children) was also distributed. Phase II encompassed two evaluations and included 20 DCCs selected from phase I after a cluster analysis (11 from Lisbon and 9 from Oporto, targeting 2287 children). In this phase, data on ventilation, IAQ, thermal comfort parameters, respiratory and allergic health, airway inflammation biomarkers, respiratory virus infection patterns and parental and child stress were collected.

RESULTS

In Phase I, building characteristics, occupant behavior and ventilation surrogates were collected from all DCCs. The response rate of the questionnaire was 61.7% (3186 children). Phase II included 1221 children. Association results between DCC characteristics, IAQ and health outcomes will be provided in order to support recommendations on IAQ and children's health. A building ventilation model will also be developed.

DISCUSSION

This paper outlines methods that might be implemented by other investigators conducting studies on the association between respiratory health and indoor air quality at DCC.

Microvascular Dysfunction Is Associated With Impaired Myocardial Work in Obstructive and Nonobstructive Hypertrophic Cardiomyopathy: A Multimodality Study

Background Two-dimensional speckle tracking echocardiography has been shown to correlate with microvascular dysfunction, a hallmark of hypertrophic cardiomyopathy (HCM). We hypothesized that there is an association between myocardial work and left ventricular ischemia, with incremental value to global longitudinal strain, in patients with HCM. Methods and Results We performed a prospective assessment of patients with HCM, undergoing 2-dimensional speckle tracking echocardiography and stress perfusion cardiac magnetic resonance. Results were stratified according to obstructive or nonobstructive HCM and the presence of significant replacement fibrosis (late gadolinium enhancement ≥15% of left ventricular mass). Seventy-five patients with HCM (63% men, age 55±15 years) were evaluated, 28% with obstructive HCM (mean gradient 89±60 mm Hg). Perfusion defects were found in 90.7%, involving 22.5±16.9% of left ventricular mass, and 38.7% had late gadolinium enhancement ≥15%. In a multivariable analysis, a lower global work index (r=-0.519, β-estimate -10.822; P=0.001), lower global work efficiency (r=-0.379, β-estimate -0.123; P=0.041), and impaired global constructive work (r=-0.532, β-estimate -13.788; P<0.001) significantly correlated with ischemia. A segmental analysis supported these findings, albeit with lower correlation coefficients. A global work index cutoff ≤1755 mm Hg% was associated with hypoperfusion with a sensitivity of 88% and a specificity of 71%, while the best cutoff for global longitudinal strain (>-15.5%) had a sensitivity of 64% and a specificity of 57%. The association between myocardial work and perfusion defects was significant independently of late gadolinium enhancement ≥15% and obstructive HCM. Conclusions Impaired myocardial work was significantly correlated with the extent of ischemia in cardiac magnetic resonance, independently of the degree of left ventricular hypertrophy or fibrosis, with a higher predictive power than global longitudinal strain.

All-fiber Mach-Zehnder curvature sensor based on multimode interference combined with a long-period grating

A novel Mach-Zehnder interferometer based on a fiber multimode interference structure combined with a long-period fiber grating (LPG) is proposed. The multimode interference is achieved through the use of a MMF section spliced between two single-mode fibers, with a length adjusted to couple a fraction of light into the cladding modes. A LPG placed after the MMF couples light back into the fiber core, completing the Mach-Zehnder interferometer. This novel configuration was demonstrated as a bending sensor.

Prognostic value of the cardiorespiratory optimal point during submaximal exercise testing

Background

Peak oxygen consumption (pVO2) is a key parameter in assessing the prognosis of heart failure with reduced ejection fraction (HFrEF) patients (pts). However, it is a less reliable parameter when the cardiopulmonary exercise test (CPET) is not maximal. It is crucial to identify the submaximal exercise variables with the best prognostic power (PP), in order to improve the management of pts that cannot attain a maximal CPET.

Purpose

The aim of this study was to evaluate and compare the PP of several exercise parameters in submaximal CPET for risk stratification in pts with HFrEF.

Methods

Prospective evaluation of adult pts with HFrEF submitted to CPET in a tertiary center. A submaximal CPET was defined by a respiratory exchange ratio (RER) ≤1.10. Pts were followed up for at least 1 year for the primary endpoint of cardiac death and urgent heart transplantation/ ventricular assist device implantation. Several CPET parameters were analyzed as potential predictors of the combined endpoint and their PP (area under the curve - AUC) was compared to that of pVO2, using the Hanley and McNeil test.

Results

CPET was performed in 487 HF pts, of which 317 (66%) performed a submaximal CPET. Pts averaged 57±12 years of age, 77% were male, 45.7% had ischemic cardiomyopathy, with a mean LVEF of 30.4±7.6%, a mean heart failure survival score of 8.6±1.1. The mean pVO2 was 17.1±5.5 ml/kg/min and the mean RER 1.01±0.08. During a mean follow-up (FU) time of 11±1 months, 18 pts (6%) met the primary endpoint. Cardiorespiratory optimal point (OP - VE/VO2) had the highest AUC value (0.915, p=0.001), followed by the partial pressure of end-tidal CO2 at the anaerobic threshold - PETCO2L (0.814, p&lt;0.001). pVO2 presented an AUC of 0.730 (p=0.001). OP≥31 and PETCO2L ≤37mmHg had a sensitivity of 100 and 76.9% and a specificity of 71.1 and 67%, respectively, for the primary outcome. OP presented a significantly higher PP than pVO2 (p=0.048), whether PETCO2L didn't achieve any statistical significance (p=0.164). Pts with anOP≥31 presented a significantly lower survival free of HT during FU (log rank p=0.002).

Conclusion

OP had the highest PP for HF events of all parameters analyzed for a submaximal CPET. This parameter can help stratify the HF pts physiologically unable to reach a peak level of exercise.

Funding Acknowledgement

Type of funding source: None

Permanent pacemaker implantation after alcoholic septal ablation induced complete heart block: Long-term impact

INTRODUCTION AND OBJECTIVES

Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy often undergo alcohol septal ablation (ASA). One of the most frequent complications is complete heart block (CHB), requiring a permanent pacemaker (PPM) in variable rates of up to 20% of patients. The long-term impact of PPM implantation in these patients remains unclear. This study aimed to evaluate the long-term clinical outcomes in patients who implant PPM after ASA.

METHODS

Patients who underwent ASA at a tertiary center were consecutively and prospectively enrolled. Patients with previous PPM or implantable cardio-defibrillator were excluded from this analysis. Patients with and without PPM implantation after ASA were compared based on their baseline characteristics, procedure data and three-year primary endpoint of composite of all-cause mortality and hospitalization and secondary endpoint of composite of all-cause mortality and cardiac cause hospitalization.

RESULTS

Between 2009 and 2019, 109 patients underwent ASA, 97 of whom were included in this analysis (68% female, mean age 65.2 years old). 16 patients (16.5%) required PPM implantation for CHB. In these patients, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics of comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with higher mean age (70.6±10.0 years vs. 64.1±11.9 years) and lower beta-blocker therapy rate (56% vs. 84%) in the PPM group. Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692 U/L vs. 1243 U/L), with no significant difference in the alcohol dose. At three years after ASA procedure, there were no differences in the primary and secondary endpoints between the two groups.

CONCLUSIONS

Permanent pacemaker after ASA induced CHB do not affect long term prognosis in hypertrophic obstructive cardiomyopathy patients.

Prognostic impact of suspected cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)&gt;12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull's eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2±5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57±15% and 26.6% presented EF&lt;50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS &gt;1 was identified in 22 P (23.4%). An EF/GLS ratio &gt;4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4±25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p=0.002) and MACE (48.7% vs 22.2%, p=0.01). RALS&gt;1 correlated also with all-cause mortality (31.8% vs. 12.5%, p=0.04) and with new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p=0.05). P with GLS&gt;−14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p=0.003) and MACE (p=0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR=4.49, p=0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Funding Acknowledgement

Type of funding source: None

[Multiple myeloma. An unusual case]

We describe the case of a 75 year old male patient, hospitalized because of sudden paraplegia. The radiological tests performed, revealed degenerative changes of the entire vertebral spine, osteolytic lesions of the seventh cervical and first two thoracic vertebrae, and lacunar lesions of the others. The erythrocyte sedimentation rate, total proteins and its electrophoretic study, as well as quantification of serum immunoglobulins were found to be normal. Regardless of these results, we continued our investigation in order to diagnose or exclude multiple myeloma (MM), which was confirmed by serum and urinary immunoelectrophoresis, that revealed monoclonal gammopathy IgG, K with low value of serum IgG and very high urinary values of Bence Jones K, and by the histological analysis of the necropsy material. In conclusion, we report a case where the probability of an alteration of the controlling immunological mechanisms must be considered. We suggest that there is a heavy chain suppression of the malignant clone, that would explain its very low value in peripheral blood. These findings associated to the absence of light chains in serum, have lead to a particular laboratorial expression of this myeloma.

Quantification of epicardial fat with cardiac CT and association with cardiovascular risk factors and obstructive coronary disease

Introduction

Recent studies advocate epicardial fat (EF) as a biologically active organ that influence coronary atherosclerosis development through endocrine and paracrine pathways. We aim to study the relations between EF, thoracic adipose tissue (TAT), cardiovascular risk factors (CRF) and obstructive coronary disease (OCD).

Methods

Retrospective analysis of patients (pts) referred to 64-multislice cardiac computed tomography (CT) in one center. The authors underwent a standardized protocol for quantification of EAT, TAT (subcutaneous and visceral), abdominal visceral fat, coronary calcium score and angiography.

Results

Total of 178 pts: male 99 (56%), mean age 65.9±12.9 years. Indications for performing CT were coronary disease (76%), valvular heart disease (15%), atrial fibrillation (6%) and congenital heart disease (2%). Regarding CRF, EF was only significant higher in patients with diabetes (115±60 vs 95±47, p=0.018), in male gender (114±60 vs 91±42, p=0.04) and was linear correlated with age (p=0.004). The authors also found that EF volume is significant higher in patients with typical angina (p=0.02) and with coronary atherosclerosis: non-obstructive (p=0.0049) and OCD (p=0.001) – Graphic 1. ROC analysis of EF (AUC 0.659, p=0.0039) and EF/TAT relation (AUC 0.704, p=0.003) allowed to estimate that EF&gt;100 ml and EF/TAT &gt;0.06 had a sensibility to predict OCD of 53% and 58%, respectively, and specificity of 66% and 60%. We did not find a correlation between EF, EF/TAT or TAT and coronary calcium score.

Conclusion

EF is higher in patients with diabetes and coronary atherosclerosis. EF and EF/TAT relation had moderate sensibility and specificity to predict OCD, irrespective of calcium score. EF and EF/TAT are promising atherosclerotic markers that could be routinely use in the near future.

Funding Acknowledgement

Type of funding sources: None.

Three dimensional myocardial deformation parameters are associated with functional capacity in hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Three-dimensional (3D) echocardiography is an emerging tool for assessment of left ventricular function, with a promising role in the evaluation of cardiomyopathies. Hypertrophic cardiomyopathy (HCM) is often associated with reduced exercise capacity. The aim of this study was to evaluate the importance of 3D myocardial deformation parameters as predictors of exercise capacity in HCM patients (P).

Methods

This prospective study enrolled P with HCM. Each P underwent a comprehensive transthoracic echocardiogram including 3D speckle-tracking to measure global longitudinal, radial and circumferential strain, twist, torsion and global area strain. Functional capacity was objectively assessed by treadmill cardiorespiratory exercise testing.

Results

83 patients with HCM, 50 (60%) male, mean left ventricular ejection fraction (LVEF) of 68 ± 7%, 27 (33%) with obstructive HCM (LV outflow tract [LVOT] gradient of 89 ± 60 mmHg). Impairment in LV myocardial deformation parameters was significantly correlated with lower peak VO2: global longitudinal 3D strain (r=-0.397, p &lt; 0.001), global radial 3D strain (r = 0.336, p = 0.003) and global circumferential 3D strain (r=-0.353, p = 0.002) (Figure 1).

Impaired LV twist was significantly correlated with inferior peak VO2 (r = 0.264, p = 0.033) (Fig.2) and peak circulatory power (r = 0.371, p = 0.003). Torsion impairment also significantly associated with lower peak VO2 (r = 0.285, p = 0.021), circulatory power (r = 0.380, p = 0.002), time to ventilatory anaerobic threshold (VAT) (r = 0.369, p = 0.003) and (VE/VCO2 slope)/peak VO2 ratio (r=-0.316, p = 0.012).

Furthermore, global area strain impairment showed significant relation with decreased peak VO2 (r=-0.368, p = 0.001), lower exercise duration (r=-0.384, p = 0.001), time to VAT (r=-0.404, p &lt; 0.001), circulatory power (r=-0.272, p = 0.032) and (VE/VCO2 slope)/peak VO2 ratio (r = 0.391, p = 0.002). LV twist (r=-0.135, p = 0.284), torsion (r=-0.120, p = 0.341) and global area strain (r = 0.152, p = 0.235) impairment did not correlate with VE/VCO2 slope. Exercise capacity was not associated with LV mass index (r = 0.209, p = 0.095), LV end-diastolic volume (r = 0.058, p = 0.639), maximum wall thickness (r = 0.041, p = 0.744), LVEF (r=-0.092, p = 0.458), 2D global longitudinal strain (r=-0.024, p = 0.848) or peak LVOT gradient (r=-0.006, p = 0.964). In a subanalysis examining only the nonobstructive (nHCM) P, we found that peak VO2 had a superior correlation with global longitudinal 3D strain (r=-0.420, p = 0.004), global radial 3D strain (r = 0.356, p = 0.016) and global circumferential 3D strain (r=-0.357, p = 0.016) as well as LV twist (r = 0.300, p = 0.046) and torsion (r = 0.336, p = 0.024).

Conclusion

Although P with HCM often have supranormal LVEF, 3D speckle-tracking echocardiographic imaging has the potential to demonstrate subclinical impairment of LV function. Impaired LV 3D strain, twist, torsion and global area strain were associated with reduced exercise capacity, particularly in nHCM P. Abstract Figure. Peak VO2 and 3D strain parameters  Abstract Figure. LV twist, torsion and global area strain

Poster No. 071 Application of artificial intelligence in coronary CT angiography:a potential gatekeeper strategy?

Introduction

Medical artificial intelligence (AI) is rapidly developing and moving from the research field to daily clinical practice. AI algorithms have demonstrated high performance and computational efficiency, reducing the degree of manual input and processing time.

Objectives

This study aimed to determine the impact of an AI-enabled coronary computed tomography angiography (CCTA) analysis for comprehensive evaluation in patients (P) with suspected coronary artery disease (CAD).

Methods

We analysed 100 CCTA exams from a cohort of symptomatic P with mild-to-moderately abnormal non-invasive ischemia test. Stenosis severity was assessed by level III experts (manual evaluation, MEv). A novel AI-based software tool (automatic evaluation, AEv) was also used to quantify coronary stenosis and characterize plaque phenotype. In P later referred for invasive coronary angiography (ICA), diagnostic and revascularization yields of MEv and AEv were compared.

Results

100P, 52% male, mean age 68 ± 10 years, one-third had typical angina. Prevalence of obstructive CAD determined by MEv and AEv was 25% and 21%, respectively, with a significant association between both assessments (P &lt; 0.001).

Based upon MEv, referring physician decided to proceed to ICA in 22P (21P with significant stenosis). For those undergoing ICA,13P also had obstructive CAD established by AEv. Diagnostic yields for MEv and AEv-guided ICA was 82% and 60%, and revascularization yields 73% and 60%, respectively.

AEv atherosclerosis quantification revealed significant differences between P who did not undergo ICA, P referred for ICA without significant stenosis and P with obstructive CAD on ICA: total (126 vs. 312 vs. 518 mm3, P &lt; 0.001), calcified (23 vs. 197 vs. 222 mm3, P &lt; 0.001), non-calcified (71 vs. 112 vs. 252 mm3, P &lt; 0.001) and low-density plaque volume (1.1 vs. 3.0 vs. 4.4 mm3, P = 0.042).

Conclusion

A diagnostic strategy using AI-based analysis of coronary stenosis severity on CCTA had a similar performance compared to MEv. In addition, risk prediction can be enhanced by AI assessment of plaque composition. This study is an example of the potential role of AI in the CCTA workflow.

Trends in mortality of adult congenital heart disease patients in the last 4 decades

Introduction

Medical, surgical, and technological advances over the past decades increased the life expectancy of congenital heart disease (CHD) patients (pts), with &gt;90% reaching adulthood. Nonetheless, mortality for adults with CHD (ACHD) is still higher than for the general population.

Purpose

To analyse trends in mortality and causes of death of ACHD.

Methods

Retrospective analysis of pts followed in an ACHD outpatient clinic, in one tertiary center, who died between 1980 and December 2020. Data relating to the cardiac diagnosis, symptoms, interventions, comorbidities, and causes of death were analysed.

Results

During a median follow-up of 8.9 years (IQR 2.2–17), 251 pts of 3725 (6.7%) died during the study period: 127 males (51%), mean age at death 44.9±18.1 years, 54% with severe CHD. The majority of these death was CHD-related (171 pts – 68.1%) with no statistically significant differences over the years vs non-cardiovascular death (Table 1). However, a paradigm shift was noticed: in the first years the main cardiac cause was sudden-death that was replaced by heart failure in the last decade. Also, the mean age at death increased over the years (33±14.9 years until 2000 vs 52.3±17 years after the year 2010, p&lt;0.001) as the number of implantable devices (4 vs 20, p=0.05).

Conclusion

Causes of death of ACHD patients are in the majority still CHD-related. However, in the last decade, according to the increase in life expectancy, heart failure became the leading cause of death.

Funding Acknowledgement

Type of funding sources: None.

Impact of coronavirus disease 2019 on adult patients with congenital heart disease

Background

COVID-19 is responsible for a worldwide pandemic, causing more than 18,000 deaths to date in Portugal. Data already exists regarding the increased risk of adverse events in patients with cardiovascular diseases, however the impact of SARS-CoV-2 infection in patients (P) with congenital heart disease (CHD) is still under investigation.

Purpose

To study the impact of COVID-19 in a adult patients with CHD

Methods

Adult patients seen at the CHD outpatient's clinic at a tertiary centre, who became infected with SARS-CoV-2 infection up to December 2021 were included. Assessment of patients' symptoms, need for hospitalization and admission in an intensive care unit was assessed based on medical records.

Results

We identified seventy-nine patients (pts) with COVID-19 infection. Symptoms were present in 67 (84%). The median age was 44 (15) years, 52% were females. Eight P (10%) had complex cyanotic disease; seven Tetralogy of Fallot; five (6%) transposition of great arteries; eight (10%) right ventricle obstacle; two (3%) atrioventricular canal defect; sixteen (20%) atrial septal defect; nine (11%) ventricular septal defect; eight (10%) aortic coarctation; two (3%) had Eisenmenger syndrome. 49% of P had previous surgery or percutaneous procedure. 63% of P were at New York Heart Association (NYHA) class of I and 30% at NYHA II. Mild symptoms were reported by 56 P (71%). Ten adults (7,9%) experienced moderate symptoms (dyspnea and hypoxia) that led to hospitalization for oxygen therapy, none required mechanical ventilation. One death was reported in an 83-year-old patient with non-corrected interventricular communication and compromised biventricular function. There was a significant association between the gravity of CHD and hospitalizations (p=0.02).

Conclusion

Our pts had mainly mild to moderate symptoms and did not appear to have a disproportionately negative outcome; the need for hospitalization was more frequent in patients with higher CHD gravity. These findings are in line with the emerging data regarding COVID-19 in CHD P, and may be in part explained by the patient's young age and functional status.

Funding Acknowledgement

Type of funding sources: None.

Preparticipation Cardiovascular Screening of Athletes: Current Controversies and Challenges for the Future

Sports cardiology is an evolving field in cardiology, with several topics remaining controversial. Beyond the several well-known benefits of regular exercise practice, the occurrence of adverse clinical events during sports in apparently healthy individuals, especially sudden cardiac death, and the described long-term adverse cardiac adaptations associated to high volume of exercise, remain challenging. The early identification of athletes with increased risk is critical, but the most appropriate preparticipation screening protocols are also debatable and a more personalized evaluation, considering individual and sports-related characteristics, will potentially optimize this evaluation. As the risk of major clinical events during sports is not zero, independently of previous evaluation, ensuring the capacity for cardiopulmonary resuscitation, especially with availability of automated external defibrillators, in sports arenas, is crucial for its prevention and to improve outcomes. As in other areas of medicine, application of new digital technologies, including artificial intelligence, is promising and could improve in near future several aspects of sports cardiology. This paper aims to review the methodology of athletes' preparticipation screening, emphasizing current controversies and future challenges, in order to improve early diagnosis of conditions associated with sudden cardiac death.

Familial hypercholesterolemia in acute coronary syndrome patients: underdiagnosis in female and in young patients

Introduction

Familial hypercholesterolemia (FH) is often underdiagnosed, particularly in female patients (P), even during hospital admission for acute coronary syndromes (ACS). The aim of this study was to apply the Dutch Lipid Clinic Network (DLCN) Criteria in P admitted for ACS and evaluate gender and age differences.

Methods

Prospective evaluation of P with ACS admitted to a tertiary center from 2005 to 2019. Data including family history and laboratory tests was analysed for the application of the DLCN criteria and results were stratified according to ACS subtype, gender and age groups (20–39, 40–59, 60–79 and ≥80 years [y]). P were followed up for 30 days for hospitalization, recurring ACS and mortality.

Results

3811 P were evaluated, mean age 63±13 years, 28% female and mean LDL cholesterol of 125±43 mg/dL. The admission diagnosis was unstable angina (UA) in 5%, non-ST-segment elevation myocardial infarction (NSTEMI) in 27% and ST-segment elevation MI (STEMI) in 68%.

Applying the DLCN criteria, 3089 P (81%) had a score of &lt;3 (unlikely FH), 675P (17.7%) a score of 3 to 5 (possible FH), 41P (1.1%) a score of 6 to 8 (probable FH) and 1P (0.03%) a score of &gt;8 (definite FH). Stratifying according to ACS type: among UA, 31P (16%) had possible FH and 4P (2.1%) had probable FH. Among NSTEMI, 145P (14.2%) had possible FH, 9P (0.9%) probable FH and 1P (0.03%) definite FH. Finally, among STEMI P, 497P (19.1%) had possible FH and 28P (1.1%) probable FH. Regarding female P, 158P (14.7%) had possible FH and 16 P (1.5%) probable FH. Among male P, 517P (18.9%) had possible FH and 25P (0.9%) probable FH (p=0.016 for interaction).

According to age groups, among P aged 20–39 y (136P), 61P (44.9%) had possible FH and 6P (4.4%) had probable FH. Concerning P aged 40–59 y (1766P), 575P (32.6%) had possible FH, 31 P (1.8%) probable FH and 1P (0.1%) definite FH. With regard to P aged 60–80 y (2122P), 80P (3.8%) had possible FH and 4P (0.2%) probable FH. Among P aged ≥80 y (1837P), only 9P (0.5%) had possible FH and no P had probable FH.

In a 30-day follow-up, there was an hospitalization rate of 3.5% (134P) and recurring ACS in 1.7% (65P), while the all-cause mortality was 2% (78P) and cardiovascular (CV) death was 1.3% (49P). Female P had a significantly lower hospitalization rate (1.8% vs 3.2%, p=0.003) as well as fewer recurring ACS (0.6% vs 1.7%, p=0.001). There was no significant gender difference regarding all-cause mortality (female 1.7% vs 1.5%, p=0.552) or CV death (0.8% vs 1.1%, p=0.323). The DLCN criteria score was significantly correlated with admission for recurring ACS (OR 1.19 [95% CI 1.04–1.36], p=0.04).

Conclusion

Application of the DLCN criteria in female P admitted for ACS revealed 158P (14.7%) with possible FH and 16P (1.5%) with probable FH. Regarding younger ACS P (20–39y), 44.9% had criteria for possible FH and 4.4% for probable FH, prompting us to do not overlook these P subgroups in daily practice and routinely assess the likelihood of FH.

Funding Acknowledgement

Type of funding sources: None.

The contribution of genetics to the understanding and management of cardiomyopathies: Part 1

Genetics has assumed a pivotal role in clarifying the pathophysiology of cardiomyopathies, facilitating molecular diagnosis, and enabling effective family screening. The advent of next-generation sequencing has revolutionized genetic testing by enabling cost-effective, high-throughput analysis. It is imperative for cardiovascular physicians to mainstream genetic testing into their clinical decision-making. Although a definitive genotype-phenotype correlation may not always be evident, several genotypes have emerged as valuable risk predictors for disease severity and progression. European guidelines emphasize the importance of genetic tests for predicting clinical outcome in cardiomyopathies. While further research is essential to bridge existing gaps in the genetic evidence on cardiomyopathies, there is considerable potential for significant advancements.

Cardiac myxomas: characteristics and outcomes in a tertiary center

Introduction

Cardiac myxoma (CM) is the most common primary cardiac tumour. It can manifest in a variety of clinical presentations or it can be asymptomatic and, ultimately, be detected with image techniques. The only successful treatment of these tumours is surgical excision, with low complications and recurrence rate.

Objectives

This analysis aims to describe the clinical forms of presentation and echocardiographic characteristics of cardiac myxomas, establish myxoma features associated with obstructive symptons, as well as describe the postoperative outcome and long-term recurrence in a tertiary center.

Methods

Between 1990 and 2021, 88 patients were diagnosed with cardiac myxoma. 84 were included in this analysis. Baseline characteristics, clinical presentation, echocardiographic findings and outcomes were noted retrospectively. A binary logistic regression analysis using SPSS statistics software, version 25.0 was performed to establish myxoma features associated with atrioventricular valves obstruction.

Results

Mean age was 63±12 years old, 75% female. All CM were sporadic. The majority of the patients (52.4%, n=44) were asymptomatic, embolic events were present in 22.9% of the patients (n=19), with the most common site being central nervous system (19.0%, n=16) and constitutional symptoms in 16.7% (n=14), the most frequent fatigue (11.9%, n=10). Atrial fibrilation was present in 9.6% of the patients (n=8). The majority of the myxomas were located in the left atrium (88.1%), followed by right atrium (10.7%) and right ventricle (1.2%). Mean myxoma dimension was 36.8±17.4mm (longer axis), with heterogeneous aspect in 63.1%, presence of calcification in 11.9%, pediculated insertion in 40.5%, mobility in 70.2% and irregular borders in 52.4%. Moderate or severe ventricular inflow obstruction was present in 13.1% (n=11), 13.6% with mitral obstruction in the left atrial myxomas and 11.1% with tricuspid obstruction in the right atrial myxomas. CM longer axis 40–59mm and superior to 60mm were independently associated with obstruction (OR 5.1, 95% CI 1.4–18.4, p0.014 and OR 11.5, 95% CI 2.9–45.4, p0.001, respectively). No other morphologic features were associated with mitral or tricuspid obstruction. All but 3 patients had the myxoma surgically removed because of advanced age and comorbidities (96.4% surgical rate). There was no in-hospital or 1 year mortality in these patients. During the follow-up period, 3.6% patients had recurrence of the myxoma, with a men period of 5 years after the first surgery (one, two and twelve years), all of them re-submitted to surgical excision.

Conclusion

Despite being asymptomatic in the majority of the patients and often diagnosed incidentally, cardiac myxomas are frequent source of morbidity and mortality due to embolic events, obstructive and constitutional symptoms. Surgery is the treatment of choice for cardiac myxomas and in most cases it is curative, with low complications and low recurrence rate.

Funding Acknowledgement

Type of funding sources: None.

Significance and distribution of aortic valve calcium score before TAVI

Introduction

Aortic valve calcium scoring by multislice computed tomography (MSCT) is an alternative load independent assessment of aortic stenosis severity. Recent studies have further demonstrated that aortic valve calcification load is related to adverse outcomes during and after transcatheter aortic valve implantation (TAVI), however reference values in this population are uncertain. This study aimed to assess aortic valve calcium in P referred for TAVI.

Methods

Retrospective analysis of consecutive patients (P) submitted to TAVI between 2014 and 2020 in a tertiary care centre. Clinical and echocardiographic characteristics, along with MSCT-derived aortic valve calcium score were collected.

Results

A total of 467 P were included, 57% female, median age 83 (9) years (minimum 45 and maximum 95 years-old). The prevalence of hypertension, dyslipidemia and diabetes was 83%, 69% and 36%, respectively. Chronic renal failure was present in 51%, atrial fibrillation in 34% and peripheral artery disease in 14%.

Considering the 346 P with aortic valve calcification quantified by MSCT, median calcium score was 2161 (1761) AU. Age did not correlate with valvular calcification (r=0.043, p=0.422). Male gender showed significantly higher calcium score (2800 (2093) vs 1850 (1584), p&lt;0.001) (Figs. 1 and 2).

11P had bicuspid aortic valve disease, with this population being younger (75 (16) vs 83 (8) years, p=0.001), nonetheless displaying higher aortic valve calcium load (2800 (2599) vs 2112 (1788), p=0.025). A weak but statistically significant correlation between calcium score and maximum (r=0.366, p&lt;0.001) and mean gradients (r=0.387, p&lt;0.001) and aortic valve area (r=−0.120, p=0.047) was demonstrated. Valvular calcification was not significantly different in P with reduced ejection fraction (&lt;50%) (p=0.388).

Conclusion

There are significant differences in aortic valve calcium score between men and women referred for TAVI. Higher maximum and mean gradients were associated with increasing valvular calcification. Age and left ventricle ejection fraction were not related. P with bicuspid aortic valve have distinct calcification characteristics. As calcification burden may influence preprocedural planning, this parameter should be incorporated in the general work-up and reference values in this population should be known.

Funding Acknowledgement

Type of funding sources: None.

Artificial intelligence-enabled comprehensive coronary phenotyping in patients with suspected CAD

Introduction

The capabilities of artificial intelligence (AI) are rapidly progressing and the research community is getting increasingly interested in its possibilities. AI algorithms are able to work continuously and at high speed, reducing human workload and saving time that physicians can spend on more complex data or rarer cases. However, many clinical AI applications are currently only used in a research setting and lack proper testing and validation.

Objectives

This study aimed to determine the accuracy and performance of a novel AI-based software tool for CCTA analysis compared to conventional expert evaluation.

Methods

We evaluated 100 CCTA exams from a cohort of symptomatic patients with mild-to-moderately abnormal non-invasive ischemia test. Stenosis severity assessed by AI-based analysis (automatic evaluation, AEv) was compared with a level III expert CCTA interpretation (manual evaluation, MEv). AI-based analysis reported exact % stenosis and obstructive CAD was considered if maximal stenosis was ≥50%. Plaque phenotype was also estimated using AI algorithms.

Results

The study cohort was as follows: 52% male, mean age 68±10 years. The prevalence of hypertension, dyslipidemia and diabetes was 77%, 81% and 23%, respectively, and 10-year cardiovascular risk was 19±10% as predicted by Framingham risk score. Typical angina was present in 33%, of which 67% had a Canadian Cardiovascular Society angina grade ≥2.

Overall prevalence of obstructive CAD determined by MEv and AEv was 25% and 21%, respectively, with a significant association between both assessments (p&lt;0.001). When compared to MEv as reference, AEv method performed with a sensitivity, specificity, positive and negative predictive values of 0.56, 0.91, 0.58 and 0.86, respectively. Area under the curve was 0.871 (p&lt;0.001) demonstrating high accuracy.

AEv atherosclerosis quantification revealed significant differences between patients with and without obstructive CAD according to MEv: median total plaque volume (569 vs 115 mm3, p&lt;0.001), calcified plaque volume (297 vs 19 mm3, p&lt;0.001), non-calcified plaque volume (235 vs 71 mm, p&lt;0.001), low-density non-calcified plaque volume (2.8 vs 1.0 mm3, p=0.023) and percent atheroma volume (16.1 vs 3.8 mm3, p&lt;0.001).

Conclusion

In patients with suspected CAD and mild-to-moderately abnormal ischemia tests, a diagnostic strategy using AEv as a gatekeeper is effective, providing a quantitative stenosis evaluation with similar diagnostic performance for obstructive CAD when compared to MEv. AI-enabled approach additionally allows a fully automated quantification of coronary plaque volumes and composition, which would further enhance risk stratification.

Funding Acknowledgement

Type of funding sources: None.

[Lupus pancreatitis]

We report the case of a sixteen year old female patient, admitted to a general hospital due to fever, poliarthritis, malar rash and vasculitis. Diagnostic studies confirmed the existence of Systemic Lupus Erythematosus. Shortly after admission, the patient was transferred to an intensive care unit due to severe acute pancreatitis. In spite of its infrequency, the diagnosis of acute pancreatitis must always be considered whenever a patient with SLE presents abdominal pain. The authors emphasise the importance of an early diagnosis of this rare complication, with high mortality rates, and present a brief review of the international literature.

Threading the needle: a case report of double-wiring technique and double intracoronary imaging guidance for a multifenestrated iatrogenic coronary artery dissection

Background

Iatrogenic coronary artery dissection (ICAD) may represent a serious complication of percutaneous coronary intervention. Stenting the dissected segment is recommended in large dissections with compromised distal blood flow, although wiring the true lumen is often difficult.

Case summary

A 64-year-old woman with effort angina was submitted to invasive coronary angiography that revealed a severe stenosis in the distal right coronary artery. A large spiral ICAD occurred after pre-dilatation and guidewire position is lost. We report the treatment of this multifenestrated dissection using combined intracoronary imaging guidance with angiographic co-registered optical coherence tomography and real-time intravascular ultrasound, which were crucial to achieve a successful outcome.

Discussion

A double-wiring technique with double intracoronary imaging guidance enables a comprehensive depiction of the compromised artery and should be considered in selected cases to guide true lumen wiring and stent implantation.