Study protocol: a pragmatic, cluster-randomized controlled trial to evaluate the effect of implementation of the Truenat platform/MTB assays at primary health care clinics in Mozambique and Tanzania (TB-CAPT CORE)

BACKGROUND

In 2020, the WHO-approved Molbio Truenat platform and MTB assays to detect Mycobacterium tuberculosis complex (MTB) and resistance to rifampicin directly on sputum specimens. This primary health care center-based trial in Mozambique and Tanzania investigates the effect of Truenat platform/MTB assays (intervention arm) combined with rapid communication of results compared to standard of care on TB diagnosis and treatment initiation for microbiologically confirmed TB at 7 days from enrolment.

METHODS

The Tuberculosis Close the Gap, Increase Access, and Provide Adequate Therapy (TB-CAPT) CORE trial employs a pragmatic cluster randomized controlled design to evaluate the impact of a streamlined strategy for delivery of Truenat platform/MTB assays testing at primary health centers. Twenty-nine centers equipped with TB microscopy units were selected to participate in the trial. Among them, fifteen health centers were randomized to the intervention arm (which involves onsite molecular testing using Truenat platform/MTB assays, process process optimization to enable same-day TB diagnosis and treatment initiation, and feedback on Molbio platform performance) or the control arm (which follows routine care, including on-site sputum smear microscopy and the referral of sputum samples to off-site Xpert testing sites). The primary outcome of the study is the absolute number and proportion of participants with TB microbiological confirmation starting TB treatment within 7 days of their first visit. Secondary outcomes include time to bacteriological confirmation, health outcomes up to 60 days from first visit, as well as user preferences, direct cost, and productivity analyses.

ETHICS AND DISSEMINATION

TB-CAPT CORE trial has been approved by regulatory and ethical committees in Mozambique and Tanzania, as well as by each partner organization. Consent is informed and voluntary, and confidentiality of participants is maintained throughout. Study findings will be presented at scientific conferences and published in peer-reviewed international journals.

TRIAL REGISTRATION

US National Institutes of Health's ClinicalTrials.gov, NCT04568954. Registered 23 September 2020.

COVID-19 in cancer patients: update from the joint analysis of the ESMO-CoCARE, BSMO, and PSMO international databases

BACKGROUND

COVID-19 has significantly affected patients with cancer and revealed unanticipated challenges in securing optimal cancer care across different disciplines. The European Society for Medical Oncology COVID-19 and CAncer REgistry (ESMO-CoCARE) is an international, real-world database, collecting data on the natural history, management, and outcomes of patients with cancer and SARS-CoV-2 infection.

METHODS

This is the 2nd CoCARE analysis, jointly with Belgian (Belgian Society of Medical Oncology, BSMO) and Portuguese (Portuguese Society of Medical Oncology, PSMO) registries, with data from January 2020 to December 2021. The aim is to identify significant prognostic factors for COVID-19 hospitalization and mortality (primary outcomes), as well as intensive care unit admission and overall survival (OS) (secondary outcomes). Subgroup analyses by pandemic phase and vaccination status were carried out.

RESULTS

The cohort includes 3294 patients (CoCARE: 2049; BSMO: 928, all hospitalized by eligibility criteria; PSMO: 317), diagnosed in four distinct pandemic phases (January to May 2020: 36%; June to September 2020: 9%; October 2020 to February 2021: 41%; March to December 2021: 12%). COVID-19 hospitalization rate was 54% (CoCARE/PSMO), ICU admission 14%, and COVID-19 mortality 22% (all data). At a 6-month median follow-up, 1013 deaths were recorded with 73% 3-month OS rate. No significant change was observed in COVID-19 mortality among hospitalized patients across the four pandemic phases (30%-33%). Hospitalizations and ICU admission decreased significantly (from 78% to 34% and 16% to 10%, respectively). Among 1522 patients with known vaccination status at COVID-19 diagnosis, 70% were non-vaccinated, 24% had incomplete vaccination, and 7% complete vaccination. Complete vaccination had a protective effect on hospitalization (odds ratio = 0.24; 95% confidence interval [0.14-0.38]), ICU admission (odds ratio = 0.29 [0.09-0.94]), and OS (hazard ratio = 0.39 [0.20-0.76]). In multivariable analyses, COVID-19 hospitalization was associated with patient/cancer characteristics, the first pandemic phase, the presence of COVID-19-related symptoms or inflammatory biomarkers, whereas COVID-19 mortality was significantly higher in symptomatic patients, males, older age, ethnicity other than Asian/Caucasian, Eastern Cooperative Oncology Group performance status ≥2, body mass index <25, hematological malignancy, progressive disease versus no evident disease, and advanced cancer stage.

CONCLUSIONS

The updated CoCARE analysis, jointly with BSMO and PSMO, highlights factors that significantly affect COVID-19 outcomes, providing actionable clues for further reducing mortality.

Simultaneous Determination of Metals in Cachaça: A Study on Comparison of Multivariate Methods and Quality Control

This study aims to compare multivariate calibration methods developed from data obtained by square wave anodic stripping voltammetry using a hanging mercury drop electrode for simultaneous determination of metals in cachaça, the following metals were studied: copper, zinc and cadmium. Multivariate calibration, partial least squares (PLS) and artificial neural network (ANN) methods were used in previous studies using other electrodes for this determination. In this new study, besides ANN and PLS, a hybrid model that combines PLS and NN, namely PLS-Neural was used. Also, samples of industrial cachaças were incorporated into the study in addition to artisanal samples.  The quality of the methods was evaluated in terms of coefficient of determination (R2) and root mean square error of prediction (RMSEP).  F test was used for comparing methods at confidence level of 95%. Based on these studies, it was found that although all methods show good results, the method employing neural networks stands out in the determination of copper in samples of cachaça. All methods proved to be fast and relatively low-cost, and they can be used for such analyses.

Evaluation of Photoelectrocatalysis with Electrode Based on Ti/RuO2-TiO2 Modified with Tin and Tantalum Oxides for the Degradation of Indigo Blue Dye

Indigo Blue (IB) is a dye widely used by the textile sector for dyeing cellulose cotton fibers and jeans, being considered a recalcitrant substance, and therefore resistant to traditional treatments. Several methodologies are reported in the literature for the removal or degradation of dyes from the aqueous medium, among which photoelectrocatalysis stands out, which presents promising results in the degradation of dyes when a dimensionally stable anode (DSA) is used as a photoanode. In the present work, we sought to investigate the efficiency of a Ti/RuO₂-TiO₂ DSA modified with tin and tantalum for the degradation of Indigo Blue dye by photoelectrocatalysis. For this, electrodes were prepared by the thermal decomposition method and then a physical-chemical and electrochemical analysis of the material was carried out. The composition Ti/RuO₂-TiO₂-SnO₂Ta₂O₅ (30:40:10:20) was compared to Ti/RuO₂-TiO₂ (30:70) in the photocatalysis, electrocatalysis, and photoelectrocatalysis tests. The photocatalysis was able to degrade only 63% of the IB at a concentration of 100 mg L^-1 in 3 h, whereas the electrocatalysis and photoelectrocatalysis were able to degrade 100% of the IB at the same initial concentration in 65 and 60 min, respectively.

Long term left ventricular impairment after SARS-COV2 infection

Funding Acknowledgements

Type of funding sources: None.

Introduction

The impact of acute infection by SARS-COV2 on the cardiovascular system has been previously reported in the literature, with a higher propensity in patients with more serious pattern of disease and pro-inflammatory status. Nevertheless, the long-term burden and sequels of COVID-19 on the cardiovascular system is still unknown.

Purpose

To evaluate the long-term impact of COVID-19 on left ventricular function in patients with severe clinical presentation requiring intensive care hospitalization.

Methods

 

This was a single-center observational, prospective study which included patients requiring admission to the Intensive Care Unit (ICU) due to COVID-19 infection from January to November 2020. All discharged patients were contacted to perform a clinical, electrocardiographic and echocardiographic evaluation and those who accepted were included on the protocol. Baseline and clinical characteristics were collected from clinical reports. For the global longitudinal strain (GLS) analysis all patients with significant wall motion abnormalities and valvular cardiopathy were excluded. Statistical analysis was performed with Mann-Whitney and a safety cut-off was established with ROC curve analysis.

Results

 

A total of 43 patients were included (mean age 64 ± 12, 67.4% males). During SARS-COV2 infection 49% presented with severe ARDS and 51% with moderate, 35% required invasive mechanical ventilation, 14% noninvasive mechanical ventilation and 52% with high nasal flow cannula. On the follow-up analysis, fatigue was the most reported in symptom (52% patients) and the majority did not present other signs or symptoms suggestive of heart failure, with the mean NT-proBNP of 49 ± 389 pg/dL. The standard ECG and echocardiogram did not show significant changes with a mean LVEF of 58 ± 7.8 and mean TAPSE of 21 ± 4. The strain analysis showed low value of GLS (mean GLS of -17.14 ± 2.36) for a reference cut-off of -18%, suggesting subclinical left ventricular dysfunction in this subset of patients with preserved ejection fraction. Maximum CPR values during ICU did not correlate either with the extent of disease evolvement in CT (p= NS) or ARDS severity (p= NS). Nevertheless, maximum CPR correlated significantly with GLS reduction (R = 0.44, p = 0.019). A CPR value higher than iger30mg/dL had 100% specificity for GLS reduction and a cut-off of 14gm/dL reported a sensitivity of 65% and specificity pf 75% for reduction in GLS.

Conclusion

In our study, we reported subclinical impairment in left ventricular function detected with global longitudinal strain after serious infection with SARS-COV2. The detected myocardial dysfunction was related with higher inflammatory as expressed by CPR values. Long-term monitoring of these patients should be undertaken in order to timely detect late complications. Abstract Figure.

Real-world comparison of different periprocedural antithrombotic strategies for atrial fibrillation catheter ablation

Introduction

Atrial Fibrillation (AF) catheter ablation carries high bleeding and thromboembolic risks, requiring a detailed assessment of overall risk-benefit profile regarding antithrombotic strategy. Vitamin K Anticoagulant (VKA) and Non-Vitamin K Antagonist Oral Anticoagulant (NOAC) have been used in the latest years in this setting, and with different interruption protocols periprocedural. Our goal was to evaluate the rate of acute adverse events (AAE) and compare them according to antithrombotic strategy used periprocedural, in a real-world basis.

Methods

A single-center retrospective study, including adult patients admitted to first AF catheter ablation, from 2004 to 2020. Different antithrombotic strategies (anticoagulation with VKA uninterrupted, anticoagulation with NOAC uninterrupted, no therapy or antiaggregation/interrupted ACO) were compared concerning the rate of any clinically relevant AAE; the composite of major AAE (hemopericardium and stroke/transient ischemic attack [TIA]) and minor AAE associated with vascular access. Descriptive statistics and logistic regression were used to compare groups according to the antithrombotic strategy with an alpha level of 0.05.

Results

Among the 868 patients included (mean age 59±12 yo, 67,5% [n=586] men), pulmonary vein isolation was performed under uninterrupted anticoagulation in 640 (73,7%), of which 595 patients with NOAC (68,5%) and 45 with VKA (5,2%). AF was paroxysmal, persistent and long-standing persistent in 63,4% (n=550), 21,4% (n=185) and 15,4% (n=133) patients, respectively. Mean CHADS-VASc score was 1,86±1,48. Over time there was a shift in the distribution of the type of antithrombotic therapy used, consistent with changes in recommendations (Graph 1).

The composite outcome occurred in 6,8% (n=62), including hemopericardium in 1,8% (n=16), stroke/TIA in 0,7% (n=6) and events related to vascular access in 1,4% (n=13) [Table 1]. No anticoagulation therapy or antiaggregation/interrupted ACO was more associated to the outcome, driven by major AAE, although the difference did not meet statistical significance (p=0,06) [Table 1]. No difference was found between VKA and NOAC group. Additionally, there was no diference in the incidence of hemorrhagic AAE since the implementation of an uninterrupted anticoagulation strategy periprocedural.

Conclusion

In our population of patients submitted to AF catheter ablation, an uninterrupted anticoagulation strategy is associated with lower rate of AAE, either with VKA or NOAC. Our real-world results are reassuring of the benefit of an uninterrupted strategy, and consistent with recent controlled trials.

Funding Acknowledgement

Type of funding sources: None. Antithrombotic therapies over timeClinically relevant acute adverse events

Long-term risk of major cardiovascular events after cavotricuspid isthmus ablation: when and in whom to discontinue oral anticoagulation?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cavotricuspid isthmus ablation (CTA) is the 1st line therapy to accomplish rhythm control in typical atrial flutter (AFL). Several studies have shown that AFL is frequently associated with AF, which may be silent, posing the patient at risk of systemic embolism. Nowadays, there are no formal recommendations for OAC after CTA in patients with isolated AFL.

Aim

To determine the risk of MACE after CTA and compare: 1) the presence of concomitant AF, 2) concomitantly performing PVI and 3) persistence on OAC.

Methods

Single-center retrospective study of  pts submitted to CTA between 2015 and 2019, comprising 3 groups: I – pts with lone AFL; II – patients with AFL and prior AF submitted to CTA only; and III – patients with AFL and prior AF submitted to PVI and CTA. Clinical records were analyzed to determine the occurrence of MACE - death (of CV or unknown cause), stroke, clinically relevant bleed or hospitalization due to HF or arrhythmic events. Long-term OAC was defined as its persistence over 18 months after CTA. Kaplan Meier survival curves were used to estimate the risk of events and the groups were compared using uni- and multivariate Cox regression analyses.

Results

A total of 476 pts (66 ± 12 years, 80% males) underwent CTA: group I – 284 pts (60%), II – 109 pts (23%) and III – 83 pts (17%). Baseline characteristics were similar between groups, except for age with group I pts being older (68 ± 12, 67 ± 11, 61 ± 11, p &lt; 0.03). The mean baseline CHA2DS2VASc was 2.3 ± 1.5 and the median post-CTA follow-up was 2.8 year. The 1-, 3- and 5-years MACE risk was 7%, 21% and 32%, respectively and did not differ significantly between groups. OAC was suspended on the long-term in 105 pts (23%), at a mean of 241 days post-CTA. Suspension of OAC was significantly associated with lower MACE risk (HR: 0.26, 95%CI 0.12-0.56, p = 0.001). This effect was independent of the age and CHA2DS2VASc. The prognostic benefit of OAC suspension was driven by the group I and was not verified in patients with concomitant AF. In group I, withdraw of OAC (56 pts - 27%) was associated with a 70% relative risk reduction in the 5-year MACE risk (16% vs 43%, HR: 0.30, 95%CI 0.13-0.69, p = 0.005). In group I, OAC was suspended in patient who were younger (65 ± 11 vs. 69 ± 12, p = 0.002), had lower CHA2DS2VASc (1.9 ± 1.6 vs. 2.7 ± 1.4, p &lt; 0.001) and less often had cerebral vascular disease (1% vs. 8%, p = 0.036), HF (14% vs. 38%, p = 0.001), ischemic cardiomyopathy (9% vs. 19%, p = 0.04) and HTN(61% vs. 75%, p = 0.019).

Conclusions

In pts with AFL submitted to CTA, the long-term risk of MACE is frighteningly high, even in the ones without prior documentation of concomitant AF. Pts with prior AF presenting at the electrophysiological procedure in typical AFL and submitted just to CTA were not significantly harmed, from a prognostic perspective. In pts with lone AFL submitted to successful CTA, it may be reasonable to suspend OAC within 18 months provided that the concomitant AF is carefully excluded. Abstract Figure.

Outcomes and predictors of clinical response after upgrade to resynchronization therapy

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

 Upgrade to  resynchronization therapy (CRT) is common practice in Europe. However, patient selection remains a challenge. Data regarding predictors of response to upgrade is currently lacking.

AIM

To identify predictors of clinical response after upgrade to CRT.

METHODS

Single-center retrospective study of consecutive patients submitted to upgrade to CRT (2007-2018). Patients underwent clinical and echocardiographic (echo) evaluation at baseline, 6-months and 1-year. Major adverse cardiac events (MACE) included hospitalization for heart failure (HF) or all-cause mortality. Clinical response was defined as New York Heart Association (NYHA) class improvement without MACE in the 1st year of follow-up (FU). Left ventricle end-systolic volume reduction of &gt;15% designated echo response. Multivariate logistic regression was performed to identify predictors of clinical response to CRT.

RESULTS

Fifty-six patients submitted to upgrade to CRT (80.4% male, mean age 70.0 ± 9.6 years) were included; 43 patients (78.2%) previously had a pacemaker and 12 (21.8%) had a defibrillator device.  Most patients had non-ischemic HF (67.9%), with a mean baseline left ventricle (LV) ejection fraction of 27.9 ± 6.4%. Indications for upgrade were mainly pacemaker dependency or pacing-induced LV dysfunction (76.6%) and de novo left bundle branch block (23.4%).

Thirty-one (59.3%) patients were clinical responders. MACE occurred in 37.5% of patients; 28.6% were hospitalized for HF and 13% died during the 1st year of FU. Clinical responders had a lower rate of atrial fibrillation (AF) (46.9% vs. 53.1%, p=.025) and a higher rate of pacemaker rythm prior to upgrade (80.6% vs 47.6%, p=.013). Among responders, the previous device was more frequently a pacemaker (87.5% vs 61.9%, p=.029), and the new device a CRT-P (81.2% vs 54.5%, p=.035). HF etiology did not differ between responders and non-responders.

Multivariate analysis identified absence of AF (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.1-17.6, p=.037), CRT-P (OR 5.7, 95% CI 1.3-25.8, p=.022) and quadripolar lead implant (OR 3.8, 95% CI 1.3-25.8, p=.024) as predictors of clinical response in upgraded patients.

CONCLUSIONS

In this cohort, absence of AF, implantation of CRT-P and use of a quadripolar lead predicted clinical response to upgrade to CRT. Larger studies are warranted to tailor selection of patients for upgrade procedures.

Superresponse to cardiac resynchronization therapy: clinical outcomes and predictors

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Resynchronization therapy (CRT) reduces morbidity and mortality in selected patients with heart failure with reduced ejection fraction (HFrEF). Patients that experience significant reverse remodelling and left ventricular (LV) ejection fraction (LVEF) improvement have been called "superresponders".

AIM

To describe a cohort of superresponders and identify predictors of superresponse to CRT.

METHODS

Single-center retrospective study of consecutive patients submitted to CRT implantation (2007-2018). Patients underwent echocardiographic (echo) assessment at baseline, 6-months and 1-year. Superresponse was defined as LVEF≥50% during the 1st year of follow-up (FU). Major adverse cardiac events (MACE) included heart failure hospitalization or all-cause mortality. Multivariate logistic regression was performed to identify predictors of superresponse. Survival analysis with Kaplan-Meier method and Log-rank test was performed to compare outcomes between superresponders and non-superresponders.

RESULTS

295 CRT patients (70.5% male, mean age 67 ± 11 years) were included. Fifty-nine (21.4%) patients were superresponders. Superresponders were more often female (42.4% vs 25.8%, p=.021), tended to be older (69.6 vs 66.7 years, p=.054) and had lower rates of coronary disease (17.2% vs 32.9%, p=.032), atrial fibrillation (20.3% vs 38.0%, p=.018), valve disease (13.6% vs 30.0%, p=.018) and chronic kidney disease (6.9% vs 26.0%, p=.003). Superresponders had higher rates of non-ischemic HF (88.1% vs 69.1%, p=.006) and were more often implanted with CRT-P (69.5% vs 37.8%, p&lt;.001). HFrEF medication did not differ between groups.

Superresponders had lower baseline LV end-systolic volumes (115.5 vs 166.2 ml, p&lt;.001) and N-terminal pro B-type natriuretic peptide (NT-proBNP) values (1232.6 vs 5252 pg/ml, p&lt;.001). Baseline QRS duration did not differ (171.7 vs 171.3 ms, p=.883). During a median FU of 3 ± 5 years, there were no differences in terms of ventricular arrythmias (5.3% vs 6.8%, p=.913) or appropriate defibrillator therapies (1.8% vs 6.8%, p=.147) between groups. In addition to LVEF improvement (53.7% vs 35.3%, p&lt;.001), superresponders also showed higher tricuspid annular plane systolic excursion values (22.1 vs 19.8 mm, p=.004) during FU. MACE occurred less frequently (Log-rank test, p=.003) and all-cause mortality (Log-rank test, p &lt; 0.001) was lower in superresponders.

Multivariate analysis identified female gender (odds ratio [OR] 5.7, 95% confidence interval [CI] 1.03-31.73, p=.045), older age (OR 1.1, 95% CI 1.02-1.24, p=.017) and lower baseline NT-proBNP (OR 0.9, 95% CI 0.99-1.00, p=.011) as independent predictors of superresponse to CRT.

CONCLUSION

In superresponders, in addition to a significant improvement in LVEF, we observed an improvement in right ventricular function. As expected, MACE and all-cause mortality were lower. Female gender, older age and lower baseline NT-proBNP predicted super-response to CRT.

Statins for venous thromboembolism prevention: old dog, new tricks

Background

Statins are highly effective in preventing major acute cardiovascular events in the setting of atherosclerotic arterial disease. On the other hand, given their antithrombotic and anti-inflammatory properties, statins may also attenuate patients' odds of developing venous thromboembolism (VTE). However, clinical studies have yielded variable estimates of this effect.

Purpose

To perform a meta-analysis designed to evaluate the extent to which statin use influences the rate of subsequent VTE events.

Methods

We systematically searched MEDLINE, Embase, Web of Science, Cochrane Library and Google Scholar for both randomized controlled trials (RCTs) and observational studies addressing the association between statins and VTE risk, published up until December 1, 2019. Manually reviewed references and key investigators interaction via e-mail correspondence were also data sources. RCTs comparing the effects of statin therapy with those of a placebo or no treatment were included, while interventional studies appraising different lipid-lowering pharmacological strategies were not. Observational studies encompassed both cohort and case-control designs. The primary endpoints were general VTE, deep vein thrombosis or pulmonary embolism. Patients with cancer, heart failure and chronic kidney disease (CKD) were further investigated separately. Study-specific relative risks (RRs) were pooled using generic inverse variance outcome meta-analytic technique with a random-effects model.

Results

23 RCTs comprising 118.464 participants, 12 cohort studies encompassing 2.881.184 patients and 9 case-control studies including 354.367 patients were regarded as eligible for quantitative evaluation. Specifically, 5 observational studies comprising 9.656 cancer patients, 3 studies encompassing 9.693 heart failure patients and 4 studies including 4.353 CKD patients were gathered. In RCTs, statin therapy was proven slightly superior to placebo or no treatment in lowering VTE incidence (RR 0.85, 95% CI 0.73–0.99, p=0.04, i2=14%). Observational studies were found to corroborate this effect, with statin treatment resulting in VTE risk reduction overall (RR 0.72, 95% CI 0.64–0.81, p&lt;0.001, i2=84%) and in both cohort (RR 0.86, 95% CI 0.83–0.90, p&lt;0.001, i2=85%) and case-control (RR 0.68, 95% CI 0.57–0.82, p&lt;0.001, i2=80%) designs. This positive effect held true in cancer patients (RR 0.56, 95% CI 0.33–0.95, p=0.03, i2=78%), but not in those with heart failure (RR 0.7, 95% CI 0.42–1.16, p=0.17, i2=2%) and CKD (RR 1.04, 95% CI 0.67–1.60, p=0.87, i2=0%).

Conclusion

Currently available evidence suggests that statins significantly reduce patients' odds of developing VTE. Given their favorable safety profile and low cost, statin treatment should now be considered in high-risk individuals, particularly in those with cancer.

Funding Acknowledgement

Type of funding source: None

Comparison of de novo and upgrade to resynchronization therapy: a propensity-score matched analysis

Background

Upgrade to resynchronization therapy (CRT) from conventional pacemaker (P) or defibrillator (D) is common practice in Europe. However, guidelines (GL) are discordant: Pacing GL give a class I recommendation, while Heart Failure (HF) GL provide a class IIb indication. Previous studies suggested worse outcomes in upgraded patients (pts).

Aim

To compare response rate and clinical outcomes in a cohort of pts receiving de novo or upgrade to CRT.

Methods

Single-center retrospective study of consecutive pts submitted to CRT implantation (2007–2017). Major adverse cardiac events (MACE) included HF hospitalization (HHF) or all-cause mortality. Clinical response was defined as New York Heart Association class improvement without MACE in the first year of follow-up (FU). Left ventricle end-systolic volume reduction of &gt;15% denoted echocardiographic (echo) response. Survival analysis with Kaplan-Meier method and Log-rank test was performed. Propensity-score matching (PSM) analysis was made to adjust for possible confounder variables.

Results

230 CRT recipients (70.9% male, mean age 67±11 years, 71.5% non-ischemic cardiomyopathy, 39.6% CRT-P) were included, of whom 46 (20%) underwent an upgrade. Upgraded pts were older (69.8 vs 65.9 years, p=0.015), with higher rates of permanent atrial fibrillation (37.0% vs 12.7%, p=0.001), moderate to severe valve disease (45.7% vs 22.3%, p=0.002), chronic kidney disease (37.0% vs 17.2%, p=0.005) and treatment with mineralocorticoid receptor antagonists (79.1% vs 52.0%, p=0.002). They were more likely to receive CRT-P (65.2% vs 33.2%, p&lt;0.001) and CRT-D were more often implanted for secondary prevention (60.0% vs 17.9%, p=0.001). No differences emerged in procedural complications, clinical (74.4% vs 71.4%, p=0.712) or echo (66.7% vs 69.7%, p=0.822) response rates.

During a median FU of 3±4 years, all-cause mortality was similar among groups (Log Rank test, p=0.522, unadjusted hazard ratio [HR] 1.25, confidence interval [CI] 95% 0.62–2.49, p=0.534). There was a statistical tendency for higher MACE rate in the upgrade group (Log Rank test, p=0.064, HR 1.66, CI 95% 0.95–2,91, p=0.076). No differences were found in lead dislodgement (10.9% vs 7.1%, p=0.368) or endocarditis (2.2% vs 4.3%, p=0.692) rates.

PSM analysis identified 88 matched pairs (46 upgrade/42 de novo pts). In this cohort, all-cause mortality (Log Rank test, p=0.77, HR 0.89, CI 95% 0.39–2.03, p=0.78) and MACE (Log Rank test, p=0.36, HR 1.38, CI 95% 0.68–2.81, p=0.37) were comparable between groups [graph no. 1].

Conclusion

Upgrade to CRT was similar to de novo implantation in terms of complications and clinical and echo response, in this cohort. The risk for MACE and mortality was also comparable.

Graph 1

Funding Acknowledgement

Type of funding source: None

Provisional versus 2-stent strategies for coronary bifurcations: is a bird in the hand worth two in the bush?

Background

Among all subsets of coronary artery lesions, bifurcations stand out due to high incidence, demanding percutaneous interventions (PCIs) and poor outcomes. Amid the different PCI strategies, the provisional (PS) approach is generally recommended over 2-stent (TS) techniques, but this paradigm has been challenged.

Purpose

To compare PS with TS for PCI of coronary bifurcation lesions, concerning procedural aspects and both immediate and long-term patient outcomes.

Methods

Retrospective study encompassing patients consecutively referred to a tertiary interventional cardiology unit for coronary angiography, who were found to have at least 1 native bifurcation lesion. According to operator experience and angiographic features, patients were managed with PS or/(and) TS. Procedural aspects regarding radiological variables, angiographic success and immediate complications were reviewed, as were in-hospital outcomes. Besides, clinical follow-up, by clinic appointment or telephone calling, was performed targeting stent failure, target vessel revascularization (TVR), acute coronary syndromes (ACS), heart failure and mortality.

Results

From January 2010 to June 2017, 404 patients with 433 bifurcation lesions were included. Median age was 70 (62–77) years and 25.3% were female. Median follow-up was 2 (1–3) years. Chronic angina was the dominant PCI context (61.3%) with 9.7% presenting with ST-segment elevation myocardial infarction (MI). Medina class 1,1,1 was documented in 54.1% and 64.9% of lesions were hailed as true bifurcations. 303 patients underwent PS, whereas 67 were managed with TS, with TAP (43.3%) and mini-crush (34.3%) as the leading techniques. True bifurcations were more frequently approached with TS (p&lt;0.001), whereas PCI context did not influence procedure selection. Fluoroscopy time (p&lt;0.001), radiation dose (p=0.003) and contrast volume (p=0.009) were higher in the TS subgroup. OCT guidance (p=0.039) was also more common with TS. Angiographic success was uniformly high (95.1% for PS and 97% for TS), while procedural complications, including iatrogenic coronary dissections (7.4%, mostly minor) and slow-reflow (3.5%), were homogenously low. Acute kidney injury and type 4a MI occurred in 14.5% and 32.3%, respectively, also with no difference between groups. As for long-term outcomes, stent failure, encompassing both stent thrombosis (1 event) and restenosis (4.2%), occurred more often with TS (p=0.046), with ACS events (9.5%) following the same trend (p=0.08). In turn, rates of TVR (12.5%), heart failure hospitalization (6.2%) and mortality, regardless of its cardiovascular nature, were similar.

Conclusion

PS outperforms TS during follow-up, particularly due to lower stent failure odds. Thus, this study further supports the concept of PS as the standard approach for coronary bifurcation lesions.

Funding Acknowledgement

Type of funding source: None

Gender in non- ST elevation myocardial infarction and unstable angina: is there any equality?

Background

Historically, women (W) with acute coronary syndrome (ACS) have worse outcomes compared with men (M). This fact may occur due to gender-specific differences in the presentation and management of patients (P), which were mainly observed in studies dealing with ST-segment elevation infarction (STEMI). There seems to be a gap of knowledge in gender-specific differences in non- ST elevation myocardial infarction (NSTEMI) and unstable angina (UA).

Purpose

Assess gender-specific differences in presentation, treatment and outcomes in NSTEMI and UA patients.

Methods

A retrospective cohort study from consecutive ACS patients enrolled in a multicentre national registry from October 2010 to December 2018 was conducted, identifying 11394 P admitted with NSTEMI or UA. Demographic, clinical and treatment variables were compared between male gender and female gender P.

A Cox multivariate regression was performed to evaluate predictor factors of stablished endpoints: mortality at 1-year (1y) and cardiovascular (CV) hospitalization at 1-year.

Results

A total 11394 P were included, 8145 M (71.5%) and 3249 W (28.5%), mean age of 68±13. W, comparing with M, had higher age (72±12 vs 66±13, p=0.001), higher prevalence of hypertension (85% vs 72%, p=0.001) and diabetes (41% vs 34%, p=0.001) and longer time from symptoms to hospital admission (360 minutes vs 297 minutes, p=0.001). Chest pain was less frequent as first symptom in W (85.6% vs 91.3%, p=0.001). In medical treatment, W had higher chance of not having administration of a loading dose of P2Y12 inhibitor (22.1% vs 18.1, p=0.001) and of being medicated with clopidogrel (85.7% vs 82.1%, p=0.002). At discharge, W were less frequently medicated with an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (82.6% vs 84.4, p=0.028). Coronary angiography was less frequently performed in W (77.3% vs 85.7%, p=0.001). Coronary artery disease was less frequently found in the female gender (12.4% vs 4.8%, p=0.001).

In-hospital mortality was higher in W (2.9% vs 2.1%), but in the multivariate analysis the female gender was not an independent predictor of in-hospital mortality (OR 1.05 [0.67- 1.65], p=0.823). 1-year mortality was higher in W (9.2% vs 7.3%) and 1-year CV hospitalization was higher in M (16.8% vs 14.4%). After adjusting for covariates in Cox regression analysis, difference was still significant for mortality (HR= 1.274 [1.038 - 1.564], p=0.02) and hospitalization (HR = 0.852 [0.726- 0.998], p=0.047).

Conclusion

In this NSTEMI and UA cohort, there are important gender-specific differences in comorbidities, diagnosis, management and outcomes. Gender was an independent predictor of 1-year mortality and 1-year CV hospitalization, but not an independent predictor for in-hospital mortality.

Funding Acknowledgement

Type of funding source: None

Ranolazine as you have never seen it before: an antiarrhythmic for atrial fibrillation

Background

Currently available pharmacological options for rhythm control in atrial fibrillation (AF) are overshadowed by suboptimal efficacy and both frequent and potentially severe adverse events. Recent studies have added evidence to the hypothesis that ranolazine might exert antiarrhythmic effects, particularly in atrial tachyarrhythmias.

Purpose

To perform a systematic review with meta-analysis in order to ascertain the potential role of ranolazine in the management of AF.

Methods

We systematically searched MEDLINE, Embase and Scopus for randomized controlled trials (RCTs) and cohort studies addressing the association between ranolazine and AF outcomes, published up until December 1, 2019. The primary endpoint was incidence of AF, which was evaluated under a ranolazine versus placebo design. In this regard, patients in the setting of postcardiac surgery were further investigated separately. Secondary endpoints included AF cardioversion outcomes, which were addressed through comparison between ranolazine plus amiodarone and amiodarone alone for proportional efficacy and temporal requirements (time-to-cardioversion). The latter analysis was also undertaken in a dose-sensitive fashion (≤1000mg vs. 1500mg of ranolazine). Tertiary endpoints covered AF burden and episodes, in paroxysmal AF patients, and safety outcomes, namely death, QTc interval prolongation and hypotension. Study-specific odds ratios (ORs) were pooled using meta-analytic techniques with a random-effects model.

Results

A total of 10 RCTs comprising 8.109 participants and 3 cohort studies encompassing 37.112 patients were regarded as eligible for evaluation. Ranolazine was found to attenuate patients' odds of developing AF (OR 0.53, 95% CI: 0.41–0.69, p&lt;0.001, i2=58%). This effect held true, with an even larger effect size, in the context of post-cardiac surgery (OR 0.34, 95% CI: 0.16–0.72, p=0.005, i2=64%). Ranolazine increased the chances of successful AF cardioversion when added to amiodarone over amiodarone alone (OR 6.67, 95% CI: 1.49–29.89, p=0.01, i2=76%), while significantly reducing time-to-cardioversion [SMD 9.54h, 95% CI: −13.3–5.75, p&lt;0.001, i2=99%]. Interestingly, cardioversion was faster with ≤1000mg of ranolazine (SMD −13.16h, 95% CI: −15.07–11.25, p&lt;0.001, i2=95%) than with 1500mg (SMD −3.57h, 95% CI: −5.06–2.08, p&lt;0.001, i2=23%). In paroxysmal AF, ranolazine was also proved to significantly reduce both AF burden and episodes. There were no safety signals regarding mortality odds, QTc interval prolongation (mostly clinically insignificant) and hypotension (mostly transitory).

Conclusion

Current evidence suggests that ranolazine provides an effective and safe option for a chemical rhythm control strategy in AF management, a field in which medical breakthroughs are desperately needed.

Funding Acknowledgement

Type of funding source: None

P1092Syncope in the emergency department: can 24-hour holter monitoring be of any help?

Background 

Syncope is a very common reason for presenting to the emergency department (ED). The existence of a telemetry unit is crucial but it is not the reality in some hospitals. In order to avoid unnecessary ward admission, 24-hour Holter (24HH) monitoring could be useful to help with the diagnosis (when the arrhythmic etiology is suspected and the symptoms are frequent enough) and also be important to safely discharge a patient. 

Purpose 

The purpose of this study is to evaluate the diagnostic performance of 24HH monitoring, during a syncope episode in the ER, and to compare the readmission rates between patients with normal and abnormal not diagnostic 24HH monitoring. 

Methods 

A cohort study of consecutive patients (P) who were monitored with 24HH in one hospital in the ED, between January 2015 and December 2017, were included. All the 24HH results were seen by a senior cardiologist and divided in three groups: A - normal, B - abnormal Holter study unlikely to explain syncope and C- Holter study considered to be diagnostic. 

Groups A and B were compared using chi-square independence test to evaluate association between the result of the 24HH and readmission rates at 30 days and 1 year, as well as mortality and device implantation at 1 year. Multivariate logistic regression was used to look for other confounders. 

Results 

A total of 111 P were included in this study. Mean age was 75 ± 14 years old, with 55.6% male patients. 

A previous emergency episode with syncope was present in 56.9% of P. The mortality at one-year follow-up was 11.9%. The 24HH was considered diagnostic in 25.2% of P (28 P), with 18.9% of all the P with necessity of pacemaker (PM) implantation. In the patients with a non-diagnostic 24HH, 6,4% implanted a loop recorder before discharge. 

Group B patients had a higher 30-day readmission rate to the ED when compared with group A (OR = 4.050 CI 95 [1.13 – 14.497], p = 0.033), but no difference in one-year readmission rate (p= 0.065). There was no difference in one-year mortality between the two groups (p= 0.731) or in one-year implantation of pacemaker (p= 0.431). 

Conclusion 

The use of 24HH in the ED could be a valuable tool in the diagnosis of rhythm disorders that cause syncope.  An abnormal non diagnostic result can still be a predictor of 30-day readmission to the ED with similar complaints.

Simultaneous metal determination in artisanal cachaça by using voltammetry and multivariate calibration

In this study, square wave anodic stripping voltammetry using two different types of electrodes (carbon nanotube electrode and graphite electrode) was combined with chemometric methods - partial least squares (PLS) and artificial neural networks (ANN) for determining copper, zinc, cadmium and lead in cachaça. The objectives were comparison of methods developed and the verification of the quality of artisanal cachaças in terms of metal content. For the development of the methodology, inductively coupled plasma optical emission spectrometry (ICP OES) was used as reference technique. The performance of multivariate models obtained was evaluated by the coefficient of determination (R²) and root mean square error of prediction (RMSEP). F test was utilized for comparing methods at confidence level of 95%. Better results were observed by using carbon nanotube electrode regardless of the multivariate method proposed. The methodology is simple, fast, and inexpensive and it can be used in quality control laboratories.

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

Introduction

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

Purpose

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

Methods

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

Results

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

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

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

Conclusion

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

Abstract Figure. Effect of LMS 40 in flecainide test

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

Introduction

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Abstract Figure.

P1433Prevalence and location of residual leaks following percutaneous left atrial appendage occlusion: the importance of 3D transesophageal echocardiography

Background

The left atrial appendage (LAA) shape and size are very variable, and incomplete appendage closure or persistent leaks around the device are common following device placement. Limited studies reported the rate of peri-device leaks (PDL) after percutaneous left atrial appendage closure, and the impact of 3D transesophageal echocardiography (3D-TEE) on the detection of those leaks.

Aim

To describe the rate and location of leaks 1 month after percutaneous closure of the LAA, with and without the use of 3D-TEE.

Methods

A cohort study of consecutive patients (P) who were submitted to a percutaneous LAA closure with success in one interventional cardiology centre, between May 2010 and October 2018, were included. Clinical and echocardiography data were recorded and analysed. Two groups were created: Group A (GA) included patients until August 2015 submitted to 2D TEE on follow up (N= 48) versus Group B (GB), which was composed of patients submitted to 3D-TEE after August 2015 (N= 76).

Results

A total of 124 P had an in-hospital admission for LAA closure, with control TEE 1 month after the procedure. Mean age was 73 ± 7 years old, with 62.9% male patients. The procedure was guided by TEE (52%) or intra cardiac echocardiography (ICE) (48%).Transeptal puncture was preferred (95% of the procedures). The most used device was Amulet (62%) vs ACP (23%) and Watchman (15%).

In the follow up TEE, 20% of patients had only 1 leak and 2% had 2 leaks. Of the detected leaks,31% were considered minor (&lt; 1 mm), 35% moderate (1-3 mm) and 34% major (&gt; 3 mm). Patients with leaks had a larger LAA diameter (22 ± 4 mm vs. 17 ± 3 mm, P = 0.01).

Of the detected leaks, 50% were located in the superior portion of the device, 23% were located in the inferior portion, 8% in the posterior portion and 8% in the lateral portion.

In GA the rate of leaks was 14% vs 24.5% in GB, with differences also when specified the size of the leak –  minor (GA 2% vs GB 8.8%), moderate (GA 8% vs GB 8.1%) and major (GA 4% vs GB 7.6%).

Conclusion

The use of 3D echocardiography, 1 month after successful percutaneous LAA closure, augmented the rate of detection of device leaks. It remains to be studied the clinical impact of this finding.

Coleta de sêmen em Leopardus guttulus pelo método do cateterismo uretral

RESUMO Considerando a realidade conservacionista dos animais mantidos em cativeiro, em especial os pequenos felídeos silvestres, objetivou-se, com este estudo, descrever o método de coleta de sêmen por cateterismo uretral em Leopardus guttulus cativos, anestesiados com cetamina-dexmedetomidina. Inicialmente foram utilizados 13 animais para coleta de sêmen por cateterismo mediante o uso de diferentes doses de cetamina-dexmedetomidina. Após determinação da dose anestésica ideal para coleta de sêmen nessa espécie, cinco L. guttulus machos foram submetidos a coletas seriadas de sêmen pelo método do cateterismo. A dose ideal para coleta de sêmen foi de 0,008mg/kg de dexmedetomidina e 10mg/kg de cetamina. Os valores médios para volume e concentração foram de 35,9µL e 552,8x106sptz/mL. Com média de 71% de motilidade e 3,1 de vigor, 68% dos espermatozoides apresentaram vitalidade (integridade de membrana) e 77% integridade acrossomal. Sobre as patologias espermáticas, obteve-se uma média de 28% de espermatozoides com defeitos maiores, 6% com defeitos menores e 67% normais. As vantagens do método, como a facilidade e o baixo custo, fazem recomendar sua utilização em L. guttulus, pois foram apresentados bons resultados quanto à concentração espermática, à motilidade, ao vigor, à viabilidade espermática e à integridade acrossomal, sendo uma técnica promissora para utilização em felinos selvagens.

P1349 POCUS by general and family physician - advancing physical examination

BACKGROUND

Alongside with the development of hand held equipment, echo is becoming more accessible to nontraditional settings. General and family medicine (GPs) are at the forefront of any health system, but the use of cardiac echo by GPs is still unexplored. PURPOSE: This study aims to evaluate the accuracy of echocardiography assessment performed as an extension of the physical exam by GPs. METHODS: Two GPs underwent standard echocardiography training for 6 months. Subsequently, patients with diabetes or arterial hypertension were submitted to an echocardiogram performed by their GPs using a pocket ultrasound. Views obtained (with and without color Doppler) were parasternal long and short axis, apical and subcostal, with measurements of the posterior wall (PW), interventricular septum (IVS), left ventricle (LV), left atrium (LA), aorta and inferior vena cava (IVC). Studies were reviewed at the workstation and measured by two experts who classified the exams according to the image quality. RESULTS: Sixty echocardiograms were analyzed (mean age of 61y, 42% females and 58% males). In 50% the image quality was considered sufficient, 42% considered good and 8% considered bad. There were statistically significant differences between the GPs and expert measurements on the sinus of Valsalva (30.3 ± 3 to 28.8 ± 3.1mm, p = 0.001), LV in systole (p &lt; 0.001, 28[24,31] for 31[29,34]mm), IVS (p = 0.001, 10.9 ± 1.7 for 10.1 ± 1.5mm), PW (p = 0.018, 8.7 ± 1.1 to 9.2 ± 1.6mm) and TAPSE (p = 0.021, 20.9 ± 2.3 to 20.1 ± 2.7mm). There were no significate differences in the measurements of the ascending aorta, LA, LV in diastole and IVC. Agreement between the GPs and the experts was moderate for the evaluation of LVH (k = 0.48). The concordance was substantial for evaluation of LV function (k = 0.66) and excellent for evaluation of pericardial effusion (k = 1) and right ventricular function (k = 1). Concordance was excellent for mitral insufficiency (k = 0.83) and substantial for aortic insufficiency (k = 0.68) and tricuspid insufficiency (k = 0.61). A case of mitral stenosis was identified by both. GPs signalized a case of mild aortic stenosis that the expert did not consider. CONCLUSION: GPs trained in echocardiography, using pocket ultrasound, can obtain cardiac images with sufficient quality for interpretation by experts in the majority of cases. In this study, differences in dimensions might be explained by interobserver variability and/or by the performance of measurements in different environments, mobile vs workstation. Overall the differences were minor and clinically meaningless.

TISSUE ENGINEERING IN PLASTIC SURGERY - WHAT HAS BEEN DONE

The field of tissue engineering applies principles of engineering and life sciences for the development of functional biologic substitutes. The increasing need of tissue for challenging reconstructive surgeries places plastic surgeons involvement as vital in the research and development of engineered constructs and subsequent use. This narrative review aims to summarize tissue engineering principles, to update on its current uses and breakthroughs, to approach its current limitations and possible future directions for this exciting new field of medicine. This revision addressed tissue engineering utilisation in skin lesions, craniocervical defects, musculoskeletal defects, peripheral nerves lesions, vascular tissue defects and adipose tissue uses. Research in tissue engineering is increasing exponentially, however, and although there are already several engineered constructs available, its widespread clinical application is still a hope. More long-term studies that answer outstanding issues are needed in order for that to become reality.

P714 Contradicting the most basic tenet of black holes: light can, indeed, escape

A 69-year-old man with history of non-insulin-treated type 2 diabetes mellitus, arterial hypertension and mixed dyslipidemia presented to the emergency department with chest pain lasting for four days. Immediate twelve-lead electrocardiogram unveiled an inferior ST-segment elevation myocardial infarction (STEMI), prompting emergent coronary angiography, which, in turn, revealed two-vessel disease, specifically proximal ramus intermedius 60-70% stenosis and proximal right coronary artery acute occlusion. Culprit lesion was successfully managed with balloon angioplasty and a single drug-eluting stent implantation. Still, clinical course was noticeable for deterioration, under the form of cardiogenic shock, which required invasive ventilation and intravenous vasopressor support with norepinephrine. Despite biventricular systolic function relative preservation, transthoracic echocardiography disclosed inferior akinesis, right ventricle dilation, mild circumferential pericardial effusion and, particularly, a 2.3cm posteroinferior ventricular septal defect (VSD), in the setting of a 4.4cm2 pseudoaneurism, resulting in left-to-right shunting, quantified through maximal/mean trans-VSD pressure gradients of 84/44mmHg. Further imaging with transesophageal echocardiography and cardiac computed tomography angiography allowing the conception of a 3D-printed model was performed. Surgical correction of the defect followed, achieving partial anatomic success, namely with residual shunting, as of a left ventricular systolic pressure of 80mmHg and a right ventricular systolic pressure of 25mmHg. Patient survived, recovered and got discharged three weeks later. At one-year follow-up, he was hospitalized for acute decompensated heart failure (hemodynamic profile C) twice, with medication non-adherence reported as the main precipitating factor. In addition to a significant remaining left-to-right shunt (maximal velocity 3m/s), adverse cardiac remodeling was recognized, featuring left ventricular ejection fraction of 30-35%, severe functional mitral regurgitation, severe postcapillary pulmonary hypertension and de novo left bundle branch block (QRS duration of 197ms). Having been deemed clinically unsuitable for another surgical correction, patient underwent percutaneous VSD closure with both AmplatzerTM septal and muscular VSD occluders, with a suboptimal result. He is now on New York Heart Association class III heart failure and on the waiting list for both MitraClip and cardiac resynchronization therapy implantation.

Reflecting numerous breakthroughs in the management of acute myocardial infarction, incidence of mechanical complications is on the decline. Nevertheless, when they occur, morbidity and mortality remain high. Acquired ventricular septal defects are no exception, demanding the best care from a tertiary hospital heart team.

Abstract P714 Figure.

Controlled biosynthesis of gold nanoparticles with Coffea arabica using factorial design

Green synthesis of metallic nanoparticles has become incredibly popular, mainly by minimizing problems of environmental contamination and by being able to reduce, stabilize and potentially functionalize nanomaterials. Such compounds have possible applications in various areas, e.g., pharmaceuticals (drug delivery systems, cosmetics), textile industry (clothing with antimicrobial properties), diagnostic medicine (imaging, high efficiency biosensors), energy (solar panels), bioremediation, among others. However, the lack of reproducibility and information on the control mechanisms during synthesis have made the application of green-synthesized nanoparticles unfeasible. Thus, this study proposed the investigation of the main mechanisms affecting synthesis control, using factorial design for the preparation of gold nanoparticles with extract of Coffea arabica. We obtained stable (Zeta Potential, UV-vis and DLS), monodisperse, and quasi-spherical (TEM) nanoparticles, which presented adsorbed aromatic molecules (FTIR and RAMAN) and defined crystal structure (XRD), proving that the plant extract acted as a reducing agent, as well as a stabilizer and functionalizer for the synthesized nanostructures. The factorial design employed here to obtain gold nanoparticles with Coffea arabica extract allowed for a controlled and reproducible synthesis, enabling new possibilities for the application in several fields.

Short communication: Molecular characterization and antimicrobial resistance of pathogenic Escherichia coli isolated from raw milk and Minas Frescal cheeses in Brazil

The aim of this study was to quantify, identify, evaluate antimicrobial resistance, and characterize the virulence factors of enteropathogenic (EPEC), Shiga-toxigenic (STEC), and enterohemorrhagic (EHEC) Escherichia coli in raw milk (RM) and legal (LMFC) and illegal (IMFC) Minas Frescal cheeses in southern and northeast Brazil. Illegal cheeses are those made without official inspection service or sanitary surveillance. We evaluated samples of RM produced in Paraná (southern) and Maranhão (northeast) States, LMFC produced using pasteurized milk in inspected industries, and IMFC potentially produced with raw milk. Mean total coliform counts were 8.4 × 10⁴ cfu/mL for RM, 1.4 × 10⁷ cfu/mL for LMFC, and 2.9 × 10⁷ cfu/mL for IMFC. Mean E. coli counts were 2.4 × 10³ cfu/mL for RM, 1.9 × 10² cfu/mL for LMFC, and 1.1 × 10⁵ cfu/mL for IMFC. Among the 205 E. coli isolates from RM, 9.75% were identified as EPEC, mainly (90%) in samples from Paraná. Of the total isolates from the cheese samples, 97.4% (n = 111) came from IMFC, of which 1.8 and 2.7% were identified as EPEC and STEC, respectively; no EHEC was detected. The phylogenetic group A (60%) and typical EPEC (68%) predominated, which confirms the possible human origin of pathogenic isolates in RM and IMFC. Of these, 50% were resistant to at least one antibiotic, and streptomycin was the antimicrobial with the highest number (8) of EPEC and STEC resistant isolates. This study reports the first isolation of serogroup O28ac in Brazilian milk. We found no predominance of a specific serogroup of EPEC or STEC in milk or cheese or clonal isolates in the same sample, indicating different origins of the contamination in these products, presumably mostly related to poor hygienic handling.

Development and validation of the EUROFORGEN NAME (North African and Middle Eastern) ancestry panel

Inference of biogeographic origin is an important factor in clinical, population and forensic genetics. The information provided by AIMs (Ancestry Informative Markers) can allow the differentiation of major continental population groups, and several AIM panels have been developed for this purpose. However, from these major population groups, Eurasia covers a wide area between two continents that is difficult to differentiate genetically. These populations display a gradual genetic cline from West Europe to South Asia in terms of allele frequency distribution. Although differences have been reported between Europe and South Asia, Middle East populations continue to be a target of further investigations due to the lack of genetic variability, therefore hampering their genetic differentiation from neighboring populations. In the present study, a custom-built ancestry panel was developed to analyze North African and Middle Eastern populations, designated the 'NAME' panel. The NAME panel contains 111 SNPs that have patterns of allele frequency differentiation that can distinguish individuals originating in North Africa and the Middle East when combined with a previous set of 126 Global AIM-SNPs.

An Interregional, Transdisciplinary and Good Practice-Based Approach for Frailty: the Mind&Gait Project

Social facilities such residential structures and day-centres increasingly seek integrated, structured, adapted, creative, dynamic and economic strategies to prevent frailty. The arising need of an aged and frail population requires innovative interventions and products to prevent cognitive and physical decline. The interregional MIND&GAIT project aims to promote independent living in frail older adults by improving cognition and gait ability by using assistive products. This transdisciplinary strategy within a 24-months period expects as project' deliverables: i) a structured and good practice-based combined intervention (CI) consisting of a cognitive stimulation programme and a physical exercise programme; ii) an auto-blocking mechanism for rolling walkers with biofeedback acquisition (ABMRW); iii) a randomized clinical trial to assess CI' effectiveness; and iv) a web-platform to be used as a repository that will support and disseminate the intervention materials, covering the action-line of translational research. Positive benefits are expected in prevention and maintenance of frail older adults' capacities. Preliminary results showed positive effects on the improvement of cognitive and physical functions, functionality and depressive symptomatology. The interregional geographical coverage induced by MIND&GAIT underlines the potential replicability of the project extension to the community in the Centro and Alentejo regions of Portugal. MIND&GAIT network supports actions and provides learning opportunities and emergence of locally-embedded support systems towards social innovation for older adults.

Correction: Development of an optimized AAV2/5 gene therapy vector for Leber congenital amaurosis owing to defects in RPE65

The authors originally published this article under the incorrect license type; this has now been corrected and is published under the CC-BY license.