Inverse Association between Educational Status and Coronary CT Calcium Scores: Should We Reflect This in Our ASCVD Risk Assumptions?

Education is not a factor included in most cardiovascular risk models, including SCORE2. However, higher education has been associated with lower cardiovascular morbidity and mortality. Using CACS as a proxy for ASCVD, we studied the association between CACS and educational status. Subjects, aged 40-69, from the Paracelsus 10,000 cohort, who underwent calcium scoring as part of screening for subclinical ASCVD, were classified into low, medium, and high educational status using the Generalized International Standard Classification of Education. CACS was dichotomised as either 0 or >0 for logistic regression modelling. Our analysis showed that higher educational status was associated with higher odds for 0 CACS (aOR 0.42; 95%CI 0.26-0.70; p = 0.001). However, there was no statistically significant association between the levels of total, HDL or LDL cholesterol and educational status, nor any statistical differences in HbA1c. SCORE2 did not differ between the three educational categories (4 ± 2% vs. 4 ± 3% vs. 4 ± 2%; p = 0.29). While our observations confirmed the relationship between increased educational status and lower ASCVD risk, the effect of educational status was not mediated via its impact on classical risk factors in our cohort. Thus, perhaps educational status should be taken into account to more accurately reflect individual risk in cardiovascular risk models.

Left Atrial Ejection Fraction Assessed by Prior Cardiac CT Predicts Recurrence of Atrial Fibrillation after Pulmonary Vein Isolation

Assuming that atrial fibrillation (AF) is associated with left atrial remodeling and dysfunction, we hypothesize that left atrial and left atrial appendage ejection fractions (LAEF and LAAEF) are useful and may be more sensitive outcome predictors of pulmonary vein isolation (PVI). Fifty patients who underwent PVI at our institution with available pre-interventional cardiac computed tomography (CT) for procedure planning were included in this retrospective study. The patients were separated into two groups by recurrence and non-recurrence of AF and subgroups of paroxysmal and persistent AF. Semiautomatic volumetric analysis of the left atrium was used to calculate morphological and functional parameters and optimal cut-offs were calculated using the Youden index. LAEF (accuracy 94%, sensitivity 67%) and LAAEF (accuracy 90%, sensitivity 67%) were significantly reduced in patients with AF recurrence (16% vs. 36%, p = 0.00002; 16% vs. 42%, p = 0.000002), and in the subgroup analysis, the functional parameters were independent from AF type (paroxysmal and persistent). With a cut-off of <23% for both LAEF and LAAEF (area under the curve (AUC) 0.94, 95%CI 0.84–0.99 and AUC 0.96, 95%CI 0.86–0.99, respectively), AF recurrence occurred in 77.8%, within a mean follow-up period of 229 days. In conclusion, left atrial function on prior cardiac CT offers useful parameters for predicting AF recurrence after PVI.

Therapy Line and Associated Predictors of Response to PD-1/PD-L1-Inhibitor Monotherapy in Advanced Non-small-Cell Lung Cancer: A Retrospective Bi-centric Cohort Study

BACKGROUND

Evidence on PD-1/PD-L1-directed immune checkpoint inhibitor (ICI) therapy for advanced non-small-cell lung cancer (NSCLC) is mainly based on clinical trials in first- or second-line settings.

OBJECTIVE

We aimed to investigate response and prognostic factors with special regard to third- or later-line therapy.

PATIENTS AND METHODS

We retrospectively analyzed all patients who had received ICI monotherapy with nivolumab, pembrolizumab, or atezolizumab for advanced NSCLC. Computed tomography evaluations were analyzed using response evaluation criteria in solid tumors (RECIST, version 1.1). Kaplan-Meier analyses were conducted to calculate progression-free (PFS) and overall (OS) survival; the impact of influencing variables was evaluated using uni- and multivariate Cox-regression analyses.

RESULTS

Among 153 patients (59% men, mean age 66 years), median PFS was 4 months [mo; 95% confidence interval (95% CI) 3-5], OS was 13 mo (10-17), and objective response rate (ORR) was 22%. Therapy line ≥ 3 was associated with significantly inferior PFS (p = 0.003) and OS (p = 0.001). In first-line therapy PFS, OS, and ORR were 7 mo (3-11), 17 mo [9-not evaluable (n.e.)], and 36%; in second-line 4 mo (3-7), 18 mo (13-n.e.) and 19%, and in ≥ third-line 2 mo (1-3), 9 mo (4-12), and 13%. PFS was significantly influenced by PD-L1 expression in first-line therapy (p = 0.006). In ≥ third-line patients, Eastern Cooperative Oncology Group (ECOG) performance status significantly affected PFS and OS (both p < 0.001).

CONCLUSIONS

Third- or later-line single-agent anti-PD-1/PD-L1 therapy is less efficacious as compared to first- and second-line treatment. In that setting, ECOG performance status predominates known predictors like PD-L1 expression or presence of an alteration in EGFR or ALK.

P1056Left atrial and left atrial appendage ejection fraction assessed by preprocedural cardiac CT are useful parameters for predicting the outcome of pulmonary vein isolation

Introduction

Pulmonary vein isolation (PVI) is an effective but complex treatment option for atrial fibrillation (AF). Therefore preprocedural outcome prediction is of special interest. Left atrial volume (LAVmax) is a commonly used predictor for recurring arrhythmia. Several studies have investigated different parameters for the prediction of sustained rhythm control. We hypothesized that left atrial and left atrial appendage ejection fraction (LAEF & LAAEF) assessed by high-resolution CT-imaging are even more sensitive predictors of the outcome of PVI than LAVmax.

Methods

All patients who underwent PVI between 2015 and 2018 with available preinterventional cardiac CT were included in this retrospective study and separated into 2 groups: Group A comprises all patients with sinus rhythm (SR) at follow-up and group B all patients in whom recurrence of AF was observed. Volumetric analysis of the left atrium was performed in ventricular systole (30%-Phase of the cardiac cycle) and diastole (0%-Phase). Obtained data were used to calculate left atrial and left appendage ejection fractions (LAEF & LAAEF). Success of pulmonary vein isolation was defined as clinical freedom of symptomatic AF together with sinus rhythm on the available Holter-ECG recordings during follow-up examinations. Uni- and multivariate logistic regression models and NAMS RMLE tests were used to compare LAVmax to these functional parameters.

Results

In total 152 patients with symptomatic paroxsymal or persistent AF underwent PVI at our hospital from 2015 to 2018. Due to inconsistencies in archiving in our PACS-system, 98 patients had to be excluded from analysis. Four patients were excluded due to motion artifacts. 50 patients were included in the final study (41 patients without and 9 patients with recurring AF on average 254 days after ablation). Significant differences in means were found for all assessed parameters. LAEF (accuracy 94%, sensitivity 67%) and LAAEF (accuracy 90%, sensitivity 67%) had a higher sensitivity than LAVmax (accuracy 86%, sensitivity 33%), though not significant in this study population (p = 0.18). LAVmax and LAEF in combination improved sensitivity significantly from 33% to 78% (p = 0.046). Measurements on cardiac-CT showed an excellent interobserver-reliability.

Conclusion

Reduced LAEF and LAAEF were found to be significant predictors of the outcome of PVI. Furthermore we found a trend that these functional parameters might be more sensitive than LAVmax. Thus we propose that left atrial function, assessed with preprocedural cardiac CT, offers important prognostic information for successful PVI.

Abstract Figure. Surface rendering of LA and LAA

Visualization and appearance of artifacts of leadless pacemaker systems in cardiac MRI : An experimental ex vivo study

Background

Leadless pacemaker systems are an important upcoming device in clinical rhythmology. Currently two different products are available with the Micra system (Medtronic) being the most used in the clinical setting to date. The possibility to perform magnetic resonance imaging (MRI) is an important feature of modern pacemaker devices. Even though the Micra system is suitable for MRI, little is yet known about its impact on artifacts within the images.

Objective

The aim of our ex vivo study was to perform cardiac MRI to quantify the artifacts and to evaluate if artifacts limit or inhibit the assessment of the surrounding myocardium.

Methods

After ex vivo implantation of the leadless pacemaker (LP) in a porcine model, hearts were filled with saline solution and fixed on wooden sticks on a plastic container. The model was examined at 1.5 T and at 3 T using conventional sequences and T2 mapping sequences. In addition, conventional X‑rays and computed tomography (CT) scans were performed.

Results

Correct implantation of the LP could be performed in all hearts. In almost all MRI sequences the right ventricle and the septal region surrounding the (LP) were altered by an artifact and therefore would sustain limited assessment; however, the rest of the myocardium remained free of artifacts and evaluable for common radiologic diagnoses. A characteristic shamrock-shaped artifact was generated which appeared to be even more intense in magnitude and brightness when using 3 T compared to 1.5 T.

Conclusion

The use of the Micra system in cardiac MRI appeared to be feasible. In our opinion, it will still be possible to make important clinical cardiac MRI diagnoses (the detection of major ischemic areas or inflammatory processes) in patients using the Micra system. We suggest the use of 1.5 T as the preferred method in clinical practice.

Disappearance of left ventricular hypertrabeculation/noncompaction and sudden death in a patient with Turner mosaic syndrome

Left ventricular hypertrabeculation/noncompaction is associated with various neuromuscular and other rare genetic disorders. In a 53-year-old man with a Turner mosaic karyotype, regression of left ventricular hypertrabeculation/noncompaction was documented by cardiac magnetic resonance imaging and echocardiography after 7 years. During that time, coronary 3-vessel disease and severe left ventricular dys function developed, necessitating coronary bypass surgery. Postoperatively, left ventricular systolic function recovered to an ejection fraction of 40%. The patient died suddenly 6 months postoperatively. In conclusion, the disappearance of left ventricular hypertrabeculation/noncompaction was most likely due to scar formation.