Mobile health for cardiovascular risk management after cardiac surgery: results of a sub-analysis of The Box 2.0 study

Aims

Lowering low-density lipoprotein (LDL-C) and blood pressure (BP) levels to guideline recommended values reduces the risk of major adverse cardiac events in patients who underwent coronary artery bypass grafting (CABG). To improve cardiovascular risk management, this study evaluated the effects of mobile health (mHealth) on BP and cholesterol levels in patients after standalone CABG.

Methods and results

This study is a post hoc analysis of an observational cohort study among 228 adult patients who underwent standalone CABG surgery at a tertiary care hospital in The Netherlands. A total of 117 patients received standard care, and 111 patients underwent an mHealth intervention. This consisted of frequent BP and weight monitoring with regimen adjustment in case of high BP. Primary outcome was difference in systolic BP and LDL-C between baseline and value after three months of follow-up. Mean age in the intervention group was 62.7 years, 98 (88.3%) patients were male. A total of 26 449 mHealth measurements were recorded. At three months, systolic BP decreased by 7.0 mmHg [standard deviation (SD): 15.1] in the intervention group vs. -0.3 mmHg (SD: 17.6; P < 0.00001) in controls; body weight decreased by 1.76 kg (SD: 3.23) in the intervention group vs. -0.31 kg (SD: 2.55; P = 0.002) in controls. Serum LDL-C was significantly lower in the intervention group vs. controls (median: 1.8 vs. 2.0 mmol/L; P = 0.0002).

Conclusion

This study showed an association between home monitoring after CABG and a reduction in systolic BP, body weight, and serum LDL-C. The causality of the association between the observed weight loss and decreased LDL-C in intervention group patients remains to be investigated.

A novel method to identify an intramural segment in interarterial anomalous coronary arteries on CT-angiography

Background/Introduction

An anomalous coronary artery originating from the opposite sinus of Valsalva (ACAOS) with an interarterial course can be assessed using Computed Tomography Angiography (CTA) for the presence of high-risk characteristics associated with sudden cardiac death. These features include a slit-like ostium, acute angle take-off, and degree of proximal luminal narrowing. However, no robust CTA criteria currently exist to determine the presence of an intramural segment.

Purpose

The aim of this study is to deduct a method to accurately identify an intramural course of interarterial ACAOS on CTA imaging.

Methods

All consecutive adult patients with an interarterial ACAOS that were evaluated at the two academic hospitals between January 2010 and July 2019 were screened for inclusion. Inclusion criteria were availability of a preoperative CTA-scan (0.5–1mm slice-thickness) and peroperative confirmation of the intramural segment. Using multiplanar reconstruction of the CTA, the distance between the lumen of the aorta and the lumen of the ACAOS (defined as “interluminal space” (ILS)) was assessed at 2mm intervals along the intramural segment (Figure 1).

Results

Twenty-five patients (64% female, mean age 46 years, 88% right ACAOS) were included. Analysis showed a mean ILS of 0.69mm±0.15mm at 2mm from the ostium. At the end of the intramural segment where the ACAOS becomes non-intramural, the mean ILS was significantly larger (1.27±0.29mm, p&lt;0.001) (Figure 2). Interobserver agreement evaluation showed good reproducibility of ILS (intraclass correlation coefficient 0.77, p&lt;0.001). ROC-analysis demonstrated that at a cut-off ILS of ≤0.95mm, an intramural segment can be diagnosed with 100% sensitivity and 84% specificity.

Conclusion(s)

The ILS is introduced as novel and robust CTA parameter to identify an intramural course of interarterial ACAOS. An ILS of ≤0.95mm is indicative of an intramural segment with 100% sensitivity and 84% specificity.

Funding Acknowledgement

Type of funding sources: None.

Myocardial function in COVID-19 patients after hospital discharge: a descriptive study comparing the first and second 'wave' patients

In hospitalized COVID-19 patients, myocardial injury and echocardiographic abnormalities have been described. The present study investigates cardiac function in COVID-19 patients 6 weeks post-discharge and evaluates its relation to New York Heart Association (NYHA) class. Furthermore cardiac function post-discharge between the first and second wave COVID-19 patients was compared. We evaluated 146 patients at the outpatient clinic of the Leiden University Medical Centre. NYHA class of II or higher was reported by 53% of patients. Transthoracic echocardiography was used to assess cardiac function. Overall, in 27% of patients reduced left ventricular (LV) ejection fraction was observed and in 29% of patients LV global longitudinal strain was impaired (> - 16%). However no differences were observed in these parameters reflecting LV function between the first and second wave patients. Right ventricular (RV) dysfunction as assessed by tricuspid annular systolic planar excursion (< 17 mm) was present in 14% of patients, this was also not different between the first and second wave patients (15% vs. 12%; p = 0.63); similar results were found for RV fraction area change and RV strain. Reduced LV and RV function were not associated with NYHA class. In COVID-19 patients at 6 weeks post-discharge, mild abnormalities in cardiac function were found. However these were not related to NYHA class and there was no difference in cardiac function between the first and second wave patients. Long term symptoms post-COVID might therefore not be explained by mildly abnormal cardiac function.

Mobile health vs. standard care after cardiac surgery: results of The Box 2.0 study

AIMS

Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery, yet difficult to detect in ambulatory patients. The primary aim of this study is to investigate the effect of a mobile health (mHealth) intervention on POAF detection after cardiac surgery.

METHODS AND RESULTS

We performed an observational cohort study among 730 adult patients who underwent cardiac surgery at a tertiary care hospital in The Netherlands. Of these patients, 365 patients received standard care and were included as a historical control group, undergoing surgery between December 2017 and September 2018, and 365 patients were prospectively included from November 2018 and November 2020, undergoing an mHealth intervention which consisted of blood pressure, temperature, weight, and electrocardiogram (ECG) monitoring. One physical outpatient follow-up moment was replaced by an electronic visit. All patients were requested to fill out a satisfaction and quality of life questionnaire. Mean age in the intervention group was 62 years, 275 (70.4%) patients were males. A total of 4136 12-lead ECGs were registered. In the intervention group, 61 (16.7%) patients were diagnosed with POAF vs. 25 (6.8%) patients in the control group [adjusted risk ratio (RR) of POAF detection: 2.15; 95% confidence interval (CI): 1.55-3.97]. De novo atrial fibrillation was found in 13 patients using mHealth (6.5%) vs. 4 control group patients (1.8%; adjusted RR 3.94, 95% CI: 1.50-11.27).

CONCLUSION

Scheduled self-measurements with mHealth devices could increase the probability of detecting POAF within 3 months after cardiac surgery. The effect of an increase in POAF detection on clinical outcomes needs to be addressed in future research.

Sbk2, a Newly Discovered Atrium-Enriched Regulator of Sarcomere Integrity

BACKGROUND

Heart development relies on tight spatiotemporal control of cardiac gene expression. Genes involved in this intricate process have been identified using animals and pluripotent stem cell-based models of cardio(myo)genesis. Recently, the repertoire of cardiomyocyte differentiation models has been expanded with iAM-1, a monoclonal line of conditionally immortalized neonatal rat atrial myocytes (NRAMs), which allows toggling between proliferative and differentiated (ie, excitable and contractile) phenotypes in a synchronized and homogenous manner.

METHODS

In this study, the unique properties of conditionally immortalized NRAMs (iAMs) were exploited to identify and characterize (lowly expressed) genes with an as-of-yet uncharacterized role in cardiomyocyte differentiation.

RESULTS

Transcriptome analysis of iAM-1 cells at different stages during one cycle of differentiation and subsequent dedifferentiation identified ≈13 000 transcripts, of which the dynamic changes in expression upon cardiomyogenic differentiation mostly opposed those during dedifferentiation. Among the genes whose expression increased during differentiation and decreased during dedifferentiation were many with known (lineage-specific) functions in cardiac muscle formation. Filtering for cardiac-enriched low-abundance transcripts, identified multiple genes with an uncharacterized role during cardio(myo)genesis including Sbk2 (SH3 domain binding kinase family member 2). Sbk2 encodes an evolutionarily conserved putative serine/threonine protein kinase, whose expression is strongly up- and downregulated during iAM-1 cell differentiation and dedifferentiation, respectively. In neonatal and adult rats, the protein is muscle-specific, highly atrium-enriched, and localized around the A-band of cardiac sarcomeres. Knockdown of Sbk2 expression caused loss of sarcomeric organization in NRAMs, iAMs and their human counterparts, consistent with a decrease in sarcomeric gene expression as evinced by transcriptome and proteome analyses. Interestingly, co-immunoprecipitation using Sbk2 as bait identified possible interaction partners with diverse cellular functions (translation, intracellular trafficking, cytoskeletal organization, chromatin modification, sarcomere formation).

CONCLUSIONS

iAM-1 cells are a relevant and suitable model to identify (lowly expressed) genes with a hitherto unidentified role in cardiomyocyte differentiation as exemplified by Sbk2: a regulator of atrial sarcomerogenesis.

The effects of high-degree AV block requiring chronic ventricular pacing after tricuspid valve surgery in patients with a systemic right ventricle

Funding Acknowledgements

Type of funding sources: None.

Background

Patients with transposition of the great arteries(TGA) after atrial switch or congenitally corrected TGA(ccTGA) are prone to systemic right ventricular(sRV) failure. Atrioventricular(AV)-conduction disturbances requiring chronic ventricular pacing and tricuspid valve(TV) regurgitation aggravate sRV dysfunction. Timely TV surgery stabilizes sRV function, yet is a risk factor for AV-block, potentially contributing to sRV failure due to pacing-induced dyssynchrony. The aim of this study is to explore the incidence, timing and functional consequences of AV-block requiring ventricular pacing after TV surgery in sRV patients.

Methods

Consecutive adolescent and adult patients with a sRV who underwent TV surgery in the period 1989-2020 and follow-up at our centre were included in this observational cohort study. Demographic and clinical data was collected from patient records.

Results

Data of 28 patients(54% female, 57% ccTGA, mean age at surgery 38±13 years) was analysed. Mean follow-up duration was 9.7±6.8 years. Five patients(18%) already had chronic(&gt;40%) subpulmonary left ventricular pacing preoperatively, of which 2 received cardiac resynchronization therapy(CRT) upgrade prior to surgery. One patient received CRT during TV surgery. Of the remaining 22 patients at risk for AV-block after surgery, 9(41%) developed an indication for chronic pacing during follow-up, of which 3(33%) before hospital discharge and a total of 5(56%) within 24 months postoperatively, Figure 1. Five(20%) patients received CRT during follow-up due to progressive heart failure(HF). In one patient with transvenous upgrade, effective resynchronization was not attained due to suboptimal lead position. Of the patients receiving chronic pacing, 9(75%) died, underwent ventricular assist device(VAD) implantation or required CRT due to progressive HF. Only 4(31%) patients with native AV-conduction reached this composite endpoint(p=0.027). QRS duration, a surrogate marker for dyssynchrony, was significantly higher in patients with chronic pacing than with native AV-conduction(217±24 vs 116±23msec, p=0.000), as was NT-pro-BNP(2746[1242–6879] vs 495[355–690]ng/L, p=0.004) and the percentage of patients with ≥1 class of deterioration of systolic sRV function(p=0.001), Figure 2.

Conclusions

Patients with a failing sRV who undergo TV surgery are prone to AV-conduction abnormalities with 41% developing an indication for chronic ventricular pacing during follow-up. The patient group with chronic pacing has significantly more events of the composite endpoint of death, VAD implantation or upgrade to CRT, higher percentage of ≥1 grade deterioration of systolic sRV function and higher levels of HF biomarker NT-pro-BNP. Implantation of an epicardial sRV lead at the time of TV surgery for future CRT may be considered to attenuate the detrimental effects of subpulmonary ventricular pacing in this HF prone patient group with complex anatomy that limits transvenous possibilities.

The Box—eHealth in the Outpatient Clinic Follow-up of Patients With Acute Myocardial Infarction: Cost-Utility Analysis

Background

Smartphone compatible wearables have been released on the consumers market, enabling remote monitoring. Remote monitoring is often named as a tool to reduce the cost of care.

Objective

The primary purpose of this paper is to describe a cost-utility analysis of an eHealth intervention compared to regular follow-up in patients with acute myocardial infarction (AMI).

Methods

In this trial, of which clinical results have been published previously, patients with an AMI were randomized in a 1:1 fashion between an eHealth intervention and regular follow-up. The remote monitoring intervention consisted of a blood pressure monitor, weight scale, electrocardiogram device, and step counter. Furthermore, two in-office outpatient clinic visits were replaced by e-visits. The control group received regular care. The differences in mean costs and quality of life per patient between both groups during one-year follow-up were calculated.

Results

Mean costs per patient were €2417±2043 (US $2657±2246) for the intervention and €2888±2961 (US $3175±3255) for the control group. This yielded a cost reduction of €471 (US $518) per patient. This difference was not statistically significant (95% CI –€275 to €1217; P=.22, US $–302 to $1338). The average quality-adjusted life years in the first year of follow-up was 0.74 for the intervention group and 0.69 for the control (difference –0.05, 95% CI –0.09 to –0.01; P=.01).

Conclusions

eHealth in the outpatient clinic setting for patients who suffered from AMI is likely to be cost-effective compared to regular follow-up. Further research should be done to corroborate these findings in other patient populations and different care settings.

Trial Registration

ClinicalTrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376

International Registered Report Identifier (IRRID)

RR2-10.2196/resprot.8038

Emergency Heart failure Mortality Risk Grade may help to reduce heart failure admissions

Introduction

Hospital admissions for heart failure (HF) are frequent and pose a heavy burden on health care resources. Currently, the decision to hospitalise is based on clinical judgement rather than on prognostic risk stratification. The Emergency Heart failure Mortality Risk Grade (EHMRG) was recently developed to identify high-risk HF patients in the emergency department (ED).

Objective

To assess the ability of the EHMRG to predict 30-day mortality in Dutch HF patients visiting the ED and to evaluate whether the EHMRG could help to reduce the number of hospital admissions for decompensated HF.

Methods

Patients visiting the ED for decompensated HF were included. The decision to hospitalise or discharge was based on clinical judgement. The EHMRG was calculated retrospectively. Based on their EHMRG, patients were stratified as very low risk, low risk, intermediate risk, high risk and very high risk.

Results

In 227 patients (age 73 ± 12 years, 69% male) 30-day mortality was 11%. Mortality differed significantly among the EHMRG risk groups at 7‑day (p = 0.012) and 30-day follow-up (p < 0.01). Based on clinical judgement, 76% of patients were hospitalised. If decision-making had been based on EHMRG, the hospitalisation rate could have been reduced to 66% (p < 0.01), particularly by reducing hospitalisations in patients at low risk of death. Mortality in discharged patients, whether the decision was based on EHMRG or clinical judgement, was 0%.

Conclusion

The EHMRG accurately differentiates between high- and low-risk decompensated HF patients visiting the ED, making it a promising tool to safely reduce the number of HF admissions.

Supplementary Information

The online version of this article (10.1007/s12471-022-01661-3) contains supplementary material, which is available to authorized users.

Transcriptome analysis of conditionally immortalized atrial myocytes: identification of a novel atrium-enriched protein involved in sarcomere assembly and maintenance

Background

Heart development relies on the tight spatiotemporal control of cardiac gene expression.

Genes involved in these processes have been identified using mainly (transgenic) animals models and pluripotent stem cell-derived cardiomyocytes (CMs). Recently, the repertoire of cardiomyocyte differentiation models has been expanded with iAM-1, a monoclonal cell line of conditionally immortalized neonatal rat atrial myocytes (NRAMs) which allows toggling between proliferative and differentiated (i.e. excitable and contractile) phenotypes in a synchronized and homogenous manner.

Purpose

To identify and characterize (lowly expressed) genes with an as-of-yet uncharacterized role in cardiomyocyte differentiation, dedifferentiation and proliferation by exploiting the unique properties of conditionally immortalized NRAMs (iAMs).

Methods and results

RNA sequencing was performed during a full cycle of iAM-1 differentiation and subsequent dedifferentiation, identifying ±13,000 transcripts, of which the dynamic expressional changes during cardiomyogenic differentiation in most cases opposed those during dedifferentiation. Among the genes whose expression increased during differentiation and decreased during dedifferentiation were many genes with a known (lineage-specific) role in cardiac muscle formation, thereby confirming the relevance of iAMs as cardiomyogenic differentiation model. Filtering for cardiomyocyte-enriched low abundancy transcripts, resulted in the identification of an uncharacterized protein, which is highly conserved among Nephrozoa and up- and downregulated during cardiomyocyte differentiation and dedifferentiation, respectively. In neonatal and adult rats, this protein is muscle-specific, highly atrium-enriched and localized around the C-zone of cardiac sarcomeres. Lentiviral shRNA-mediated knockdown resulted in loss of sarcomeric organization in both NRAMs and iAMs. Neither knockdown nor overexpression of this protein affected the electrophysiological properties of differentiated iAM monolayers.

Conclusions

iAM-1 cells offer a relevant model to identify and characterize novel (low abundancy) genes involved in cardiomyocyte (de)differentiation as exemplified by the identification a novel uncharacterized protein that is muscle-specific, highly atrium-enriched, localized around the C-zone of cardiac sarcomeres and plays a specific role in atrial sarcomerigenesis.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Organisation for Health Research and Development (ZonMw) Leiden Regenerative Medicine Platform Holding project with number (LRMPH) Figure 1. (A) Experimental setup. At the indicated timepoints iAM-1 cells were fixed for immunostaining and RNA extraction for transcriptome analysis. (B) Immunochemical staining of iAM-1 cells for the proliferation marker Ki-67 and the Z-line marker sarcomeric α-actinin. (C & D) Immunohistological double stainings of longitudinal sections of neonatal rat hearts for the uncharacterized protein (GOI 1) and the sarcomeric protein cardiac troponin I (TNNI3). LA, left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle. Scale bar, 250 μm.

Atrioventricular-block necessitating ventricular pacing after tricuspid valve surgery in patients with a systemic right ventricle: long term follow-up

Background

Patients with transposition of the great arteries (TGA) after atrial switch or congenitally corrected TGA (ccTGA) are prone to systemic right ventricular (sRV) failure. Atrioventricular (AV)-conduction disturbances and tricuspid regurgitation aggravate the course of sRV dysfunction. Timely tricuspid valve (TV) surgery stabilizes sRV function. However, TV surgery is an independent risk for AV-block and ventricular pacing in non-congenital cardiothoracic surgery patients. Chronic subpulmonary ventricular pacing-induced dyssynchrony further contributes to sRV failure, potentially reducing the beneficial effects of the tricuspid valve surgery.

Purpose

The aim of this study is to explore the incidence, timing and functional consequences of AV-conduction block requiring ventricular pacing after TV surgery in sRV patients.

Methods

Consecutive adolescent and adult patients with a sRV who underwent TV surgery in the period 1989–2020 and follow-up at our tertiary care center were included in this observational cohort study. Patients who were &lt;10 years of age at the time of operation and/or died in perioperative, in-hospital, setting were excluded from analysis (n=5). Demographic and clinical data was collected from the patient records.

Results

Data of 28 patients (54% female, 57% ccTGA) was analysed (Figure). The mean age at surgery was 38±13 years, 5 patients (18%) received chronic ventricular pacing preoperatively. Mean follow-up was 9.7±6.8 years, during which 7 patients (25%) died and 3 (11%) underwent ventricular assist device implantation (VAD). Two patients died awaiting VAD/HTx, one patient died awaiting CRT upgrade. Seven (25%) patients underwent a re-operation, of which 3 (11%) TV replacement, 3 (11%) VAD and 1 (4%) pulmonary valve replacement. Of the 23 patients at risk of developing AV-block, 11 (48%) developed an indication for chronic ventricular pacing, of which 6 within 24 months postoperatively (4 before hospital discharge). Of the 21 patients with a device, 7 (25%) had successful resynchronization therapy (2 before TV surgery). Patients with chronic ventricular pacing had a wider QRS-duration (mean 121 ms vs 194 ms in those without pacing, p&lt;0.001) and 43% had a severely reduced sRV function (vs 36% in those without pacing) at latest follow-up.

Conclusions

Patients with a failing sRV who undergo TV surgery are prone to AV-conduction abnormalities with 48% of this group developing an indication for chronic ventricular pacing during follow-up. Pacing-induced dyssynchrony can further contribute to sRV dysfunction. Implantation of an epicardial sRV lead at the time of TV surgery for future CRT may be considered to attenuate the detrimental effects of subpulmonary ventricular pacing in this heart failure prone patient group with complex anatomy, limiting transvenous possibilities.

Funding Acknowledgement

Type of funding sources: None.

Long-term prognosis after ST-elevation myocardial infarction in cancer patients

Purpose

To assess survival trends after ST-elevation myocardial infarction (STEMI) in patients with a prior cancer diagnosis and to evaluate the drivers of prognosis over a follow-up period of five years.

Methods

Patients with a known cancer diagnosis, admitted with STEMI between 2004–2014 and treated with primary PCI were recruited from the STEMI-clinical registry of our institution. Detailed information on cancer diagnosis, -stage, and treatment regimen were collected from the institutional and national cancer registry system and all patients were followed prospectively.

Results

In the 215 included patients the cumulative incidence of all-cause death after 5 years of follow-up was 38.2% (N=61). The cause of death was predominantly malignancy-related (N=29, 47.4% of deaths) and only 9 patients (14.8% of deaths) died of a cardiovascular cause.

After correcting for age and sex – a recent cancer diagnosis (&lt;1yr relative to &gt;10 yr, HR 3.405 [95% CI: 1.552–7.470], p=0.002), distant metastasis at presentation (HR 2.603 [1.236–5.481], p=0.012), ongoing cancer treatment at presentation (HR 1.878 [1.015–3.475], p=0.045) and natural logarithm of maximum creatinine kinase level (HR 1.345 [1.044–1.733], p=0.022) were significant predictors of long-term mortality.

While prevalent renal insufficiency showed significant association with all-cause mortality (HR 2.302 [1.289–4.111], p=0.005), other known determinants of long-term prognosis after STEMI – a history of diabetes mellitus (HR 1.250 [0.566–2.761], p=0.581), hypertension (HR 0.623 [0.393–1.085], p=0.150), and culprit vessel left anterior descending artery or left main artery (HR 1.066 [0.641–1.771], p=0.806) were not significantly associated with survival at 5-years follow-up.

Conclusion

Cancer patients admitted with STEMI have a poor survival with one third of patients died at 5 year follow up. Cancer was the most common cause of death and malignancy-related factors made a significant impact on prognosis, while most of the established cardiovascular determinants of prognosis were not significantly associated with long-term survival.

Funding Acknowledgement

Type of funding sources: None. Cumulative incidence curve

Results from HART-c: innovations in prehospital triage for acute cardiac symptoms, a multicentre prospective study

Introduction

Cardiac symptoms are one of the most prevalent reasons for emergency department (ED) visits [1], however most of these patients do not have acute cardiovascular disease. This leads to ED overcrowding which subsequently leads to worse patient outcomes and increased costs [2,3]. Attempts to reduce overcrowding have focused mostly on in-hospital triage. The Hollands-midden Acute Regional Triage – cardiology (HART-c) study uses a newly developed triage platform which includes live monitoring, real-time admission capacity, in-hospital data and cardiologist consultation for improved prehospital triage.

Purpose

The HART-c study aims to safely increase the percentage of patients with cardiac symptoms not referred to the hospital after emergency medical service (EMS) consultation.

Methods

Patients aged 18 years or older visited by the EMS for cardiac symptoms were included in the region Hollands-Midden from September 2019 till March 2020 (non-COVID period) and compared with the year earlier. Patients were excluded when primary PCI was indicated. EMS consultation consisted of medical history, physical examination, vital parameters and ECG. All data were transferred to a newly developed platform combining pre-hospital data, shown in real-time, and hospital data, such as medical records and admission capacity. The paramedic contacted an on-call triage cardiologist and decided whether admission was necessary and, if so, which regional hospital was most appropriate (figure 1). The study objective was defined as the percentage of patients not referred to the hospital after EMS consultation. Safety of the triage method was defined in the non-referred patients in the intervention as the percentage of MACE (death and acute coronary syndrome) 30 days after non-referral.

Results

In the intervention group 1755 patients (age 69±15 years, 53% men), and in the control group 1629 patients (age 68±15 years, 53% men) were consulted by the EMS during the HART-c study. In the intervention group 11.4% of patients consulted to the EMS were left at home, compared to 5.5% in the control group (figure 2). Logistic regression was performed to evaluate the effect of the triage intervention. The model was corrected for gender, age and seasonal changes. The chance of being left at home after EMS consultation was 2.29 (95% CI 1.73–3.02, p&lt;0.001) times higher in the intervention group compared to the control. All patients left at home in the intervention group and their GP's were contacted for adverse events, after case-by-case review the MACE rate was &lt;1%. Furthermore a decrease in interhospital transfers was seen, from 206 in the intervention to 173 in the control.

Conclusion

Implementation of an innovative triage method successfully increased the percentage of patients with cardiac symptoms safely left at home.

Funding Acknowledgement

Type of funding sources: None. Triage without (A) and with (B) platformNon-referral in intervention and control

Modelling of atrial fibrillation at physiologically relevant scales enabled by massive expansion of native human atrial cardiomyocytes

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): LUMC

Background

Current in vitro models of atrial fibrillation have limited translational potential due to a lack of relevant human physiology or the inability to reach the high activation frequencies present in human atrial fibrillation. Absence of relevant models is the result of a general deficit of readily available and standardized sources of well-differentiated human atrial cardiomyocytes. Therefore, we aimed to immortalize native human atrial cardiomyocytes to produce natural and standardized lines of these cells.

Methods

Human fetal atrial cardiomyocytes were transduced with a lentiviral vector directing myocyte-specific and doxycycline-inducible expression of simian virus 40 large T antigen. Addition of doxycycline to the culture medium pushed cardiomyocytes towards a highly proliferative phenotype (proliferation up to 10^12 cells). These cells were labelled hiAMs (human immortalised Atrial Myocytes). After differentiation upon doxycycline removal, hiAM cells were characterized using various molecular, biological and electrophysiological assays.

Results

Following cardiomyogenic differentiation, hiAMs no longer expressed the proliferation marker Ki67, revealed striated α-actinin and troponin T staining patterns and displayed synchronous contractions. Optical voltage mapping of hiAM monolayers revealed excitable cells showing homogeneous spreading of action potentials at 22.5 ± 3.1 cm/s with a mean APD80 of 139 ± 22 ms. Addition of flecainide (10 µM) to hiAM monolayers decreased the conduction velocity by 35% and increased the APD80 by 107%. Dofetilide (10 nM) addition had no effect on the conduction velocity, but did increase the APD80 by 81%. Due to their scalability, monolayers of hiAMs as big as 10 cm2 showing homogenous action potential propagation could easily be created. Following high-frequency electrical pacing, rotors could be induced with an average activation frequency of 7.5 ± 0.9 Hz. Infusion of flecainide during arrhythmic activity resulted in termination of the rotor in 18 of 24 attempts (75%), whereas addition of 0.1% DMSO (vehicle control) did not result in termination in any of the attempts. Dofetilide infusion did not result in termination. However, it did lower the average activation frequency to 2.1 ± 0.7 Hz.

Conclusion

We have generated first-of-a-kind lines of human atrial cardiomyocytes, allowing massive cell expansion under proliferation conditions and robust formation of cross-striated, contractile and excitable cardiomyocytes after differentiation. These characteristics allow, for the first time, the modelling, at a large-scale, of human atrial arrhythmias with frequencies similar to human atrial fibrillation. With the generation of hiAMs, a user-friendly, clinically-relevant and much-anticipated human atrial research model has been produced. Abstract Figure. hiAM AF Model

Emergency medical services evaluations for chest pain during first COVID-19 lockdown in Hollands-Midden, the Netherlands

Objective

To assess whether the COVID-19 lockdown in 2020 had negative indirect health effects, as people seem to have been reluctant to seek medical care.

Methods

All emergency medical services (EMS) transports for chest pain or out-of-hospital cardiac arrest (OHCA) in the Dutch region Hollands-Midden (population served > 800,000) were evaluated during the initial 6 weeks of the COVID-19 lockdown and during the same time period in 2019. The primary endpoint was the number of evaluated chest pain patients in both cohorts. In addition, the number of EMS evaluations of ST-elevation myocardial infarction (STEMI) and OHCA were assessed.

Results

During the COVID-19 lockdown period, the EMS evaluated 927 chest pain patients (49% male, age 62 ± 17 years) compared with 1041 patients (51% male, 63 ± 17 years) in the same period in 2019, which corresponded with a significant relative risk (RR) reduction of 0.88 (95% confidence interval (CI) 0.81–0.96). Similarly, there was a significant reduction in the number of STEMI patients (RR 0.52, 95% CI 0.32–0.85), the incidence of OHCA remained unchanged (RR 1.23, 95% CI 0.83–1.83).

Conclusion

During the first COVID-19 lockdown, there was a significant reduction in the number of patients with chest pain or STEMI evaluated by the EMS, while the incidence of OHCA remained similar. Although the reason for the decrease in chest pain and STEMI consultations is not entirely clear, more attention should be paid to the importance of contacting the EMS in case of suspected cardiac symptoms in possible future lockdowns.

Supplementary Information

The online version of this article (10.1007/s12471-021-01545-y) contains supplementary material, which is available to authorized users.

Utilization of diagnostic resources and costs in patients with suspected cardiac chest pain

AIMS

Non-acute chest pain is a common complaint and can be caused by various conditions. With the rising healthcare expenditures of today, it is necessary to use our healthcare resources effectively. This study aims to give insight into the diagnostic effort and costs for patients with non-acute chest pain.

METHODS AND RESULTS

Financial data of patients without a cardiac history from 4 hospitals (January 2012-October 2018), who were registered with the national diagnostic code 'No cardiac pathology' (ICD-10 Z13.6), 'Chest wall syndrome' (ICD-10 R07.4) or 'stable angina pectoris' (ICD-10 I20.9) were extracted. In total, 74.091 patients were included for analysis and divided into the following final diagnosis groups: No cardiac pathology: N = 19.688 (age 53±18), 46% male), Chest wall syndrome: N = 40.858 (age 56±15), 45% male), and stable angina pectoris: N = 13.545 (age 67±11), 61% male). A total of approximately €142,7 million was spent during diagnostic work-up. The total expenditure during diagnostic effort was €1.97, €8.13, and €10.7 million respectively for no cardiac pathology, chest wall syndrome, and stable AP per year. After 8 years follow up ≥ 95% of the patients diagnosed with no cardiac pathology or chest wall syndrome had an (cardiac) ischemic free survival.

CONCLUSION

The diagnostic expenditure and clinical effort to ascertain non-cardiac chest pain is high. We should define what we as society find acceptable as 'assurance costs' with an increasing pressure on the healthcare system and costs.

Effect of Smartphone-Enabled Health Monitoring Devices vs Regular Follow-up on Blood Pressure Control Among Patients After Myocardial Infarction: A Randomized Clinical Trial

IMPORTANCE

Smart technology via smartphone-compatible devices might improve blood pressure (BP) regulation in patients after myocardial infarction.

OBJECTIVES

To investigate whether smart technology in clinical practice can improve BP regulation and to evaluate the feasibility of such an intervention.

DESIGN, SETTING, AND PARTICIPANTS

This study was an investigator-initiated, single-center, nonblinded, feasibility, randomized clinical trial conducted at the Department of Cardiology of the Leiden University Medical Center between May 2016 and December 2018. Two hundred patients, who were admitted with either ST-segment elevation myocardial infarction or non-ST-segment acute coronary syndrome, were randomized in a 1:1 fashion between follow-up groups using smart technology and regular care. Statistical analysis was performed from January 2019 to March 2019.

INTERVENTIONS

For patients randomized to regular care, 4 physical outpatient clinic visits were scheduled in the year following the initial event. In the intervention group, patients were given 4 smartphone-compatible devices (weight scale, BP monitor, rhythm monitor, and step counter). In addition, 2 in-person outpatient clinic visits were replaced by electronic visits.

MAIN OUTCOMES AND MEASURES

The primary outcome was BP control. Secondary outcomes, as a parameter of feasibility, included patient satisfaction (general questionnaire and smart technology-specific questionnaire), measurement adherence, all-cause mortality, and hospitalizations for nonfatal adverse cardiac events.

RESULTS

In total, 200 patients (median age, 59.7 years [interquartile range, 52.9-65.6 years]; 156 men [78%]) were included, of whom 100 were randomized to the intervention group and 100 to the control group. After 1 year, 79% of patients in the intervention group had controlled BP vs 76% of patients in the control group (P = .64). General satisfaction with care was the same between groups (mean [SD] scores, 82.6 [14.1] vs 82.0 [15.1]; P = .88). The all-cause mortality rate was 2% in both groups (P > .99). A total of 20 hospitalizations for nonfatal adverse cardiac events occurred (8 in the intervention group and 12 in the control group). Of all patients, 32% sent in measurements each week, with 63% sending data for more than 80% of the weeks they participated in the trial. In the intervention group only, 90.3% of patients were satisfied with the smart technology intervention.

CONCLUSIONS AND RELEVANCE

These findings suggest that smart technology yields similar percentages of patients with regulated BP compared with the standard of care. Such an intervention is feasible in clinical practice and is accepted by patients. More research is mandatory to improve patient selection of such an intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02976376.

P5392Epicardium derived cells promote sympathetic ganglionic outgrowth towards myocardium in vitro

Background

The autonomic nerve system is essential to maintain homeostasis in the body. In the heart, autonomic innervation is important for adjusting the physiology to the continuously changing demands such as stress responses. After cardiac damage, excessive neurite outgrowth, referred to as autonomic hyperinnervation, can occur which is related to ventricular arrhythmias and sudden cardiac death. The cellular basis for this hyperinnervation is as yet unresolved. Here we hypothesize a role for epicardium derived cells (EPDCs) in stimulating sympathetic neurite outgrowth.

Purpose

To investigate the potential role of adult EPDCs in promoting sympathetic ganglionic outgrowth towards adult myocardium.

Method

Fetal murine superior cervical ganglia were dissected and co-cultured with activated adult mesenchymal epicardium-derived cells (EPDCs) or/and adult myocardium in a 3D collagen gel culture system. Four experiment groups were included: Group 1: Vehicle cultures (ganglia cultured without EPDC/myocardium) (n=48); Group 2: ganglia co-cultured with EPDCs (n=38); Group 3: ganglia co-cultured with myocardium (n=95); and group 4: ganglia co-cultured with both EPDCs and myocardium (n=96). The occurrence of neurite outgrowth was assessed in each group. The density of neurites that showed directional sprouting (i.e. sprouting towards myocardium) was assessed as well with a semi-automatic quantification method. Finally, sub-analyses were made by taking gender into account.

Results

Cervical ganglia cultured with EPDCs alone (group 2) showed increased neurite outgrowth compared to vehicle cultures (group 1), however the neurites did not show directional sprouting towards EPDCs. When co-cultured with myocardium (group 3), directional neurite outgrowth towards myocardium was observed. Compared to the ganglia-myocardium co-cultures, directional outgrowth was significantly increased in co-cultures combining myocardium and EPDCs (group 4), and the neurite density was also significantly augmented. Comparison between males and female ganglia demonstrated that more neurite outgrowth occurred in female-derived ganglia than in male-derived ganglia under the same co-culture conditions.

Conclusion

Activated adult EPDCs promote sympathetic ganglionic outgrowth in vitro. Sex differences exist in the response of ganglia to EPDCs, and female-derived ganglia appear more sensitive to EPDC-signalling. Results support a role of EPDCs in cardiac autonomic innervation and open avenues for exploring of their role in ventricular hyperinnervation after cardiac damage.

P5606Incidence and clinical impact of type A aortic dissection detected during invasive coronary procedures. Results from an international, multicentre, all-comer registry

Background

Type A aortic dissection (AD) is an extremely severe condition with high mortality. Its clinical presentation may mimic other conditions such as myocardial ischemia. Furthermore, coronary hypoperfusion may occur. This may result in misdiagnosis and subsequent referral to the cath-lab, implying potential catastrophic consequences.

Purpose

To determine the incidence and clinical impact of type A AD detected at the cath-lab in all-comers referred for invasive coronary procedures (both diagnostic and therapeutic).

Methods and results

Data was obtained from three high-volume centers from different countries. 41.186 procedures performed in all-comers between 2011–2018 were analyzed, of which 20.067 (49%) were PCIs. Iatrogenic AD resulting from the procedure were excluded. In 17 patients (0.002%; age 75±11 years, 72% male) a type A AD was detected during the procedure. The diagnosis was established by aortic angiography in 15 (88%); in 2 (12%) the diagnosis was suspected based on difficult coronary cannulation or the presence of a fluoroscopically-visible fluttering flap, requiring confirmation with aortic imaging tests. The procedure was performed in a emergent fashion in 14 patients (89%): due to suspected acute coronary syndrome in 11 (65%) (8 [72%] STEMI and 3 [18%] NSTEMI) and because of out of hospital cardiac arrest in 4 (24%). Loading dose of antiplatelets (aspirin 76%, P2Y12 inhibitors 100%) and heparin (100%) were administered in the majority of patients. Either the left main or right coronary artery ostia were involved in 8 patients (47%), although in a significant number of cases coronary anatomy was not fully evaluated due to problematic cannulation of the coronary arteries (left main 18%, right coronary artery 30%). Previous history of aortic root dilatation was present in 5 cases (30%). None of the patients had previous history of connective tissue disorders or bicuspid aortic valve. CT scan was feasible in 9 cases (59%). A DeBakey type I AD was observed in 8 patients (47%) and a DeBakey type II in 9 cases (53%). Overall in-hospital mortality rate was 59% (10 patients). 3 patients (30%) died during the procedure. 10 (59%) underwent surgical treatment (4 of them with concomitant aortic valve replacement). Perioperative mortality rate was 30% (1 due to hemorrhagic stroke, 1 due to massive bleeding during surgery; 1 due to cardiac tamponade). All patients who were not candidates for surgery (7 cases, 41%) died during admission. Patients successfully discharged presented a median survival of 17 months (4–78).

Conclusions

The detection of a type A AD during invasive coronary procedures is rare and is predominantly observed in patients referred for urgent interventions. The overall in-hospital mortality is very high (59%) and therefore prompt identification by the operator is mandatory. Surgery, when feasible, is the treatment of choice, although perioperative mortality rate is high, mostly due to bleeding complications.

Acknowledgement/Funding

None

P5725Identification of novel cardiomyogenic factors by transcriptome analysis of conditionally immortalized atrial myocytes

Background

Cardiac development involves the properly timed expression of cardiomyogenic differentiation factors (CDFs). CDFs have mainly been discovered using animal models and, more recently, pluripotent stem cell-derived cardiomyocytes (PSC-CMCs). These models are, however, laborious, time-consuming and costly. Also, cardiomyogenic differentiation of CMCs is heterogeneous and yields phenotypically immature CMCs. Recently, our research group generated a monoclonal line of conditionally immortalized atrial myocytes, called iAM-1. After removal of the proliferation stimulus these cells spontaneously and synchronously differentiate into mature atrial myocytes, making them ideally suited for transcriptome analysis and the discovery of novels factors involved in cardiomyogenic differentiation.

Methods

Whole transcriptome analysis of iAM-1 cells was performed at 9 different time points during cardiomyogenic differentiation and subsequent dedifferentiation by RNA sequencing. Six genes upregulated during cardiomyogenic differentiation were selected for knockdown studies in differentiating iAM-1 cells. Each of these genes was targeted by a bicistronic lentiviral vector (LV) driving expression of a specific short hairpin RNA (shRNA) and of enhanced green fluorescent protein (eGFP). Knockdown effects during cardiomyogenic differentiation were studied by immunocytology. The LVs were also used in primary neonatal atrial and ventricular rat cardiomyocytes to study the role of the selected genes in cardiomyocyte homeostasis.

Results

Whole transcriptome analysis of differentiating iAM-1 cells identified the dynamic expression levels of ± 13.000 genes, including the expected profile for genes known to play a role in atrial myocyte differentiation, like Nkx2–5, Tbx3, Tbx5 and Nppa. Six genes with an unknown role in cardiomyocyte differentiation and homeostasis were selected based on significant upregulation during iAM-1 differentiation, substantial mRNA levels and selective expression in cardiac tissue. Inhibiting gene expression by lentiviral RNA interference resulted for Nkx2–5 as well as for 3 out of 6 target genes in disturbed iAM-1 differentiation, as evinced by loss of sarcomeric cross-striations. Similar effects were observed in shRNA-expressing (i.e. eGFP-positive) primary atrial and ventricular neonatal rat myocytes. Taken together, these results highlight the importance of these novel genes during cardiomyogenic differentiation and homeostasis in atrial as well as ventricular myocytes.

Conclusions

Transcriptome analysis of cardiomyogenic differentiation in conditionally immortalized atrial myocytes combined with genetic knockdown experiments led to the identification of several novel factors involved in the differentiation and homeostasis of atrial and ventricular myocytes. These results highlight the suitability of iAM-1 as model for fundamental research of cardiomyogenic differentiation.

Acknowledgement/Funding

ZonMW

2160Continuous shock-free termination of atrial fibrillation by local optogenetic therapy and arrhythmia-triggered activation of an implanted light source

Background

Maintenance of sinus rhythm is the primary therapeutic goal for symptomatic atrial fibrillation (AF) patients but remains difficult to achieve because of suboptimal treatment options. While being effective in detecting and terminating AF, the widespread use of implantable atrial defibrillators is limited due to patients intolerance to repeated shocks. The negative adverse effects of electroshock therapy can hypothetically be overcome by allowing the heart itself to produce the electric current required for arrhythmia termination. As a result, the effector function of an electrical defibrillator would be provided by the heart itself, and therefore no longer rely on electronics, but on bioelectricity instead.

Purpose

To develop a hybrid bio-electronic system for automated and acute shock-free AF treatment.

Methods

To equip the heart with the effector function of the envisioned AF termination system, adeno-associated virus (AAV) vectors encoding red-activatable channelrhodopsin (ReaChR) (n=12) or citrine (n=4) were delivered locally to the right atrium (RA) of adult Wistar rats by gene painting. Four to 8 weeks later, AF was induced in vivo by atrial burst pacing after carbachol administration, followed by programmed local illumination of the RA by an implanted intrathoracic LED device whose activation was automatically regulated by an electrocardiogram (ECG)-based cardiac rhythm monitor.

Results

Gene painting of the RA resulted in transmural transduction of right atrial myocytes (78±6%) with minimum transgene expression of the left atrium and ventricles (6±2% and <0.5%, respectively). Electrophysiological assessments revealed no significant differences in ECG characteristics, atrial action potential duration and conduction velocity when compared to baseline or citrine control animals. Feasibility of optical AF termination was first assessed in an open-chest rat model, showing that a single 470-nm light pulse (3.5 mW/mm2, 1000 ms) efficiently terminated AF in all ReaChR-expressing rats with an average termination efficacy of 94±3% (n=12) vs. 3±3% (n=4) in citrine-expressing control animals (p<0.01). AF termination efficacy remained superb following automated detection and termination of AF by ECG-triggered activation of the implanted intra-thoracic LED in closed-chest ReaChR-expressing rats (96±4%), n=4), whereas none of the AF episodes were terminated in control rats (0%, n=4) (p<0.01). No bradycardias or other arrhythmias were observed following optical AF termination.

Conclusions

By using a hybrid bio-electronic approach to modulate cardiac excitability, our study delivers proof that AF can be detected and terminated automatically in a safe, effective and repetitive, yet shock-free manner. These findings may create the basis for the development of pain-free device therapy for cardiac arrhythmias, thereby paving the way for ambulatory AF treatment with the perspective to improve patients' prognosis and quality of life.

Acknowledgement/Funding

NWO Vidi grant (1714336) and ERC Starting Grant (716509) both to D.A.P.

P1229Massive expansion of native human atrial cardiomyocytes through immortogenetics: generation of the hiAM cell lines

Background

Preclinical cardiac research greatly depends on animal-derived cellular models, thereby hampering clinical translation. While upcoming human pluripotent stem cell technology seems to decrease this gap between bench and bedside, its complex/multi-step protocol to produce cardiac muscle cells, its required expertise, and its trouble to produce large numbers of phenotypically homogeneous cardiomyocytes so far has limited broad application.

Purpose

We aimed to conditionally immortalize native human atrial cardiomyocytes to produce natural and standardized lines of these cells by gaining full control over their proliferation and differentiation.

Methods

Human fetal atria (gestational age 18 weeks) were dissociated and transduced with a lentiviral vector directing myocyte-specific and doxycycline-inducible expression of simian virus 40 large T antigen (here defined as immortogenetics). Addition of doxycycline to the culture medium pushed cardiomyocytes towards a proliferative phenotype. In total, 125 proliferating monoclones were isolated, expanded and screened for their cardiomyogenic differentiation capacity upon doxycycline removal. Selected clones were characterised using various molecular biological and electrophysiological assays.

Results

Upon doxycycline removal (i.e. under differentiation conditions), cells spontaneously reacquired a cardiomyocyte-like appearance as judged by phase-contrast microscopy and were observed contracting. Simultaneously, these cells stopped proliferating, which was accompanied by a drop in large T level, loss of Ki67 expression and the development of sarcomeres with striated α-actinin and troponin T staining patterns. These cells were tagged conditionally immortalized human atrial cardiomyocytes (hereinafter called hiAMs). Optical voltage mapping of hiAM monolayers revealed excitable cells showing homogeneous spreading of action potentials at 22,5±3,1 cm/s following 1-Hz point stimulation, with a mean APD80 of 139±22 ms. Monolayers of hiAMs could easily be created as big as 10cm2 while continuing to display homogenous conduction throughout the culture. Single-cell patch clamp recordings of a hiAM clone in current-clamp mode confirmed excitability with a resting membrane potential of −62,2±4,3 mV, peak potential of 39,4±3,9 mV and APD80 of 339±9 ms.

Excitable monolayer of hiAMs

Conclusion

We have generated first-of-a-kind lines of natural human atrial cardiomyocytes through immortogenetics, allowing massive cell expansion under proliferation conditions and robust formation of cross-striated, contractile and excitable cardiomyocytes after differentiation. Thereby, a user-friendly, clinically-relevant and much-anticipated research model has been produced, which application could range from multi-scale electrophysiological studies and drug response studies to disease modelling and myocardial regeneration.

2402Reduced heart rate variability is linked to clinical status in patients with a systemic right ventricle

Background

Adult patients with congenital heart disease and a systemic right ventricle (sRV) are prone to develop heart failure. Decreased heart rate variability (HRV), a measure of autonomic dysfunction, is associated with morbidity and mortality in patients with congestive heart failure. The standard deviation of all intervals between normal sinus beats (SDNN) is a HRV parameter commonly reported as an indicator of autonomic function in these patients. Data about HRV and its clinical implications in patients with a sRV are scarce.

Purpose

To compare HRV parameters between patients with a sRV and healthy controls, and to assess their association with clinical status.

Methods

All available 24-hour Holter monitoring records of sRV patients under follow-up in our center and one record per healthy control subject were analysed. Holters with non-sinus rhythm were excluded. Time and frequency domain parameters were calculated and compared between both groups. Clinical landmarks such as arrhythmias or an episode of congestive heart failure, which occurred up until the time of the ambulatory ECG, were combined in a clinical event score. Determinants of SDNN were investigated with mixed model linear regression in the patients and with multivariate linear regression in the controls. Baseline characteristics, medication use, global longitudinal strain, validity as measured with bicycle exercise testing, and the clinical event score were taken into account.

Results

113 Holters of 43 patients and 39 Holters of healthy controls were analysed. The patient group included 30 patients (70%) late after Mustard or Senning correction for transposition of the great arteries, and 13 patients with congenitally corrected transposition of the great arteries (30%). Age and gender were comparable in patients and controls. Several HRV parameters were significantly worse in patients compared with controls, including SDNN (138 in patients vs. 161 in controls, p=0.021). In the patients, clinical event score was the only significant determinant of a lower SDNN (p<0.001). In the controls, age was the only significant determinant of a lower SDNN (p=0.039).

Conclusion

Contrary to the healthy population, in patients with a sRV, HRV is associated with clinical status rather than age. This indicates that disease progression affects autonomic function more than ageing in this group. Further research is needed to clarify the relation between clinical outcome and autonomic function in sRV patients.

Acknowledgement/Funding

The Department of Cardiology of the LUMC received research grants from Medtronic, Biotronik, Boston Scientific and Edwards Lifesciences

P1797Prevalence of coronary anomalies in tetralogy of Fallot and its clinical implications, a meta-analysis

Background

In literature, anomalous coronary arteries from the opposite sinus of Valsalva or opposite coronary artery (ACAOS) are reported between 2% to 39% of patients with Tetralogy of Fallot (TOF). Knowledge of coronary anatomy prior to corrective surgery is vital to avoid damage to vessels crossing the right ventricular outflow tract (RVOT). The current range of reported prevalences is broad and a general overview comparing current knowledge on anomalous coronary arteries in TOF is lacking to date.

Purpose

In this meta-analysis, we aim to provide a detailed overview of current knowledge on prevalence of coronary anomalies in TOF and discuss the implications for patient management.

Methods

PubMed, Embase and Web of Science were searched for articles on TOF and coronary anomalies. Analysis was done using Revman 5.3 (Cochrane Community, London). The primary analysis focused on the origin and proximal course of the right and left coronary arteries. Also, the prevalences of large conus arteries and coronary arteriovenous fistulas were calculated.

Results

Twenty-nine studies, comprising 6977 patients all together, were included for primary meta-analysis of ACAOS. 6% of TOF patients have an ACAOS. Of these anomalous vessels, 72% crosses the RVOT. 6% of patients have a large conus artery and 4% a coronary arteriovenous fistula. Other incidentally reported coronary anomalies in TOF include a left or right coronary artery originating from the pulmonary artery, an accessory left anterior descending artery, hypoplasia of the entire coronary tree and anastomoses between coronary and bronchial arteries. CT-angiography is the imaging modality of preference because of its high spatial resolution. Transthoracic echocardiography can be used in younger children as well for discerning the coronary anatomy. Most surgical approaches can be adapted to an anomalous coronary artery coursing over the RVOT.

Overall prevalence of ACAOS in TOF

Conclusions

Coronary anomalies have a high prevalence in TOF. An ACAOS occurs in 6%, large conus arteries exist in 6% and coronary arteriovenous fistulas in 4% of cases. A substantial part crosses the RVOT. This has to be taken into account during surgery.

Ventricular assist device implantation in patients with a failing systemic right ventricle: a call to expand current practice

Ventricular assist device (VAD) implantation is an established treatment modality for patients with end-stage heart failure, and improves symptoms and survival. In the Netherlands, it is not yet routinely considered in patients with congenital heart disease and failing systemic right ventricle (SRV). Recently, a VAD was implanted in 2 SRV patients, one who underwent a Mustard procedure during infancy for transposition of the great arteries (male, 47 years old) and one with a congenitally corrected transposition of the great arteries (male, 54 years old). The first patient is doing well >1 year after implantation; the second patient will be discharged home soon. These examples and other reports demonstrate the feasibility of adopting VAD implantation into routine care for SRV failure. In conclusion, patients with SRV failure may be suitable candidates for VAD implantation: they are relatively young, usually have a preserved subpulmonary left ventricular function, and their specific anatomical and physiological characteristics often make them unsuitable for cardiac transplantation. Therefore it is important to recognise the possibility of VAD implantation early in the process of SRV failure, and to timely refer these patients to a heart failure clinic with experience in VAD implantation in this group of patients for optimisation, screening, and implantation.

Mobile Health for Central Sleep Apnea Screening Among Patients With Stable Heart Failure: Single-Cohort, Open, Prospective Trial

Background

Polysomnography is the gold standard for detection of central sleep apnea in patients with stable heart failure. However, this procedure is costly, time consuming, and a burden to the patient and therefore unsuitable as a screening method. An electronic health (eHealth) app to measure overnight oximetry may be an acceptable screening alternative, as it can be automatically analyzed and is less burdensome to patients.

Objective

This study aimed to assess whether overnight pulse oximetry using a smartphone-compatible oximeter can be used to detect central sleep apnea in a population with stable heart failure.

Methods

A total of 26 patients with stable heart failure underwent one night of both a polygraph examination and overnight saturation using a smartphone-compatible oximeter. The primary endpoint was agreement between the oxygen desaturation index (ODI) above or below 15 on the smartphone-compatible oximeter and the diagnosis of the polygraph.

Results

The median age of patients was 66.4 (interquartile range, 62-71) years and 92% were men. The median body mass index was 27.1 (interquartile range, 24.4-30.8) kg/m². Two patients were excluded due to incomplete data, and two other patients were excluded because they could not use a smartphone. Seven patients had central sleep apnea, and 6 patients had obstructive sleep apnea. Of the 7 (of 22, 32%) patients with central sleep apnea that were included in the analysis, 3 (13%) had an ODI≥15. Of all patients without central sleep apnea, 8 (36%) had an ODI<15. The McNemar test yielded a P value of .55.

Conclusions

Oxygen desaturation measured by this smartphone-compatible oximeter is a weak predictor of central sleep apnea in patients with stable heart failure.

Frailty score for elderly patients is associated with short-term clinical outcomes in patients with ST-segment elevated myocardial infarction treated with primary percutaneous coronary intervention

Objective

Consistent with the aging population in the Western world, there is a growing number of elderly patients with ST-segment elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) is the recommended reperfusion strategy in elderly patients; risk models to determine which of these patients are prone to have poor clinical outcomes are, however, essential. The purpose of this study was to assess the association between frailty and short-term mortality and PCI-related serious adverse events (SAE) in elderly patients.

Methods

All STEMI patients (aged ≥70 years) treated with primary PCI in 2013–2015 at the Leiden University Medical Centre were assessed. The Safety Management Programme (VMS) score was used to identify frail elderly patients. The primary endpoint was 30-day all-cause mortality; the secondary endpoint included 30-day clinical death, target vessel failure, major bleeding, contrast induced kidney insufficiency and stroke.

Results

A total of 206 patients were included (79 ± 6.4 years, 119 [58%] male). The VMS score was ≥1 in 28% of all cases. Primary and secondary endpoint rates were 5 and 23% respectively. VMS score ≥1 was an independent predictor for both 30-day mortality (odds ratio [OR] 9.6 [95% confidence interval, CI 1.6–56.9] p-value = 0.013) and 30-day SAE (OR 2.9 [95% CI 1.1–7.9] p-value = 0.038).

Conclusions

VMS score for frailty is independently associated with short-term mortality and PCI-related SAE in elderly patients with STEMI treated with primary PCI. These results suggest that frailty in elderly patients is an important feature to measure and to be taken into account when developing risk models.

Electronic supplementary material

The online version of this article (10.1007/s12471-019-1240-7) contains supplementary material, which is available to authorized users.

Intramyocardial bone marrow cell injection does not lead to functional improvement in patients with chronic ischaemic heart failure without considerable ischaemia

Background

It has been suggested that bone marrow cell injection may have beneficial effects in patients with chronic ischaemic heart disease. However, previous trials have led to discrepant results of cell-based therapy in patients with chronic heart failure. The aim of this study was to evaluate the efficacy of intramyocardial injection of mononuclear bone marrow cells in patients with chronic ischaemic heart failure with limited stress-inducible myocardial ischaemia.

Methods and results

This multicentre, randomised, placebo-controlled trial included 39 patients with no-option chronic ischaemic heart failure with a follow-up of 12 months. A total of 19 patients were randomised to autologous intramyocardial bone marrow cell injection (cell group) and 20 patients received a placebo injection (placebo group). The primary endpoint was the group difference in change of left ventricular ejection fraction, as determined by single-photon emission tomography. On follow-up at 3 and 12 months, change of left ventricular ejection fraction in the cell group was comparable with change in the placebo group (P = 0.47 and P = 0.08, respectively). Also secondary endpoints, including left ventricle volumes, myocardial perfusion, functional and clinical parameters did not significantly change in the cell group as compared to placebo. Neither improvement was demonstrated in a subgroup of patients with stress-inducible ischaemia (P = 0.54 at 3‑month and P = 0.15 at 12-month follow-up).

Conclusion

Intramyocardial bone marrow cell injection does not improve cardiac function, nor functional and clinical parameters in patients with severe chronic ischaemic heart failure with limited stress-inducible ischaemia.

Clinical Trial Registration: NTR2516

Electronic supplementary material

The online version of this article (10.1007/s12471-018-1213-2) contains supplementary material, which is available to authorized users.

Expectations and perceived barriers to widespread implementation of e‑Health in cardiology practice: Results from a national survey in the Netherlands

INTRODUCTION

Expectations of physicians concerning e‑Health and perceived barriers to implementation in clinical practice are scarcely reported in the literature. The purpose of this study was to assess these aspects of cardiovascular e‑Health.

METHODS

A survey was sent to members of the Netherlands Society of Cardiology. In total, the questionnaire contained 30 questions about five topics: personal use of smartphones, digital communication between respondents and patients, current e‑Health implementation in clinical practice, expectations about e‑Health and perceived barriers for e‑Health implementation. Age, personal use of smartphones and professional environment were noted as baseline characteristics.

RESULTS

In total, 255 respondents filled out the questionnaire (response rate 25%); 89.4% of respondents indicated that they considered e‑Health to be clinically beneficial, improving patient satisfaction (90.2%), but also that it will increase the workload (83.9%). Age was a negative predictor and personal use of smartphones was a positive predictor of having high expectations. Lack of reimbursement was identified by 66.7% of respondents as a barrier to e‑Health implementation, as well as a lack of reliable devices (52.9%) and a lack of data integration with electronic medical records (EMRs) (69.4%).

CONCLUSION

Cardiologists are in general positive about the possibilities of e‑Health implementation in routine clinical care; however, they identify deficient data integration into the EMR, reimbursement issues and lack of reliable devices as major barriers. Age and personal use of smartphones are predictors of expectations of e‑Health, but the professional working environment is not.

Nationwide claims data validated for quality assessments in acute myocardial infarction in the Netherlands

INTRODUCTION

Since health insurance is compulsory in the Netherlands, the centrally registered medical claims data might pose a unique opportunity to evaluate quality of (cardiac) care on a national level without additional collection of data. However, validation of these claims data has not yet been assessed.

DESIGN

Retrospective cohort study.

METHODS

National claims data ('national registry') were compared with data collected by patient records reviews in four representative hospitals ('validation registry'). In both registries, we extracted the national diagnosis codes for ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction of 2012 and 2013. Additionally, data on medication use at one year after acute myocardial infarction (AMI) was extracted from the Dutch pharmacy information systems and also validated by local patient records reviews. The data were compared at three stages: 1) validation of diagnosis and treatment coding; 2) validation of the hospital where follow-up has taken place; 3) validation of follow-up medical treatment after 365 days.

RESULTS

In total, 3,980 patients ('national registry') and 4,014 patients ('validation registry') were compared at baseline. After one-year follow-up, 2,776 and 2,701 patients, respectively, were evaluated. Baseline characteristics, diagnosis and individual medication were comparable between the two registries. Of all 52,672 AMI patients in the Netherlands in 2012 and 2013, 81% used aspirin, 76% used P2Y12 inhibitors, 85% used statins, 82% used beta-blockers and 74% angiotensin converting enzyme inhibitors/angiotensin II antagonists. Optimal medical treatment was achieved in 49% of the patients with AMI.

CONCLUSION

Nationwide routinely collected claims data in patients with an acute myocardial infarction are highly accurate. This offers an opportunity for use in quality assessments of cardiac care.

Using Smart Technology to Improve Outcomes in Myocardial Infarction Patients: Rationale and Design of a Protocol for a Randomized Controlled Trial, The Box

Background

Recent evidence suggests that frequent monitoring using smartphone-compatible wearable technologies might improve clinical effectiveness and patient satisfaction of care.

Objective

The aim of this study is to investigate the clinical effectiveness and patient satisfaction of a smart technology intervention in patients admitted with a ST elevation myocardial infarction (STEMI) or non-ST acute coronary syndrome (NST-ACS).

Methods

In this single center, open, randomized controlled trial patients who suffered from STEMI or NST-ACS will be randomized 1:1 to an intervention group or control group. Both groups will be followed up to one year after the index event. The intervention group will take daily measurements with a smartphone-compatible electrocardiogram device, blood pressure (BP) monitor, weight scale, and activity tracker. Furthermore, two of four outpatient clinic visits will be replaced by electronic visits (1 and 6 months after index event). The control group will receive regular care, consisting of four outpatient clinic visits (1, 3, 6, and 12 months after index event). All patients will be asked to fill in validated questionnaires about patient satisfaction, quality of life, propensity of medication adherence, and physical activity.

Results

The primary outcome of this trial will be percentage of patients with controlled BP. Secondary outcomes include patient satisfaction, health care utilization, major adverse cardiac events, medication adherence, physical activity, quality of life, and percentage of patients in which a sustained arrhythmia is detected.

Conclusions

Smart technology could potentially improve care in postmyocardial infarction patients. This trial will investigate whether usage of smart technology can improve clinical- and cost-effectiveness of care.

Trial Registration

Clinicaltrials.gov NCT02976376; https://clinicaltrials.gov/ct2/show/NCT02976376 (Archived by WebCite at http://www.webcitation.org/6tcvAdbdH)

Abdominal aortic calcification on a plain X-ray and the relation with significant coronary artery disease in asymptomatic chronic dialysis patients

Background

Coronary artery disease (CAD) is common in asymptomatic chronic dialysis patients and plays an important role in their poor survival. Early identification of these high-risk patients could improve treatment and reduce mortality. Abdominal aortic calcification (AAC) has previously been associated with CAD in autopsy studies. Since the AAC can be quantified easily using a lateral lumbar X-ray we hypothesized that the extent of AAC as assessed on a lateral lumbar X-ray might be predictive of the presence of significant CAD in dialysis patients.

Methods

All patients currently enrolled in the ICD2 trial without a history of CABG or a PCI with stent implantation were included in this study. All patients underwent CT-angiography (CTA) and a lateral X-ray of the abdomen. AAC on X-ray was quantified using a previously validated scoring system whereupon the association between AAC and the presence of significant CAD was assessed.

Results

A total of 90 patients were included in this study (71% male, 67 ± 7 years old). Forty-six patients were found to have significant CAD. AAC-score was significantly higher in patients with CAD (10.1 ± 4.9 vs 6.3 ± 4.6 (p < 0.05). Multivariate regression analysis revealed that AAC score is an independent predictor for the presence of CAD with a 1,2 fold higher risk per point increase (p < 0.01). The AAC score has a sensitivity of 85% and a specificity of 57% for the presence of significant CAD.

Conclusion

This study shows that abdominal aortic calcification as assessed on a lateral lumbar X-ray is predictive for the presence of significant coronary artery disease in asymptomatic dialysis patients. This simple, non-invasive and cheap screening method could contribute to early identification of patients eligible for further screening of CAD.

Trial registration

NTR948, registered 10-4-2007 ; ISRCTN20479861, registered 2-5-2007

Very Long-Term Follow-Up After Coronary Rotational Atherectomy: A Single-Center Experience

We assessed the very long-term follow-up of a large cohort of unselected patients treated with coronary rotational atherectomy (RA). All 143 patients who underwent RA at our institution from 2000 to 2013 and with complete baseline and follow-up information were analyzed in a retrospective manner. Major adverse cardiac events (MACE) were defined as the composite of target vessel revascularization (TVR), acute myocardial infarction, and all-cause mortality. The mean follow-up was 8.2 years. The 10-year cumulative incidence of MACE for all patients was 57.9% (standard error [SE]: 5.0%). When comparing patients who received a drug-eluting stent (DES; n = 68) versus patients who did not (balloon only, bare-metal stent, or none of the aforementioned; n = 75), the RA + DES demonstrated very long-term MACE of 49.2% (SE: 7.5%) versus 62.7% (SE: 6.1%), P = .160 with TVR as the most discriminating factor, 10.7% (SE: 4.0%) versus 29.2% (SE: 6.0%), P = .016. Our results point to RA having reasonable long-term clinical results, especially in combined treatment with DES. To date, our study has the longest follow-up after RA.

Tailored circulatory intervention in adults with pulmonary hypertension due to congenital heart disease

BACKGROUND

Adults with pulmonary hypertension associated with congenital heart disease (PH-CHD) often have residual shunts. Invasive interventions aim to optimise pulmonary flow and prevent right ventricular failure. However, eligibility for procedures strongly depends on the adaptation potential of the pulmonary vasculature and right ventricle to resultant circulatory changes. Current guidelines are not sufficiently applicable to individual patients, who exhibit great diversity and complexity in cardiac anomalies.

METHODS AND RESULTS

We present four complex adult PH-CHD patients with impaired pulmonary flow, including detailed graphics of the cardiopulmonary circulation. All these patients had an ambiguous indication for shunt intervention. Our local multidisciplinary Grown-Ups with Congenital Heart Disease team reached consensus regarding a patient-tailored invasive treatment strategy, adjacent to relevant guidelines. Interventions improved pulmonary haemodynamics and short-term clinical functioning in all cases.

CONCLUSIONS

Individual evaluation of disease characteristics is mandatory for tailored interventional treatment in PH-CHD patients, adjacent to relevant guidelines. Both strict registration of cases and multidisciplinary and multicentre collaboration are essential in the quest for optimal therapy in this patient population.

Outcome of stand-alone thoracoscopic epicardial left atrial posterior box isolation with bipolar radiofrequency energy for longstanding persistent atrial fibrillation

Introduction

Catheter ablation of longstanding (> 1 year) persistent atrial fibrillation (AF) is associated with poor outcome. This might be due to remodelling and fibrosis formation, mainly located in the posterior left atrial (LA) wall. Therefore, we adopted a thoracoscopic epicardial box isolation of the posterior left atrium using bipolar RF energy with intraoperative testing of conduction block.

Methods and results

Bilateral thoracoscopic box isolation was performed with a bipolar RF clamp. Entrance block was defined as absence of a conducted electrogram within the box, while exit block was confirmed by pacing at 10.0 V/2 ms. Ablation outcome was evaluated after 3, 6, 12 and 24 months with 12-lead ECGs and 24-hour Holter recordings.

Twenty-five consecutive patients were included (58 ± 7 years, persistent AF duration 1.8 ± 0.9 years). Entrance block was achieved in all patients and exit block confirmed if sinus rhythm was achieved. After 17 ± 7 months, 76 % of the patients (n = 19) were free of AF recurrence. One patient died within 1 month and was considered an ablation failure. Four patients with AF recurrences regained sinus rhythm with additional catheter ablation or antiarrhythmic drugs.

Conclusions

Treatment of longstanding persistent AF with thoracoscopic epicardial LA posterior box isolation using bipolar RF energy with intraoperative testing of conduction block is feasible and highly effective.

The extent of the raphe in bicuspid aortic valves is associated with aortic regurgitation and aortic root dilatation

Background

The clinical course of bicuspid aortic valves (BAVs) is variable. Data on predictors of aortopathy and valvular dysfunction mainly focus on valve morphology.

Aim

To determine whether the presence and extent of the raphe (fusion site of valve leaflets) is associated with the degree of aortopathy and valvular dysfunction in patients with isolated BAV and associated aortic coarctation (CoA).

Methods

Valve morphology and aortic dimensions of 255 BAV patients were evaluated retrospectively by echocardiography.

Results

BAVs with a complete raphe had a significantly higher prevalence of valve dysfunction (especially aortic regurgitation) than BAVs with incomplete raphes (82.9 vs. 66.7 %, p = 0.01). Type 1A BAVs (fusion of right and left coronary leaflets) and complete raphe had larger aortic sinus diameters compared with the rest of the population (37.74 vs. 36.01, p = 0.031). Patients with CoA and type 1A BAV had significantly less valve regurgitation (13.6 vs. 55.8 %, p < 0.001) and smaller diameters of the ascending aorta (33.7 vs. 37.8 mm, p < 0.001) and aortic arch (25.8 vs. 30.2 mm, p < 0.001) than patients with isolated BAV.

Conclusions

Type 1A BAV with complete raphe is associated with more aortic regurgitation and root dilatation. The majority of CoA patients have incomplete raphes, associated with smaller aortic root diameters and less valve regurgitation.

Electrocardiographic detection of pulmonary hypertension in patients with systemic sclerosis using the ventricular gradient

BACKGROUND

Pulmonary hypertension (PH) is a leading cause of death in systemic sclerosis (SSc) patients. The current study assessed the ability of the ECG-derived ventricular gradient (VG-RVPO) to detect PH and predict all-cause mortality in PH patients with subtypes of SSc differing in the extent of multi-organ involvement.

METHODS

ECGs were obtained from 196 patients with limited and 77 patients with diffuse SSc included from our screening programme on cardiac complications. The association of the VG-RVPO with (1) the presence of PH, (2) conventional screening parameters and (3) survival in PH patients was assessed.

RESULTS

In limited SSc patients an elevated VG-RVPO corresponded with the presence of PH (-5±12 mV.ms vs -22±16 mV.ms, P<0.01), correlated significantly with conventional screening parameters and had a better diagnostic performance than the presence of a right heart axis (AUC 0.81 vs 0.60; P=0.04). These differences were not observed in patients with diffuse SSc. An elevated VG-RVPO was associated with decreased survival in all SSc patients with PH (3 year survival 30% vs 64%, P=0.02).

CONCLUSION

An elevated VG-RVPO is associated with PH in limited SSc patients and with decreased survival in all SSc patients with PH.

High survival rate of 43% in out-of-hospital cardiac arrest patients in an optimised chain of survival

AIMS

Survival to hospital discharge after out-of-hospital cardiac arrest (OHCA) varies widely. This study describes short-term survival after OHCA in a region with an extensive care path and a follow-up of 1 year.

METHODS

Consecutive patients ≥16 years admitted to the emergency department between April 2011 and December 2012 were included. In July 2014 a follow-up took place. Socio-demographic data, characteristics of the OHCA and interventions were described and associations with survival were determined.

RESULTS

Two hundred forty-two patients were included (73 % male, median age 65 years). In 76 % the cardiac arrest was of cardiac origin and 52 % had a shockable rhythm. In 74 % the cardiac arrest was witnessed, 76 % received bystander cardiopulmonary resuscitation and in 39 % an automatic external defibrillator (AED) was used. Of the 168 hospitalised patients, 144 underwent therapeutic procedures. A total of 105 patients survived until hospital discharge. Younger age, cardiac arrest in public area, witnessed cardiac arrest, cardiac origin with a shockable rhythm, the use of an AED, shorter time until return of spontaneous circulation, Glasgow Coma Scale (GCS) ≥13 during transport and longer length of hospital stay were associated with survival. Of the 105 survivors 72 survived for at least 1 year after cardiac arrest and 6 patients died.

CONCLUSION

A survival rate of 43 % after OHCA is achievable. Witnessed cardiac arrest, cardiac cause of arrest, initial cardiac rhythm and GCS ≥13 were associated with higher survival.

Role of the ECG in initial acute coronary syndrome triage: primary PCI regardless presence of ST elevation or of non-ST elevation

The major initial triaging decision in acute coronary syndrome (ACS) is whether or not percutaneous coronary intervention (PCI) is the primary treatment. Current guidelines recommend primary PCI in ST-elevation ACS (STEACS) and initial antithrombotic therapy in non-ST-elevation ACS (NSTEACS). This review probes the question whether this decision can indeed be based on the ECG. Genesis of STE/NSTE ECGs depends on the coronary anatomy, collateral circulation and site of the culprit lesion. Other causes than ischaemia may also result in ST-segment changes. It has been demonstrated that the area at risk cannot reliably be estimated by the magnitude of the ST change, that complete as well as incomplete occlusions can cause STE as well as NSTE ECGs, and that STE and NSTE patterns cannot differentiate between transmural and non-transmural ischaemia. Furthermore, unstable angina can occur with STE and NSTE ECGs. We conclude that the ECG can be used to assist in detecting ischaemia, but that electrocardiographic STE and NSTE patterns are not uniquely related to distinctly different pathophysiological mechanisms. Hence, in ACS, primary PCI might be considered regardless of the nature of the ST deviation, and it should be done with the shortest possible delay, because ‘time is muscle’.