Stereoselective protecting-group-free synthesis of alkyl glycosides using dibenzyloxy triazine type glycosyl donors

Chemical O-glycosylation is a key step for the synthesis of sugar-containing molecules such as glycolipids. However, traditional carbohydrate chemistry is characterized by extensive use of protective groups, resulting in laborious manipulations and poor atom economy. Here, we present a protecting-group-free glycosylation strategy employing dibenzyloxy-1,3,5-triazin-2-yl glycosides (DBT-glycosides) as glycosyl donors. The DBT-glycosyl donors could be prepared directly through an alkaline nucleophilic substitution from unprotected sugars in aqueous media. The O-glycosylation of alcohols by using DBT-glycosyl donors has been carried out under mild hydrogenolytic conditions, affording the corresponding alkyl glycosides stereo-selectively in good yields.

Meningoencephalomyelitis Caused by Brucella Canis: A Case Report and Literature Review

Human brucellosis, one of the most common zoonoses worldwide, is rare in Japan. Brucella canis is the specific pathogen of human brucellosis carried by dogs. According to an epidemiological study of B. canis infection in Japan, B. canis is the specific pathogen of human brucellosis in dogs. We herein report a rare case of meningoencephalomyelitis caused by B. canis in a 68-year-old Japanese man. Neurobrucellosis was diagnosed based on a serum tube agglutination test and abnormal cerebrospinal fluid findings. The patient was started on targeted treatment with a combination of doxycycline and streptomycin. Although extremely rare, neurobrucellosis should be considered in patients with a fever of unknown origin and unexplained neurological symptoms.

Pharmacokinetic/pharmacodynamic analysis of vancomycin in patients with Enterococcus faecium bacteraemia: a retrospective cohort study

OBJECTIVES

The trough concentration of vancomycin and the area under the concentration-time curve (AUC)/minimum inhibitory concentration (MIC) ratio are crucial in determining vancomycin efficacy against methicillin-resistant Staphylococcus aureus. However, the use of similar pharmacokinetic principles in determining antibiotic efficacy against other gram-positive cocci is lacking. We performed a pharmacokinetic/pharmacodynamic analysis (association of target trough concentration values and AUC/MIC with therapeutic outcome) of vancomycin in patients with Enterococcus faecium bacteraemia.

METHODS

Between January 2014 and December 2021 we performed a retrospective cohort study of patients with E. faecium bacteraemia treated with vancomycin. Patients who received renal replacement therapy or had chronic kidney disease were excluded. Clinical failure, the primary outcome, was defined as a composite of 30-day all-cause mortality, vancomycin-susceptible infection requiring change of treatment, and/or recurrence. AUC24 was estimated using a Bayesian estimation approach based on an individual vancomycin trough concentration. The MIC for vancomycin was determined using a standardised agar dilution method. Additionally, classification was used to identify the vancomycin AUC24/MIC ratio associated with clinical failure.

RESULTS

Of the 151 patients identified, 69 were enrolled. All MICs of vancomycin for E. faecium were ≤1.0 µg/mL. The AUC24 and AUC24/MIC ratio were not significantly different between the clinical failure group and the clinical success group (432±123 µg/mL/hour vs 488±92 µg/mL/hour; p=0.075). However, 7 of 12 patients (58.3%) in the clinical failure group and 49 of 57 patients (86.0%) in the clinical success group had a vancomycin AUC24/MIC ratio ≥389 (p=0.041). No significant association between trough concentration or AUC24 ≥600 µg/mL×hour and acute kidney injury was observed (p=0.365 and p=0.487, respectively).

CONCLUSION

The AUC24/MIC ratio is associated with the clinical outcome of vancomycin administration in E. faecium bacteraemia. In Japan, where vancomycin-resistant enterococcal infection is rare, empirical therapy with a target AUC24 ≥389 should be recommended.

Post-Stroke Pneumonia in Real-World Practice: Background, Microbiological Examination, and Treatment

Post-stroke pneumonia (PSP) has an impact on acute ischemic stroke (AIS). Although predictive scores for PSP have been developed, it is occasionally difficult to predict. Clarifying how PSP was treated after its onset in clinical practice is important. Admitted patients with AIS over a 2-year period were retrospectively reviewed. Of 281 patients with AIS, 24 (8.5%) developed PSP. The integer-based pneumonia risk score was higher in patients with PSP. The onset of PSP was frequently seen up to the 4th day of hospitalization. Of patients with PSP, sputum examination yielded Geckler 4 or 5 in only 8.3%. Angiotensin-converting enzyme inhibitor (ACE-I) was more frequently administered to patients with PSP; however, all these cases were started with ACE-I following PSP onset. Nasogastric tubes (NGTs) were inserted in 16 of the patients with PSP, of whom 11 were inserted following PSP onset. Multivariate analysis showed that PSP onset was a poor prognostic factor independent of the female sex, urinary tract infection, and National Institutes of Health Stroke Scale. PSP treatment would benefit from the administration of antimicrobials and ACE-I, as well as NGT insertion. To select effective agents for PSP and evaluate the indications for NGT insertion, further case studies are needed.

Use of the FilmArray® Meningitis/Encephalitis panel to detect pathogenic microorganisms in cerebrospinal fluid specimens: a single-center retrospective study

OBJECTIVE

Meningitis and encephalitis are neurological emergencies requiring rapid diagnosis and treatment. The performance of the FilmArray® Meningitis/Encephalitis (ME) panel, a multiplex polymerase chain reaction test, and conventional methods for diagnosing meningitis and encephalitis was compared.

METHODS

This retrospective study assessed 20 patients diagnosed with meningitis or encephalitis according to clinical symptoms and laboratory examination findings between January 2018 and December 2019. The results of the FilmArray® ME panel were compared with those of conventional methods.

RESULTS

Pathogens were identified in 11 (55%) patients using the FilmArray® ME panel and in nine (45%) patients using conventional methods. The test identified herpes simplex virus type 1 in two patients, herpes simplex virus type 2 in one, varicella-zoster virus in four, Streptococcus pneumoniae in three, and Cryptococcus neoformans in one. Furthermore, additional pathogens were detected (n = 1, S. pneumoniae and n = 1, varicella-zoster virus). The median times to pathogen identification were 2 hours using the FilmArray® ME panel and 96 hours with conventional methods.

CONCLUSIONS

The sensitivity of the FilmArray® ME panel for rapidly detecting the most common pathogens was similar to that of conventional methods. Hence, this method could decrease the time to definitive diagnosis and treatment initiation.

Sodium-glucose cotransporter 2 inhibitors not only suppress recurrence after atrial fibrillation ablation but also cause atrial reverse remodeling

Background

Sodium-glucose cotransporter 2 (SGLT2) inhibitors have shown fewer heart failure (HF) hospitalization and cardiovascular death in patients with type-2 diabetes mellitus (DM). Atrial fibrillation (AF) is associated with both HF and DM, and we reported SGLT2 suppressed AF recurrence after catheter ablation (CA) than dipeptidyl peptidase-4 (DPP4) inhibitor.

Purpose

We evaluated whether SGLT2 itself induces atrial reverse remodeling.

Methods

This is a sub-analysis of a prospective randomized controlled open-label clinical study for comparing the suppressive effect of SGLT2 inhibitor with DPP4 inhibitor on AF recurrence after CA. Eighty AF patients with type-2 DM were randomized to Tofogliflozin group or Anagliptin group with a computer-generated random sequence, which was stratified by left atrial diameter and AF type at screening. Primary outcome is AF recurrence at 12 months after CA, and secondary outcomes include the echocardiographic findings.

Results

70 patients (70.3±8.1 years, 58 male, 30 paroxysmal AF, 38 Tofogliflozin) were analyzed. Recurrent AF was detected in 24 patients (34.3%), and the AF recurrence ratio was higher in the Anagliptin group than the Tofogliflozin group. In 46 patients without AF recurrence (17 Anagliptin, 29 Tofogliflozin), LAVI has shrunk in 12 months compared to the baseline (42.8±11.9 to 36.6±11.2ml/m2) and the reduction of LAVI was larger in Tofogliflozin group than Anagliptin group (−8.6±2.0ml/m2 vs. −2.0±2.6ml/m2, P=0.0471).

Conclusion

Tofogliflozin not only suppressed AF recurrence after CA but also caused atrial reverse remodeling than Anagliptin in type-2 DM patients.

Funding Acknowledgement

Type of funding sources: None.

Locked-in Syndrome Due to Meningovascular Syphilis: A Case Report and Literature Review

We herein report a 46-year-old man presenting with locked-in syndrome secondary to meningovascular syphilis. Brain magnetic resonance imaging (MRI) demonstrated multiple acute infarctions in the left ventromedial pons, right basis pontis, and left basal ganglia. His locked-in syndrome was hypothesized to have been caused by thrombosis of the small paramedian branches of the basilar artery due to syphilitic arteritis. This is a unique case of bilateral ventromedial pontine infarction caused by meningovascular syphilis that presented as locked-in syndrome. Meningovascular syphilis should be included in the differential diagnosis of uncommon stroke, particularly in young men.

[Cryptococcal Meningitis with Inadequate Response to Antifungal Therapy or Drug-Induced Side Effects That Make It Difficult to Continue Treatment: Eleven Clinical Issues in Medical Practice]

Cryptococcal meningoencephalitis is mainly caused by Cryptococcus neoformans and accounts for 90% of fungal meningitis cases in Japan. Cryptococcal meningoencephalitis is a rare disease, and similar to tuberculosis meningitis. It often exhibits subacute or chronic progression symptoms such as headache, fever, coma, personality changes, and memory disturbance. Cryptococcal meningoencephalitis often develops in immunosuppressed hosts, but can sometimes occur in healthy individuals, and the mortality rate is 10-25%, indicating a poor prognosis. For the treatment of cryptococcal meningoencephalitis, introduction therapy using a combination of liposomal amphotericin B and flucytosine is recommended. However, in practice, cryptococcal meningoencephalitis is refractory and often requires prolonged treatment; therefore, it is the most difficult to treat among the central nervous system infections. We discuss the following 11 issues: I. Sustainability of first-line treatments, II. Treatment options in case of decreased renal function, III. Association with increased intracranial pressure IV. Causes of visual impairment, V. Necessary steps when symptoms/laboratory findings worsen during antifungal treatment, VI. Cerebral infarction, VII. Difficulty in controlling underlying and comorbid diseases, VIII. Indications for lumbar and ventricular drainage (Ommaya reservoir placement), IX. Pros and cons of concomitant use of corticosteroids, X. Treatment evaluation index: usefulness of head MRI, and XI. Determining the end of treatment and the need for preventive medication.

Thromboembolic risk of movable type left atrial appendage thrombi in patients with atrial fibrillation under widespread use of anticoagulants

Background

Left atrial appendage thrombi (LAAT), especially movable type LAAT, have been reported to be high-risk for thromboembolic events in patients with atrial fibrillation (AF). However, thromboembolic risk of the movable-type LAAT under widespread use of anticoagulant therapy remains unclear.

Methods

We retrospectively studied 65 LAAT patients taking anticoagulants out of 1381 consecutive patients who underwent transthoracic echocardiography prior to cardioversion or catheter ablation for AF. Patients with significant valvular disease and coagulation disorder were excluded. Clinical data were evaluated at the time of TEE. The LAAT were classified into movable and fixed type LAAT by three independent observers.

Results

Sixteen of 65 LAAT patients showed movable type LAAT. During follow-up (42±34 months), one patient underwent emergency thrombectomy, 5 patients developed thromboembolic event, and 12 patients died. There were no differences in clinical data, parameters, thrombectomy/thromboembolic event, and survival rate between patients with movable and fixed type LAAT.

Conclusion

Thromboembolic risk of the movable-type LAAT is the same as fixed type LAAT, under widespread use of anticoagulant therapy.

Funding Acknowledgement

Type of funding sources: None.

The impact of abnormal conduction zone on outcomes after catheter ablation for atrial fibrillation

Background

The abnormal conduction zone (ACZ) in the left atrium (LA) has attracted attention as an arrhythmia substrate in atrial fibrillation (AF).

Purpose

We investigated whether the ACZ affects outcomes after catheter ablation (CA) for AF.

Methods

We studied 78 patients (42 Non-paroxysmal AF, 49 males, and 68±10 years) who received CA for AF. High-density LA mapping during high right atrial pacing was constructed gaining than 2000 points (average 4377±846 points). Isochronal activation maps created at 5-ms interval setting. ACZ was identified by locating a site with isochronal crowding of ≥3 isochrones, and ≥8 isochrones were defined as the conduction block zone (CBZ) in a 4-mm diameter tag (conduction velocity were calculated as ≤27 cm/s and≤10 cm/s, respectively).

Result

Recurrent AF was detected in 25/78 patients (32%) during the follow-up period (9.2±3.0 month). ACZ and CBZ were distributed linearly, and ACZ was observed in 73 of 78 patients and 8 of these 73 patients had the CBZ. Univariate analysis revealed that elevated body mass index (26.2±3.8 vs. 24.3±3.3 kg/m2, P=0.0303), the higher prevalence of non-paroxysmal AF (72% vs. 45%, P=0.0272), larger LA diameter (47.6±6.6 vs. 42.1±6.9 mm, P=0.0014), and longer length of ACZ (79.7±45.1 vs. 52.9±35.7 mm, P=0.0058) were associated with recurrent AF after CA. On multivariate analysis, longer ACZ was independently associated with recurrent AF. Moreover, patients with longer ACZ (cutoff value: 84 mm) had a higher risk of recurrent AF than shorter ACZ (12/22; 55% vs 13/56; 23%, log-rank P=0.0024).

Conclusion

The length of ACZ was associated with recurrent AF after CA.

Funding Acknowledgement

Type of funding sources: None.

The impact of oral direct thrombin inhibitors on activated clotting time during catheter ablation in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

Background

Direct thrombin inhibitors (DTIs) unlike factor Xa-inhibitors (Xa-inhibitors) is associated with fewer bleeding complications than warfarin in patients who had catheter ablation (CA) for atrial fibrillation (AF). However, the mechanisms remains unclear, and activated clotting time (ACT) is used to control heparin-dose for thromboembolic prevention during CA. Methods: We retrospectively studied 543 patients taking direct oral anticoagulant (DOAC) who underwent CA for AF (375 males, age 67 ± 10, 251 non-paroxysmal AF, 142 DTIs). Patients with off-label usage of DOAC were excluded. ACT was measured before (Pre-ACT) and after (post-ACT) initial heparin administration (3000U + 100U/kg), and total heparin-dose was evaluated. Results: Pre-ACT and post-ACT were extended in patients with DTIs (150 ± 21 vs 123 ± 15; P < 0.0001 and 322 ± 39 vs 309 ± 42 sec; P = 0.0013). Patients with Xa-inhibitors required higher total heparin-dose (199 ± 43 vs 175 ± 34 U/kg; P < 0.0001). During and after CA, none had thromboembolic events and 14 patients (3 DTIs, 11 Xa-inhibitor) showed bleeding events (Figure). Conclusions: ACT is extended in patients taking DTIs. Xa-inhibitors might have anticoagulant effects which are not reflected in ACT. Abstract Figure.

Living-Cell Diffracted X-ray Tracking Analysis Confirmed Internal Salt Bridge Is Critical for Ligand-Induced Twisting Motion of Serotonin Receptors

Serotonin receptors play important roles in neuronal excitation, emotion, platelet aggregation, and vasoconstriction. The serotonin receptor subtype 2A (5-HT_2AR) is a Gq-coupled GPCR, which activate phospholipase C. Although the structures and functions of 5-HT_2ARs have been well studied, little has been known about their real-time dynamics. In this study, we analyzed the intramolecular motion of the 5-HT_2AR in living cells using the diffracted X-ray tracking (DXT) technique. The DXT is a very precise single-molecular analytical technique, which tracks diffraction spots from the gold nanocrystals labeled on the protein surface. Trajectory analysis provides insight into protein dynamics. The 5-HT_2ARs were transiently expressed in HEK 293 cells, and the gold nanocrystals were attached to the N-terminal introduced FLAG-tag via anti-FLAG antibodies. The motions were recorded with a frame rate of 100 μs per frame. A lifetime filtering technique demonstrated that the unliganded receptors contain high mobility population with clockwise twisting. This rotation was, however, abolished by either a full agonist α-methylserotonin or an inverse agonist ketanserin. Mutation analysis revealed that the “ionic lock” between the DRY motif in the third transmembrane segment and a negatively charged residue of the sixth transmembrane segment is essential for the torsional motion at the N-terminus of the receptor.

A Case of High Altitude Cerebral Edema With a Prolonged Motivational Deficit

We report a case of prolonged motivational deficit as a sequela of high altitude cerebral edema (HACE), the most severe form of neuropsychiatric dysfunction arising from traveling to high altitude. Magnetic resonance imaging of the brain showed hyperintense lesions in the globi pallidi bilaterally on T2-weighted images. Single-photon emission computed tomography showed hypoperfusion in dorsolateral and orbital prefrontal cortices bilaterally and in the anterior cingulate cortex. This case suggests that a prolonged motivational deficit can occur in patients with HACE. The case may also suggest that HACE can cause network disturbances between the prefrontal cortex and the globi pallidi.

Impact of lipoprotein(a) levels on angiographic severity of femoropopliteal lesions

Background

High lipoprotein(a) [Lp(a)] levels are a risk factor for peripheral artery disease (PAD). However, the association between Lp(a) levels and angiographic severity of PAD has not been systematically studied.

Purpose

The aim of this study was to assess the impact of Lp(a) levels on angiographic severity of femoropopliteal lesions in patients with PAD.

Methods

We retrospectively analyzed a single-center database including 108 patients (74±8 years, 69% male) who underwent endovascular therapy for de novo femoropopliteal lesions and measured Lp(a) levels before therapy between June 2016 and September 2019. Patients were divided into low Lp(a) [LP(a) <30 mg/dL; 77 patients] and high Lp(a) [LP(a) ≥30 mg/dL; 31 patients] groups. Trans-Atlantic Inter-Society Consensus (TASC) II classification, calcification [referring to peripheral arterial calcium scoring system (PACSS) classification] and lesion length were compared between the groups.

Results

Median Lp(a) was 16 (7–31) mg/dL.The prevalence of TASC II class D (13% vs 38%, P<0.01) and severe calcification (PACSS 4) (6% vs 23%, P=0.02) was significantly higher and lesion length was longer (123±88 mm vs 175±102 mm, P<0.01) in the high Lp(a) group than in the low Lp(a) group.(Table and Figure) In multivariate analysis, Lp(a)≥30 was an independent predictor for TASC II class D (HR=3.67, P=0.02) and PACSS 4 (HR=4.97, P=0.02) prevalence.

Conclusion

Lp(a) was associated with angiographic severity of femoropopliteal lesions in patients with PAD.

Comparison of angiographic severity

Funding Acknowledgement

Type of funding source: None

Increased left ventricular stiffness assessed by diastolic wall strain causes symptoms in patients with premature ventricular contraction

Background

Premature ventricular contraction (PVC) is one of common arrhythmias and only some patients complain of PVC-related symptoms, however the mechanisms which cause the symptoms remain unclear in patients with PVCs.

Purpose

We investigated whether the left ventricular (LV) stiffness assessed by diastolic wall strain (DWS) relate symptoms or not in patients with PVC.

Methods

We studied 109 patients (48 males, age 60±19) with frequent monomorphic PVCs who underwent 12-leads electrocardiogram (ECG), signal-averaged electrocardiogram (SAECG), 24h-Holter ECG recording, and transthoracic echocardiography (TTE). Patients with structural heart disease or other arrhythmias such as atrial fibrillation were excluded. Clinical factors, blood samples for atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), and filtered QRS duration (f-QRS) and root mean square voltage of the terminal 40ms of the QRS complex (RMS40) obtained by SAECG were evaluated. We assessed PVC-SV (stroke volume during PVC), PVC-CI (CI between the previous sinus beat and VPC), and left ventricular (LV) stiffness assessed by diastolic wall strain (DWS). DWS was calculated from the M-mode echocardiographic measurement of the LV posterior wall thickness at end-systole (PWs) and end-diastole (PWd) during sinus rhythm, and DWS was defined as (PWs − PWd)/PWs.

Results

31patients (28%) had PVC-related symptoms (18 palpitation and 13 pulse deficit). Patients with PVC-related symptoms showed shorter PVC coupling interval index (52±10 vs. 58±11%, p=0.0140), reduced PVC-SV (21±12 vs. 29±17ml, p=0.0103) and decreased DWS (0.38±0.06 vs. 0.42±0.06, p=0.0011). Meanwhile, the level of BNP and ANP, f-QRS, RMS40, QRS morphology of PVC and the total number of PVC per day were not associated with PVC-related symptoms. On multivariate analysis, decreased DWS was only independently associated with PVC-related symptoms (p=0.0357, OR 2.3629 for each 0.1 decrease in DWS 95% CI 1.0583–5.5815).

Conclusion

The reduced diastolic wall strain relates with PVC-related symptoms. The increased left ventricular stiffness might cause symptoms in patients with PVC.

Funding Acknowledgement

Type of funding source: None

Left ventricular stiffness assessed by diastolic wall strain predicts asymptomatic atrial high rate episodes in patients with pacemaker implantation

Background

Asymptomatic atrial fibrillation has been reported to be associated with an increased risk of embolism.

Purpose

We investigated whether the left ventricular (LV) stiffness assessed by diastolic wall strain (DWS) predicts atrial high rate episodes (AHREs) in patients with pacemaker implantation (PMI).

Methods

One hundred forty seven patients (76 males, 75.2±8.9 years, 62 with sick sinus syndrome; SSS and 85 with atrioventricular block) who did not show atrial tachyarrhythmia before PMI were studied. DWS and other measurements were assessed using transthoracic echocardiography before DDD-pacemaker implantation. DWS was calculated from the M-mode echocardiographic measurement of the LV posterior wall thickness at end-systole (PWs) and end-diastole (PWd), and DWS was defined as (PWs-PWd)/PWs.

Results

AHREs (>5 min and >180 beats/min) were detected in 50/147 patients during follow-up periods (38.3±13.8 months). Patients with AHREs showed reduced DWS (0.29±0.07 vs. 0.39±0.06, p<0.0001), larger left atrial volume index, elevated E/e' ratio, thicker LV PWd, higher prevalence of SSS, and left bundle branch block pattern during ventricular pacing. On multivariate analysis, DWS was only independently associated with AHREs (p<0.0001, HR 1.987 for each 0.1 decrease in DWS, 95% CI 1.553–2.650). Patients with reduced DWS (<0.33) had a higher risk of incidences of AHREs (Figure 1).

Conclusions

LV stiffness assessed by DWS predicts AHREs in patients with PMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Slow conduction zone as an early electrical remodeling change in patients with atrial fibrillation

Background

The slow conduction zone (SCZ) in the left atrium (LA) detected using 3-D mapping and high-resolution imaging system has attracted attention as an arrhythmia substrate of atrial fibrillation (AF). However, the occurrence mechanism of SCZ remains unclear.

Purpose

This aim of this study is to clarify whether SCZ is related to the low voltage zone (LVZ) or the LA anatomical contact areas with other organs such as aorta or thoracic spine in patients with AF.

Methods

We studied 36 patients (21 males, 68±10 years, 14 paroxysmal AF; PAF, 17 persistent AF; PeAF, 5 long-standing persistent AF; LS-PeAF) who received catheter ablation for AF. High-density LA mapping during sinus rhythm or right atrial pacing after pulmonary vein isolation were constructed by acquiring more than 2000 endocardial points in each patient. Isochronal activation maps were created at 5-ms interval setting, and the SCZ was identified on the activation map by finding a site with isochronal crowding of ≥3 isochrones, which are calculated as ≤27 cm/s (figure). The LVZ was defined as the following; mild (<1.5 mV), moderate (<1.0 mV), and severe LA-LVZ (<0.5 mV). The LA contact areas (CoAs; ascending aorta-anterior LA, descending aorta-posterior LA, and vertebrae-posterior LA) were assessed using computed tomography.

Results

The SCZ was distributed linearly (figure), and observed in 35 of 36 patients (97.2%). The SCZ was often found in the anterior (89%), roof (64%), and septal wall (47%) of LA, and longest in patients with LS-PeAF (PAF: 56±34 mm, PeAF; 79±41 mm, LS-PeAF; 107±34mm, P=0.0351). The prevalence rate of SCZ (97.2%) was higher than LVZ (figure, mild LA-LVZ; 91.7%, moderate LA-LVZ: 66.7%, severe LA-LVZ; 25%). The 55.8% of SCZ overlapped with mild LA-LVZ, 37.6% of SCZ with moderate LA-LVZ, and 19.1% of SCZ with severe LA-LVZ. The LA CoAs were found in all patients. A total of 72 CoAs (average surface area, 7.0±4.0 cm2) were identified. A CoA was found in each of the three representative regions, ascending aorta-anterior LA (4.1±2.0 cm2, 36 of 36 patients, 100%), descending aorta-posterior LA (2.3±1.2 cm2, 12 of 36 patients, 33%), and vertebrae-posterior LA (3.4±2.1 cm2, 24 of 36 patients, 67%). However, only 22% of SCZ matched with the LA anatomical contact areas.

Conclusion

The slow conduction zone reflects LA electrical remodeling and may be a precursor finding of the low voltage zone, not LA contact areas in patients with atrial fibrillation.

Funding Acknowledgement

Type of funding source: None

X-ray-based living-cell motion analysis of individual serotonin receptors

G protein-coupled receptors (GPCRs) are seven-transmembrane proteins, which transmit extracellular signals inside cells via activating G proteins. GPCRs are involved in a wide variety of physiological functions, such as signal sensing, immune system processes, and neurotransmission. Although the structures and functions of GPCRs have been well studied, little has been known about their real-time dynamics on live cells. In this study, we used Diffracted X-ray Tracking (DXT) and Diffracted X-ray Blinking (DXB) techniques for analysis. These methods are very precise single-molecular analytical techniques that elucidate protein dynamics by analyzing the diffraction spots from the gold nanocrystals labeled on the protein surface. DXT tracks diffraction spot movements, whereas DXB analyzes continuation of signals by calculating the autocorrelation function of each pixel from the recorded data. Serotonin receptor subtype 2A (5-HT_2A receptors) were transiently expressed on HEK 293 cells, and the gold nanocrystals were attached to the N-terminally introduced FLAG-tag via anti-FLAG antibodies. Fast- and mid-range motions were recorded by DXT with 100μs and 1.25 ms/frame rate, respectively. Slow-range motion was obtained using the DXB method with 100 ms/frame rate. An agonist interestingly suppressed the fluctuations of 5-HT_2A receptors at the microsecond-ranged fast measurement. On the contrary, the motion was enhanced by the agonist in the hundred-millisecond-ranged slow time scale. These dual-natured data may suggest that we succeeded in extracting different modes of receptor's motion on live cells; microsecond ranged fluctuation on the cell membrane, and millisecond-ranged dynamic movement comprising interactions with intracellular signaling molecules.

Improving transport and optimizing deceleration of ion beams from electron cyclotron resonance multicharged ion sources

Electron cyclotron resonance ion sources (ECRISs) are widely applied for ion beam applications, e.g., plasma processing, cancer therapy, and ion engine of an artificial satellite. In our ECRIS, we aim at producing and extracting various ion beams from this device, in particular, Xe^q+ ion beams at low energy. In the aerospace engineering field, there are problems of accumulated damages on various component materials caused by low energy of Xe ions from the engine. There are not enough experimental sputtering data for satellite materials at the Xe^q+ in the low energy region. Then, we are trying to investigate the sputtering yield experimentally by irradiating the low energy Xe ion beams. To perform this experiment, it is necessary to acquire a certain amount of beam current with low energy. Then, we generate the low energy ion beams by the following steps: First, the ion beams are extracted from the ECRIS at high voltage. Next, these are transported to an ion beam irradiation system (IBIS). Finally, the ion beams are decelerated by the deceleration voltage in the IBIS. We adjusted the beamline. We measure the characteristics of the transport efficiency and decelerated ion beam currents. In this paper, we describe the experimental setup using an existing ECRIS for decelerated heavy ion beams and the results of decelerated ion beam currents.

Coaxial semi-dipole antenna microwave feeding on electron cyclotron resonance multicharged ion source

How to produce multicharged ions efficiently on an electron cyclotron resonance ion source (ECRIS) has been investigated at Osaka University. Notably, in recent years, we have focused on heating by new resonance superimposing to electron cyclotron resonance (ECR) plasma. To evaluate its efficiency, we need to know the maximum efficiency of heating with ECR alone, and then, further optimization of ECR heating is required. In consideration of wave propagation, we installed the coaxial semi-dipole antenna on the mirror end along the geometrical axis of the vacuum chamber. We aim at exciting the strength of right-hand polarization (RHP) waves for efficient ECR because RHP waves give rise to ECR. We measure plasma parameters by Langmuir probes and charge state distributions (CSDs) of the extracted ion beams and investigate their qualitative tendencies to incident microwave powers and pressures. We compare the qualitative trend of ion beams and their CSD on microwave power in the case of both the microwave feeding system by the coaxial semi-dipole antenna and that by the rod antenna. Differences between the microwave feeding system before improving and then after upgrading are made clear.

Improving multipole magnets and background vacuum conditions on electron cyclotron resonance ion sources

Electron cyclotron resonance ion sources (ECRISs) are used in various fields such as accelerator physics, engineering, cancer therapy, and ion engines in the satellite. We are aiming to improve the production of multicharged ions efficiently at the point of view from the length of multipole magnets and vacuum conditions in the ECRIS. The diameter of the connection pipe between the main chamber and diffusion pump was made larger to improve vacuum conductance. Moreover, the length of multipole magnets with the direction along the geometrical axis in the ECRIS was extended. The effects of these improvements are investigated experimentally to measure the pressure in the vacuum chamber, beam intensity, charge state distributions of extracted ion beams, and plasma parameters. The purity of extracted ion beams and magnetic confinement have been enhanced. These results are expected to have positive effects on the production of various species and synthesized ion beams, e.g., production of iron endohedral fullerene in the future experiments in the ECRIS.

Upper hybrid resonance heating experiments by X-mode microwaves on electron cyclotron resonance ion source

We have considered the accessibility condition of electromagnetic and electrostatic waves propagating in an electron cyclotron resonance (ECR) ion source (ECRIS) plasma and then investigated experimentally their correspondence relationships with production of multicharged ions. It has been clarified that there exists an efficient configuration of ECR zones for producing multicharged ion beams and has been suggested that a new resonance, i.e., upper hybrid resonance (UHR), must have occurred. We have been trying to perform advanced experiments with 4-6 GHz X-mode microwaves to the 2.45 GHz ECRIS plasma, and we have succeeded in enhancing the production of multicharged ions by launching X-mode microwaves of these bands. Furthermore, at the same time, we have observed sharp increases in electron energy distribution functions in the ECRIS plasma by means of probe methods. It has been concluded that the UHRs must have occurred when applying multiplex microwaves with their frequencies away from those frequencies for ECR in the ECRIS. In this paper, we will describe in brief the theoretical background and the results of these new experiments.

P3704Silent ischemic brain lesion detected in patients with subclinical paroxysmal atrial fibrillation

Background

Long-lasting atrial fibrillation (AF) has been reported to be associated with an increased risk of dementia, independent of clinical stroke. However, the mechanisms or association in patients with subclinical paroxysmal AF (S-PAF) remain unclear. We evaluated whether S-PAF is associated with silent ischemic brain lesion (S-IBL), one of causes of dementia.

Methods

We studied 46 patients (35 male, 68±15 yrs) without a history of stroke/transient ischemic attack and AF, who implanted insertable cardiac monitoring (ICM) for unexplained syncope (n=33) or embolic stroke of undetermined source (ESUS) (n=13). All patients underwent cerebral magnetic resource imaging (c-MRI), and S-IBL was defined as infarction, lacuna and microbleeds. The lesions in an acute stage were excluded in patients with ESUS.

Results

AF was detected in 15/46 patients (11 with unexplained syncope and 4 with ESUS) during follow-up of 7.0±6.6 months, and S-IBL was observed in 18/46 patients (9 infarction, 8 lacuna, or 8 microbleeds). Univariate analysis revealed that higher prevalence of AF (61% vs. 14%, p=0.0015), elder age (73±10yrs vs. 65±16yrs, p=0.0445), dyslipidemia (67% vs. 25%, p=0.007), structural heart disease (44% vs. 14%, p=0.0383), and larger left atrium diameter (41±6 mm vs. 37±5 mm, p=0.0267) were related to S-IBL. On multivariate analysis, prevalence of AF was independently associated with S-IBL (p=0.0070, OR 13.4, 95% CI 1.945–155.813). When receiver-operating-characteristics (ROC) curve analysis and prevalence of AF were used to detect S-IBL, the area under the ROC curve was 0.7341 (sensitivity: 61.1%, specificity: 85.7%).

Conclusion

Subclinical paroxysmal AF is associated with silent ischemic brain lesion and might cause to dementia.

P5654Brain natriuretic peptide and left atrial volume predict the reduced flow velocity of left atrial appendage during sinus rhythm in patients with atrial fibrillation

Background

It remains controversial whether or not to discontinue anticoagulation therapy after catheter ablation (CA) for atrial fibrillation (AF). The reduced flow velocity of the left atrial appendage (FV-LAA) during AF causes left atrial appendage thrombus and increases the risk of stroke. However, some AF patients show reduced FV-LAA even during sinus rhythm (SR).

Methods

398 patients who showed SR during transesophageal echocardiography (TEE) before CA for AF were studied (259 males, 68±10 years, 77 with non-paroxysmal AF). Clinical factors, transthoracic echocardiography and blood samples were obtained before TEE. Reduced FV-LAA was defined as <35 cm/sec of FV-LAA.

Results

Reduced FV-LAA was observed 70/398 patients (18%). Reduced FV-LAA was significantly associated with elevated brain natriuretic peptide (BNP) (p<0.0001), increased LA volume index (p<0.0001), reduced left ventricular ejection fraction (p=0.0017), high prevalence of non-paroxysmal AF (p=0.0048), prior history of heart failure (p=0.0172), and no administration of angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB) (p=0.0403), while CHADS2 factors were not significantly associated.

On multivariate analysis, LA volume index (p<0.0001, OR 1.049 for each 1 increase in LA volume index, 95% CI 1.025–1.073) and no administration of ACEI/ARB (p=0.0015, OR 0.339 for administration, 95% CI 0.173–0.662) and BNP (p=0.0048, OR 1.035 for each 10 pg/ml increase in BNP, 95% CI 1.011–1.061) and were associated with reduced FV-LAA.

Rate of reduced flow velocity

Conclusion

The elevated BNP level and large LA volume index predict reduced FV-LAA during SR. AF patients with increased BNP and larger LA volume index might require long-term anticoagulation taking after CA procedure.

P3790Left ventricular stiffness assessed by diastolic wall strain predicts infrequent atrial fibrillation

Background

Left ventricular (LV) stiffness as the passive LV filling property in the LV diastolic function has been reported to be related with the prevalence of atrial fibrillation (AF). On the other hand, a novel insertable monitoring (ICM) system is a powerful tool to detect AF with rare appearance in patients with embolic stroke of undetermined source (ESUS). We investigated whether the LV stiffness assessed by diastolic wall strain (DWS) predicts infrequent atrial fibrillation.

Methods

Fifty-five patients (41 males, 68±14 years) who underwent ICM implantation for ESUS (n=19) or unexplained syncope (n=36) were studied. DWS, left atrial (LA) stiffness and other measurements were assessed using transthoracic echocardiography before the ICM implantation. DWS was calculated from the M-mode echocardiographic measurement of the LV posterior wall thickness at end-systole (PWs) and end-diastole (PWd) during sinus rhythm, and DWS was defined as PWd/PWs. LA stiffness index was defined as the ratio of E/e' to LA peak strain.

Results

AF was detected in 20 patients (36%) during the follow-up periods (280±243 days). Patients with AF showed reduced DWS (0.30±0.07 vs. 0.41±0.08, p<0.0001), larger LA volume index (39.0±10.9 vs. 32.3±9.0, p=0.0174), and higher age (74.6±10.4 vs. 64.6±14.9, p=0.0105). On the other hand, LA stiffness index, LA function (reservoir, booster, and conduit function estimated by LA volume), and LV relaxation function (E wave, E/A ratio, deceleration time) were not associated with detection of AF. There was no difference on AF detection rate between ESUS and unexplained syncope (26% vs. 42%, p=0.2604). On multivariate analysis, DWS was only independently associated with detection of AF (p<0.0001, OR 5.647 for each 0.1 decrease in DWS, 95% CI 1.084–1.338). Moreover, patients with reduced DWS (<0.38) had a higher risk of incidences of AF than patients with preserved DWS (figure).

Figure 1

Conclusions

LV stiffness assessed by DWS predicts infrequent AF. Reduced LV stiffness rather than LA dysfunction or LV relaxation dysfunction may be the main cause of AF in the early stages.

P5502Comparison of clinical characteristics and prognosis between non-octogenarians and octogenarians with cardiac troponin positive acute myocardial infarction

Background

Cardiac troponin (cTn) is the preferred biomarker for the diagnosis of acute myocardial infarction (AMI). Octogenarians who presented cTn positive AMI are not usually recruited in clinical trials. Therefore, their clinical characteristics and prognosis are rarely investigated.

Objective

To study the characteristics and prognosis in octogenarians who presented cTn positive AMI.

Methods and results

The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective and multicenter registry. A total of 3,283 consecutive AMI patients who were diagnosed by cTn-based criteria were included. The patients were divided into non-octogenarians (n=2,593) and octogenarians (n=690). Compared with non- octogenarians, octogenarians showed significantly lower incidence of diabetes mellitus (37.6% and 31.9%, p=0.006) and dyslipidemia (53.6% and 45.6%, p<0.001), and significantly higher incidence of hypertension (64.1% and 75.3%, p<0.001) and chronic kidney disease (38.7% and 68.7%, p<0.001). Octogenarians showed significantly longer onset to door time (p<0.001) and longer door to device time (p<0.001). Though, compared with non-octogenarians, octogenarians showed lower peak CK (2,506 and 1,926, p<0.001), LVEF was significantly lower in octogenarians (54.6% and 52.6%, p=0.005). The presentation of AMI was different between the two group. The incidence of ST-segment elevation MI (STEMI) was 70.7% in non-octogenarians and 62.0% in octogenarians. Non-STEMI with CK elevation and without CK elevation were 16.2% and 13.1% in non- octogenarians, and 20.9% and 17.1% in octogenarians. In-hospital mortality was higher in octogenarians (4.7% and 13.2%, P<0.001). Especially, octogenarians with STEMI and non-STEMI with CK elevation showed the highest in-hospital mortality. And octogenarians without CK elevation showed similar in hospital mortality with non-octogenarians with STEMI (Figure).

Conclusions

J-MINUET showed the poor prognosis of octogenarians who were diagnosed as AMI based on cTn.

Acknowledgement/Funding

None

P3392Potential of imaging-guided PCI for event suppression in Japanese acute myocardial infarction patients: J-MINUET substudy

Background

Intravascular ultrasound (IVUS) and Optical Coherence Tomography (OCT) has been widely used in clinical settings. Although favorable results of imaging-guided percutaneous coronary intervention (PCI) compared with angio-guided PCI were observed in several studies, impacts of institutional-based usage frequency, about imaging-guided PCI, have not been well elucidated.

Methods

To elucidate the impact of imaging-guided PCI and the effects of frequency of its usage, we analyzed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48 hours of onset from July 2012 to March 2014. Clinical follow-up data was obtained for 3 years. In this sub-study, a total of 2,788 patients who underwent urgent PCI having detailed procedural information were enrolled. We analyzed the differences of utilization rates of imaging-guided PCI among the participating institutions and the impacts for the clinical events. The participating institutions were divided into 3 groups by the frequency of IVUS usage: low frequency institutions: under 50%; moderate frequency institutions: 50% to 90%; and, high frequency institutions: over 90%.

Results

In this cohort registry, patients were enrolled from 28 institutions. The utilization rate of coronary imaging varied widely depending on each institution from 15.4% to 100% (mean 85.7%±24.3, median 97.4%). When the institutions were divided into 3 groups by the frequency of intravascular imaging usage, four low frequency institutions enrolled 295 patients, five moderate frequency institutions enrolled 624 patients, and 19 high frequency institutions enrolled 1,491 patients. Although the incidence of MACE (death, MI, stroke, cardiac failure, or revascularization for unstable angina) decreased stepwise (33.2%, 23.7%, and 19.7%) (gray bar in the Figure), the event rates of the imaging-guided PCI cases among the 3 groups were comparable (21.6%, 21.9%, and 19.6%) (white bar in the Figure). On the other hand, a gradual event reduction between the 3 groups was observed in the angio-guided PCI cases (black bar in the Figure). In comparison of MACE rate between imaging-guided and angio-guided PCI, there were statistically significant differences in the low frequency and moderate frequency institutions (p=0.001 and p=0.012, respectively). In contrast, comparable event rates were observed in the high frequency institutions (p=0.441).

MACE rate by imaging usage frequency

Conclusions

In Japanese ACS patients treated with imaging-guided PCI, better suppression of clinical events during 3-year was found in the institutions with the more frequent use of intravascular imaging, mainly due to stepwise event suppression in the cases of angio-guided PCI. On the other hand, the clinical benefit of coronary imaging was obtained independently of the frequency of use and its experience.

P2461The presence of L wave was associated with non-invasively estimated left atrial stiffness in heart failure patients

Background

The mid-diastolic L wave is recorded as mid-diastolic mitral forward flow with conventional Doppler echocardiography. L wave is occasionally detected in heart failure (HF) patients but its mechanism of occurrence is still unknown. It is hypothesized that L wave was induced by a positive atrioventricular gradient caused by left atrial filling via pulmonary veins, and the magnitude of the L wave is augmented by increasing ventricular stiffness. We speculate that also Left atrium (LA) function will relate with the presence of L wave because the L wave flow occurs passing LA. LA function has been known to have reservoir, booster pump and conduit function. It is reported that LA conduit function related to LA stiffness. The aim of this study is to clarify the association between LA functions and presence of L wave in HF patients.

Methods and results

Eighty two patients who admitted to our hospital for HF were enrolled in this study. We performed echocardiography before discharge. LA speckle-tracking strain was analyzed by an external software program using apical 4 chamber view. Reservoir function was measured as peak strain value at end systole, and booster pump function was measured as the value of atrial contraction. Conduit function was calculated as the difference of the peak value at end systole and atrial contraction. There were 23 patients who had L wave before discharge and 59 patients without L wave. Transmitral E wave (E) and left atrial volume index (LAVI) were higher in patients with L wave than in those without L wave. LA reservoir strain was not different in two groups, but poster pump strain was lower and conduit strain was higher in patients with L wave than those without. LA reservoir strain and booster pump strain weakly correlated with A wave velocity (r=0.39 p=0.004, r=46 p=0.001) and LAVI (r=−0.23 p=0.0383, r=−0.31 p=0.005), but conduit strain had no correlation with A wave (r=0.12 p=0.26) and LAVI (r=−0.04 p=0.67). In multivariate regression analysis for the presence of L wave with A wave velocity, LAVI and LA conduit strain, LA conduit strain remained independent predictors of the presence of L wave (HR 1.12 95% CI 1.04–1.23; p=0.004).

Conclusion

LA conduit function was not correlated with conventional echo parameters of LA function (A wave velocity and LAVI). The presence of L wave was associated with LA conduit strain.

P6466Novel index with combined echocardiographic parameter and CT parameter (pPAT) is useful for screening pulmonary hypertension in Systemic Sclerosis Patients

Background

Systemic sclerosis (SSc) patients with pulmonary arterial hypertension (PAH) had poor survival rate. Usual index of estimating PH is tricuspid regurgitate jet pressure gradient (TRPG). Accurate assessment of PAH is important for the management of SSc patients. However, estimated mean pulmonary arterial pressure (mPAP) using TRPG by echocardiography does not always reflect actual mPAP by right heart catheterization (RHC) in SSc patients. On the other hand, recent reports have shown that rPA, a ratio of diameter of pulmonary artery to ascending aorta (PA/Ao) calculated by computed tomography (CT), was associated with mPAP. However, both index are not sufficient for evaluation of PH. We hypothesized that the product of TRPG and rPA (pPAT) could estimate mPAP of SSc patients more accurately than TRPG or rPA.

Purpose

We investigated the usefulness of the product of TRPG and rPA for detecting actual mPAP in SSc patients.

Methods

Thirty-six SSc patients who suspected PH were enrolled retrospectively. We defined PH as resting mPAP from RHC of >25 mmHg. We measured both a widest pulmonary artery diameter and an adjacent ascending aorta diameter at the same level of the bifurcation of the main pulmonary artery using CT images.

Results

The average age was 67 years old and average mPAP by RHC was 24.7 mmHg. Mean TRPG and mean rPA were 35.1 mmHg and 1.06, respectively. Furthermore, mean pPAT was 37.9. We found pPAT had a stronger correlation with actual mPAP (r=0.848, p<0.001) than TRPG (r=0.754, p<0.001) or rPA (r=0.584, p<0.001). On ROC analysis, pPAT predicted PH with high accuracy for a cut-off of 33.1. In order to evaluate the usefulness of pPAT, we compared false-negative patients between two cutoff values of TRPG 34 mmHg described in ESC guideline and pPAT 33.1. Among the patients with TRPG <34mmHg, 4 patients (18%) had PH. In contrast, when screening PH using pPAT, the diagnosis of PH was missed in only one patient.

Figure 1

Conclusion

The product of TRPG and PA/Ao (pPAT) could be a novel and useful noninvasive index for identifying PH in SSc patients.

P5974Prognostic value of global tangential strain by three-dimensional echocardiography heart failure patients with intermediate ECG criteria for cardiac resynchronization therapy

Background

In the current clinical guidelines, cardiac resynchronization therapy (CRT) is recommended in heart failure (HF) patients with left bundle branch block (LBBB) with QRS width ≥150ms as Class I indication. In terms of HF patients with intermediate ECG criteria, prediction for benefit of CRT is still controversial in routine echocardiography.

Purpose

The aim was to assess whether three-dimensional (3D) echocardiographic indexes of global LV function at baseline has a prognostic value following CRT implantation in patients who fulfilled with intermediate ECG criteria.

Methods

We studied 62 HF patients who fulfilled with the indication criteria of CRT implantation according to current the clinical guidelines. In addition to routine two-dimensional echo, 3D echo dataset was acquired for determination of 3D global tangential strain (GTS) and 3D global longitudinal strain (GLS). We tracked predefined unfavorable outcomes for 3 years after CRT implantation: death, hospitalization due to worsening HF.

Results

LBBB with QRS width ≥150ms was evident in 26 of 62 patients (aged 68±11 years with 160±26 ms of QRS duration and 29±7% of LV ejection fraction), and the other 36 patients only fulfilled intermediate ECG criteria (QRS width 120–149ms or non-LBBB). Unfavorable events occurred in 21 patients (34%). The median GTS was −15.4%. Although GLS was not predictive, GTS greater than −15.4% had high probability of unfavorable outcomes over 3 years (Log-rank, p<0.05). There is no difference in the probability of unfavorable outcomes between LBBB and intermediate ECG criteria. Baseline GTS in patients with intermediate ECG criteria was associated with unfavorable outcomes: −12.6±2.6% vs. −17.3±3.8% (p<0.05). Outcome was better in the intermediate ECG criteria patients with GTS ≤−15.4% than in those with LBBB and in those with intermediate ECG criteria patients with GTS >−15.4% (Log-rank: p<0.05, p<0.0001, respectively).

Conclusions

Baseline GTS by 3D echocardiography is useful for predicting outcome over 3 years after CRT implantation regardless of the ECG criteria for CRT indication.

P4591Impact of extent of non-culprit lesions on one-year outcomes in patients with acute myocardial infarction

Background

Presence of severe stenosis in non-infarct related arteries, i.e. multi-vessel disease (MVD), is associated with poor outcomes after acute myocardial infarction (AMI). However, impact of mild to moderate stenosis in non-culprit lesions remains unclear.Gensini score is an angiographic application grading the extent of coronary artery lesions including mild to moderate stenosis.

Purpose

To evaluate whether the extent of non-culprit lesion is related to one-year outcomes after AMI.

Methods

This study consisted of consecutive 168 patients who underwent primary percutaneous coronary intervention (PPCI) for AMI between 2015 and 2017. Patients with coronary bypass grafts were excluded from the analysis. To assess the extent of non-culprit lesions, we used “non-culprit Gensini score”, which is calculated by excluding score of the culprit lesion from the original Gensini score. Patients were divided into 2 groups by the median ofnon-culprit Gensini score: low score (0–14, n=84) and high score (>15, n=84). Major adverse cardiac events (MACE) included all cause of deaths, non-fatal MI, stroke and ischemia driven coronary revascularization during one-year follow-up period.

Results

MVDwas more frequent in patients with high score than those in those with low score (90% vs 25%, P<0.05). Kaplan-Mayer curves of patients with and without MVD are shown in left figure, and curves of patients with low score and those with high score are shown in right figure. Multivariable analysis showed that high score was an independent predictor of one-year MACE (HR 5.28, 95% CI 1.93–14.9, P<0.05), but MVD was not (HR 0.56, 95% CI 0.23–1.54, P=0.25) (Table).

Multivariable analyses Univariable analyses Multivariable analyses HR (95% CI) P-value HR (95% CI) P-value Age 1.03 (1.01, 1.06) <0.05 1.15 (0.99, 1.05) 0.31 eGFR (<45ml/min/1.73m2) 2.95 (1.59, 5.38) <0.05 2.35 (1.26, 4.35) <0.05 Multi-vessel disease 1.84 (1.01, 3.55) <0.05 0.56 (0.23, 1.54) 0.25 Non-culprit-Gensini score (>15) 3.37 (1.79, 6.78) <0.05 5.28 (1.93, 14.9) <0.05 HR = hazard ratio; CI = confidence interval; eGFR = estimated glomerular filtration rate.

Kaplan-Meier curves

Conclusion

These findings suggested that extent of mild to moderate stenosis in non-culprit lesions might affect the prognosis after AMI in patients undergoing PPCI. Non-culprit Gensini score may be useful to predict outcomes of patients with AMI.

Acknowledgement/Funding

None

P1954Prognostic value of the CHADS2 score for adverse cardiovascular events in acute myocardial infarction patients without atrial fibrillation: J-MINUET Substudy

Background

The CHADS2score has mainly been used to predict the likelihood of cerebrovascular accidents in patients with atrial fibrillation. However, increasing attention is being paid to this scoring system for risk stratification of patients with coronary artery disease. We investigated the value of the CHADS2 score in predicting cardiovascular events in Japanese acute myocardial infarction (AMI) patients without atrial fibrillation.

Methods

To elucidate the prognostic value of CHADS2score in AMI patients, we analysed data of the Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET). This was a prospective and multicenter registry consisting of 3,283 AMI patients, who were hospitalized within 48-hours of onset from July 2012 to March 2014. We calculated the CHADS2 scores for 3,044 patients without clinical evidence of atrial fibrillation. The presence of heart failure was substituted by Killip classification>2 on admission. Clinical follow-up data was obtained for 3 years. In addition to the in-hospital mortality,we evaluated cardiovascular events, defined as all cause deathor non-fatal MI during 3-year follow up periods.

Results

In this study, enrolled patients were classified into low- (point 0–1), intermediate- (point 2–3), and high-score (point 4–6) groups by calculating CHADS2 score. Overall patients with low, intermediate and high score were divided into 1,395, 1,393 and 256 patients, respectively. In-hospital mortality among low, intermediate, and high score groups were 2.8%, 7.4% and 14.8%, respectively (P<0.001). The incidence of cardiovascular eventsamong low, intermediate, and high score groups were 7.8%, 16.3%, 29.3%, respectively (P<0.001). Kaplan-Meier analysis showed a significant difference between the groups (Figure). The event rates were significantly higher in both high score and intermediate score group than in low score group (P<0.001). Multivariate Cox hazard analysis identified CHADS2 score (per 1 point) as an independent predictor of cardiovascular events in addition to chronic kidney disease and lower body mass index. (hazard ratio, 1.344; 95% CI, 1.239–1.459; P<0.001). Among the factors constituting CHADS2 score, heart failure and age were identified as independent predictors for in-hospital mortality. With respect to the cardiovascular event during 3 years, heart failure, age, and previous stroke were revealed as significant independent predictors.

Conclusion

This large cohort study indicated that the CHADS2 score is useful for the prediction of in-hospital mortality and the cardiovascular events during 3-year follow up in Japanese AMI patients without atrial fibrillation.

P3406Validation of atherothrombotic risk score for secondary prevention in patients with acute myocardial infarction: the J-MINUET study

Background

Thrombolysis in Myocardial Infarction (TIMI) Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score are contemporary secondary prevention risk scoring systems. However, these scoring systems have not been validated in other populations.

Purpose

The aim of this study was to validate of the TIMI Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score in patients in the early phase of acute myocardial infarction (AMI).

Methods

The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry conducted in 28 Japanese medical institutions. We enrolled 3,283 consecutive patients with AMI who were admitted to participating institutions within 48 hours of symptom onset between July 2012 and May 2014. Among them, 3,070 patients were included in this study after excluding 213 patients who died in the hospital. Clinical follow-up data were obtained up to 3 years. The primary endpoint was a composite of all-cause death, non-fatal MI and non-fatal stroke. The patients were stratified by the TIMI Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score.

Results

At the 3-year follow-up, the primary endpoint had occurred in 337 patients (11.0%). All-cause death, non-fatal MI and non-fatal stroke had occurred in 177 (5.8%), 80 (2.6%) and 80 (2.6%) patients, respectively. TIMI Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score showed a graded association with the composite of all-cause death, non-fatal MI and non-fatal stroke at 3 years in the J-MINUET population (Figure).

Validation of atherothrombotic risk

Conclusions

TIMI Risk Score for Secondary Prevention and CREDO-Kyoto Thrombotic Risk Score were shown to be applicable to the patients in the early phase of AMI.

Beam Energy and Centrality Dependence of Direct-Photon Emission from Ultrarelativistic Heavy-Ion Collisions

The PHENIX collaboration presents first measurements of low-momentum (0.4<p_{T}<3  GeV/c) direct-photon yields from Au+Au collisions at sqrt[s_{NN}]=39 and 62.4 GeV. For both beam energies the direct-photon yields are substantially enhanced with respect to expectations from prompt processes, similar to the yields observed in Au+Au collisions at sqrt[s_{NN}]=200. Analyzing the photon yield as a function of the experimental observable dN_{ch}/dη reveals that the low-momentum (>1  GeV/c) direct-photon yield dN_{γ}^{dir}/dη is a smooth function of dN_{ch}/dη and can be well described as proportional to (dN_{ch}/dη)^{α} with α≈1.25. This scaling behavior holds for a wide range of beam energies at the Relativistic Heavy Ion Collider and the Large Hadron Collider, for centrality selected samples, as well as for different A+A collision systems. At a given beam energy, the scaling also holds for high p_{T} (>5  GeV/c), but when results from different collision energies are compared, an additional sqrt[s_{NN}]-dependent multiplicative factor is needed to describe the integrated-direct-photon yield.

Nationwide survey of influenza-associated acute encephalopathy in Japanese adults

BACKGROUND

Knowledge of adult patients with influenza-associated acute encephalopathy (IAE) is limited. We conducted a detailed survey to investigate the prevalence, clinical features, associated outcomes, and prognostic factors in adult IAE patients.

METHOD

A nationwide questionnaire on IAE patients was sent to the departments of Internal Medicine, Neurology, Neurosurgery, and Emergency and Critical Care at all hospitals with ≥200 beds in Japan.

RESULTS

118 patients were diagnosed with IAE during the 2013/14 to 2015/16 influenza seasons, and the estimated annual incidence of IAE in Japanese adults was 0.98/1000,000 population. 44 patients were subsequently enrolled in the detailed study. 93% of patients exhibited disturbance of consciousness. Convulsions and delirious behavior were present in 26% and 40% of patients, respectively. 65% of patients received pulse corticosteroid therapy with methylprednisolone and 21% of patients received intravenous gamma-globulin therapy. 63% of patients achieved a good recovery, but 7% died. Multiple logistic regression analysis revealed that plasma glucose level demonstrated a statistically significant association with poor outcome.

CONCLUSION

This nationwide survey provided data for the annual incidence and clinical features of IAE in Japanese adults. Hyperglycemia was indicated as an independent predictor of poor prognosis in IAE patients and reflected systemic hypercytokinemia in IAE pathogenesis.