Transcatheter electrosurgical septotomy technique for chronic postdissection aortic aneurysms

Aortic dissection often results in chronic aneurysmal degeneration due to progressive false lumen expansion. Thoracic endovascular aortic repair and other techniques of vessel incorporation such as fenestrated-branched or parallel grafts have been increasingly used to treat chronic postdissection aneurysms. True lumen compression or a vessel origin from the false lumen can present considerable technical challenges. In these cases, the limited true lumen space can result in inadequate stent graft expansion or restrict the ability to reposition the device or manipulate catheters. Reentrance techniques can be used selectively to assist with target vessel catheterization. Transcatheter electrosurgical septotomy is a novel technique that has evolved from the cardiology experience with transseptal or transcatheter aortic valve procedures. This technique has been applied in select patients with chronic dissection to create a proximal or distal landing zone, disrupt the septum in patients with an excessively compressed true lumen, or connect the true and false lumen in patients with vessels that have separate origins. In the present report, we summarize the indications and technical pitfalls of transcatheter electrosurgical septotomy in patients treated by endovascular repair for chronic postdissection aortic aneurysms.

The addition of a leaded arm sleeve to leaded aprons further decreases operator upper outer quadrant chest wall radiation dose during fluoroscopically guided interventions

OBJECTIVE

Breast cancer most commonly occurs in the upper outer quadrant (UOQ) chest wall (CW). The effectiveness of routine leaded aprons to protect this region of the body in interventionalists during fluoroscopically guided interventions (FGIs) is unknown. Given the high lifetime attributable risks of prolonged occupational exposure to ionizing radiation and the increasing number of practicing female vascular surgeons and interventionalists, we sought to determine if the use of a leaded arm shield would offer additional protection to the lateral CW and axilla in operators compared with routine leaded aprons.

METHODS

Effectiveness of leaded sleeves in attenuating radiation dose to the axilla and UOQ was evaluated in clinical practice and simulated scenarios. In the clinical setting, optically stimulated luminescence nanoDot detectors were placed at the UOQ lateral CW position, both over and under a standard leaded apron vest with and without the addition of an antimony/bismuth Enviro-Lite sleeve on two vascular surgeons performing FGIs. In the simulation, nanoDots were similarly placed on an anthropomorphic phantom positioned to represent a primary operator performing right femoral access. Fluorography was performed on 12-inch-thick acrylic scatter phantom at 80 kVp for an exposure of 3 Gy reference air kerma. Experiments were done with and without the sleeve. Paired Wilcoxon and χ2 tests were performed to identify the statistical significance of radiation attenuation.

RESULTS

Operator UOQ CW dose was measured during 61 FGIs: 33 cases (54%) with and 28 cases (46%) without the sleeve. Median procedure reference air kerma and fluoroscopy time was 180 mGy (interquartile range [IQR], 85-447 mGy) and 21 minutes (IQR, 11-39 minutes) when the sleeve was worn vs 100 mGy (IQR, 67-270 mGy) and 11 minutes (IQR, 6.3-25 minutes) without the sleeve. Radiation dose to the operator's UOQ was reduced by 96% (IQR, 85%-96%) when the sleeve was present and by 62% (IQR, 44%-82%; P < .001) without the sleeve. In the simulated setting, the sleeve reduced the radiation dose to the UOQ compared with the apron alone (96% vs 67%; P < .001).

CONCLUSIONS

Routine leaded aprons do attenuate the majority of UOQ chest wall radiation dose; however, the addition of a lead-equivalent sleeve further significantly reduces this dose. Because this area of the body has a high incidence of cancer formation, additional protection, especially to female interventionalists, seems prudent. Vascular surgeons should consider using a protective sleeve with their personal protective equipment when performing complex fluoroscopically guided procedures.

An international survey of 1014 hernia surgeons: outcome of GLACIER (global practice of inguinal hernia repair) study

INTRODUCTION

The practice of inguinal hernia repair varies internationally. The global practice of inguinal hernia repair study (GLACIER) aimed to capture these variations in open, laparoscopic, and robotic inguinal hernia repair.

METHODS

A questionnaire-based survey was created on a web-based platform, and the link was shared on various social media platforms, personal e-mail network of authors, and e-mails to members of the endorsed organisations, which include British Hernia Society (BHS), The Upper Gastrointestinal Surgical Society (TUGSS), and Abdominal Core Health Quality Collaborative (ACHQC).

RESULTS

A total of 1014 surgeons from 81 countries completed the survey. Open and laparoscopic approaches were preferred by 43% and 47% of participants, respectively. Transabdominal pre-peritoneal repair (TAPP) was the favoured minimally invasive approach. Bilateral and recurrent hernia following previous open repair were the most common indications for a minimally invasive procedure. Ninety-eight percent of the surgeons preferred repair with a mesh, and synthetic monofilament lightweight mesh with large pores was the most common choice. Lichtenstein repair was the most favoured open mesh repair technique (90%), while Shouldice repair was the favoured non-mesh repair technique. The risk of chronic groin pain was quoted as 5% after open repair and 1% after minimally invasive repair. Only 10% of surgeons preferred to perform an open repair using local anaesthesia.

CONCLUSION

This survey identified similarities and variations in practice internationally and some discrepancies in inguinal hernia repair compared to best practice guidelines, such as low rates of repair using local anaesthesia and the use of lightweight mesh for minimally invasive repair. It also identifies several key areas for future research, such as incidence, risk factors, and management of chronic groin pain after hernia surgery and the clinical and cost-effectiveness of robotic hernia surgery.

Hemorrhage Occluder™ Pin to control life-threatening bleeding during the removal of an infected sacrocolpopexy mesh: A case report

Vaginal mesh exposures and infections are recognized complications of open and laparoscopic sacrocolpopexy performed for vault prolapse. In severe cases, complete sacrocolpopexy mesh removal may be necessary. This case report presents a 72-year-old woman with previous mesh sacrocolpopexy who presented with infected mesh and recurrent vaginal bleeding despite multiple attempts at surgical transvaginal mesh excision. A life-threatening massive hemorrhage occurred intra-operatively. After several failed attempts to control bleeding, hemorrhage Occluder™ Pins were successfully placed by vascular surgery to control presacral veins. Although an exceedingly rare complication, anticipation and rapid management of life-threatening bleeding are critical to save life during complicated mesh removals.

Operator Lower Leg Radiation Dose during Fluoroscopically Guided Interventions is Effectively Reduced by Wearing Lead-Equivalent Leg Wraps

BACKGROUND

The intensity of radiation scatter that emanates from the X-ray beam during fluoroscopically guided interventions is greater below the fluoroscopy table than above. Yet interventionalists' lower legs are typically unshielded and table skirts are often positioned incorrectly. We sought to characterize the efficacy of the leg protector wraps (Leg Wraps, Burlington Medical Inc.) in reducing the radiation dose to the operator's lower leg during fenestrated and branched endovascular aneurysm repair (F-BEVAR).

METHODS

A prospective cohort study was performed evaluating the lower leg radiation dose reduction of one vascular surgeon during F/BEVAR using antimony/bismuth Enviro-Lite leg wraps (0.35 mm lead equivalency, 99.7% attenuation at 50 kVp; Burlington Medical, Hampton Roads, Virginia). Optically Stimulated Luminescence nanoDot detectors (microSTARii System, LANDAUER, Inc., Glenwood, Illinois) were placed over and under the left leg wrap at the anterior tibial tuberosity position to compare operator leg dose with and without this additional protection. The table-mounted lead skirt was used consistently in all cases. The nanoDot detectors were cross-calibrated with a survey meter (RaySafe X2 survey sensor, Fluke Biomedical, Cleveland, Ohio) by measuring scattered radiation at a position equivalent to an operator's mid-tibia while performing digital acquisitions of a 25-cm thick, 30 cm × 30 cm acrylic phantom with a Philips FD20 fluoroscope (Philips Healthcare, Best, The Netherlands) with the table skirt removed. The measured radiation doses were converted to a Hp (0.07) skin dose, assuming an RQR6 beam spectrum (IEC-61267). Paired Wilcoxon test was performed to identify significant attenuation of radiation exposure.

RESULTS

Leg dose measurements from 40 F-BEVARs were analyzed. The patients had a median (interquartile range) body mass index of 27 (24-32) kg/m². Median procedure reference air kerma was 1,100 (728-1,601) mGy, kerma-area product was 127 (73-184) Gycm², and fluoroscopy time was 69 (54-86) min. The median skin dose H_p (0.07) over the leg wraps (n = 40) was 54.2 (24-100) μSv and under the leg wraps (n = 40) was 2.7 μSv (1.0-5.8). The leg wraps attenuated the radiation dose by 95% (89-98%) (P < 0.001). The unprotected, H_p (0.07) per kerma-area product was determined to be 0.38 (0.30-0.55) μSv/Gycm².

CONCLUSIONS

The 0.35-mm lead-equivalent leg wraps significantly decreased scattered radiation to the lower leg during F-BEVAR. Protective leg wraps should be recommended to operators performing complex fluoroscopically guided procedures.

Characterisation of patients referred to a tertiary-level inherited cardiac condition clinic with suspected arrhythmogenic right ventricular cardiomyopathy (ARVC)

BACKGROUND

Arrhythmogenic right ventricular cardiomyopathy (ARVC) or arrhythmogenic cardiomyopathy is a rare inherited disease with incomplete penetrance and an environmental component. Although a rare disease, ARVC is a common cause of sudden cardiac death in young adults. Data on the different stages of ARVC remains scarce. The purpose of this study is to describe the initial presentation and cardiac phenotype of definite and non-definite ARVC for patients seen at a tertiary service.

METHODS

This is a single centre, observational cohort study of patients with definite and non-definite ARVC seen at the Inherited Cardiac Conditions services at University Hospital Birmingham (UHB) in the period 2010-2021. Patients were identified by interrogation of digital health records, medical history, imaging and by examining 12-lead electrocardiograms (ECG).

RESULT

The records of 1451 patients were reviewed; of those, 165 patients were at risk of ARVC (mean age 41 ± 17 years, 56% male). 60 patients fulfilled task force criteria for definite ARVC diagnosis (n = 40, 67% males), and 38 (72%) of them carried a known pathogenic variant. The remaining 105 patients (50% males) were non-definite, and of these 45 (62%) carried a known pathogenic variant. Patients in the definite group were more symptomatic, with palpitations (57% vs. 17%), syncope (35% vs. 6%) and shortness of breath (28% vs. 5%, p < 0.001). T-wave inversion in V1-V3 and epsilon waves were observed only in the definite group. Both PR interval and QRS duration were longer in the definite (170 ± 34 ms and 100 ± 19 ms, p < 0.001) compared to (149 ± 25 and 91 ± 14 ms, p = 0.005). Patients with definite ARVC had significantly larger RV end diastolic areas and significantly reduced biventricular function (RVEDA = 27 ± 10 cm², RVFAC = 37 ± 11% and EF = 56 ± 12%) compared to the non-definite group (RVEDA = 18 ± 4 cm², RVFAC 49 ± 6% and LVEF 64 ± 7%, p < 0.001). Sustained ventricular tachycardia (VT) occurred more frequently in the definite group compared to the non-definite group (27% vs. 2%, p < 0.001). Ventricular fibrillation was observed in the definite group only (8 of 60 patients, 13%).

CONCLUSION

Our study showed differences between definite and non-definite ARVC patients in terms of clinical, electrophysiological and imaging features. Major adverse cardiac events occurred more commonly in the definite group, but also were observed in non-definite ARVC. This single centre observational cohort study forms a basis for further prospective multicentre interventional studies.

Climate change, water and agriculture linkages in the upper Indus basin: A field study from Gilgit-Baltistan and Leh-Ladakh

The Indus is one of three largest river systems emerging from the Hindu-Kush Himalaya (HKH). In the Upper Indus Basin (UIB), water resources, agriculture and livelihoods are highly vulnerable to climate change induced hazards and risks. Present study investigates impacts of climate change on water availability, agriculture and livelihoods based on perception data collected through focus group discussions and key informant interviews from selected study sites in Gilgit-Baltistan and Leh-Ladakh subregions of the UIB. Findings revealed that climate change is inducing both direct and indirect impacts on water availability, agriculture, and livelihoods. Local people reported that changes in precipitations patterns, temperature and timing of seasons, and increased incidence of crop pest attacks are resulting in the decline of crop and livestock productivity (direct impacts). Climate change is also impacting productivity indirectly through degradation of rangelands/pastures and water variability in traditional irrigation systems. Local people are taking diverse adaptation measures to cope with climate change impacts. These measures include revival of less water intensive traditional crops, start of enterprises and value chain developments in Gilgit-Baltistan, and improvement in water management practices and integration of traditional agricultural products with tourism in Leh-Ladakh. Some adaptation measures are likely to have negative impacts on sustainability of local agriculture. For instance, inorganic agricultural practices in Gilgit-Baltistan, and unplanned shift to water intensive crops and improved breeds of livestock in both Gilgit-Baltistan and Leh-Ladakh. Based on findings, this study suggests establishing a learning mechanism for local communities through collaboration of local institutions from both sides of border and people to people connections.

P-132 MANAGEMENT OF VENTRAL HERNIA IN OBESITY: OUR ALGORITHM

Introduction

Management of ventral hernia in obese is a complex problem. The methods of weight loss, alternatives if the patient cannot undergo bariatric surgery, timing, and type of hernia surgery lacks clarity and are dependent on resources and expertise. There is a need for algorithms based on local population and expertise. In this paper, we present the outcomes of our institutional algorithm.

Methods

It was a retrospective analysis of prospectively collected data. Patients with body mass index(BMI) &gt; 30Kg/m2 were included to undergo surgery as per algorithm considering (a) presentation(symptomatic vs asymptomatic), (b) hernia characteristics(defect width, site, reducibility), and (c) obesity characteristics(BMI, subcutaneous fat, android vs gynecoid). Data on age, BMI, comorbidities, tobacco consumption, hernia width, location, contents, previous surgery, intraoperative parameters(the type of surgery, mesh, drain, fixation), and outcomes(seroma, hematoma, infection, recurrence) were collected.

Results

50 patients underwent treatment as per the algorithm. Mean BMI was 36.6 ± 7.3 kg/m2. The mean follow-up was 17.6 ± 7.2 months. The mean defect width was 4.8 ± 2.9 cm. There were two (4%) recurrences in patients who underwent an anatomical repair under emergency conditions. None of the patients who underwent an elective repair had a recurrence. Total surgical site occurrence was 12% and surgical site occurrence requiring procedural intervention was 8%. There was one (2%) mortality on postoperative day7 due to myocardial infarction.

Conclusion

The algorithm has shown encouraging results in the short-to-medium term. Long-term evaluation with a higher number of patients is needed to confirm its usefulness.

OC-084 PRACTICE AND SHORT-TERM OUTCOMES IN VENTRAL HERNIA REPAIR: FIRST PROSPECTIVE MULTICENTER DATA ANALYSIS FROM INDIA

Aim

Recording short and long term outcomes of primary ventral hernia (PH) and incisional hernia (IH) surgeries performed in India.

Materials and Methods

Members of Indian Association of Gastrointestinal Endo Surgeons (IAGES) were approached via mails and social media. Forty-five centres agreed to participate. The participating surgeons prospectively recorded the data of patients who underwent VHR from January 21, 2021- April 20, 2021, on a predesigned excel sheet. They were followed for 6 months.

Results

Data from 648 patients were analysed in this study for demographics, hernia characteristics, technical variations, and outcomes. 375 (57.8%) were primary ventral hernias (PH) and 273 (42.15%) were incisional hernias (IH), of which 63 (9.7%) were recurrent hernias.

In the PH group, 171 patients underwent minimal access repair (MAS) and 170 patients underwent open repair. The commonest procedure were open onlay and open pre-peritoneal repairs were performed least frequently. There were 3.73% seroma, 3.2% SSI, 0% 90-day readmission, 0% recurrence, and 0.3% mortality.

In the IH group, 164 patients underwent open repair and 104 underwent MAS repair. The most commonly performed procedure were open onlay and IPOM/IPOM plus. There were 13.92% seroma, 4.4% hematoma, 9.5% SSI, 1.1% mesh explantation, 0.4% wound sinus, 2.2% 90-day readmission, 0% recurrence, and 1.1% mortality.

Conclusion

Despite the guidelines favouring sublay repairs, onlay mesh hernioplasty is the commonest procedure practiced in India. IPOM/IPOM plus is the second commonest procedure. TAR is the preferred component separation technique in India. Complication rates in this study are comparable to published world literature.

Community- vs. hospital-based management of multidrug-resistant TB in Pakistan

BACKGROUND Multidrug-resistant TB (MDR-TB) treatment takes 18-24 months and is complex, costly and isolating. We provide trial evidence on the WHO Pakistan recommendation for community-based care rather than hospital-based care.METHODS Two-arm, parallel-group, superiority trial was conducted in three programmatic management of drug-resistant TB hospitals in Punjab and Sindh Provinces, Pakistan. We enrolled 425 patients with MDR-TB aged >15 years through block randomisation in community-based care (1-week hospitalisation) or hospital-based care (2 months hospitalisation). Primary outcome was treatment success.RESULTS Among 425 patients with MDR-TB, 217 were allocated to community-based care and 208 to hospital-based care. Baseline characteristics were similar between the community and hospitalised arms, as well as in selected sites. Treatment success was 74.2% (161/217) under community-based care and 67.8% (141/208) under hospital-based care, giving a covariate-adjusted risk difference (community vs. hospital model) of 0.06 (95% CI -0.02 to 0.15; P = 0.144).CONCLUSIONS We found no clear evidence that community-based care was more or less effective than hospital-based care model. Given the other substantial advantages of community-based care over hospital based (e.g., more patient-friendly and accessible, with lower treatment costs), this supports the adoption of the community-based care model, as recommended by the WHO.

New imaging technology system reduces patient radiation dose during peripheral arterial endovascular interventions

BACKGROUND

Radiation exposure and imaging quality are among the main concerns in endovascular procedures. The Clear VD11 PURE platform technology system (Siemens Healthineers, Erlangen, Germany) has been reported to lower the radiation dose and improve image quality. In the present study, we evaluated whether the radiation dose during peripheral arterial endovascular procedures had decreased after implementation of this new imaging system.

METHODS

The patient characteristics (age, gender, body mass index [BMI]), procedure type (diagnostic, balloon angioplasty, atherectomy, stenting), body location (aortoiliac, superficial femoral artery, tibial artery), reference air kerma (RAK), kerma area product (KAP), and fluoroscopy time (FT) were recorded during peripheral artery interventions performed 1 year before (group A) and 1 year after (group B) the CLEAR system upgrade. The procedures were performed in an Artis zeego hybrid room (Siemens Healthineers) with the same providers. A general linear model was used to estimate the average difference between groups adjusted by procedure type and patient age, gender, and BMI. Additionally, to control for variations in case complexity, groups A and B were matched by age, gender, BMI, lesion location, and intervention type. Propensity score matching and a paired t test were used to compare the KAP, RAK, and FT stratified by single intervention procedures.

RESULTS

A total of 487 endovascular procedures were performed: 209 in group A and 278 in group B. A total of 111 single intervention procedures from each group were matched (1:1), with a mean age of 61 ± 8 years and a BMI of 26.5 ± 4 kg/m². The median KAP, RAK, and FT for group A were 28.8 Gy · cm² (interquartile range [IQR], 24-34 Gy · cm²), 146 mGy (IQR, 123-173 mGy), and 12 minutes (IQR, 10-14 minutes), respectively. The median KAP, RAK, and FT for group B were 18.3 Gy · cm² (IQR, 16-22 Gy · cm²), 71.2 mGy (IQR, 60-85 mGy), and 10.4 minutes (IQR, 9-12 minutes), respectively. The KAP, RAK, and FT were significantly decreased in group B by 24% (P = .005), 41% (P < .001), and 22% (P = .002), respectively, compared with the values for group A. Stratified by single intervention procedures, the KAP and RAK had decreased significantly in group B (36% [P = .002] and 51% [P < .001], respectively) compared with group A. The FT decrease of 13% in group B was not statistically significant (P = .20).

CONCLUSIONS

Use of the Clear VD11 PURE platform system (Siemens Healthineers) reduced the patient radiation dose by 51% during endovascular peripheral interventions. The similar FTs for the matched single intervention procedures before and after the upgrade indicated consistent case complexity and surgeon practice. This platform appears to be an effective system for lowering the radiation dose.

Disposable, Lightweight Shield Decreases Operator Eye and Brain Radiation Dose When Attached to Safety Eyewear During Fluoroscopically-Guided-Interventions

OBJECTIVE

Long-term radiation exposure from fluoroscopically-guided-interventions (FGIs) can cause cataracts and brain tumors in the operator. We have previously demonstrated that leaded eyewear does not decrease operator eye dose unless lead shielding is added to the lateral and inferior portions. Therefore, we developed a disposable, lightweight, lead-equivalent shield that can be attached to the operator's eyewear, conforming around the face and adhering to the surgical mask. This study evaluates the efficacy of our new prototype in lowering operator brain and eye dose when added to both leaded and non-leaded eyewear.

METHODS

The attenuating efficacy of leaded eyewear alone, leaded eyewear + prototype and non-leaded eyewear + prototype were compared to no eyewear protection in both a simulated setting and clinical practice. In the simulation, optically stimulated, luminescent nanoDot detectors (Landauer, Glenwood, II) were placed inside the ocular, temporal lobe, and midbrain spaces of a head phantom (ATOM model-701: CIRS, Norfolk, VA). The phantom was positioned to represent a primary operator performing right femoral access. Fluorography was performed on a plastic scatter phantom at 80kVp for an exposure of 3 Gy RAK. In the clinical setting, nanoDots were placed below the operator's eye both inside and outside the prototype during FGIs. Median and interquartile ranges were calculated for the dose at each nanoDot location for both the phantom and clinical study, with average dose reduction also reported.

RESULTS

Wearing standard leaded eyewear alone did not decrease operator ocular or brain dose. In the phantom experiment, the leaded glasses + prototype reduced dose to the lens, temporal lobe and midbrain by 83% (p<0.001), 78% (p<0.001), and 75% (p<0.001), respectively. The non-leaded glasses + prototype also reduced dose to the lens, temporal lobe and midbrain by 85% (p<0.001), 81% (p<0.001), and 71% (p<0.001). In the clinical setting, 15 FGIs were included, with median RAK of 98.4 mGy. Our prototype led to an average operator eye dose reduction of 89% (p<0.001).

CONCLUSIONS

Attaching our prototype to both leaded and non-leaded glasses significantly decreased eye and brain radiation dose to the operator. This face shield attachment provides meaningful radiation protection and should be considered as either a replacement or adjunct to routine eyewear.

Vitamin D and bisphosphonate therapy in systemic lupus erythematosus patients who receive glucocorticoids: are we offering the best care?

OBJECTIVE

This study aimed to evaluate management practices for glucocorticoid (GC)-induced osteoporosis (GIOP) in systemic lupus erythematosus (SLE) patients using 2017 American College of Rheumatology guidelines as a gold standard.

METHODS

We conducted a retrospective cohort study using a clinical database from the years 2011 to 2016. SLE cases with >90 days continuous prednisone use at doses of ≥7.51 mg daily were identified. Osteoporosis risk factors were assessed via chart review. The Fracture Risk Assessment (FRAX) score was estimated for patients > 40 years of age. Vitamin D, bisphosphonate prescriptions, and osteoporotic (OP) fractures were ascertained through chart review. A classification tree was used to identify the key patient-related predictors of bisphosphonate prescription.

RESULTS

A total of 203 SLE patients met the inclusion criteria. The recommended dose of vitamin D supplement was prescribed to 58.9% of patients < 40 years of age and 61.5% of patients ≥ 40 years of age. Among patients aged ≥ 40 years, 25% were prescribed bisphosphonates compared to 36% who met indications for bisphosphonates per the ACR guidelines. Another 10% were prescribed a bisphosphonate, despite not having indication per the ACR guidelines, which was considered as overtreatment. Among patients aged ≥ 40 years, older age and a higher FRAX score for major OP fracture and hip fracture predicted bisphosphonate prescription. In a classification tree analysis, patients with FRAX scores (for major OP fracture) of ≥ 23.5% predicted bisphosphonate prescription in this SLE population. Among patients who had OP fractures in the follow-up period, nine (6.50%) were inpatients receiving appropriate GIOP care versus 12 (13.6%) who were inpatients not receiving ACR-appropriate care (p = 0.098).

CONCLUSIONS

In clinical practice, fewer SLE patients with or at risk for GIOP are prescribed vitamin D and bisphosphonates than recommended by the 2017 ACR guidelines. Also, in this study, another 10% were prescribed a bisphosphonate, despite not having an indication per the ACR guidelines. Patients were most likely to receive a bisphosphonate prescription if they had a major OP FRAX score of > 23.5%.

1673 Accuracy and prognostic value of physiologist-led stress echocardiography for coronary disease

Funding Acknowledgements

No funding sources

Background

Cardiac physiologist-led stress echocardiography (PLSE) services provide potential for expansion of SE services and increased productivity for cardiologists. There is no published data on the accuracy or prognostic value of PLSE.

Purpose

To assess and compare the accuracy and prognostic value of PLSE and cardiologist-led stress echocardiography (CLSE) for CAD assessment

Methods

Retrospective study of 898 subjects undergoing PLSE (n = 393) or CLSE (n = 505) for CAD assessment using exercise or dobutamine. For accuracy assessment, the primary outcome was the ability of stress echocardiography to identify significant CAD on invasive angiography (ICA). Incidence of 24-month non-fatal myocardial infarction (MI), total and cardiac mortality, revascularisation and combined major adverse cardiac events (MACE) were assessed.

Results

Demographics, comorbidities, CAD predictors and cardiac medications were matched between the PLSE and CLSE groups. PLSE had high sensitivity, specificity, positive and negative predictive value and accuracy (85%, 74%, 69%, 88%, 78% respectively). PLSE accuracy measures were similar and non-inferior to CLSE. There was a similar incidence of individual and combined outcomes in PLSE and CLSE subjects. Negative stress echocardiography conferred a low incidence of non-fatal MI (PLSE 1.4% vs. CLSE 0.9%, p = 0.464), cardiac mortality (0.6% vs. 0.0%, p = 0.277) and MACE (6.8% vs. 3.1%, p = 0.404).

Conclusion

This is the largest study of PLSE accuracy and first study of the prognostic value of PLSE. PLSE demonstrates high and non-inferior accuracy compared with CLSE for CAD assessment. Negative PLSE and CLSE confer a similarly very low incidence of cardiac outcomes, confirming for the first time the important prognostic value of PLSE.

Accuracy of PLSE and CLSE for CAD Marker of diagnostic test Total (n = 72) PLSE (n = 32) CLSE (n = 40) p Significant CAD present (n, %) 20 (27.8%) 12 (37.5%) 8 (20.0%) 0.167 * Single-vessel CAD 12 (60.0%) 7 (58.3%) 5 (62.5%) 0.325 * Multi-vessel CAD 8 (40.0%) 5 (41.7%) 3 (37.5%) 0.325 Sensitivity 76% (66-76%) 85% (73-97%) 63% (48-78%) Non-significant Specificity 73% (63-73%) 74% (59-89%) 72% (58-86%) Non-significant Positive predictive value (PPV) 53% (42-64%) 69% (53-85%) 29% (15-43%) Significant Negative predictive value (NPV) 88% (80-96%) 88% (77-99%) 88% (78-98%) Non-significant Overall accuracy 74% (64-84%) 78% (64-92%) 70% (56-84%) Non-significant Accuracy data expressed as value (95% confidence interval). CAD= coronary artery disease. Differences in values between PLSE and CLSE considered statistically significant if no crossover in 95% confidence intervals

Abstract 1673 Figure. Predicted coronary artery lesion from SE

P340Inflammatory cardiomyopathy in Fabry disease

Background

Fabry disease (FD) is an X-linked lysosomal storage disorder caused by mutations in α-galactosidase A. Cardiovascular magnetic resonance (CMR) has helped unveil the pathogenesis of Fabry cardiomyopathy: sphingolipid storage (low T1 mapping values), left ventricular hypertrophy (LVH) and myocardial fibrosis with late gadolinium enhancement (LGE) characteristically present in the basal inferolateral (BIFL) wall. Recent evidence has suggested that the LGE may be inflammation and oedema as part of this pathogenic process.

Purpose

To assess the presence of inflammation in patients with FD using T2 mapping (for oedema/inflammation) supported by blood troponin levels (showing myocyte death and by inference inflammation).

Methods

A multi-centre international study in gene positive FD patients using CMR and blood biomarkers. All participants underwent CMR at 1.5 T. Native T1 and T2 mapping were performed. The T1 mapping sequence was MOLLI with sampling scheme in seconds. LGE used a phase sensitive inversion recovery sequence. Global longitudinal 2D strain (GLS) values were obtained using feature tracking analysis. Blood high-sensitivity troponin T (hsTnT) was measured on the same day.

Results

100 FD patients (age 43.8±1.3 years, 42% male) were included. 45% had LVH, 35% LGE. Low T1 mapping (normal <943ms) was found in 49% and 33% had high hsTnT values (normal <15ng/L). Mean T2 mapping values were 52.6±0.6ms in the BIFL wall and 49.5±0.3ms in the remote myocardium/septum (p<0.001, normal <53ms). T2 values in the BIFL wall were significantly higher among patients with LGE (58.2±6.1ms vs 49.2±3.1ms, p<0.001, Figure 1). In a per-segment analysis of 1600 segments, higher T2 values correlated positively with percentage of LGE per segment (r=0,262, p<0.001), T1 values (r=0,205, p<0.001), maximum wall thickness (r=0,253, p<0.001) and GLS values (r=0,212, p<0.001). HsTnT values were higher among patients with LGE (median of 31 vs 3ng/L in patients without LGE, p<0.001). There was a strong positive correlation between T2 values in the BIFL wall and ln(hsTnT) (r=0.776, p<0.001, Figure 2). The strongest predictor of increased hsTnT in multivariate analysis (age, sex, LVH, septum T1, T2 in the BIFL, GLS, LGE) was T2 in the BIFL wall (β=0.4, p=0.001).

Conclusions

Cardiac involvement in FD goes beyond storage (low T1 values). When LGE is present, this is almost always associated with a high T2 and troponin elevation supporting FD as a chronic inflammatory cardiomyopathy. Initial reports of LGE being fibrosis are too simplistic – LGE in FD appears to have a significant chronic inflammation/oedema component.

Diagnosis and treatment of the cardiovascular consequences of Fabry disease

Fabry disease (FD) has been a diagnostic challenge since it was first recognized in 1898, with patients traditionally suffering from considerable delay before a diagnosis is made. Cardiac involvement is the current leading cause of death in FD. A combination of improved enzyme assays, availability of genetic profiling, together with more organized clinical services for rare diseases, has led to a rapid growth in the prevalence of FD. The earlier and more frequent diagnosis of asymptomatic individuals before development of the phenotype has focussed attention on early detection of organ involvement and closer monitoring of disease progression. The high cost of enzyme replacement therapy at a time of constraint within many health economies, moreover, has challenged clinicians to target treatment effectively. This article provides an outline of FD for the general physician and summarizes the aetiology and pathology of FD, the cardiovascular consequences thereof, modalities used in diagnosis and then discusses current indications for treatment, including pharmacotherapy and device implantation.

Potential of apoptotic pathway-targeted cancer therapeutic research: Where do we stand?

Underneath the intricacy of every cancer lies mysterious events that impel the tumour cell and its posterity into abnormal growth and tissue invasion. Oncogenic mutations disturb the regulatory circuits responsible for the governance of versatile cellular functions, permitting tumour cells to endure deregulated proliferation, resist to proapoptotic insults, invade and erode normal tissues and above all escape apoptosis. This disruption of apoptosis has been highly implicated in various malignancies and has been exploited as an anticancer strategy. Owing to the fact that apoptosis causes minimal inflammation and damage to the tissue, apoptotic cell death-based therapy has been the centre of attraction for the development of anticancer drugs. Increased understanding of the molecular pathways underlying apoptosis has enabled scientists to establish unique approaches targeting apoptosis pathways in cancer therapeutics. In this review, we reconnoitre the two major pathways (intrinsic and extrinsic) targeted cancer therapeutics, steering toward chief modulators of these pathways, such as B-cell lymphoma 2 protein family members (pro- and antiapoptotic), inhibitor of apoptosis proteins, and the foremost thespian of extrinsic pathway regulator, tumour necrosis factor-related apoptosis-inducing agent. Together, we also will have a look from clinical perspective to address the agents (drugs) and therapeutic strategies adopted to target these specific proteins/pathways that have entered clinical trials.

Active contact investigation and treatment support: an integrated approach in rural and urban Sindh, Pakistan

BACKGROUND

Although household contacts of persons with tuberculosis (TB) have high rates of active TB, contact investigations are often not conducted. We present the results from a large-scale active contact investigation combined with treatment support in Sindh, Pakistan.

METHODS

Trained lay workers visited consenting smear-positive index patient homes in seven urban and 15 rural facilities. People with suspected TB were provided free transport to diagnostic centres, and sputum samples were collected for microscopy. Those diagnosed with smear-positive TB were given food baskets and sent text reminders to promote adherence.

RESULTS

From 3037 index cases, 19,191 household contacts were screened for TB symptoms and 3478 (18.1%) symptomatic persons were identified. Of these, 2160 (62.1%) produced sputum samples on the spot for testing and 490 (22.7%) had smear-positive results. TB prevalence in urban households was 1504 per 100,000 population compared to 4044/100,000 in rural households (P < 0.001) and 2553/100,000 overall. Treatment success was high, with 80.4% cured and 17.6% completing treatment.

DISCUSSION

Lay workers given basic training can conduct active contact investigations and provide treatment support to improve case detection and treatment outcomes in urban and rural areas of Pakistan. In areas with high levels of undiagnosed TB, particularly in rural areas, contact investigation should be prioritised as a means of improving case detection and early diagnosis.

Development of quantitative-fluorescence polymerase chain reaction for the rapid prenatal diagnosis of common chromosomal aneuploidies in 1,000 samples in Singapore

INTRODUCTION

We aimed to develop a rapid quantitative-fluorescence polymerase chain reaction (QF-PCR) to detect common foetal aneuploidies in the Singapore population within 48 hours of sample collection in order to alleviate parental anxiety.

METHODS

DNA from 1,000 foetal samples (978 amniotic fluids, 14 chorion villi and eight foetal blood samples) was analysed using a QF-PCR of 19 microsatellite markers located on chromosomes 13, 18, 21, X and Y. A total of 523 samples were archived before the QF-PCR analysis (archived), while QF-PCR was performed and the results obtained within 48 hours of sample collection in the remaining 477 samples (live). The results were confirmed with their respective karyotypes.

RESULTS

In total, 47 autosomal trisomies (T) were found: 30 among the archived (three T13, 12 T18, 15 T21) and 17 among the live (four T18, 13 T21) samples. The QF-PCR results were verified with their respective karyotypes. We achieved 100 percent sensitivity (lower 95 percent confidence interval [CI], 92.8 percent) and specificity (lower 95 percent CI, 99.5 percent), and the time taken from sample collection to the obtaining of results for the 477 live samples was less than 48 hours.

CONCLUSION

Prenatal diagnostic results of common chromosomal abnormalities can be released within 48 hours of sample collection using QF-PCR. Parental anxiety is alleviated and clinical management is enhanced with this short waiting time.

Refining quantitative fluorescent polymerase chain reaction for prenatal detection of X chromosomal anomalies in the major Southeast Asian populations

INTRODUCTION

This study aimed to refine the current quantitative fluorescent polymerase chain reaction (QF-PCR) screen to detect X chromosome anomalies for prenatal diagnosis in the major Southeast-Asian populations.

METHODS

100 amniotic fluid samples from Chinese, Malay and Indian origins were subjected to QF-PCR using the X chromosome markers, HPRT, X22 and AMXY, along with the autosomal marker D21S1411.

RESULTS

Out of the 100 samples tested by markers X22 and HPRT, eight samples were homozygous for both markers, of which seven were resolved by comparison with the autosomal marker D21S1411.

CONCLUSION

99 percent of samples could be tested for X chromosome copy numbers, increasing the stringency for detection of X chromosome anomalies by QF-PCR. All results were confirmed by cytogenetics.