TBX3 transfection and nodal signal pathway inhibition promote differentiation of adipose mesenchymal stem cell to cardiac pacemaker-like cells

BACKGROUND

Mesenchymal stem cells (MSCs) are known as one of the best candidate cells to produce cardiac pacemaker-like cells (CPLCs). Upregulation of TBX3 transcription factor and inhibition of the nodal signal pathway have a significant role in the formation of cardiac pacemaker cells such as sinoatrial and atrioventricular nodes, which initiate the heartbeat and control the rhythm of heart contractions. This study aimed to confirm the effects of transfection of TBX3 transcription factor and inhibition of the nodal signal pathway on differentiating adipose-derived MSCs (AD-MSCs) to CPLCs. AD-MSCs were characterized using flow cytometry and three-lineage differentiation staining.

METHODS

The transfection of TBX3 plasmid was carried out using lipofectamine, and inhibition of the nodal signal pathway was done using the small-molecule SB431542. The morphology of the cells was observed using a light microscope. Pacemaker-specific markers, including TBX3, Cx30, HCN4, HCN1, HCN3, and KCNN4, were evaluated using the qRT-PCR method. For protein level, TBX3 and Cx30 were evaluated using ELISA and immunofluorescence staining. The electrophysiology of cells was evaluated using a patch clamp.

RESULTS

The TBX3 expression in the TBX3, SM, and TBX + SM groups significantly higher (p < 0.05) compared to the control group and cardiomyocytes. The expression of Cx40 and Cx43 genes were lower in TBX3, SM, TBX + SM groups. In contrast, Cx30 gene showed higher expression in TBX3 group. The expression HCN1, HCN3, and HCN4 genes are higher in TBX3 group.

CONCLUSION

The transfection of TBX3 and inhibition of the nodal signal pathway by small-molecule SB431542 enhanced differentiation of AD-MSCs to CPLCs.

Gender Differences of Gly972Arg Polymorphism of the IRS-1 Gene Related to Cardiovascular Disease Risk Factors Among Indonesians

BACKGROUND

Cardiovascular disease is driven by traditional risk factors, sex, and genetic differences. The Asian population, specifically Indonesians, has been known at high risk of insulin resistance and endothelial dysfunction. A possible genetic risk factor related to cardiovascular diseases is Gly972Arg polymorphism of insulin receptor substrate 1 (IRS-1) gene, as this impairs endothelial function. To date, whether there is a gender difference in Gly972Arg polymorphism of the IRS-1 gene in Indonesians is unknown. This study aimed to to define whether there is a gender difference in Gly972Arg polymorphism of the IRS-1 gene in Indonesians.

METHODS

We studied adults living in two areas (rural and urban) in Indonesia. We collected demographic and clinical data from the study subjects. Gly972Arg polymorphism of the IRS-1 gene (rs1801278) was detected using TaqMan real-time polymerase chain reaction.

RESULTS

A total of 378 subjects were recruited. The wild-type allele (CC) was found in 86 (22.8%) subjects, heterozygous mutant allele (CT) in 245 (64.8%), and homozygous mutant allele in 47 (12.4%). The proportion of subjects with T alleles was significantly higher among women than men (54.6% vs. 45.4%, odds ratio: 1.89; p = 0.01). Subjects with T allele more often have hypertension (odds ratio: 1.69, p = 0.058).

CONCLUSION

There were a higher proportion of women than men carrying the T allele of Gly972Arg polymorphism among Indonesians. Individuals with the T allele appeared to show a greater prevalence of hypertension. These results may explain a possible mechanism of the high prevalence of metabolic syndrome in Indonesia, especially in women.

Simple electrocardiography algorithm for localizing accessory pathway in patients with Wolff-Parkinson-White syndrome

BACKGROUND

Existing algorithms to predict the location of an accessory pathway (AP) in Wolff-Parkinson-White Syndrome (WPW) have good sensitivity and specificity but complex with various accuracy and inter-observer agreement rates. A simple algorithm with high accuracy and inter-observer agreement rates is needed.

METHODS

This was a cross-sectional and retrospective diagnostic study. The data were collected by total population sampling from January 2015 to January 2017. Forty-seven patients were included in the study. Data collected were pre-ablation 12-lead ECGs and ablation reports. These ECGs were evaluated by two independent observers using the simplified algorithm and compared with ablation results.

RESULTS

The algorithm had a sensitivity of 45% on the left free wall, 80% on septal, 92% on the right free wall, and the specificity of 96% on the left free wall, 69% on the septal, 85% on the right free wall for AP prediction. The positive predictive value was 90% on the left free wall, 55% on the septal, and 67% on the right free wall APs. The negative predictive value was 70% on the left free wall, 88% on the septal, and 97% on right free wall AP. The positive likelihood ratio was 11.23 on the left free wall, 2.23 on septal and 6.57 on right free wall APs, and the negative likelihood ratio was 0.57 on left free wall APs, 0.28 on septal, and 0.09 on the right free wall APs. Algorithm accuracy varied from 73-87%. Inter-observer agreement calculation was kappa 0.93 for left free wall AP, 0.78 for septal AP, and 0.74 for right free wall AP.

CONCLUSION

This simple algorithm has a remarkable accuracy and inter-observer agreement; therefore, it may prove to be helpful even to non-electrophysiologists and has the potential to be integrated into clinical practice.

Rapid Atrial Fibrillation in the Emergency Department

Atrial fibrillation (AF) is the most common rhythm disorder seen in doctors' offices and emergency departments (EDs). In both settings, an AF holistic pathway including anticoagulation or stroke avoidance, better symptom management, and cardiovascular and comorbidity optimization should be followed. However, other considerations need to be assessed in the ED, such as haemodynamic instability, the onset of AF, the presence of acute heart failure and pre-excitation. Although the Advanced Cardiovascular Life Support guidelines (European Society of Cardiology guidelines, Acute Cardiac Care Association/European Heart Rhythm Association position statements) and several recent AF publications have greatly assisted physicians in treating AF with rapid ventricular response in the ED, further practical clinical guidance is required to improve physicians' skill and knowledge in providing the best treatment for patients. Herein, we combine multiple strategies with supporting evidence-based treatment and experiences encountered in clinical practice into practical stepwise approaches. We hope that the stepwise algorithm may assist residents and physicians in managing AF in the ED.

Giant lipoma in superior vena cava: A case report and literature review

INTRODUCTION

Intravascular lipomas are rare occurrences, especially in major vessels. This tumour is composed of adipocytes in a fibrous capsule that has a slow growth rate and usually shows no symptoms. There were only eight reports in the literature regarding intravascular lipoma located in the superior vena cava.

CASE PRESENTATION

A 54-year-old man had episodes of supraventricular tachycardia and atrial flutter for over a year. Preoperative radiological findings showed a giant mass that arose from the superior vena cava to the right atrium and a biopsy catheter showed that there were no signs of malignancy. The patient then underwent surgery through median sternotomy and the mass was extirpated on the highest part of the stalk that could be reached. The patient was stable and remained to show no symptoms or evidence of residual mass or stalk in 2 years follow-up.

CONCLUSION

The surgical approach in excising lipoma in SVC should be considered wisely with the support of adequate preoperative diagnosis. Since lipoma is a very slow-growing tumour, extensive manipulation that could increase surgical technique difficulty or postoperative morbidity and mortality is not necessary.

ECG characteristics of COVID ‐19 patient with arrhythmias: Referral hospitals data from Indonesia

Background

Arrhythmia is a significant clinical modifier in COVID‐19 patient outcomes. Currently, data on arrhythmia and ECG characteristics in COVID‐19 from lower middle‐income countries are limited.

Methods

COVID‐19 was confirmed by polymerase chain reaction testing of a nasopharyngeal sample. All clinical records were systematically evaluated to obtain demographic characteristics and medical comorbidities. The ECG was recorded on admission, in‐hospital, and at discharge.

Results

Total documented arrhythmia events account for 22% of patients, comprising 6% of new‐onset arrhythmia and 16% of existing arrhythmia. Atrial fibrillation is the most common arrhythmia. The ECG changes were a decrease in heart rate (91 ± 22 vs. 83 ± 20, p < .001) and an increase in the QT interval (354.7 ± 53.70 vs. 371.4 ± 59.48 msec, p < .001) from hospital admission to hospital discharge, respectively. The in‐hospital HR of 85 bpm or higher increases the risk of death (OR = 2.69, p = .019).

Conclusion

The incidence of arrhythmias in COVID‐19 patients at COVID‐19 referral hospitals in Indonesia is 22%. Atrial fibrillation is the most common arrhythmia in COVID‐19 patients. Prolongation of QRS duration from admission to discharge was related to the occurrence of new‐onset arrhythmia. The in‐hospital HR of 85 bpm or higher increased the risk of death.

OR19. Correlation between Circadian Variation of Idiopathic Ventricular Arrhytmia and Left Ventricular Intrinsic Systolic Function assessed by Speckle Tracking Echocardiography

Aims

To investigate the correlation between circadian variation of idiopathic ventricular arrhytmia (IVA) and left ventricular (LV) intrinsic systolic function.

Methods

This cross sectional study included 67 patients with IVA originated from ventricular outflow tract. All patients underwent 24-hour Holter monitoring and speckle tracking echocardiography examinations. The circadian variation of IVA burden and global longitudinal strain (GLS) were determined and statistical analysis was conducted to evaluate their correlation.

Results

A total 31 patients (46.3%) had impaired LV systolic function by GLS (-15.1% + 1.8% vs -21.3% + 2.0%; p = &lt;0.001) with less variation in circadian PVC distribution (coefficient of variation 6 hourly 26.8% + 15.6 vs 52.0 % + 28.2%; p = &lt;0.00). Impaired LV systolic function was found in 31 patients (46.3%) with less variation in circadian IVA distribution (coefficient of variation/CoV 6 hourly 26.8%+15.6) compared to patients with normal LV systolic function (CoV: 52.0%+28.2%; p = &lt;0.001). Multivariate analysis showed that less variation in circadian PVC distribution [CoV&lt;35%) is correlated with LV dysfunction (OR = 3.89, 95%CI 1.09-13.80, p = 0.036). Other independent factors were episode of non-sustained VT (OR = 14.4, 95%CI=2.36-88.55, p = 0.008), IVA burden &gt;9% (OR = 6.81, 95%CI 1.35-34.41, p = 0.020), and male gender (OR = 14.4, CI 95%=2.02-101.1, p = 0.004).

Conclusion

This study is the first to show that lack of circadian variation of IVA is associated with impaired LV systolic function by GLS. The finding of this study suggested that chronotherapy of antiarrhytmia medication may prevent the development of LV dysfunction.

OR41. Hypertension and Abnormal Renal Function Increased the Risk of Ischemic Stroke in Anticoagulated EHRA type-1 Valvular Atrial Fibrillation

Aims

Atrial fibrillation increases the risk of stroke substantially, many scores have been developed to risk stratify these patients. Most of the studies have focused on non-valvular AF. The most widely used risk stratification score is the CHA2DS2-VASC score. Unfortunately, the validation of this score in valvular AF is poor. This study aimed to evaluate the clinical factors and echocardiographic parameters related to the incidence of ischemic stroke in anticoagulated EHRA (Evaluated Heartvalves, Rheumatic or Artificial) type-1 valvular AF patients.

Methods and Results

We conducted a retrospective cohort study based on data from the Indonesian Registry on Atrial Fibrillation (OneAF). Patients with EHRA type-1 valvular AF between January 2015 and December 2019 were analysed. The clinical outcome was an ischemic stroke that occurred during the monitoring period of January 2015 - December 2019. Among 329 AF patients with mitral stenosis or prosthetic heart valves, the incidence of ischemic stroke was 17 (5.2%). Multivariate logistic regression analysis showed that two clinical factors, i.e., history of hypertension (OR 5.59; 95% CI: 1.93-16.15; p= 0.001) and estimated Glomerular Filtration Rate (eGFR) ≤59 mL/min/m2 (OR 3.62; 95% CI: 1.30-10.02; p= 0.013) were independently associated with the incidence of ischemic stroke. No echocardiographic parameters were associated with the incidence of ischemic stroke in this population.

Conclusion

We observed that two clinical factors i.e., history of hypertension and abnormal renal function, were markedly associated with stroke incidence in anticoagulated EHRA type-1 valvular AF patients.

OR7. Validation study: Association between aortoseptal angulation on echocardiography with the origin of outflow tract ventricular arrhythmias

Background

Radiofrequency ablation (RFA) has become therapeutic modality with high success rate for outflow tract ventricular arrhythmia (OTVA). Determining the origin of OTVA before ablation is important to choose the appropriate approach, avoiding multiple complications, and saving fluoroscopy time. ECG-based criteria is a method that has been widely used to predict the origin of OTVA, but it oftenly has inconsistent diagnostic value. Previous study showed that aortoseptal angulation by echocardiography might be beneficial to predict the origin of OTVA. We need to validate the result in a prospective manner.

Objective

To validate the association between aortoseptal angulation measurements by echocardiography and OTVA origin.

Methods

A validation of diagnostic study involving patients VTs/PVCs with the ECG’s morphology of LBBB and inferior axis who underwent RFA therapy. An echocardiography examination was held before RFA therapy. Aortoseptal angulation is measured on parasternal long axis (PLAX)view to measure the angle between the aortic root and interventricular septum. The origin of OTVA was determined by mapping during RFA.

Results

There were 41 subjects with a mean age of 44.7±12.6 years. Majority of subjects were patients with right OTVA (n = 34, 82.9%). The mean aortoseptal angulation of the left OTVA 127.2±2.8 was significantly smaller than the right OTVA 136.7±5.7(p &lt; 0.001). An angle below 129.2o has 71.4% sensitivity and 85.29% specificity to predict an LVOT origin.

Conclusion

This validation study proved that aortoseptal angulation measurement by echocardiography &lt;129,2o is a valid diagnostic tool to differentiate left OTVA origin with OR 10,1.

Indonesian registry on atrial fibrillation (OneAF)

BACKGROUND

Data on the optimal therapeutic international normalized ratio (INR) for non-valvular and valvular atrial fibrillation (AF) in Indonesia is currently unavailable. Therefore, we designed the Indonesian Registry on Atrial Fibrillation (OneAF) registry in order to seek a safe and beneficial range of INR in Indonesian patients with non-valvular and valvular AF.

METHODS/DESIGN

The OneAF registry is a nationwide collaboration of the Indonesian Heart Rhythm Society (InaHRS) enrolling all hospitals with cardiac electrophysiologists in Indonesia. It is a prospective, multicentre, nationwide, observational study aiming to recruit non-valvular and valvular AF patients in Indonesia. The registry was started in January 2020 with a planned 2 years of recruitment. There are 2 respondents for this registry: non-cohort and cohort respondents. Non-cohort registry respondents are AF patients at hospitals who fulfill inclusion and exclusion criteria but did not consent for a 24 month follow up. Whereas patients who consented for a 24 month follow up were included as cohort registry respondents. Key data collected includes basic sociodemographic information, symptoms and signs, medical history, results of physical examination and laboratory test, details of diagnostics and treatment measures and events.

RESULTS

Currently, a total of 1568 respondents have been enrolled in the non-cohort registry, including 1065 respondents with non-valvular AF (67.8%) and 503 respondents with valvular AF (32.2%). We believe that the OneAF registry will provide insight into the regional variability of anticoagulant treatment for AF, the implementation of rhythm/rate control approaches, and the clinical outcomes concerning cardiocerebrovascular events.

TRIAL REGISTRATION

Registered at clinicaltrials.gov (NCT04222868).

Trainees’ perceptions and expectations of formal academic mentoring during the COVID-19 pandemic in Indonesian cardiology residency programs

PURPOSE

During medical residency programs, physicians develop their professional identities as specialists and encounter high expectations in terms of achieving competencies. The responsibilities of medical trainees include caring for patients, balancing work with personal life, and weathering stress, depression, and burnout. Formal academic mentoring programs strive to ease these burdens. The coronavirus disease 2019 (COVID-19) pandemic has altered the trainee–academic mentor relationship, and solutions are needed to address these challenges. The present study aimed to evaluate the formal academic mentoring process through trainees’ perceptions and expectations of formal mentoring programs during COVID-19 in Indonesian cardiology residency programs.

METHODS

This cross-sectional study used a self-administered online questionnaire to capture trainees’ perceptions and expectations regarding academic mentoring programs in 3 cardiology residency programs in Indonesia from October to November 2020. The questionnaire was developed before data collection. Perceptions of the existing mentoring programs were compared with expectations.

RESULTS

Responses were gathered from 169 out of 174 residents (response rate, 97.3%). Most trainees reported having direct contact with COVID-19 patients (88.82%). They stated that changes had taken place in the mode and frequency of communication with their academic advisors during the pandemic. Significant differences were found between trainees’ perceptions of the existing mentoring programs and their expectations for academic mentoring programs (P<0.001).

CONCLUSION

Despite the challenges of interacting with their academic mentors, trainees still perceived academic mentors as a vital resource. Study programs need to consider trainees’ expectations when designing academic mentoring programs.

Incidence and impact of cardiac arrhythmias in coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis

BACKGROUND

Studies have shown that cardiac arrhythmias may occur in up to 44% of patients with severe coronavirus disease 2019 (COVID-19) and has been associated with an increased risk of death. This systematic review and meta-analysis aimed to evaluate the incidence of cardiac arrhythmias in patients with COVID-19 and their implications on patient prognosis.

METHODS

We performed a systematic literature search from PubMed, SCOPUS, Europe PMC, Cochrane Central Databases, and Google Scholar + Preprint Servers. The primary endpoint of the study was poor outcomes including mortality, severe COVID-19, and the need for ICU care.

RESULTS

A total of 4 studies including 784 patients were analyzed. The incidence of arrhythmia in patients with COVID-19 was 19% (9-28%; I²: 91.45). Arrhythmia occurred in 48% (38-57%; I²: 48.08) of patients with poor outcome and 6% (1-12%; I²: 85.33%) of patients without poor outcome. Patients with COVID-19 experiencing arrhythmia had an increased risk of poor outcome (RR 7.96 [3.77, 16.81], p < 0.001; I²: 71.1%). The funnel-plot analysis showed an asymmetrical funnel plot with most of the studies on the right side of the effect estimate. The regression-based Egger's test showed indication of small-study effects (p = 0.001).

CONCLUSION

Cardiac arrhythmias were significantly associated with an increased risk of poor outcome in COVID-19. Arrhythmias were observed in 19% of patients with COVID-19 and in 48% of patients with COVID-19 and poor outcomes.

Elevated N-terminal pro-brain natriuretic peptide is associated with increased mortality in patients with COVID-19: systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to assess the association between N-terminal pro-brain natriuretic peptide (NT-proBNP) and mortality in patients with COVID-19.

METHODS

Systematic literature search from several electronic databases were performed. The outcome was mortality (non-survivor) in patients with COVID-19 pneumonia. NT-proBNP data were in continuous variable (pg/mL), dichotomous data (elevated/non-elevated) and effect estimate adjusted to cardiac injury/elevated biomarkers of cardiac injury.

RESULTS

A total of 967 patients from six studies were included in this analysis. NT-proBNP was higher in non-survivor group (standardised mean difference 0.75 (0.44, 1.07), p<0.001; I2: 61%). Elevated NT-proBNP was associated with increased mortality (RR 3.63 (92.21, 5.95), p<0.001; I2: 60%). Sensitivity analysis by removing a study reduces heterogeneity (risk ratio 3.47 (2.36, 5.11), p<0.001; I2: 49%). Pooled adjusted HR (adjusted to cardiac injury/elevated biomarkers of cardiac injury) showed that elevated NT-proBNP was independently associated with mortality (HR 1.37 (1.19, 1.57), p<0.001; I2: 0%, p=0.77). Pooled analysis of multiple cut-off point resulted in a sensitivity of 76% (46%-92%) and specificity of 88% (71%-96%). Summary receiver operating characteristic curve analysis demonstrates an area under curve of 0.90 (0.87-0.93). Elevated NT-proBNP has a likelihood ratio (LR) +6.4 and LR -0.3.

CONCLUSION

Elevated NT-proBNP level was associated with increased mortality in COVID-19 pneumonia.

Efficacy and safety of renal denervation in addition to pulmonary vein isolation for atrial fibrillation and hypertension-Systematic review and meta-analysis of randomized controlled trials

Introduction

This systematic review and meta‐analysis aimed to assess the latest evidence on the use of renal denervation (RDN) + pulmonary vein isolation (PVI) compared to PVI alone for treating atrial fibrillation (AF) with hypertension.

Methods

A systematic literature search from several electronic databases was performed up until January 2020. The primary outcome was AF recurrence defined as AF/atrial flutter (AFL)/atrial tachycardia (AT) ≥30 seconds at 12‐month follow‐up and the secondary outcome was procedure‐related complications.

Results

There were 568 subjects from five studies. AF recurrence was 90/280 (32.1%) in the RDN + PVI group and 142/274 (51.8%) in the PVI group. RDN + PVI was associated with a lower incidence of AF recurrence (RR 0.62 [0.51, 076], P < .001; I²: 0%). Pooled analysis of HR showed that RDN + PVI was associated with reduced AF recurrence (HR 0.51 [0.38, 0.70], P < .001; I²: 0%). Complications were 7/241 (2.9%) in the RDN + PVI group and 8/237 (3.4%) in the PVI group. The rate of complications between the groups was similar (RR 0.87 [0.33, 2.29], P = .77; I²: 0%). In the subgroup analysis of paroxysmal AF, RDN + PVI was shown to reduce AF recurrence (RR 0.64 [0.49, 0.82], P < .001; I²: 0% and HR 0.56 [0.38, 0.82], P = .003; I²: 0%) compared to PVI alone. RDN + PVI has a moderate certainty of evidence in the reducing AF recurrence with an absolute reduction of 197 fewer per 1000 (from 254 fewer to 124 fewer).

Conclusion

RDN in addition to PVI, is associated with reduced 12‐month AF recurrence and similar procedure‐related complications compared to PVI alone.

Hypertension is associated with increased mortality and severity of disease in COVID-19 pneumonia: A systematic review, meta-analysis and meta-regression

OBJECTIVE

To investigate the association between hypertension and outcome in patients with Coronavirus Disease 2019 (COVID-19) pneumonia.

METHODS

We performed a systematic literature search from several databases on studies that assess hypertension and outcome in COVID-19. Composite of poor outcome, comprising of mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care unit (ICU) care and disease progression were the outcomes of interest.

RESULTS

A total of 6560 patients were pooled from 30 studies. Hypertension was associated with increased composite poor outcome (risk ratio (RR) 2.11 (95% confidence interval (CI) 1.85, 2.40), p < 0.001; I2, 44%) and its sub-group, including mortality (RR 2.21 (1.74, 2.81), p < 0.001; I2, 66%), severe COVID-19 (RR 2.04 (1.69, 2.47), p < 0.001; I2 31%), ARDS (RR 1.64 (1.11, 2.43), p = 0.01; I2,0%, p = 0.35), ICU care (RR 2.11 (1.34, 3.33), p = 0.001; I2 18%, p = 0.30), and disease progression (RR 3.01 (1.51, 5.99), p = 0.002; I2 0%, p = 0.55). Meta-regression analysis showed that gender (p = 0.013) was a covariate that affects the association. The association was stronger in studies with a percentage of males < 55% compared to ⩾ 55% (RR 2.32 v. RR 1.79).

CONCLUSION

Hypertension was associated with increased composite poor outcome, including mortality, severe COVID-19, ARDS, need for ICU care and disease progression in patients with COVID-19.

Serum Galectin-3 level and recurrence of atrial fibrillation post-ablation - Systematic review and meta-analysis

BACKGROUND

Serum galectin-3, a circulating biomarker of fibrosis, has been associated with atrial remodelling. Recent studies investigating serum galectin-3 and AF recurrence post-ablation have shown mixed results. We aimed to analyze the latest evidence on the association between serum galectin-3 and AF recurrence after catheter ablation.

METHODS

We performed a comprehensive search on topics that assesses serum galectin-3 and AF recurrence post-ablation up until August 2019.

RESULTS

There were 597 patients from seven studies. The mean difference of serum galectin-3 was similar in both AF recurrence and non AF recurrence group (mean difference 0.78 ng/mL [-0.56, 2.13]; p = 0.25; I2: 69%. Upon removal of a study in sensitivity analysis, the serum galectin-3 became higher in AF recurrence group (mean difference 1.41 ng/mL [0.47, 2.34], p = 0.003; I2: 17%). Serum galectin-3 was associated with a higher risk for AF recurrence (HR 1.25 [1.01, 1.55]; p = 0.04; I2: 76%). Upon removal of a study in sensitivity analysis, HR became 1.45 [1.07, 1.96], p = 0.02; I2: 47%. Meta-analysis of adjusted HR demonstrated that high serum galectin-3 independently predicts AF recurrence (HR 1.15 [1.02, 1.29], p < 0.02; I2: 57%, p = 0.10) CONCLUSION: Serum galectin-3 is associated with an increased risk of AF recurrence post-ablation. Further studies are required, especially emphasis on the cut-off point should be given, before integrating it in routine risk stratification for AF ablation.

P194 Trimetazidine preserves right ventricular function on pulmonary arterial hypertension patients in national cardiovascular center harapan kita hospital indonesia

Funding Acknowledgements

National Cardiovascular Center Harapan Kita Hospital

Background

Right ventricular dysfunction is the worst mortality predictor in pulmonary arterial hypertension (PAH). Recent animal PAH studies have demonstrated the benefit of partial fatty acid inhibitor such as trimetazidine in improving right ventricular function. Therefore, we hypothesize that trimetazidine can improve right ventricular ejection fraction (RVEF) in PAH patients.

Purpose

Investigating the effect of  trimetazidine on right ventricle function in PAH patients.

Methods

We conducted 3 months randomized double blind placebo controlled trial on PAH patients at outpatient clinic in National Cardiovascular Center Harapan Kita Hospital Indonesia. Those who fulfilled the inclusion criteria will be randomized into trimetazidine or placebo group for 3 months on top of their standard PAH regime. Clinical and cardiovascular magnetic resonance imaging (CMR) parameters will be evaluated before and after 3 months therapy. The primary outcome of this study is the differences of RVEF from CMR.

Results

We randomly enrolled 26 PAH patients equally to receive placebo or trimetazidine for 3 months on top of their standard PAH regime. Total of 10 patients in each group was able to finish the study. There was significant improvement of RVEF in trimetazidine group 3.78 + 1.5% compared to placebo 2.76 + 1.6% (p 0.008, CI 1.96 to 10.96). Furthermore, we also observed improvement of functional capacity in trimetazidine group 0.24 + 0.09 compared to placebo -0.44 + 0.16 (p 0.002, CI 0.28 s/d 1.08).

Conclusions

Trimetazidine therapy for 3 months on top of standard PAH regime significantly improve RVEF and functional capacity in PAH patients.

Abstract P194 Figure. Effect of trimetazidine on RV function

Electrocardiographic early repolarization is associated with future ventricular arrhythmia after acute myocardial infarction-Systematic Review and Meta-Analysis

BACKGROUND

Early repolarization (ER) has been linked to ventricular arrhythmia (VA) and sudden cardiac death in patients without structural heart disease. We aimed to assess the latest evidence on whether ER is associated with future VA after acute myocardial infarction (AMI).

METHODS

We performed a comprehensive search on the topic that assesses ER and VA/adverse cardiovascular events in AMI. We included studies with sufficient details on ER and VA, we also performed a meta-analysis on their morphology.

RESULTS

A total of 3350 subjects from 9 studies were included. Five hundred and twenty-one (15.55%) had ER and 2829 (84.45%) did not. On meta-analysis, ER (+) in AMI was associated with VA with a pooled odds ratio (OR) of 3.58 (2.70-4.73), P < 0.001; heterogeneity I 2 34%. Subgroup analysis of patients with ST-segment elevation myocardial infarction (STEMI) showed an OR of 2.79 [1.98-3.93], P < 0.001; heterogeneity I 2 0%. Inferior location of ER (+) was associated with VA OR 3.98 [1.86-8.53], P = 0.008; I 2 67%. Notching had a 5.41 [3.52-8.32], P < 0.001; low heterogeneity I 2 0% of having VA. Pooled OR for J-point elevation was 4.72 [2.63-8.46], P < 0.001; I 2 25%. Horizontal ST-segment was associated with VA with an OR of 4.30 [1.89-975], P < 0.001; I 2 59%. Lateral location and slurred morphology were not associated with VA. Upon sensitivity analysis for inferior location and horizontal ST-segment, removal of a study reduces heterogeneity significantly.

CONCLUSION

Early repolarization especially those with the inferior location, notching morphology, an elevated J-point and horizontal ST-segment had a higher likelihood of VA in AMI including STEMI patients.

Association between PR Interval, First-degree atrioventricular block and major arrhythmic events in patients with Brugada syndrome - Systematic review and meta-analysis

BACKGROUND

Risk stratification in patients with asymptomatic Brugada Syndrome is challenging, and despite recent advances, there is no clear evidence. The first-degree atrioventricular block was hypothesized to be a predictor of arrhythmic events. Measurement of the PR interval and diagnosing atrioventricular block from surface ECG is easy, noninvasive, and cost-effective. We aimed to assess the latest evidence on PR interval or first-degree atrioventricular block and major arrhythmic events related to Brugada Syndrome.

METHODS

We performed a comprehensive search in PubMed for "atrioventricular block" OR "PR interval" and "Brugada syndrome." We included studies that have a component of PR interval and/or first-degree atrioventricular block and major arrhythmic events related to Brugada Syndrome including syncope/VT/VF/appropriate ICD shocks/ICD implantation.

RESULTS

We included 1526 subjects from 7 studies. Pooled mean difference of PR interval in 4 studies showed a significant difference [MD 10.77 ms (2.97-18.57) P = 0.007, moderate-high heterogeneity I2 = 53% P = 0.08]. On sensitivity analysis by removing a study, it became MD 6.50 ms [1.97-11.03], P = 0.005, heterogeneity I2 = 0% P = 0.52. Indicating that PR interval was prolonged by small margin. Pooled analysis of the association between a first-degree atrioventricular block and major arrhythmic events was significant [OR 3.33 (2.02-5.50) P < 0.001, low heterogeneity I2 = 0% P = 0.57].

CONCLUSION

First-degree AV block is associated with more frequent major arrhythmic events in Brugada syndrome patients. PR interval seemed to be prolonged but is yet to be determined whether the PR interval association is still significant if it did not cross the first-degree AVB threshold.

Evidence-Based Case Report: The Use of D-Dimer Assay to Exclude Left Atrial Thrombus in Patient with Atrial Fibrillation >48 Hours

Introduction

Patients with atrial fibrillation (AF) for >48 hours who are a candidate for cardioversion should have transesophageal echocardiography (TEE) performed to exclude left atrial thrombus (LAT) that may cause systemic thromboembolism upon conversion to sinus rhythm. However, TEE facilities were limited, especially in developing countries.

Case Illustration

A 50 years-old man presented with exertional dyspnea and palpitation for 72 hours prior to admission. Electrocardiography showed AF with a ventricular rate of 140x/minute. Cardioversion was decided to be the best approach. This patient has an AF >48 hours of onset, hence, LAT should be excluded by the use of TEE. Unfortunately, there was no TEE facility nearby.

Discussion

Upon comprehensive search on the use of D-Dimer assay to exclude the LAT in AF patients, we found seven studies showed increased D-dimer level in those with left atrial thrombus. In 4 studies, AUC was > 0.70, sensitivity and specificity varied from 75.9% to 89% and 73.1% to 95% respectively. However, there is no single cut-off point, due to the heterogeneity of cut-off points.

Conclusion

D-dimer assay combined with other variables of atrial thrombus exclusion score is valuable in excluding LAT. Previously, weeks of anticoagulation is more advisable before attempting cardioversion in the absence of nearby TEE facilities. With current evidence, a low D-dimer and ATE score of 0 is safe for cardioversion.

SCN5A gene mutations and the risk of ventricular fibrillation and syncope in Brugada syndrome patients: A meta-analysis

Mutations in the gene encoding the main cardiac sodium channel (SCN5A) are the commonest genetic cause of Brugada syndrome (BrS). However, the effect of SCN5A mutations on the outcomes of ventricular fibrillation (VF) and syncope remains uncertain. To clarify this relationship, a meta-analysis was performed. A comprehensive search was conducted to identify all eligible studies from PubMed, MEDLINE, EBSCO, ProQuest, Science Direct, Clinical Key, and Cochrane database for cohort studies of BrS populations that had been systematically tested for SCN5A mutations. We did meta-analysis to see the relationship between SCN5A mutations and the occurrence of VF and/or syncope using RevMan 5.3. Five clinical studies met our criteria and included a total of 665 BrS patients. These studies included 45 patients with VF and 178 patients with syncope. We found that in BrS patients with SCN5A mutations the rate of VF event was 30.7% while in patients without mutations was 28.5% (Risk Ratio [RR] = 1.11, [95% CI: 0.61, 2.00], P = 0.73, I 2 = 0%). The occurrence of syncope events was 35.9% in patients with SCN5A mutations and 34.5% in patients without mutations (RR = 1.12, [95% CI: 0.87, 1.45], P = 0.37, I 2 = 39%). Furthermore, the occurrence of combined VF and syncope events were similar between the 2 groups (RR = 1.12, [95% CI: 0.89, 1.42], P = 0.34, I 2 = 11%). BrS patients with SCN5A mutations exhibit a similar risk of future occurence of VF and/or syncope as compared to those without SCN5A mutations.

A novel noninvasive surface ECG analysis using interlead QRS dispersion in arrhythmogenic right ventricular cardiomyopathy

Background

This study investigated the feasibility of using the precordial surface ECG lead interlead QRS dispersion (IQRSD) in the identification of abnormal ventricular substrate in arrhythmogenic right ventricular cardiomyopathy (ARVC).

Methods

Seventy-one consecutive patients were enrolled and reclassified into 4 groups: definite ARVC with epicardial ablation (Group 1), ARVC with ventricular tachycardia (VT, Group 2), idiopathic right ventricular outflow tract VT without ARVC (Group 3), and controls without VT (Group 4). IQRSD was quantified by the angular difference between the reconstruction vectors obtained from the QRS-loop decomposition, based on a principal component analysis (PCA). Electroanatomic mapping and simulated ECGs were used to investigate the relationship between QRS dispersion and abnormal substrate.

Results

The percentage of the QRS loop area in the Group 1–2 was smaller than the controls (P = 0.01). The IQRSD between V1-V2 could differentiate all VTs from control (P<0.01). Group 1–2 had a greater IQRSD than the Group 3–4 (V4-V5,P = 0.001), and Group 1 had a greater IQRSD than Group 3–4 (V6-Lead I, P<0.001). Both real and simulated data had a positive correlation between the maximal IQRSD (γ = 0.62) and the extent of corresponding abnormal substrate (γ = 0.71, both P<0.001).

Conclusions

The IQRSD of the surface ECG precordial leads successfully differentiated ARVC from controls, and could be used as a noninvasive marker to identify the abnormal substrate and the status of ARVC patients who can benefit from epicardial ablation.

Characteristics of diurnal ventricular premature complex variation in right ventricular outflow tract arrhythmias after catheter ablation

Diurnal variations in ventricular tachyarrhythmias (VAs) have been demonstrated in idiopathic arrhythmogenic heart disease. The electrophysiological characteristics of diurnal variations in idiopathic right ventricular outflow tract (RVOT) VA have not previously been elucidated. Sixty-two consecutive patients undergoing catheter ablation for idiopathic RVOT VA (mean age: 42.8 ± 12.3 years, 35 females) were enrolled. The diurnal variation type (group 1, n = 36) was defined as those patients who had most ventricular premature contractions (VPCs) during the night hours by preprocedure Holter recordings. Group 2 (n = 26) was defined as those patients who did not have significant VPC variations. The baseline characteristics and electrophysiological properties were collected and analyzed, and the rates of recurrence after catheter ablation were compared between the 2 groups. In this study, heart rate variability analysis demonstrated lower low frequency/high frequency ratios in group 1 than in group 2 (3.95 ± 3.08 vs 6.26 ± 5.33; P = 0.042). There were no significant differences in baseline characteristics, echocardiography and electrophysiological characteristics between the 2 groups. During a mean follow-up period of 13.5 ± 11.0 months, a total of 16 patients had VA recurrences, including 13 patients from group 1 and 3 patients from group 2 (36.1% vs 12.5%, P = 0.039). This study demonstrated the effect of the autonomic nervous system in idiopathic RVOT VAs and that the diurnal variation type leads to a higher recurrence rate after catheter ablation.

A novel method to enhance phenotype, epicardial functional substrates, and ventricular tachyarrhythmias in Brugada syndrome

BACKGROUND

Fever is associated with the manifestation of Brugada phenotype and ventricular tachycardia/ventricular fibrillation (VT/VF) in patients with Brugada syndrome (BrS). The thermal effect on the pathogenesis of functional substrates in BrS remains unknown.

OBJECTIVE

This study aimed to elucidate the thermal effect on BrS phenotype, VT/VF, and electrophysiological characteristics of epicardial functional substrates in BrS.

METHODS

We consecutively studied 15 patients with BrS receiving radiofrequency catheter ablation for drug-refractory ventricular tachyarrhythmias. Baseline characteristics, electrocardiographic features, and changes in epicardial functional substrates before and after epicardial warm water instillation (n = 6) were recorded and analyzed.

RESULTS

A total of 15 male patients (mean age 41.3 ± 10.3 years) with type 1 BrS presenting with ventricular tachyarrhythmias were consecutively enrolled. Epicardial mapping in 11 patients demonstrated a significantly larger epicardial scar/low-voltage zone (LVZ) area within the right ventricular outflow tract and anterior right ventricular free wall than within the endocardium (6.32 ± 12.74 cm² vs 52.91 ± 45.25 cm²; P = .007). Epicardial warm water instillation in 6 patients led to a significant enlargement of the functional scar/LVZ area (123.83 ± 35.26 cm² vs 63.53 ± 40.57 cm²; P = .03), accelerated conduction velocity of the endocardium and epicardium without scar/LVZ area, and increased VT/VF inducibility (16.7% vs 100%; P = .02). Ablation by targeting premature ventricular complexes and/or epicardial abnormal substrates rendered noninducibility of VT/VF and prevented the recurrences of VT/VF.

CONCLUSION

Epicardial warm water instillation enhanced functional epicardial substrates, which contributed to the increased inducibility of ventricular tachyarrhythmias in BrS. Ablation by targeting the triggers and abnormal epicardial substrates provided an effective strategy for preventing ventricular tachyarrhythmia recurrences in BrS.

Right ventricular dysfunction as predictor of longer hospital stay in patients with acute decompensated heart failure: a prospective study in Indonesian population

BACKGROUND

Hospital length of stay (LOS) is a key determinant of heart failure hospitalization costs. Longer LOS is associated with lower quality of care measures and higher rates of readmission and mortality. Right ventricular (RV) dysfunction predicted poor outcomes in patients with stable chronic heart failure (CHF), however, its prognostic value in the acute decompensated heart failure (ADHF) patients has not been sufficiently clarified. This study investigated the prognostic value of RV dysfunction in predicting longer LOS in ADHF patients.

METHODS

A prospective cohort study was conducted in National Cardiovascular Center Harapan Kita to all patients admitted with ADHF. Clinical data and baseline RV function assessed by tricuspid annular plane systolic excursion (TAPSE) were collected. Clinical comorbidities including malnutrition, pneumonia and worsening renal function (WRF) were monitored during hospitalization. The primary outcome was hospital LOS. Cox regression analysis was used to identify independent predictors for longer LOS.

RESULTS

Two hundred and fifty-nine ADHF patients were included in this cohort study. On time-to-event analysis, diastolic blood pressure (HR = 1.011; 95 % CI = 1.004-1.018; p = 0.002), hemoglobin levels (HR = 1.102; 95 % CI = 1.045-1.162; p < 0.001), RV function (HR = 0.659; 95 % CI = 0.506-0.857; p = 0.002), WRF (HR = 2.015; 95 % CI = 1.520-2.670; p < 0.001) and malnutrition (HR = 5.965; 95 % CI = 4.402-8.082; p < 0.001) were associated with longer LOS. In a multivariate Cox regression model, RV function (HR = 0.466; 95 % CI = 0.238-0.915; p = 0.026), WRF (HR = 2.985; 95 % CI = 2.032-4.386; p < 0.001) and malnutrition (HR = 7.479; 95 % CI = 5.071-11.030; p < 0.001) were the independent predictors of longer hospital LOS. Based on the median TAPSE values, patients with TAPSE ≤ 16 mm had significantly longer LOS (HR = 2.227; 95 % CI = 1.103-4.494; p = 0.026) compared to those with TAPSE > 16 mm.

CONCLUSIONS

Right ventricular dysfunction, WRF and malnutrition are important predictors of longer LOS. This is the first study to describe that in ADHF patients, lower the TAPSE resulted in longer the LOS.

Dual ECE/NEP inhibition on cardiac and neurohumoral function during the transition from hypertrophy to heart failure in rats

CGS 26303 is a vasopeptidase inhibitor that simultaneously inhibits endothelin-converting enzyme (ECE) and neutral endopeptidase (NEP). We compared the effects of chronic treatment with CGS 26303 to the selective inhibition of angiotensin-converting enzyme (ACE) and NEP during the transition from left ventricular hypertrophy (LVH) to congestive heart failure (CHF) in hypertensive rats. LV geometry and function were assessed in Dahl salt-sensitive rats placed on a high-salt diet from age 6 weeks (hypertensive rats) and in control rats fed a low-salt diet. The hypertensive rats were randomized into groups that received no treatment or were treated with an ACE inhibitor (temocapril), an ECE/NEP inhibitor (CGS 26303), or a NEP inhibitor (CGS 24592) from the LVH stage (11 weeks) to the CHF stage (17 weeks). All treatments decreased the systolic blood pressure equally and significantly improved LV fractional shortening. Both temocapril and CGS 26303 ameliorated LV perivascular fibrosis, reduced mRNA levels of types I and III collagen, and decreased the heart weight/body weight ratio. CHF rats had increased plasma ET-1 levels compared with control rats. Only CGS 26303 reduced ET-1 to normal levels. ET-1 levels were found to correlate with heart/body weight, right ventricle/body weight and perivascular fibrosis ratios. During the transition to CHF, CGS 26303 produces effects that are comparable to temocapril and superior to CGS 24592. The beneficial effects of CGS 26303 are likely caused in part by the greater reduction of plasma ET-1. Dual ECE/NEP inhibitor may provide a new strategy for the treatment of human heart failure.

The effects of phosphoramidon on the expression of human endothelin-converting enzyme-1 (ECE-1) isoforms

Endothelin-1 (ET-1) is generated from big ET-1 by endothelin converting enzyme-1 (ECE-1). This process is inhibited by phosphoramidon through binding to the catalytic domain of ECE-1. There are four isoforms of human ECE-1 (ECE-1a, ECE-1b, ECE-1c and ECE-1d) which possess a conserved catalytic domain. Interestingly, a recent study has shown that in ECE-1b-transfected CHO cells phosphoramidon increases the expression and activity of ECE-1b. It is not known, however, whether phosphoramidon has similar effects on the expression of other ECE-1 isoforms. To address this point, we have established recombinant CHO cell lines that permanently express either human ECE-1a, ECE-1b or ECE-1c. Incubation of CHO/ECE-1a, -1b, and -1c with phosphoramidon (100 microM) for 16 hours markedly elevated the intracellular expression of ECE-1a and ECE-1b, but not ECE-1c protein, as indicated by Western blotting and immunocytochemistry. These increases appear to be due to inhibition of intracellular degradation of the protein because metabolic labeling followed by immunoprecipitation showed ECE-1a and ECE-1b proteins had prolonged half-lives in the phosphoramidon-treated cells. This is further supported by the finding that ECE-1 mRNA levels were unchanged following phosphoramidon treatment. Taken together, our results demonstrate that phosphoramidon differentially affects the expression of three human ECE-1 isoforms.

Angiotensin II induces circadian gene expression of clock genes in cultured vascular smooth muscle cells

BACKGROUND

Daily rhythms of mammalian physiology and endocrinology are regulated by circadian pacemakers. The master circadian pacemaker resides in the suprachiasmatic nucleus, which is located in the hypothalamus of the brain, but circadian oscillators also exist in peripheral tissues. Because many studies have demonstrated apparent circadian variations in the frequency of cardiovascular disorders, it is of great interest to investigate a possible relation between circadian gene expression and cardiovascular function. We examined whether a circadian oscillation system exists in the aorta and/or in cultured vascular smooth muscle cells (VSMCs).

METHODS AND RESULTS

The mRNA levels of clock genes were assayed by northern blot analysis. The mouse aorta showed a clear circadian oscillation in the expression of mPer2, dbp, and Bmal1. Brief treatment of VSMCs with angiotensin II induced a robust increase in mPer2 gene expression, followed by a marked reduction in mPer2 mRNA levels and subsequent synchronous cycling of mPer2, dbp, and Bmal1 mRNAs. The induction of mPer2 in VSMCs by angiotensin II was completely abolished by treatment with CV11947, a specific angiotensin II type1 receptor antagonist.

CONCLUSIONS

The present results demonstrate that the aorta and VSMCs possess a circadian oscillation system which is comparable to that of the suprachiasmatic nucleus and that the circadian gene expression in VSMCs is induced by angiotensin II through the angiotensin II type1 receptor. Our in vitro system will provide a useful tool to further analyze the physiological significance of the peripheral clock in cardiovascular function.

Alternative splicing regulates the endoplasmic reticulum localization or secretion of soluble secreted endopeptidase

A subfamily of zinc metalloproteases, represented by Neutral endopeptidase (EC ) and endothelin-converting enzyme, is involved in the metabolism of a variety of biologically active peptides. Recently, we cloned and characterized a novel member of this metalloprotease family termed soluble secreted endopeptidase (SEP), which hydrolyzes many vasoactive peptides. Here we report that alternative splicing of the mouse SEP gene generates two polypeptides, SEP(Delta) and SEP. After synthesis, both isoforms are inserted into the endoplasmic reticulum (ER) as type II membrane proteins. SEP(Delta) then becomes an ER resident, whereas SEP, which differs by only the presence of 23 residues at the beginning of its luminal domain, is proteolytically cleaved by membrane secretase(s) in the ER and transported into the extracellular compartment. An analysis of the chimeric proteins between SEP(Delta) and bovine endothelin-converting enzyme-1b (bECE-1b) demonstrated that the retention of SEP(Delta) in the ER is mediated by the luminal domain. In addition, the dissection of the chimeric bECE-1b/SEP insertion showed that its insertion domain is obviously responsible for its secretion. A series of mutagenesis in this region revealed that the minimal requirement for cleavage was found to be a WDERTVV motif. Our results suggest that the unique subcellular localization and secretion of SEP proteins provide a novel model of protein trafficking within the secretory pathway.

Molecular identification and characterization of novel membrane-bound metalloprotease, the soluble secreted form of which hydrolyzes a variety of vasoactive peptides

One class of zinc metalloproteases, represented by neutral endopeptidase 24.11 and endothelin-converting enzyme, has been shown to be involved in proteolytic activation or inactivation of many regulatory peptides. Here, we report molecular cloning and characterization of a novel member of this type II membrane-bound metalloprotease family, termed soluble secreted endopeptidase (SEP). Alternative splicing results in the generation of another transcript, SEP(Delta), which lacks a 69-base pair nucleotide segment following the transmembrane helix. Both SEP and SEP(Delta) mRNA are detected in all mouse tissues examined. Transfection of an SEP cDNA expression construct resulted in the expression of the membrane-bound form of SEP in the early secretory pathway as well as the soluble secreted form of the enzyme in the culture medium. In contrast, transfection of the SEP(Delta) cDNA only results in the expression of the membrane-bound form. In vitro enzymological analysis of the recombinant soluble form of SEP demonstrated that it hydrolyzes a variety of vasoactive peptides, including endothelin-1, atrial natriuretic peptide, and angiotensin I. This activity of SEP was inhibited by phosphoramidon and the neutral endopeptidase 24.11 specific inhibitor thiorphan, but it was only partially inhibited by the endothelin-converting enzyme specific inhibitor FR901533. These findings suggest that SEP is a novel metalloprotease that possesses a broad substrate specificity and that it may be involved in the metabolism of biologically active peptides intracellulary as well as extracellularly.