Impact of Persistent Inflammation, Immunosuppression, and Catabolism Syndrome during Intensive Care Admission on Each Post-Intensive Care Syndrome Component in a PICS Clinic

BACKGROUND

Persistent inflammation, immunosuppression, and catabolism syndrome (PIICS) is known as a prolonged immunodeficiency that occurs after severe infection. Few studies have demonstrated a direct relationship between PIICS and physical dysfunction in post-intensive care syndrome (PICS). We herein investigated how each component of PICS was affected by the diagnosis of PIICS during hospitalization and examined the relationship between PIICS and PICS using PICS assessments performed at the Hitachi General Hospital PICS Clinic.

METHODS

The 273 patients who visited the PICS clinic at one month after discharge from the ICU at Hitachi General Hospital were included in the study. We used the diagnostic criteria for PIICS described in previous studies. At least two of the following blood test values on day 14 of hospitalization had to be met for a diagnosis of PIICS: C-reactive protein (CRP) > 2.0 mg/dL, albumin (Alb) < 3.0 g/dL, and lymphocytes (Lym) < 800/μL. Blood test values closest to day 14 out of 11-17 days of hospitalization were used. The primary outcome was a Barthel Index (BI) < 90, while secondary outcomes were the results of various PICS assessments, including mental and cognitive impairments, performed at the PICS clinic. We supplemented missing data with multiple imputations by chained equations. We performed a nominal logistic regression analysis with age, sex, BMI, SOFA, and the presence of PIICS as variables for BI < 90.

RESULTS

Forty-three out of two hundred seventy-three PICS outpatients met the diagnostic criteria for PIICS during hospitalization. In comparisons with non-PIICS patients, significantly higher severity scores for APACHE II and SOFA and a longer hospital stay were observed in PIICS patients, suggesting a higher clinical severity. The primary outcome, BI, was lower in the PIICS group (97.5 (58.5, 100) vs. 100 (95, 100), p = 0.008), as were the secondary outcomes (FSS-ICU: 35 (31, 35) vs. 35 (35, 35), MRC score: 55 (50.25, 58) vs. 58 (53, 60), grip strength: 16.45 (9.2, 25.47) vs. 20.4 (15.3, 27.7)). No significant differences were noted in mental or cognitive function assessments, such as HADS, IES-R, and SMQ. A multivariable analysis supplemented with missing data revealed that PIICS (odds ratio: 1.23 (1.08-1.40 p = 0.001) and age (odds ratio: 1.007 (1.004-1.01), p < 0.001) correlated with BI < 90, independent of clinical severity such as sequential organ failure assessment (SOFA). Similar results were obtained in the sensitivity analysis excluding missing data.

CONCLUSIONS

The present study revealed a strong relationship between PIICS and post-discharge PICS physical dysfunction in patients requiring intensive care.

PI3K/mTOR Inhibitor Dactolisib Attenuates Allergic Response Through Inhibitions of the Sensitization and Mast Cell Activation

The aim of this study was to evaluate the anti-allergic potentials of dactolisib, a dual PI3K/mTOR kinase inhibitor, on two important events for allergy: sensitization and the onset of anaphylactic symptoms. After sensitization with the antigen ovalbumin (OVA), five successive oral administrations of dactolisib effectively decreased serum anti-OVA antibody-an indicator of sensitization-levels in mice. In parallel with the antibody levels in their serum, anaphylactic rectal temperature decrease induced by the re-administration of OVA to dactolisib-treated mice was strongly diminished compared to that in vehicle-treated mice. The inhibitor also inhibited ex vivo splenic B cell activation indicated by the increase of phosphorylation of Akt, CD69 expression levels, and proliferation upon anti-B cell receptor antibody treatment, suggesting that suppressive effects of the inhibitor on B cell activation plays a role in its ability to decrease sensitization in vivo. We concurrently observed the anti-anaphylactic ability of dactolisib in vivoand in vitro. A single oral administration of the inhibitor attenuated the anaphylactic rectal temperature decrease induced in a mouse model of passive systemic anaphylaxis. In in vitro mast cell models, pretreatment with the drug inhibited the degranulation response and cytokine production in RBL2H3 cells triggered by IgE and antigens, without affecting cell viability. These results suggest that dactolisib, as well as other PI3K/mTOR inhibitors, might be a good candidate for anti-allergic drugs that exhibit both anti-sensitizing and anti-anaphylactic effects.

The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study

BACKGROUND

Vasopressin is a second-line vasoactive agent for refractory septic shock. Vasopressin loading is not generally performed because of the lack of evidence for its effects and safety. However, based on our previous findings, we hypothesized it can predict the responsibility to vasopressin infusion with safety, and prospectively examined it in the present study.

METHODS

Vasopressin loading was performed via the intravenous administration of a bolus of 1 U, followed by its continuous infusion at 1U/h in patients with septic shock treated with ≥ 0.2 μg/kg/min noradrenaline. An arterial pressure wave analysis was conducted, and endocrinological tests were performed immediately prior to vasopressin loading. We classified patients into responders/non-responders based on mean arterial pressure (MAP) changes after vasopressin loading. Based on our previous findings, the lower tertile of MAP changes was selected as the cut-off. The change in the catecholamine index (CAI) after 6 h was assigned as the primary outcome. Digital ischemia, mesenteric ischemia, and myocardial ischemia during the admission period were prospectively and systematically recorded as adverse events.

RESULTS

Ninety-two patients were registered during the study period and examined. Sixty-two patients with a MAP change > 22 mmHg were assigned as responders and the others as non-responders. Blood adrenocorticotropic hormone levels were significantly higher in non-responders. Stroke volume variations were higher in responders before loading, while stroke volume and dP/dtmax were higher in responders after loading. Median CAI changes were - 10 in responders and 0 in non-responders, which was significantly lower in the former (p < 0.0001). AUROC of MAP change with vasopressin loading to predict CAI change < 0 after continuous infusion was 0.843 with sensitivity of 0.92 and specificity of 0.77. Ischemia events were observed in 5 cases (5.4%).

CONCLUSIONS

Vasopressin loading may be safely introduced for septic shock. Vasopressin loading may be used to predict responses to its continuous infusion and select appropriate strategies to increase blood pressure.

Differences in Cerebral Oxygenation in Cardiogenic and Respiratory Cardiac Arrest Before, During, and After Cardiopulmonary Resuscitation

We compared the changes in cerebral oxygen saturation (ScO₂) levels during cardiac arrest (CA) events using porcine models of ventricular fibrillation CA (VF-CA) and asphyxial CA (A-CA). Twenty female pigs were randomly divided into VF-CA and A-CA groups. We initiated cardiopulmonary resuscitation (CPR) 4 min after CA and measured the cerebral tissue oxygenation index (TOI) using near-infrared spectroscopy (NIRS) before, during, and after CPR. In both groups, the TOI was the lowest at 3-4 min after pre-CPR phase initiation (VF-CA group: 3.4 min [2.8-3.9]; A-CA group: 3.2 min [2.9-4.6]; p = 0.386). The increase in TOI differed between the groups in the CPR phase (p < 0.001); it increased more rapidly in the VF-CA group (16.6 [5.5-32.6] vs. 1.1 [0.6-3.3] %/min; p < 0.001). Seven pigs surviving for 60 min after the return of spontaneous circulation in the VF-CA group recovered limb movement, whereas only one in the A-CA group (p = 0.023) achieved movement recovery. The increase in the TOI did not differ significantly between the groups in the post-CPR phase (p = 0.341). Therefore, it is better to monitor ScO₂ concomitantly with CPR initiation using NIRS to assess the responsiveness to CPR in clinical settings.

Tracheoarterial fistula in a patient with amyotrophic lateral sclerosis successfully managed by overinflation of the tracheostomy tube cuff alone: a case report

BACKGROUND

Tracheoarterial fistula is the most devastating complication after tracheostomy, and its mortality, without definitive treatment, approaches 100%. In general, the combination of bedside emergency management, that is, overinflation of the tracheostomy tube cuff, and definitive treatment such as surgical or endovascular intervention is necessary to prevent the poor outcome. Patients with neuromuscular diseases such as amyotrophic lateral sclerosis are susceptible to tracheoarterial fistula because of long-term mechanical ventilation and muscle weakness.

CASE PRESENTATION

We describe a case of tracheoarterial fistula in a Japanese 39-year-old patient with amyotrophic lateral sclerosis with long-term ventilator management. The patient was clinically diagnosed with a tracheoarterial fistula because of massive bleeding following sentinel hemorrhage. The massive hemorrhage was controlled by overinflation of the tracheostomy tube cuff alone, without definitive treatment.

CONCLUSIONS

This case suggests overinflation of the tracheostomy tube cuff alone plays an important role, semi-permanently, in the management of tracheoarterial fistula, especially in cases where surgical or endovascular intervention is not indicated. Clinicians taking care of patients with tracheostomy undergoing long-term mechanical ventilation should be aware that tracheoarterial fistula might occur following tracheostomy.

Extensive ablation strategy for persistent atrial fibrillation impairs left atrial function but reduces recurrence rate

Background

In catheter ablation for persistent atrial fibrillation (AF), extensive ablation strategy, such as linear ablation and/or complex fractionated atrial electrogram (CFAE) ablation in addition to pulmonary vein isolation (PVI-plus), might impair left atrial function more severely than PVI-alone strategy.

Purpose

The aim of this study is to investigate the impact of extensive ablation strategy on LA function and assess the relationship between post-ablation LA function and recurrence.

Methods

This study is a post-hoc subanalysis of the EARNEST-PVI randomized controlled trial, which investigated the efficacy of the PVI-alone strategy in comparison with PVI-plus strategy for persistent AF. From the 497 participants of EARNEST-PVI trial, we enrolled 191 patients with full datasets of pre- and post-ablation cardiac computed tomography (CT) at our Hospital. Patients were divided into PVI-alone and PVI-plus groups. Within one month before and 3 months after ablation, LA volume index (LAVI) and LA emptying fraction (LAEF) were calculated by using the Comprehensive Cardiac Analysis software on the Extended Brilliance Workspace. We assessed i) post-ablation LA function, ii) AF/atrial tachycardia (AT) -free rate after single and final session, and iii) relationship between post-ablation LAEF and ablation success in each group.

Results

The indices of baseline LA remodeling were not different between PVI-alone (N=96) and PVI-plus groups (N=95) [LAVI: 71.4 (57.8, 82.0) vs. 68.7 (61.0, 78.1), P=0.92, LAEF: 13.7 (10.0, 17.4) vs. 13.0 (10.0, 16.9), PVI-alone vs. PVI-plus, P=0.78]. In overall patients, post-ablation LAEF did not differ among them [34.4 (26.1, 40.7) vs. 31.6 (26.0, 37.4), P=0.13]. In the analysis of patients showing sinus rhythm during the CT study, LAEF was significantly higher in PVI-alone (N=87) than in PVI-plus group (N=93) [35.7 (29.0, 41.0) vs. 31.7 (26.1, 37.5), P=0.011] (Figure 1A). AF/AT-free survival rate during median follow-up of 44 months was not different after first session (63.5% vs. 68.4%, P=0.33), while PVI-plus had a tendency towards higher success rate after final session (72.9% vs. 84.2%, P=0.053) (Figure 2). In receiver operating characteristics analysis for recurrence after first session, post-ablation decreased LAEF had significantly related to recurrence after PVI-alone (AUC: 0.733, P&lt;0.0001), but not after PVI-plus (AUC: 0.567, P=0.31) (Figure 1B, C).

Conclusion

Compared with PVI-alone strategy, PVI-plus strategy damaged LA function more severely, but tended to be related to higher success rate. Post-ablation LA function was related to recurrence in PVI-alone, but not in PVI-plus. Extensive ablation might have additional anti-arrhythmic effect regardless of iatrogenic myocardial damage. Myocardial injury by extensive ablation may less attribute to recurrence than intrinsic damage of LA.

Funding Acknowledgement

Type of funding sources: None.

Development of the new risk score to predict occurrence of atrial fibrillation early after acute myocardial infarction

Background/Introduction

New onset of atrial fibrillation (AF) is associated with adverse short- and long-term outcomes after acute myocardial infarction (AMI), and its prediction is relevant for the risk stratification in patients with AMI. Although several risk scores were developed for AF in the general population, there is no established risk score for AF occurrence after AMI.

Purpose

To develop a risk score to predict occurrence of AF early after AMI.

Methods

We enrolled consecutive 751 patients with AMI who admitted to our hospital between April 2006 and September 2012 for the present study. New occurrence of AF was defined as AF detected during hospital stay in a patient showing normal regular sinus rhythm at admission. Parameters relevant to the occurrence of AF was selected from the clinical characteristics, physical status and blood test data at admission, and peak CK/CK-MB, by stepwise logistic regression analysis. We constructed a risk score model to predict the new occurrence of AF, using selected parameters and their logistic regression coefficients. C-statistics was determined by constructing a receiver operating characteristic curve to evaluate the accuracy of the risk score for prediction of AF occurrence.

Results

We excluded 48 patients (6.4%) who had AF at admission, and 208 patients without sufficient data at admission, and thus, the study group consisted of 459 patients (age; 65±13 years, male gender; 79.6%). New AF occurrence was observed in 72 patients (14.5%). The following 7 parameters was selected as parameters related with AF (as p&lt;0.1); Inferior/posterior AMI, use of β blockers, use of diuretics, single vessel disease, absence of reperfusion therapy, systolic blood pressure (sBP) at admission, and smoking. One point was given to sBP&gt;128mmHg, 2 points to absence of reperfusion, and one point to other parameters. Sum of these points was calculated as the AF risk score (Table 1). AF occurred in 27.1% of patients with ≥5 points whereas it was observed 5.2% of those with &lt;5 points. C-statistics of the risk score was 0.75 (95% CI 0.68–0.83).

Conclusion

We developed a novel risk score to estimate the risk of AF occurrence early after AMI, which can be a useful tool for the risk stratification after AMI.

Funding Acknowledgement

Type of funding sources: None.

Untreated sleep apnea and left atrial dilatation in patients with atrial fibrillation prior to catheter ablation

Background

Sleep apnea and left atrial dilatation are both risk factors for an arrhythmia recurrence after catheter ablation (CA) of atrial fibrillation (AF). Negative intrathoracic pressure fluctuations during an obstructive apnea episode may cause the left atrium to distend and stretch its wall. Whether sleep apnea is associated with left atrial dilatation in patients receiving CA of AF remains unknown.

Purpose

We sought to elucidate whether moderate or severe untreated sleep apnea was associated with left atrial dilatation in patients with AF before CA.

Methods

This study was conducted under a retrospective, single-center, observational design. The data were derived from screening tests for sleep apnea, which were routinely performed in patients scheduled to receive CA of AF in our institution. After excluding patients who were already diagnosed with sleep apnea, we enrolled 1265 consecutive patients (age 65±11 years, 27.8% females, and 46.2% of non-paroxysmal AF) who underwent both home sleep apnea testing and multidetector computed tomography (MDCT) before the CA of AF. The severity of the sleep apnea was evaluated by the apnea-hypopnea index (AHI) using a watch-type peripheral arterial tonometry. Left atrial dilatation was evaluated by the left atrial maximum volume (LA max V) using 256-slice MDCT.

Results

The age was 65±11 years, 27.8% were females, and 46.2% had non-paroxysmal AF. The mean AHI was 20.3±15.3 and LA max V 105±34 ml (R2=0.075, p&lt;0.0001). LA dilatation was defined by larger than mean LA max V (LA max V≥105 ml). We examined an LA max V≥105 ml as a predictor. After an adjustment by an advanced age (≥65 years), non-paroxysmal AF, male sex, obesity, hypertension, and congestive heart failure, all of which were significant predictors of an LA max V≥105ml in the univariate analysis, moderate or severe sleep apnea (AHI≥15) was a significant predictor of an LA max V≥105 ml (odds ratio 1.63, 95% confidence interval 1.24–2.14, p=0.0005).

Conclusion

Among the patients scheduled to receive catheter ablation of AF, moderate or severe sleep apnea was independently associated with left atrial dilatation.

Funding Acknowledgement

Type of funding sources: None.

Sex differences in terms of recurrent atrial fibrillation after catheter ablation according to the history of heart failure: insights from the Kansai Plus Atrial Fibrillation (KPAF) registry

Background

There are significant differences in the prevalence and prognosis of cardiovascular diseases between male and female. We previously reported that catheter ablation (CA) of atrial fibrillation (AF) was less effective in female than male, but whether their history of heart failure influence the recurrence after CA of AF remains still unknown.

Purpose

We sought to clarify sex differences in terms of AF recurrence after RFCA of AF according to the history of heart failure.

Methods

We conducted a large-scale, prospective, multicenter, observational study (Kansai Plus Atrial Fibrillation Registry). We enrolled 5010 consecutive patients who underwent an initial RFCA of AF at 26 centers (64±10 years; 1369 [27.3%] females; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years.

Results

Fourteen % of female had a history of heart failure prior to CA, while 12.8% of male had a history of heart failure at baseline (p=0.29). The 3-year cumulative incidence of AF recurrence after a single procedure was 43.3% in female and 39.0% in male (log rank P=0.0046). In patients with the history of heart failure, AF recurrence rates were 42.2% in female and 45.8% in male (log rank P=0.51). On the other hand, in patients without history of heart failure, more females experienced AF recurrence (female vs. male, 43.5% vs. 38.0%, log rank P=0.001).

The rate of AF recurrence after multiple procedures was higher in female (24.2% vs. 19.6%, log rank P&lt;0.0001). AF recurrence rates were similar between sexes in patients with history of heart failure (female vs. male, 26.0% vs. 26.7%, log rank P=0.86), while AF recurrence rates were higher in female without history of heart failure than those in male (females vs. males, 23.9% vs. 18.5%, log rank P&lt;0.0001).

Conclusion

The Kansai Plus Atrial Fibrillation Registry revealed a distinct sex difference in terms of the AF recurrence after CA of AF. Females had higher recurrence rates compared with males in patients without history of heart failure, while recurrence rates were similar between sexes in patients with history of heart failure.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development in Kyoto, Japan.

POS0390 GENES OF “DEFENSE RESPONSE TO VIRUS” IN PERIPHERAL BLOOD OF ANTI-MDA5 POSITIVE DERMATOMYOSITIS WERE UPREGULATED AS COMPARE WITH OTHER FORMS OF DERMATOMYOSITIS. ~SUPPRESSING RIG-I LIKE RECEPTOR SIGNALING OR TYPE 1/2 INTERFERON SIGNALING WERE THE KEYS FOR SURVIVAL

Background

Anti-melanoma differentiation-associated gene 5–positive dermatomyositis (MDA5 DM) is a rare but distinct subtype of idiopathic inflammatory myopathy (IIM) that is characterized by high mortality due to rapid progressive interstitial lung disease (ILD). MDA5 is a cytosolic protein and a family of retinoic-acid inducible gene-I (RIG-I) like receptor, which functions as a virus RNA sensor and induces the production of type I interferons (IFN-I) and proinflammatory cytokines. This leads to the death of infected cells and the activation of the antigen-specific antiviral immune response. Although the pathogenesis of MDA5 DM is largely unknown, a hypothesis that pathogenic involvement of anti-MDA5 antibodies has been proposed. Recently, similarities have been noted between multifaceted features of COVID-19 and MDA5 DM, which suggests shared underlying autoinflammatory mechanisms.

Objectives

To detect the critical actors in the pathogenesis of MDA5 DM by gene expression analysis of peripheral blood.

Methods

Total of 31 DM cases were investigated, including anti-aminoacyl-tRNA synthetase positive (ARS) DM (n=12), MDA5 DM (n=7, survivor=3) and others (n=12). Peripheral blood was drawn at baseline and 2 to 3 months after treatments. Total RNAs were then extracted with using PAXgene miRNA kit. After quantifying the expressions of transcripts by multiplex sequencing. And then, hierarchical clustering analysis, enrichment analysis using gene ontology (GO) terms, single sample gene set enrichment analysis (ssGSEA) and weighted gene co-expression network analysis (WGCNA) were performed.

Results

The hierarchical clustering with expression profiles of peripheral blood at baseline showed major 3 clusters. Interestingly, ARS DM cases were segregated into right side of the 3rd cluster while MDA5 DM cases fell into 1st and 2nd clusters. ARS and MDA5 DM were clearly discriminated if differentially expressed genes (DEGs) between these subtypes of DM were analyzed. By GO enrichment analysis, the terms, such as related to “defense response to virus” including “type1 interferon signaling pathway” were found in the DEGs. In the MDA5 DM cases, ssGSEA revealed that genes of “Fcγ receptor mediated phagocytosis pathway” or “complement and coagulation cascade” were significantly enriched and WGCNA showed that pathways of “T-cell antigen receptor signaling” or “lung fibrosis” were significantly upregulated. Next, we also investigated the DEGs of peripheral blood at 2-3 months after treatment between survival and fatal cases in MDA5 DM. We found that suppressing RIG-I like receptor and type 1 and type 2 interferon (IFN) signaling were the keys for survival.

Conclusion

MDA5 is a key sensor of several RNA viruses including coronavirus families and then activate antiviral gene transcription such as type 1 IFN genes, leading to establish an antiviral host response. As the pulmonary damage of COVID-19 is known to be difficult to distinguish from the ILD associated with anti-MDA5 DM, the life-threating ILD of MDA5 DM may be caused by the over-activation of RIG-I like receptor signaling via MDA5. The hypothesis is supported by our findings that the defining features of MDA5 DM are activation of “type 1 IFN pathways” and antigen-specific antiviral immune responses including “Fcγ receptor mediated phagocytosis pathway” or “T-cell antigen receptor signaling”. As the levels of anti-MDA5 antibodies reported to be important prognostic parameter, it may be involved in pathogenesis of MDA5 DM. As we found that suppression of type 1 and type 2 IFN signaling were the keys for survival, it seems to be reasonable to use inhibitors of Janus Kinases (JAK) for treatment of MDA5 DM.

Disclosure of Interests

Yoshinobu Koyama Speakers bureau: Abbvie, Asahikasei, Ayumi, BMS, Eli-Lilly, Mitsubishi Tanabe, Grant/research support from: Abbvie, GSK, Yoshiharu Sato: None declared, Moe Sakamoto: None declared

Adequacy of compression positioning using the feedback device during chest compressions by medical staff in a simulation study

Background

The 2020 American Heart Association guidelines recommend the use of a feedback device during chest compressions (CCs). However, these devices are only placed visually by medical personnel on the lower half of the sternum and do not provide feedback on the adequacy of the pressure-delivery position. In this study, we investigated whether medical staff could deliver CCs at the adequate compression position using a feedback device and identified where the inadequate position was compressed.

Methods

This simulation-based, prospective single-centre study enrolled 44 medical personnel who were assigned to four different groups based on the standing position and the hand in contact with the feedback device as follows: right–left (R–l), right–right (R–r), left–right (L–r), and left–left (L–l), respectively. The sensor position where the maximal average pressure was applied during CCs using the feedback device were ascertained with a flexible capacitive pressure sensor. We determined if this position is the adequate compression position or not. The intergroup differences in the frequency of the adequate compression position, the maximal average pressure, compression rate, depth and recoil were determined.

Results

The frequencies of adequate compression positioning were 55, 50, 58, and 60% in the R–l, R–r, L–r, and L–l groups, respectively, with no significant intergroup difference (p = 0.917). Inadequate position occurred in the front, back, hypothenar and thenar sides. The maximal average pressure did not significantly differ among the groups (p = 0.0781). The average compression rate was 100–110 compressions/min in each group, the average depth was 5–6 cm, and the average recoil was 0.1 cm, with no significant intergroup differences (p = 0.0882, 0.9653, and 0.2757, respectively).

Conclusions

We found that only approximately half of the medical staff could deliver CCs using the feedback device at an adequate compression position and the inadequate position occurred in all sides. Resuscitation courses should be designed to educate trainees about the proper placement during CCs using a feedback device while also evaluating the correct compression position.

Association between haemodynamics during cardiopulmonary resuscitation and patient outcomes

AIM

There is no defined target for blood flow during chest compressions (CC). We previously reported various haemodynamic patterns in which dominant arterial and venous pressures were observed during CC. This study aimed to evaluate arterial and venous perfusion pressures during CC and determine their association with patient outcomes.

METHODS

In this prospective observational single-centre study, arterial and venous pressures were recorded continuously on arrival at the emergency department for patients with non-traumatic out-of-hospital cardiac arrest. Parameters included multiple pressure measurements: the arterial systolic (A sys), mean (A mean), and diastolic (A dias); the venous systolic (V sys), mean (V mean), and diastolic (V dias); and the differences between arterial and venous systolic (ΔSys A-V), mean (ΔMean A-V), and diastolic (ΔDias A-V). We compared patients with and without return of spontaneous circulation (ROSC).

RESULTS

Among 50 patients, 16 (32%) had ROSC. Of the total measurement time, average A sys, A dias, ΔSys A-V, ΔDias A-V, A mean, and ΔMean A-V were significantly higher in patients with ROSC. When the average ΔMean A-V was stratified, there were 19 (38%) patients with negative average ΔMean A-V values, none of whom had ROSC. As the average ΔMean A-V increased, the ROSC rate also increased (p = 0.00002).

CONCLUSIONS

ROSC did not occur in patients with negative average ΔMean A-V values. ROSC may be achieved through individualised resuscitation that places a greater emphasis on differences between mean arterial and venous pressure, rather than through uniform resuscitation.

Association between myocardial wall thickness and left ventricular functional recovery after catheter ablation of atrial fibrillation in patients with reduced ejection fraction

Background

Catheter ablation of atrial fibrillation (AFCA) is an effective treatment to develop left ventricular (LV) functional recovery. However, the degree of recovery differs between individuals due to the different extent of myocardial fibrosis and scarring.

Purpose

To examine whether pre-ablation LV wall thickness (WT) and its regional heterogeneity predict LV functional recovery after AFCA in patients with LV systolic dysfunction.

Methods

Of 3682 consecutive patients who underwent first-time AFCA between January 2012 and September 2020 in our institution, 174 (age, 63±10 years; male, 83%; ischemic cardiomyopathy, 14%) with a baseline LV ejection fraction (LVEF) of &lt;40% were retrospectively evaluated. They were subjected to 256-slice MDCT scanning at baseline and 3 months after AFCA. Baseline WT was evaluated by 16-segment model. Mean and standard deviation (SD) of 16 regional WT were calculated in both end-systolic and end-diastolic phase.

Results

LVEF significantly improved from 30±7% to 57±17% (p&lt;0.001) after AFCA. Increase in LVEF (delta-LVEF) was positively correlated with baseline end-diastolic WT (r=0.31, p&lt;0.001) and negatively correlated with SD of end-systolic WT (r=−0.21, p=0.007). Independent of WT measurements, delta-LVEF was negatively correlated with LV end-diastolic volume (r=−0.42, p&lt;0.001). We created a scoring system to predict the degree of wall motion recovery using the median value of the 3 variables; assigned 1 point each for end-diastolic WT &gt;7.4mm, SD of end-systolic WT &lt;1.61mm, and LV end-diastolic volume &lt;125ml. The model successfully predicted improvement in LVEF after AFCA (0 point (N=13) vs. 1 point (N=72) vs. 2–3 point (N=89), 11±16% vs. 20±17% vs. 33±12%, p&lt;0.001).

Conclusion

Myocardial WT and its regional heterogeneity as well as LV end-diastolic volume predicted functional recovery after AFCA in patients with reduced LVEF.

Funding Acknowledgement

Type of funding sources: None.

Prediction of functional capacity by the HFA-PEFF score in patients with acute decompensated heart failure with preserved ejection fraction: a post-hoc analysis from the PURSUIT-HFpEF registry

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) is still challenging, and the H2FPEF- and the HFA-PEFF score were proposed as simple and reliable diagnostic tools. We recently reported that the HFA-PEFF score was significantly associated with the composite endpoint of all-cause death and heart failure readmission in patients with acute decompensated HFpEF (Sotomi. Eur J Heart Fail, in press).

Purpose

To investigate the relation whether the HFA-PEFF or H2FPEF score can evaluate functional capacity in patients with HFpEF

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for acute decompensated HFpEF. We performed 6 minute walk (6MW) test and measured NT-proBNP before discharge. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients (age 81±9 years, male gender 45%) hospitalized for acute decompensated HFpEF for the present study. The H2FPEF score was obtained in 588 (77.7%) patients and all patients had ≥2 points. The HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. We divided these patients into 3 groups based on the HFA-PEFF score (score 2 to 4, 5, and 6) or on the H2FPEF score (score 0 to 3, 4 to 5 and 6 to 8). There were a significant difference in NT-pro BNP between 3 groups based on HFA-PEFF score (p=0.01, Table 1), and patients with score 6 had significantly higher NT-proBNP than those with score 2 to 4 (p=0.02). A significant difference was observed in 6MW distance among these groups (p=0.04, Table), and those with score 6 had significantly shorter distance than those with score 2 to 4 (p=0.04). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE, and Kaplan-Meier survival analysis demonstrated that classification of HFA-PEFF score significantly stratified the patients' risk for MACE. On the other hand, there was no significant difference in 6MW distance among 3 groups based on H2FPEF score (p=0.53), and H2FPEF score was not an independent predictor for MCE by the Cox model analysis. Moreover, the lowest H2PEF score group had higher NT-proBNP than other 2 groups (p=0.02)

Conclusions

The HFA-PEFF score predicted functional capacity as well as prognosis in patients hospitalized for HFpEF, while the H2PEF score did not.

Funding Acknowledgement

Type of funding sources: None. Table 1

Development of an application tool to support returnees in Fukushima

To promote radiation protection and health promotion among returning residents (returnees) in coastal areas of Fukushima, eHealth principles were used to develop a new application tool (app) that can record radiation exposure and health status while providing comprehensive support to returnees. Intended users are returnees and health and welfare workers. After assessing their needs, a flowchart and prototype for operational logic were created using commercially available software tools. Professional developers will focus on improving the user interface and ensuring data security. The finished app will be compatible with mobile telephones and tablets. Utility and ease of use are paramount to serve returnees of all ages effectively.

POS0881 DETECTION OF THE GENE EXPRESSIONS IN PERIPHERAL BLOOD INVOLVED IN THE PROGRESSION OF PULMONARY VESSEL DISEASE AT THE SUBCLINICAL STAGE OF PULMONARY HYPERTENSION ASSOCIATED WITH SYSTEMIC SCLEROSIS

Background:

Pulmonary hypertension (PH) is prominent as a vascular involvement of systemic sclerosis (SSc), which remains a leading cause of death in spite of current best treatments. Recently, hemodynamic definition of PH was updated from mPAP≥25mmHg to mPAP>20mmHg and PVR≥3WU. Although new definition may improve the prognosis of PH associated with SSc by giving a chance to start management early, it may be insufficient as more than 2/3 of the pulmonary circulation is already impaired by the time of meeting the definition. Therefore, the ideal therapeutic intervention should be started at the subclinical stage of PH in SSc patients, but little is known about underlying pathological mechanisms at the stage. In this study, we investigate progression to exercise-induced PH (exPH)1), which is considered subclinical PH, in the prospective registry of high-risk population for developing PH associated with SSc.

Objectives:

To detect the gene expressions in peripheral blood involved in the progression of pulmonary vessel disease (PVD) at the subclinical stage of PH associated with SSc.

Methods:

Total of 180 patients who had not met PH criteria with Raynaud phenomenon, skin sclerosis or SSc-related autoantibody was registered. To detect the early PVD, exercise Doppler echocardiography (exDE) was carried out every 6 or 12 months for up to 6 years. The definition of exPH was maximum sPAP>40mmHg or increase in sPAP>20mmHg estimated by exDE during exercise. For gene expression analysis, total RNAs from whole peripheral blood cells were extracted by PAXgene system, and then multiplex sequencing was done. To identify candidate genes involved in the progression to exPH, random forest machine learning method was employed. Volcano plots, a scatter plots to visualize fold-changes and p-values of differentially expressed genes (DEGs) between exPH and others (exN), were also used for seeking the important genes for disease progression.

Results:

At the time of registration, 34.4% of patients met exPH criteria, and 15.6% of patients developed exPH during follow-up period (35.0±18.1 months). Expression of TNF gene was selected as the most useful genes to predict progression to exPH by random forest, and the accuracy of the model was about 87%. Volcano plots indicated that expressions of TMEM176A and TMEM176B were prominent (fold-change >2.4 and -log10 p-value >3.5) in exPH patients. The accuracy was improved to 90% if the expression of TNF and TMEMA/B were used for the prediction of progression to exPH. We found that statistically significant increase in the expression of TNF was eliminated at the time of fulfilling the exPH criteria, while increase in expressions of TMEM A/B were still kept.

Conclusion:

It was reported that TNFα drives pulmonary arterial hypertension by suppressing the BMP type-II receptor and altering NOTCH signalling2). Our findings suggest that TNFα plays important role only in the period of pre-exPH. On the other hand, increase in expressions of TMEM A/B were observed through the period of pre-exPH to post-exPH. It suggests that there are multiple phases before developing PH associated with SSc. It is very important to understand the phases for the precise treatment to arrest the progression of PVD.

References:

[1]R. Naeije et al., Am J resp and critical care med 187, 576-583 (2013). 2) LA. Hurst et al., Nat Commun. 13;8:14079 (2017).

Disclosure of Interests:

Yoshinobu Koyama Speakers bureau: Asahikasei, Ayumi, BMS, Mitsubishi Tanabe, Shin-nihon, Paid instructor for: Asahikasei, Asteras, BMS, Grant/research support from: Eli-Lilly, Yoshiharu Sato: None declared, Tatsuma Shoji: None declared, Soichiro Fuke: None declared, Takatsune Umayahara: None declared, Moe Sakamoto: None declared

Adequacy of hand positioning by medical personnel during chest compression in a simulation study

Aim

During chest compressions (CCs), the hand position at the lower half of the sternum is not strictly maintained, unlike depth or rate. This study was conducted to determine whether medical staff could adequately push at a marked location on the lower half of the sternum, identify where the inappropriate hand position was shifted to, and correct the inappropriate hand position.

Methods

This simulation‐based, prospective single‐center study enrolled 44 medical personnel. Pressure and hand position during CC were ascertained using a flexible pressure sensor. The participants were divided into four groups by standing position and the hand in contact with the sternum: right–left (R–l), right–right (R–r), left–right (L–r), and left–left (L–l). We compared the groups and the methods: the manual method (MM), the thenar method, and the hypothenar method (HM).

Results

Among participants using the MM, 80% did not push adequately at the marked location on the lower half of the sternum; 60%–90% of the inadequate positions were shifted to the hypothenar side. CCs with the HM facilitated stronger pressure, and the position was minimally shifted to the hypothenar side.

Conclusion

Medical staff could not push at an appropriate position during CCs. Resuscitation courses should be designed to educate personnel on the appropriate position for application of maximal pressure while also evaluating the position during CCs.

The utility of a novel approach to quantify dyssynchrony by multidetector computed tomography

Funding Acknowledgements

Type of funding sources: None.

Background

Quantification of left ventricular (LV) dyssynchrony is of great interest for resynchronization therapy (CRT). Recently, cardiac computed tomography (CCT) is feasible for evaluation of dyssynchrony. Our aim was to assess a novel simplified approach using CCT to quantify LV dyssynchrony.

Methods

We studied 346 consecutive patients with a wide range of QRS width and ejection fractions (EF). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT (Brilliance 256 iCT, Philips Medical Systems) was performed before CRT. After CCT scan, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and a time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software "Myocardial Contraction Map" (Argus, Inc Ehime, Japan). The standard deviation of all segments modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT.

Results

%SD was feasible in all patients, respectably. %SD was significantly different between the different QRS duration groups; narrow QRS (&lt;120ms): 9 ± 5%, relatively wide QRS (120-150 ms): 11 ± 6%, and significantly wide QRS (&gt;150 ms): 14 ± 7% (p &lt;0.001). Moreover, there was significantly difference in %SD between the different morphology groups; normal: 9 ± 7%, Non-left bundle branch block (Non-LBBB): 10 ± 6%, LBBB: 17 ± 7% (p &lt;0.001).

Conclusion

This novel simplified approach by CCT can quantify dyssynchrony in different QRS duration and morphology groups. This method has promise for clinical applications to the evaluation of patients for CRT.

Abstract Figure.

Automated heart segmentation using a convolutional neural network accelerates 3D model creation for cardiac surgery

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Japan Organization of Occupational Health and Safety

onbehalf

J3D

Introduction

Improvements in cardiovascular imaging have contributed to the accurate diagnosis and treatment of cardiovascular diseases. In recent years, we can find a new demand from surgical departments, i.e., 3D heart models of patients for preoperative simulations. However, a 3D surgical model needs a detailed segmentation of heart structures from clinical images because these details are essential for achieving accurate polygon data of an exact 3D model. Thus, in most cases, manual segmentation is required for complicated heart shapes such as the chamber wall, valves, and papillary muscles, which causes a prolonged duration time.

Purpose

We aim to achieve an automated heart segmentation using a convolutional neural network (CNN) trained using deep learning techniques for the rapid creation of 3D surgical heart models of individual patients.

Methods

We constructed our original CNN program based on the latest artificial intelligence techniques and trained it to extract shapes of the heart from cardiac computed tomography (CT) images. The training data was 361 slices selected from CT scans of 10 patients. We used data augmentation to increase the amount and diversity of the data into 24,052 slices. The training result with the best Intersection over Union (IoU), one of the evaluation metrics used in deep learning, was saved. Finally, we used the best-trained CNN to construct 3D polygon data of two surgical cases of hypertrophic obstructive cardiomyopathy (HOCM) for preoperative assessments.

Results

The IoU attained 0.85 after deep learning. The time required to complete the 3D polygon data for the first HOCM case was 5 minutes for segmentation by the trained CNN and 3 hours for data correction by a human operator. Similarly, the time required for the second case was 5 minutes for segmentation without manual correction. We had to correct the segmentation for the first case because we needed an exact 3D model for the preoperative assessment (Fig. 1). According to our records of the other eight 3D heart models in the lab, the work for a 3D polygon shape from CT images needs a median 30 hours (quartiles 23-50 hours) when the procedure is fully manual and non-continuous with breaks in between.

Conclusion

The CNN-based segmentation aided the constructing heart shapes from cardiac CT images of preoperative patients. Although the performance, reaching IoU of 0.85, was insufficient for fully automatic segmentation, the methodology can shorten the process duration from several hours to several minutes for detailed segmentation of heart structures.

We previously applied the CNN-based segmentation to the aorta, aortic stenosis valves, and atheromatous plaque in clinical images, demonstrating adequate segmentation performance. The proposed methodology can be applied as a fundamental technology of cardiovascular imaging for obtaining the actual structures of a target object as 3D coordinate values or a 3D model within a reasonable duration time.

Abstract Figure 1

Validation of the HFA-PEFF- and H2FPEF score in Japanese patients with heart failure with preserved ejection fraction

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) still remains challenging, and simple and reliable diagnostic tools have been required. Recently, novel and evidence-based diagnostic algorithms for HFpEF were proposed, such as H2FPEF score (Circulation. 2018) and HFA-PEFF score (Eur Heart J 2019), and their accuracy was validated in the outside patient group. However, there are regional and ethnic variations in patient characteristics of HFpEF, particularly between Western and Asian countries, and it is not elucidated whether these diagnostic scores are useful in Asian population.

Purpose

To investigate the validity of the HFA-PEFF- and H2FPEF score in Japanese patients with HFpEF.

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for HFpEF. The obtained scores were compared with the scores of the HFpEF cohort in the previous validation studies. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients hospitalized for HFpEF between June 2016 and August 2019 for the present study. H2FPEF score was obtained in 588 (77.7%) patients among them. Compared with the HFpEF cohorts in the previously reported sub-analysis of TOPCAT trial, the PURSUIT-HFpEF cohort had lower mean value of HFpEF score (4.0±1.8 points vs. 6.0±2.0 points in Americans or 5.3±1.9 points in Russians). It had significantly higher proportion (40.3%, p&lt;0.001) of patients in the low likelihood of HFpEF category (0–3 points) than the TOPCAT cohorts (8.0% in Americans and 19.6% in Russians).

HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. The mean value of HFA-PEFF score was 5.0±0.8, and all patients had ≥2 points. The proportion of patients in the high likelihood of HFpEF category (5–6 points) was 88.3%, which was significantly higher (p&lt;0.001) than those of the HFpEF cohort from Europe and USA in the previous validation study (Eur J Heart Fail 2019). There was no correlation between H2FPEF score and HFA-PEFF score (R=0.06, p=0.14). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE during follow-up period, whereas H2PEF score was not selected. Kaplan-Meier survival analysis demonstrated that patients with 6 points of HFA-PEFF score had higher incidence rate of MACE than those with ≤5 points (p=0.002).

Conclusion

The HFA-PEFF score could be more useful for the diagnosis and risk stratification for HFpEF than the H2PEF score in the Japanese cohort.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

High incidence of left atrial dysfunction and low voltage zone in patients requiring multiple atrial fibrillation ablation

Background

While multiple catheter ablation for recurrent atrial fibrillation (AF) is effective for the maintenance of sinus rhythm, some of patients have ablation-refractory AF. Left atrial (LA) dysfunction and the presence of low voltage zone (LVZ) are associated with recurrence after AF ablation. The association between recurrence and LA dysfunction/ LVZ among patients undergoing multiple AF ablation remains unclear.

Purpose

We aimed to compare (i)LA function, (ii)the prevalence of LVZ among patients undergoing first, second and third or more AF ablation procedures. Further, we investigated whether LA dysfunction and LVZ are associated with recurrence after multiple procedures.

Methods

We retrospectively analyzed 460 patients undergoing AF ablation procedures including first, second and third or more sessions from January 2017 to October 2019 in our institute. Before each session, 256-slice MDCT was performed under sinus rhythm to measure pre-ablation LA emptying fraction (LAEF) as the representative of LA function. At the end of each session, we checked the presence of LVZ, which was defined as regions where bipolar peak-to-peak voltage was &lt;0.5mV. All patients underwent pulmonary vein isolation (PVI). If necessary, additional ablation (e.g. linear ablation, non-PV foci ablation and LVZ ablation) was performed.

Results

Out of 460 sessions, 295 were first (follow-up years: 1.5 [0.8, 2.0]), 134 were second (1.0 [0.5, 1.8]), and 31 were third or more sessions (1.2 [0.7, 2.0]). As the number of sessions increased, the recurrence rate was increased (19% vs. 31% vs. 61%, first vs. second vs. ≥third, P&lt;0.0001), LAEF decreased (39.7±10.5% vs. 32.6±10.1% vs. 25.3±11.8%, P&lt;0.0001) and the incidence of LVZ increased (18% vs. 34% vs. 68%, P&lt;0.0001) (Figure 1). In patients with recurrence (N=104) after multiple ablation (second or more sessions), LAEF was lower and the prevalence of LVZ was higher than those without recurrence (N=61) (LAEF: 27.3±10.3% vs. 33.5±10.5%, with vs. without, P=0.0003; LVZ: 57% vs. 31%, P=0.0014).

Conclusions

As the number of sessions increased, the recurrence rate was increased. The prevalence of LA dysfunction and LVZ was high in patients requiring multiple ablation procedure. LA dysfunction and LVZ possibly reflect arrhytmogenic substrate causing recurrence of ablation-refractory AF. We should carefully consider repeated AF ablation in patients with severe LA dysfunction and extensive LVZ.

Figure 1

Funding Acknowledgement

Type of funding source: None

Pre-ablation left atrial function predicts the presence of low voltage zone in patients undergoing paroxysmal atrial fibrillation ablation: OLAF-LVZ predictive score

Background

Preoperative left atrial (LA) function is associated with paroxysmal atrial fibrillation (PAF) ablation outcome. The presence of left atrial low voltage zone (LVZ) is also associated with recurrence. We hypothesized that reduced pre-ablation LA function reflects the presence of LVZ.

Purpose

We investigated the association between baseline LA function and the presence of LVZ in patients undergoing initial PAF ablation. Further, we sought to create the new predictive scoring for the presence of LVZ.

Methods

Consecutive 305 patients who underwent LA voltage mapping during initial PAF ablation from January 2017 to October 2019 in our institute were retrospectively analyzed. We performed 256-slice MDCT at baseline. As the representative of LA function, we calculated LA emptying fraction (LAEF), where LAEF = {[(maximum LAV) − (minimum LAV)]/(maximum LAV)} x 100. LVZ was defined as regions where bipolar peak-to-peak voltage was &lt;0.5mV. We performed the univariate and multivariate analysis to assess the association between LAEF and the presence of LVZ. Second, we performed receiver operating characteristic (ROC) analysis for the prediction of LVZ. We combined multivariate predictors and created the predictive scoring for LVZ.

Results

Out of 305 pts, 56 pts (18%) had LVZ in LA. In univariate analysis, low body mass index, higher percentage of female sex, higher age, higher E/e', larger maximum LA volume and lower LAEF (29.3±11.8% vs. 41.2±9.7, P&lt;0.0001) was associated with the presence of LVZ. In multivariate logistic regression analysis, Low LAEF revealed the strongest predictor for LVZ (LAEF; Odds ratio [OR]/10% increase: 0.54, 95% CI: 0.39–0.82, P=0.0016). High age and female sex also remained as the independent predictors (Age; OR/10 y.o. increase: 1.80, 1.23–3.03, P=0.0042, Female; OR: 2.51, 1.15–5.49, P=0.0213). In ROC analysis, LAEF had moderate predictive accuracy for the presence of LVZ. (Area under the ROC curve: 0.77, Best cut-off value: 31%, P&lt;0.0001) (Figure 1). We created OLAF-LVZ predictive score by combining Old age (1 point, ≥65), LAEF (2 points, LAEF ≤31%) and Female sex (1 point). OLAF score had gradient effect on the incidence of LVZ (2%, 11%, 25%, 45%, 71%, OLAF score; 0, 1, 2, 3, 4, respectively, P&lt;0.0001) (Figure 2).

Conclusions

In PAF patients, preoperative LAEF was strongly associated with the presence of LVZ. LVZ might reflect the myocardial injury causing LA dysfunction. OLAF-LVZ predictive score: combination of Old age (≥65), Female sex, and LAEF (≤31%) could be useful to stratify the risk of the presence of LVZ.

Funding Acknowledgement

Type of funding source: None

Quantitative analysis of dyssynchrony assessed by multidetector computed tomography can predict clinical outcome after cardiac resynchronization therapy

Background

The degree of mechanical dyssynchrony has been suggested as a predictor for long-term survival after cardiac resynchronization therapy (CRT). There have been little reports of dyssynchrony assessment with the use of cardiac computed tomography (CCT).

Methods

We studied 35 heart failure (HF) patients (average age 67±10 years) referred for CRT with NYHA III-IV heart failure, left ventricular (LV) ejection fraction (EF) 20±10% (all ≤35%), and QRS duration 156±22 ms (all ≥120ms). Electrocardiogram-gated contrast-enhanced 256-slice multidetector CT was performed before CRT. Based on CCT, the LV endocardial boundaries from short-axis images reconstructed at 5% increments of cardiac cycle were automatically detected, and the time from R-wave to maximal wall motion was calculated for each of the 16 standardized segments for all slices using software “Myocardial Contraction Map”. The standard deviation modified by mean heart rate (%SD) was respectively calculated as the global parameter of dyssynchrony. LVEF was also measured using MDCT. The predefined primary end-point was the first HF hospitalization or death over 2 years.

Results

%SD was feasible in all patients, respectably. There were 16 events over 2 years; 11 HF hospitalizations and 5 deaths. Patients with %SD ≥22% (optimal cutoff for outcome by ROC curve analysis) had a better clinical outcome than patients with %SD &lt;22% (p=0.01, Figure).

Conclusion

Patients who had %SD ≥22% assessed by MDCT had a particularly favorable event-free survival following CRT, and this appears to be an important prognostic marker.

Funding Acknowledgement

Type of funding source: None

Evaluation of the local atrial function by regional speckle tracking imaging using intracardiac echocardiography

Background

It has been reported that low voltage areas and conduction abnormalities detected by electrophysiology catheters in the left atrium (LA) represent regional degeneration and fibrosis of the atrium and are related to a poor atrial fibrillation (AF) ablation outcome. Assessment of the local atrial function is clinically useful because atrial degeneration does not occur uniformly throughout the atrium. Though evaluating the global atrial function using speckle tracking imaging (STI) by transthoracic echocardiography (TTE) has been attempted, TTE does not have a sufficient image quality to assess local atrial STI.

Purpose

To evaluate the local atrial function by STI using intracardiac echocardiography (ICE) and to elucidate the characteristics of the STI in normal and abnormal voltage regions in the LA.

Methods

We included 9 patients undergoing AF ablation with written informed consent for this prospective observational study. After pulmonary vein isolation, we performed voltage mapping of the LA in sinus rhythm using a CARTO system (Biosense). Abnormal regions and normal regions were defined as those with low voltage areas (&lt;0.5 mV) and those with normal voltages, respectively. Echo images were recorded by an ACUSON SC2000 (Siemens) and SOUNDSTAR catheter (Biosense). We inserted the SOUNDSTAR catheter into the LA to obtain clear images, recorded the STI of the anterior and inferior wall, and performed an offline analysis of the atrial strain with an eSie VVI work station (Siemens) and the LA voltage data with CARTO system at each site simultaneously (left figure). We compared the strain during the atrial contraction phase (Sct) between the normal and abnormal regions.

Results

Among the study population, 5 patients had low voltage areas in the LA. We evaluated the STI at 26 normal regions and 44 abnormal regions. The typical regional speckle tracking waveform in the normal region was similar to a jugular vein pressure waveform (right figure). There was a difference in the amplitude of the Sct between the groups; it was significantly smaller in the abnormal regions (normal and abnormal regions, 9.8±5.0% and 5.6±3.8%, p=0.0001). The duration of the Sct was significantly more prolonged in the abnormal regions than normal regions (98.8±26.3ms and 118.2±33.9ms, p=0.015).

Conclusions

This pilot study demonstrated that the local atrial function was evaluable by STI using ICE and that the regional strain tracking waveform during the atrial contraction phase in abnormal voltage regions was smaller and more prolonged than that in normal regions. An evaluation of the regional STI with an ICE may be useful to detect regional abnormalities of the atrium.

Representative case

Funding Acknowledgement

Type of funding source: None

Anti-allergic effect of the Src family kinase inhibitor saracatinib

The aim of this study was to evaluate the anti-anaphylactic and anti-allergic potentials of saracatinib, a Src family kinase inhibitor that was already shown to be safe in clinical trials when it was used as an anti-cancer drug. Using in vitro mast cell models, we found that saracatinib inhibited the degranulation response and cytokine production in RBL2H3 cells that were stimulated with IgE and antigen without affecting cell viability. Phosphorylation of Lyn, Akt, a PI3K substrate, and MAPKs including ERK, JNK, and p38, as well as the intracellular Ca²⁺ increase induced by this stimulation were also suppressed by saracatinib. This drug also inhibited symptoms in our established anaphylaxis mouse model, anaphylaxis-dependent spotted distribution of immune complex in skin (ASDIS). The intravenous injection of the mixture of IgE and antigen induced acute spotted distribution of immune complex in skin in hairless HR-1 mice, and its inhibition by intradermal injection of saracatinib was observed. Moreover, toluidine blue-stained skin sections indicated that the degranulation ratio of dermal mast cells was reduced in saracatinib-treated skin compared with vehicle-treated skin. Because only a few signaling inhibitors are used as anti-anaphylaxis and anti-allergic drugs, these results indicated the valuable suggestion that saracatinib and the Src family kinase inhibitors are good candidates for anti-anaphylaxis and anti-allergic drugs.

Use of vertebral left atrial size for staging of dogs with myxomatous valve disease

INTRODUCTION/OBJECTIVES

The American College of Veterinary Internal Medicine (ACVIM) guidelines suggest that pimobendan should be initiated in dogs which meet all criteria of stage B2 myxomatous mitral valve disease (MMVD): murmur intensity ≥ 3/6, left atrial-to-aortic ratio ≥ 1.6, normalized left ventricular internal diameter in diastole ≥ 1.7, and vertebral heart size > 10.5. Recently, a new radiographic index for left atrial enlargement, vertebral left atrial size (VLAS), was proposed. The objective of the present study was to evaluate whether VLAS is useful in staging MMVD and if it can distinguish between ACVIM stages B1 and B2.

ANIMALS

Ninety-seven client-owned dogs with MMVD were evaluated and classified as ACVIM stage B1, B2, or C-D.

MATERIALS AND METHODS

The echocardiographs and radiographs of all the dogs were retrospectively evaluated to obtain left atrial-to-aortic ratio, normalized left ventricular internal diameter in diastole, and VLAS values. The data were analyzed to assess the correlation between these measurements and VLAS, and the optimal cutoff value of VLAS was determined.

RESULTS

A VLAS cutoff value of 2.6 provided the greatest diagnostic accuracy for identification of dogs with ACVIM stage B2 MMVD (area under the curve, 0.96; sensitivity, 95%; specificity, 84%). A VLAS ≥2.5 exhibited the highest sensitivity (sensitivity, 100%; specificity, 78%), and a VLAS ≥ 3.1 exhibited the highest specificity (sensitivity, 47%; specificity, 100%).

CONCLUSIONS

VLAS is a helpful index for monitoring MMVD using radiography. A VLAS cutoff value of 2.5 could be used to identify dogs that may benefit from echocardiography to determine if they have reached ACVIM stage B2.

SAT0119 PARADOXICAL NEUTROPHIL ACTIVATION BY ANTI-IL6 THERAPY: TRANSCRIPTOME ANALYSIS SHOWS A RATIONALE FOR DERMATOLOGICAL ADVERSE REACTIONS AND DECREASED NEUTROPHIL COUNTS AFTER TOCILIZUMAB TREATMENT

Background:

Skin rashes as a side effect of Tocilizumab therapy (TCZ- Tx) has not been paid much attention, because the incidence was only 1~2% in the drug information sheets. However, we experienced several RA cases with development of various skin rashes associated with neutrophil activation after TCZ-Tx. On the other hand, it is well known that the neutrophil counts in peripheral blood decreases after TCZ-Tx, whereas it does not affect the rate of serious infections. The detailed mechanism is still unclear.

Objectives:

To detect the characteristics of the changes in gene expressions of peripheral blood associated with TCZ-Tx and the development of skin rashes as its side effect.

Methods:

Total of 14 RA patients with TCZ-Tx were included. Among them, 4 patients developed TCZ-related rashes (group S) and 10 patients did not show any side effects (group C). Peripheral whole blood at just before (pre) and 3 months after (post) TCZ-Tx from each patient were subjected to the analysis. Total RNAs were extracted with PAXgene miRNA kit and analyzed with next-generation sequencing. First, group C was investigated for the normal response to TCZ-Tx. Differentially expressed genes (DEGs) were selected by paired comparison (post vs. pre). And then, enrichment analysis using gene ontology (GO) terms were performed. Second, to explore the characteristics of group S, all expressed genes in 14 cases at just before TCZ-Tx were subjected to a hierarchical clustering analysis. The DEGs (group S vs. C and post vs. pre) were also investigated with weighted gene co-expression network analysis (WGCNA) and GO analysis. Meanwhile, the total eigengene expressions of the important modules identified by WGCNA in each cases were also calculated.

Results:

Surprisingly, 8 out of the top 10 enriched GO terms in the up-regulated genes were relevant to leukocyte activation such as ‘neutrophil migration” by the analysis of DEGs (post vs. pre) in group C. The cluster analysis of ‘pre’ genes confirmed that the patterns of gene expression between group S and C was different. WGCNA analysis of DEGs (group S vs. C) revealed that genes related to acute inflammation such as ‘leukocyte mediated immunity’ were activated in group S. Interestingly, it was not correlated with disease activity score (DAS) of RA. By the analysis of DEGs (post vs. pre) of upregulated genes, we found that the total eigengene expressions of the module enriched with genes related to ‘cell adhesion’ or ‘leukocyte migration’ were significantly increased in all cases of group S.

Conclusion:

This is the first evidence that the genes associated with neutrophil migration is significantly activated after TCZ-Tx. It is noteworthy that the gene activation was observed in cases without any side effects. The decreased neutrophil counts in peripheral blood have been known after initiation of TCZ-Tx, which did not affect the rate of serious infections. Recently, It was reported that TCZ affects neutrophil trafficking to the bone marrow1). Our findings will provide a rationale for its cause. On the other hand, we experienced several RA cases with development of various skin rashes associated with neutrophil activation after TCZ-Tx. However, majority of patients do not develop the side effect, even though genes related to ‘neutrophil migration’ are activated. In group S, our findings indicate that the genes related to ‘leukocyte mediated immunity’ was already activated at the initiation of treatment without correlating to DAS of RA, furthermore, the gene upregulation related to ‘leukocyte migration’ was more prominent after TCZ-Tx. Although it is difficult to predict the patients developing skin rashes before TCZ-Tx, we do not recommend to use TCZ for the patients with neutrophilic dermatosis which is often associated with RA.

References: :

[1]Lok LSCet al.,Eur J Clin Invest. 47(10):736-745 (2017).

Disclosure of Interests: :

Moe Sakamoto: None declared, Akemi Senoh: None declared, Yoshiharu Sato: None declared, Hiroshi Iijima: None declared, Mari Yamaguchi: None declared, Toshie Higuchi: None declared, Yoshinobu Koyama Grant/research support from: Eli-Lilly and Mochida., Speakers bureau: BMS, Ayumi, Chugai, Ono, Mitsubishi Tanabe, Abbvie and Eisai.

THU0208 AFFECTING COMMON BIOLOGICAL PROCESSES OR DISPARATE?: COMPARISON OF GENE-EXPRESSION MODIFICATION PROFILES AMONG TARGETING IL-6 AND TARGETING SPECIFIC JAK TREATMENTS

Background:

After accumulation of evidences, it is recognized that inhibition of IL-6 signaling is one of the most established strategies for rheumatoid arthritis (RA) treatment. Tocilizumab (TCZ), an anti-IL6 receptor monoclonal antibody, is the pioneer which blocks IL-6 signaling by preventing IL-6 from binding to both membrane-bound and soluble receptors. Tofacitinib (TOF) inhibits Janus kinase (JAK) 1, JAK3 and, to a lesser extent, JAK2. Recently, Baricitinib (BAR), JAK 1 and JAK2 selective kinase inhibitor, were also approved to treat RA. These JAK inhibitors are known to inhibit cytokine signaling including interleukin (IL)-6. It is very important for clinicians to know whether these treatments affect common biological processes or disparate, because it will provide a rationale for switching each other if one of these treatments resulted in lack of efficacy.

Objectives:

To compare the gene-expression modification profiles among TOF, BAR and TCZ treatments.

Methods:

Total of 38 RA cases were analyzed, including TOF (n=15: 6-20mg/d), BAR (n=10: 2-4mg/d) and TCZ (n=13: 8mg/kg/4w or 163mg/2w) treatment groups. Peripheral blood was drawn at just before (pre) and 3 months after (post) these treatments. Total RNAs were then extracted with using PAXgene miRNA kit. After constructing single-stranded, strand-specific libraries, multiplex sequencing was done. After quantifying the expressions of transcripts, differentially expressed genes (DEGs) were selected by paired comparison (post vs. pre), setting thresholds at 2-fold change up/down and less than P=0.05 in paired T-test. And then, hierarchical clustering analysis and enrichment analysis using gene ontology (GO) terms were performed.

Results:

From the comparison of post- vs. pre-treatment of TOF, BAR and TCZ, the 120 (up-regulated=25/down-regulated=95), 62 (up=20/down=42) and 193 (up=54/ down=139) genes were selected as DEGs respectively. It seems to be discrete depending on the treatment, because overlapped genes were only 1.0% in up-regulated and 5.7% in down-regulated genes. The hierarchical clustering with expression profiles of these DEGs showed major 4 clusters. 92.3% of TCZ and 70% of BAR cases were segregated into 1stand 3rdclusters respectively, while those of TOF cases fell into 2ndand 4thclusters. Disparate GO terms were enriched in each DEGs group. For example, genes relevant to viral defense including ‘response to type I interferon (IFN)’ were suppressed in TOF group. Meanwhile, down regulation of genes involved in phosphorylation process including ‘IL-7 signaling’ seemed to be significant in BAR group. It is noteworthy that terms related to wound healing such as ‘platelet activation’ were enriched in the down-regulated genes of TCZ group.

Conclusion:

It is speculated that the downstream biological cascade for TOF, BAR and TCZ treatment might be shared, as IL-6 signaling is mediated by JAK1/JAK2/TYK2 activation. However, the influence of these treatments over the transcriptome in the peripheral blood seems to be disparate. Enrichment analysis using GO terms also indicated that different biological processes were involved in the effect of each treatment. Our findings will support a rationale for switching each other if one of these treatments resulted in lack of efficacy. An increased risk of herpes zoster by a treatment with JAK inhibitors has been well recognized. It makes sense because IFN signaling is also mediated by JAK/STAT pathway. On the other hand, we have experienced a case with exacerbation of skin ulcer during TCZ treatment despite the activity of RA was absolutely under control. It is accounted for by the suppression of genes involved in wound healing after TCZ treatment.

Disclosure of Interests: :

Yoshinobu Koyama Grant/research support from: Eli-Lilly and Mochida., Speakers bureau: BMS, Ayumi, Chugai, Ono, Mitsubishi Tanabe, Abbvie and Eisai., Yoshiharu Sato: None declared, Moe Sakamoto: None declared, Hiroshi Iijima: None declared, Toshie Higuchi: None declared

Acute mitral valve regurgitation causing severe alveolar hemorrhage

Background

Acute mitral regurgitation could occur without common symptoms like hemodynamic instability, but with dyspnea, hemoptysis, and right‐sided infiltration on radiography. We report a case of severe alveolar hemorrhage caused by acute mitral regurgitation, which occurred in the absence of shock.

Case Presentation

A 40‐year‐old man presented with dyspnea with bloody phlegm and hypoxia, despite being hemodynamically stable. Chest radiography revealed right‐sided infiltration, and bronchoscopy showed fresh bloody phlegm in his tracheae. No specific findings were detected with any tests. After treatment with several medications and support with extracorporeal membrane oxygenation, his condition improved, although the etiology of the disease remained unknown. Transthoracic and transesophageal echocardiogram revealed severe mitral valve regurgitation with ruptured mitral chordae tendineae. These suggested that the sudden onset of mitral valve regurgitation had caused severe alveolar hemorrhage.

Conclusion

Severe alveolar hemorrhage, especially with right‐sided infiltration on chest radiography, should be considered a symptom of acute mitral regurgitation.

Structure-Activity Relationship between Thiol Group-Trapping Ability of Morphinan Compounds with a Michael Acceptor and Anti-Plasmodium falciparum Activities

7-Benzylidenenaltrexone (BNTX) and most of its derivatives showed in vitro antimalarial activities against chloroquine-resistant and -sensitive Plasmodium falciparum strains (K1 and FCR3, respectively). In addition, the time-dependent changes of the addition reactions of the BNTX derivatives with 1-propanethiol were examined by ¹H-NMR experiments to estimate their thiol group-trapping ability. The relative chemical reactivity of the BNTX derivatives to trap the thiol group of 1-propanethiol was correlated highly with the antimalarial activity. Therefore, the measurements of the thiol group-trapping ability of the BNTX derivatives with a Michael acceptor is expected to become an alternative method for in vitro malarial activity and related assays.

Effects of Manual Rib Cage Compressions on Mucus Clearance in Mechanically Ventilated Pigs

BACKGROUND

Manual rib cage compression is a chest physiotherapy technique routinely used in clinical practice. However, scientific evidence remains scarce on the effects of manual rib cage compression on airway clearance and oxygenation in mechanically ventilated patients.

METHODS

Anesthetized pigs were intubated via the trachea and mechanically ventilated. To create atelectasis, artificial mucus was infused into the airway. Each pig was randomly assigned to 1 of 2 groups: closed suctioning alone (control group, 7 pigs), or manual rib cage compression combined with closed suctioning (manual rib cage compression group, 8 pigs). Hard and brief rib cage compression synchronized with early expiratory phase was tested. Mucus clearance and oxygenation were assessed after the intervention. Sequential changes of hemodynamics were assessed after the intervention.

RESULTS

During hard manual rib cage compression, the mean ± SD peak expiratory flow increased to 44 ± 7 L/min compared with 31 ± 7 L/min without treatment (P < .001). Manual rib cage compression combined with endotracheal suctioning increased mucus clearance compared with closed suctioning alone (mucus amounts, 5.5 [3.4-9.4] g vs 0.7 [0.5-2.0] g; P = .004); however, it did not improve gas exchange and radiologic findings. There were no significant differences in hemodynamic variables between the 2 groups.

CONCLUSIONS

Our findings indicated that hard and brief manual rib cage compression combined with closed suctioning was safe and led to improvement of mucus clearance; however, no effectiveness was confirmed with regard to oxygenation and ventilation.

Risk factors for prolonged intensive care unit and hospital stay among patients with acute drug overdose in Japan

Aim

Hospital selection for patients with drug overdose (DOD) is a critical issue. In Tokyo, the 50‐tablet rule has been widely utilized by paramedics for triaging patients with DOD given that it shortens the triage time. However, studies have not investigated the utility of such a rule in local cities. The present study aimed to identify prognostic pre‐ and in‐hospital factors among patients with DOD and determine whether the 50‐tablet rule benefits local cities.

Methods

Clinical records of patients with DOD admitted at the University of Tsukuba Hospital (Tsukuba, Japan) between 2013 and 2017 were retrospectively reviewed.

Results

A total of 93 patients with DOD were enrolled in this study. Multivariate analysis showed that creatine kinase and C‐reactive protein values and the total number of ingested pills were in‐hospital risk factors that significantly prolonged intensive care unit (ICU) and hospital stay. Moreover, Glasgow Coma Scale score on admission and the total number of ingested pills were identified as significant pre‐hospital risk factors for prolonged ICU and hospital stay. Setting the total number of ingested pills to 50 tablets did not significantly influence ICU and hospital stay.

Conclusion

The total number of ingested pills and creatine kinase and C‐reactive protein values were identified as predictive factors for prolonged ICU and hospital stay in patients with DOD after admission. Moreover, pre‐hospital risk factors included Glasgow Coma Scale score and the total number of ingested pills. However, the 50‐tablet rule was determined to be a poor cut‐off value for patients with DOD. We presented a subset of our findings at the 46th annual meeting of the Japanese Society for Acute Medicine (Yokohama, Japan) on 20 November 2018.

1677 Global longitudinal strain during dobutamine stress echocardiography can predict left ventricular remodeling after anterior wall acute myocardial infarction

Background

Although dobutamine stress echocardiography (DSE) at the early stage of acute myocardial infarction (AMI) is useful for the prediction of functional and clinical prognosis, the interpretation requires expertise. In this study, we sought to investigate if global longitudinal strain (GLS) during DSE after AMI can predict left ventricular remodeling (LVR).

Methods

Consecutive 30 patients with anterior wall AMI (18 male, age = 58 ± 13 years) were performed DSE 3 days after AMI. GLS was calculated as an averaged value of peak longitudinal strain in the apical 4- and 2-chamber views at baseline echocardiography, low-dose DSE (10 μg/kg/min) using available software (QLAB, Philips Medical Systems). Left ventricular remodeling (LVR) was defined as an echocardiographically determined increase in both EDVI and ESVI of 20% or more from baseline to the 6 month follow-up echocardiography.

Results

12 patients (40%) evolved with LVR. The change in GLS during low-dose DSE was significantly different between the remodeling and non-remodeling group (8 ± 5% v.s. 27 ± 20%, p &lt; 0.05). Interestingly, it predicted LVR with sensitivity of 88%, specificity of 92% at the cut-off value of 12% (Area under the curve = 0.94, p &lt; 0.0001).

Conclusion

The change in GLS during low-dose DSE can be used as a predictor for the LVR after AMI. This observation has promise for clinical applications.

Abstract 1677 Figure.

Influence of psychiatric or social backgrounds on clinical decision making: a randomized, controlled multi-centre study

BACKGROUND

Frequent and repeated visits from patients with mental illness or free medical care recipients may elicit physicians' negative emotions and influence their clinical decision making. This study investigated the impact of the psychiatric or social background of such patients on physicians' decision making about whether to offer recommendations for further examinations and whether they expressed an appropriate disposition toward the patient.

METHODS

A randomized, controlled multi-centre study of residents in transitional, internal medicine, or emergency medicine was conducted in five hospitals. Upon randomization, participants were stratified by gender and postgraduate year, and they were allocated to scenario set 1 or 2. They answered questions pertaining to decision-making based on eight clinical vignettes. Half of the eight vignettes presented to scenario set 1 included additional patient information, such as that the patient had a past medical history of schizophrenia or that the patient was a recipient of free care who made frequent visits to the doctor (biased vignettes). The other half included no additional information (neutral vignettes). For scenario set 2, the four biased vignettes presented to scenario set 1 were neutralized, and the four neutral vignettes were rendered biased by providing additional information. After reading, participants answered decision-making questions regarding diagnostic examination, interventions, or patient disposition. The primary analysis was a repeated-measures ANOVA on the mean management accuracy score, with patient background information as a within-subject factor (no bias, free care recipients, or history of schizophrenia).

RESULTS

A total of 207 questionnaires were collected. Repeated-measures ANOVA showed that additional background information had influence on mean accuracy score (F(7, 206) = 13.84, p <  0.001 partial η2 = 0.063). Post hoc pairwise multiple comparison test, Sidak test, showed a significant difference between schizophrenia and no bias condition (p <  0.05). The ratings for patient likability were lower in the biased vignettes compared to the neutral vignettes, which was associated with the lower utilization of medical resources by the physicians.

CONCLUSIONS

Additional background information on past medical history of schizophrenia increased physicians' mistakes in decision making. Patients' psychiatric backgrounds should not bias physicians' decision-making. Based on these findings, physicians are recommended to avoid being influenced by medically unrelated information.

A night on call or an overnight shift does not reduce residents' empathy: a randomized crossover multicenter survey

BACKGROUND

Studies have shown that sleep deprivation may reduce empathy among medical students. Yet, little is known about the empathy after a night on call or an overnight shift among resident physicians. Hence, we aimed to examine whether a night on call or an overnight shift reduces the physicians' empathy.

METHODS

We conducted a multicenter randomized crossover survey using the Jefferson Scale of Physician Empathy (JSE). A total of 260 physicians who worked at academic hospitals and community hospitals in Japan in 2016 were recruited and randomized into two groups. Group A first completed the JSE prior to a night on call or an overnight shift; then, 8 weeks later, Group A completed the JSE after a night on call or an overnight shift. Group B first completed the JSE after a night on call or an overnight shift; then, 8 weeks later, Group B completed the JSE prior to a night on call or an overnight shift. Statistical analyses were performed to compare the JSE scores of pre- and post-night on call or overnight shifts.

RESULTS

A total of 117 Group A physicians and 112 Group B physicians returned a completed JSE. The overall response rate was 88.08%. There was no significant difference in the JSE scores between pre- and post-night on call or overnight shift. (Group A before night vs Group B after night, p = 0.40, Group A after night vs Group B before night, p = 0.68).

CONCLUSION

As per our results, a night on call or an overnight shift did not reduce the Japanese physicians' empathy. To the best of our knowledge, this is the first study on physicians' empathy after a night on call or an overnight shift.

P3587Tip detection method using the new short-tip IVUS with pull-back system which facilitates the 3D wiring technique in percutaneous coronary intervention for chronic total occlusion

Background

The strategy of intravascular ultrasound (IVUS)-guided wiring for CTO PCI, that is, leading the second guidewire into the true lumen under observing by IVUS from subintimal space, is the last resort. We developed the angiography-based 3D wiring method. During establishment of the angiography-based 3D wiring method, we deduced that observation of the guidewire tip as well as the shaft named “The tip detection method” simplifies and facilitates 3D wiring under IVUS-guided wiring. Therefore, we produced New CTO IVUS which is the upgraded version of Navifocus WR IVUS by adding the pull-back transducer system. This pull-back system enables us to detect the tip as well as the shaft of the second guidewire in real time (tip detection method), which facilitates the 3D wiring technique under IVUS-guided wiring.

Objective

We evaluated the efficacy of the tip detection method during 3D wiring for CTO PCI with New CTO IVUS.

Method

We created a target pinpoint penetration model and performed the procedures using an experimental heartbeat model. The target (a tube with a lumen 0.6 mm in diameter) was placed in the distal part of a CTO 20 mm in length made of 2.5% agar. After the second guidewire (Conquest-12g) was advanced into the CTO lesion to within 5mm of the target using the angiography-based wiring, IVUS-guided wiring was performed by using Navifocus WR or New CTO IVUS each five times.

Result

The frequency of the puncture time was reduced using the new CTO IVUS compared to the Navifocus WR (1.7±0.8 vs. 28.8±23.2, p=0.17). The procedure time was significantly shorter using the new CTO IVUS compared to the Navifocus WR (103±61 vs. 459±373 seconds, p=0.04).

Conclusion

The tip detection method during 3D wiring with the new short tip IVUS with the pull-back system enables us to easily perform 3D wiring and will change the CTO PCI strategy.

P5305Oxidized high-density lipoprotein is associated with progression of coronary artery calcification

Introduction

As a residual cardiovascular risk, high-density lipoprotein (HDL) is of great interest in lipid management. Native HDL has an anti-atherogenic role, while oxidized HDL (oxHDL) has atherogenic property because of reduced anti-inflammatory properties compared with native HDL. Meanwhile, recent studies showed that rapid progression of coronary artery calcification (CAC), a marker of subclinical atherosclerosis, was associated with greater incidence of cardiovascular events. However, the role of oxHDL in the pathogenesis of CAC remains unclear.

Purpose

The purpose of this study was to examine the association between the annual change in oxHDL and the progression of CAC (Agatston score) in a substudy of prospective multicenter randomized study.

Methods

In the principal study, patients with a CAC score of 1 to 999 were treated with pitavastatin with/without eicosapentaenoic acid. Measurement of CAC with MDCT and a blood test were performed at baseline and at the 1-year follow-up. The principal study showed 30–40% of annual change in CAC in all patients and no difference in the progression of CAC among treatment groups. In this substudy (n=140), patients were divided into 2 groups: CAC progression (change in Agatston score of >0, n=103) and no CAC progression (n=37). The serum concentration of oxHDL was measured using an antibody against oxidized human apoA-I with ELISA. The difference in oxHDL between patients with hypercholesterolemia and healthy subjects (n=30) was also evaluated.

Results

OxHDL levels were significantly lower in healthy subjects than in patients with hypercholesterolemia (150 [107–176] and 167 [132–246], respectively; median [25th-75th percentile], U/ml) (p=0.006). The baseline log-transformed oxHDL level was correlated with total cholesterol (r=0.21, p=0.01), HDL-cholesterol (r=0.33, p<0.01), and triglycerides (r=−0.21, p=0.01), but not correlated with age, body mass index, hemoglobinA1c, LDL-cholesterol, serum creatinine, or high-sensitivity C-reactive protein. After treatment, the oxHDL level significantly decreased from 167 (132–246) at baseline to 122 (103–149) (median [25th–75th percentile], U/ml) (p<0.001). The annual change in CAC was significantly positively associated with changes in oxHDL (r=0.17, p=0.04), triglycerides (r=0.17, p=0.04), and hsCRP (r=0.22, p=0.01) but not associated with changes in LDL-C or HDL-C. Multiple logistic analysis demonstrated that the decrease in oxHDL per 10 U/ml was independently associated with CAC progression after adjusting for variables including baseline oxHDL, LDL-cholesterol, Agatston score and current smoking (odds ratio, 0.95; 95% confidence interval, 0.90–0.99; p=0.04).

Conclusion

The decrease in oxHDL is associated with the attenuation of CAC progression, suggesting that oxHDL is a potential target for preventing atherosclerosis.

P980Post-procedural plasma brain natriuretic peptide level early after catheter ablation predicts the future clinical outcome in patients with persistent atrial fibrillation and reduced ejection fraction

Background

Successful restoration of sinus rhythm (SR) by catheter ablation (CA) for persistent atrial fibrillation (AF) improves cardiac function, resulting in decrease of plasma brain natriuretic peptide (BNP) level. The exact significance and prognostic implications of this change have yet to be determined.

Purpose

To examine the impact of pre- and post-procedural BNP level on the clinical outcome after CA in patients with persistent AF and reduced left ventricular ejection fraction (LVEF).

Methods

Out of 242 patients with LVEF <50% who underwent first-time CA for persistent AF between March 2012 and September 2018 at our institute, we enrolled 137 patients (61±10 years, 83% male) whose plasma BNP level was available both at baseline and early after CA (during 1–3 month). We evaluated the impact of the BNP levels on future AF recurrence 3 months after CA as the primary endpoint. Additional secondary endpoints included heart failure (HF) hospitalization and cardiovascular death.

Results

All patients successfully restored SR at the end of CA. Within 3 months of a blanking period (BP), improvement of LVEF (from 39±10% to 65±12%, p<0.001) and reduction of BNP levels (from 178 [107–332] pg/ml to 42.3 [21.1–78.6] pg/ml, p<0.001) were observed. During the median follow-up of 21 months after BP, the incidence of AF recurrence, HF hospitalization, and cardiovascular death was 37% (n=50), 3% (n=4), and 1% (n=1), respectively. Cox proportional hazard regression analysis after adjustment for age and gender revealed that post-procedural BNP level was a significant predictor of the AF recurrence (hazard ratio [HR] per 100-pg/ml increase, 1.13; 95% confidence interval [CI], 1.02–1.25; p=0.023), but pre-procedural BNP level was not (1.02; 0.95–1.09; p=0.56). Receiver operating curve analysis determined the post-procedural BNP level of 55.5 pg/ml as the best cut-off value for predicting the AF recurrence, with area under the curve of 0.620 (95% CI, 0.534–0.702; p=0.018). The incidence of AF recurrence was significantly higher in patients with post-procedural BNP level >55.5 pg/ml (n=50) than the others (50% vs. 29%; HR, 3.99; 95% CI, 2.07–7.68; p<0.001). No patients with post-procedural BNP level ≤55.5 pg/ml experienced HF hospitalization and cardiovascular death (8% vs. 0% and 2% vs. 0%, p=0.006 and p=0.17, respectively)

Conclusions

Not pre-procedural but post-procedural BNP level early after CA predicted the future clinical outcome in patients with persistent AF and reduced LVEF. Decreased but still elevated BNP level after restoration of SR would identify the residual risk for developing unfavorable outcome.

Abstract P2-01-19: Sphingosine-1-phosphate affects tumor-associated macrophages in breast cancer patients

Background: Tumor-associated macrophages (TAMs) are considered to be one of the key players in the tumor microenvironment, which regulates cancer invasion and metastases. TAMs can be divided into two phenotypes with opposite functions. While M1 macrophages are known to exert anti-tumor activity by promoting pro-inflammatory effects and immune responses such as intereukin-6 (IL-6) and tumor necrosis factor-α (TNF-α), M2 macrophages influence an anti-inflammatory response, wound healing, and pro-tumorigenic properties. A bioactive lipid mediator, sphingosine-1-phosphate (S1P) has emerged as a key regulatory molecule in cancer progression. We previously demonstrated that S1P generated by sphingosine kinase 1 (SPHK1), is a crucial mediator of breast cancer-induced angiogenesis and lymphangiogenesis, and promotes its metastasis. In particular, we found that SPHK1 is highly expressed in HER2 negative breast cancer, and the patients who developed lymph node metastasis demonstrated significantly higher levels of S1P (J Surg Res 2016). Although we have previously reported the role of S1P in recruitment of TAMs in vivo (Cancer Res 2018), its relevance in patients is yet to be uncovered. Here, we test our hypothesis that S1P signaling affects TAMs in human patients with breast cancer.

Materials and Methods: The expression level of each enzyme-encoding gene involved in S1P production was evaluated by retrieving RNA sequencing and gene expression quantification data using the Genomics Data Commons (GDC) data portal of the The Cancer Genome Atlas cohort. Gene expression levels were derived using normalization methods provided in the DESeq2 package. We compared the difference in expression levels of tumor associated macrophage related genes, including CD68, CD163, IL-6, andTNF-α between SPHK1-high breast tissue, and SPHK1-low breast tissue in the group of HER2 negative or positive patients. Unpaired t-tests were performed to compare expression differences between SPHK1-high and SPHK1-low breast tissue. All tests were two-sided and P values &lt; 0.05 were considered statistically significant.

Results: CD68, pan-macrophage marker, is significantly increased in SPHK1-high breast cancer tissues both in HER2 negative and positive breast cancer patients (p=&lt;0.001, &lt;0.01). CD163 which is a scavenger receptor that is regarded as highly specific for M2 macrophages is significantly increased in SPHK1-high breast cancer tissues in HER2 negative breast cancer patients, but not in HER2 positive breast cancer patients (p=&lt;0.001, 0.2). IL-6, which characterize M1 phenotype is significantly increased in SPHK1-high breast cancer tissues both in HER2 negative and positive breast cancer patients (p=&lt;0.001, &lt;0.001). TNF-α, which also characterizes M1 phenotype, is significantly increased in SPHK1-high breast cancer tissues in HER2 negative breast cancer patients, but not in HER2 positive breast cancer patients (p=&lt;0.001, 0.05).

Conclusion: Our results suggest that S1P affects TAMs in breast cancer patients, which implicate the important roles of S1P in the complicated immune system related to tumor progression. Our results also indicate that S1P have a large role in HER2 negative breast cancer patients. Further investigations are needed to understand the underlying mechanisms.

Citation Format: Tsuchida J, Nagahashi M, Moro K, Ikarashi M, Koyama Y, Sakata J, Kobayashi T, Kameyama H, Qi Q, Yan L, Takabe K, Wakai T. Sphingosine-1-phosphate affects tumor-associated macrophages in breast cancer patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-01-19.

Effectiveness of a comprehensive oral management protocol for the prevention of severe oral mucositis in patients receiving radiotherapy with or without chemotherapy for oral cancer: a multicentre, phase II, randomized controlled trial

The aim of this phase II, multicentre, randomized controlled trial was to evaluate the effectiveness of a comprehensive oral management protocol for the prevention of severe oral mucositis in patients with oral cancer receiving radiotherapy alone or chemoradiotherapy. In total, 124 patients with oral cancer were enrolled from five institutions. Of these, 37 patients undergoing radiotherapy were randomly divided into an intervention group (n=18) and a control group (n=19). The remaining 87 patients, who were undergoing chemoradiotherapy, were also randomized into an intervention group (n=42) and a control group (n=45). During radiotherapy, patients in the control group received only oral care, while those in the intervention group additionally received spacers to cover the entire dentition, pilocarpine hydrochloride, and topical dexamethasone ointment for oral mucositis. The primary endpoint was the incidence of severe oral mucositis. The intervention was significantly associated with a decreased incidence of severe oral mucositis in patients receiving radiotherapy alone (P=0.046), but not in those receiving chemoradiotherapy (P=0.815). These findings suggest that an oral management protocol can prevent severe oral mucositis in patients with oral cancer undergoing radiotherapy without concurrent chemotherapy.