Impact of prior coronary artery bypass grafting and coronary lesion complexity on outcomes of transcatheter aortic valve replacement for severe aortic stenosis

OBJECTIVE

To investigate the impact of prior coronary artery bypass grafting (CABG) and coronary lesion complexity on transcatheter aortic valve replacement (TAVR) outcomes for aortic stenosis.

METHODS

Clinical outcomes of TAVR were retrospectively compared between patients with and without prior CABG, and between patients with prior CABG and without coronary artery disease (CAD). The impact of the CABG SYNTAX score was also evaluated in patients with prior CABG.

RESULTS

The study included 1042 patients with a median age and follow-up of 82 years and 25 (range: 0-72) months, respectively. Of these, 175 patients had a history of CABG, while 401 were free of CAD. Patients with prior CABG were more likely to be male and had higher rates of diabetes, peripheral artery disease and atrial fibrillation compared with patients without prior CABG. After 2 : 1 propensity score matching, all-cause mortality (P = 0.17) and the composite of all-cause mortality, stroke and coronary intervention (P = 0.16) were similar between patients with (n = 166) and without (n = 304) prior CABG. A 1 : 1 propensity score-matched analysis, however, showed lower rates of all-cause mortality (P = 0.04) and the composite outcome (P = 0.04) in patients with prior CABG (n = 134) compared with patients without CAD (n = 134). The median CABG SYNTAX score was 16 (interquartile range: 9.0-23), which was not associated with better/worse clinical outcomes in patients with prior CABG.

CONCLUSION

Prior CABG may positively affect mid-term TAVR outcomes for aortic stenosis compared with no CAD when adjusted for other comorbidities. The CABG SYNTAX score did not influence the prognosis after TAVR.

Impact of mitral stenosis on early and late outcomes of transcatheter aortic valve replacement for aortic stenosis: a single-center analysis

OBJECTIVES

To assess the impact of concomitant mitral stenosis (MS) on early and late outcomes of transcatheter aortic valve replacement (TAVR) for aortic stenosis.

METHODS

This study involved 952 patients undergoing TAVR for severe tricuspid aortic stenosis. The patients were classified into 3 groups: without MS, with progressive MS, and severe MS (mitral valve area ≤ 1.5 cm2). Clinical outcomes between these groups were compared.

RESULTS

The median age of the overall cohort was 82 years, and patients in the progressive (n = 49) and severe (n = 24) MS groups were more likely to be female than those in the no-MS group (n = 879). Periprocedural mortality rate was lowest in the no-MS group (1.8%) compared with the progressive (4.1%) and severe (4.2%) MS groups, which were not significantly different (P = .20). During 5 years of follow-up (median: 27, range: 0-72 months), there was no significant difference in all-cause mortality (log-rank P = .99), a composite of all-cause mortality or rehospitalization for heart failure (log-rank P = .84), or cardiovascular death (log-rank P = .57) between groups. Although crude analysis showed a significant difference in rehospitalization for heart failure in the severe MS group compared with the no-MS group (P = .049), the difference was not significant in the multivariate analysis (adjusted hazard ratio: 1.36 [95% CI, 0.66-2.80], P = .41).

CONCLUSIONS

TAVR can be safely performed in patients with severe tricuspid aortic stenosis and concomitant MS, with early and mid-term outcomes comparable to those in patients without MS.

Improved Hemodynamics with Self-Expanding Compared to Balloon Expandable Transcatheter Aortic Valve Implantation in Small Annulus Patients: A Propensity-Matched Analysis

Patients with small aortic annuli (SAA) pose a challenge in aortic valve replacement patients due to potential for prosthesis-patient mismatch (PPM). The objective of this study was to compare clinical and hemodynamic outcomes of self-expandable valves (SEV) versus balloon-expandable valves (BEV) transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and SAA. All patients who underwent TAVI for severe native aortic stenosis with a SAA between January 2018 and December 2022 were retrospectively included in the study from a single center. Propensity score matching was performed to balance baseline characteristics. Bioprosthesis valve dysfunction (BVD) was based on modified Valve Academic Research Consortium 3 (VARC-3) criteria. A total of 1170 TAVI procedures were performed between 2018 and 2022. After applying the exclusion criteria, 332 patients reported a SAA at CT scan and matching created 109 balanced pairs. Echocardiographic data at discharge showed higher mean transvalvular gradients (p<0.001), higher grades of mitral regurgitation (p=0.029), and lower ejection fraction (p<0.043) in BEV when compared to SEV. At follow-up, significant differences favoring the SEV group regarding BVD were observed (p=0.002), especially in terms of severe PPM (p=0.046), and at least moderate structural valve deterioration (p=0.040). In conclusion, TAVI in patients with SAA using a BEV was associated with lower valve areas, higher mean pressure gradients and PPM (including severe) compared to SEV. Short- and midterm all-cause and cardiac-related mortality did not differ between the two groups. Future randomized studies with extended follow-ups are warranted to validate these outcomes.

Development of a Risk Score for Long-term Survival and MACCE After Coronary Artery Bypass Grafting Surgery

OBJECTIVE

To develop risk scoring models predicting long-term survival and major adverse cardiovascular and cerebrovascular events (MACCE) including myocardial infarction and stroke after coronary artery bypass grafting (CABG).

METHODS

All-consecutive 4,821 patients undergoing isolated CABG at Lankenau between 01/2005-07/2021 were included. MACCE was defined as all-cause mortality+myocardial infarction (MI)+stroke. Variable selection for both outcomes was obtained using a double selection logit Lasso with adaptive selection. Models performance was internally evaluated by calibration and accuracy using bootstrap cross-validation. Mortality and MACCE were compared among patients split into three groups based on the predicted risk scores for all-cause mortality and MACCE. An external validation of our database was performed with 665 patients from the University of Brescia, Italy.

RESULTS

Pre-operative risk predictors were found to be predictors for all-cause mortality and MACCE. In addition, being of African American ethnicity is a significant predictor for MACCE after isolated CABG. The AUC which measures the discrimination of the models were 80.4%, 79.1%, 81.3%, and 79.2% for mortality at 1,2,3, and 5 years follow-up. The AUC for MACCE were 75%, 72.5%, 73,8%, and 72.7% at 1, 2, 3, and 5-years follow-up. For external validation, AUC for all-cause mortality and MACCE at 1, 2, 3, and 5 years was 73.7%, 70.8%, 68.7%, and 72.2% and 72.3%, 68.2%, 65.6%, 69.6%, respectively.

CONCLUSIONS

The Advanced (AD) Coronary Risk Score for All-Cause Mortality and MACCE provide good discrimination of long-term mortality and MACCE after isolated CABG. External validation observed a more AUC's above 70%.

Photoelectron Holographic Study for Atomic Site Occupancy for Si Dopants in Si-Doped κ-Ga2O3(001)

We investigated atomic site occupancy for the Si dopant in Si-doped κ-Ga2O3(001) using photoelectron spectroscopy (PES) and photoelectron holography (PEH). From PES and PEH, we found that the Si dopant had one chemical state, and three types of inequivalent Si substitutional sites (SiGa) were formed. The ratios for the inequivalent tetrahedral, pentahedral, and octahedral SiGa sites were estimated to be 55.0%, 28.1%, and 16.9%, respectively. Higher (lower) ratios for the three inequivalent SiGa sites may come from a lower (higher) formation energy. The Tetra (Octa) SiGa site has the highest (lowest) ratio of the three SiGa sites since it has the lowest (highest) formation energy. We suggest that the tetrahedral SiGa site is due to the active dopant site, whereas the pentahedral and octahedral SiGa sites can be attributed to the inactive dopant sites for Si-doped κ-Ga2O3(001).

Hybrid robotic-assisted coronary revascularization and transcatheter aortic valve replacement: a single-center experience

OBJECTIVES

The efficacy of hybrid robotic-assisted coronary artery bypass grafting (CABG) and transcatheter aortic valve replacement (TAVR) for coronary and aortic valve disease is poorly reported. Herein, we report our experience with this hybrid approach.

METHODS

Between January 2018 and June 2022, 10 (7 male, 3 female) patients with a mean age of 81 years underwent the hybrid procedure. Coronary revascularization was performed prior to TAVR with robotic-assisted left internal mammary artery-to-left anterior descending (LAD) bypass grafting for left main or proximal LAD lesions with or without multivessel disease with or without hybrid percutaneous coronary intervention (PCI).

RESULTS

Five patients had left main disease, and 5 had proximal LAD disease with or without multivessel disease. All patients tolerated the robotic-assisted CABG procedure well; 9 patients were extubated in the operating room and all patients were ambulatory on postoperative day 1. Five patients underwent hybrid PCI for non-LAD lesions. TAVR was subsequently performed at intervals ranging from 3 days to 5 months after CABG. One patient with end-stage renal disease on hemodialysis required hospitalization for heart failure during the interval period. The 1-year mortality rate was 0%, and 3 patients died during late follow-up (24-43 months).

CONCLUSIONS

This innovative, less invasive approach demonstrates the potential for early recovery in appropriately selected patients with complex coronary and aortic valve disease with promising mid-term outcomes.

Crystal structures and photoluminescence characteristics of cesium lead bromide perovskite nanoplatelets depending on the antisolvent and ligand used in their syntheses

Cesium lead bromide (CsPbBr3) nanocrystals (NCs) with nanoplatelet shapes and different crystal structures were synthesized via the ligand-assisted reprecipitation (LARP) method using different pairs of ligands and antisolvents, namely oleic acid (OA) or linoleic acid (LA) as the ligand and toluene or chloroform as the antisolvent. The XRD data revealed that the obtained CsPbBr3 NCs have different crystal structures, namely orthorhombic, tetragonal, and cubic, depending on the ligand and antisolvent pair, which exhibited significantly different photoluminescence (PL) characteristics. From the XPS data, these CsPbBr3 nanoplatelets showed two doublet peaks of the Br-3d orbital at different binding energies, representing two different chemical environments of the Br bonds. The doublet peak apparent at a higher binding energy was associated with the Br chemical states at the crystal surface, which appeared because of the distorted crystal structure resulting from the interaction of the solvent and ligand with Br ions. The PL emission consists of three luminescence centers: a PL band peaked at 520 nm (A band), a PL band peaked at 540 nm (B band), and a PL band tail, which can be discussed in terms of exciton models. Stable and intense luminescence was observed in CsPbBr3 nanoplatelets synthesized using a pair of toluene antisolvent and LA ligand, namely CsPbBr3#(Tl/LA). The orthorhombic crystal structure and distorted crystal surface in this sample may lead to confinement of the photogenerated small exciton-polaron and weak phonon interactions, which effectively hinder exciton dissociation, particularly at the crystal surface, resulting in intense PL. The results of this study may provide additional important insights into the role of the antisolvent and ligand in the formation of CsPbBr3 NCs and the exciton behavior in their PL characteristics, which may also be found in other types of halide perovskites.

Safety and Effectiveness of OnabotulinumtoxinA in Patients with Laryngeal Dystonia: Final Report of a 52-Week, Multicenter Postmarketing Surveillance Study

This postmarketing surveillance study was conducted to evaluate the safety and effectiveness of onabotulinumtoxinA in Japanese patients with laryngeal dystonia (LD). Patients receiving onabotulinumtoxinA for the first time were enrolled and observed for up to 12 months following the first injection. Safety assessment included adverse drug reactions (ADRs), and effectiveness assessments included the Voice Handicap Index-10 (VHI-10) and physician's global assessment (PGA). ADRs were observed in 48 (5.8%) of 834 patients in the safety analysis set, including dysphonia in 43 (5.2%) patients and dysphagia in 7 (0.8%) patients. The change in total VHI-10 score (mean) in 790 patients included in the effectiveness analysis set showed that improvement in adductor LD peaked at 2 months after the first injection, while patients with abductor or mixed LD showed a gradual attenuation of effect 2-4 weeks post-injection. The change in total VHI-10 score in subsequent injections was generally similar to that following the first injection. The overall effectiveness rate according to the PGA was 93.4% (738/790 patients). The results demonstrate that onabotulinumtoxinA is a well-tolerated and effective treatment for LD in real-world clinical practice.

High-Resolution Detection of Translocation of Oral Bacteria to the Gut

Ectopic enrichment of oral microbes in the gut is a notable alteration in gut microbial balance. These microbes are likely delivered from the oral cavity with saliva and food; however, evidence of oral-gut microbial transmission is insufficient and needs further investigation. In this observational study, we examined 144 pairs of saliva and stool samples collected from community-dwelling adults to verify the oral-gut microbial link and identify the relevant influencing factors on the increased abundance of oral microbes within the gut. The bacterial composition of each sample was determined using PacBio single-molecule long-read sequencing of the full-length 16S ribosomal RNA gene and amplicon sequence variant (ASV) analysis. Although the bacterial compositions of salivary and gut microbiota were distinctly different, at least 1 ASV was shared between salivary and gut microbiota in 72.9% of subjects. Shared ASVs accounted for 0.0% to 63.1% (median 0.14%) of the gut microbiota in each subject and frequently included abundant Streptococcus salivarius and Streptococcus parasanguinis. Their total relative abundance in the gut was significantly higher in older subjects or those with dental plaque accumulation. The gut microbiota with ≥5% of shared ASVs displayed a higher abundance of Streptococcus, Lactobacillus, and Klebsiella and a lower abundance of Faecalibacterium, Blautia, Megamonas, and Parabacteroides. Our study presents evidence for the translocation of oral bacteria to the gut in community-dwelling adults and suggests that aging and dental plaque accumulation contribute to an increased abundance of oral microbes in the gut, which might be relevant to the compositional shift in the gut commensals.

Formation and evolution of carbonaceous asteroid Ryugu: Direct evidence from returned samples

Samples of the carbonaceous asteroid Ryugu were brought to Earth by the Hayabusa2 spacecraft. We analyzed 17 Ryugu samples measuring 1 to 8 millimeters. Carbon dioxide-bearing water inclusions are present within a pyrrhotite crystal, indicating that Ryugu's parent asteroid formed in the outer Solar System. The samples contain low abundances of materials that formed at high temperatures, such as chondrules and calcium- and aluminum-rich inclusions. The samples are rich in phyllosilicates and carbonates, which formed through aqueous alteration reactions at low temperature, high pH, and water/rock ratios of <1 (by mass). Less altered fragments contain olivine, pyroxene, amorphous silicates, calcite, and phosphide. Numerical simulations, based on the mineralogical and physical properties of the samples, indicate that Ryugu's parent body formed ~2 million years after the beginning of Solar System formation.

[Stanford Type A Acute Aortic Dissection with Myonephropathic Mrtabolic Syndrome]

A 57-year-old man was transferred with sudden onset chest pain and evolving paralysis and numbness in the left leg. Contrast computed tomography (CT) revealed Stanford type A acute aortic dissection from the ascending aorta to bilateral internal and external iliac arteries with blood flow obstruction to the left kidney and left lower limb. Surgery was initiated 10 hours after onset of ischemic symptoms in the leg. Femoro-femoral bypass was carried out first, and we ensured sufficient phlebotomy from the ischemic limb during reperfusion and continuous hemodiafiltration to prevent myonephropathic metabolic syndrome. Total aortic arch replacement was then performed. Our treatment strategy was effective in this case of Stanford type A aortic dissection with prolonged lower limb ischemia. Although left hip disarticulation was subsequently required due to intractable infection, the patient became able to walk with an artificial limb after post-rehabilitation.

P-185 The migration speed of nucleolar precursor bodies in pronuclei affects in vitro fertilization-derived human embryo ploidy status

Study question

Does the migration speed of nucleolar precursor bodies (NPBs) in male and female pronuclei (mPN and fPN) affect in vitro fertilization (IVF)-derived embryo ploidy status?

Summary answer

The NPB migration speed in mPN impacts the IVF-derived human embryo ploidy status and this indicator could be an attractive marker for noninvasive embryo selection.

What is known already

NPBs are not considered as simple nucleolar components transmitted from an oocyte to an embryo, and they could participate in genome remodeling during embryo development. NPBs are essential only shortly after fertilization, suggesting that they may actively participate in centromeric chromatin establishment. A previous study demonstrated that NPBs migrated faster in intracytoplasmic sperm injection-derived zygotes having the potential to develop into a blastocyst and eventually into a baby (Inoue et al., 2021). However, the relationship between NPB migration speed and IVF-derived embryo ploidy status is unclear.

Study design, size, duration

The relationship between the NPB migration speed and embryo ploidy status was retrospectively analyzed in patients with recurrent assisted reproductive technology failure (euploid n =18; aneuploid n =19; and total = 219 NPBs). Archived time-lapse videos (images were recorded every 5 min; Geri+) from incubation after IVF were retrieved after the patients were identified for the study, and the NPB migration speed was analyzed. The retrospective analyses were performed with the patient’s identities masked.

Participants/materials, setting, methods

mPN and fPN were identified by appearance location in a zygote (fPN appearance is just below the polar bodies). The mPN, fPN, and 2–3 NPBs/PN central coordinates were measured by Kinovea (motion capture software). Their central coordinates were confirmed/revised every image and were decided. The migration distance of NPBs between two sequential images was calculated as the standard of the central PN coordinates. Thereafter, the migration speed of NPBs was calculated.

Main results and the role of chance

Both NPB speeds were significantly faster in the euploid than in the aneuploid groups (mPN: 4.08±0.61 vs. 3.54±0.54 µm/h, P =0.003, power [1-β]: 0.999, fPN: 4.03±0.89 vs. 3.26±0.45 µm/h, P &lt;0.003, 1-β: 0.987). The NPB speed in mPN was correlated with that in fPN (rs =0.523, P =0.001). The ploidy status was related to the NPB speeds in mPN and fPN (P &lt;0.05) in univariate logistic analysis including male/female ages, ICM/TE grades, and 29 morphokinetic parameters. The factors associated with ploidy status were the NPB speed in mPN (odds ratio [OR], 10.2; 95% confidence interval [CI], 1.90–54.90; P =0.007) and female age (OR, 0.8; 95%CI, 0.64–0.98; P =0.03) in multivariate logistic analysis. The cutoff value for the NPB speeds in mPN and fPN were 3.65 μm/h (specificity, 73.7%; sensitivity, 77.8%; AUC, 0.78; 95%CI, 0.62–0.93) and 3.77 μm/h (specificity, 89.5%; sensitivity, 66.7%; AUC, 0.78; 95%CI, 0.62–0.94). When the zygotes were categorized by their cutoff values, the euploid rate in zygotes with NPB speeds greater than the cutoff value was significantly higher than that in zygotes with the speeds less than the cutoff value (mPN = 73.7% vs. 22.2% [P =0.003]; fPN = 85.7% vs. 26.1% [P &lt;0.001]).

Limitations, reasons for caution

The NPB migration in the z-axis direction could not be analyzed. NPB tracking could not be performed when NPBs were large in number or drastically moved. Our findings should help in elucidating the relationship, although they did not completely explain the relationship between NPB migration and embryo development.

Wider implications of the findings

The migration speed of NPBs impacts human embryo ploidy status. NPB migration speed may add clinical value for embryo selection, which may be associated with live birth, and consequently, the time of the live birth could be shorter. The indicator could be an attractive marker for noninvasive embryo selection.

Trial registration number

Not applicable

Surgical repair of the adult form of scimitar syndrome

Scimitar syndrome has various clinical presentations and anatomic features, and some cases are diagnosed in adulthood. Reconstruction using autologous tissue to reroute the right pulmonary venous blood flow to the left atrium is ideal. However, if the scimitar vein drains to the caudal segment of the inferior vena cava, reconstruction using prosthetic material may be necessary due to the distance between the left atrium and the scimitar vein. We describe the case of a 16-year-old boy with scimitar syndrome. We anastomosed the scimitar vein to the right atrium using an artificial graft and created an atrial septal defect for rerouting the right pulmonary venous blood to the left atrium. It has been 9 years since this procedure, and the patient has not experienced graft stenosis or thromboembolic events.

Therapeutic efficacy of intra-arterial docetaxel and nedaplatin infusion concomitant with radiotherapy for T4 maxillary sinus squamous cell carcinoma

The aim of this study was to evaluate the efficacy of intra-arterial chemoradiotherapy with docetaxel and nedaplatin for T4 maxillary sinus squamous cell carcinoma (MSSCC). Data were retrospectively analysed for 22 consecutive patients with T4 MSSCC who underwent intra-arterial chemoradiotherapy. Participants received intensity-modulated radiotherapy (70 Gy in 35 fractions) concomitantly with docetaxel (60 mg/m²) and nedaplatin (80 mg/m²) administered every 4 weeks for a total of three sessions. The median follow-up period was 49 months (range 12-91 months). T4a tumours were found in 16 patients (73%) and T4b tumours in six patients (27%). Cervical metastasis was found in nine patients (41%; five N2b, four N2c). The 5-year loco-regional control, disease-free survival, and overall survival rates for patients with T4a disease were 92.3%, 92.3%, and 90.3%, respectively, compared to 83.3% (P = 0.42), 66.7% (P = 0.07), and 83.3% (P = 0.46), respectively, for those with T4b disease. The 5-year loco-regional control, disease-free survival, and overall survival rates for patients with cervical lymph node metastasis were all 87.5% compared to 92.3% (P = 0.86), 84.6% (P = 0.69), and 92.3% (P = 0.93), respectively, for those without cervical metastasis. Intra-arterial chemoradiotherapy with docetaxel and nedaplatin may provide favourable loco-regional control and increased survival in T4 MSSCC.

Efficacy of the spiral flow generating extended tube during paediatric CCTA

INTRODUCTION

To compare the computed tomography (CT) number for paediatric cardiac computed tomography angiography (CCTA) and visualisation score of the three-dimensional (3D) images using the conventional T-shaped extended tube (T-tube) and spiral flow-generating extended tube (spiral-tube) connected between the contrast injector and cannula.

METHODS

In total, 108 patients suspected to have congenital heart disease (CHD) were considered for inclusion. We utilised the T-tube for intravenous contrast and spiral-tube in 54 patients each. Observers individually inspected randomized volume rendering images of the internal thoracic artery, each acquired from the with or without spiral-tube groups, using a four-point scale. We compared the mean CT number of the ascending aorta (AAO) and pulmonary artery (PA), contrast noise ratio (CNR), CT number for the AAO and PA enhancement ratio, and the visualisation scores between the groups.

RESULTS

There were no significant differences in patient characteristics between the with or without spiral-tube groups (p > 0.05). The mean CT number ±standard deviation for the AAO and PA, and the CNR without or with spiral-tube groups were 441.2 ± 89.2 and 489.8 ± 86.1 HU for the AAO, 436.3 ± 100.6 and 475.3 ± 85.2 HU for the PA, and 9.5 ± 2.2 and 10.8 ± 2.4 for the CNR, respectively (p < 0.05). In the spiral-tube group, the CT number, CNR, and visualisations score of the 3D images were significantly higher for the AAO and PA than those in the T-tube group (p < 0.05).

CONCLUSION

The spiral-tube proved to be beneficial in improving the CT number for the AAO and PA, CNR, and visualisation score compared with the conventional T-tube during paediatric CCTA.

IMPLICATIONS FOR PRACTICE

The spiral-tube may allow the visualisation of smaller blood vessels than those visualised by the conventional T-tube for paediatric patients in CCTA.

Starting Neurohormonal Antagonists in Patients with Acute Heart Failure with Mid-Range and Preserved Ejection Fraction

Background

The clinical benefits of neurohormonal antagonist in patients with heart failure (HF) with mid-range and preserved ejection fraction (HFmrEF and HFpEF) were uncertain. This study aimed to evaluate the prognostic effect of starting angiotensin-converting enzyme inhibitors (ACE-I) / angiotensin II receptor blockers (ARB) and β-blocker during HF hospitalization in these patients.

Methods

We analyzed 858 consecutive patients with HFmrEF (EF:40–49%) or HFpEF (EF≥50%), who were hospitalized for acute decompensated HF, were discharged alive, and were not taking ACE-I/ARB or β-blockers at admission. The study population was classified into four groups according to the status of prescription of ACE-I/ARB and β-blocker at discharge: no neurohormonal antagonist (N=342, 39.9%), ACE-I/ARB only (N=128, 14.9%), β-blocker only (N=189, 22.0%), and both ACE-I/ARB and β-blocker (N=199, 23.2%) groups. The primary outcome measure was a composite of all-cause death or HF hospitalization.

Results

The cumulative 1-year incidence of the primary outcome measure was 41.2% in the no neurohormonal antagonist group, 34.0% in the ACE-I/ARB only group, 28.6% in the β-blocker only group, and 16.4% in the both ACE-I/ARB and β-blocker group (P&lt;0.001). Compared with the no neurohormonal antagonist group, the both ACE-I/ARB and β-blocker group were associated with a significantly lower risk for a composite of all-cause death or HF hospitalization (HR: 0.59, 95% CI: 0.38–0.91, P=0.02).

Conclusions

In hospitalized patients with HFmrEF and HFpEF, starting both ACE-I/ARB and β-blocker was associated with a reduced risk of a composite of all-cause death or HF hospitalization compared with not starting ACE-I/ARB or β-blocker.

Funding Acknowledgement

Type of funding sources: None.

Autoimmune disorders and venous thromboembolism: a report from the COMMAND VTE Registry

Background/Introduction

Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is a major health problem in the world. Several studies reported that autoimmune disorder is one of important risk factors for development of VTE. Furthermore, autoimmune disorder is thought to be a relatively strong risk factor for VTE recurrence, and extended anticoagulation therapy are recommended for prevention of VTE recurrence in patients with autoimmune disorders. However, it remains controversial whether patients with autoimmune disorders have higher risk for clinical events after VTE than those without.

Purpose

We sought to evaluate the clinical characteristics, management strategies, and long-term outcomes of patients with autoimmune disorders after excluding patients with active cancer in a large observational database in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE. After excluding patients with active cancer, the current study population consisted of 2332 patients, who were divided into 2 groups: patients with autoimmune disorders and those without. We estimated the cumulative incidences of the clinical outcomes. To adjust for the clinically relevant confounders, we used the multivariable Cox proportional hazard model to estimate the hazard ratio (HR) and their 95% confidence interval (CI) for the risk of patients with autoimmune disorders relative to those without for the clinical outcome measures. Furthermore, we added corticosteroids use at discharge to explore the effect of corticosteroids use.

Results

There were 188 patients (8.1%) with autoimmune disorders and 2144 patients (92%) without autoimmune disorders. Patients with autoimmune disorders were more often women (74%), and more often received corticosteroids at discharge (69%). The discontinuation rate of anticoagulation therapy was not significantly different between patients with autoimmune disorders and those without (38.0% vs. 39.7% at 3-year, P=0.35). The cumulative 5-year incidences of recurrent VTE and major bleeding were significantly higher in patients with autoimmune disorders than in those without (recurrent VTE: 14.3% vs. 8.3%, P=0.01; major bleeding: 14.9% vs. 8.8%, P=0.02). Even after adjusting confounders of patient characteristic, the excess risk of patients with autoimmune disorders relative to those without remained significant for recurrent VTE (HR 1.81, 95% CI 1.08–2.88, P=0.03) and major bleeding (HR 1.70, 95% CI 1.05–2.63, P=0.03). However, after adjusting for corticosteroids use at discharge, the excess risk was no longer significant for recurrent VTE (HR 1.42, 95% CI 0.75–2.61, P=0.27) nor major bleeding (HR 1.53, 95% CI 0.84–2.69, P=0.16).

Conclusions

Patients with autoimmune disorders had a higher risk for recurrent VTE and major bleeding than those without, and the excess risk could at least partly be attributable to corticosteroids use.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Risk factors of recurrence and major bleeding in patients with intermediate-risk for recurrence of venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Patients with venous thromboembolism (VTE), including pulmonary embolism (PE), have a long-term risk of recurrence, and anticoagulation therapy is recommended for the prevention of recurrence. The latest 2019 European Society of Cardiology (ESC) guideline classified the risks of recurrence into low- (&lt;3%/year), intermediate- (3–8%/year), and high- (&gt;8%/year) risk, and recommended the extended anticoagulation therapy of indefinite duration for high-risk patients as well as intermediate-risk patients. However, extended anticoagulation therapy of indefinite duration for all of intermediate-risk patients have been a matter of active debate. Thus, additional risk assessment of recurrence in intermediate-risk patients might be clinically relevant in defining the optimal duration of anticoagulation therapy. Furthermore, bleeding risk during anticoagulation therapy should also be taken into consideration for optimal duration of anticoagulation therapy. However, there are limited data assessing the risk of recurrence as well as bleeding in patients with intermediate-risk for recurrence based on the classification in the latest 2019 ESC guideline.

Purpose

The current study aimed to identify the risk factors of recurrence as well as major bleeding in patients with intermediate-risk for recurrence, using a large observational database of VTE patients in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling consecutive 3027 patients with acute symptomatic VTE among 29 centers in Japan. The current study population consisted of 1703 patients with intermediate-risk for recurrence. The primary outcome measure was recurrent VTE during the entire follow-up period, and the secondary outcome measures were recurrent VTE and major bleeding during anticoagulation therapy.

Results

In the multivariable Cox regression model for recurrent VTE incorporating the status of anticoagulation therapy as a time-updated covariate, off-anticoagulation therapy was strongly associated with an increased risk for recurrent VTE (HR 9.42, 95% CI 5.97–14.86). During anticoagulation therapy, the independent risk factor for recurrent VTE was thrombophilia (HR 3.58, 95% CI 1.56–7.50), while the independent risk factors for major bleeding were age ≥75 years (HR 2.04, 95% CI 1.36–3.07), men (HR 1.52, 95% CI 1.02–2.27), history of major bleeding (HR 3.48, 95% CI 1.82–6.14) and thrombocytopenia (HR 3.73, 95% CI 2.04–6.37).

Conclusions

Among VTE patients with intermediate-risk for recurrence, discontinuation of anticoagulation therapy was a very strong independent risk factor of recurrence during the entire follow-up period. The independent risk factors of recurrent VTE and those of major bleeding during anticoagulation therapy were different: thrombophilia for recurrent VTE, and advanced age, men, history of major bleeding, and thrombocytopenia for major bleeding.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Risk factors of recurrence in patients with cancer-associated venous thromboembolism: from the COMMAND VTE Registry

Background/Introduction

Cancer is a strong risk factor for the development of venous thromboembolism (VTE) including pulmonary embolism (PE) and deep vein thrombosis (DVT). Patients with VTE have a long-term risk of recurrence, which can be prevented by anticoagulation therapy. Prolonged anticoagulation therapy is recommended for patients with cancer-associated VTE, although the risk of recurrence might depend on the individual patient.

Purpose

We aimed to identify the risk factors of recurrence in patients with cancer-associated VTE.

Methods

The COMMAND VTE Registry is a multicenter retrospective registry enrolling 3027 consecutive patients with acute symptomatic VTE among 29 Japanese centers between January 2010 and August 2014. The present study population consisted of 695 cancer-associated VTE patients. The primary outcome measure in the present study was recurrent VTE, which was defined as PE and/or DVT with symptoms accompanied by confirmation of a new thrombus or exacerbation of the thrombus by objective imaging examinations or autopsy. Discontinuation of anticoagulation was defined as a withdrawal of anticoagulation therapy lasting &gt;14 days for any reason. We selected clinically relevant variables and variables with P values &lt;0.1 in a univariate analysis as potential risk factors, and constructed a multivariable Cox proportional hazard model for recurrent VTE incorporating the anticoagulation therapy status as a time-updated covariate.

Results

Among the 695 study patients, recurrent VTE occurred in 78 patients, of whom 54 (69%) occurred within 6 months. The cumulative incidence of recurrent VTE was 7.7% at 3-months, 8.9% at 6-months, 11.8% at 1-year, and 17.7% at 5-years. The cumulative incidence of discontinuation of anticoagulation therapy was 18.0% at 3-months, 29.5% at 6-months, 43.4% at 1-year, and 66.5% at 5-years. The cumulative 5-year incidence of recurrent VTE was most frequent in patients with uterus/ovary cancer (26.0%), followed by those with lung cancer (24.7%). The multivariable Cox proportional hazard model revealed that chronic kidney disease (HR, 2.27; 95% CI, 1.36–3.77, P=0.002), a high D-dimer level at the time of VTE diagnosis (HR, 2.85; 95% CI, 1.71–4.74, P&lt;0.001), advanced cancer (HR, 1.69; 95% CI, 1.05–2.72, P=0.03) and discontinuation of anticoagulation therapy (HR, 2.66; 95% CI, 1.53–4.63, P&lt;0.001) were independently associated with an increased risk of recurrent VTE. No cancer site was independently associated with an increased risk for recurrent VTE when adjusting for the above mentioned risk factors in the multivariable Cox proportional hazard model, although the risk of recurrent VTE numerically differed according to the cancer site.

Conclusions

Among patients with cancer-associated VTE, chronic kidney disease, a high D-dimer level at the time of VTE diagnosis, advanced cancer, and discontinuation of anticoagulation therapy were independent risk factors of recurrence.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation Figure 1Figure 2

Coronary artery patch augmentation for congenital left coronary ostial stenosis in Williams syndrome

Left coronary ostial stenosis, which is associated with sudden death, occasionally occurs in individuals with Williams syndrome. However, surgical methods that provide reliable long-term revascularization remain unknown among infants and young children with coronary ostial stenosis. We describe the case of an 18-month-old boy with Williams syndrome who presented with cardiogenic shock due to left coronary ostial stenosis. We performed patch augmentation of the left coronary ostium using glutaraldehyde-treated autologous pericardium. At the last follow-up, the patient was well without any adverse events or myocardial ischemia.

Safety and feasibility of laparoscopic surgery for elderly rectal cancer patients in Japan: a nationwide study

Background

This study aimed to analyse the perioperative results from a national dataset of rectal cancer resections in elderly patients.

Methods

The clinical records of patients undergoing rectal cancer surgery between 2012 and 2014 were retrieved from the Japanese National Clinical Database and analysed retrospectively. Patients were categorized according to age and those 80 years or older were defined as elderly. Subgroups were also defined according to the surgical approach (laparoscopy versus open surgery). The short-term outcomes, including mortality, anastomotic leak, surgical site infections and medical complications were compared between subgroups.

Results

Of 56 175 patients undergoing rectal cancer surgery, some 6717 patients were elderly and laparoscopy was performed in 46.8 per cent of the sample. When comparing laparoscopy and open surgery in elderly patients, the operative mortality rate (1.5 versus 2.8 per cent; P < 0.001), the incidence of anastomotic leakage (5.2 versus 6.5 per cent; P = 0.026), surgical site infections (6.0 versus 8.0 per cent; P = 0.001), pneumonia (1.4 versus 2.5 per cent; P = 0.001), renal failure (0.7 versus 1.3 per cent; P = 0.016) and cardiac events (0.3 versus 0.8 per cent; P = 0.008) were lower for laparoscopy than for open surgery. The overall complication rate in elderly patients (19.5 per cent) was comparable to that in the younger group (P = 0.07). However, incidence of systemic complications was significantly higher in elderly than in younger patients (all P < 0.001).

Conclusion

Laparoscopy was safe and feasible in elderly patients compared with open surgery. However, the rates of systemic complications were significantly higher than in younger patients.

Diagnostic performance of computed tomography digital subtraction angiography of the lower extremities during haemodialysis in patients with suspected peripheral artery disease

INTRODUCTION

With intra-arterial digital subtraction angiography (DSA) considered as the gold standard, we compared the diagnostic value of computed tomography angiography (CTA) and computed tomography-digital subtraction angiography (CT-DSA in hemodialysis (HD) patients suspected of having lower limb peripheral artery disease (PAD).

METHODS

In this retrospective study, we enrolled 220 HD patients with suspected PAD. CT-DSA images were obtained by subtracting unenhanced images from enhanced images. The research team calculated the area under the curve (AUC), sensitivity, specificity, positive and negative predictive value (PPV, NPV), and recorded the diagnostic accuracy between the CTA and CT-DSA images using the DSA as gold standard. Visual evaluation of calcifications in the peripheral arteries were also compared between CTA and CT-DSA images.

RESULTS

At the above-knee level, the CTA AUC [95% confidence interval (CI)] was 0.68 (CI 0.64-0.72), sensitivity and specificity were 60 and 81%, PPV and NPV were 85 and 53%, and accuracy was 67%. Below the knee, these values were 0.66 (CI 0.62-0.70), 71 and 79%, 79 and 47%, and 66%. For CT-DSA, above-knee, the AUC [95% CI] was 0.88 (CI 0.85-0.91), sensitivity and specificity were 84 and 92%, PPV and NPV were 89 and 97%, and accuracy was 93%. Below the knee, these values were 0.95 (CI 0.93-0.97), 95 and 93%, 96 and 83%, and 93%. The scores for the visualization of calcification in the peripheral arteries was significantly higher for CT-DSA than CTA (p < 0.05).

CONCLUSIONS

CT-DSA helps to assess stenotic PAD with high calcification in the lower extremities of HD patients.

IMPLICATIONS FOR PRACTICE

On CT-DSA images, the severity of vascular calcification can be assessed for HD patients suspected of PAD of the lower extremities.

Phenotyping right heart function for prognosticating heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Right heart failure has been shown to portend poor prognosis. The pathophysiology of right heart function is complex, as right ventricular (RV) function is easily affected by preload and afterload.

Purpose

To test the hypothesis that machine learning would detect heterogeneity in right heart function and improve risk stratifications in a heart failure population

Methods

This study included 403 heart failure patients who had a history of hospitalization for decompensation. Patients were excluded if they had primary heart valve disease or pericardial disease or a previous cardiac surgery. Hierarchical clustering was undertaken on right heart variables (RV strain, right ventricular systolic pressure (RVSP), vena contracta of tricuspid regurgitation (TR) and diameter of inferior vena cava) to identify homogenous groups of patients with similar profiles of the variables. Cox hazard analysis was used to elucidate the benefit of clustering over each variable for prognosticating heart failure. Endpoint was hospitalization for worsening heart failure.

Results

Cluster analysis identified three groups with distinct right heart function. Cluster 1 (n = 191) represented patients with preserved RV function and low RVSP (figure A).  On the other hand, cluster 2 (n = 144) had reduced RV function and low RVSP, while cluster 3 (n = 68) had preserved RV function and high RVSP, associated with severe TR and high central venous pressure. The latter 2 clusters carried worse outcome than cluster 1 (p &lt; 0.001, figure B). Cox hazard analysis demonstrated that, although the addition of each right heart variable to baseline model constructed from left heart variables did not improve predictive power, clusters predicted events with a hazard ratio of 1.566, independent from and incremental to the left heart variables (Figure C).

Conclusion

Cluster analysis identified two distinct phenotypes of right heart failure that were associated with adverse outcomes. This data-driven phenotyping can help in categorizing right heart failure and better prognosticating heart failure.

Abstract Figure.

The combined application of the contrast-to-noise index and 80 kVp for cardiac CTA scanning before atrial fibrillation ablation reduces radiation dose exposure

INTRODUCTION

To compare the radiation dose, diagnostic accuracy, and the resultant ablation procedures using 80 and 120-kVp cardiac computed tomography angiography (CCTA) protocols with the same contrast-to-noise ratio in patients scheduled for atrial fibrillation (AF) ablation.

METHODS

This retrospective study was performed following institutional review board approval. We divided 140 consecutive patients who had undergone CCTA using a 64-MDCT scanner into two equal groups. Standard deviation (SD) of the CT number was set at 25 Hounsfield units (HU) for the 120-kVp protocol. To facilitate a reduction in radiation dose it was set at 40 HU for the 80 kVp protocol. We compared the two protocols with respect to the radiation dose, the diagnostic accuracy for detecting left atrial appendage (LAA) thrombi, matching for surface registration, and the resultant ablation procedures.

RESULTS

At 120 kVp, the dose length product (DLP) was 2.2 times that at 80 kVp (1269.0 vs 559.0 mGy cm, p < 0.01). The diagnostic accuracy for thrombus detection was 100% using both protocols. There was no difference between the two protocols with respect to matching for surface registration. The protocols did not differ with respect to the subsequent time required for the ablation procedures and the ablation fluoroscopy time, and the radiation dose (p = 0.54, 0.33, and 0.32, respectively).

CONCLUSION

For the same CNR, the DLP at 80 kVp (559.0 mGy cm) was 56% of that delivered at 120 kVp (1269.0 mGy cm). There was no reduction in diagnostic accuracy.

IMPLICATIONS FOR PRACTICE

Maintaining CNR allows for a reduction in the radiation dose without reducing the image quality.

Successful papillary muscle approximation for severe mitral regurgitation via apical cuff hole in HeartMate 3 implantation via left anterior thoracotomy

We herein report a case of successful papillary muscle approximation for severe mitral regurgitation and HeartMate 3 left ventricular assist device implantation via left anterior thoracotomy in a 39-year-old man diagnosed with dilated cardiomyopathy. He underwent papillary muscle approximation in the mitral valve for severe functional regurgitation via the apical cuff hole. The postoperative course was uneventful. Echocardiography revealed that mitral regurgitation has disappeared. He was awaiting heart transplantation while working.

Simultaneous Aortic Valve-in-Valve and Ascending Stent Grafting for Prosthetic Valve Stenosis and Ascending Flap

Report on total endovascular repair for a diseased aortic valve and the ascending aorta is few. Therefore, we report a case of prosthetic aortic valve stenosis and internal bovine pericardial flap after ascending aortic replacement complicated by congestive heart failure and hemolysis. Because the patient had high surgical risk and was anatomically suitable to undergo ascending endovascular repair, simultaneous transcatheter aortic valve-in-valve implantation and ascending endografting were performed. Her symptoms of heart failure and hemolysis resolved postoperatively. Thus, a simultaneous transcatheter procedure for a diseased aortic valve and the ascending aorta is a feasible option for appropriately selected patients.

Clinical characteristics and outcomes of patients with venous thromboembolism according to diagnosis on weekends versus weekdays: from the COMMAND VTE Registry

Background/Introduction

The medical systems of hospitals often differs between on weekends and weekdays. These differences could lead different clinical outcomes for patients with acute medical conditions that require complex treatment strategies. However, the effect of the time of diagnosis on clinical outcomes in patients with acute venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis (DVT), is still controversial.

Purpose

We sought to evaluate the clinical characteristics and outcomes of patients with VTE comparing on weekends and weekdays in a large observational database of VTE in Japan.

Methods

The COMMAND VTE Registry is a multicenter registry enrolling 3027 consecutive patients with acute symptomatic VTE objectively confirmed by imaging examination or by autopsy among 29 centers in Japan between January 2010 and August 2014. In the current analysis, diagnosis on weekends was defined as diagnosis during the period from 00:00 hours on Saturday to 24:00 on Sunday. All other times were defined as weekdays. We divided the entire cohort into 2 groups; diagnosis on weekends and diagnosis on weekdays groups, and we compared the clinical characteristics, management strategies and 30-day outcomes between the 2 groups.

Results

The current study population consisted of 337 patients diagnosed on weekends and 2690 patients diagnosed on weekdays. The median days from onset to diagnosis were shorter in the patients diagnosed on weekends than in those diagnosed on weekdays (2 days vs. 4 days, P&lt;0.001). The patients diagnosed on weekends presented with PE more frequently (72% vs. 55%, P&lt;0.001), and they showed more severe condition for PE with a higher simplified pulmonary embolism severity index score. The vast majority of PE patients were diagnosed by contrast-enhanced computed tomography in both groups (97% vs. 97%, P=0.67). The patients diagnosed on weekends more often received initial parenteral anticoagulation therapy and thrombolysis than those diagnosed on weekdays. The cumulative 30-day incidence of all-cause death was not significantly different between the 2 groups among PE patients (diagnosis on weekends: 6.2% vs. diagnosis on weekdays: 6.5%, P=0.87), as well as among DVT patients (0.0% vs. 1.5%, P=0.24) (Figure). After adjusting the confounders, the risk of diagnosis on weekends relative to diagnosis on weekdays for all-cause death among PE patients was still insignificant (adjusted HR: 0.76; 95% CI: 0.42–1.28). The most frequent cause of deaths was fatal PE in both groups among PE patients. The risks for recurrent VTE and major bleeding at 30 days were not significantly different between the 2 groups among PE patients nor DVT patients.

Conclusions

The VTE patients diagnosed on weekends presented with PE more frequently, and they showed more severe condition for PE, although the risks for short-term mortality were not significantly different between patients diagnosed on weekends and weekdays.

Kaplan-Meier curves for all-cause death

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Predictive ability of modified Ottawa score for recurrence in patients with cancer-associated venous thromboembolisms: from the COMMAND VTE Registry

Background/Introduction

Patients with cancer-associated venous thromboembolisms (VTEs) have a markedly higher risk of recurrence as well as bleeding, compared to those without, leading to difficulty in achieving a good risk-to-benefit balance with anticoagulation therapy. Thus, the assessment of the risk of recurrence in an individual patient is essential. The modified Ottawa score has been developed to predict the risk of recurrence in patients with cancer-associated VTEs during anticoagulation therapy, however, the validity of the score is still controversial.

Purpose

We aimed to evaluate the utility and limitations of the modified Ottawa score in the risk stratification of recurrent VTEs in patients with cancer-associated VTEs.

Methods

The COMMAND VTE Registry is a multicenter retrospective registry enrolling 3027 consecutive patients with acute symptomatic VTEs among 29 Japanese centers between January 2010 and August 2014. The present study population consisted of 614 cancer-associated VTE patients with anticoagulation therapy beyond 10 days after the diagnosis, who were divided into 3 groups; High-risk group with a modified Ottawa score ≥1, Intermediate-risk group with a score = 0, and Low-risk group with a score ≤−1. To evaluate the discriminating power of the modified Ottawa score for recurrence, we described the receiver operating characteristic curve with a C-statistic, and evaluated the positive likelihood ratio as the predictive performance of the score for recurrence in each subgroup.

Results

The high-risk group accounted for 202 patients (33%), intermediate-risk group for 269 (44%), and low-risk group for 143 (23%). During the first 6 months of anticoagulation therapy, recurrent VTEs occurred in 39 patients. The cumulative incidence of recurrent VTEs substantially increased in the higher risk categories by the modified Ottawa score (High-risk group: 13.6%, Intermediate-risk group: 5.9%, and Low-risk group: 3.0%, Log-rank P=0.02) (Figure 1). The discriminating power of the score was modest with a C-statistic of 0.63 (95% CI 0.55–0.71). The positive likelihood ratios as the predictive performance of the score were 1.71 in the high-risk group, 0.81 in the intermediate-risk group, and 0.42 in the low-risk group. Women and patients with prior VTEs had numerically higher cumulative 6-month incidences of recurrent VTEs compared with those without, while patients with lung cancer, breast cancer, and without metastasis had numerically lower cumulative 6-month incidences of recurrent VTEs. Depending on the presence or absence of each score component, the risks of recurrence seemed to differ in the low-, intermediate-, and high-risk groups.

Conclusions

The risks of recurrence in patients with cancer-associated VTEs substantially increased in the higher risk categories by using the modified Ottawa score, but the discriminating power of the score for recurrence was modest with a widely variable impact of each score component on recurrence.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Risk factors for major bleeding during prolonged anticoagulation therapy in cancer-associated venous thromboembolisms: from the COMMAND VTE registry

Background/Introduction

Patients with cancer-associated venous thromboembolisms (VTEs) are at a high risk for recurrent VTEs and are recommended to receive prolonged anticoagulation therapy if they are at a low risk for bleeding. However, there are no established risk factors for bleeding during prolonged anticoagulation therapy.

Purpose

We aimed to identify the risk factors for major bleeding during prolonged anticoagulation therapy in cancer-associated VTE patients.

Methods

The COMMAND VTE Registry is a multicenter retrospective registry enrolling 3027 consecutive patients with acute symptomatic VTEs among 29 Japanese centers between January 2010 and August 2014. After excluding those without active cancer (N=2332), patients with major bleeding (N=15), death (N=17), and lost to follow-up (N=10) within 10 days after the diagnosis, and those without anticoagulation therapy beyond 10 days after the diagnosis (N=61), the present study population consisted of 592 cancer-associated VTE patients with anticoagulation therapy beyond 10 days after the diagnosis. The outcome measurement was International Society of Thrombosis and Hemostasis (ISTH) major bleeding during anticoagulation therapy beyond 10 days, which occurred before the first discontinuation of the anticoagulation therapy. We constructed a multivariable Cox proportional hazard model to estimate the hazard ratio (HR) and 95% confidence intervals (CIs) of the potential risk factors for major bleeding. As a sensitivity analysis, we used Fine and Gray's method to estimate the HR and 95% CI, taking into account the competing risk of all-cause death.

Results

During a median follow-up period of 199 days, major bleeding occurred in 72 patients (31 patients within 3 months; 41 beyond 3 months). The cumulative incidence of major bleeding was 5.8% at 3-months, 13.8% at 1-year, 17.5% at 2-year, and 28.1% at 5-years. The most frequent major bleeding site was gastrointestinal (47%), followed by intracranial (17%) and genitourinary (11%). Major bleeding tended to occur from the sites of the cancer, however, the sites of the cancer and sites of major bleeding were not necessarily concordant. The multivariable Cox regression model demonstrated that terminal cancer (adjusted HR, 4.17; 95% CI, 2.22–7.85, P&lt;0.001), chronic kidney disease (adjusted HR, 1.89; 95% CI 1.06–3.37, P=0.031), and gastrointestinal cancer (adjusted HR, 1.78; 95% CI, 1.04–3.04, P=0.037) were independently associated with an increased risk of major bleeding. After taking into account the competing risk of all-cause death, the multivariable Cox regression model demonstrated almost consistent results with the main analysis.

Conclusions

Major bleeding events were common during prolonged anticoagulation therapy in real-world cancer-associated VTE patients. Terminal cancer, chronic kidney disease, and gastrointestinal cancer were the independent risk factors for major bleeding.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Research Institute for Production Development, Mitsubishi Tanabe Pharma Corporation

Determinants of Changes in Arterial Stiffness after Thoracic Endovascular Aortic Repair

BACKGROUND

Aortic stent grafting can cause aortic stiffening and increase pulse wave velocity (PWV), which can potentially affect long-term cardiovascular outcomes. The aim of this study was to clarify the factors contributing to increases in PWV after thoracic endovascular aortic repair (TEVAR).

METHODS

We included 64 patients with thoracic aortic pathology (51 men; mean age, 73 years) who underwent elective TEVAR, in this study. TEVAR was performed for degenerative aortic aneurysm (n = 43) or aortic dissection (n = 21), and the treatment length was 175 ± 52 mm. Brachial-ankle PWV (baPWV) was obtained before and 1 week after TEVAR. Univariable and multivariable logistic regression analyses were used to determine the predictors of increases in baPWV of ≥100 cm/sec after TEVAR.

RESULTS

baPWV increased from 1,851 ± 392 cm/sec to 2,047 ± 479 cm/sec, and the change in baPWV (ΔbaPWV) was 195 ± 339 cm/sec (95% confidence interval, 111-280). Thirty-seven patients (58%) had ΔbaPWV ≥100 cm/sec after TEVAR. In the multivariable analysis, in addition to Δheart rate and Δsystolic blood pressure, age (odds ratio, 1.21/year; 95% confidence interval, 1.05-1.40) and coronary artery disease (odds ratio, 12.0; 95% confidence interval, 1.20-121) were independent determinants of ΔbaPWV ≥100 cm/sec after TEVAR, whereas ΔbaPWV ≥100 cm/sec was not associated with treatment length or device type.

CONCLUSIONS

TEVAR was associated with PWV progression, especially in older patients with coronary artery disease, whereas treatment length or device type was not a predictor of PWV progression after TEVAR.

Preoperative distal aortic diameter is a significant predictor of late aorta-related events after endovascular repair for chronic type B aortic dissection

OBJECTIVES

Long-term therapeutic effects of thoracic endovascular aortic repair (TEVAR) for chronic type B aortic dissection remain controversial. This study aimed to evaluate the possible predictors of late aortic rupture and re-interventions after TEVAR.

METHODS

We retrospectively reviewed the operative outcomes of 40 patients who underwent TEVAR for chronic type B aortic dissection at Kyushu University Hospital. During a mean follow-up period of 39.2 months, we assessed aortic morphology via computed tomography and then employed a multivariable Cox regression analysis in an attempt to identify the predictors of late aorta-related events.

RESULTS

The early success rate of TEVAR was 100%. During the follow-up, however, three patients died from aortic rupture. Eight patients required aortic re-intervention, including thoraco-abdominal aortic graft replacement, repeated TEVAR, total arch replacement and EVAR. Multivariable Cox regression analysis revealed that the preoperative maximum distal aortic diameter was a significant predictor of late aorta-related events. The cutoff value of the distal aortic diameter was 40 mm. Freedom from aorta-related events was 94.6% at 1 year and 78.3% at 3 years. The survival rate was not significantly different despite the re-intervention.

CONCLUSIONS

TEVAR is an effective treatment for chronic type B dissection, with acceptable mid-term results. The preoperative distal aortic diameter is a significant risk factor for late aorta-related events. When the maximum distal aortic diameter is ≥ 40 mm, a therapeutic strategy should be developed taking into consideration the possible need for aortic re-intervention.