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Aims The concept of proportionate/disproportionate functional mitral regurgitation (FMR) has been limited by the lack of a simple way to assess it and by the paucity of data showing its prognostic superiority. The aim of this study was to evaluate the prognostic value of an individualized method of assessing FMR proportionality. Methods and results We retrospectively identified 572 patients with at least mild FMR and reduced left ventricular ejection fraction ( Conclusion Disproportionate FMR is independently associated with all-cause mortality and improves the risk stratification of current guidelines.

Background In heart failure with reduced ejection fraction (HFrEF), uptitration of neurohormonal antagonists to trial-proven doses shown to reduce mortality is challenging and seldomly achieved in clinical practice. A major reason for underdosing of these agents is the lack of a clear description of what constitutes an acceptable standard of care in HFrEF. To address this limitation, a novel framework for describing the physician adherence to evidence-based treatment was recently proposed. The aim of our study was to evaluate and validate the proposed framework in a real-world population of patients with HFrEF. Methods A cohort of patients with HFrEF, defined as left ventricular ejection fraction (LVEF) Results A total of 408 patients (mean age 68±12 years, 78% male, 63% ischemic etiology) were included. The median LVEF was 31% (IQR 25–36) and most patients were in NYHA class II or III [210 (51.5%) and 163 (40%), respectively]. Medical therapy is described in Table 1. During a median follow-up of 3.3 years (IQR 1.4–5.6), 210 patients died. On univariable analysis, achieving Status I of beta-blocker (BB) therapy (HR: 0.50; 95% CI: 0.32–0.81; P=0.004) or ACEi/ARB (HR: 0.56; 95% CI: 0.36–0.86; P=0.012) was associated with reduced all-cause mortality. The mortality of patients in Status II of BB or ACEi/ARB was similar to the mortality of those not receiving the drug (HR for BB: 0.90; 95% CI: 0.53–1.52; P=0.69 and HR for ACEi/ARB: 0.71; 95% CI: 0.42–1.18; P=0.182) – figure 1. Achieving Status I of BB remained independently associated with reduced mortality after adjustment for several clinical and echocardiographic confounders (n=13) (adjusted HR: 0.59; 95% CI: 0.35–0.98; P=0.041). Conclusions In this real-world population of patients with HFrEF, the vast majority of patients were in Status I of BB and ACEi/ARB therapy. Achieving Status I of BB therapy seems to be associated with reduced mortality, even after adjustment for several markers of disease severity, highlighting the need for uptitration of medical therapy to maximal tolerated doses according to trial-proven regimens. Funding Acknowledgement Type of funding sources: None.

Background The SMART-REACH score (SRS) was developed to predict the risk of major adverse cardiovascular events in ambulatory patients with established cardiovascular disease, although it has not been extensively validated. Patients at higher risk of recurrent ischemic events may benefit from novel, more intensive treatment options, and earlier identification of these patients can potentially improve outcomes. Purpose We aimed to validate the SRS and evaluate its performance in a population recently admitted with acute coronary syndrome. Methods In this single-centre retrospective cohort, we included 320 patients aged 45 to 80 years, who were discharged following admission for an acute coronary syndrome between 2016 and 2018. To calculate the SRS for each patient, we considered clinical data on admission (age, gender, smoking, diabetes, prior history of vascular disease, heart failure or atrial fibrillation), lipid values obtained within the first 24 hours of hospitalization, serum creatinine level at baseline and once the patient was deemed clinically stable, and discharge medication. The outcome of interest was defined as stroke, myocardial infarction or cardiovascular death (MACE) at two years of follow-up. SRS was assessed for discrimination and calibration. Results Mean age was 63±9 years, and 240 (75%) were male. There was high prevalence of cardiovascular risk factors: 71% had hypertension, 32% had diabetes mellitus, 42% were active smokers and 25% had previously established cardiovascular disease. The outcome of interest was observed in 38 patients (22 cardiovascular deaths, 6 strokes and 14 myocardial infarctions). SRS showed good discrimination of the estimated MACE risk with overall C-statistic of 0.646 (95% CI, 0.554–0.737, p=0.004) (picture 1) and calibration (p-value for the goodness-of-fit test of 0.544). The global estimated risk of MACE at 2-years was 4.8% (3.8%-6.8%). The expected/ observed ratio was 0.56 for the occurrence MACE (picture 2). Conclusions Over the first two years after discharge from an acute coronary syndrome, one of every 8 patients developed a potentially fatal recurrent ischemic event. The SRS performed reasonably well in discriminating those at highest risk of MACE, suggesting that this score may help select patients at discharge for ad initium more intensive pharmacological therapy. Funding Acknowledgement Type of funding sources: None. ROC curve for the SMART-REACH scoreExpected versus observed MACE

Masson’s lesion is a rare type of vascular tumor usually found in the skin and soft tissues. Histological examination remains the gold-standard for diagnosis. Treatment involves complete surgical excision and correct diagnosis is essential to avoid unnecessary aggressive therapy. A unique case of Masson’s lesion presenting as an asymptomatic pericardial mass is reported for the first time. Multimodality imaging was used for a comprehensive non-invasive mass characterization. Relevant imagiological and pathological findings for differential diagnosis are discussed. The importance of close coordination between different medical specialties for optimal care of this unusual clinical condition is highlighted.

Objective Female neurointerventionalists make up a minority of the neurointerventional work force. We sought to evaluate the contributions of this group to the Journal of Neurointerventional Surgery (JNIS) by identifying all papers published by female first authors or last authors in 2019 and 2020. Methods The online issues of JNIS from January 2019 through December 2020 were reviewed. Data was collected on the number and types of articles published in each monthly issue. For each article, the gender of the first author and the last author were determined based on their names. If an author’s name was ambiguous as to their gender, an online search of the individual’s public LinkedIn or ResearchGate profile was performed. In rare cases, gender was deduced by evaluating different individuals with the same name. Analysis was performed by calculating the percentage of female involvement in the different types of articles published. Results Over a 24-month period, there were 517 articles published and 104 (20%) had either a female first author, last author or both. Of those articles, 71 had a female first author and male last author. In contrast, there were 413 articles with male first and last authors. Having a female first and last author was found in only 8 articles over this period. The majority of the papers with female first or last author involvement were original research articles (n=84). There were only 14 case reports, and even fewer reviews (n=3). There was only one Editorial Commentary written by a female last author, and zero Editor’s Columns. There was an increase number of papers published in JNIS between 2019 (n=254) and 2020 (n=263) as well as an increased trend in female first or last author involvement (17.3% in 2019 vs 22.8% in 2020). In 2020, 15 papers were published on special topics such as the Pandemic and Neurointervention. Of those, only two had a female first author and no female last author. Conclusion There was an increase in the number of papers published by female authors in 2020 relative to 2019. The majority of papers with female involvement had a female first author. Most of the papers published by female authors were original research articles. Female neurointerventionalists were poorly represented as authors of invited commentaries, columns or special topics. As the percentage of females in neurointervention is growing, we would like to see their academic contributions to JNIS increase as well. Disclosures K. Javed: None. D. Altschul: 5; C; Editor of JNIS. F. Albuquerque: 5; C; Editor-in-chief of JNIS. J. Hirsch: None.

Funding Acknowledgements Type of funding sources: None. Introduction Clinical guidelines recommend against the use of coronary computed tomography angiography (CCTA) in patients with heavy calcification due to interpretability concerns, but no specific approach or threshold is provided. Recently, alternative methods have been proposed as more reliable predictors of CCTA interpretability than the classic coronary artery calcium score (CACS). The purpose this study was to compare the performance of different measures of coronary calcification as predictors of CCTA interpretability. Methods We conducted a retrospective analysis of consecutive patients undergoing CACS and CCTA between 2018 and 2020. The key exclusion criteria were known coronary artery disease, CACS of zero, and presence of non-assessable coronary lesions for reasons other than calcification (movement/gating artifacts or vessel diameter < 2mm). CCTA studies were considered non-interpretable if the main reader considered one or more coronary lesions non-assessable due to calcification. Three different measures of coronary calcification were compared using ROC curve analysis: 1) total CACS; 2) CACS-to-lesion ratio (total CACS divided by the number of calcified plaques); and 3) calcium score of the most calcified plaque. Decision-tree analysis was performed to identify the algorithm that best predicts CCTA interpretability. Results A total of 432 patients (191 women, mean age 64 ± 11 years) were included. Overall, 31 patients (7.2%) had a non-interpretable CCTA due to calcification. Patients with non-interpretable CCTA had higher CACS (median 589 vs. 50 AU, p Decision-tree analysis identified a single-variable algorithm (CACS value ≤ 515 AU) as the best discriminator of CCTA interpretability: 396 of the 409 patients (97%) with CACS ≤ 515 AU had an interpretable CCTA, whereas only 5 of the 23 patients (22%) with CACS > 515 AU had an interpretable test, yielding a total of 96% correct predictions. Conclusions The recently proposed and more complex measures of coronary calcification seem unable to outperform total CACS as a predictor of CCTA interpretability. A simple CACS cutoff-value around 500 AU remains the best discriminator for this purpose.

Funding Acknowledgements Type of funding sources: None. Background Anomalous origin of the right coronary artery (right ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomographic angiography (CCTA) has led to increasing recognition of this condition, even among healthy individuals. This study sought to examine the prevalence, anatomical characteristics and outcomes of right ACAOS with IAC in patients undergoing CCTA for all-indications. Methods We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital between January 2012 and December 2020. Right ACAOS patients with IAC were analyzed for cardiac symptoms (anginal chest pain, syncope, aborted SCD) and long-term outcomes were evaluated for myocardial infarction, ischemic test results, revascularization procedures and all-cause or cardiovascular (CV) mortality. CCTAs were reviewed for proposed high-risk features (ie., take-off angle, length and severity of proximal narrowing, intramural course, interarterial length) and concomitant coronary artery disease (CAD). Association between high-risk features was analyzed. Long-term outcomes were evaluated. Results Among 10,928 patients referred for CCTA during the study period, we identified 28 patients (0.3% prevalence) with right ACAOS and IAC. Mean age was 55 ± 17 years, 64% were male and 11 (39.3%) presented cardiac symptoms. During a median follow-up of 44.1 ± 31.8 months, there were no CV deaths and only 1 patient (3.65%) underwent surgical revascularization. Baseline characteristics and CCTA findings are presented in figure 1. Conclusion Right ACAOS and IAC is an uncommon finding, with an observed prevalence of 0.3%. CCTA provides excellent anatomical characterization of anomalous vessels, including suggested high-risk features. In a population of asymptomatic patients who survived this condition well into adulthood, the risk of events was very low and medical follow up might be a reasonable option.

Anomalous origin of the right coronary artery from the opposite sinus (right-ACAOS) with interarterial course (IAC) has been associated with increased risk of sudden cardiac death (SCD). Widespread use of coronary computed tomography angiography (CCTA) has led to increased recognition of this condition, even among healthy individuals. Our study sought to examine the prevalence, anatomical characteristics, and outcomes of right-ACAOS with IAC in patients undergoing CCTA for suspected coronary artery disease (CAD). We conducted a retrospective analysis of consecutive patients referred for CCTA at one tertiary hospital from January 2012 to December 2020. Patients exhibiting right-ACAOS with IAC were analyzed for cardiac symptoms and mid-term occurrence of first MACE (cardiac death, SCD, non-fatal myocardial infarction (MI) or revascularization of the anomalous vessel). CCTAs were reviewed for anatomical high-risk features and concomitant CAD. Among 10,928 patients referred for CCTA, 28 patients with right-ACAOS with IAC were identified. Mean age was 55 ± 17 years, 64% were male and 11 (39.3%) presented stable cardiac symptoms. Most patients had at least one high risk anatomical feature. During follow-up, there were no cardiac deaths or aborted SCD episodes and only 1 patient underwent surgical revascularization of the anomalous vessel. Right-ACAOS with IAC is an uncommon finding (prevalence of 0.26%). In a contemporary population of predominantly asymptomatic patients who survived this condition well into adulthood, most patients were managed conservatively with a low event rate. Additional studies are needed to support medical follow-up as the preferred option in this setting.

Funding Acknowledgements Type of funding sources: None. Background Despite its theoretical appeal, the concept of Proportionate and Disproportionate FMR has been limited by the lack of a simple way to assess it and by the paucity of data showing its prognostic superiority over currently established ways of grading FMR. Objectives This study sought to evaluate the prognostic value of a new and individualized method of assessing Functional Mitral Regurgitation (FMR) Proportionality. Methods Patients with at least mild FMR and reduced left ventricular ejection fraction (< 50%) under optimal guideline-directed medical therapy were retrospectively identified at a single-center. To determine FMR proportionality status, we used a novel approach where two simple equations establish an individual cut-off of regurgitant volume/effective regurgitant orifice area, categorizing the study population into non-severe, proportionate and disproportionate FMR (Figure 1). The primary endpoint was all-cause mortality. Results A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Disproportionate FMR was present in 109 patients (19%) with a median EROA of 26 mm2 (IQR 22-31) and a median RegVol of 40 ml (IQR 34-48), proportionate FMR in 148 patients (26%) with a median EROA of 16mm2 (IQR 12-21) and a median RegVol of 26 ml (IQR 19-32). During a median follow-up of 3.8 years (interquartile range: 1.8 to 6.2 years) there were 254 deaths (44%). The unadjusted mortality incidence per 100 persons-year rose as the degree of FMR disproportionality worsened. On multivariable analysis, disproportionate FMR remained independently associated with all-cause mortality (adjusted hazard ratio: 1.785; 95% confidence interval [CI]: 1.249 to 2.550; P = 0.001). The FMR proportionality concept showed greater discriminative power (C-statistic 0.639; 95% CI: 0.597 to 0.680) than the American (C-statistic 0.588; 95% CI: 0.550 to 0.626; P for comparison = .001) and European guidelines (C-statistic 0.563; 95% CI: 0.534 to 0.591; P for comparison < .001). It was also able to increase the net reclassification index (0.167 [P < 0.001] and 0.084 [P = 0.001], respectively). Conclusions A new, simplified and individualized method of assessing FMR Proportionality showed that disproportionate FMR is independently associated with all-cause mortality. This approach seems to outperform the risk stratification of current guidelines. Abstract Figure 1

Funding Acknowledgements Type of funding sources: None. Background A Unifying Concept for the Quantitative Assessment of Secondary Mitral Regurgitation (SMR) was recently proposed in order to provide a solution for the ongoing guideline controversy. However, these data were derived from a single center cohort and lacks external validation. We aimed to validate the proposed algorithm in a different patient population. Methods Patients with at least mild SMR and reduced left ventricular ejection fraction (< 50%) under optimal guideline-directed medical therapy were retrospectively identified at a single-center. The cohort was stratified in low-risk (effective regurgitant orifice area [EROA] < 20 mm2 and regurgitant volume [RegVol] < 30 ml), intermediate-risk (EROA 20 to 29 mm2 and RegVol 30 to 44 ml) and high-risk (EROA ≥ 30 mm2 and RegVol ≥ 45ml) according to the defined risk-based thresholds tailored to the pathophysiological concept of SMR. In the intermediate-risk group, patients were further stratified on the basis of the hemodynamic severity of SMR, into intermediate low-risk and intermediate high-risk (regurgitant fraction < 50% or ≥ 50%, respectively). The primary endpoint was all-cause mortality. Results A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Median measures of SMR severity were EROA of 14 mm2 (IQR 8-22) and RegVol of 23 ml (12-34). During a median follow-up of 3.8 years (interquartile range: 1.8 to 6.2 years) there were 254 deaths (44%). The mortality at 6-years was 38.9% for the low-risk group, 30.7% for the intermediate low-risk, 64.9% in the intermediate high-risk and 63.2% in the high-risk group. On multivariable analysis, the defined thresholds of risk for SMR severity remained independently associated with all-cause mortality (adjusted hazard ratio: 1.164; 95% confidence interval [CI]: 1.020 to 1.327; P = 0.024). The unifying concept showed similar discriminative power (C-statistic 0.588; 95% CI: 0.540 to 0.635) to the American (C-statistic 0.588; 95% CI: 0.541 to 0.635; P for comparison = 1) and European guidelines (C-statistic 0.563; 95% CI: 0.515 to 0.610; P for comparison = 0.458), but it was able to increase the net reclassification index (0.143 [P < .001] and 0.026 [P = .025], respectively). Conclusions In this cohort of patients with SMR and LVEF Abstract Figure.

Introduction New evidence on the role of myocardial revascularization in stable ischemic heart disease (SIHD), recently presented, showed that revascularization guided by the presence of moderate-to severe ischemia relieves angina more effectively than optimal medical therapy (OMT), without a significant benefit in hard clinical endpoints. Aim To assess the representativeness of the ISCHEMIA trial in a real-world population and compare management strategies between patients who fulfill the eligibility criteria of the trial (Group 1, G1) and those who do not (Group 2, G2). Methods and population Single centre retrospective analysis including all consecutive patients referred to coronary angiography (CA) for SIHD from January 2018 to December 2019. Patients were stratified in two groups (G1 and G2) according to the ISCHEMIA trial inclusion and exclusion criteria. G1 was compared with G2 and with a subset of G2 with obstructive coronary artery disease (CAD), defined as ≥70% luminal stenosis in at least one coronary artery or >50% for the left main. Results A total of 1020 patients underwent CA, of whom only 124 (12.2%) would have been eligible for the ISCHEMIA trial (G1). Overall, there were no significant differences in baseline characteristics between the two groups. G1 patients had more extensive and severe disease, presenting more frequently with proximal left anterior descending (LAD) involvement (26.6% vs 10.4%; p Conclusions Patients included in the ISCHEMIA trial are underrepresented in a real-world population of SIHD patients referred to coronary angiography. PCI rates were similar among patients with at least one significant coronary artery stenosis, regardless of previous evidence or severity of ischemia. Our findings underline the need for further refinement in criteria for revascularization in SIHD. Funding Acknowledgement Type of funding source: None

Introduction Computed tomography (CT) is often performed before atrial fibrillation (AF) ablation to assess the anatomy of the pulmonary veins and exclude left atrial (LA) and left atrial appendage (LAA) thrombus. With the growing use of new oral anticoagulants (NOACs), a reassessment of the need for systematic thrombus exclusion in this context seems warranted. Objective To evaluate the prevalence of thrombus in LA/LAA in pre-ablation CT in a contemporary cohort of patients predominantly anticoagulated with NOACs. Methods We evaluated 789 consecutive patients (mean age 61±12 years; 38% female; 84% with paroxysmal AF) who underwent pre-ablation CT between Oct/2015 and Oct/2019. ECG-gated CT-angiography was performed using a dual-source 64-slice CT after iodinated contrast injection. Whenever necessary, a second dedicated acquisition was made 60 seconds after the first set of images. Presence of thrombus was defined as a persistent opacification defect. For each patient, thromboembolic risk was assessed with the CHA2DS2-VASc score. Results The median interval between CT and AF ablation was 1 day (IQR 1 – 2 days). The median CHA2DS2-VASc was 2 points (IQR 0 – 3 points), with 590 patients (75%) having CHA2DS2-VASc ≥1. Among the 199 patients (25%) with CHA2DS2-VASc = 0, 118 (59,3%) were anticoagulated with a NOAC and 14 (7%) with a vitamin K antagonist; 67 (34%) were not anticoagulated. Conversely, amongst the 590 patients with CHA2DS2-VASc ≥1, 84% were anticoagulated with a NOAC (n=494), 11% used vitamin K antagonists (n=62), and 34 patients were not anticoagulated (23 with CHA2DS2-VASc = 1). On cardiac CT, 521 (66%) patients were in sinus rhythm. Overall, only one LAA thrombus was found (0.12% [1/789]; 95% CI: 0.0–0.7%) – in a patient with CHA2DS2-VASc = 0, anticoagulated with a NOAC. The median effective radiation dose was 3.2 mSv (IQR 2.1–4.8 mSv). There were 5 minor allergic reactions to iodinated contrast. No strokes were documented within the first 24 hours after ablation. Conclusion In this contemporary cohort of patients with predominantly paroxysmal AF and anticoagulated with NOAC, the prevalence of intracavitary thrombus was extremely low (0.12%). While these findings do not compromise the multipurpose role of pre-ablation CT, they should nevertheless inform future discussions on the risk/benefit and cost/benefit of performing systematic exclusion of LA/LAA thrombi prior to AF ablation. Funding Acknowledgement Type of funding source: None

Background Disproportionate functional mitral regurgitation (FMR) is a novel concept that tries to identify hemodynamically significant FMR by readjusting the effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) cut-offs according to left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF). However, this theoretical concept lacks clinical validation. The aim of this study was to assess the clinical significance of disproportionate FMR. Methods Patients with at least mild FMR and reduced LVEF (50% and the patient-specific theoretical RegVol cut-off was calculated according to the formula presented in Fig. 1a. The difference between the estimated RegVol by the PISA method and the theoretical RegVol cut-off was considered to represent the haemodynamic burden of MR. The primary endpoint was all-cause death. Patients were censured if mitral intervention or heart transplant was undertaken. Survival analysis was used to assess the effect of disproportionate FMR on mortality in 2 subgroups (LVEF Results A total of 289 patients (median age 69 years [IQR 60–77], 75% male, 53% of ischemic aetiology) were included. More than 90% were on beta-blockers and renin-angiotensin inhibitors, 44% on aldosterone receptor antagonists, and 73% had implanted devices. The median LVEF and LVEDV were 34% (IQR 27–41) and 170mL (IQR 128–220), respectively. Median EROA was 10mm2 (IQR 3–21) and RegVol was 15 mL (IQR 4–30). RegVol distribution across the cohort was: 30mL: 26%. Disproportionate FMR was present in 83 patients (29%). These patients had significantly higher SPAP values (41mmHg [IQR 33–50] vs. 33mmHg [IQR 29–40]; p During a median follow-up of 44 months (IQR 19–73), 106 patients died. In the LVEF Conclusions Disproportionate FMR proved to be an important independent predictor of mortality in patients with LVEF between 30–49%. These findings were not replicated in those with LVEF Figure 1 Funding Acknowledgement Type of funding source: None

Background Previous 2013 ESC guidelines recommended the use of the Modified Diamond-Forrester method to assess the pre-test probability (PTP) of obstructive coronary artery disease (CAD). The 2019 ESC Chronic Coronary Syndrome guidelines updated this recommendation with a major downgrade in PTP. The aim of this study was to compare the performance of these two methods in patients with stable chest pain undergoing coronary computed tomography angiography (CCTA) for suspected CAD. Methods We performed a retrospective analysis on prospectively collected data from a cohort of consecutive patients undergoing CCTA for suspected CAD from October 2016 to 2019. Key exclusion criteria were age Results A total of 320 patients (median age 63 years [IQR 53–70], 59% women) were included. Chest pain characteristics were: 48% atypical angina, 38% non-anginal chest pain, 14% typical angina. The observed prevalence of obstructive CAD was 16.3% (n=52). Patients with obstructive CAD were more often male, were significantly older and had a higher prevalence of typical angina and cardiovascular risk factors (except for family history of CAD). On average, individual PTP was 22.1% lower in the new guidelines. The 2013 prediction model significantly overestimated the likelihood of obstructive CAD (mean PTP 37.3% vs 16.3%; relative overestimation of 130%, p-value for miscalibration 0.005). The updated 2019 method showed good calibration for predicting the likelihood of obstructive CAD (mean PTP 15.2% vs 16.3%; relative underestimation of 6.5%, p-value for miscalibration 0.712). The two approaches showed similar discriminative power, with a C-statistics of 0.730 and 0.735 for the 2013 and 2019 methods, respectively (p-value for comparison 0.933). Stratification by gender produced similar results. Conclusions In patients with stable chest pain undergoing CCTA, the updated 2019 prediction model allows for a more precise estimation of pre-test probabilities of obstructive CAD than the previous model. Adoption of this new score may improve disease prediction and change the downstream diagnostic pathway in a significant proportion of cases. Graph 1 Funding Acknowledgement Type of funding source: None

Funding Acknowledgements Type of funding sources: None. Background A new clinical tool was recently proposed to improve the estimation of pre-test probability of obstructive coronary artery disease (CAD) by incorporating coronary artery calcium score (CACS) with clinical risk factors. This new model (Clinical + CACS) showed improved prediction when compared to the method recommended by the 2019 ESC guidelines on chronic coronary syndromes, but was never tested or adjusted for use in our population. The aim of this study was to assess the performance of this new method in a Portuguese cohort of symptomatic patients referred for coronary computed tomography angiography (CCTA), and to recalibrate it if necessary. Methods We conducted a two-center cross-sectional study assessing symptomatic patients who underwent CCTA for suspected CAD. Key exclusion criteria were age < 30 years, known CAD, suspected acute coronary syndrome, or symptoms other than chest pain or dyspnea. Obstructive CAD was defined as any luminal stenosis ≥50% on CCTA. The Clinical + CACS prediction model was assessed for discrimination and calibration. A logistical recalibration of the model was conducted in a random sample of 50% of the patients and subsequently validated in the other half. Results A total of 1910 patients (mean age 60 ± 11 years, 60% women) were included in the analysis. Symptom characteristics were: 39% non-anginal chest pain, 30% atypical angina, 19% dyspnea and 12% typical angina. The observed prevalence of obstructive CAD was 12.9% (n = 247). Patients with obstructive CAD were more often male, were significantly older, had higher prevalence of typical angina and cardiovascular risk factors, and higher CACS values. The new Clinical + CACS tool showed greater discriminative power than the ESC 2019 prediction model, with a C-statistic of 0.83 (CI 95% 0.81-0.86) versus 0.67 (CI 95% 0.64-0.71), respectively (p-value for comparison < 0.001). Before recalibration, the Clinical + CACS model underestimated the likelihood of CAD in our population across all quartiles of pretest probability (mean relative underestimation of 49%), which was subsequently corrected by the recalibration procedure - Figure. Conclusions In a Portuguese cohort of symptomatic patients undergoing CCTA for suspected CAD, the new Clinical + CACS model showed better discrimination power than the 2019 ESC method. The underestimation of the Clinical + CACS model was corrected by recalibrating it for our population. This new tool might prove useful for guiding decisions on the need for further testing.

Introduction There is currently no published data evaluating the incidence of mechanical thrombectomy among stroke centers, the times at which they occur, or their burden on physicians that perform these procedures. Methods Ten institutions queried their stroke databases to identify all patients undergoing emergent angiography with intent to perform thrombectomy for ELVO during a three month time period (June 1 st , 2016 to August 31 st , 2016). Data collected included origin of patient, time of initial consultation or completion of angiographic imaging, time of groin puncture, time of groin closure, and day of the week. Results During the 92 day study period, a total of 189 patients underwent emergent angiography with intent to pursue mechanical thrombectomy for ELVO at the 10 centers. The average number of procedures per hospital over the study period was 18.9 (average of 0.2 cases per day per center). This ranged from 0.49 cases per day at the highest volume center to 0.09 cases per day at the lowest volume center. Most procedures (75%) started during daytime hours (6a-10p) with the majority of groin punctures occurring during non-work hours (59%; Figure). There was no differences in procedural frequency based on day of the week. The three-hour peak time period where most procedures were started was between 8pm and 11 pm (42 cases; 22.2% of the total). The median time from notification to groin puncture was 84 min (SEM 10.0, interquartile range 55.5–144.5) and median procedural time was 57 min (SEM 2.5, interquartile range 33–79.5 min). The average overall physician time required for each individual patient from time of notification until groin closure was just over 2.5 hours at 154 min (SEM 8.0, interquartile range 114–206.5). Time from imaging to puncture was longer during nighttime hours than during daytime (median 113 vs. 87 min; p=0.03) but procedural length did not differ based on time of day (p=0.21). Conclusion This is the first study to quantify the time requirement of mechanical thrombectomy and the call burden on neurointerventional physicians at stroke centers. Over a three month period at 10 stroke centers across the United States, mechanical thrombectomy procedures occurred once every 5 days on average, although nearly 60% occurred during non-work hours. As ELVO awareness increases, thrombectomy call has important operational implications for hospitals implementing stroke call coverage. Disclosures T. Wilson: None. T. Kim: None. C. Frey: None. A. Spiotta: None. R. de Leacy: None. J. Mocco: None. F. Albuquerque: None. A. Ducruet: None. A. Cheema: None. A. Arthur: None. V. Srinivasan: None. P. Kan: 2; C; Stryker; Medtronic. M. Mokin: None. T. Dumont: None. A. Rai: None. T. Leslie-Mazwi: None. J. Hirsch: None. J. Singh: None. J. Singh: None. S. Wolfe: None. K. Fargen: None.

Introduction The benefit of pre-operative embolization of meningioma and hemangiopericytoma continues to be debated. Several large cohort studies of 80–198 patients have reported complication rates of 2.5% to 9% using particles or n-butyl cyanoacrylate (nBCA).[1–5] However, although a recent national registry of 898 patients found an association between liquid embolysate and complication rates, with an odds ratio of 3.9.[6] Endovascular technology continues to evolve and ethylene vinyl alcohol (EVOH or Onyx Medtronic) has been available for embolization of arteriovenous malformations for over a decade. The off-label use of EVOH for pre-operative embolization of meningiomas or hemangiopericytomas has only been reported in small series. This study reviewed the safety profile and embolization duration of our experience with EVOH embolization. Methods Review of institutional records identified 72 consecutive cases of meningiomas and hemangiopericytomas that underwent pre-operative embolization with EVOH prior to surgical resection from 2007 to 2017. The imaging and medical records were reviewed to identify tumor dimensions, vascular pedicles, endovascular equipment, outcomes and complications. Embolization rate was compared with Wilcox signed-rank test and complication rates were compared using the Fisher exact test. Results The tumors measured 5 cm (IQR 4.4–6.3) or 45 cm3 (23–71) and were located on the convexity (26%), tentorium (22%), falx (20%), sphenoid ridge (15%), petrous (5%), anterior cranial fossa (5%), infratemporal fossa (4%), and middle cranial fossa (3%). The most frequent pedicle embolized was a middle meningeal artery. In 83% of cases, this was the first pedicle embolized and in 24% of cases, an additional MMA catheterization was used for embolization. Additional pedicles included the internal maxillary (8), occipital artery (7), superficial temporal (4), posterior meningeal (2), posterior auricular (1), and ascending pharyngeal (1) arteries. Tumor supply from branches of the internal carotid artery were typically not embolized: anterior cerebral branches (3 embolized: 7 not embolized), middle cerebral branches (0:11), ophthalmic branches (0:11). In 7 cases, nBCA was also used, most commonly in the superior cerebellar artery (3:7). There were symptomatic complications from embolization in 8% of cases. Twice, tumor necrosis and edema required earlier craniotomy and tumor evacuation, and four patients had new neurologic deficit from infarct. Two occurred from reflux and two occurred from embolysate migration across the tumor to pial vessels. The complication rate was not different from studies in meningiomas with 75 or more cases using other embolysates (p-value 0.15–1.0). In power analysis, comparison against previously published studies would distinguish a complication rate of 23% in a series of this size. Conclusion Embolization with EVOH is comparable in safety to other embolization techniques in meningioma or hemangiopericytoma. Similar to what has been described in arteriovenous malformations, simultaneous dual catheter embolization may decrease procedural time and radiation exposure. Disclosures A. See: None. B. Flores: None. A. Ducruet: None. F. Albuquerque: None.

The aim of this study is to report cases of spontaneous poisoning of cattle by Ricinus communis (castor beans) in Paraíba, a semiarid region of northeastern Brazil. The cases were observed in 2 herds on neighboring properties in 2013. Clinical signs developed within 6-24 h and consisted of weakness, tachycardia, dyspnea, profuse watery diarrhea, dehydration, depression, instability, cramps, permanent lateral recumbency and death within 48-72 h. Of the 60 cattle at risk, 19 were affected and 14 died. Five fully recovered after the course of 12 days. Three animals were necropsied. The main gross lesions were hemopericardium, hemothorax, pulmonary edema, petechial hemorrhages in the epicardium and endocardium, ecchymoses at the papillary muscles and suffusions on the intercostal muscles. Hemorrhages were also observed in the abdominal cavity, spleen and mucosa of the abomasum and small intestine. The rumen content was liquid with a large amount of castor bean seeds. There were circular, whitish and focally diffuse areas in the liver parenchyma. The main microscopic lesions consisted of multifocal coagulative myocardial necrosis with the presence of mononuclear cell infiltration and varying degrees of bleeding between cardiac muscle fibers. The abomasum and small intestine mucosae and submucosa had mild edema and mononuclear and polymorphonuclear inflammatory cell infiltration. The diagnosis of R. communis was based on the history of plant consumption, clinical signs, pathology of the disease and the presence of large amounts of castor bean seeds in the forestomachs. O objetivo deste trabalho é relatar casos de intoxicação espontânea em bovinos por Ricinus communis (mamona) na Paraíba, região semi-árida do nordeste do Brasil. Os casos foram observados em dois rebanhos de propriedades vizinhas no ano de 2013. Os primeiros sinais clínicos se desenvolveram dentro de 6-24 h e consistiam em fraqueza, taquicardia, dispnéia, diarréia aquosa profusa, desidratação, depressão, instabilidade, cólicas, decúbito lateral permanente e morte em 48-72h. Dos 60 bovinos sob risco, 19 foram afetados e 14 morreram. Cinco bovinos se recuperaram totalmente após um período de 12 dias. Três bovinos foram necropsiados. As principais lesões macroscópicas foram hemopericárdio, hemotórax, edema pulmonar, petéquias no epicárdio e endocárdio, equimoses nos músculos papilares e sufusões nos os músculos intercostais. Hemorragias também foram observadas na cavidade abdominal, baço e na mucosa do abomaso e intestino delgado. O conteúdo ruminal estava líquido, e continha grande quantidade de sementes de R. communis. No parênquima hepático havia áreas circulares, esbranquiçadas e distribuídas focalmente. As principais lesões microscópicas consistiam em necrose miocárdica coagulativa multifocal com a presença de infiltrado de células mononucleares e graus variados de hemorragias entre as fibras musculares cardíacas. O abomaso e a mucosa e submucosa do intestino delgado apresentavam edema discreto e infiltrado de células inflamatórias mononucleares e polimorfonucleares. O diagnóstico da intoxciação por R. communis foi baseado na história de consumo de planta, sinais clínicos, patologia da doença e pela presença de grandes quantidades de sementes de R. communis no sistema digestório dos bovinos.

ResumoA vasculite mesentérica lúpica (VML) é uma rara causa de dor abdominal aguda. Há poucos relatos de caso demonstrando VML em adultos e, particularmente, em crianças e adolescentes. No entanto, para o nosso conhecimento, a prevalência dessa grave vasculite em uma população pediátrica com lúpus ainda não foi estudada. Portanto, dados de 28 anos consecutivos foram revisados e incluídos 5.508 pacientes em seguimento no Hospital da Faculdade de Medicina da Univesidade de São Paulo (FMUSP). Identificamos 279 (5,1%) casos que preencheram critérios de classificação diagnóstica do American College of Rheumatology para lúpus eritematoso sistêmico (LES) e um (0,4%) desses apresentou VML. Este paciente recebeu diagnóstico de LES aos 11 anos de idade. Aos 13 anos foi hospitalizado com dor abdominal difusa e aguda, náuseas, vômitos biliosos, distensão e rigidez abdominal, com descompressão brusca positiva. O paciente foi prontamente submetido à laparotomia exploradora, identificando isquemia intestinal segmentar, com edema de parede intestinal e aderências. Foi realizada ressecção parcial de intestino delgado, com lise das aderências e pulsoterapia com metilprednisolona. A análise histopatológica identificou arterite de vasos mesentéricos. Após 13 dias, apresentou recorrência de dor abdominal difusa intensa, sendo novamente submetido à laparotomia exploradora, identificando obstrução em intestino delgado por aderências, com gangrena intestinal. Nova ressecção intestinal foi realizada, além de pulsoterapia com metilprednisolona e infusão de imunoglobulina. Portanto, VML é uma rara e grave manifestação abdominal na população com lúpus pediátrico, e pode ser a única manifestação de atividade da doença. Além disso, este estudo reforça a importância do diagnóstico precoce e do tratamento imediato.AbstractLupus mesenteric vasculitis (LMV) is a rare cause of acute abdominal pain. Few cases of LMV have been reported in adults, children and adolescents. However, to our knowledge, the prevalence of that severe vasculitis in a pediatric population with lupus is yet to be studied. This study reviewed data from 28 consecutive years and included 5,508 patients being followed up at the hospital of the Faculdade de Medicina of the Univesidade de São Paulo (FMUSP). We identified 279 (5.1%) patients meeting the American College of Rheumatology classification criteria for the diagnosis of systemic lupus erythematosus (SLE), one of whom (0.4%) had LMV. That male patient was diagnosed with SLE at the age of 11 years. At the age of 13 years, he was hospitalized with diffuse and acute abdominal pain, nausea, bilious vomiting, abdominal distension, rebound tenderness, and abdominal muscle guarding. The patient underwent laparotomy immediately, and segmentary intestinal ischemia with intestinal wall edema and adhesions were identified. Partial small bowel resection with lysis of the adhesions was performed, as were pulses of intravenous methylprednisolone. The histopathologic analysis evidenced mesenteric arteritis. After 13 days, the diffuse and intense abdominal pain recurred, and the patient underwent a new laparotomy, during which adhesive small bowel obstruction with intestinal gangrene was identified. New intestinal resection was performed, and the patient received pulses of intravenous methylprednisolone and infusion of immunoglobulin. Thus, LMV is a rare and severe abdominal manifestation of the pediatric population with lupus, and can be the only manifestation of disease activity. In addition, this study stresses the importance of the early diagnosis and immediate treatment.

Lupus mesenteric vasculitis (LMV) is a rare cause of acute abdominal pain. Few cases of LMV have been reported in adults, children and adolescents. However, to our knowledge, the prevalence of that severe vasculitis in a pediatric population with lupus is yet to be studied. This study reviewed data from 28 consecutive years and included 5,508 patients being followed up at the hospital of the Faculdade de Medicina of the Univesidade de São Paulo (FMUSP). We identified 279 (5.1%) patients meeting the American College of Rheumatology classification criteria for the diagnosis of systemic lupus erythematosus (SLE), one of whom (0.4%) had LMV. That male patient was diagnosed with SLE at the age of 11 years. At the age of 13 years, he was hospitalized with diffuse and acute abdominal pain, nausea, bilious vomiting, abdominal distension, rebound tenderness, and abdominal muscle guarding. The patient underwent laparotomy immediately, and segmentary intestinal ischemia with intestinal wall edema and adhesions were identified. Partial small bowel resection with lysis of the adhesions was performed, as were pulses of intravenous methylprednisolone. The histopathologic analysis evidenced mesenteric arteritis. After 13 days, the diffuse and intense abdominal pain recurred, and the patient underwent a new laparotomy, during which adhesive small bowel obstruction with intestinal gangrene was identified. New intestinal resection was performed, and the patient received pulses of intravenous methylprednisolone and infusion of immunoglobulin. Thus, LMV is a rare and severe abdominal manifestation of the pediatric population with lupus, and can be the only manifestation of disease activity. In addition, this study stresses the importance of the early diagnosis and immediate treatment.

Stryphnodendron fissuratum Mart. (Fabaceae) is an importantly toxic plant for livestock in Central-Western Brazil. Despite the recently published clinical descriptions of the poisoning, the gross and histopathological lesions of the disease needed to be better characterized. For this reason the pods of S. fissuratum were given orally to 10 young goats. The goats that received single doses of 10 g/kg, 20 g/kg and 40 g/kg and 4 fractioned doses of 5 g/kg, died poisoned. One goat that received a single dose of 10 g/kg recovered. Only those animals that received one dose of 5 g/kg did not become ill. At post mortem examination, the main lesions were associated with the digestive system and consisted of broken up epithelium and congestion of the mucosa of forestomachs and abomasum. Widespread areas of erosion and ulcerations were observed at the reticula and abomasal mucosa. Int these areas, the main lesions were neutrophil infiltration, vacuolization of the epithelial lining, swelling and dissociation of cells with cytoplasmic eosinophilia, pyknosis, karyorrhexis and nuclear karyolysis. In the central nervous system, the main lesions were identified in the brain of goats that received 20 g/kg and 40 g/kg of pods and consisted of spongiosis of the brainstem white matter. Based on these results, it was proved that the pods of S. fissuratum are acutely toxic for goats under the conditions of this experiment. The poisoning was characterized by damage to the organs of the digestive system and the central nervous system.

Evidence synthesized based on randomized controlled trials (RCT) results are recognized as the pinnacle of research excellence; however, the conduction of RCT in workplace environment is not always possible. This study comparatively reviewed evidence from RCT and non-RCT studies in which participants performed workplace exercise for musculoskeletal pain control. Up to February 2011, PubMed, MEDLINE, Embase, Cochrane, PEDro and Web of Science databases were searched. All trials that evaluated workplace exercise interventions for controlling musculoskeletal pain were included. The PEDro scale was used to rate the studies' quality, PRISMA and Cochrane recommendations were applied, and association between frequencies of effect size categories (small, moderate, large) from various outcomes by study type was tested (2x3 contingency table). The search yielded 10239 references in English, from which 21 RCT and 12 non-RCT were selected. Both groups of studies presented methodological flaws including descriptions of randomization, blinding of examiners and absence of intention-to-treat analysis for the RCT, and further absence of controls and blind assessor for the non-RCTs. RCTs had significantly more moderate and large effect size reported in their results compared to non-RCTs (p=0.04). Considering the difficulties in randomizing participants in occupational settings, all studies would benefit from better describing pertinent methodological information.

The aim of this study was to report a neurological disease in goats caused by the plant I. sericophylla. The epidemiology, clinical signs, histological findings and the results of the lectin histochemistry analysis of a nervous cells and epithelial cells are also reported. Five goats that remained with neurological signs were examined in more detail. Two goats were necropsied. Histological lesions consisted of neurons with thin cytoplasm vacuolation, presence of axonal spheroids and vacuolation in pancreatic acinar cells, thyroid folliculars cells, hepatocytes and renal tubular cells. On lectin-histochemical analysis, cerebellar cells, pancreatic acinar cells and follicular thyroid cells showed positive staining for Concanavalia ensiformis, Triticum vulgaris, succinylated Triticum vulgaris and Lens culinares, which indicate the storage of α-D-mannose, α-D-glucose, β-D-N-acetyl-glucosamine, and acetyl-neuraminic acid. It is concluded that I. sericophylla is an important toxic plant that causes lysosomal storage disease in goats at semi-arid region of Pernambuco, Brazil.

The objective of this study was to describe the epidemiological, clinical, and pathological aspects of Palicourea aeneofusca poisoning in cattle in the region of Pernambuco, Brazil and to determine if it is possible to induce food aversion by P. aeneofusca poisoning in cattle raised under extensive management conditions. To determine the occurrence of poisoning, 30 properties were visited in five municipalities of the region of Pernambuco. Three outbreaks of poisoning of cattle were monitored. To induce conditioned food aversion by the consumption of P. aeneofusca, 12 animals were randomly distributed into two groups of six animals each. Cattle were weighed and received green P. aeneofusca leaves in their trough at a dose of 35mg kg-1 body weight for spontaneous consumption. The control group (CG) animals received water (1ml kg-1 body weight) via a feeding tube after the first ingestion of the plant, while the other animals, constituting the aversion test group (ATG), underwent induced aversion with lithium chloride (LiCl - 175mg kg-1 body weight) via a feeding tube. For the ATG cattle, the aversion to P. aeneofusca induced by a single dose of LiCl persisted for 12 months. In contrast, the CG animals continued to consume the plant in all tests performed, indicating the absence of aversion. This study showed that aversive conditioning using LiCl was effective in preventing poisoning by P. aeneofusca for a period of at least 12 months. RESUMO: O objetivo deste trabalho foi descrever os aspectos epidemiológicos, clínicos e patológicos da intoxicação por Palicourea aeneofusca em bovinos, no Agreste de Pernambuco, e comprovar se é possível induzir aversão alimentar à intoxicação por P. aeneofusca em bovinos criados sob manejo extensivo. Para determinar a ocorrência da intoxicação, foram visitadas 30 propriedades em cinco municípios do Agreste de Pernambuco. Três surtos de intoxicação em bovinos foram acompanhados. Para se induzir aversão alimentar condicionada ao consumo de P. aeneofusca, 12 bovinos foram distribuídos aleatoriamente em dois grupos de seis animais cada. Os bovinos foram pesados e receberam, no cocho, folhas verdes de P. aeneofusca, na dose de 35mg kg-1 de peso corporal, para consumo espontâneo. Os bovinos do GC receberam água (1mL kg-1 de peso corporal), via sonda esofágica, após a primeira ingestão da planta, e os demais constituíram o GTA, que foram induzidos à aversão com cloreto de lítio (LiCl - 175mg kg-1 de peso corporal), via sonda esofágica. Para os bovinos do GTA, a indução de aversão a P. aeneofusca, em que se utilizou dose única de LiCl, persistiu por 12 meses. Por outro lado, os bovinos do grupo GC continuaram ingerindo a planta em todos os testes realizados, indicando a ausência de aversão. Este trabalho comprova que o condicionamento aversivo usando LiCl foi eficaz para prevenir a intoxicações por P. aeneofusca por um período de, pelo menos, 12 meses.

The hallmark of chronic Chagas' disease cardiomyopathy (CCC) is the finding of a T cell-rich inflammatory mononuclear cell infiltrate in the presence of extremely few parasites in the heart lesions. The scarcity of parasites in affected heart tissue casts doubt on the direct participation of Trypanosoma cruzi in CCC heart tissue lesions, and suggests the possible involvement of autoimmunity. The cells in the infiltrate are presumably the ultimate effectors of tissue damage, and there is evidence that such cells recognize cardiac myosin in molecular mimicry with T. cruzi proteins rather than primary reactivity to T. cruzi antigens (Cunha-Neto et al. (1996) Journal of Clinical Investigation, 98: 1709-1712). Recently, we have studied heart-infiltrating T cells at the functional level. In this short review we summarize the studies about the role of cytokines in human and experimental T. cruzi infection, along with our data on heart-infiltrating T cells in human Chagas' cardiomyopathy. The bulk of evidence points to a significant production of IFN-g and TNF-a which may be linked to T. cruzi-induced IL-12 production