Search

Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter aortic valve implantation (TAVI) is a worldwide accepted treatment for severe aortic stenosis (AS). Conduction system disturbances, frequently requiring permanent pacemaker (PM) implantation, remain one of the most common procedural complication. Whether the permanent ventricular pacing has a deleterious impact on the prognosis of this population remains unclear. Objectives To assess the long-term impact of permanent PM implantation in clinical outcomes after TAVI. Methods We performed a retrospective analysis of consecutive patients (P) who underwent TAVI between 2009 and 2021 in a single tertiary center.P with a PM implanted before TAVI or with in-hospital mortality were excluded from the analysis. PM implantation post-TAVI was defined as an implant during hospital stay after TAVI or in the first month after discharge. Kaplan Meier survival curves were used to estimate the impact of permanent PM after TAVI, regarding the composite endpoint of all-cause mortality and heart failure (HF) hospitalization during a 4 years follow-up period, and a comparison performed according to the presence or absence of baseline intraventricular conduction disturbances. Results 549 P (82±6.6 years, 56.8% female, left ventricular ejection fraction 53±10%, peak gradient 51±15.6 mmHg, aortic valve area 0.7± 0.2 cm2) were included. At baseline, 108 P (20%) had intraventricular conduction disturbances on ECG (50 P with right bundle branch block [RBBB] and 58 P with left bundle branch block [LBBB]). 127 P (23%) required PM implantation after TAVI. Baseline characteristics were similar between P with and without PM implantation, except for age, gender, previous valvular surgery and RBBB (Table 1). At 48 months follow-up, 35% (n=193) met the composite endpoint, that was similar between both groups (35.8% vs. 34.1%, p=0.731). Kaplan-Meier survival curves revealed no difference in the composite endpoint between the two groups (log-rank p=0.170). Further analysis of subgroups according to the presence or absence of baseline intraventricular conduction disturbances revealed a significant difference among the subgroup of P without previous intraventricular conduction disturbances that underwent PM implantation after TAVI (log rank p=0.02) (Fig 1). This difference in the composite endpoint after PM was not found in the subgroups of P with RBBB (log rank p=0.656) or LBBB (log rank p=0.975) at baseline (Fig 2).* Conclusions Permanent PM implant after TAVI does not have an impact on long-term HF hospitalization and mortality. However, in the specific subgroup of P without previous intraventricular conduction disturbances, PM implantation seems to be associated with worse prognosis.

Introduction The coronary sinus Reducer device (CSRD) emerged as a complementary therapy in patients with severe angina refractory to optimal medical therapy and not amenable to revascularization. Our aim was to assess the safety and efficacy of the CSRD in a real-world setting. Methods Twenty-six patients with refractory angina (RA), evidence of myocardial ischemia attributable to the left coronary artery unsuitable for revascularization were treated with the CSRD at two centres between May 2017 and July 2019. Safety endpoints were procedural success and complications. Efficacy endpoints, assessed at 6-month follow-up, were a reduction in CCS class, improvement in quality of life (QoL) assessed using the short version of the Seattle Angina Questionnaire (SAQ-7) and reduction in anti-anginal therapy. Results Twenty-three patients had end-stage CAD without revascularization targets and 3 patients had microvascular disease without epicardial stenosis. Procedural success was achieved 23 patients, with 2 device/procedural-related complications and one anatomically-related failure to deliver the device. Ultimately 25 patients implanted the device and entered the efficacy analysis. Eighteen patients (75.0%) had at least 1 reduction in CCS class, 41.7% had at least 2 class reductions, and 16.7% became asymptomatic, with a mean reduction of CCS class of 1.3±0.2 (p=0.001) at 6-month follow-up. All SAQ-7 domains improved, namely physical limitation (p=0.001), angina frequency (p=0.005) and QoL (p=0.006). There was a mean reduction of anti-ischemic drugs from 3.4±1.1 to 2.9±1.2 (p=0.010). Conclusion In this real-world, multicentric experience, implantation of the CSRD was associated with improvement of angina and QoL in patients with RA. Funding Acknowledgement Type of funding sources: None.

Introduction Oral anticoagulants are the standard treatment for prevention of stroke in patients with atrial fibrillation (AF). However, some patients still have stroke despite anticoagulation or have contraindications to anticoagulation. The left atrial appendage occlusion (LAAO) is an option for those patients. The use of intracardiac echocardiography (ICE) instead of Transesophageal echocardiography guiding LAAO procedures has increased, allowing to reduce the use of general anesthesia. Objectives The aim of this study is to describe data regarding safety and efficacy in patients submitted to ICE-guided LAAO. Methods In a tertiary center, patients submitted to ICE-guided LAAO were identified. Information regarding baseline characteristics, procedure technical success, complications, hospitalization and follow-up data was noted retrospectively. The registered stroke and bleeding rates were compared with predicted rates using CHA2DS2-VASc and HAS-BLED scores, respectively. Results 45 patients underwent ICE-guided LAAO, mean age 75.5±9.6 years old, 71.1% male (detailed characteristics in table 1). Permanent AF was present in 68.9% (n=31), with average CHA2DS2-VASc and HAS-BLED scores of 4.0±1.4 and 3.6±1.1, respectively (predicting a stroke risk of 4.0% per year and a major bleeding risk of 8.7% per year). The LAAO indication was previous major bleeding in 64.4% (n=29), high bleeding risk in 24.4% (n=11) and embolic events despite therapeutic anticoagulation in 11.1% (n=5). The LAAO devices were implanted successfully in 96% of the patients (n=43). It was noted a complication rate of 8.8% (n=4), perforation in 4.4% (n=2), device embolization in 4.4% (n=2, one of them leading to cardiac arrest and death) and no major vascular complications occurred. No other procedure-related deaths occurred. The average duration of hospitalization after the procedure was 5.7 days. All patients were followed-up for a mean period of 19.0 months. During that period, another death (2.2%) occurred with a non-cardiac cause and the re-hospitalization rate was 26.7% (n=12), 11.1% (n=5) for cardiac causes. During the same period, 1 stroke (2.2%) and 6 major bleeding (13.3%) occurred – yearly rates of 1.4% and 8.4%, respectively. The stroke rate is markedly inferior to predicted by the score and the major bleeding is slightly inferior to predicted. Conclusions This study provides data about the safety and mainly about the efficacy of the LAAO guided by ICE in a cohort of patients with high hemorrhagic and embolic risk. Funding Acknowledgement Type of funding sources: None.

Background There are limited data about the outcomes of transcatheter aortic valve implantation (TAVI) in patients with low flow – low gradient (LF-LG) aortic stenosis (AS), but some studies suggest that these patients may have worse results. Purpose To compare outcomes between LF-LG AS and high gradient AS patients submitted to TAVI. Methods Retrospective analysis of consecutive patients (P) submitted to TAVI between 2009 and 2020 in a tertiary center. Baseline characteriscs and outcomes after the procedure were collected. LF-LG AS was considered in patients with mean gradient 40mmHg, or high aortic calcium score in angio-CT. Results A total of 480P (56.9% female) were included, with a mean age of 82±7 years. Patients with LF-LG AS (81P, 16.9%) had worse baseline characteriscs, with higher new euroscore (10.4% vs 6.3%, p Conclusion Patients with LF-LG AS have worse short and long-term outcomes, even when adjusted for baseline characteriscs differences. The sub-group of patients with LVEF Funding Acknowledgement Type of funding sources: None.

Introduction Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy are often submitted to alcohol septal ablation (ASA). One of the most frequent complications is the complete hear block (CHB), requiring permanent pacemaker (PPM) in variable rates, up to 20% of the patients. The long-term impact of PPM implantation in these patients remains unclear. Objectives This study aims to evaluate the long-term clinical outcomes in patients who implant PPM after ASA. Methods In a tertiary center, patients who underwent ASA were consecutively enrolled prospectively. Patients with previous PPM or implantable cardio-defibrillator were from this analysis. The groups with and without PPM implantation after ASA were compared regarding baseline characteristics, procedure data and 3-year primary and secondary endpoints. Results Between 2009 and 2020, 109 patients underwent ASA. 97 patients were included in this analysis (68% female, mean age 65.2 years-old). 16 patients (16.5%) required PPM implantation for CHB. In those, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics regarding comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with statistically significant differences in the mean age (70.6y/o in the PPM group versus 64.1y/o) and in the beta-blocker therapy rates previously to the intervention (56% in the PPM group versus 84%). Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692U/L versus 1243U/L, p0.05), without significant differences in the alcohol dose (2.1ml in both groups, p0.33). At 3 years after ASA procedure, the primary endpoint (composite of all-cause mortality and all-cause re-hospitalization) showed a statistical tendency to a lower event rate in the group who implanted PPM (p-value 0.097, Graphic 1). The secondary endpoint (composite of all-cause mortality and cardiac cause re-hospitalization) did not show any significant statistical difference between the two groups (p-value 0.216, Graphic 2). Conclusions The long-term endpoint analysis suggests that the outcomes in patients who implant PPM after ASA are non-inferior to those who do not, with a tendency to a lower rate of the endpoint composite of all-cause mortality and all cause re-hospitalizations. Funding Acknowledgement Type of funding sources: None.

Introduction Aortic valve calcium scoring by multislice computed tomography (MSCT) is an alternative load independent assessment of aortic stenosis severity. Recent studies have further demonstrated that aortic valve calcification load is related to adverse outcomes during and after transcatheter aortic valve implantation (TAVI), however reference values in this population are uncertain. This study aimed to assess aortic valve calcium in P referred for TAVI. Methods Retrospective analysis of consecutive patients (P) submitted to TAVI between 2014 and 2020 in a tertiary care centre. Clinical and echocardiographic characteristics, along with MSCT-derived aortic valve calcium score were collected. Results A total of 467 P were included, 57% female, median age 83 (9) years (minimum 45 and maximum 95 years-old). The prevalence of hypertension, dyslipidemia and diabetes was 83%, 69% and 36%, respectively. Chronic renal failure was present in 51%, atrial fibrillation in 34% and peripheral artery disease in 14%. Considering the 346 P with aortic valve calcification quantified by MSCT, median calcium score was 2161 (1761) AU. Age did not correlate with valvular calcification (r=0.043, p=0.422). Male gender showed significantly higher calcium score (2800 (2093) vs 1850 (1584), p 11P had bicuspid aortic valve disease, with this population being younger (75 (16) vs 83 (8) years, p=0.001), nonetheless displaying higher aortic valve calcium load (2800 (2599) vs 2112 (1788), p=0.025). A weak but statistically significant correlation between calcium score and maximum (r=0.366, p Conclusion There are significant differences in aortic valve calcium score between men and women referred for TAVI. Higher maximum and mean gradients were associated with increasing valvular calcification. Age and left ventricle ejection fraction were not related. P with bicuspid aortic valve have distinct calcification characteristics. As calcification burden may influence preprocedural planning, this parameter should be incorporated in the general work-up and reference values in this population should be known. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Background Conduction disturbances after transcatheter aortic valve replacement (TAVR) are common with a variable risk of long-term pacemaker dependency (PD), being influenced by patient- and procedure-specific factors. As pacemaker (PM) implantation is associated with potential complications, our aim was to assess predictors of PD requirement after TAVR. Methods Retrospective analysis of consecutive patients (P) who underwent TAVR with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. Cumulative percentage of ventricular pacing (%Vp) was determined from stored PM data. P with a PM implanted previous to TAVR were excluded. PM implantation post-TAVR was defined as a device implant performed during hospital stay in the context of TAVR or during the first month after discharge. PD was defined as a %Vp > 80% at one-year follow-up. Multivariate analysis for the prediction of PD was done using Cox regression. Results A total of 474 P (57% male, age 81.7±6.5 years, left ventricular ejection fraction 51.5±14.6%) were analysed. Mean follow-up was 18.7 months. Mean baseline gradient was 51.7 mmHg with a mean aortic valve area of 0.71 cm2. One hundred and four P (21.9%) required PM implantation after TAVR, with a mean %Vp of 65.3±43.4%, presenting PD in 60% of the cases at one-year follow-up. A glomerular filtration rate > 60 ml/min (OR 0.87, CI 95% 0.74-0.96, p=0.021) and mean aortic annulus perimeter (OR 0.89, CI 95% 0.80-0.98, p=0.029) were independent predictors of a PD < 5%. Arterial hypertension (OR 7.00, CI 95% 1.31-37.40, p=0.023), baseline right bundle branch block (OR 10.2, CI 95% 1.21-18.45, p=0.033), and the EUROSCORE II (OR 1.05, CI 95% 1.01-1.10, p=0.044) were predictors of PD > 80%. Baseline left bundle branch block, implantation depth and aortic valve calcium score were not predictors of PD. Conclusion Predictors of PD after TAVR may influence PM implantation, as well as device selection and programming. P with a higher aortic annulus perimeter and preserved kidney function may undergo a more expectant management, as PD rates are low after 1 year follow-up.

Funding Acknowledgements Type of funding sources: None. Background Percutaneous balloon mitral valvuloplasty (PBMV) is the cornerstone of the treatment of rheumatic mitral stenosis (MS) in suitable patients. Pulmonary hypertension (PH) is a common coexisting finding and an indication for intervention. We sought to assess the influence of PH in PBMV immediate results and in very longterm outcome. Methods Between 1991 and June 2021, 202 consecutive patients underwent PBMV in a single tertiary centre. Clinical data, echocardiographic parameters, and MACE (cardiovascular mortality, need for percutaneous or surgical mitral reintervention) were analysed. Results Mean age was 47.3 ± 13.6 years and 89.6% were women. A previous commissurotomy or PBMV was found in 10.4% and mean Wilkins score was 7.6 ± 1.4. PH, defined as pulmonary artery systolic pressure (PASP) ≥45mmHg, was present in 32.7% of patients. A successful procedure was achieved in 89.1% of total population. Mean mitral valve (MV) gradient decreased from 13.1 to 5.0 mmHg (p Conclusions PBMV in patients with MS and PH is a safe and effective intervention, achieving a significant decrease in PASP after procedure. Baseline PH was not associated with success or MACE. However, PH persistence after PBMV, correlated with worse prognosis in longterm follow up. Special attention and further investigation for this subgroup is needed. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Introduction Recent studies have demonstrated the potential of epicardial fat volume (EFV) to predict obstructive coronary artery disease (CAD), however its impact in clinical outcomes remains elusive. Objectives To assess the association between EFV and demo­graphic and morphometric data, coronary atherosclerotic burden and adverse events in a population of patients (pts) referred for coronary computed tomography angiography (CTA). ­Methods: Retrospective analysis of pts without known CAD referred for coronary CTA in a single tertiary care centre. A standardized protocol for quantification of EFV, thoracic fat volume (TFV), coronary artery calcification (CAC) and coronary angiography was performed. Endpoint was composite of cardiovascular death, nonfatal myocardial infarction and urgent hospitalization leading to revascularization at 12 months. Results 72 pts were included, 58% male, mean age 67 ± 9 years. The prevalence of hypertension, dyslipidemia and diabetes was 75%, 82% and 24%, respectively. Median EFV was 101 (68) ml and total TFV 1504 (694) ml. EFV was directly related with age (rs= 0.42, p 124 ml had a sensibility and specificity to predict clinical outcomes of 69% and 71%, respectively. Conclusion EFV positively relates to coronary atherosclerotic burden. This study also advocates that EFV may improve risk stratification for clinical outcomes. Larger studies are required to evaluate these results. Abstract Figure 1

Funding Acknowledgements Type of funding sources: None. Background In the era of innovative transcatheter valve interventions, percutaneous balloon mitral valvuloplasty (PBMV) remains the primary treatment option in anatomic suitable patients. Purpose This study aimed to evaluate longterm follow-up (FU) of PBMV and to determine predictors of MACE. Methods Between 1991 and June 2021, 202 consecutive patients underwent PBMV in a single tertiary centre. Clinical data, echocardiographic parameters, and MACE (cardiovascular mortality, need for percutaneous or surgical mitral reintervention and hospitalization for heart failure) were analysed. Predictors of MACE were determined by Cox regression analysis. Results Mean age was 47.3 ± 13.6 years, 89.6% female, 47.3% patients presenting atrial fibrillation. Mean Wilkins score was 7.6 ± 1.4, 51.5% had mild or moderate mitral regurgitation and mean pulmonary artery systolic pressure (PASP) of 46.7 ± 17.1 mmHg. Mean pre MVA and mean mitral valve (MV) gradient were 1.1 ± 0.2 cm2 and 10.8 ± 5.6 mmHg, respectively. Successful PMBV was achieved in 89.1%. During a mean FU of 12.0 ± 8.8 years, there were 25 deaths (12.4%) and 33.3% needed MV reintervention (6.5% underwent PBMV and 29.7% needed MV surgery). At univariate analysis, previous MV intervention [HR = 1.95 (1.02–3.72), p 45 mmHg [HR = 3.29 (1.13–9.55), p Conclusions PBMV remains a reliable and efficient therapeutic option of mitral stenosis, warranting event-free survival at 10 years in most patients selected for the procedure. Mean MV gradient after procedure was independent predictor of MV reintervention and MACE during follow-up. Abstract Figure. Abstract Figure.

Background There are limited data about the outcomes of non-elective transcatheter aortic valve implantation (TAVI), but some studies suggest that these patients have worst results. Purpose To compare outcomes in patients submitted to urgent versus elective TAVI. Methods Retrospective analysis of consecutive patients (P) submitted to TAVI between 2018 and 2020 in a tertiary center. Baseline characteristics and outcomes after the procedure were collected. Urgent TAVIwas considered when patients were not electively admitted for the procedure but required the intervention on the current admission for medical reasons and could not be sent home without a definitive procedure. Results A total of 208P (55,3% female) were included, with a mean age of 82±7 years. Patients submitted to urgent TAVI (57P, 27,4%) had worse baseline characteristics, with higher EuroScore risk (10,7% vs 5,4%, p Conclusion Patients submitted to urgent TAVI tend to have worse short-term outcomes, but this seems to be attributable to the worse baseline characteristics of these cases instead of the urgent nature of the procedure. Even with the adjustment for baseline differences, these patients have longer global hospital stays, but they don't have latter post-TAVI discharge. Funding Acknowledgement Type of funding sources: None.

During the BP Deepwater Horizon (DWH) oil spill in 2010, 319 live oiled sea turtles were rescued and admitted to rehabilitation centers for decontamination and veterinary care. Most turtles were small, surfaceñpelagic juveniles that were collected from oiled habitat distant from shore. Serial hematology, plasma biochemistry, and blood gas analyses were reviewed to characterize abnormalities relative to observed degree of oiling. Clinicopathological abnormalities upon admission indicated acute, nonspecific metabolic and osmoregulatory derangements that were attributable to a combination of events including stress, exertion, physical exhaustion, and dehydration related to oiling, capture, and transport. Specific toxicological effects reported in other taxa were not observed. Initial point-of-care blood data from one rescue center were evaluated using clinical assessment of physiological status for all turtles of all species with available data for pH, pCO2, sodium, and potassium. In addition, a prognostic model that was specifically developed for cold-stunned Kempís ridley sea turtles Lepidochelys kempii was applied to oiled Kempís ridley turtles from one center. Thirty-six percent of oiled turtles were identified as physiologically deranged based on a clinical assessment of their physiological status, and 25% of oiled Kempís ridley sea turtles exceeded the mortality risk threshold of the prognostic model. These results indicate that the physiological derangements in these animals were relatively severe and clinically relevant. Based on observations during the DWH spill, adverse physiological effects in sea turtles may be an important consequence of stress, exertion, physical exhaustion, and dehydration secondary to oiling, capture, and transport.

The Oil Pollution Act of 1990 establishes liability for injuries to natural resources because of the release or threat of release of oil. Assessment of injury to natural resources resulting from an oil spill and development and implementation of a plan for the restoration, rehabilitation, replacement or acquisition of natural resources to compensate for those injuries is accomplished through the Natural Resource Damage Assessment (NRDA) process. The NRDA process began within a week of the Deepwater Horizon oil spill, which occurred on April 20, 2010. During the spill, more than 8500 dead and impaired birds representing at least 93 avian species were collected. In addition, there were more than 3500 birds observed to be visibly oiled. While information in the literature at the time helped to identify some of the effects of oil on birds, it was not sufficient to fully characterize the nature and extent of the injuries to the thousands of live oiled birds, or to quantify those injuries in terms of effects on bird viability. As a result, the US Fish and Wildlife Service proposed various assessment activities to inform NRDA injury determination and quantification analyses associated with the Deepwater Horizon oil spill, including avian toxicity studies. The goal of these studies was to evaluate the effects of oral exposure to 1-20ml of artificially weathered Mississippi Canyon 252 oil kg bw

762 Table. Age (years) ,50 50-59 60-69 ≥70 Overall N 477 713 873 901 2,968 Peak SBP (mean+SD) 137+25 130+25 131+25 133+23 132+25 Hypertensive cut-point value (mean + 2SD) 187 180 181 179 182 Hypotensive cut-point value (mean -2SD) 87 80 81 87 82 763 Contribution of dobutamine stress echocardiography to the diagnosis and prognosis of low-flow/low-gradient aortic stenosis S. Aguiar Rosa1; G. Portugal1; L. Moura Branco1; A. Galrinho1; M. Afonso Nogueira1; J. Abreu1; D. Cacela1; A. Abreu1; J. Fragata2; R. Cruz Ferreira2 Hospital de Santa Marta, Cardiology, Lisbon, Portugal; Hospital de Santa Marta, Cardiothoracic Surgery , Lisbon, Portugal Purpose: Aortic valve replacement is the treatment of choice in patients (pts) with severe symptomatic aortic stenosis (AS). Pts with depressed left ventricular function and low ejection fraction (LVEF) present as a challenge. Dobutamine Stress Echocardiography (DSE) allows distinguishing fixed Low-Flow/Low-Gradient Aortic Stenosis (LF/LG AS) from pseudo severe AS. Methods: Retrospective analysis of pts who underwent DSE for severe AS investigation, between March 2001 and October 2013. DSE was performed in 3-5 min steps until a maximum dose of 20mcg/kg/min was reached. The baseline echocardiograms, peak DSE, and one year post-op follow-up echocardiograms were analysed. The following parameters were evaluated at basal and peak dose of DSE: left ventricular (LV) end diastolic volume (EDV) and LV end systolic volume (ESV) determined by the Simpson’s biplane method, LVEF, maximum gradient (MaxG), mean gradient (MG) and aortic valve area (AVA) determined by the continuity equation. AS was considered severe if AVA at peak dose was ≤ 1 cm2. The pts were divided into 2 groups according to follow up therapy: aortic valve replacement (GI) or only medical treatment (GII). The average of follow-up period was 26+37 months. Results: 56 pts were analysed, 77% men, with a mean age of 72+7 years. Severe AS was diagnosed in 37 pts (66%). Baseline echocardiographic characteristics were: AVA 0.79+ 0.24cm2, MaxG 45.1+11.6mmHg, MG 27.5+8.5mmHg, LVEF 38.3+13.9%, EDV 155+42 ml, ESV 100+46ml. Peak DSE showed: AVA 0.87+0.36 cm2, MaxG 69.0+ 23.7mmHg, MG 41.5+14.3 mmHg, LVEF 46.2+11.9%, EDV 144.3+35.5 ml, ESV 84.4+32.8 ml. 27 pts (48%) belonged to GI: 2 intervened by transcatheter aortic valve implantation (TAVI) and the remaining 25 by surgery. In GI the mortality was significantly lower than in GII (6pts (22%) VS 20pts (68%); p=0.001). One month after intervention the mortality was null. The survival after one year of follow-up was 91.7% in intervened pts (GI) and 67.9% in non-intervened pts (GII) (p=0.04). In GI with depressed LVEF, there was a significant improvement in LVEF (30.4+5.2% to 42.4+7.0%, p=0.003). On univariate analysis, the predictors of mortality were: age (p=0.023, OR 1.09), peak DSE EDV (p=0.037,OR 1.03), peak DSE ESV (p=0.01, OR 1.07), peak DSE LVEF (p=0.006, OR 0.90) and LVEF improvement , 20% during DSE (p=0.04, OR 1.26). Conclusions: LF/LG AS has a poor prognosis without intervention. DSE permits to establish the lesion severity and define predictors of mortality. In this study age, lack of contractile reserve, peak DSE LVEF,peak DSE EDVandpeak DSE ESVwere predictors ofmortality in follow up. Abstract 760 Figure. ii138 Abstracts Eur Heart J Cardiovasc Imaging Abstracts Supplement, December 2014 by gest on F ebuary 2, 2016 D ow nladed fom 764 The quantitative assessment of the rotation and twist of the left ventricle during dobutamine stress echocardiography A. Mielczarek; JD. Kasprzak; L. Chrzanowski; M. Plewka; P. Lipiec; D. Qawoq; T. Rechcinski; K. Wierzbowska-Drabik Medical University, Lodz, Poland Background: Rotation (R) and twist (T) of the left ventricle (LV) reflects three-layer structure of myocardium and can be assessed quantitatively by speckle tracking echocardiography (STE). Although evaluated in various clinical settings at rest it is poorly validated during stress echocardiography. Aim:Ouraimwas tocalculate and compare rotation atbasalandapical levelsofLVand net twist of LV at rest (0), during peak stage (1) and at recovery (2) of dobutamine stress echocardiography (DSE) in patients without significant lesions in coronary arteries and with negative DSE test. Methods: We analyzed 44 patients with angiographically excluded coronary stenosis ≥50% in left main and ≥70% in other epicardial arteries (27 female, mean age 60+10 years, mean heart rate at baseline 70+12, at the peak 134+17 and at the recovery 92+11, p,0.0001) in whom DSE was performed. Rotation was measured at basal and apical levels of LV. We compared peak systolic rotation (RPS), rotation measured at aortic valve closure (RAVC) and twist (Tcalculated as a difference of basal and apical RAVC) using paired t-test. Results: Neither peak systolic rotation nor rotation measured at endsystole changed significantly during DSE. Similarly twist was practically constant at rest, during peak stage of DSE and at recovery, amounting 6.388, 6.738 and 6.278 respectively, see Table. Conclusions: Peak systolic and end systolic rotation as well as twist of the LV showed distinct independence from heart rate during dobutamine stress echocardiography in patients without significant coronary stenoses. This relationship was observed both at basal and apical level of LV and suggests that rotational parameters are intrinsic features of individual LV mechanics which are constant despite changing inotropic and chronotropic challenge. Abstract 764 Table. Rotation and twist parameters during DSE764 Table. Rotation and twist parameters during DSE Parameter baseline (0) peak DSE (1) recovery (2) p RPS basal segments [8] 23.52+3.17 23.51+4.03 24.15+3.39 ns RPS apical segments [8] 3.93+3.48 3.98+3.75 3.14+2.83 ns RAVC basal segments [8] 22.91+3.33 23.17+3.94 23.87+3.37 ns RAVC apical segments [8] 3.62+3.33 3.71+3.52 2.87+2.73 ns Twist [8] 6.38+4.48 6.73+5.3 6.27+4.01 ns 765 Determinants and prognostic impact of Left Ventricular Contractile Reserve in asymptomatic Aortic Stenosis J. Magne1; E. Donal2; R. Dulgheru3; L. Pierard3; P. Lancellotti3 University Hospital of Limoges, Cardiology, Limoges, France; University Hospital of Rennes Hospital Pontchaillou, Rennes, France; University of Liege Sart Tilman, Liege, Belgium Background: The management of asymptomatic patients with severe aortic stenosis (AS) is extremely controversial. This emphasizes the profound need of new echocardiographic parameters accurate to identify patients at higher risk of poor outcome. There are very few data regarding the assessment, determinants and prognostic value of left ventricular contractile reserve (LVCR) in these patients. We aimed to quantify LVCR and to evaluate its determinants and usefulness for risk stratification in asymptomatic patients with severe AS. Methods and Results: Asymptomatic patients with severe AS (n=150, aortic valve area,1cm, 70+9 years, 64% of male) and preserved left ventricular (LV) systolic function (LV ejection fraction≥55%) were prospectively referred to exercise stress echocardiography. Using 2D speckle tracking analysis, LVCR was defined as an exercise-induced changes in LV global longitudinal strain .2%. LVCR was present in 62 patients (41%) and there was no significant difference between LVCR and no LVCR groups regarding demographic, clinical and exercise data, as well as risk factors. However, patients without LVCR had significantly lower E/Ea ratio and resting LV global longitudinal strain, and higher both resting and exercise indexed left atrial (LA) area. Using multiple linear regression, after adjustment for age, sex and E/Ea ratio, the independent determinant of exercise-induced changes in LV global longitudinal strain were aortic mean pressure gradient (b=0.05+0.02, p=0.005), LV ejection fraction (b=0.06+0.03, p=0.035) and exercise indexed LA area (b=0.20+0.06, p=0.002). During a mean follow-up of 19+12 months, 76 events (51%) occurred. The absence of LVCR was associated with reduced 4-year cardiac event-free survival (26+6 vs. 53+11%, p,0.0001). By opposition, exercise-induced changes in LV ejection fraction did not predict the outcome (p=0.96). In multivariate Cox proportional hazard model, the independent predictors of events were resting brain natriuretic peptide level (p,0.0001), aortic mean pressure gradient (p=0.037), exercise cardiac output (p=0.004) and absence of LVCR (hazard ratio=1.8, 95% of confidence interval: 1.05-3.08, p=0.033). Conclusion: In asymptomatic patients with severe AS, the main determinants of LVCR, as assessed using exercise-induced changes in LV global longitudinal strain, were related to AS severity and exercise LA size. The absence of LVCR is a powerful predictor of reduced cardiac event-free survival. These results strongly support the use of exercise stress echocardiography in asymptomatic AS. Abstracts ii139 Eur Heart J Cardiovasc Imaging Abstracts Supplement, December 2014 by gest on F ebuary 2, 2016 D ow nladed fom

We conducted a 56-day sub-chronic test on the effects of Cu on rainbow trout (Oncorhynchus mykiss) fry at a nominal water hardness of 100 mg l(-1) (as CaCO(3)). Response measures were growth, whole body Cu concentrations, and mortality. Significant mortality was observed in fish exposed to 54.1 microg Cu l(-1) (47.8%) and 35.7 microg Cu l(-1) (11.7%). Growth was dose-dependent over the range of Cu treatments (0-54 microg Cu l(-1)), and was modeled as a function of Cu exposure concentration and exposure duration. Calculated inhibition concentrations (based on change in wet weight through a 56-day Cu exposure) were IC(50)=54.0 microg Cu l(-1), IC(20)=21.6 microg Cu l(-1), IC(10)=10.8 microg Cu l(-1), and IC(01)=1.1 microg Cu l(-1). Measured whole body Cu was also dose-dependent, and growth of trout fry was readily modeled as a function of tissue Cu and exposure duration. This model was virtually identical to a model previously developed for rainbow trout exposed to Cu at a hardness of 25 mg l(-1). Following the 56-day exposure period, we performed a 96-h acute challenge to Cu and Cd to evaluate the effects of Cu acclimation on acute Cu and Cd toxicity. Sensitivity to Cu was dependent on the 'acclimation dose'; trout previously held in control aquaria (i.e. not acclimated to Cu) suffered over 80% mortality, whereas trout previously exposed to 35.7 microg Cu l(-1) for 56 day suffered 20% mortality. These fish also showed somewhat reduced sensitivity to Cd, suggesting acclimation to Cu can enhance tolerance to other metals. Finally, the relationship between growth response and hardness (derived from several studies) appeared to have a different slope than the hardness relationship previously observed for lethality responses.

Metal toxicity from mine wastes has been identified as a potential contributor to declining populations of the federally threatened bull trout Salvelinus confluentus. Although several studies have been published on the effects of long-term Cu exposure on growth in salmonid fish, none have been conducted with bull trout. We evaluated the effects of a 60-d Cu exposure on bull trout in water at 220 mg/L hardness (as CaCO3) and pH 7.9. The endpoints measured were growth, whole-body Cu concentration, and mortality. Exposure to Cu at 179 μg/L resulted in 7% mortality (compared with a mortality of 2% in controls), but no effects of Cu exposure on growth were observed at any Cu concentration tested. Measured tissue residues of Cu in these bull trout were higher than those associated with reduced growth in rainbow trout Oncorhynchus mykiss, indicating that bull trout may be more tolerant of long-term Cu exposure than rainbow trout. This greater tolerance to Cu may be associated with a lower rate of Cu acc...

Copper bioavailability and toxicity to early life stage rainbow trout (Oncorhynchus mykiss) were evaluated by laboratory toxicity testing performed using organic acid mixtures. Geochemical modeling was used to design exposure solutions that simulate dissolved organic carbon (DOC) of a natural aquatic system and to determine the fractions of total Cu present as inorganic species (e.g., Cu2+) and as individual Cu-organic complexes. Failure time modeling indicated that mortality was best predicted by a combination of total inorganic Cu and distinct Cu-organic complexes. The Cu-organic complexes that contributed to toxicity are characterized as low-affinity Cu-ligands, and our results support the hypothesis that Cu toxicity in nature is a function of the binding characteristics of individual ligands. Estimates of time-independent median lethal concentration thresholds determined at widely varying equivalent concentrations of DOC (0-16 mg/L) were constant (7.9-8.6 µg Cu/L) when modeled using the sum of inorganic Cu and Cu bound to the two low-affinity ligands as predictors of toxicity. Our results indicate that Cu bound to organic complexes may be available to fish and that acute toxicity of Cu is determined by the binding affinities of specific DOC components relative to Cu-binding affinity of fish gill.

We conducted 14-day laboratory toxicity tests with rainbow trout to evaluate, (1) the acute toxicity of Co and Cu, and (2) the effects of selected Co concentrations on the toxicity of Cu in Co/Cu mixtures. A one-compartment, uptake-depuration model was used to estimate incipient lethal levels (ILLs) and quantify differences in lethality responses among the Co-only, Cu-only and Co/Cu exposures. Additionally, we compared mortality percentages observed in Co/Cu mixtures to those predicted from two models of joint toxicity. Co was a slower-acting and less potent toxicant than was Cu. For Co, the ILL for 50% mortality was 346 μg l −1 ; for Cu, the ILL for 50% mortality was 14 μg l −1 . Moreover, in Co/Cu mixtures, Co acted as an antagonist during the first 48–96 h, but later acted as an additive or slightly synergistic toxicant—making it difficult to predict short-term mortality of fish in Co/Cu mixtures. Lethality thresholds for Cu were reduced by 11–26% and 37–45%, respectively, in the presence of 50 and 250 μg l −1 Co, although those differences were not statistically significant. The ordering of ILLs for the metal exposures tested was: 250 μg l −1 Co+Cu>50 μg l −1 Co+Cu>Cu-only>Co-only.

Rainbow trout fry were exposed in soft water to sublethal concentrations of copper for 60 days under controlled laboratory conditions. At 20-day intervals, fish were sampled for weight, length, and whole-body copper and metallothionein concentrations. Exposures to waterborne copper concentrations as low as 4.6 μg 1−1 resulted in significantly reduced growth and significantly elevated whole-body copper concentrations after 20 days. Whole-body metallothionein concentrations did not differ significantly from controls. Fish did not recover or return to control growth rates throughout the entire exposure period; a 45% reduction in mean weight relative to controls observed on day 40 in the 9.0 μg 1−1 Cu exposure was sustained through day 60. Whole-body accumulation rates of copper in fish exposed to 4.6 μg 1−1 and higher levels of Cu increased significantly between 0 and 40 days and appeared to reach steady-state after 40 days. Copper accumulation was found to depend on dose and time. Trout exposed to higher copper concentrations accumulated more whole-body copper, with longer times to reach steady-state. Our data suggest that both accumulation capacity and copper depuration rates from a slowly exchangeable pool are concentraion-dependent. A linear model was developed for the relationship between exposure duration, copper accumulation, and fish weight: In (wet wt., μg) = 4.8 + 0.03 (exposure duration, days)—0.04 (whole-body copper, mg g−1 dry wt.) (P

Brown trout (Salmo trutta) and rainbow trout (Oncorhynchus mykiss) fry and juveniles were episodically or continuously exposed to a metals mixture (Zn, Cu, Pb, Cd): the concentrations and ratios of the metals, and variations in water quality (pH, hardness), were selected to represent conditions measured during episodic storm events in the Clark Fork River, Montana. Brown trout fry were more sensitive (lower LC50) than rainbow trout fry to the metals in 8-h exposures with constant hardness and pH, but less sensitive to elevated metal concentrations in conjunction with depressed hardness and pH. Fry were more sensitive than juveniles when exposure was continuous, but neither life stage was clearly more sensitive when exposure was pulsed. Whole-body concentrations of K+ and Ca2+ but not Na+ were significantly depressed in fry exposed to metals. Results support the hypotheses that changes in water quality during thunderstorms are lethal to fry and juvenile life stages of brown and rainbow trouts and that the relative sensitivity of the species to the metals mixture may explain their distributions in the Clark Fork River. Low-frequency extreme conditions may effectively act as a bottleneck on the viability of populations whose relative sensitivities to such extremes may control distributions of species in a system.

The authors describe a new elecrocardiographic criterion to diagnose atrioventricular node reentrant tachycardia, review the electrocardiographic and electrophysiological diagnosis of this tachyarrhythmia and analyse the results of catheter ablation of fast versus slow pathway, selecting the fast pathway whenever the induction of atrioventricular node reentrant tachycardia is performed only after pharmacological maneuvers. The high specificity for atrioventricular node reentrant tachycardia of the criterion characterized by the absence of ST-segment depression found in left precordial leads from V4 to V6 suggests the need to include it in electrocardiographic algorithms for the differential diagnosis of tachycardias with a narrow QRS complex. The high primary and final success rates of catheter ablation obtained after a therapy stratification based on induction criteria, emphasize the use of the fast pathway ablation as a first option in selected cases and for the treatment of recurrences.

The aim of this study was to make a noninvasive comparison, by means of Doppler echocardiography, of the hemodynamic performance of biological stentless xenografts and mechanical bileaflet (MB) prostheses (P) in aortic position.We studied 20 patients (pts) with normofunctional (nf) aortic Toronto (T) Stentless Porcine valves (SPV)--Group I--8 males, aged 69 +/- 12 years, 32 +/- 9 months after surgery, and 30 pts with nf MB aortic P (Carbomedics or St. Jude Medical)--Group II--17 males (p = NS vs G I), aged 61 +/- 12 years (p0.01 vs G I), 30 +/- 12 months after implantation (p = NS vs G I). Both groups were comparable with regard to body surface area and surgical indication. P diameters ranged from 21 to 25 mm (G I: 22.9 +/- 1.7; G II: 22.8 +/- 1.7 - p = NS), the number of pts with the same P diameter in each group being similar. We analysed, at rest: aortic orifice diameter (AoOd - cm), maximal (GMax) and mean (GMean) transprosthesic pressure gradients, P functional area (PFA) and P resistance (PRes). Gradients (mm Hg) were calculated by means of the Bernoulli equation, PFA (cm2) by means of the continuity equation and PRes (dynes.s.cm-5) as 1333 x Gmean x SEP/SV (SEP = systolic ejection period; SV = stroke volume).AoOd (G I vs G II): P 21--1.78 +/- 0.04 vs 2.00 +/- 0.10 (p0.001); P 23--1.91 +/- 0.10 vs 2.19 +/- 0.10 (p = 0.01); P 25--2.22 +/- 0.24 vs 2.29 +/- 0.19 (NS). Doppler parameters: [table: see text]P T SPV show better hemodynamic performance when compared to P MB with the same diameter, in aortic position. In addition, our results suggest that P T SPV allow the use of larger valve sizes for the same aortic orifice diameter.

The authors describe the main etiopathogenic factors and clinical importance of atrial fibrillation and analyse the results of catheter ablation of atrioventricular accessory pathways in Wolff-Parkinson-White syndrome. Atrial vulnerability is the principal mechanism and radiofrequency catheter ablation of atrioventricular accessory pathways seems to be useless to prevent atrial fibrillation.

The aim of this study was to evaluate the clinical profile and prognosis of patients with an angiographically proven thromboembolism.Data from 22 consecutive patients (13 males, 9 females; mean age 57.3 +/- 16.8 years) with pulmonary embolism confirmed by pulmonary angiography were reviewed. All our patients were previously submitted to non-invasive diagnostic procedures (blood examinations, EKG, chest x-ray, echocardiography). A V/Q scan was also performed in 5 patients. Fourteen patients were traditionally treated with heparin alone and the rest received thrombolytic therapy and heparin. Two patients had a thromboembolectomy. At discharge, all our patients were submitted to an oral anticoagulant therapy. The mean duration of the follow-up period was 26 +/- 12 months.The majority of the patients were in the 6th decade of life and it was possible to identify a hypercoagulable state in 82%. The most common symptom at the time of presentation was sudden chest pain (64%). The most specific sign in non-invasive procedures were right side cardiac dilatation seen echocardiographically (73%) and the mismatch in the V/Q scan (80%). The most common haemodynamic parameter (91%) observed in the right heart catheterization of these patients was the finding of a gradient between diastolic pulmonary artery and pulmonary capillary wedge pressures. Uneventful angiography was performed in all patients who showed massive pulmonary embolism (86%). Three patients (13.6%) died during the acute phase. At the end of the follow-up period, 10 patients were asymptomatic and 5 had heart failure. Four died, which corresponds to an overall mortality of 31.8% in 2.2 years of follow-up. None of the clinical or haemodynamic parameters analyzed (age, gender, arterial blood gases at presentation, hypercoagulable states, thrombolysis, pulmonary hypertension and extension of the embolism) were related to mortality.Angiographically confirmed pulmonary thromboembolism is still a poor outcome situation, even when a lot of diagnostic and therapeutic procedures are available.