Detection Of Ischemia Research Articles

Validation of a Novel Multiphase CTA Perfusion Tool Compared to CTP in Patients With Suspected Acute Ischemic Stroke

Background We recently developed a novel machine learning‐based algorithm using multiphase computed tomography angiography (mCTA) to generate perfusion maps of the brain, similar to computed tomography perfusion (CTP) (ie, multiphase CTA perfusion [mCTAp]). Here, we aim to validate the clinical utility of mCTAp in detection of brain ischemia and its side, extent, and location. Methods In this prospective multi‐reader‐multi‐case analysis, we included baseline images: mCTAp ( StrokeSENS ‐algorithm) and CTP (4D; GE Healthcare) from 121 randomly selected patients whose scans were not part of algorithm‐development. After excluding 2/121 scans because of poor image‐quality, 3 experienced radiologists read time to maximum, and relative cerebral blood flow‐maps generated by the test (mCTAp) and reference (CTP) modality. The 2 reading sessions were separated by 5 days although the reading order was randomized. Core laboratory imaging assessments – that used non contrast computed tomography, mCTA, and CTP – were considered as ground‐truth. A mixed‐effects statistical model with “reader” as random effects variable was used to calculate the area under the curve (with 95% CI), sensitivity, and specificity for both modalities (mCTAp/CTP) for ischemia detection, affected side, and occlusion location. The time required for interpretation and inter‐rater variability in assessments were compared across the 2 modalities. Results Area under the curves (95% CI) for detecting ischemia using mCTAp and CTP were 0.85 (95% CI, 0.8–0.9) and 0.84 (0.8–0.9) respectively ( P =0.43). Area under the curves for the affected side were 0.94 (0.92–0.97) and 0.96 (0.94–0.98) ( P =0.69), respectively; for detecting large vessel occlusion were 0.84 (0.8–0.9) and 0.86 (0.8–0.9), ( P =0.31), respectively; M2‐or‐distal occlusion were 0.79 (0.73–0.84) and 0.88 (0.83–0.92) ( P =0.22), respectively, for anterior cerebral artery‐occlusion 0.82 (0.66–0.98) and 0.93 (0.82–1.00) ( P =0.15), respectively, and for posterior cerebral artery‐occlusions 0.9 (0.8–1) and 0.99 (0.98–0.99) ( P =0.01), respectively. The median (interquartile range [IQR]) time for image interpretation was 62 seconds (IQR, 46–78) and 59 seconds (IQR, 42–69) for mCTAp and CTP, respectively, ( P =0.15). Fleiss` Kappa‐values for inter‐rater reliability in detecting ischemia were 0.5 and 0.8 for mCTAp and CTP, respectively. Conclusion mCTAp shows similar performance and interpretation times compared to CTP in assisting readers to detect brain ischemia, affected side, and occlusion location, but mainly as it relates to proximal vessel occlusions. The proposed tool still needs further refinement for distal vessel occlusions. Nonetheless, mCTAp is a promising tool as it allows for acquisition of brain perfusion maps with lower radiation exposure, acquisition time, and contrast dose compared with additional CTP.

Myocardial Revascularization in Patients With Ischemic Cardiomyopathy: For Whom and How.

Background Myocardial revascularization has been advocated to improve myocardial function and prognosis in ischemic cardiomyopathy (ICM). We discuss the evidence for revascularization in patients with ICM and the role of ischemia and viability detection in guiding treatment. Methods and Results We searched for randomized controlled trials evaluating the prognostic impact of revascularization in ICM and the value of viability imaging for patient management. Out of 1397 publications, 4 randomized controlled trials were included, enrolling 2480 patients. Three trials (HEART [Heart Failure Revascularisation Trial], STICH [Surgical Treatment for Ischemic Heart Failure], and REVIVED [REVascularization for Ischemic VEntricular Dysfunction]-BCIS2) randomized patients to revascularization or optimal medical therapy. HEART was stopped prematurely without showing any significant difference between treatment strategies. STICH showed a 16% lower mortality with bypass surgery compared with optimal medical therapy at a median follow-up of 9.8 years. However, neither the presence/extent of left ventricle viability nor ischemia interacted with treatment outcomes. REVIVED-BCIS2 showed no difference in the primary end point between percutaneous revascularization or optimal medical therapy. PARR-2 (Positron Emission Tomography and Recovery Following Revascularization) randomized patients to imaging-guided revascularization versus standard care, with neutral results overall. Information regarding the consistency of patient management with viability testing results was available in ≈65% of patients (n=1623). No difference in survival was revealed according to adherence or no adherence to viability imaging. Conclusions In ICM, the largest randomized controlled trial, STICH, suggests that surgical revascularization improves patients' prognosis at long-term follow-up, whereas evidence supports no benefit of percutaneous coronary intervention. Data from randomized controlled trials do not support myocardial ischemia or viability testing for treatment guidance. We propose an algorithm for the workup of patients with ICM considering clinical presentation, imaging results, and surgical risk.

Early detection of myocardial ischemia in resting ECG: analysis by HHT

BackgroundExercise electrocardiography (ECG) is a noninvasive test aiming at producing ischemic changes. However, resting ECG cannot be adopted in diagnosing myocardial ischemia till ST-segment depressions. Therefore, this study aimed to detect myocardial energy defects in resting ECG using the Hilbert–Huang transformation (HHT) in patients with angina pectoris.MethodsElectrocardiographic recordings of positive exercise ECG by performing coronary imaging test (n = 26) and negative exercise ECG (n = 47) were collected. Based on the coronary stenoses severity, patients were divided into three categories: normal, < 50%, and ≥ 50%. During the resting phase of the exercise ECG, all 10-s ECG signals are decomposed by HHT. The RT intensity index, composed of the power spectral density of the P, QRS, and T components, is used to estimate the myocardial energy defect.ResultsAfter analyzing the resting ECG using HHT, the RT intensity index was significantly higher in patients with positive exercise ECG (27.96%) than in those with negative exercise ECG (22.30%) (p < 0.001). In patients with positive exercise ECG, the RT intensity index was gradually increasing with the severity of coronary stenoses: 25.25% (normal, n = 4), 27.14% (stenoses < 50%, n = 14), and 30.75% (stenoses ≥ 50%, n = 8). The RT intensity index of different coronary stenoses was significantly higher in patients with negative exercise ECG, except for the normal coronary imaging test.ConclusionsPatients with coronary stenoses had a higher RT index at the resting stage of exercise ECG. Resting ECG analyzed using HHT could be a method for the early detection of myocardial ischemia.

Spectral imaging enables contrast agent–free real-time ischemia monitoring in laparoscopic surgery

Laparoscopic surgery has evolved as a key technique for cancer diagnosis and therapy. While characterization of the tissue perfusion is crucial in various procedures, such as partial nephrectomy, doing so by means of visual inspection remains highly challenging. We developed a laparoscopic real-time multispectral imaging system featuring a compact and lightweight multispectral camera and the possibility to complement the conventional surgical view of the patient with functional information at a video rate of 25 Hz. To enable contrast agent-free ischemia monitoring during laparoscopic partial nephrectomy, we phrase the problem of ischemia detection as an out-of-distribution detection problem that does not rely on data from any other patient and uses an ensemble of invertible neural networks at its core. An in-human trial demonstrates the feasibility of our approach and highlights the potential of spectral imaging combined with advanced deep learning-based analysis tools for fast, efficient, reliable, and safe functional laparoscopic imaging.

Wireless Single-Lead versus Standard 12-Lead ECG, for ST-Segment Deviation during Adenosine Cardiac Stress Scintigraphy.

Wearable wireless electrocardiographic (ECG) monitoring is well-proven for arrythmia detection, but ischemia detection accuracy is not well-described. We aimed to assess the agreement of ST-segment deviation from single- versus 12-lead ECG and their accuracy for the detection of reversible ischemia. Bias and limits of agreement (LoA) were calculated between maximum deviations in ST segments from single- and 12-lead ECG during 82Rb PET-myocardial cardiac stress scintigraphy. Sensitivity and specificity for reversible anterior-lateral myocardial ischemia detection were assessed for both ECG methods, using perfusion imaging results as a reference. Out of 110 patients included, 93 were analyzed. The maximum difference between single- and 12-lead ECG was seen in II (-0.019 mV). The widest LoA was seen in V5, with an upper LoA of 0.145 mV (0.118 to 0.172) and a lower LoA of -0.155 mV (-0.182 to -0.128). Ischemia was seen in 24 patients. Single-lead and 12-lead ECG both had poor accuracy for the detection of reversible anterolateral ischemia during the test: single-lead ECG had a sensitivity of 8.3% (1.0-27.0%) and specificity of 89.9% (80.2-95.8%), and 12-lead ECG a sensitivity of 12.5% (3.0-34.4%) and a specificity of 91.3% (82.0-96.7%). In conclusion, agreement was within predefined acceptable criteria for ST deviations, and both methods had high specificity but poor sensitivity for the detection of anterolateral reversible ischemia. Additional studies must confirm these results and their clinical relevance, especially in the light of the poor sensitivity for detecting reversible anterolateral cardiac ischemia.

Cost-effectiveness of 82-Rubidium PET myocardial perfusion imaging for the diagnosis of myocardial ischemia depending on the prevalence of coronary artery disease

Background82-Rubidium-Positron emission tomography myocardial perfusion imaging (Rb-PET-MPI) offers higher diagnostic performance for the detection of myocardial ischemia compared to Tc-SPECT-MPI. The aim of this economic evaluation was to perform a cost-effectiveness analysis of Rb-PET-MPI versus Tc-SPECT-MPI in patients with suspected myocardial ischemia according to pretest probabilities (PTP) of obstructive coronary artery disease based on the results of the RUBIS Trial.MethodsCosts and effectiveness were calculated for all patients over 1 year and an incremental analysis of differences in costs and effectiveness in terms of diagnostic accuracy was performed. The uncertainty of the results was estimated using bootstrap. The analysis was conducted from the perspective of the French health care system with a time horizon of 12 months.ResultsThe average cost of a Rb-PET-MPI-based strategy for the detection of myocardial ischemia was €219 lower than a SPECT-MPI-based strategy (€1192 (± 1834) vs €973 (± 1939), p < 0.01). The one-year incremental cost-effectiveness ratio was negative: − €2730 (money saved per additional accurate diagnosis) in patients presenting PTP > 15% for the Rb-PET-MPI vs. Tc-SPECT-MPI strategy. Analysis of the joint distribution of costs and outcomes found that the Rb-PET-MPI strategy had a 92% probability to be dominant (cost-saving and outcome-improving).ConclusionsRb-PET-MPI is cost-effective compared to Tc-SPECT-MPI for the detection of myocardial ischemia in patients with PTP > 15% of obstructive coronary artery disease.Trial registrationRUBIS Trial registration: NCT01679886, Registered 03 September 2012, https://clinicaltrials.gov/ct2/show/NCT01679886.

Abstract WP108: A Novel Multiphase CTA Perfusion Tool Compared To CTP In Patients With Suspected Acute Ischemic Stroke

Introduction: We recently published a Machine Learning-based algorithm using mCTA (mCTAp) that generates perfusion maps of the brain, similar to CTP. Here, we aim to validate the clinical utility of mCTAp in detection of ischemia, it’s side, extent and location. Methods: One hundred and twenty-one subjects were included in the test dataset. These subjects had completed mCTAp (StrokeSENS) and CTP (4D; GE Healthcare) at baseline. After excluding 2/121 subjects due to poor image quality, a multi-reader-multi-case (n=119) study design was conducted with 3 experienced radiologists, reading post-processed maps (Tmax and rCBF) generated by both mCTAp and CTP. Both reading sessions were separated by a few days. All readers were blinded to modality and clinical information and the reading order was randomized between sessions. Core lab imaging assessments that used NCCT, mCTA and CTP were considered as ground truth. A mixed effect regression model with the reader as random effect variable was used to calculate the AUC, sensitivity, and specificity for both imaging arms regarding ischemia detection, ischemia side, and occlusion site selection (i.e., ICA/M1[considered LVO], M2 or distal, ACA or PCA). The time required for image interpretation was compared between the two modalities. Results: The AUCs for detecting ischemia were comparable between mCTAp and CTP (0.85 [95%CI:0.8-0.9] and 0.84 [95%CI:0.8-0.9] respectively; p=0.43), the affected ischemic side (0.94 [0.92-0.97] and 0.96 [0.94-0.98] respectively; p=0.69), detecting a LVO (0.84 [0.8-0.9] and 0.86 [0.8-0.9]; p=0.31) and M2 or distal occlusions (0.8 [0.7-0.8] and 0.9 [0.84-0.92]; p=0.22). The median (IQR) time for interpretation was 62s (46-78) and 59s (42-69) for mCTAp and CTP respectively (p=0.15). Conclusion: mCTAp shows similar performances when compared to CTP in assisting readers to detect ischemia, location, and extent by using Tmax and rCBF perfusion maps.

Advances in the Assessment of Coronary Artery Disease Activity with PET/CT and CTA.

Non-invasive testing plays a pivotal role in the diagnosis, assessment of progression, response to therapy, and risk stratification of coronary artery disease. Although anatomical plaque imaging by computed tomography angiography (CTA) and ischemia detection with myocardial perfusion imaging studies are current standards of care, there is a growing body of evidence that imaging of the processes which drive atherosclerotic plaque progression and rupture has the potential to further enhance risk stratification. In particular, non-invasive imaging of coronary plaque inflammation and active calcification has shown promise in this regard. Positron emission tomography (PET) with newly-adopted radiotracers provides unique insights into atheroma activity acting as a powerful independent predictor of myocardial infarctions. Similarly, by providing a quantitative measure of coronary inflammation, the pericoronary adipose tissue density (PCAT) derived from standard coronary CTA enhances cardiac risk prediction and allows re-stratification over and above current state-of-the-art assessments. In this review, we shall discuss the recent advances in the non-invasive methods of assessment of disease activity by PET and CTA, highlighting how these methods could improve risk stratification and ultimately benefit patients with coronary artery disease.

Quantitative model for assessment of lower-extremity perfusion in patients with diabetes.

Although diabetic and atherosclerotic vascular diseases have different pathophysiological mechanisms, the screening methods currently used for diabetic lower-extremity vascular diseases are mainly based on the evaluation methods used for atherosclerotic vascular diseases. Thus, assessment of microvascular perfusion is of great importance in early detection of lower-extremity ischemia in diabetes. This cross-sectional study aimed to develop a quantitative model for evaluating lower-extremity perfusion. We recruited 57 participants (14 healthy participants and 43 diabetes patients, of which 16 had lower-extremity arterial disease [LEAD]). All participants underwent technetium-99m sestamibi (99mTc-MIBI) scintigraphy and ankle-brachial index (ABI) examination. We derived two key perfusion kinetics indices named activity perfusion index (API) and basal perfusion index (BPI). This study was registered in ClinicalTrials.gov (URL: https://www. gov, NCT02752100). The estimated limb perfusion values in our lower-extremity perfusion assessment (LEPA) model showed excellent consistency with the actual measured data. Diabetes patients showed reduced lower-extremity perfusion in comparison with the control group (BPI: 106.21±11.99vs. 141.56±17.38, p<0.05; API: 12.34±3.27vs. 14.56±3.12, p<0.05). Using our model, the reductions in lower-extremity perfusion could be detected early in approximately 96.30% of diabetes patients. Patients with LEAD showed more severe reductions in lower-extremity perfusion than diabetes patients without LEAD (BPI: 47.85±20.30vs. 106.21±11.99, p<0.05; API: 7.06±1.70vs. 12.34±3.27, p<0.05). Discriminant analysis using API and BPI could successfully screen all diabetes patients with LEAD with a sensitivity of 100% and specificity of 80.77%. We established a LEPA model that could successfully assess lower-extremity microvascular perfusion in diabetes patients. This model has important application value for the recognition of early-stage LEAD in patients with diabetes.

Application of Dual-Source CT Using Iterative Reconstruction Technology Combined with CT-FFR Parameters in the Diagnosis of Coronary Heart Disease.

In order to achieve early detection of myocardial ischemia and improve the diagnosis of coronary heart disease (CHD), it is necessary to find a convenient, non-invasive and effective examination method. This study aimed to explore the application value of dual-source computed tomography (CT) by using advanced modeled iterative reconstruction (ADMIRE) combined with computed tomography-fractional flow reserve (CT-FFR) technique in CHD, which provides imaging basis for early diagnosis of CHD and myocardial ischemia. Seventy-five CHD patients were examined by coronary computed tomography angiography (CCTA). Their CCTA images were reconstructed by iterative algorithm in ADMIRE 1-5 using post-processing workstation. The standard deviation (SD), signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of proximal vascular images in right coronary artery (RCA), left main coronary artery (LM), left anterior descending artery (LAD) and left circumflex artery (LCX) were analyzed and compared. Invasive coronary angiography (ICA) was adopted in patients with ≥50% stenosis of coronary artery diameter. Taking ICA as the gold-standard method to accurately assess coronary arterial stenosis degree, the diagnostic efficiency of dual-source CT to diagnose coronary artery stenosis was analyzed. Some patients were subjected to myocardial CT perfusion (CTP) scanning and CT-FFR analysis, which facilitated analyzing the correlation and consistency between the diagnostic results of CTP and analysis results of CT-FFR. There was no statistical difference in the CT values of RCA, LM, LAD and LCX in groups with different ADMIRE reconstruction intensities (p > 0.05). But the noise, SNR and CNR interval were different among the iterative intensity groups (p < 0.05). Kappa consistency analysis was used to analyze the subjective evaluation results of image quality under different iterative reconstruction grades. The independent sample t-test performed on the subjective scores revealed that the scores on images were the best at ADMIRE 4. CCTA has sensitivity, specificity, positive predictive value, and negative predictive value of 91.52%, 97.59%, 97.98%, and 96.42% for identifying coronary artery stenosis, respectively. The diagnostic efficacy of CT-FFR, the Kappa analysis of myocardial CTP and CT-FFR results, which yields a Kappa value of 0.830 (p < 0.05). Spearman correlation analysis was used to statistically analyze the results of myocardial CTP and CT-FFR (correlation coefficient r = 0.774, p < 0.05). Diagnostic sensitivity and specificity were 93% and 95%, respectively. The dual-source CT using ADMIRE iterative algorithm has the best display of coronary vessels and higher image quality when the intensity is 4, and CT-FFR can be used as a non-invasive method for early detection of myocardial ischemia, which is worthy of clinical application.

Update on biomarkers for early detection of intestinal ischaemia

Angiología es una revista científica bimensual editada desde 1949. Está dedicada al estudio de las enfermedades vasculares, incluyendo todos los aspectos de la medicina vascular, el diagnóstico no invasivo, el tratamiento quirúrgico tradicional arterial y venoso, así como el mínimamente invasivo y/o endovascular.

Relation between quantitative measurement of the foveal avascular zone, outer retinal layers disruptions, and visual acuity in diabetic macular ischemia

Background: With the potential to offer more in-depth images of the macula than foveal avascular (FA) imaging, optical coherence tomography angiography (OCTA) is emerging as a novel imaging tool for the detection of diabetic macular ischemia (DMI). The study's goal was to determine the relationship between visual acuity (VA) in DMI, foveal avascular zone (FAZ) and retinal vessel density (VD) as measured by OCTA, and the integrity of the outer retinal layers as measured by optical coherence tomography angiography (OCT). Methods: This a cross sectional research enrolled 25 eyes of 25 diabetic cases diagnosed with DMI using FFA, and 25 normal eyes as a control group. All cases underwent ocular exam including VA testing, anterior segment exam, intra ocular pressure, fundus exam, and fundus fluorescein angiography (FFA). Results: Reduction of vision was noticed in ischemic cases, the mean BCVA for the cases was 0.88±0.27 (LogMAR), while for the control was 0.03±0.04. A statistically prominent positive relation was detected between best corrected visual acuity (BCVA) (LogMAR) and (FAZ) area (rs=0.530, P=0.006), a statistically prominent negative relation was detected between BCVA (LoMAR) and both vessel area density (VAD) parameters (SCP and DCP) (VADSCP: rs= -0.415, P=0.039) (VADDCP: rs = -0.525, P =0.007). Conclusions: OCTA allows for the quick, automated, and non-invasive quantification of vascular density and FAZ in DMI.

Applications of machine learning for nursing monitoring of electroencephalography

The nursing monitoring of electroencephalography (EEG) during neurosurgery includes verifying the proper placement of electrodes on the patient's scalp and ensuring the accurate display of EEG readings on the monitoring apparatus. This study aims to examine the use of machine learning (ML) in EEG monitoring by analyzing the R programming language. The results will provide insights into surgical nursing care by evaluating EEG patterns. The preceding evidence was collected following the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines in the present study. The logical analysis of the data was conducted using the R programming language. ML algorithms based on usage rate included logistic regression (LR), support vector machine (SVM), random forest (RF), artificial neural networks (ANN), and convolutional neural network (CNN). Also, the use of ML in nursing monitoring of EEG is categorized into three indications rehabilitation measurement (post-operation), delayed cerebral ischemia (DCI) detection (pre-operation), hypotension identification (intra-operation), surgical outcomes measurement(post-operation), and seizure prediction. In sum, the algorithm, including LR and SVM, have been frequently utilized in the realm of EEG evaluation, as indicated by the results obtained.

Tell-a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system.

Telemetry is often a scarce resource at hospitals and is important for arrhythmia and myocardial ischemia detection. Overuse of telemetry monitoring leads to alarm fatigue resulting in failure to respond to arrhythmias, patient harm, and possible unnecessary testing. This quality improvement initiative was implemented across NYC Health and Hospitals, an 11-hospital urban safety net system. The electronic health record intervention involved the addition of a mandatory indication in the telemetry order and a best practice advisory (BPA)that would fire after the recommended time period for reassessment had passed. The average telemetry hours per patient encounter went from 60.1 preintervention to 48.4 postintervention, a 19.5% reduction (p < .001). When stratified by the 11 hospitals, decreases ranged from 9% to 30%. The BPA had a 53% accept rate and fired 52,682 times, with 27,938 "discontinue telemetry" orders placed. The true accept rate was 50.4%, as there was a 2.6% 24-hreorder rate. There was variation based on clinician specialty and clinician type (attending, fellow, resident, physician associate, nurse practitioner). We successfully reduced telemetry monitoring across a multisite safety net system using solely an electronic health record (EHR) intervention. This expands on previous telemetry monitoring reduction initiatives using EHR interventions at single academic sites. Further study is needed to investigate variation across clinician type, specialty, and post-acute sites.

Review of current ECG consumer electronics (pros and cons)

BackgroundSeveral wearable, medical-grade consumer ECG devices are now available and integrated into consumer electronics like multi sensor fitness watches and scales. Specific consumer ECGs can also come in the form of patches or thin sensor plates in credit card or other shapes. Watches with ECG capabilities are often multi vital sign sensor devices. The majority of these devices are usually connected to a mobile smartphone. However, there are pros and cons to their use. MethodsWe review here an exemplary selection of modern consumer ECG devices based on device type, recording method and the number of standard ECG channels derived. ResultsSingle-channel consumer ECG devices such as Smart Watches can be useful for detecting and monitoring atrial fibrillation and flutter and other arrhythmias, as well as ectopic complexes. However, they are currently limited with respect to recording duration and information content (a single-channel or limb‑lead ECG having less diagnostic information than a 12‑lead ECG). While some non watch-based consumer ECG devices can now record all 6 limb leads to yield increased information, no consumer ECG devices can currently reliably detect ST-segment deviations, potentially indicating myocardial infarction or ischemic episodes. Moreover, barriers to use still exist for at-risk elderly people. Finally, there currently is no universal data exchange format. ConclusionConsumer ECG devices, whether in fitness or fashionable design, allow for reliable detection of atrial fibrillation. Timely detection of atrial fibrillation and subsequent treatment might protect against stroke, especially in high-risk groups, yet prospective evidence is still lacking. Six-channel consumer ECG and longer data collection capabilities extend potential functionality, including for the monitoring of ST-segments and QT intervals. However, no currently available devices are sufficiently suitable for the detection of myocardial infarction or ischemia, which is why portable 12-channel technologies are desirable. For the reliable detection of a myocardial infarction, the determination of specific myocardial infarction blood markers and evaluation of patient medical history still is indispensable in addition to the 12 lead ECG.

405 A NATURAL HISTORY OF VERY LONG-TERM BIORESORBABLE ATHEROSCLEROTIC RESTORATION THERAPY

Abstract A 49-year-old man was referred to our cath-lab in 2015 after the detection of inducible ischaemia in the infero-lateral wall on single-photon emission CT performed due to a worsening stable angina. His cardiovascular risk factors accounted for family history of ischemic disease, high blood pressure and dyslipidaemia. The echocardiography highlighted a mildly reduced left ventricular function with infero-lateral wall hypokinesia. Coronary angiography revealed a chronic total occlusion (CTO) of the left circumflex artery (LCX) and a long diffuse severe disease of the right coronary artery (RCA). The left anterior descending artery (LAD) showed a diffuse atherosclerotic involvement without critical stenoses. Percutaneous coronary intervention (PCI) was performed after Heart Team discussion with implantation of two 3.5×28mm and 3.5×23mm Absorb bioresorbable vascular scaffold (BVS) on the RCA. Moreover, the LCX CTO was successfully treated by anterograde approach with implantation of a 3.0×28 mm Absorb BVS. Intravascular ultrasound confirmed the optimal result of both the interventions, while confirmed the long diffuse calcific involvement of the LAD with a thick cap calcific fibroatheroma at the virtual histology. The patient was discharged on dual antiplatelet therapy for twelve months. After five uneventful years, he was readmitted to our department for recurrence of worsening stable angina. At the coronary angiography a significant progression of the proximal LAD disease was noted. The lesion was judged hemodynamic relevant with pressure derived indices (instantaneous wave-free ratio 0.86; fractional flow reserve 0.70). The IVUS and optical coherence tomography (OCT) analysis confirmed the significant progression of the disease with a long, diffuse, sub-occlusive thick cap fibroatheroma stenosis (minimal lumen area 1.9 mm2; plaque burden 91%). The OCT analysis showed the complete resorption of the devices previously implanted to the RCA and the LCX, with optimal long-term results and positive remodelling in the LCX. Therefore, an OCT-guided PCI with marker-to-marker implantation of two 3.5×25 and 3×20 mm magnesium-based Magmaris BVS was performed. In 2022, the patient underwent an elective coronary angiography that demonstrated a complete resorption of both the Magmaris with an optimal OCT result. Conversely, the positive remodelled segment resulting from complete resorption of the poly-L-lactic-based BVS in the mid-LCX was shown to be progressed to a critical sub-occlusive fibroatheroma. A further OCT-guided PCI with deployment one 3.5×20mm Magmaris BVS was performed. Six months later, patient was asymptomatic with a good performance status. To the best of our knowledge, the present is the first case of multivessel repetitive imaging-based percutaneous revascularizations with the use of two different BVS technologies and a total of six devices implanted, with very long-term intracoronary imaging result. Through the paired intravascular imaging analysis, this case sought to provide insightful findings on vulnerable plaque atherosclerotic progression and on BVS biologic restoration therapy, a process that appears particularly appealing in young patients with advanced CAD, namely multivessel involvement and diffuse disease that still poses limitations to PCI.

521: CEREBRAL ISCHEMIA AND OUTCOMES WITH RAPID BLOOD PRESSURE LOWERING IN INTRACEREBRAL HEMORRHAGE

Introduction: Guidelines support acute systolic blood pressure (SBP) lowering in intracerebral hemorrhage (ICH) if SBP is between 150 and 220 mmHg to improve outcomes. Recommendations for SBP >220 mm Hg are less clear. A proposed risk is failure of cerebral autoregulation, leading to brain ischemia and poor outcomes. Methods: A single center, retrospective cohort study of adult ICH patients from July 2017 to 2021. Patients from outside of the hospital system, in-hospital ICH, pregnant, or a prisoner were excluded. The primary outcome was incidence of cerebral ischemia in patients with SBP >220 mmHg (high) vs. 150-219 mmHg (low), assessed through percent SBP lowering and evaluation of radiographic imaging during admission. Secondary outcomes included poor neurologic status with mRS of 4 to 6 at discharge. Results: Of the 393 patients included, median (IQR) premorbid mRS was 0 in both groups, median (IQR) NIHSS was high; 16 (8, 23) vs. low; 13 (5, 19), p < 0.01. The median (IQR) presenting SBP was high; 236 (225, 246) mmHg vs. low; 180 (166, 197) mmHg. SBP goal was achieved in the first 24 hours in high; 86% vs. low; 77%, p = 0.09. Median (IQR) change in SBP 12 hours after arrival was high; -98 (-112, -83) mmHg vs. low; -47 (-62, -25) mmHg (p < 0.01) with a percent change in 12 hour SBP of 41% vs. 25%, p < 0.01. Significance persisted at 18 and 24 hours after arrival. Both groups had a mean (SD) of 7 (4) radiographic images obtained during admission. The median (IQR) time to detection of ischemia was high; 2.8 (1.4, 5.7) days vs. low; 3.1 (1.2, 6.6) days, p = 0.6. Presence of ischemic insults did not differ in the regression model based on presenting SBP groups [HR 0.57 (0.25, 1.3) p = 0.81] or percent change in SBP > or < 25% at 24 hours [HR 0.83 (0.41, 1.69) p = 0.61]. Poor neurologic outcome at discharge was present in high; 82% vs. low; 69% of patients (p = 0.07). Higher admission ICH score (p < 0.01) and NIHSS (p < 0.01) was associated with a poor outcome in the regression model. Conclusions: These results suggest there was no difference in the development of ischemic changes based on presenting SBP or percent change in the SBP. Poor neurologic outcome was associated with higher NIHSS and ICH score on admission in the analysis. These results will need to be confirmed in a randomized study.

Postoperative Sigmoidoscopy and Biopsy After Elective Endovascular and Open Aortic Surgery for Preventing Mortality by Colonic Ischemia (PSB-Aorta-CI): Protocol for a Prospective Study.

Endovascular aortic repair is considered the standard procedure in treating patients diagnosed with pathologies of the abdominal aorta with suitable anatomy. Open surgery remains an option mostly for patients not suitable for endovascular surgery. Colonic ischemia is an important and life-threatening postoperative complication of these procedures. The aim of this study is to evaluate the clinical value and safety of performing a planned sigmoidoscopy and biopsy for detection of colonic ischemia in patients undergoing elective aortic surgery. We also aim to develop prediction scores which could identify patients at risk for colonic ischemia and facilitate their timely treatment. The trial is designed as a prospective study. The decision for aortic surgery and eligibility for these procedures will be ascertained according to current guidelines. Afterward, screening of the patient for the remaining inclusion and exclusion criteria will occur. If eligibility for study inclusion is confirmed, the patient will be informed about the aims of the study and all study-specific procedures (sigmoidoscopy and biopsy) and asked to provide informed consent. The primary end point is the proportion of patients diagnosed endoscopically with subclinical and clinically relevant colonic ischemia among all patients undergoing aortic surgery. Patient recruitment started on June 2021. The final patient is expected to be treated by the end of June 2023. Institutional Review Board review has been completed at the University of Halle (Saale; reference #052-2021). this shows that sigmoidoscopy can be performed safely and is effective for the timely diagnosis of colonic ischemia in these patients, this could result in its routine implementation in both elective and emergency settings. German Clinical Trials Register DRKS00025587; https://www.drks.de/drks_web/navigate.do?navigationId =trial.HTML&TRIAL_ID=DRKS00025587. DERR1-10.2196/39071.

Kinetics of d-lactate and ischemia-modified albumin after abdominal aortic surgery and their ability to predict intestinal ischemia

ObjectivesAcute intestinal ischemia is a severe complication of abdominal aortic surgery that is difficult to diagnose early and therefore to treat adequately and timely. In this study the perioperative kinetics of d-lactate and ischemia-modified albumin (IMA) are described and the predictive value of these markers for the early diagnosis of acute intestinal ischemia is assessed. Design & methodsThis non-randomised, single-centre cohort study enrolled 50 patients with abdominal aortic aneurysm (AAA) and 30 patients with aortoiliac occlusive disease (AOID). Serum d-lactate and IMA were assessed pre-, intra-, and postoperatively at eight defined time points. ResultsThe highest serum d-lactate was at 6 h after complete declamping of the vascular graft. The highest predictive power of d-lactate was at 3 h after complete declamping (AUC 0.857). IMA was found to be higher in the AAA group in ischemic patients 10 min after complete declamping than in the AOID group. The highest predictive values of IMA were at 1 h after aortic cross-clamping (AUC 0.758) and 3 and 6 h after complete declamping (0.745 and 0.721, respectively). Moreover, the multivariate model with both markers at 3 h after complete declamping improved the detection of intestinal ischemia (AUC 0.894). ConclusionsSerum levels of IMA and d-lactate seem to be influential predictive markers for postoperative intestinal ischemia, especially after 3 h from complete declamping of vascular reconstruction.

Ultra‐wide field fluorescein angiography in intermediate and posterior uveitis: A retrospective study

AbstractPurpose: To review the diagnostic value of the Ultra‐wide field imaging system Optomap Panoramic 200A (Optos, PLC, Scotland) in patients with intermediate, posterior uveitis or panuveitis of our department and the presence of findings in the periphery of the retina compared to the conventional 7 standard field fluorescein (7SF) angiography, as well as the contribution of the findings to the change of the therapeutic approach.Methods: This is a retrospective study. A medical records electronic search using Medisoft (Medisoft Limited, UK) conducted and included 69 patients and 121 eyes with intermediate, posterior uveitis or panuveitis that underwent Ultra‐wide field fluorescein angiography imaging. Subsequently, imaging was observed for detection of vasculitis, ischemia, neovascularisation and/or choroidal lesions in areas beyond 75° that was detected by conventional fluorescein angiography. The therapeutic approach based on the presence/absence of relevant findings was also reviewed.Results: Out of 121 eyes in total, 67 were classified as intermediate uveitis, 44 as posterior uveitis and 5 as panuveitis. The presence of at least one form of peripheral angiographic finding was noted in 52 eyes, peripheral vasculitis was observed in 40 eyes and peripheral ischemia in 31 eyes. Decision to change the therapeutic approach was decided in 42 eyes overall, 31 of which presented peripheral findings and 11 lacked any. 21 eyes were noted with peripheral findings, but no change of treatment was decided. There was a statistically significant correlation between presence and absence of findings and change of treatment (p &lt; 0.00001). No other statistically significant correlation between treatment alteration and score or specific uveitis type was found.Conclusions: Compared with conventional 7SF imaging, the Ultra‐wide field fluorescein angiography is an extremely useful diagnostic test for the detection of active disease and can significantly change the therapeutic approach in patients with intermediate, posterior uveitis or panuveitis.