non-CS Patients Research Articles

The Expanding Role of Posterior Vault Distraction Osteogenesis in Idiopathic Intracranial Hypertension and Slit Ventricle Syndrome.

The purpose of this study was to compare perioperative safety and efficacy of posterior vault distraction osteogenesis (PVDO) in patients with primary nonsynostotic cephalo-cranial disproportion, namely slit ventricle syndrome and idiopathic intracranial hypertension (IIH), to a cohort of patients with craniosynostosis (CS). A retrospective review of patients undergoing PVDO from 2009 to 2019 at our institution was performed. Craniosynostosis patients were matched by sex and age at PVDO to the nonsynostotic cohort. Operative details, perioperative outcomes, and distraction patterns were analyzed with appropriate statistics. Nine patients met inclusion criteria for the non-CS cohort. Six patients (67%) underwent PVDO for slit ventricle and the remaining 3 patients (33%) underwent PVDO for IIH. The majority of CS patients were syndromic (n = 6, 67%) and had multisuture synostosis (n = 7, 78%). The non-CS cohort underwent PVDO at a median 56.1 months old [Q1 41.1, Q3 86.6] versus the CS cohort at 55.7 months [Q1 39.6, Q3 76.0] (P = 0.931). Total hospital length of stay was longer in the non-CS patients (median days 5 [Q1 4, Q3 6] versus 3 [Q1 3, Q3 4], P = 0.021). Non-CS patients with ventriculoperitoneal shunts had significantly less shunt operations for ICP concerns post-PVDO (median rate: 1.74/year [Q1 1.30, Q3 3.00] versus median: 0.18/year [Q1 0.0, Q3 0.7]; P = 0.046). In this pilot study using PVDO to treat slit ventricle syndrome and IIH, safety appears similar to PVDO in the synostotic setting. The cohort lacks adequate follow-up to assess long term efficacy, although short-midterm follow-up demonstrates promising results with less need for shunt revision and symptomatic relief. Future studies are warranted to identify the preferred surgical approach in these complex patients.

Short- and long-term outcomes after concurrent splenectomy during thoracoabdominal aortic aneurysm repair

ObjectiveSplenectomy is often performed during open thoracoabdominal aortic aneurysm (TAAA) repair, because capsular tears are common and can be associated with significant bleeding. It is unknown whether splenectomy affects the short- or long-term outcomes after TAAA repair. MethodsAll open type I to IV TAAA repairs performed from 1987 to June 2015 were evaluated using a single institutional database. The primary endpoints were in-hospital death, major adverse events (MAE) and long-term survival. The secondary endpoint was hospital length of stay (LOS). All repairs performed for aneurysm rupture were excluded. Univariate analysis was conducted using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Logistic and linear multivariable regression were used for the in-hospital endpoints, and survival analyses were performed using Cox proportional hazards modeling and Kaplan-Meier techniques. ResultsA total of 649 patients met the study inclusion criteria. Of the 649 patients, 150 (23%) underwent concurrent splenectomy (CS) and six required emergency splenectomy secondary to bleeding postoperatively, leading to 156 cases of total in-hospital splenectomy. The perioperative mortality rate was 5.2% in the CS group and 5.2% in the non-CS group (P = 1.0). MAE were experienced by 48% of the CS patients compared with 34% of the non-CS patients (P = .003). Multivariable analysis revealed splenectomy was not independently predictive of perioperative death (adjusted odds ratio, 0.95; 95% confidence interval [CI], 0.41-2.23; P = .9). However, splenectomy was independently associated with any MAE (adjusted odds ratio, 1.78; 95% CI, 1.19-2.65; P = .005). Splenectomy was also associated with a longer length of stay (+5.39 days; 95% CI, 1.86-8.92; P = .003). No survival difference was found between the cohorts in the total splenectomy cohort in the unadjusted (log-rank P = 1.0) or adjusted (splenectomy adjusted hazard ratio, 1.02; 95% confidence interval, 0.78-1.35; P = .9). ConclusionsCS during open TAAA repair did not lead to increased perioperative mortality but did lead to significantly increased perioperative morbidity and longer hospital lengths of stay. We found no difference in long-term survival outcomes when CS was performed. Splenectomy during TAAA repair did not affect long-term survival.

Management of Cardiac Sarcoidosis after Orthotopic Heart Transplant: A Multi-Institutional Experience

<h3>Purpose</h3> Cardiac sarcoidosis (CS) is a chronic granulomatous disease of uncertain etiology that has the potential to recur in transplanted hearts. Practice guidelines outlining the optimal care of CS patients do not currently exist for heart transplant recipients. We therefore conducted an online survey of heart transplant providers to gain insight into current practice patterns. <h3>Methods</h3> An online survey was distributed to members of the International Society for Heart and Lung Transplantation. It consisted of 16 questions designed to classify provider type, location and management preferences. Differences between groups were analyzed for significance using Chi-square and/or Fisher exact tests. <h3>Results</h3> 82 providers from 49 different transplant centers responded to our survey. Among respondents, 56 (69%) were cardiologists, 11 (13.1%) advanced practice providers, and 3 (3.6%) surgeons. A significantly greater percentage of centers maintained their CS versus non-CS patients on lifelong prednisone (58.2% vs 4.9%, p<0.001). Most selected low dose (prednisone 1-5 mg daily) vs higher or high dose prednisone (67.5% vs 9.9% vs 0%). The majority of responders (60.3%) routinely monitored for recurrence of CS beyond their center-specific period of performing protocol biopsies. For responders that chose to routinely screen for CS recurrence with more than one modality allowed), 17 (19.3%) utilized cardiac MRI and 25 (28.4%) utilized cardiac PET (Figure A). <h3>Conclusion</h3> A significantly greater proportion of CS patients are maintained on lifelong prednisone post-OHT compared to non-CS patients. For routine monitoring of CS recurrence, cardiac MRI and PET appear to be the preferred modalities for assessing CS recurrence in the allograft. However, a significant percentage of providers do not routinely monitor for CS recurrence post-OHT.

Moderate Dose of Tranexamic Acid and Complications after Valvular Heart Surgery.

In valvular open-heart surgery, data regarding the effect of a moderate dose of tranexamic acid (TXA) on clinical outcomes are limited. Out of a cohort of 13,293 patients, we performed a propensity-score-matched analysis in 6,106 patients and assessed the risk of convulsive seizures (CS, primary endpoint), stroke, renal replacement therapy, and mortality (secondary endpoints). In the entire study cohort of 13,293 patients, we also assessed the multivariable-adjusted association of CS with postoperative outcomes. The risk of CS was significantly higher in the TXA group (2.4%; n = 72) than in the non-TXA group (1.0%; n = 32), with a relative risk ratio (RR) of 2.28 (95% confidence interval [CI]: 1.50-3.47; p < 0.001). The risk of CS was also higher in patients receiving TXA doses ≥25 mg/kg body weight (3.7%; n = 40) than in patients receiving <25 mg/kg body weight (1.6%; n = 32; p < 0.001). Perioperative secondary clinical endpoints and 1-year mortality did not differ significantly between study groups (p-value > 0.05). Compared with non-CS patients (n = 13,000), patients with nonhemorrhagic, nonembolic CS (n = 253) revealed higher multivariable-adjusted in-hospital risks of stroke (RR: 3.82 [95% CI: 2.44-5.60; p < 0.001]) and mortality (RR: 2.07 [95% CI: 1.23-3.48; p = 0.006]), and a higher 1-year mortality risk (RR: 1.85 [95% CI: 1.42-2.41; p < 0.001]). A moderate TXA dose was associated with a significantly higher risk of seizure, but not with other clinical complications such as stroke, renal replacement therapy, and mortality. However, in the small group of patients experiencing a seizure, the risks of stroke and short- and mid-term mortality were substantially higher than in patients not experiencing a seizure, indicating that the use of a low-dose TXA protocol (<25 mg/kg body weight) should be considered.

Texture analysis of delayed contrast-enhanced computed tomography to diagnose cardiac sarcoidosis.

To investigate the diagnostic value of texture analysis to differentiate cardiac sarcoidosis (CS) from other non-ischemic cardiomyopathies (non-CS). Twenty CS patients and 15 non-CS patients who had undergone myocardial CT delayed enhancement (CTDE) were included. A total of 36 texture features were calculated according to the CT attenuation of CTDE. We investigated the diagnostic value to differentiate CS from non-CS. We also assessed the intra- and inter-rater reproducibility for each feature and inter-observer agreement for visual assessment. Seven extracted features had significantly higher run length non-uniformity (RLNU) values (5.4 × 102 ± 6.2 × 102 vs. 11.2 × 102 ± 4.9 × 102, p = 0.037) and significantly lower low gray-level zone emphasis (LGZE) values (7.1 × 10-3 ± 8.6 × 10-3 vs. 18.1 × 10-3 ± 16.9 × 10-3, p = 0.017) in CS than in non-CS. Intra- and inter-rater reproducibility of RLNU and LGZE were excellent (ICCs > 0.8), while inter-observer agreement of visual assessment was poor (kappa = 0.19). The accuracies of texture analysis were 69% with RLNU and 71% with LGZE, which were better than that of visual assessment. Texture analysis of CTDE could differentiate CS from non-CS with high reproducibility.

Surgical Gastrostomy in Pediatric Patients Undergoing Cardiac Surgery

BackgroundPractices of performing gastrostomy tubes vary across institutions for patients undergoing cardiac surgery. We aim to elucidate the outcomes of gastrostomy and the duration of feeding assistance in these patients. Materials and methodsPatients undergoing cardiac surgery (CS) at our institution from 2013 to 2017 were retrospectively reviewed using the Society of Thoracic Surgery database. A cohort of non-CS patients undergoing gastrostomy tube (g-tube) placement from 2013 to 2015 was used as control. Technical complications and postoperative feeding intolerance were analyzed. Duration of need for g-tube was also analyzed in patients undergoing CS. ResultsThe CS group had 144 patients, and the non-CS group had 677 patients. CS patients had a higher incidence of feeding intolerance (18.8% versus 5.6%, P < 0.001) and took longer to attain full feeds (median of 2 versus 1 d, P < 0.001), and this was confirmed on propensity matched analysis. In addition, technical g-tube complications were similar in the two groups. No mortality in CS was attributed to the g-tube. 58% of patients undergoing CS were able to wean from g-tube feeding by 6-12 mo after g-tube placement. ConclusionsG-tube placement in patients undergoing CS by any technique is safe without increased complications. A significant portion of these patients was able to wean off supplemental enteral feeding assistance by a year after g-tube placement.

Distance of Cervico-Vaginal Junction to Anterior Cul-de-sac during Vaginal Hysterectomy in Patients with and without Prior Cesarean Section

Study Objective Incomplete dissection of vaginal attachments to cervix during vaginal hysterectomy (VH) can lead to incorrect plane and injury to the bladder. This study aims to compare the mean distance between the cervico-vaginal (CV) incision to the anterior cul-de-sac (AC) during VH between women with and without a history of cesarean section (CS). Design Prospective cohort study of women who underwent VH. Intraoperative measurements taken: Distance from external cervical os to initial incision at CV, distance from CV to peritoneal entry into the AC, and distance from AC to the uterine fundus. Measurements were compared between patients with and without CS. We determined that 40 patients were needed to study our primary outcome: 20 CS and 20 non-CS. Setting VH performed in high lithotomy position. Patients or Participants Women who were undergoing VH for benign gynecologic conditions were included. Patients were excluded if gynecologic malignancy, prior vaginal or pelvic radiation, and/or presence of lower anterior uterine segment myoma. Interventions N/A Measurements and Main Results Preliminary data are presented (incomplete accrual as yet of patients due to the COVID19). Of the 35 patients with complete data, 23 (62.1%) had vaginal delivery(ies) only, 12 (32.4%) had at least one CS. The mean distance from CV to AC entry in all patients was 5.0 (1.55) cm, 5.4 (1.92) cm with CS, and 4.79 (1.31) cm without CS (p=0.27). The mean distance of the AC entry to fundus was longer in patients without CS (6.48cm vs 4.49cm, p=0.01). This finding remained significant when we controlled for both uterine length and weight. Conclusion Preliminary data suggests that in CS patients, the mean distance from the initial incision to AC tended to be greater and distance of AC to fundus was significantly shorter compared to non-CS patients.

PATIENT CHARACTERISTICS ASSOCIATED WITH VENTRICULAR ARRHYTHMIAS, HEART BLOCK, AND HEART FAILURE IN CARDIAC SARCOIDOSIS PATIENTS

SESSION TITLE: Cardiovascular Disease SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Cardiac sarcoidosis (CS) has varied presentations, including ventricular tachycardia (VT), heart block (HB), and systolic heart failure (HF). Patient characteristics associated with these varied clinical findings remains unknown, and could inform choice of cardiac implantable electronic device (CIED) in CS patients. The purpose of this study is to determine patient characteristics associated with VT, HB, and HF in patients with CS. METHODS: We combined our large, racially diverse registry of CS patients with that of another large academic center, and included patients if they had clinical suspicion of CS and corroborating endocardial biopsy, PET scan, or cardiac MRI. Patients were grouped by presence or absence of VT, HB, or HF over the duration of a follow-up, and patient characteristics associated with VT, HB, and HF were identified. RESULTS: A total of 94 CS patients were included in the combined registry, capturing all patients with a CS diagnosis over the preceding 5 years in the respective institutions. Patients who developed VT (n=32, 34%) were more likely to be male (78% vs 57%, p=0.04). No other characteristics were associated with VT. This includes the presence of systolic dysfunction (p=0.20) and CAD (p=0.32). There were no significant characteristics associated with patients with HB (n=52, 55%) or patient with HF with ejection fraction < 35% (n=14, 17%). CONCLUSIONS: Male patients with cardiac sarcoidosis were more likely to have VT. No other characteristics were associated with VT, HB or HF. CLINICAL IMPLICATIONS: This demonstrates the significant difficulty in predicting arrhythmias and HF in patients with cardiac sarcoidosis, and that typical risk factors in non-CS patients for these endpoints may not apply to CS patients. DISCLOSURES: No relevant relationships by Anuj Basil, source=Web Response No relevant relationships by Matthew Bocchese, source=Web Response No relevant relationships by Crystal Chen, source=Web Response Consultant relationship with Abbott Laboratories Please note: $5001 - $20000 Added 04/11/2020 by Joshua Cooper, source=Web Response, value=Consulting fee Advisory Committee Member relationship with Abbott Medical Please note: $5001 - $20000 Added 04/11/2020 by Joshua Cooper, source=Web Response, value=Consulting fee Consultant relationship with Johnson & Johnson Please note: $20001 - $100000 Added 04/11/2020 by Joshua Cooper, source=Web Response, value=Consulting fee Consultant relationship with Boston Scientific Please note: $5001 - $20000 Added 04/11/2020 by Joshua Cooper, source=Web Response, value=Consulting fee Consultant relationship with Biosense Webster Please note: $5001 - $20000 Added 04/11/2020 by Joshua Cooper, source=Web Response, value=Consulting fee Consultant relationship with Medtronic Inc Please note: $1001 - $5000 Added 04/11/2020 by Joshua Cooper, source=Web Response, value=Consulting fee No relevant relationships by Edmond Cronin, source=Web Response No relevant relationships by chethan gangireddy, source=Web Response No relevant relationships by Rohit Gupta, source=Web Response No relevant relationships by Abdullah Haddad, source=Web Response No relevant relationships by Benjamin Rosenfeld, source=Web Response No relevant relationships by David Rosenthal, source=Web Response no disclosure on file for Vasanth Vedantham; No relevant relationships by Isaac Whitman, source=Web Response

Natural History of Patients Diagnosed with Cardiac Sarcoidosis at Left Ventricular Assist Device Implantation or Cardiac Transplantation.

To our knowledge, natural history has not been reported for cardiac sarcoidosis (CS) diagnosed by pathologic evaluation of the apical core at left ventricular assist device (LVAD) implantation or cardiac transplantation. We retrospectively identified 232 consecutive patients meeting CS criteria. Of these patients, 54 were diagnosed by pathologic confirmation of CS, 10 after evaluation of the apical core (LVAD implant) or explanted heart (transplant). We compared clinical characteristics at initial evaluation and outcomes for these 10 patients with those of 10 patients with known CS before LVAD implant/transplant. In the study group, five patients (50%) had confirmed extracardiac sarcoidosis before LVAD implant/transplant; five had not been diagnosed with sarcoidosis. Mean (standard deviation) left ventricular ejection fraction at initial evaluation was 23% (16%), and left ventricular end-diastolic dimension was 61 (10) mm. Four patients died during follow-up; however, no survival difference was found for the 10 patients diagnosed incidentally and the group with a previous diagnosis or institutional LVAD/transplant cohorts. Patients diagnosed with CS on pathological examination of the apical core/explanted heart may have severe dilated cardiomyopathy as the initial presentation. Outcomes for patients with CS after advanced heart failure therapies may be comparable with those of non-CS patients.

How Does Preoperative Central Sensitization Affect Quality of Life Following Total Knee Arthroplasty?

BackgroundCentral sensitization (CS) has been recently identified as a significant risk factor for persistent pain and patient dissatisfaction following total knee arthroplasty (TKA). However, it remains unclear as to whether the preoperative CS persists after the elimination of a nociceptive pain source by TKA, or how CS affects the quality of life after TKA. MethodsA total of 222 consecutive patients undergoing primary TKA were enrolled in the study. All patients were preoperatively screened for CS using the Central Sensitization Inventory (CSI) and categorized into either a CS (n = 55; CSI ≥ 40) or non-CS group (n = 167; CSI < 40). CSI, pain visual analog scale (VAS), Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index score, and satisfaction were recorded at postoperative 2 years. ResultsTwo years after TKA, preoperative CS remained unchanged; there was no difference between preoperative and postoperative CSI scores, and both preoperative and postoperative CSI severity levels were similar (P > .1). The CS group showed worse pain VAS, KSS, and Western Ontario and McMaster Universities Osteoarthritis Index scores than did the non-CS group (P < .01) and more patients in the CS group were dissatisfied with all activities (P < .01). However, a similar percentage of the CS group achieved the previously documented minimal clinically important difference in pain VAS and KSS, compared with the non-CS group. Multivariate regression analysis revealed that preoperative CSI scores were associated with dissatisfaction at postoperative 2 years. ConclusionPreoperative CS was persistent at 2 years after TKA. Although CS patients achieved comparable clinical improvement following TKA, CS patients had worse quality of life, functional disability, and dissatisfaction than non-CS patients.

Management of Cardiac Sarcoidosis Post Heart Transplantation: Survey of Transplant Centers

Background: Cardiac sarcoidosis (CS) can result in end stage infiltrative cardiomyopathy. Heart transplantation (HT) is an effective therapy for advanced CS, with outcomes similar to non-CS patients. Rarely, recurrence of sarcoidosis in the allograft can occur. Ideal immunosuppression and surveillance strategies in patients with CS are unknown. The aim of our study is to look at practice patterns regarding treatment of CS patients post HT. Methods: A survey concerning HT attitudes and outcomes in CS patients was distributed to 98 HT centers in the United States via email. Results: Twenty-six centers responded to the survey (28%). In year 2018 alone, these centers did 964 transplants. All centers reported having performed HT in CS patients, reported approximately 194 HT in CS patients. Most centers reported similar outcomes for patients with CS compared to other etiologies (96.4%). 17(72%)centers report using mechanical circulatory support as bridge to transplant. Regarding post-HT management of these patients, 62.5% of participants reported a dedicated immunosuppression strategy for CS patients with most respondents reporting long-term steroid use in patients with CS and 37.5 % of participants using induction therapy for CS patients (with either thymoglobulin or basiliximab). Approximately 37.5% of participants have seen recurrence of sarcoidosis post HT in the allograft ranging from 0 to 50% recurrence either in allograft or other site. 28% of respondents reported performing prolonged surveillance for sarcoid recurrence with 34.8% using either PET scan or Cardiac MR for evaluation. This survey sheds light into post-transplant management of patients with CS with most centers reporting recurrence of sarcoidosis in the allograft and using long term steroids to prevent recurrence.

Dexamethasone measurement during low-dose suppression test for suspected hypercortisolism: threshold development with and validation.

Dexamethasone Suppression Test (DST), recommended for Cushing's Syndrome (CS) diagnosis, explores the pituitary feedback to glucocorticoids. Its diagnostic accuracy could be affected by dexamethasone bioavailability, and therefore, we have developed and validated a dexamethasone threshold after 1-mg DST. We studied 200 subjects: 125 patients were considered retrospectively and 75 were enrolled prospectively as the validation cohort. Serum dexamethasone, Late Night Salivary Cortisol (LNSC), and Urinary Free Cortisol (UFC) were measured with LC-MS/MS. Normal LNSC and UFC levels were used to exclude CS. The lower 2.5th percentile of dexamethasone distribution in non-CS patients with cortisol ≤ 50nmol/L after 1-mg DST was used as threshold. 16 patients were CS and 184 non-CS (108 adrenal incidentaloma and 76 excluded CS); 4.5nmol/L resulted the calculated threshold. Cortisol after 1-mg DST confirmed high sensitivity (100% at 50nmol/L cut-off) and moderate-low specificity (63%, increased to 91% at 138nmol/L) to diagnose CS in the whole cohort of patients. We could reduce the number of false-positive results (from 10 to 6 and from 7 to 4 in AI and excluded CS) considering adequate dexamethasone levels. Dexamethasone levels were not affected by hypercortisolism, age, gender, smoke, weight, and creatinine. 6% of non-CS patients did not achieve adequate dexamethasone levels (40% of tests with serum cortisol > 138nmol/L after 1-mg DST). We developed and validated the routine dexamethasone measurement during 1-mg DST: it is independent from patient's clinical presentation, and it should be used to increase the specificity of serum cortisol levels.

Scaling the great wall: The impact of communication barriers on quality of psychiatric care in Chinese patients.

Racial and ethnic minorities (such as Chinese-speaking (CS)) are known to have less equitable access to mental health services than Caucasians. These disparities have a powerful influence on minority groups that already endure a greater burden from mental health needs. The aim was to identify perceived provider barriers to care for CS patients. The study involved an 11-item web-based survey to multidisciplinary health professionals in the department of psychiatry at a 75-bed teaching community mental health center. More than half the respondents agreed that there are disparities in the management of CS versus non-CS patients primarily due to the language barrier (46%). However, older participants and participants who worked fewer hours per week in patient care were less likely to agree (rho = -.27, p = .05 and rho = .33, p = .015, respectively) that these perceived difficulties prevented them from caring for these patients. The study revealed that certain modifiable factors like the limited availability of interpreters and culturally appropriate services, rendering psychoeducation and forming therapeutic alliances with CS patients, posed the greatest challenges on inpatient units. In light of these findings, we aim to make recommendations to remediate concerns of limited provider availability by proposing ways to efficiently utilize current resources and advocate for better staffing to improve the overall well-being of this challenging patient subset.

3073Leveraging transcriptome sequencing for detecting novel disease-related pathways using human cardiac sarcoidosis myocardium biopsies

Abstract Background/Introduction Cardiac sarcoidosis (CS) is one of the main causes of poor outcomes in patients with sarcoidosis, a systemic granulomatous disorder of complex etiology including a genetically susceptible host and specific exposure to disease-triggering antigens. Recently, transcriptome analysis using sarcoidosis peripheral monocytes was reported to be useful for exploring genetic susceptibility and novel disease-causing pathways. However, transcriptome sequencing has not been used to explore disease-related genes and pathways directly using human CS myocardial biopsies. Purpose This study aimed to identify transcriptome profiles and novel disease-related pathways of CS by comparing human CS myocardial biopsies with control samples using ribonucleic acid (RNA) sequencing (RNA-Seq). Methods We assessed 30 patients with suspected myocardial disorders who underwent transcatheter endomyocardial biopsies at our University Hospital, Japan. Of those, 7 were clinically diagnosed with CS, 9 with hypertrophic cardiomyopathy (HCM), and 14 with dilated cardiomyopathy (DCM). Messenger RNAs were extracted from cardiac muscle biopsies using the Ovation SoLo RNA-Seq System (NuGEN Technologies), according to the manufacturer's instructions. Sequencing was performed with coverage of approximately 20 million reads per sample using Illumina HiSeq 2000. Sequencing reads were mapped using the STAR 2-pass method with GRCh37 as the reference. The DESeq2 R package (version 3.8) was used for further analyses. Principal component analysis (PCA) on gene expression was conducted for detecting outliers such as non-muscular samples. Differential gene expression analysis was performed between the 7 patients with CS and 23 patients with cardiomyopathy (HCM and DCM, non-CS). Gene Ontology (GO) enrichment analysis was conducted to estimate possible disease-related pathways. Results We successfully sequenced 60 myocardial biopsy samples (original and biological duplicates) from 30 CS patients. Of these, 2 outlier samples shown by the PCA plot were removed, and 58 were used for further analyses. We found 243 genes that were differentially expressed between CS patients and non-CS patients. Top-rated genes were RP11–366M4.8, RELN, S100A6, WASF3and UCHL1. Pathway analysis using GO demonstrated enrichment oflymphocyte activation (P=4.8x10–16), organelle fission (P=6.1x10–14), the M phase of the mitotic cell cycle (P=2.2x10–13), nuclear division (P=2.4x10–13), mitosis (P=2.4x10–13) and T-cell activation pathways (P=1.2x10–12). Conclusions Our differential gene expression and pathway analysis results using human CS myocardial biopsies suggested that lymphocyte activation, specifically the T-cell activation pathway, is linked to CS pathogenesis. Further studies are needed to decipher the role of specific genes related to genetic susceptibility and/or pathways associated with CS occurrence.

Safety and effectiveness of coronary sinus leads extraction - single high-volume centre experience.

IntroductionTransvenous leads extraction (TLE) of permanently implanted coronary sinus (CS) leads is widely believed to present greater risks than the removal of other leads.AimTo assess the safety and efficacy of CS leads extraction based on large research material obtained by one operator performing procedures in two TLE centres.Material and methodsWe extracted 408 CS leads from 389 patients, and the results were compared to a control group of 2465 patients who underwent non-CS lead TLE procedures.ResultsThere were no significant differences in the clinical success rate (97.9% vs. 98.0%) or the major complication rate (2.1% vs. 1.8%) between the CS and control group. CS lead destination (LV/LA pacing) and tip location (CS ostium/mid CS /CS tributaries) influenced the procedural and radiological success rates and procedural complexity but not the complications. CS lead extraction did not affect the necessity for a cardiosurgical intervention or presence of procedure-related death.ConclusionsTLE of CS leads can be achieved with a high procedural success rate. The major complication rate is not higher than that seen in non-CS lead extraction patients. More than half of CS leads cannot be removed by simple traction and the use of mechanical sheaths may be necessary. The detachment of CS leads from connective tissue scars in the venous and atrial areas up to the CS ostium is generally sufficient for further removal of the lead using simple traction.

Cardiac sarcoidosis classification with deep convolutional neural network-based features using polar maps

AimsThe aim of this study was to determine whether deep convolutional neural network (DCNN)-based features can represent the difference between cardiac sarcoidosis (CS) and non-CS using polar maps. MethodsA total of 85 patients (33 CS patients and 52 non-CS patients) were analyzed as our study subjects. One radiologist reviewed PET/CT images and defined the left ventricle region for the construction of polar maps. We extracted high-level features from the polar maps through the Inception-v3 network and evaluated their effectiveness by applying them to a CS classification task. Then we introduced the ReliefF algorithm in our method. The standardized uptake value (SUV)-based classification method and the coefficient of variance (CoV)-based classification method were used as comparative methods. ResultsSensitivity, specificity and the harmonic mean of sensitivity and specificity of our method with the ReliefF algorithm were 0.839, 0.870 and 0.854, respectively. Those of the SUVmax-based classification method were 0.468, 0.710 and 0.564, respectively, and those of the CoV-based classification method were 0.655, 0.750 and 0.699, respectively. ConclusionThe DCNN-based high-level features may be more effective than low-level features used in conventional quantitative analysis methods for CS classification.

Effect of Cardiac Resynchronization Therapy on Left Ventricular Remodeling in Patients With Cardiac Sarcoidosis

Cardiac resynchronization therapy (CRT) has been shown to be beneficial in patients with medically refractory heart failure. Although it has been found to be effective in a wide range of etiologies for nonischemic cardiomyopathy, its role in improving remodeling and survival of patients with cardiac sarcoidosis (CS) remains undefined. We performed a retrospective review of all patients at our institution with CS who underwent implantation of a CRT device from 2007 to 2017. The outcomes of this population were compared with the outcomes of a cohort of patients with nonischemic cardiomyopathy with an etiology other than sarcoidosis. Nineteen patients in our institution with CS underwent CRT implantation during the time period. This group was compared with 311 consecutive patients with other etiologies of nonischemic cardiomyopathy who underwent CRT implantation. CRT improved left ventricular ejection fraction (LVEF) from 28.8% to 35.9% (p <0.05) in CS, whereas it improved LVEF from 25% to 36.6% (p <0.01) in non-CS group (difference in means of 0.13). CRT significantly improved diastolic and systolic LV diameters, mitral regurgitation, and right ventricular systolic function in non-CS patients but failed to improve same parameters in CS patients. In conclusion, CRT significantly improved LVEF in patients with CS. There is no significant evidence that survival outcomes of CRT patients with CS are significantly worse than other etiologies of nonischemic cardiomyopathy.

Risk of posterior circulation stroke in patients with cervical spondylosis: A nationwide, population-based study

Background and aimsCervical spondylosis (CS) is reported to be associated with vertebrobasilar insufficiency. However, few cohort studies have investigated the association between CS and posterior circulation ischemic stroke. MethodsThe study cohort comprised 27,990 patients aged ≥18 years with a first diagnosis of CS. The controls consisted of patients with propensity score matched for age, sex, and comorbidities at a ratio of 1:1. We investigated the relationships of CS with ischemic stroke and all-cause mortality. Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs). The average follow-up duration was 6.13 (SD = 3.18) and 6.07 (SD = 3.19) years in the CS and non-CS cohorts, respectively. ResultsThe mean age of CS patients and non-CS patients was 54.9 ± 13.4 and 55.1 ± 14.9 years. Fifty-eight point five percent of CS patients and 59.2% of non-CS patients were women. CS patients were 1.46 folds more likely to develop a posterior circulation ischemic stroke (95% CI, 1.23–1.72) than non-CS patients. CS patients with myelopathy exhibited a 1.50–fold risk (95% CI, 1.21–1.86) of posterior circulation ischemic stroke compared with non-CS patients; CS patients without myelopathy were at a 1.43-fold risk (95% CI, 1.18–1.73) of posterior ischemic stroke compared with non-CS patients. The risk of posterior ischemic stroke was non-significant between non-CS patients and CS patients who had received spinal anterior decompression (adjusted HR, 1.66; 95% CI, 0.78–3.52), while receiving posterior decompression was associated with a 4.23-fold risk of posterior ischemic stroke (95% CI, 1.05–17.0). ConclusionsThis population-based study showed that CS is associated with an increased risk of posterior circulation ischemic stroke. Surgical posterior decompression was associated with the highest risk of posterior ischemic stroke.

The diagnostic accuracy of increased late night salivary cortisol for Cushing's syndrome: a real-life prospective study.

A prompt diagnosis of Cushing's Syndrome (CS) in high-risk populations is mandatory: 1-mg dexamethasone suppression test (1-mg DST), late night salivary cortisol (LNSC), and urinary-free cortisol (UFC) are recommended, despite thresholds calculated in retrospective studies. Our aim was to study the diagnostic accuracy of LNSC measured with chemiluminescence assay in a prospective study, confirming discrepancies with mass spectrometry (MS). We enrolled 117 controls and 164 suspected CS (CS = 47, non-CS = 117). In case of increased LNSC, high clinical suspicion of CS or adrenal incidentaloma, patients were hospitalized to exclude/confirm CS. LNSC levels were higher in patients with suspected CS, CS, and non-CS than controls. Considering 16nmol/L as threshold for CS, overall LNSC revealed SE 97% and SP 84% in the whole group of subjects considered, achieving positive/negative likelihood ratio of 5.56/0.045, respectively. 35 out of 81 subjects with increased LNSC were non-CS (15 diabetic and 20 obese): considering only those patients with increased likelihood to have a CS (the non-CS patients) SP decreased to 70%, and further reduced to 60% if we discharged subjects with adrenal incidentaloma. MS analyses reduced partially the number of false-positive LNSC. LNSC measured in automated chemiluminescence is reliable in clinical practice: it present a high diagnostic accuracy to exclude hypercortisolism in patients with normal cortisol levels. MS could be used to reduce the number of false-positive results; nevertheless, some non-CS subjects with functional hypercortisolism could have a mild impairment of cortisol rhythm.

The diagnostic accuracy of increased late night salivary cortisol for Cushing's Syndrome: a real-life prospective study

A prompt diagnosis of Cushing’s Syndrome (CS) in high-risk populations is mandatory: 1-mg dexamethasone suppression test (1-mg DST), late night salivary cortisol (LNSC), and urinary-free cortisol (UFC) are recommended, despite thresholds calculated in retrospective studies. Our aim was to study the diagnostic accuracy of LNSC measured with chemiluminescence assay in a prospective study, confirming discrepancies with mass spectrometry (MS). We enrolled 117 controls and 164 suspected CS (CS = 47, non-CS = 117). In case of increased LNSC, high clinical suspicion of CS or adrenal incidentaloma, patients were hospitalized to exclude/confirm CS. LNSC levels were higher in patients with suspected CS, CS, and non-CS than controls. Considering 16 nmol/L as threshold for CS, overall LNSC revealed SE 97% and SP 84% in the whole group of subjects considered, achieving positive/negative likelihood ratio of 5.56/0.045, respectively. 35 out of 81 subjects with increased LNSC were non-CS (15 diabetic and 20 obese): considering only those patients with increased likelihood to have a CS (the non-CS patients) SP decreased to 70%, and further reduced to 60% if we discharged subjects with adrenal incidentaloma. MS analyses reduced partially the number of false-positive LNSC. LNSC measured in automated chemiluminescence is reliable in clinical practice: it present a high diagnostic accuracy to exclude hypercortisolism in patients with normal cortisol levels. MS could be used to reduce the number of false-positive results; nevertheless, some non-CS subjects with functional hypercortisolism could have a mild impairment of cortisol rhythm.