Multicenter Retrospective Study Research Articles

Noonan Syndrome: Relation of Genotype to Cardiovascular Phenotype—A Multi-Center Retrospective Study

Background: Noonan syndrome (NS) is a congenital genetic disorder with a prevalence of 1 in 1000 to 2500 live births, and is characterized by distinctive facial features, short stature, chest deformities, and congenital heart disease. This study aims to evaluate the prevalence of specific genetic mutations and their impact on cardiovascular and other outcomes in NS. Methods: We conducted a retrospective clinical study of 25 pediatric patients diagnosed with NS at two institutions: The Mother and Child Health Care Institute of Serbia and the Clinic for Children Diseases, University Clinical Center of the Republic of Srpska. Patients underwent whole-exome sequencing (WES) to identify genetic mutations. Clinical data, including cardiovascular manifestations, psychomotor development, and stature, were analyzed in relation to mutation types. Results: The cohort comprised 60% male and 40% female patients, with a median age at diagnosis of 7.2 years. Cardiovascular abnormalities were present in 88% of patients. Mutations in PTPN11 were most commonly associated with pulmonary valve stenosis (PVS), while RAF1 mutations were prevalent in patients with hypertrophic cardiomyopathy (HCM). No significant association was found between cardiac disease and delayed psychomotor development (p = 0.755), even though the likelihood ratio showed significance in that regard (p = 0.018). Short stature was observed in 48% of patients but was not significantly correlated with genetic type of disease, presence of cardiac disease, or developmental delay. Conclusions: The study confirms the high prevalence of cardiovascular manifestations in NS and highlights genotype–phenotype correlations. While cardiac abnormalities are common, their impact on psychomotor development and stature is less clear. Further research is needed to explore genetic interactions influencing these outcomes and refine clinical management strategies.

Efficacy and safety of CalliSpheres drug-eluting bead bronchial arterial infusion chemoembolization vs. bland embolization in advanced lung cancer with hemoptysis: A multicenter retrospective study.

Massive hemoptysis is a life-threatening complication in patients with advanced primary lung cancer, and effective, safe treatments are crucial. This study aimed to investigate the efficacy and safety of CalliSpheres drug-eluting bead bronchial arterial infusion chemoembolization (DEB-BACE) for managing this condition. A retrospective analysis included 144 patients with advanced primary lung cancer and massive hemoptysis treated at multiple hospitals from January 2019 to January 2023. Patients undergoing bronchial artery embolization were divided into two groups: the observation group (n=76) received CalliSpheres DEB-BACE with epirubicin, and the control group (n=68) received 8spheres blank embolization. Both groups achieved successful hemostasis, with no statistically significant difference in success rates (observation group: 88.16%, control group: 86.76%). However, the observation group had a significantly longer median duration without hemoptysis (96 days vs. 50 days). Two months post-therapy, the observation group showed higher objective response rates (82.89% vs. 38.24%) and disease control rates (92.11% vs. 66.18%) compared to the control group. Adverse reactions were manageable and similar between groups, with no serious complications observed. By January 31, 2024, the observation group had significantly longer median overall survival (11 months vs. 7 months). The DEB-BACE treatment demonstrates safety and efficacy in managing massive hemoptysis in patients with advanced lung cancer. However, the superiority of this approach over bland embolization remains to be established through well-designed prospective studies. Future research is anticipated to provide a definitive comparison and further validate the role of DEB-BACE in clinical practice.

Oocyte maturity rate is an age-independent predictor of blastocyst development and euploidy rates: a multicenter retrospective study

Research Question Can oocyte maturity rate predict blastocyst development and euploidy rates independently of patient age? Design A multicenter retrospective study including 1547 consecutive women undergoing first in-vitro fertilization cycle of oocyte retrieval-intracytoplasmic sperm injection with preimplantation genetic testing for aneuploidy (IVF/ICSI/PGT-A). Both centers used the same PGT lab for PGT-A testing. Oocyte maturity rate as a predictor for cycle outcomes of blastocyst development and euploidy rates was analyzed by Poisson regression model, after controlling for other known confounders. Results Oocyte maturity rate is positively correlated with blastocyst development rate and euploidy rate after controlling for patient age at cycle start, BMI, AMH levels, total FSH dosage, number of days of ovarian stimulation, and peak estradiol level (p<0.01). Conclusion This study demonstrated that oocyte maturity rate can predict blastocyst development and euploidy rates independently of other confounding factors including patient age. This finding suggests that oocyte maturity rate may serve as an important biomarker for oocyte quality. This can be used by physicians to evaluate and improve the efficacy of ovarian stimulation regimens for IVF. This may further enhance artificial intelligence (AI) capabilities in optimizing ovarian stimulation protocols and outcomes of Assisted Reproductive Technologies (ART).

Clinical characteristics and prognosis of steroid-resistant nephrotic syndrome in children: a multi-center retrospective study.

This study investigated the factors influencing the prognosis of children with steroid-resistant nephrotic syndrome (SRNS) in patients from the Guangxi region. We retrospectively analyzed clinical and pathological data of 279 patients with SRNS from six tertiary hospitals in Guangxi. Clinical data were compared between initial (I-SRNS) and secondary (S-SRNS) steroid resistance subgroups and Cox regression analysis was used to determine risk factors for chronic kidney disease (CKD) and CKD stage 5 (CKD5) in patients with SRNS. The median age of onset was 54 months. Thirty-three patients had extra-kidney manifestations. Fifty-two, 24, 57, 33, and 41 patients had hypertension, acute kidney injury, vitamin D deficiency, high intraocular pressure, and dwarfism, respectively. One hundred eighty-two and 92 patients had I-SRNS and S-SRNS, respectively. There were significant differences in sex, ethnicity, family history, incidence of hematuria, clinical classification, efficacy of immune agents, and prognosis between groups (P < 0.05). Among the 279 cases of SRNS, 239 had normal kidney function, 37 developed CKD, and 16 had CKD5. An increase in serum creatinine level (HR = 1.003) was significantly associated with CKD in children with SRNS, and effective immunosuppressant therapy decreased the CKD risk (HR = 0.168). Patients with increased serum creatinine levels (HR = 1.003) and acute kidney injury (HR = 4.829) were more likely to progress to CKD5. Children with S-SRNS showed a higher response to immunosuppressants than those with I-SRNS. Effective immunosuppressant therapy was found to protect against CKD, whereas increased acute kidney injury was an independent risk factor for CKD5.

Characteristics of Side Effects in Non-Emergency Indications Using Computer-Controlled Pressurized Monoplace Hyperbaric Chambers: A Retrospective Multicenter Study

Background: Hyperbaric oxygen therapy (HBOT) involves inhaling nearly 100% oxygen in a pressurized environment and is commonly used to treat various diseases and injuries. Despite its well-known safety, HBOT is associated with side effects, with frequent middle ear barotrauma (MEB) and oxygen toxicity. Understanding the characteristics and risk factors associated with these side effects is critical for improving patient compliance and treatment outcomes. Methods: This retrospective multicenter study aimed to analyze the characteristics and factors associated with side effects during HBOT using a computer-controlled pressurized monoplace hyperbaric chamber. We conducted a retrospective observational study across the two tertiary hospitals in Korea, involving patients who received HBOT from October 2016 for one hospital and October 2017 for another hospital to June 2020. Data were extracted from electronic medical records and hyperbaric chamber logs, including patient demographics, medical history, HBOT indications, and details of side effects. Statistical analyses, including chi-square and t-tests, were used to compare variables. Results: A total of 247 patients (mean age: 59.35 ± 15.05 years, 63.56% male) were included. The most common indications for HBOT were sudden sensorineural hearing loss (27.94%) and post-graft/flap (24.29%). Hypertension (46.15%) and diabetes mellitus (39.27%) were the most frequent comorbidities. Otalgia was the most prevalent side effect (33.20%), followed by chest discomfort (2.02%) and headache (1.62%). A significant proportion of patients (11.74%) terminated HBOT due to side effects, with most pauses occurring at pressures between 1.2 and 1.4 ATA (26.67%). Side effects, particularly otalgia, significantly impact patient compliance with HBOT. Conclusions: The incidence of side effects varies by pressure level during treatment, suggesting the need for tailored strategies to minimize side effects. This study highlights the importance of patient monitoring and education to improve the safety and efficacy of HBOT in monoplace chambers.

Clonal hematopoiesis in patients with autoimmune thrombocytopenia: an international multicenter study.

Diagnostic boundaries between immune thrombocytopenia (ITP) and other thrombocytopenic states such as thrombocytopenic myelodysplastic syndromes, may be difficult to establish, and the detection of somatic mutations by next generation sequencing (NGS) may be of aid. Here we aimed at characterizing the prevalence and clinical significance of clonal hematopoiesis in ITP. In this multicentric retrospective observational study we enrolled 167 adult ITP patients, followed at 13 centers in Italy, UK, and USA. Patients underwent NGS evaluation after a median of 3.6 years from ITP onset and 83% had received at least one therapy line, median 2 (0-9) lines; 51 out of 167 patients had at least one mutation (30%). After exclusion of germline variants and polymorphisms, 18.5% (31/167) were defined as having clonal hemopoiesis. Most commonly mutated genes were TET2, DNMT3A, SRSF2, and ASXL1 (median VAF 29%); 19 of 31 subjects (68%) had high-risk variants, and 8 multiple mutations. Mutated patients were more frequently elderly males and showed a shorter time from first to second line therapy, particularly with TPO-RA. Additionally, clonal hematopoiesis was associated with increased thrombotic risk (26% vs 8% in NGS-negative cases, p=0.01), independently from TPO-RA exposure, though with an age effect. These data demonstrated the prevalence of clonal hematopoiesis in 18% of adult ITP patients, being associated with older age, relapsed/refractory disease, and high risk of thrombotic complications.

HPB SO01 - Preoperative respiratory disease and outcomes of pancreatoduodenectomy performed for malignancy

Abstract Background Despite improvements to morbidity and mortality rates in recent decades, pancreatoduodenectomy (PD) remains a high-risk operation. Patients with pre-existing respiratory disease are likely to be at increased risk of developing postoperative complications but few prior studies have investigated this. This may be as few patients with significant respiratory pathology are considered appropriate surgical candidates. This study aimed to compare PD outcomes in patients with a prior respiratory condition to those without. The outcomes of interest were median length of stay (LOS), 30-day readmission, 90-day mortality, unplanned return to theatre rate and five-year survival. Method Data was extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for pancreatic head malignancy (29 centres in 8 countries, n=1484). Pre-existing respiratory disease included a prior diagnosis of asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, pulmonary embolism, asbestosis, obstructive sleep apnoea, pleural effusion, tuberculosis, pulmonary sarcoidosis, pneumoconiosis or hypersensitivity pneumonitis. The Mann-Whitney U test and Fisher exact test were used to compare the two groups. Results Out of a total of 1484 cases, 142 patients (9.6%) had a pre-existing respiratory comorbidity. Asthma and COPD both affected 4.2% of patients. All other included pathologies affected less than one percent of patients. 30-day readmission (8.5% vs 9.1%, p=0.1), 90-day mortality (1.4% vs 3.7%, p=0.2), and unplanned return to theatre rate (3.5% vs 5.1%, p=0.5) were similar between the two groups, however, median LOS was significantly longer in those with a prior respiratory disease (14 vs 13 days, p&amp;lt;0.0001). Five-year survival was also higher in those without respiratory disease, but this was not quite significant (24.6% vs 32.5%, p=0.06). Conclusion In our multicentre study of patients with confirmed malignancy, PD patients with a preoperative respiratory disease had significantly longer length of stay. Five-year survival rates were slightly lower but this was not quite significant.

HPB SO03 - Preoperative biliary drainage prior to pancreaticoduodenectomy for pancreatic head malignancy: Guidelines versus the reality

Abstract Background British guidelines currently advise against routine preoperative biliary stenting (PBS) unless patients have cholangitis or organ failure secondary to biliary obstruction. If stenting is required, self-expanding metal stents are advocated. Using a large multicentre cohort, this study aimed to investigate the proportion of patients who underwent PBS prior to pancreatoduodenectomy (PD) and describe the approach used. Method Data were extracted from the Recurrence After Whipple’s (RAW) study, a multicentre retrospective cohort study of outcomes of PD performed for histologically confirmed pancreatic head malignancy (29 centres from 8 countries, n=1484). Patients who underwent PBS were identified and the details surrounding this were obtained. Results 1482 patients had data on use of PBS. 427 didn't undergo PBS, 1055 underwent attempted PBS. Of the latter, 989 had a stent placed successfully, 38 had PBS failed , and 28 had an external biliary drain . when PBS performed, Among 857 were primary endoscopically placed , 75 had percutaneously placed PBS having failed endoscopy , and 50 had a primary percutaneously placed PBS . 755 patients known stent material ( 66% were plastic, 34% metal). In 671 who had data regarding cytology from PBS known, 48% had cytology suggestive/diagnostic of malignancy, 25% had inadequate histology, and 28% did not send a cytology sample. Conclusion Despite guidelines advising against routine PBS, over two thirds of PD patients in our study underwent stenting. Despite guidelines advocating metal stents when PBS is necessary, two thirds of the stents deployed were plastic. Stent cytology has a low sensitivity for pancreatic head malignancy.

Real-World Comparative Effectiveness and Safety of Filgotinib and Upadacitinib for Ulcerative Colitis: A Multicentre Cohort Study.

Janus kinase (JAK) inhibitors, filgotinib (FIL) and upadacitinib (UPA) have emerged as promising treatments for ulcerative colitis (UC). However, a comparative analysis of these JAK inhibitors, particularly in patients previously treated with tofacitinib (TOF), has not been performed. To compare the efficacy and safety of FIL and UPA in patients with UC, including those previously exposed to TOF. A multicentre retrospective cohort study was conducted to compare the effectiveness and safety of FIL and UPA in patients with UC whose treatment was initiated between March 2022 and December 2023. The co-primary outcomes were clinical response and remission at week 8. The secondary outcomes included treatment persistence and adverse events (AEs). Modified Poisson and Cox regression models with multivariable analysis to adjust for confounders and propensity score matching were conducted. Subgroup analyses stratified by previous exposure to TOF and biologics were also conducted. In total, 168 patients (98 treated with FIL and 70 treated with UPA) were enrolled in this study, with a median follow-up period of 181days. The clinical response/remission rates at week 8 were 55.1/46.9% for FIL and 71.4/65.7% for UPA, respectively. UPA was associated with significantly higher rates of clinical response (adjusted risk ratio [RR] 1.40 [95% confidence interval [CI], 1.09 to 1.80]) and clinical remission (adjusted RR 1.54 [95% CI, 1.16 to 2.05]) compared with FIL. This result was consistent across subgroup analyses based on previous exposure to TOF or biologics, except for bio-naive patients. There was no significant difference in the treatment persistence. AEs were more frequent with UPA (45.7%) than with FIL (24.5%) (p=0.0049). Propensity score matching confirmed the superior overall effectiveness of UPA. UPA demonstrated better short-term effectiveness than FIL, with a higher incidence of AEs.

False-Positive Diagnosis of Congenital Heart Defects at First-Trimester Ultrasound: An Italian Multicentric Study

Objective. Our objective was to assess the proportion of false-positive CHD cases at the first-trimester evaluation of the fetal heart, performed by experienced operators. Methods. This multicenter retrospective study included of pregnant women with suspicion of CHDs during first-trimester screening for aneuploidies. In all cases, the fetal heart assessments were performed by obstetricians with extensive experience in first-trimester scanning, following an extended protocol proposed by SIEOG national guidelines, which included an axial view of the fetal abdomen and chest to assess visceral situs and evaluation of the four-chamber view (4CV) and three-vessel trachea view (3VTV) with color Doppler. In all suspected cases, fetal echocardiography was offered within 16 and/or at 19–22 weeks’ gestation. Results. From a population of 4.300 fetuses, 46 CHDs were suspected. Twenty-four cases were excluded from this analysis because the parents opted for early termination of the pregnancies due to associated structural and/or genetic anomalies. For the remaining 22, echocardiography was performed by 16 weeks in 14 cases (64%) and after 16 weeks in 8 cases. In 19 cases (86.4%), a fetal cardiologist confirmed the presence of a CHD. In three cases (13%), the cardiac anatomy was found to be normal at the fetal echocardiography and postnatally. Conclusions. This study shows that the proportion of false-positive cases at the first-trimester ultrasound examination of the fetal heart, performed by experienced operators, may carry a higher risk of false-positive diagnosis than expected. Therefore, this issue must be discussed in instances where a CHD is suspected at the first-trimester screening.

MS O06 - HPB The ORDEAL Study: A National Survey of Surgeon Operative Preferences for Resection of Duodenal Adenocarcinoma

Abstract Background Duodenal adenocarcinoma (DA) accounts for over 50% of all small bowel adenocarcinomas, however there is a paucity of data on outcomes, no UK guidelines for surgical management, and current national standards of practice are unknown. There is ongoing debate whether long-term survival, perioperative outcomes, resection margin, and lymph node yield differ between pylorus-preserving pancreaticoduodenectomy (PPPD) and classical PD (cPD) in proximal DA (D1/D2), and between PD and limited resection (LR) in distal DA (D3/D4). The study aimed to discern current standards of practice and identify underlying reasons for operative preferences for proximal and distal DA. Method An anonymised survey was included as part of the registration form for a wider multicentre retrospective study looking at outcomes following resection for proximal and distal DA on Google Forms®. The survey was distributed via direct surgeon email correspondence, weekly newsletters and surgical society endorsement by PSGBI. Responses were collected between February-June 2024 and responses were analysed with quantitative and qualitative (inductive thematic analysis) methods. Results Responses were received from 61 surgeons across 27 centres. For proximal DA, surgeons are more likely to consider a classical Whipple’s (93.4%) compared to PPPD (29.5%). For distal DA, surgeons are equally likely to consider LR (73.8%) as PD (classical Whipple’s -37.7%, PPPD - 41%). These preferences have mostly remained consistent over time. Key themes identified from thematic analysis included oncological considerations, morbidity, surgeon preference, tumour characteristics, standards of practice, patient factors and anatomical considerations, with the former two themes being the most prominent. Conclusion For proximal DA, cPD is preferred over PPPD and for distal DA, LR and PD are equally considered, with oncological and morbidity considerations largely influencing decision making. This qualitative data will be compared to actual practice following completion of the wider ORDEAL study to identify discrepancies in practice and possible effect on patient outcomes.

Abstract 4138483: Outcomes of Hypoplastic Left Heart Syndrome by Subtype and Presence of Ventriculocoronary Connections: A Fetal Heart Society Multi-Center Retrospective study

Background: Hypoplastic left heart syndrome (HLHS) is classified by subtype: mitral atresia and aortic atresia (MA-AA), mitral stenosis and aortic atresia (MS-AA), and mitral stenosis and aortic stenosis (MS-AS). It is controversial whether specific HLHS subtypes and presence of ventriculocoronary connections (VCC) are associated with transplant-free survival. We aimed to determine whether there is an increased risk of mortality associated with specific HLHS subtypes, whether this risk is stratified by the presence of VCC, and if a specific type of stage I palliation in patients with VCC improves survival. We also aimed to determine practice variation in the evaluation of HLHS patients with VCC. Methods: We performed a multicenter retrospective cohort study of fetuses and infants &lt; 2 months of age with HLHS admitted between 1/2012-12/2016 to participating Fetal Heart Society institutions. Patients with HLHS variants were excluded. We collected patient specific data and surveyed participating centers for practice variation. Kaplan-Meier curves with log-rank test were used to assess transplant-free survival and cox proportional hazard analysis was performed with adjustment for center as a random intercept. Results: 341 patients from nine centers were included. MA-AA was the most common subtype (177, 52%), followed by MS-AA (102, 30%), and MS-AS (62, 18%). VCC were diagnosed or suspected in 65 patients (19%). A total of 287 patients were live born with intention to treat. HLHS subtype was not associated with transplant-free survival (Figure 1A). Presence of VCC was associated with a lower transplant-free survival (p=0.026, Figure 1B). In the subset of patients diagnosed with VCC, there was not a significant difference in survival based on type of stage I palliation (Figure 1C). Cox proportional hazard modeling adjusted for center demonstrates that presence of VCC has a hazard ratio of 1.74 (CI 1.02-2.98), p =0.04. Survey data regarding practice variation for patients with VCC (Figure 2) demonstrates 33% of centers modify the type of stage I palliation based on presence of VCC. Conclusions: In a multicenter cohort of HLHS patients, patients with VCC had lower transplant-free survival compared to those without VCC, while subtype and type of stage I palliation did not have a statistical difference. There is considerable practice variation in the management of HLHS patients with VCC that may warrant further investigation.

The Impact of Timing of Temozolomide Chemoradiotherapy for Newly Diagnosed Glioblastoma on Patient Overall Survival: A Multi-centre Retrospective Study

Abstract Background The optimal timing of initiating adjuvant temozolomide (TMZ) chemoradiotherapy after surgery in patients with glioblastoma is contentious. This study aimed to determine whether the timing of adjuvant treatment affects their overall survival (OS). Methods Consecutive adult patients with histologically-confirmed newly-diagnosed glioblastoma treated with adjuvant TMZ chemoradiotherapy across all neurosurgical centers in Hong Kong between 2006 and 2020 were analyzed. The surgery-to-chemoradiotherapy (S-CRT) interval was defined as the date of the first surgery to the date of initiation of adjuvant TMZ chemoradiotherapy. Results Four-hundred and seventy-two patients were reviewed. The median S-CRT interval was 41 days (IQR: 33-48) and the mOS was 16.7 months (95% CI: 15.9-18.2). The median age was 58 years (IQR: 50-63). Multivariable Cox regression with restricted cubic splines identified a non-linear relationship between the S-CRT interval and mOS. Post-hoc analysis-derived S-CRT intervals revealed that early CRT (&amp;lt; 5 weeks; adjusted hazard radio (aHR): 1.11; 95% CI 0.90-1.37) or late CRT (&amp;gt; 9 to 12 weeks; aHR 1.07; 95% CI 0.67-1.71) were not significantly associated with OS. Subgroup analyses for extent of resection (EOR) and pMGMT methylation status revealed no significant difference in treatment timing on OS. Conclusion The timing of adjuvant TMZ chemoradiotherapy if commenced within 12 weeks after glioblastoma diagnosis did not influence OS, regardless of EOR or pMGMT methylation status. Clinical judgement should be exercised in optimizing the timing of initiating adjuvant therapy.

Abstract 4136085: The Prognostic Impact of Thrombocytopenia at 6 months after Transcatheter Aortic Valve Replacement: A Retrospective Multicenter Study

Background: Transient thrombocytopenia after transcatheter aortic valve replacement (TAVR) is a common phenomenon. Thrombocytopenia after TAVR during the perioperative period has been reported to impact prognosis. However, the impact of thrombocytopenia in the mid-term post-TAVR period is currently unknown. Methods: A retrospective observational study was conducted on 1405 patients who underwent TAVR from May 2016 to February 2023 at four institutions. Of these, 850 patients were analyzed. Patients who underwent dialysis (67), converted to an open chest surgery (8), had a Valve-in-Valve procedure (30), underwent a direct aortic approach (16), had a malignant tumor (66), and patients whose platelet levels could not be measured at 6 months after TAVR due to death or dropout were excluded from the analysis. The clinical follow-up occurred at 1, 6, and 12 months after the procedure. Laboratory testing was conducted before TAVR, during the perioperative period, 1 month post-procedure, and 6 months later. The decrease in platelet count (DPC) 6 months after TAVR was calculated by the following formula: [(Baseline platelet – 6 months platelet)/baseline platelet *100]. A receiver operating characteristics curve was plotted for all-cause mortality at 1 year and DPC at 6 months. The calculated cutoff value for the DPC at 6 months (28.68%) was utilized to classify and compare the two groups. Multivariate logistic regression models were also used to examine the association between the DPC at 6 months and all-cause mortality at 1 year. Adjusted for propensity score matching, the DPC was compared at 6 months in self-expandable and balloon-expandable prosthetic valves. Result: Of the 850 eligible patients (age: 85.5 ± 4.9 years), 31 (3.4%) died between 6 months and 1 year after TAVR. The DPC at 6 months after TAVR was 11.9 ± 22.5%. Multivariate logistic regression analysis including the DPC at 6 months, age, gender, and STS score showed that the DPC at 6 months was independently associated with all-cause mortality at 1 year (odds ratio: 1.03, 95% confidence interval: 1.005-1.046, p=0.01). After adjustment for propensity score matching, the balloon-expandable prosthetic valve had a higher rate of thrombocytopenia at 6 months (15.0% vs. 9.6%, p=0.04). Conclusion: The DPC at 6 months after TAVR may predict all-cause mortality at 1 year.

Abstract 4138024: Identifying the Medications with the Greatest Reduction in Mortality in Coronary Artery Dissection

Introduction: Coronary artery dissection (CD) is a potentially fatal complication, usually arising either spontaneously or iatrogenically. Therefore, identifying treatment methods that reduce mortality is of great importance. The American College of Cardiology recommendations stipulate that patients who have experienced CD may benefit from beta-blocker therapy, as beta-blockers have been shown to reduce the incidence of recurrent CD. Currently, there is little published data in support of beta-blockers providing mortality reduction for CD. Given the significant risk of mortality from CD, we aimed to test the veracity of these recommendations using a retrospective multicenter study as well as having a main objective of exploring means to lower mortality in CD. Methods: We conducted a retrospective, multicenter cohort that identified 2,104 patients diagnosed with CD. We extracted the data from across 16 West Florida hospitals in between the years of 2017-2022. Our patients were identified and stratified based on common lab values and cardioprotective medications they were taking. Chi-square and binary logistic regression was used to calculate odds ratios for mortality. The odds ratio estimate for mortality was our primary outcome with attention given to factors that were associated with an increased or decreased likelihood of mortality in patients with CD. Results: Patients on beta-blockers, angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) were the only variables that were statistically significant. Out of 2,104 patients, 1,562 patients were on beta-blockers (74.2%), and 921 were on an ACEi/ARB (43.8%). Our data revealed that the odds ratio for mortality in patients with CD while on beta blockers was 0.375 (p-value 0.0009, confidence interval 0.210-0.669), and while on ACEi/ARBs was 0.447 (p-value 0.0077, confidence interval 0.247-0.808). These results indicate a significant reduction in mortality in patients who are taking beta-blockers and/or ACEi/ARB medications after being diagnosed with CD. Conclusion: Our data can be viewed as supportive of the current recommendation for the primary use of beta-blockers in patients with spontaneous CD, as well as suggesting angiotensin receptor blockers and angiotensin-converting enzyme inhibitors as possible additional therapies

Abstract 4119189: Imaging practices prior to cardioversion in patients presenting post percutaneous left atrial appendage occlusion.

Background: Direct current cardioversion (DCCV) carries a risk for stroke in AF patients, for that reason there are guidelines for mitigating this risk in AF patients on oral anticoagulation (OAC). Meanwhile, no consensus on the best approach for cardioverting patients with an appendage occlusion device in situ. This led to a very wide variation in pre and post DCCV practices in these patients. Aims: We aim to explore different factors that might be associated with the variation seen in pre-DCCV imaging practices in patients presenting post- percutaneous LAAO. Methods: This was a multi-center retrospective cohort study of patients who received DCCV for AF or AFL during follow up after LAAO procedure within a single healthcare system from 2016-2024. Results: A total of 119 patients were included, there were more females 70 (59%), with more than half (64 (54%)) receiving a first-generation WATCHMAN™ 2.5, while the rest had WATCHMAN FLX™. Median age at presentation was 77 years (72,82), BMI of 31 kg/m 2 (26,37), average CHADSVASC score of 4.5 and HASBLED score of 3. A median duration of 10 months (3,21) between LAAO to presentation for DCCV . Forty-four (37%) patients had pre-DCCV imaging (imaging cohort). Number of males was significantly higher in the imaging cohort (24 (54.5%) vs 25 (33.3%), p=0.038), compared to those without imaging. There was a significant difference (p&lt;0.001) between the two cohorts in the location (center) where DCCV was done. The site with the highest number of pre-DCCV imaging cases had an equal gender ratio of patients presenting for DCCV. Patients who received imaging presented earlier (11.2 months vs 15.8 months, p=0.068) compared to those without imaging, though the difference was not significant. Between the two groups, there was no significant difference in OAC (VKA-antagonist/DOAC) usage prior to presentation (8 (18.6%) vs 12 (16.4%), P=0.9). There was no significant difference in baseline CHADSVASC score, HASBLED score, age, LVEF. Higher percentage of patients were discharged on OAC post DCCV in the imaging arm (13 (30.2%) vs 14 (19.4%), p=0.27), but the difference was non-significant. No Device related thrombus nor significant PDL was detected on imaging. Conclusion: There was male preference in providing pre-DCCV imaging for ruling out DRT. Location of care was also associated with the variation in pre-DCCV protocols. Additional research is needed to understand other factors associated with variation seen in pre-DCCV practices.

Abstract 4137534: Troponin Can Predict Late Gadolinium Enhancement on Cardiac MRI in COVID-19 Vaccine-Associated Myocarditis

Background/Aim: We previously reported that late gadolinium enhancement (LGE) on cardiac MRI (CMR) was as high as 82% in pediatric patients with COVID-19 vaccine-associated myocarditis (C-VAM) despite mild clinical symptoms and normal left ventricular function. As LGE can be a harbinger for future adverse events including arrhythmias, heart failure or sudden cardiac death, we sought to identify predictors for LGE in C-VAM, specifically assessing troponin as a screening marker for C-VAM patients at risk for myocardial scarring who could then be referred for a confirmatory CMR with LGE. Methods: In this longitudinal multicenter retrospective observational study across 38 U.S. member institutions of the M yocarditis A fter C OVID V accination (MACiV) study network, 333 patients with C-VAM based on CDC criteria were included from April 2021 to November 2022. Data collected included demographics, laboratory values, clinical and cardiac imaging characteristics and outcomes. Using logistic regression, troponin levels at presentation were assessed as a log transformed continuous variable and categorized into tertiles. Results: The C-VAM patients were predominantly white (67%) adolescent males (91%, 15.7± 2.8 years). There were 216/333 (65%) patients who had both a reported troponin value and had a CMR. On univariate analysis, elevated troponin increased the probability of having LGE (OR=1.29, 95% CI: 1.06, 1.58, p=0.012). Even after controlling for age, race, sex, number of vaccine doses and left ventricular ejection fraction (OR=1.32, 95% CI: 1.06, 1.65, p=0.013). Patients &gt;15 years compared to those ≤15 years of age were 2.94 (95% CI: 1.28, 6.75, p=0.011) times more likely to have LGE at presentation. Patients with troponin levels in the highest tertile compared to lowest tertile were 2.66 times (95% CI: 1.04, 6.83, p=0.042) more likely to have LGE along with a greater involvement &gt; 4 AHA myocardial segments with LGE (p=0.004) Conclusions: Higher troponin values are associated with presence of late gadolinium enhancement on cardiac MRI in patients with COVID-19 vaccine-associated myocarditis. Troponin levels at presentation may facilitate risk stratification and function as a screening tool to identify those C-VAM patients with the greatest likelihood of myocardial scarring, who may benefit from undergoing CMR for tissue characterization.

ArtiSentialⓇ versus conventional laparoscopic colorectal cancer surgery: a multicenter retrospective matched cohort study

Background: This study aims to compare outcomes of colorectal cancer surgeries performed using the newly developed articulating laparoscopic instrument, ArtiSential®, with those using conventional non-articulating or rigid laparoscopic instruments. Methods: This multicenter, retrospective, matched cohort study enrolled patients with colorectal cancer undergoing laparoscopic surgery in seven tertiary referral hospitals from January 2021 to October 2022. A 1:1 propensity score matching was performed between the articulating (Arti-LAP) and conventional (Rigid-LAP) laparoscopic groups. The primary outcome was the overall incidence of short-term complications. Results: The study initially comprised 694 and 2008 patients in the Arti-LAP and Rigid-LAP groups, respectively. After matching, each group consisted of 694 patients, with no significant differences in baseline clinical characteristics. Mean operation time was 161 ± 32 min in Arti-LAP and 152 ± 25 min in Rigid-LAP groups (P=0.105). Open conversion rates were 0% (0/694) in Arti-LAP and 1.0% (7/694) in Rigid-LAP groups (P=0.024). Overall morbidity rates were 9.5% (66/694) in Arti-LAP and 12.8% (89/694) in Rigid-LAP (P=0.061), with similar rates of severe morbidities. Specimen quality was acceptable in both groups. Multivariable regression analysis showed that the choice of instrument type (articulating or rigid) was not associated with perioperative morbidity. Despite a short median follow-up period of 19.5 months, no significant difference in disease-free survival was observed between the groups. Conclusion: Laparoscopic surgery using ArtiSential® was performed safely and effectively for patients with colorectal cancer. Articulating laparoscopic instruments may offer an advantage in reducing open conversion rates.

MRI variables and peripheral inflammatory response biomarkers predict severity and prognosis in patients with acute cervical traumatic spinal cord injury.

Traumatic spinal cord injury (TSCI) stands as one of the most profoundly damaging and debilitating conditions. This study aims to explore the potential of magnetic resonance imaging (MRI) variables and peripheral inflammatory indicators as promising biomarkers. It aims to understand their significance in evaluating the severity and predicting the prognosis of TSCI. Furthermore, the study aims to ascertain whether combining these indicators could enhance the accuracy of injury assessment and predictive prognostic ability. A multicentre retrospective cohort study was conducted to assess the severity and prognostic value of MRI variables and peripheral inflammatory response biomarkers in patients with acute cervical TSCI. The study involved 374 patients with acute cervical TSCI drawn from the First Affiliated Hospital of Nanchang University and the Second Affiliated Hospital of Nanchang University. The severity and prognosis of patients with acute cervical TSCI were assessed using the American Spinal Injury Association Impairment Scale (AIS). The correlation between MRI variables, peripheral inflammatory response biomarkers, admission severity, and the 1-year follow-up prognosis was analysed. After the initial assessment using the AIS grade system, 169 (49.2%) patients fell into the severe category for cervical TSCI (AIS A-B), while 205 (50.8%) patients were classified as non-severe cases (AIS C-E). The MRI variables (intramedullary lesion length [IMLL], Brain and Spinal Injury Centre [BASIC], maximum spinal cord compression [MSCC], and maximum canal compromise [MCC]) and inflammatory response biomarkers (white blood cells [WBCs], neutrophils, and C-reactive protein [CRP]) exhibited a consistent decrease correlating with the severity grades noted upon admission. Among the 374 patients assessed, 147 (39.3%) experienced a poor prognosis, as indicated by the AIS grade during the 1-year follow-up. MRI variables and peripheral inflammatory response biomarkers declined in correspondence with the follow-up AIS grades. Sex (p < 0.001), IMLL (p < 0.001), MSCC (p < 0.001), MCC (p < 0.001), BASIC (p < 0.001), WBC (p < 0.001), neutrophils (p < 0.001), and CRP (p < 0.001) were statistically significant in predicting poor outcomes. Through multivariate logistic regression analysis, BASIC score and CRP emerged as independent predictors of poor prognosis. Notably, the model combining the BASIC score and CRP yielded a larger area under the curve compared to models using only the BASIC score or CRP individually. The BASIC score and CRP are crucial biomarkers for evaluating the severity of cervical TSCI and predicting prognosis. Their combination proved to be a more robust determinant of injury severity and a better predictor of neurological recovery.

Multicentre retrospective analysis of physician-modified fenestrated/inner-branched endovascular repair for complex aortic aneurysms.

In this multicentre retrospective observational study, we present the early outcomes of physician-modified fenestrated/inner-branched endovascular repair for pararenal and thoraco-abdominal aortic aneurysms in patients at high risk for open surgical repair. We comprehensively reviewed the clinical data and outcomes of consecutive patients treated with physician-modified fenestrated/inner-branched endovascular repair for pararenal or thoraco-abdominal aortic aneurysms at six centres between December 2020 and December 2021. Primary end-points included technical success, in-hospital mortality rates, major adverse events. Seven and 31 patients (median age, 80.5 years) had pararenal and thoraco-abdominal aortic aneurysms, respectively, involving 93 renal-mesenteric arteries incorporated through 10 fenestrations or 83 inner branches. Seven patients (18.4%) were treated non-elective conditions. The technical success rate was 89.5%. The median operative time was 334.5 min. Ten patients (26.3%) experienced major adverse events, including in-hospital mortality in six patients (15.8%), acute kidney injury in three patients (7.9%), respiratory failure in three patients (7.9%), bowel ischaemia in one patient (2.6%), stroke in one patient (2.6%), and paraplegia in one patient (2.6%). Among elective cases, in-hospital deaths occurred in three patients (9.7%), while in non-elective cases, the mortality rate was higher, with three patients (42.9%) succumbing. The median follow-up duration was 14 months. physician-modified fenestrated/inner-branched endovascular repair is a viable treatment for pararenal or thoraco-abdominal aortic aneurysms in patients at high risk for open surgical repair. It provides customization without location constraints or production delays, but further validation is needed to ensure long-term reliability.