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Water quality, Endocrine disruptors, Marine pollution, and Sewage disposal plants

Endocrine disrupting compounds (EDCs) can be found in domestic sewage, wastewater treatment plant effluents, natural water, rivers, lakes and in the marine environment. Jurujuba Sound, located in the state of Rio de Janeiro, Southeastern Brazil, receives untreated sewage into its waters, one the main sources of aquatic contamination in this area. In this context, the aim of the present study was to evaluate the estrogenic potential of water sampled from different depths and from areas with differential contamination levels throughout Jurujuba Sound. Water quality was evaluated and acute toxicity assays using Allviibrio fischeri were conducted, while estrogenic activity of the water samples was determined by a Yeast Estrogen Screening assay (YES). Water quality was mostly within the limits established for marine waters by the Brazilian legislation, with only DOC and ammoniacal nitrogen levels above the maximum permissible limits. No acute toxicity effects were observed in the Allivibrio fisheri assay. The YES assay detected moderate estrogenic activity in bottom water samples from 3 sampling stations, ranging from 0.5 to 3.2 ng L −1 , as well as in one surface water sample. Estrogenic activity was most frequently observed in samples from the bottom of the water column, indicating adsorption of estrogenic compounds to the sediment. [ABSTRACT FROM AUTHOR]

Pollination, Agricultural productivity, Crop yields, Sustainable agriculture, Pollinators, Apple orchards, Factorial experiment designs, and Orchards

The alarming loss of pollinator diversity world‐wide can reduce the productivity of pollinator‐dependent crops, which could have economic impacts. However, it is unclear to what extent the loss of a key native pollinator species affects crop production and farmer's profits.By experimentally manipulating the presence of colonies of a native bumblebee species Bombus pauloensis in eight apple orchards in South Argentina, we evaluated the impact of losing natural populations of a key native pollinator group on (a) crop yield, (b) pollination quality, and (c) farmer's profit. To do so, we performed a factorial experiment of pollinator exclusion (yes/no) and hand pollination (yes/no).Our results showed that biotic pollination increased ripe fruit set by 13% when compared to non‐biotic pollination. Additionally, fruit set and the number of fruits per apple tree was reduced by less than a half in those orchards where bumblebees were absent, even when honeybees were present at high densities. Consequently, farmer's profit was 2.4‐fold lower in farms lacking bumblebees than in farms hosting both pollinator species. The pollination experiment further suggested that the benefits of bumblebees could be mediated by improved pollen quality rather than quantity.Synthesis and applications. This study highlights the pervasive consequences of losing key pollinator functional groups, such as bumblebees, for apple production and local economies. Adopting pollinator‐friendly practices such as minimizing the use of synthetic inputs or restoring/maintaining semi‐natural habitats at farm and landscape scales, will have the double advantage of promoting biodiversity conservation, and increasing crop productivity and profitability for local farmers. Yet because the implementation of these practices can take time to deliver results, the management of native pollinator species can be a provisional complementary strategy to increase economic profitability of apple growers in the short term. [ABSTRACT FROM AUTHOR]

Water treatment plants, Ozonization, Estrogen, Hydrological research, and Yeast

The estrogenicity of waters collected from an important hydrological system in Brazil (Paraiba do Sul and Guandu Rivers) was assessed using the yeast estrogen screen (YES) assay. Sampling was performed in rivers and at the outlets of conventional water treatment plants (WTP). The removal of estrogenic activity by ozonation and chlorination after conventional water treatment (clarification and sand filtration) was investigated employing samples of the Guandu River spiked with estrogens and bisphenol A (BPA). The results revealed a preoccupying incidence of estrogenic activity at levels higher than 1 ng L −1 along some points of the rivers. Another matter of concern was the number of samples from WTPs presenting estrogenicity surpassing 1 ng L −1 . The oxidation techniques (ozonation and chlorination) were effective for the removal of estrogenic activity and the combination of both techniques led to good results using less amounts of oxidants. [ABSTRACT FROM AUTHOR]

The contamination of water sources by pharmaceutically active compounds (PhACs) and their effect on aquatic communities and human health have become an environmental concern worldwide. Membrane bioreactors (MBRs) are an alternative to improve biological removal of recalcitrant organic compounds from municipal sewage. Their efficiency can be increased by using high retention membranes such as forward osmosis (FO) and membrane distillation (MD). Thus, this research aimed to evaluate the performance of an anaerobic osmotic MBR coupled with MD (OMBR-MD) in the treatment of municipal sewage containing PhACs and estrogenic activity. A submerged hybrid FO-MD module was integrated into the bioreactor. PhACs removal was higher than 96% due to biological degradation, biosorption and membrane retention. Biological removal of the PhACs was affected by the salinity build-up in the bioreactor, with reduction in biodegradation after 32 d. However, salinity increment had little or no effect on biosorption removal. The anaerobic OMBR-MD removed >99.9% of estrogenic activity, resulting in a distillate with 0.14 ng L−1 E2-eq, after 22 d, and 0.04 ng L−1 E2-eq, after 32 d. OMBR-MD treatment promoted reduction in environmental and human health risks from high to low, except for ketoprofen, which led to medium acute environmental and human health risks. Carcinogenic risks were reduced from unacceptable to negligible, regarding estrogenic activity. Thus, the hybrid anaerobic OMBR-MD demonstrated strong performance in reducing risks, even when human health is considered. [Display omitted] • Biological removal of estrogenic compounds was governed mainly by biodegradation. • Biological removal of micropollutants (MP) was affected by the salinity build-up. • MgCl 2 as draw solute reduced the negative impacts on biological removal of MP. • Ketoprofen in distillate led to medium acute environmental and human health risks. • Carcinogenic risk, regarding estrogenicity, reduced from unacceptable to negligible. [ABSTRACT FROM AUTHOR]

ATHLETES, FATIGUE (Physiology), PHYSICAL education, QUESTIONNAIRES, and SPORTS medicine

Abstract: Objective. – The group of consensus of the French Society of Sport Medicine prepared a questionnaire in order to detect early stage of overtraining. This questionnaire includes 54 items which the subjects have to answer by “yes” or by “not”. A score is then established by summing the “yes”. Taking into account the formulation of the questions, this score will increase with the training load. The aim of our study is to propose a score of overtraining, and also to highlight the importance of some items or groups of items. Methods. – Our population consisted of French sportsmen of both sexes, from different geographical origins, age, sporting practice and level. A multicentric analysis was carried out on the basis of 1984 collected questionnaires. We analysed the evolution of the percentage of subjects, the weight of various parameters (age, overtraining) and the evolution of the frequency of each item as a function of the score. Results. – A score of 20 was proposed as an overtraining state threshold, which has to be confirmed on the basis of correlations with biological indices, in particular with a state of clinically established overtraining. Sixteen items present a linear evolution traducing an increase of tiredness according to the overload. Six items have a logarithmic increase, traducing a kind of “background noise”. The others items (N =32) presenting a non-linear increase are sign of a decompensation phenomenon. Conclusion. – This analysis by item make possible an improve of the questionnaire, by selecting items groups which may give an orientation on the type of tiredness. It also confirms the usefulness of this questionnaire as a tool for the follow-up of the training state of sportsmen, a score equal to or higher than 20 constituting the overtraining threshold. [Copyright &y& Elsevier]

Wastewater treatment, Sewage purification, Sewage disposal plants, Yeast-free diet, Leavening agents, and Fire assay

Effluents from wastewater treatment plants (WWTPs) are responsible for the input of estrogenic contaminants into aquatic ecosystems, leading to widespread effects in wildlife. In the present work, levels of estrone (E1), 17α- and 17β-estradiol (E2), 17α-ethinylestradiol (EE2), bisphenol A (BPA), and nonylphenol (NP) were quantified in effluents from WWTPs located in Ria de Aveiro (NW Portugal), as well as in the final effluent discharged into the Atlantic Ocean through the S. Jacinto submarine outfall. Reference sites, located at the entrance of the estuarine system and at the seaside, were also included. Samples were collected under summer (June 2005) and winter (February 2006) conditions. For the summer survey samples, estrogenicity and androgenicity were evaluated using the yeast estrogen screen (YES) and the yeast androgen screen (YAS) assay. Estrone levels varied from 0.5 to 85 ng/L in the summer survey and between L in winter; estradiol levels ranged from L in summer and were always L up to 2,350 ng/L in summer and from 10 to 2,410 ng/L in winter; BPA levels varied from 2.8 to 897 ng/L in summer and from 2.6 up to 316 ng/L in winter. Biological assays disclosed estrogenic levels at reference sites lower than the ones reported to pose risk for wildlife. However, the S. Jacinto outfall effluent released high concentrations of NP and BPA into the marine environment. [ABSTRACT FROM AUTHOR]

BIPOLAR disorder, MENTAL depression, DEPRESSED persons, ANTIPSYCHOTIC agents, and MENTAL health

Abstract: Introduction: Although depressive moods are recognised as a very broad condition, there is still only one definition in international classifications for describing a major depressive episode (MDE). However, there is currently some controversy surround the treatment of depressive states. This includes SSRIs and suicide in adolescents, and more specifically in bipolar disorders where some depressions are made worse by antidepressants. New data has suggested that depressive states in BP patients can be improved by atypical antipsychotics. Aim: We aimed to assess 1) whether it is possible to distinguish different forms of bipolar depression using a dimensional approach, and 2) if, yes, whether there are different patterns of treatment response. Method: We characterised 60 bipolar patients with a Major Depressive Episode (DSM-IV) using a new tool (MATHYS: Multidimensional Assessment of Thymic States) assessing five fundamental dimensions (emotional reactivity, cognitive speed, psycho-motricity, motivation and senses perception) of mood states (full description elsewhere). Results: A cluster analysis using the items of the dimensional scale revealed two types of depressive states. One group (G1; N =38), which had a low score, is characterised by an inhibition in all dimensions, whereas the other group (G2; N =22) is characterised by an over-activation. Emotional reactivity is a useful dimension for discriminating these two types of depression (G1: hyporeactivity; G2: hyperreactivity) whereas sadness is not. A lower score on the MAThyS scale at day 1 was associated with a good response to antidepressant treatment, whereas higher scores were linked to a good response to a mood stabilizers alone or in combination with an antipsychotic. Conclusion: Bipolar depressive states are not homogeneous and this heterogeneity can explain various patterns of treatment response. A dimensional approach could be useful for discriminating the different forms of bipolar depression and to help manage treatment. [Copyright &y& Elsevier]

ETHICS, PSYCHIATRISTS, MENTAL health personnel, PSYCHIATRY, and PSYCHOTHERAPISTS

Abstract: In legal proceedings the expert witness testimony may be considered a medical act only if the expert conducts his clinical observations within the limits established by the medical code of ethics. This will then allow the psychiatrist to help the judge reach a more informed legal decision. The difficulty inherent in this process is for the expert to give an exact answer (“yes” or “no”) to the questions formulated in order for the judge to arrive at an accurate decision. To better understand the evidence presented, the judge may ask empirical questions that require the expert witness to give testimony going beyond the information directly gathered through clinical observations. It is the expert witness'' responsibility to determine what amount of interpretation of material drawn from a clinical observation is appropriate to help the judge make a legal decision. This requires defining legal standards such as credibility, truth, and suggestibility. One must also recognize that the clinical observation of a victim is often the person''s first contact with a psychiatrist. [Copyright &y& Elsevier]

Health risk assessment, Endocrine disruptors, Water purification, Water supply, and Drinking water quality

Endocrine disrupting chemicals (EDCs) are ubiquitous in the environment and have been detected in drinking water from various countries. Although various water treatment processes can remove EDCs, chemicals can also migrate from pipes that transport water and contaminate drinking water. This study investigated the estrogenic activity in drinking water from various distribution points in Pretoria (City of Tshwane) (n = 40) and Cape Town (n = 40), South Africa, using the recombinant yeast estrogen screen (YES) and the T47D-KBluc reporter gene assay. The samples were collected seasonally over four sampling periods. The samples were also analysed for bisphenol A (BPA), nonylphenol (NP), di(2-ethylhexyl) adipate (DEHA), dibutyl phthalate (DBP), di(2-ethylhexyl) phthalate (DEHP), diisononylphthalate (DINP), 17β-estradiol (E 2 ), estrone (E 1 ) and ethynylestradiol (EE 2 ) using ultra-performance liquid chromatography-tandem mass spectrophotometry (UPLC-MS/MS). This was followed by a scenario based health risk assessment to assess the carcinogenic and toxic human health risks associated with the consumption of distribution point water. None of the water extracts from the distribution points were above the detection limit in the YES bioassay, but the EEq values ranged from 0.002 to 0.114 ng/L using the T47D-KBluc bioassay. BPA, DEHA, DBP, DEHP, DINP E 1 , E 2, and EE 2 were detected in distribution point water samples. NP was below the detection limit for all the samples. The estrogenic activity and levels of target chemicals were comparable to the levels found in other countries. Overall the health risk assessment revealed acceptable health and carcinogenic risks associated with the consumption of distribution point water. [ABSTRACT FROM AUTHOR]

For the development of the subject we first need the concept of constitutional state -aluding to its substantive distancing with the old rule of law-, and seeking its direct entanglement with a broad democratic order, yes, in Colombia, impaired with the continuity of the everlasting reformist custom of the Political Charter, basically along the way of art. 375 constitutional (and mainly on initiative or with the endorsement of the executive in office), which, for that task, the referred rule empowers the Congress of the Republic through the figure of legislative acts. Next (point 2), we alluded to tht' theme of the different constitutional reforms that have cracked the text of the Charter, and on them we need and develop (point 3), in our opinion, one of the most reactionary reforms, if not the most, altering the precarious state legitimacy achieved with the issuance of the Constitution itself. We refer here to the detriment that, by different legal paths, the democratic figure of the administrative career has suffered. In this last aspect we specify the obstinacy of the Uribe Velez period for depreciating and despising the importance of the institution of merit in the public service; inheritance received by the Santos government, trying to give continuity. [ABSTRACT FROM AUTHOR]

Litter (Trash), Waste management, Environmental responsibility, Environmentalism, Environmental sociology, Behavior, Social norms, Surveys, and Psychology

Two studies tested littering norm activation by trash can design. The first was a scenario study using a 4 (norm type: social injunctive vs. social descriptive vs. personal vs. control) × 2 (activation type: explicit vs. implicit activation) between-group design, with judgments of a litterer as the dependent variable. Explicit norm activation was more effective than implicit activation. A field study subsequently tested the effect of personal norm activation on actual littering behavior, following a 2 (explicit activation: no vs. yes) × 2 (Implicit activation: no vs. yes) between-group design. Here, both explicit activation through a verbal prompt and implicit activation through design had significant effects, reducing the amount of litter by 50%. A post hoc survey revealed significant effects of age and gender on the personal norm against littering. These findings helped explain the absence of norm activation effects in the youngest age group as found in the field study. [ABSTRACT FROM AUTHOR]

Environmental monitoring, Water pollution measurement, Water quality monitoring, Biological assay, Xenoestrogens, Analytical chemistry techniques, In vitro toxicity testing, and Evaluation

Bioassays are well established in the pharmaceutical industry and single compound analysis, but there is still uncertainty about their usefulness in environmental monitoring. We compared the responses of five bioassays designed to measure estrogenic activity (the yeast estrogen screen, ER-CALUX, MELN, T47D-KBluc, and E-SCREEN assays) and chemical analysis on extracts from four different water sources (groundwater, raw sewage, treated sewage, and river water). All five bioassays displayed similar trends and there was good agreement with analytical chemistry results. The data from the ER-CALUX and E-SCREEN bioassays were robust and predictable, and well-correlated with predictions from chemical analysis. The T47D-KBluc appeared likewise promising, but with a more limited sample size it was less compelling. The YES assay was less sensitive than the other assays by an order of magnitude, which resulted in a larger number of nondetects. The MELN assay was less predictable, although the possibility that this was due to laboratory-specific difficulties cannot be discounted. With standardized bioassay data analysis and consistency of operating protocols, bioanalytical tools are a promising advance in the development of a tiered approach to environmental water quality monitoring. [ABSTRACT FROM AUTHOR]

Sewage disposal plants, Sewage purification, Refuse disposal facilities, Environmental impact charges, Water quality management, Water utilities, Hospitals, Steroids, and Hormones

Influent and effluent samples originating from two wastewater treatment plants (WWTPs) (treating hospital wastewater and domestic wastewater, Belgium) have been analyzed in order to estimate their steroid hormone content. The natural estrogens estrone (E1), 17β-estradiol (E2), and the synthetic 17α-ethinylestradiol (EE2) together with other steroid hormones progesterone (P) and testosterone (T) metabolites were detected in these samples. The hormone concentrations in both the hospital and the domestic WWTP samples were not significantly different and ranged from <0.2 ng EE2/L to 114 ng EE2/L, from <0.2 ng E1/L to 58 ng E1/L and from <0.2 ng P/L to >100 ng P/L. E2 was detected once at a concentration of 17 ng/L. In the domestic WWTP which comprises a conventional activated sludge treatment in parallel with a membrane bioreactor, no differences in estrogen removal efficiency could be observed for both treatments. In comparison to chemical analysis data, the Yeast Estrogen Screen (YES) appears to underestimate the influent estrogen concentrations, probably due to influent toxicity for the YES. Effluent estrogen concentrations, on the other hand, were overestimated by the YES test, probably due to the presence of other estrogenic compounds in the effluent. [ABSTRACT FROM AUTHOR]

Organic water pollutants, Particulate matter, Endocrine disruptors, Sewage disposal plants, and Estrogen

Trace emerging contaminants (ECs) occur in both waste and surface waters that are rich in particulates that have been found to sorb several organic contaminants. An analytical method based on off-line solid-phase extraction (SPE) followed by liquid chromatography-mass spectrometry (LC-MS) analysis was developed for the detection and quantification of 31 ECs from surface water, wastewater, suspended particulate matter (SPM) as well as sediments. Lyophilized sediments and air-dried SPM were subjected to ultrasonic extraction. Water samples and extracts were then concentrated and cleaned-up by off-line SPE. Quantification was realized using a Q Exactive mass spectrometer in both full scan (FS) and MS 2 modes. These two modes were optimized and compared to determine which one was the most suitable for each matrix studied. Yeast estrogen screen assay (YES-assay) adapted from the direct measurement of estrogenic activity without sample extraction was tested on filtered wastewater samples. An endocrine disrupting effect was detected in all effluent samples analyzed with estradiol equivalent concentrations ranging from 4.4 to 720 ng eq E2 L −1 for the WWTP-1 and 6.5–42 ng eq E2 L −1 for the WWTP-2. The analytical methods were also applied on six samples of surface water, the corresponding SPM, the sediments and thirty-nine effluent samples from two wastewater treatment plants (WWTPs) sampled over a period of five months (February to June 2014). [ABSTRACT FROM AUTHOR]

ANESTHESIA, PLACEBOS, ETOMIDATE, and HEART beat

Abstract: Objective: Various drugs including hydroxyzine are preoperatively administered to facilitate the induction of general anaesthesia. We investigated the effect of hydroxyzine premedication on BIS-based etomidate induction of general anaesthesia. Patients and methods: Sixty-seven ASA I–II consecutive patients were randomly allocated to receive oral hydroxyzine 1.5 mg/kg or placebo, 90 min prior to inducing general anaesthesia using intravenous etomidate alone 0.3 mg/kg. BIS values were continuously recorded. The times for the BIS to decrease to 50 and to loss of eyelid reflex; the evolution of arterial pressure and heart rate; and myoclonia rate and grade were investigated and compared. Results: The results for the hydroxyzine and placebo groups were similar with respect to: a) time [median (range) (seconds)] to a BIS decrease to 50 [100 (21–266) versus 113 (30–510), P =0.1] and to loss of eyelid reflex [83 (21–210) versus 97 (30–300), P =0.1]; b) myoclonia frequency (yes/no) (9/26 versus 4/28, P =0.2) and grade (P =0.3); the evolution of mean arterial pressure and heart rate (P =0.3). Conclusion: Oral weight-related hydroxyzine premedication does not alter BIS-based etomidate induction of GA. [Copyright &y& Elsevier]

Corbicula fluminea, Caffeine, Ibuprofen, Carbamazepine, Novobiocin, Tamoxifen, DNA damage, and Oxidative stress

Reports indicating the presence of pharmaceutical in fresh water environment in the ng L −1 to µg L −1 range are occurring with increasing frequency. It is also a fact that pharmaceuticals may produce adverse effects on aquatic organisms. Nevertheless, there is still a lack of knowledge regarding how these emergent contaminants may affect aquatic biota. The goal of this research was to evaluate the sublethal responses in Corbicula fluminea such as, general stress (lysosomal membrane stability [LMS]), biomarkers of phase I and II (etoxyresorufin O-deethylase [EROD], dibenzylfluorescein dealkylase [DBF], gluthathione-S-transferase [GST]), oxidative stress (gluthathione reductase [GR], gluthathione peroxidase [GPX], lipid peroxidation [LPO]), and biomarkers of effect (DNA damage) after 21 days of exposure to caffeine, ibuprofen, carbamazepine, novobiocin and tamoxifen at 0.1, 1, 5, 10, 15, 50 µg L −1 . Environmental concentrations tested in this study caused general stress and produced changes on biomarkers tested. LMS, responses from phase I and II enzymatic activity, oxidative stress, and biomarker of effect represent important ecotoxicological information, and will provide a useful reference for the assessment of selected drugs and the effects which these compounds may have on aquatic invertebrates, using C. fluminea as a bioindicator species. [ABSTRACT FROM AUTHOR]

Humic acid, Pollutants, Sewage disposal plants, Endocrine disruptors, Humus, Complex matrices, and Xenoestrogens

The presence of estrogenic endocrine disruptors in aquatic environments has been a concern and bioassays are recommended tools for their monitoring. However, the physicochemical properties of contaminants and the environmental matrix features may influence the resultant response. This study aimed to assess this influence on the Yeast Estrogen Screen (YES) assay. Mixtures of 17β-estradiol (E2) and humic acid (HA) were evaluated through the Schild approach aiming to investigate the interactions between estrogens and dissolved organic matter (DOM). Moreover, environmental samples from municipal landfill leachate and wastewater treatment plant (WWTP) influents and effluents were screened for (anti)estrogenic activity at both dissolved and particulate phases. Finally, results were statistically confronted with physicochemical parameters through principal component analysis (PCA). The HA test concentrations strongly reduced the E2 response, even at low levels. Humic substances may not only reduce estrogen bioavailability, but also interfere with the assay mechanism through enzymatic inhibition thus masking the sample estrogenic potential. Landfill leachate had total E2-Eq in the range 1282–2591 ng L−1, while WWTP influent and effluent were in the range 12.1–41.4 and L−1, so estrogenicity was reduced 92% in average. Particulate phase was responsible for 33–100% of measured E2-Eq between matrices, though cytotoxicity occurred in some extracts. Antiestrogenic activity was observed in both phases and might also have masked the estrogenicity of samples. PCA did not resulted in positive correlations supporting a multiphase distribution pattern of estrogenic compounds. Nevertheless, the solids and organic matter characteristics supported the data interpretation. In conclusion, the in vitro YES assay is subjected to factors intrinsic to the environmental sample that can influence on the measured estrogenic response. Therefore, results interpretation should be performed together with organic matter characterization parameters, cytotoxicity and antiestrogenic activity evaluation. [Display omitted] • Humic acid induces strong antagonistic effect in the Yeast Estrogen Screen. • Landfill leachate, WWTP influents and effluents were highly estrogenic. • Cytotoxicity was recurrently associated with particles >0.7 μm. • DOM, antiestrogenic activity and phase distribution influenced on estrogenic response. [ABSTRACT FROM AUTHOR]

Environmental monitoring, Environmental quality, Sediments, Extraction (Chemistry), Atmospheric chemistry, and Mixtures

Aquatic environments are often contaminated with complex mixtures of chemicals that may pose a risk to ecosystems and human health. This contamination cannot be addressed with target analysis alone but tools are required to reduce this complexity and identify those chemicals that might cause adverse effects. Effect-directed analysis (EDA) is designed to meet this challenge and faces increasing interest in water and sediment quality monitoring. Thus, the present paper summarizes current experience with the EDA approach and the tools required, and provides practical advice on their application. The paper highlights the need for proper problem formulation and gives general advice for study design. As the EDA approach is directed by toxicity, basic principles for the selection of bioassays are given as well as a comprehensive compilation of appropriate assays, including their strengths and weaknesses. A specific focus is given to strategies for sampling, extraction and bioassay dosing since they strongly impact prioritization of toxicants in EDA. Reduction of sample complexity mainly relies on fractionation procedures, which are discussed in this paper, including quality assurance and quality control. Automated combinations of fractionation, biotesting and chemical analysis using so-called hyphenated tools can enhance the throughput and might reduce the risk of artifacts in laboratory work. The key to determining the chemical structures causing effects is analytical toxicant identification. The latest approaches, tools, software and databases for target-, suspect and non-target screening as well as unknown identification are discussed together with analytical and toxicological confirmation approaches. A better understanding of optimal use and combination of EDA tools will help to design efficient and successful toxicant identification studies in the context of quality monitoring in multiply stressed environments. [ABSTRACT FROM AUTHOR]

ANTIBIOTICS, MOLECULES, PHARMACEUTICAL industry, SCIENCE, and CLINICAL trials

Abstract: The golden age of antibacterial antibiotics extend from year 1941 to the 1990s decade. At that time, something like an earth quake occurred: from the thirty molecules or so whose development was being achieved or was already marketed, only three were put on the French market, and faced the greatest difficulties to be prescribed by practicians, because: [-] the knights of good practice want a strict limitation of their use to precise indications; [-] the pharmaceutical companies find that the return on investment is almost impossible; [-] the prescribers are stunned by the inconsistency between the MAs, the advances in science and the health economic authorities advices which claim that these products are not very interesting; [-] the research for new antibiotics is stalling; [-] thus, for the first time in 60 years, an iconoclastic question arises: do we need new antibiotics? However, while the debate is raging, many of us think “yes we do”, as it is a duty to anticipate today the consequences of tomorrow''s bacterial resistances. This paper presents three types of propositions to optimise the development of future molecules: [-] sharpening of the data concerning preclinical security for a better predicting both the activity and the toxicity; [-] improvement in performances and organization of clinical trials, which implicates to reconsider some of the present methodological rules; [-] inclusion in the evaluation data of some relevant and new features measuring the anti-bacterial activity while taking into account the present and future bacterial resistances. The development of new concepts to develop new drugs which would be active against tomorrow''s bacteria compels us to manage in a new fashion today''s systems, which have reached their own limits. [Copyright &y& Elsevier]

DRUG discovery, DATA mining, and CHEMINFORMATICS

INTONATION (Phonetics), PROSODIC analysis (Linguistics), CATALAN language, INTERROGATIVE (Grammar), ROMANCE languages, SENTENCES (Grammar), MODALITY (Linguistics), and CORPORA

In this work, the intonation of broad focus statements and information-seeking yes-no questions of Catalan obtained using an induced corpus (ICD) is analyzed. The study is carried out within the framework of the AMPERCAT project (Contini et al., 2002; Fernández Planas, 2005). Data obtained with DCT are compared with those obtained through textual elicitation in AMPER and other prosodic studies of Catalan (Prieto et al., 2015). The majority nuclear contours for the broad focus statements is L*L%, while for the interrogatives there are different contours: two falling contours (H+L*L% and ¡H+L*L%) and two raising patterns (L*H% and H+L*LH%). [ABSTRACT FROM AUTHOR]

Introduction: The newborn undergoing a surgery is exposed to the development of infections. The serum lactate has been recommended as a diagnostic criterion of sepsis. Objective: To determine the magnitude of association of the value of serum lactate with sepsis in the newborn undergoing a surgery. Methods: Study conducted from 2013 to 2016 in "William Soler" Pediatric Teaching Hospital, to 307 newborns whom underwent surgery. The variables were grouped in: clinical (gestational age, birth weight, cause of surgical intervention, location of the infection) and paraclinical (causative microorganisms, serum lactate). The partial Pearson's test of linear correlation was applied and it was estimated the odds ratio with the control of the variable infection (yes and no) to identify correlation between serum lactate values in the preoperative and postoperative results. Results: Of the newborns, 63 were under weight (20.52%) and 55 were preterm infants (17.92%). In the infected newborns, 20.83% were operated due to digestive conditions (n= 35); systemic infections reached 67.74% (n= 42), caused in 45.24% by Candida sp. The rate of change of the values of serum lactate in infected subjects (p= 0.001) meant that for each unit in mmol/L in which increased the preoperative lactate, the postoperative increased 0.489 mmol/L; and these changes were due in a 16.9% to the values of preoperative lactate. Conclusions: The serum lactate is associated to the infection in newborns that underwent surgery and is a useful biomarker of sepsis in neonatal intensive care. [ABSTRACT FROM AUTHOR]

Cadmium & the environment, Physiological effects of cadmium, Industrial toxicology, Atomic absorption spectroscopy, and Blood testing

Background Mexico City has air, water and food pollution problems; however, human exposure to cadmium and its sources have not been described. Objectives To determine the blood cadmium (BCd) level and its main exposure sources among males aged 40 years or older living in different areas of Mexico City. Methods After receiving informed consent, we interviewed 702 males aged ≥40 years to collect data on their sociodemographic characteristics, lifetime occupation, smoking history, and dietary habits, using a validated questionnaire. The BCd level (μg/L) was determined by atomic absorption spectrophotometry. Results The BCd mean level ± SD was 2.61 ± 0.82 μg/L, and 20% of men reported a potential cadmium occupational exposure. After adjusting for age and other potential confounders, the main determinants of the BCd level were the current smoking status at interview, with low (β ≤8.5packs/year vs. non-smoker  = 0.46; 95% CI: 0.28–0.64 μg/L; p < 0.01) and high (β > 8.5 packs/year vs. non-smoker  = 0.71; 95% CI: 0.56–0.87 μg/L; p < 0.01) smoking intensity, and living in the Center (β Center vs. South  = 0.20; 95% CI: 0.02–0.37 μg/L; p = 0.02) or West area of the city (β West vs. South  = 0.40, 95% CI: 0.21–0.58 μg/L; p < 0.001). Moreover, the potential dietary sources of BCd included: liver (β Yes vs. No  = 0.13, 95% CI: 0.03–0.23 μg/L; p = 0.01), “ Chorizo” (β >1–3servings/month vs. No  = 0.14, 95% CI: 0.01–0.26 μg/L; p < 0.001), sausage and ham. Conclusions The BCd levels observed in this population are high and only similar to those observed in workers from a sanitary landfill area in Southern Thailand. Potential environmental Cd exposure sources, such as industrial activity and previous land use, in the West and Center areas of the city should be explored in detail, especially in vulnerable population groups, such as children. [ABSTRACT FROM AUTHOR]

ULCER treatment, COMBINATORIAL optimization, SURGICAL emergencies, ORAL diseases, HOSPITAL care, and PHYSICIAN practice patterns

Résumé: La prise en charge chirurgicale de l’escarre en France demeure très coûteuse même si les mesures de prévention et l’amélioration du parcours de soins ont permis de limiter les dépenses dans ce domaine ces dernières années. Depuis 2004, le mode de financement des établissements de santé français par la tarification à l’acte (TAA) et la maîtrise médicalisée des dépenses de soins hospitaliers nous obligent forcément à nous intéresser à ces considérations purement économiques et parfois à nuancer nos besoins en durée d’hospitalisation ou en soins spécialisés pour optimiser le groupe homogène de séjour (GHS) d’un patient. Cela ne risque-t-il pas à l’avenir d’obliger le chirurgien à biaiser les réels besoins du patient au profit de l’établissement hospitalier ? Au travers d’une analyse médico-économique de nos pratiques, réalisée dans le service de chirurgie plastique du CHU de Toulouse, nous avons tenté d’identifier comment optimiser la prise en charge chirurgicale de l’escarre en termes de valorisation de séjour. L’objectif étant néanmoins de rester critique sur les dérives que cela pourrait instaurer à l’avenir pour notre activité clinique. [ABSTRACT FROM AUTHOR]

ATTITUDE (Psychology), CULTURE, EXPERIENTIAL learning, FAMILY psychotherapy, HOSPITAL medical staff, INTERPROFESSIONAL relations, INTERVIEWING, MEDICAL personnel, PROFESSIONS, SELF-efficacy, SUPERVISION of employees, PEER relations, and THEMATIC analysis

This article explores family therapy trainees' subjective experiences of working as cotherapists with a supervisory‐level therapist in a Chinese context, regarding their perceptions of and positioning in it and also their opinions on the benefits and/or pitfalls of cotherapy. Individual interviews with a total of six cotherapists revealed three themes: (1) Cotherapy was perceived as an experiential learning journey that evolved from anxiety and excitement to empowerment and nurturing; (2) a collaborative master–apprentice relationship of openness, trust, and mutual respect was developed with both sides' interactive effort, which included common commitment and concern for the client, the supervisor's awareness and explicit address of the role hierarchy, principle setting prior to the cooperation, and honest pre‐ and‐postsession sharing and discussion; (3) the dual‐purpose supervisor–trainee cotherapy brought direct benefits for all involved parties and for others. The findings have useful implications for integrating treatment and training for optimal training/learning outcomes and for advancing knowledge transfer from senior to junior and from academia to the field, with reference to local cultural characteristics.comment="AUTHOR: Please suggest whether the terms ‘co‐therapy, co‐learning, and cotherapist’ could be changed to ‘cotherapy, colearning, and cotherapist’ throughout the article as per style sheet requirement."comment="Dear Editor,Yes, I think these terms could be changed as suggested according to the style sheet requirement, as the meaning remains the same. Thank you.Best regards,Lily" [ABSTRACT FROM AUTHOR]

SECOND language acquisition, DOMINANT language, CHINESE language, LANGUAGE & languages, NATIVE language, and NATURAL languages

And even though I do not think that most domain-general models of L SB 1 sb /L SB 2 sb acquisition are going to come under further scrutiny, Mazuka's distinction is likely to be valuable for domain-specific models of acquisition (of phonology). Yes, L SB 2 sb learners do not parse de-RCs in the same way as native speakers do, but that only indicates that they have not achieved ultimate attainment; not that there are fundamental differences in L SB 1 sb and L SB 2 sb processing. Martohardjono, Valian and Klein (MVK) take up the deficit and transfer accounts (d/t) of L SB 2 sb acquisition in their chapter, while looking at acquisition of tense. [Extracted from the article]

DIABETIC retinopathy, VISUAL acuity, VISION, CAPILLARIES, and RETINAL diseases

Background/Aim. The relationship between the foveal avascular zone (FAV) and visual acuity (VA) in retinal diseases remains a matter of discussion. The aim of this study was to determine the impact of diabetic macular ischemia (DMI) on VA through the analysis of the perifoveal capillary network in various stages of diabetic retinopathy - DR (non-proliferative diabetic retinopathy – NPDR and proliferative diabetic retinopathy – PDR). Methods. Qualitative and quantitative analysis of 143 angiograms of patients with different stages of DR was performed. The degree of macular ischemia was assessed by the analysis of 2 parameters: perifoveal capillary ring, ie, the FAZ outline irregularity, and capillary loss. Finally, a comparison was made between the degree of macular ischemia with the best-corrected VA, depending on macular thickness. Results. In the eyes with mild and moderate NPDR, without significant macular thickening, no statistically significant decrease in VA caused by macular ischemia was noticed (p = 0.81). Opposite, in a subgroup with severe NPDR and PDR, without significant macular thickening, a statistically significant difference was presented among eyes with moderate and severe macular ischemia compared to e yes with l ower g rades of m acular i schemia (p = 0.021 and p = 0.018, respectively). In the eyes with moderate NPDR and mild macular ischemia, the increase in macular thickness resulted in a statistically insignificant decrease in VA compared to eyes with a normal macular thickness (p = 0.088). However, in the eyes with severe NPDR, every pathological increase in macular thickness caused a statistically significant decrease in VA, regardless of the degree of macular ischemia (p = 0.018–0.040). A similar relationship was also found in the eyes with PDR (p = 0.017–0.042). In the eyes with a statistically significant decrease in VA, most of the examined eyes (98%) had the FAZ outline irregularity in the nasal perifoveal subfield. Conclusion. In the absence of significant macular thickening, the destruction of one-half of the perifoveal capillary network, or greater, is associated with reduced VA. The location of macular ischemic changes in the nasal parts of the perifoveal capillary ring plays a crucial role in its effects on visual function. [ABSTRACT FROM AUTHOR]

ACTINOMYCETALES, COMMON bean, RHIZOCTONIA solani, CORTICIUM sasakii, and GREENHOUSES

The effect of seed treatment with the actinomycetes strains EA2 and CB14, and their combination, on damping-off incidence caused by Rhizoctonia solani Kühn in Phaseolus vulgaris L. cv. Velasco largo was evaluated under greenhouse conditions. These strains were compared with Trichoderma harzianum A-34, Celest®Top 312 FS and two controls (positive and negative). Inceptisol sterile and non-sterile soil was used under a completely randomized design. The coating seeds with strains were made using 8 % cassava starch. The incidence of R. solani was determined 21 days after sowing. In non-sterile soil, the lowest incidences caused by R. solani were found with Celest®Top 312 FS, which did not significantly differ from the combination of actinomycete strains CB14 + EA2, but yes with the rest of the treatments. In the sterile soil, the lowest percentages of incidences were obtained with the combination of actinomycete strains (CB14 + EA2). [ABSTRACT FROM AUTHOR]

SYMMETRY (Physics), INVARIANT measures, DE Bruijn graph, ENTROPY, and LATTICE constants

We investigate the following questions: Given a measure $$\mu _\Lambda $$ on configurations on a subset $$\Lambda $$ of a lattice $$\mathbb {L}$$ , where a configuration is an element of $$\Omega ^\Lambda $$ for some fixed set $$\Omega $$ , does there exist a measure $$\mu $$ on configurations on all of $$\mathbb {L}$$ , invariant under some specified symmetry group of $$\mathbb {L}$$ , such that $$\mu _\Lambda $$ is its marginal on configurations on $$\Lambda $$ ? When the answer is yes, what are the properties, e.g., the entropies, of such measures? Our primary focus is the case in which $$\mathbb {L}=\mathbb {Z}^d$$ and the symmetries are the translations. For the case in which $$\Lambda $$ is an interval in $$\mathbb {Z}$$ we give a simple necessary and sufficient condition, local translation invariance ( LTI), for extendibility. For LTI measures we construct extensions having maximal entropy, which we show are Gibbs measures; this construction extends to the case in which $$\mathbb {L}$$ is the Bethe lattice. On $$\mathbb {Z}$$ we also consider extensions supported on periodic configurations, which are analyzed using de Bruijn graphs and which include the extensions with minimal entropy. When $$\Lambda \subset \mathbb {Z}$$ is not an interval, or when $$\Lambda \subset \mathbb {Z}^d$$ with $$d>1$$ , the LTI condition is necessary but not sufficient for extendibility. For $$\mathbb {Z}^d$$ with $$d>1$$ , extendibility is in some sense undecidable. [ABSTRACT FROM AUTHOR]

TALAROMYCES, CACAO, FUNGAL growth, NATURAL resources, SOIL pollution, and SOILS

Inorganic pollutants in Colombian cocoa (Theobroma cacao L.) agrosystems cause problems in the production, quality, and exportation of this raw material worldwide. There has been an increased interest in bioprospecting studies of different fungal species focused on the biosorption of heavy metals. Furthermore, fungi constitute a valuable, profitable, ecological, and efficient natural soil resource that could be considered in the integrated management of cadmium mitigation. This study reports a new species of Talaromyces isolated from a cocoa soil sample collected in San Vicente de Chucurí, Colombia. T. santanderensis is featured by Lemon Yellow (R. Pl. IV) mycelium on CYA, mono-to-biverticillade conidiophores, and acerose phialides. T. santanderensis is distinguished from related species by its growth rate on CYAS and powdery textures on MEA, YES and OA, high acid production on CREA and smaller conidia. It is differentiated from T. lentulus by its growth rate on CYA medium at 37 °C without exudate production, its cream (R. PI. XVI) margin on MEA, and dense sporulation on YES and CYA. Phylogenetic analysis was performed using a polyphasic approach, including different phylogenetic analyses of combined and individual ITS, CaM, BenA, and RPB2 gene sequences that indicate that it is new to science and is named Talaromyces santanderensis sp. nov. This new species belongs to the Talaromyces section and is closely related to T. lentulus, T. soli, T. tumuli, and T. pratensis (inside the T. pinophilus species complex) in the inferred phylogeny. Mycelia growth of the fungal strains was subjected to a range of 0–400 mg/kg Cd and incorporated into malt extract agar (MEA) in triplicates. Fungal radial growth was recorded every three days over a 13-day incubation period and In vitro cadmium tolerance tests showed a high tolerance index (0.81) when the mycelium was exposed to 300 mg/kg of Cd. Results suggest that T. santanderensis showed tolerance to Cd concentrations that exceed the permissible limits for contaminated soils, and it is promising for its use in bioremediation strategies to eliminate Cd from highly contaminated agricultural soils. [ABSTRACT FROM AUTHOR]

Colorrectal adenocarcinoma it's a common entity, but the vulvar metastasis from it, it's very rare, they can be metachronous. The vulvar metastasis it's only 5 to 8 % of all of the site tumors. W e present a case of a 35 years old woman, who was diagnosed with a poorly differentiated, infiltrating and ulcerated colorrectal adenocarcinoma by colonoscopy biopsy, latter a surgical resection it's taken so Dukes C2 stratification it's made. After 14 months a skin injury appears in vulvar and perirectal area, the next step skin biopsy is realized, the histopathological findings are a metastasic disease from invasive adenocarcinoma, an immunohistochemical cytokeratin (Cl<) 20 reactive shows positivity therefore the origin its colorrectal adenocarcinoma. The most frequent metastasis from colon adenocarcinoma is the liver, the female genital tract is rare, but within this system the ovary is the most common. Metastasis to skin is exceptional, but when it happens periumbilical area is the most frequent site, that means our case presentation has low incidence so the importance of it and the bad prognosis of it. [ABSTRACT FROM AUTHOR]

This work aims at describing differences between the dialectal varieties of Portuguese spoken at Salvador, Fortaleza and Rio de Janeiro, Brazil, in both the declarative and interrogative modalities. Analyses of prosodic parameters (fundamental frequency, duration, intensity) are made on the final nucleus of oxytonic, paroxytonic and proparoxytonic sentences. There are systematic prosodic changes between modalities - with a higher / rising F0 in interrogative nucleus where it is lower / decreasing for declaratives. The interrogative nucleus are also longer and stronger than the declaratives. Dialectal variations are also observed. The accentual patterns H + L*L% for declaratives and L + H*L% for interrogatives proposed by Moraes (2008) are observed in Rio de Janeiro speakers - the latter being truncated or compressed in oxytonic sentences due to lack of post-tonic material. Meanwhile, in the Salvador and Fortaleza varieties, interrogatives may also be performed with a L + H*H% pattern. More syllable elisions are also observed in Fortaleza speakers. [ABSTRACT FROM AUTHOR]

ACUTE otitis media, ANTIBIOTICS, DISEASE relapse, DRUG efficacy, DRUG prescribing, and THERAPEUTICS

Objective: Antibiotic treatment of acute otitis media (AOM) has been suggested to increase the risk of future AOM episodes by causing unfavorable shifts in microbial flora. Because current evidence on this topic is inconclusive and long-term follow-up data are scarce, we wanted to estimate the effect of antibiotic treatment for a first AOM episode occurring during infancy on AOM recurrences and AOM-related health care utilization later in life. Methods: We obtained demographic information and risk factors from data of the Wheezing Illnesses Study Leidsche Rijn, a prospective birth cohort study in which all healthy newborns born in Leidsche Rijn (between 2001 and 2012), The Netherlands, were enrolled. These data were linked to children’s primary care electronic health records up to the age of four. Children with at least one family physician-diagnosed AOM episode before the age of two were included in analyses. The exposure of interest was the prescription of oral antibiotics (yes vs no) for a child’s first AOM episode before the age of two years. Results: 848 children were included in analyses and 512 (60%) children were prescribed antibiotics for their first AOM episode. Antibiotic treatment was not associated with an increased risk of total AOM recurrences (adjusted rate ratio: 0.94, 95% CI: 0.78–1.13), recurrent AOM (≥3 episodes in 6 months or ≥4 in one year; adjusted risk ratio: 0.79, 95% CI: 0.57–1.11), or with increased AOM-related health care utilization during children’s first four years of life. Conclusions: Oral antibiotic treatment of a first AOM episode occurring during infancy does not affect the number of AOM recurrences and AOM-related health care utilization later in life. This information can be used when weighing the pros and cons of various AOM treatment options. [ABSTRACT FROM AUTHOR]

CARDIOVASCULAR diseases risk factors, MYELOPEROXIDASE, CORONARY disease, CARDIOVASCULAR diseases, CIRCULATING tumor DNA, and HDL cholesterol

Introduction: Neutrophil extracellular traps (NETs) are DNA scaffolds enriched with antimicrobial proteins. NETs have been implicated in the development of various diseases, such as cardiovascular disease. Here, we investigate the association of demographic and cardiovascular (CVD) risk factors with NETs in the general population. Material and methods: Citrated plasma was collected from 6449 participants, aged ≥55 years, as part of the prospective population-based Rotterdam Study. NETs were quantified by measuring MPO-DNA complex using an ELISA. We used linear regression to determine the associations between MPO-DNA complex and age, sex, cardio-metabolic risk factors, and plasma markers of inflammation and coagulation. Results: MPO-DNA complex levels were weakly associated with age (log difference per 10 year increase: -0.04 mAU/mL, 95% confidence interval [CI] -0.06;-0.02), a history of coronary heart disease (yes versus no: -0.10 mAU/mL, 95% CI -0.17;-0.03), the use of lipid-lowering drugs (yes versus no: -0.06 mAU/mL, 95% CI -0.12;-0.01), and HDL-cholesterol (per mmol/l increase: -0.07 mAU/mL/, 95% CI -0.12;-0.03). Conclusions: Older age, a history of coronary heart disease, the use of lipid-lowering drugs and higher HDL-cholesterol are weakly correlated with lower plasma levels of NETs. These findings show that the effect of CVD risk factors on NETs levels in a general population is only small and may not be of clinical relevance. This supports that NETs may play a more important role in an acute phase of disease than in a steady state situation. [ABSTRACT FROM AUTHOR]

ACADEMIC medical centers, CANCER genetics, CHI-squared test, CONFIDENCE intervals, EMPLOYMENT, GENETIC counseling, HEALTH services accessibility, HEALTH status indicators, HEALTH insurance, MARITAL status, MEDICAL care use, MEDICAL referrals, METROPOLITAN areas, MULTIVARIATE analysis, RACISM, LOGISTIC regression analysis, ELECTRONIC health records, DESCRIPTIVE statistics, ODDS ratio, and DISEASE risk factors

Purpose: Genetic counseling (GC) provides critical risk prediction information to women at-risk of carrying a genetic alternation; yet racial/ethnic and socioeconomic disparities persist with regard to GC uptake. This study examined patterns of GC uptake after a referral in a racially diverse population. Materials and Methods: In an urban academic medical center, medical records were reviewed between January 2016 and December 2017 for women who were referred to a genetic counselor for hereditary breast and ovarian cancer. Study outcomes were making an appointment (yes/no) and keeping an appointment. We assessed sociodemographic factors and clinical factors. Associations between factors and the outcomes were analyzed using chi square, and logistic regression was used for multivariable analysis. Results: A total of 510 women were referred to GC and most made appointments. More than half were white (55.3%) and employed (53.1%). No significant associations were observed between sociodemographic factors and making an appointment. A total of 425 women made an appointment and 268 kept their appointment. Insurance status ( p = 0.003), marital status ( p = 0.000), and work status ( p = 0.039) were associated with receiving GC. In the logistic model, being married (odds ratio [OR] 2.119 [95% confidence interval, CI 1.341–3.347] p = 0.001) and having insurance (OR 2.203 [95% CI 1.208–4.016] p = 0.021) increased the likelihood of receiving counseling. Conclusions: Racial disparities in GC uptake were not observed in this sample. Unmarried women may need additional support to obtain GC. Financial assistance or other options need to be discussed during navigation as a way to lessen the disparity between women with insurance and those without. [ABSTRACT FROM AUTHOR]

RESPIRATORY infections, OTITIS media, MEDICAL care, PEDIATRICS, and PRIMARY care

Background Daycare attendance is an established risk factor for upper respiratory tract infections (URTI) and acute otitis media (AOM). Whether this results in higher use of healthcare resources during childhood remains unknown. We aim to assess the effect of first year daycare attendance on the timing and use of healthcare resources for URTI and AOM episodes during early childhood. Methods In the Wheezing-Illnesses-STudy-LEidsche-Rijn birth cohort, 2,217 children were prospectively followed up to age six years. Children were categorized according to first-year daycare attendance (yes versus no) and age at entry when applicable (age 0 to 2 months, 3 to 5 months and 6 to 12 months). Information on general practitioner (GP) diagnosed URTI and AOM, GP consultations, antibiotic prescriptions and specialist referral was collected from medical records. Daycare attendance was recorded by monthly questionnaires during the first year of life. Results First-year daycare attendees and non-attendees had similar total six-year rates of GPdiagnosed URTI and AOM episodes (59/100 child-years, 95% confidence interval 57 to 61 versus 56/100 child-years, 53 to 59). Daycare attendees had more GP-diagnosed URTI and AOM episodes before the age of one year and fewer beyond the age of four years than nonattendees (Pinteraction <0.001). Daycare attendees had higher total six-year rates for GP consultation (adjusted rate ratio 1.15, 1.00 to 1.31) and higher risk for specialist referrals (hazard ratio:1.43, 1.01 to 2.03). The number of antibiotic prescriptions in the first six years of life was only significantly increased among children who entered daycare between six to twelve months of age (rate ratio 1.32, 1.04 to 1.67). This subgroup of child-care attendees also had the highest overall URTI and AOM incidence rates, GP consultation rates and risk for specialist referral. Conclusions Children who enter daycare in the first year of life, have URTI and AOM at an earlier age, leading to higher use of healthcare resources compared to non-attendees, especially when entering daycare between six to twelve months. These findings emphasize the need for improved prevention strategies in daycare facilities to lower infection rates at the early ages. [ABSTRACT FROM AUTHOR]

CATALAN language, OPTIMALITY theory (Linguistics), LANGUAGE & languages, ACCOMMODATIONISM, and AUTOSEGMENTAL theory (Linguistics)

This paper aims at contributing to ascertain the principles of intonational grammar that lie behind the realization of nuclear contours and at presenting them in terms of Optimality Theory constraints. In order to do so, we analyse the prosody of the nuclear configuration of Southern Valencian Catalan yes-no questions, with special emphasis on situations where text-tune accommodation phenomena take place. The empirical data, which are analysed according to the principles of the autosegmental-metrical model, show a complex interplay of different phenomena at the text-tune interface, like vowel lengthening, tonal spreading, tonal retraction and intonation-driven schwa epenthesis. We argue that the variation detected in the data can be accounted for by the interaction of nine constraints (i.e., Max-IO(µp), Dep-IO(µs), Anchor(T%,Rt,IP,Rt), Anchor(L*,Rt,ˈσ,Rt), *Anchor(T,C), *Anchor(T,-voice), Share(T*,NC), Dep-IO(Associate), Max-IO(Associate)), whose ranking is established by means of a Stochastic Optimality Theory analysis. [ABSTRACT FROM AUTHOR]

SELF-deception, COVID-19, PSYCHOLOGICAL well-being, COVID-19 pandemic, SOCIAL attitudes, FEAR, and ATTITUDE (Psychology)

Background: Poland's inhabitants have often expressed disbelief and negative attitudes toward social isolation, combined with restlessness. This is due to a tendency to discount troubling informa tion while facing the unknown and counter-argue against information that causes discomfort and fear. This tendency helps humans to maintain hope and well-being. The study aimed to determine if Polish citizens tend to downplay or even deny danger when faced with a death threat. Material/Methods: The study comprised 58 adults - 46 females 12 males, aged 21 to 49. The participants were asked to answer 12 questions defining their beliefs and attitudes towards the COVID-19 pandemic threat and its consequences. The subjects gave answers on the 5-point Likert scale, from "definitely not" to "de finitely yes". Results: The findings of the present study show that a considerable number of the participants tend to exhibit an optimistic bias. This is reflected in their direct statements and in the lack of congruence of their opinions. They do feel the threat of becoming ill but also seem to believe it need not affect them personally. They are also relatively optimistic about the outcomes of the pandemic. At the same time, they realize that COVID-19 may lead to severe psychological, neurological, and mental disorders. Conclusions: The study confirmed a tendency to deny the threat that can pose a severe risk to health and psychological well-being. This is a manifestation of an optimism bias that has its roots in the way the human brain works. The participants did express concerns about the future but at the same time hoped that life after the pandemic would return to normal. It reflects a benevolent facet of self-deception since it makes it possible to cope with highly threatening and impossible to control events. [ABSTRACT FROM AUTHOR]

COMPOSITION of feeds, INSECT proteins, FOOD chains, SUSTAINABILITY, FEED utilization efficiency, ANIMAL feeds, and SAFETY

In the framework of sustainability and a circular economy, new ingredients for feed are desired and, to this end, initiatives for implementing such novel ingredients have been started. The initiatives include a range of different sources, of which insects are of particular interest. Within the European Union, generally, a new feed ingredient should comply with legal constraints in terms of ‘yes, provided that’ its safety commits to a range of legal limits for heavy metals, mycotoxins, pesticides, contaminants, pathogens etc. In the case of animal proteins, however, a second legal framework applies which is based on the principle ‘no, unless’. This legislation for eradicating transmissible spongiform encephalopathy consists of prohibitions with a set of derogations applying to specific situations. Insects are currently considered animal proteins. The use of insect proteins is a good case to illustrate this difference between a positive, although restricted, modus and a negative modus for allowing animal proteins. This overview presents aspects in the areas of legislation, feed safety, environmental issues, efficiency and detection of the identity of insects. Use of insects as an extra step in the feed production chain costs extra energy and this results in a higher footprint. A measure for energy conversion should be used to facilitate the comparison between production systems based on cold- versus warm-blooded animals. Added value can be found by applying new commodities for rearing, including but not limited to category 2 animal by-products, catering and household waste including meat, and manure. Furthermore, monitoring of a correct use of insects is one possible approach for label control, traceability and prevention of fraud. The link between legislation and enforcement is strong. A principle called WISE (Witful, Indicative, Societal demands, Enforceable) is launched for governing the relationship between the above-mentioned aspects. [ABSTRACT FROM AUTHOR]

Introduction: the Danish questionnaire entitled The Copenhagen Neck Functional Disability Scale(CNFDS) is a tool for self-assessment of cervical complaints,originally developed in English, of which there is, so far, no translation into Brazilian Portuguese. The process involvedin this researchproved to be relevant for the exploration of the questionnaire and the realization of adjustments necessary for it to be functiona l and applicable in Portuguese Language and Brazilian Culture settings. Thus, once this has been carried out, many health professionals will benefit from this version in their clinical practice. Objective: To perform the translation and cultural adaptation to Brazilian Portuguese of the Escala funcional de incapacidade do pescoço de Copenhagen (The Copenhagen Neck Functional Disability Scale -- CNFDS). Methods: The questionnaire was translated into Brazilian Portuguese by two bilingual, Brazilian physiotherapists who were aware of the objective of this research. The back-translation was performed by a third person, a Brazilian, bilingual English teacher, who had not participated in the previous step. After comparing the resulting translations, a single translated version was produced named the Escala Funcional de Incapacidade do Pescoço de Copenhagen (EFIPC) and in each question the option "not applicable" was added to the answer key. During the translation and cultural adaptation process there were no changes and/or eliminations of any questions. Result: The composition of the Escala Funcional de Incapacidade do Pescoço de Copenhagen reflects the original English version, with a total of 15 questions, with the questions numbered 1 to 5 presenting a positive direction response (a "yes" answer indicates good cervical condition), and questions numbered 6 to 15 presenting a negative direction response (a "yes" answer indicates poor cervical condition). Conclusion: The process involved in this research allowed the achievement of thedesired goal, and thus it was possible totranslate and culturally adapt to Brazilian Portuguese the content of the CNFDS questionnaire, giving riseto the Escala funcional de incapacidade do pescoço de Copenhagen. [ABSTRACT FROM AUTHOR]

CROP genetics, SOYBEAN, SWEETPOTATO whitefly, DISEASE resistance of plants, BIOLOGICAL control of plant parasites, ANTIBIOSIS, OVIPARITY, GREENHOUSE plants, and TRICHOMES

Since it was first reported in Brazil in the 1990s, the B biotype of silverleaf whitefly (Bemisia tabaci [Genn.], Hemiptera Aleyrodidae) has been recognized as an important pest in soybeans (Glycine max L.), reducing the productivity of this legume species in some areas of the country. As an alternative to chemical control, the use of resistant genotypes represents an important tool for integrated pest management (IPM). This study evaluated the performance of 10 soybean genotypes prior to whitefly infestation, by testing attractiveness and preference for oviposition in the greenhouse and antibiosis in the laboratory. In a multiple-choice test, 'IAC-17' was the least attractive to insects. In a no-choice test, 'IAC-17' was the least attractive for egg deposition, indicating the occurrence of non-preference for oviposition on this genotype. Trichome density was positively correlated with the oviposition site and may be associated with the resistance of 'IAC-17' to infestation. The genotypes 'IAC-PLI', 'IAC-19', 'Conquista', 'IAC-24' and 'IAC-17' extended the insect's life cycle, indicating occurrence of a small degree of antibiosis and/or non-preference for feeding. [ABSTRACT FROM AUTHOR]

The waltz of Afrikaans "a" with "l" The present study is a follow-up of previous ones on the rounding of the long low /a/ vowel in Afrikaans, a relatively new sound variation. Against the background of existing descriptions I report a similar tendency of rounding of short /a/ vowel, specifically when followed by the lateral consonant /l/. I suggest an explanation of such rounding as being the result of a process of coarticulation, specifically under the influence of a distinct dark, retroflex quality of this lateral. A post hoc investigation with an ultrasound scanner and lip video camera confirmed this to be the case. The vowel productions of a single speaker, known to be a clear rounding of long /a/ was explored in an extensively designed case study. The phenomenon of /a/-rounding implies a qualitative change of the /a/ to [ɒ] as in [jɒ] (ja; "yes") and in [snɒks (snaaks; "funny"). Apart from superficial references to its existence in linguistic handbooks, such as De Villiers and Ponelis (1987:100), the first systematic study was done by Wissing (2006), followed-up by more recent other studies (Wissing 2010; 2013). Rounding is currently seemingly limited to the speech of young adult female speakers of Afrikaans, but it appears as if it has lately been spreading to the broader Afrikaans speaking community at a rather noticeable pace. It is provoking extremely negative reactions in especially the case of older, or more conservative Afrikaans speaking persons. On the other hand, younger users of Afrikaans do not even seem to notice the existence of this phenomenon, especially in their own language use. Such a vowel change is apparently part of a larger vowel shift which has recently been taking place, viz. the lowering of the front-mid vowel /ε/ to almost the position of the short low /a/, or the shifting of /u/ from a back to a more centralised position (cf. Wissing 2010). Broadly defined, language change is a topic that integrates the social as well as the cognitive aspects of what it means to be human. A central feature of a language in the process of change is variation. During a period of change, there is variation in the language between forms that represent the current/previous stage and forms that represent the innovative/new stage of the language. Consequently, the rounding of /a/ could be of linguistic significance when considered against this general linguistic backdrop. The present investigation aims in particular at both broadening, developing and understanding of /a/-rounding to [ɒ] in modern Afrikaans. In order to achieve this, firstly the existing knowledge concerning this phenomenon was summarised, whereafter a variety of carefully constructed stimuli were used in an in-depth case study of the pronunciation of a young female radio presenter at Radio Sonder Grense, the leading Afrikaans public broadcaster (hence referred to as C). The testing material was created with a view to obtaining a fuller understanding of /a/- rounding to [ɒ] in Afrikaans in two respects. Firstly, the stimulus series concerning the degree to which long /a/ vowels are subjected to such rounding was expanded considerably. Secondly, stimuli were included with the aim of examining the possible co-articulatory influence of the rounding of /a/ followed by the lateral consonant /l/ (characterised as a dark l in the case of English pronunciation) on especially the short /ɑ/-vowel, as in wals ("waltz"). Dark /l/ has received much attention in literature. Moreover, word frequency also has been shown (Lin, Beddor & Coetzee 2013) to influence the magnitude of the tongue tip gesture in laterals, especially with regard to /l/ vocalization. It might be applicable on the case of /l/-velarisation as well. Degree of darkness, differences in articulatory closure, dorsopalatal contact size, closure duration, relative timing of events and formant frequency (cf. Recasens & Espinosa 2005) are some of the important factors to take into account when studying this consonant and its co-articulatory effects on phonetic environment. Up until now none of these have been mentioned in Afrikaans phonetic literature. In the present article I superficially touch on some of them. Obviously these facets deserve fundamental attention. I utilised three different types of recording tasks, namely firstly the reading of carrier phrases containing a focus form with the structure /sVs/ (eg. among others, saas and sas); secondly, the naming of the letters of the alphabet (with an interest in a, h, k; all pronounced with a long [a]), and thirdly, the reading of a variety of isolated words and phrases, mostly containing words relevant to this study. In some cases C was prompted to orally complete a task, for example, a noun like val was to be read, but its diminutive (valletjie) and plural forms (valle) were to be completed without visual stimulus. Syllable structure was controlled systematically. In the case of val, /a/ appears in a closed syllable, but in valletjie and valle the syllables are open. These tasks had to be carried out twice. Recordings were done with high quality equipment, in use by RSG. Processing and acoustic analyses of the recordings were performed by means of standard procedures. As is conventional in studies of this nature, acoustic characteristics of the production of long /a/ and short /Q/ were investigated via vowel formant frequencies, F1 as well as F2. F1, the first formant, corresponds to vowel openness (vowel height). An open vowel, such as /a/, has high F1 frequencies, while close vowels, like /i/, have low F1 frequencies. The second formant, F2, corresponds to the front positions of a vowel. Back vowels, which are normally at the same time also rounded, have low F2 frequencies, in contrast to front vowels, which have high F2 frequencies. Generally the results clearly confirm the audible perception that C is a strong rounder of the long /a/. There is a very positive correlation between C's acoustic measurements and that previously found for another young female individual (Wissing 2006) as well as that of twenty others of about the same age (Wissing 2013). This finding strongly suggests a restriction on the number of participants as well as the range of required stimuli in instances of experiments of this kind, especially in the case of pilot studies. The role of syllable structure was found to be of limited importance. The short /a / was rounded to a significant degree when followed by /l/ in open as well as closed syllables, but to a small degree as in the case of open syllables. Of special importance is the finding that F1 also plays a significant role in the expression of degree of roundedness of the /a/ vowel, albeit not quite to the same extent as is the case with F2, generally considered to be the sole carrier of roundedness. The fact that the rounded [594;] is frequently misinterpreted (as the rounded vowel [ɔ] (in kom "come")), from a perceptual angle supports the current results of the analysis of the rounded [594;] in Afrikaans. Of course, [ɔ] is characterised inter alia by a higher F1 than that of the unrounded [a]. In many languages the existence of dark /l/ ([ɫ]) is well-known (cf. Hamann 2003; also Lin, Beddor & Coetzee 2014 and references cited by them). With regard to Afrikaans, a co-articulatory effect of this lateral was found to be clearly manifested in the present study on the rounding to [...] of the short /a/, but also of the long /a/. In a broader linguistic perspective the present findings should be of distinctive importance to those interested in language change in general, and more specifically in sound variation. [ABSTRACT FROM AUTHOR]

KINASES, YAP signaling proteins, FIBROBLAST growth factor 2, FIBROBLAST growth factor receptors, HIPPO signaling pathway, DRUG toxicity, and CHOLANGIOCARCINOMA

There is an unmet need to develop novel, effective medical therapies for cholangiocarcinoma (CCA). The Hippo pathway effector, Yes-associated protein (YAP), is oncogenic in CCA, but has historically been difficult to target therapeutically. Recently, we described a novel role for the LCK proto-oncogene, Src family tyrosine kinase (LCK) in activating YAP through tyrosine phosphorylation. This led to the hypothesis that LCK is a viable therapeutic target in CCA via regulation of YAP activity. A novel tyrosine kinase inhibitor with relative selectivity for LCK, NTRC 0652-0, was pharmacodynamically profiled in vitro and in CCA cells. A panel of eight CCA patient-derived organoids were characterized and tested for sensitivity to NTRC 0652-0. Two patient-derived xenograft models bearing fibroblast growth factor receptor 2 (FGFR2)-rearrangements were utilized for in vivo assessment of pharmacokinetics, toxicity, and efficacy. NTRC 0652-0 demonstrated selectivity for LCK inhibition in vitro and in CCA cells. LCK inhibition with NTRC 0652-0 led to decreased tyrosine phosphorylation, nuclear localization, and co-transcriptional activity of YAP, and resulted in apoptotic cell death in CCA cell lines. A subset of tested patient-derived organoids demonstrated sensitivity to NTRC 0652-0. CCAs with FGFR2 fusions were identified as a potentially susceptible and clinically relevant genetic subset. In patient-derived xenograft models of FGFR2 fusion-positive CCA, daily oral treatment with NTRC 0652-0 resulted in stable plasma and tumor drug levels, acceptable toxicity, decreased YAP tyrosine phosphorylation, and significantly decreased tumor growth. A novel LCK inhibitor, NTRC 0652-0, inhibited YAP signaling and demonstrated preclinical efficacy in CCA cell lines, and patient-derived organoid and xenograft models. Although aberrant YAP activation is frequently seen in CCA, YAP targeted therapies are not yet clinically available. Herein we show that a novel LCK-selective tyrosine kinase inhibitor (NTRC 0652-0) effectively inhibits YAP tyrosine phosphorylation and cotranscriptional activity and is well tolerated and cytotoxic in multiple preclinical models. The data suggest this approach may be effective in CCA with YAP dependence or FGFR2 fusions, and these findings warrant further investigation in phase I clinical trials. [Display omitted] • LCK is a novel therapeutic target in cholangiocarcinoma. • Cholangiocarcinoma organoid and xenograft tumor models respond to LCK inhibition. • FGFR2-altered cholangiocarcinomas have enriched YAP activity and are sensitive to LCK inhibition. [ABSTRACT FROM AUTHOR]

CANCER treatment, SMALL cell lung cancer, OLDER patients, CANCER chemotherapy, POPULATION health, and DRUG toxicity

Background: Twenty percent of all newly diagnosed patients with small-cell lung cancer (SCLC) are >75 years. Elderly patients may show more toxicity due to co-morbidity. We evaluated motives for adherence to treatment guidelines, completion of treatment and toxicity.Patients and methods: Population-based data from patients aged ≥75 years and diagnosed with SCLC in 1997–2004 in The Netherlands were used (368 limited disease and 577 extensive disease). Additional data on co-morbidity (Adult Co-morbidity Evaluation 27), World Health Organisation performance status (PS), treatment, motive for no chemotherapy, adaptations and underlying motive and grade 3 or 4 toxicity were gathered from the medical records.Results: Forty-eight percent did not receive chemotherapy. The most common motives were refusal by the patient or family, short life expectancy or a combination of high age, co-morbidity and poor PS. Although only relatively fit elderly were selected for chemotherapy, 60%–75% developed serious toxicity, and two-thirds of all patients could not complete the full chemotherapy.Conclusions: We hypothesise that a better selection by proper geriatric assessments is needed to achieve a more favourable balance between benefit and harm. [ABSTRACT FROM AUTHOR]

ELECTRONIC health records, ACUTE leukemia, HEMORRHAGE, HEMOGLOBINS, and BLOOD transfusion

Introduction: Electronic health care data offers the opportunity to study rare events, although detecting these events in large datasets remains difficult. We aimed to develop a model to identify leukemia patients with major hemorrhages within routinely recorded health records. Methods: The model was developed using routinely recorded health records of a cohort of leukemia patients admitted to an academic hospital in the Netherlands between June 2011 and December 2015. Major hemorrhage was assessed by chart review. The model comprised CT-brain, hemoglobin drop, and transfusion need within 24 hours for which the best discriminating cut off values were taken. External validation was performed within a cohort of two other academic hospitals. Results: The derivation cohort consisted of 255 patients, 10,638 hospitalization days, of which chart review was performed for 353 days. The incidence of major hemorrhage was 0.22 per 100 days in hospital. The model consisted of CT-brain (yes/no), hemoglobin drop of ≥0.8 g/dl and transfusion of ≥6 units. The C-statistic was 0.988 (CI 0.981–0.995). In the external validation cohort of 436 patients (19,188 days), the incidence of major hemorrhage was 0.46 per 100 hospitalization days and the C-statistic was 0.975 (CI 0.970–0.980). Presence of at least one indicator had a sensitivity of 100% (CI 95.8–100) and a specificity of 90.7% (CI 90.2–91.1). The number of days to screen to find one case decreased from 217.4 to 23.6. Interpretation: A model based on information on CT-brain, hemoglobin drop and need of transfusions can accurately identify cases of major hemorrhage within routinely recorded health records. [ABSTRACT FROM AUTHOR]

PLURALISM, ABORIGINAL Canadians, INDIGENOUS peoples, MARRIAGE, and HUMAN rights

In the case of Connolly v Woolrich, decided by the Québec Superior Court within ten days of Canadian Confederation in 1867, a judge upheld the validity of a marriage conducted according to Cree customary law in what is now northern Alberta. In doing so, the judge advanced a complex and far-reaching theory of legal pluralism and multi-layered governance within territories under the "joint occupation" of Europeans and Aboriginal peoples -- territories that would soon become part of the new Dominion of Canada. Canada thus began its life with a constitutional vision that was inclusive and respectful of Indigenous legal traditions. However, that vision was quickly lost. For over one hundred years, the case of Connolly v Woolrich was forgotten. Only in recent years has the case found its way back into mainstream legal discourse. Indeed, it is now often feted as a model for a multijuridical legal reality in Canada. But could this old case really provide a way forward for acknowledging Indigenous legal traditions in Canada today? There are good reasons to doubt this possibility, given the colonial legal sensibilities that informed the reasoning that the judge employed. However, after considering three readings of Connolly v Woolrich, the incorporative, assimilationist, and reconciliatory readings, the author argues that, yes, properly interpreted, Connolly v Woolrich may indeed provide eff ective insights into the status of Indigenous legal traditions in Canadian law today. The case of Connolly v Woolrich may well be worth celebrating 150 years or so after it was decided. [ABSTRACT FROM AUTHOR]

GAIT disorders, ANATOMICAL planes, CEREBRAL palsy, THERAPEUTICS, and INTER-observer reliability

Aim: To assess interobserver reliability in the interpretation of three-dimensional gait analysis (3DGA) of children with gait disorders within a single institution.Method: Seven experienced interpreters in our institution participated in a quality-assurance program reviewing one unique patient's 3DGA data every 3 months. Between 2014 and 2017, 15 patients' data were interpreted (14 with spastic cerebral palsy, 1 with myelodysplasia). Interpreters were asked to select 'yes', 'no', or 'indeterminate' from a list of problems and treatment recommendations. Kappa and percent agreement calculations were performed to evaluate consistency.Results: Average percentage agreement in problem identification and treatment recommendation was greater than 84 percent and 90 percent for all interpreters respectively. Average kappa for the 10 most consistently identified problems and recommended treatments were 0.69 and 0.59 respectively. Interpreter consistency was moderate or better for the most commonly performed operations at our institution (0.44-0.59). Sagittal plane abnormalities of the hip and knee had the highest consistency.Interpretation: When institutional differences in data collection and regional variations in management philosophies are removed, interobserver consistency in 3DGA interpretation is moderate to substantial for many commonly selected items. Identification of areas with poor consistency may help address underlying causes and improve data processes.What This Paper Adds: Consistency in three-dimensional gait analysis interpretation and treatment recommendation is high within a single institution. There is moderate or better consistency for most commonly identified problems and recommended treatments. Sagittal plane problem identification of the hip and knee have the highest consistency. Lower consistency is seen in areas with poor objective measures, such as dystonia and balance. [ABSTRACT FROM AUTHOR]

FACTOR analysis, JOINT diseases, LONGITUDINAL method, MEDICAL cooperation, MENTAL health, HEALTH outcome assessment, POSTOPERATIVE period, QUESTIONNAIRES, RESEARCH, STATISTICS, TOTAL knee replacement, PAIN measurement, PATIENTS' attitudes, and FUNCTIONAL assessment

Background There is conflicting evidence about what factors influence outcomes after total knee replacement (TKR). The objective is to identify baseline factors that differentiate patients who achieve both, minimal clinically important difference (MCID) and a patient acceptable symptom state (PASS) in pain and function, measured by WOMAC, after TKR from those who do not attain scores above the cutoff in either of these dimensions. Methods One-year prospective multicentre study. Patients completed WOMAC, SF-12, EQ-5D, expectations, other joint problems and sociodemographic data while in the waiting list, and 1-year post-TKR. Dependent variable was a combination of MCID and PASS in both dimensions (yes/no). Univariate analysis was performed to identify variables associated. Exploratory factor analysis (EFA) was performed to study how these variables grouped into different factors. Results Total sample comprised 492 patients. Mean (SD) age was 71.3 (6.9), and there were a 69.7% of women. Of the total, 106 patients did not attain either MCID or PASS in either dimension, and 230 exceeded both thresholds in both dimensions. In the univariate analysis, 13 variables were associated with belonging to one group or another. These 13 variables were included in EFA; 3 factors were extracted: expectations, mental health, and other joints problems. The percentage of variance explained by the 3 factors was 80.4%. Conclusion We have found 2 modifiable baseline factors, expectations and mental health, that should be properly managed by different specialist. Indication of TKR should take into account these modifiable factors for improving outcomes after TKR. [ABSTRACT FROM AUTHOR]

DE facto doctrine, ADMINISTRATIVE law, CONSTITUTIONAL law, CHARTERING, and CORPORATION law

Despite over 200 years of deliberation and debate, the United States has not adopted a federal corporate chartering law. Instead, Delaware is the "Federal Option" for corporate law and adjudication. The contemporary federal corporate chartering debate is, in part, a referendum on its role. Although the federal government has regulated other aspects of interstate commerce and has the power to charter corporations and preempt Delaware pursuant to its Commerce Clause power, it has not done so. Despite the rich and robust scholarly discussion of Delaware's jurisdictional dominance, its role as a de facto national regulator remains underdeveloped. This Article addresses a vexing question: Can Delaware, a haven for incorporation and adjudication, serve as an effective national regulator? Following an analysis of federal chartering alternatives, such as the Nader Plan, the Warren Plan, the Sanders Plan, and other modes of regulation, the answer is yes, but with some caveats and qualifications. Delaware's adequate, if imperfect, performance as a surrogate national regulator of corporate internal affairs argues against the upheaval of the existing corporate law framework federal chartering would bring. Even in the contemporary moment where longstanding concerns about corporate power, purpose, accountability, and the uneasy relationship between corporations and society are amplified, Delaware can continue to perform an important agency-like role in collaboration with federal regulators and regulated firms. A deeper examination comparing the merits of federal corporate chartering with Delaware's de facto agency function illuminates the potential of existing and future reforms. This Article concludes that federal chartering proposals have an important impact despite not being adopted for centuries. First, federal chartering proposals encourage policymakers to look beyond the status quo toward greater hybridization in regulatory design. Second, elements of previous federal chartering proposals have historically become successful "à la carte" reforms or part of other successful reform measures. Third, federal chartering proposals provide value as a bargaining tool where the threat of more intrusive federal regulation makes other reform methods more palatable to diverse corporate constituencies. [ABSTRACT FROM AUTHOR]

LUNG transplantation, TRANSPLANTATION of organs, tissues, etc., BIOMARKERS, PERFUSION, and LUNGS

Biomarker-based scoring algorithms have been reported throughout the EVLP literature; however, the role that prediction models play in influencing surgical decision-making is not known. Herein, we sought to assess the impact of biomarker scoring on EVLP-decisions in a retrospective, single center study. A total of n=20 clinical EVLP cases were used in this study. Each case was independently assessed by n=15 study participants that included surgeons, surgical fellows, organ perfusion specialists, and EVLP assistants. Each EVLP case was de-identified and presented alongside an intended recipient. Participants were asked to determine the suitability of the lung for transplant (yes/no) based on standard EVLP assessments alone and their impression of the organ on a scale from 0-10. Biomarker scores were then revealed and participants were then asked to re-answer the transplant and lung suitability questions. There were a total of n=300 transplant decisions in this study with and without biomarker scoring. The use of biomarker scoring greatly increased the recommendation to transplant lungs predicted to result in post-transplant extubation <72h [OR=13; 95%CI:4-45] and significantly increased a participant's lung suitability score [+1.0; 95%CI:0.4-1.5]. For lungs predicted to have excellent recipient outcomes and the historical decision was to transplant the organ, there was a 6.7% increase in transplant recommendation. Importantly, there was a net 13.3% increase in transplant recommendation when the historical decision was to decline an organ likely to result in a good outcome. Conversely, there was a 13.3% decrease in the recommendation to transplant lungs likely to produce poor outcomes (i.e., prolonged ventilation or PGD 3) using biomarker scores (OR=0.4; 95%CI:0.16-0.98). This study demonstrates that the inclusion of biomarker scoring during EVLP can lead to an increase in organ acceptance following EVLP. Furthermore, we demonstrate that organs that were associated with poor patient outcomes are less likely to be transplanted as a result of biomarker scoring being included in EVLP assessments. Taken together, this study provides strong rationale for the adoption of biomarker scoring algorithms during EVLP. [ABSTRACT FROM AUTHOR]

Background: Soft tissue sarcoma is a rare but serious side-effect of radiotherapy to treat breast cancer, and rates are increasing in the USA. We evaluated potential co-factors in two complimentary cohorts of US breast cancer survivors.Methods: In this retrospective cohort study, we sourced data from the Kaiser Permanente (KP) cohort and the Surveillance, Epidemiology, and End Results (SEER) 13 registries cohort, both in the USA. The KP cohort included 15 940 women diagnosed with breast cancer from Jan 1, 1990, to Dec 31, 2016, in KP Colorado, KP Northwest (which serves Oregon and Southwest Washington state), or KP Washington, with detailed treatment data and comorbidities (including hypertension and diabetes at or before breast cancer diagnosis) from electronic medical records. The SEER cohort included 457 300 women diagnosed with breast cancer from Jan 1, 1992, to Dec 31, 2016, within the 13 SEER registries across the USA, with initial treatment data (yes vs no or unknown). Eligibility criteria in both cohorts were female breast cancer survivors (stage I-III) aged 20-84 years at diagnosis who had breast cancer surgery, and had survived at least 1 year after breast cancer diagnosis. The outcome of interest was any second thoracic soft tissue sarcoma (angiosarcomas and other subtypes) that developed at least 1 year after breast cancer diagnosis. Risk factors for thoracic soft tissue sarcoma were assessed using multivariable Poisson regression models.Findings: In the KP cohort, median follow-up was 9·3 years (IQR 5·7-13·9) and 19 (0·1%) of 15 940 eligible, evaluable women developed a thoracic soft tissue sarcoma (11 angiosarcomas, eight other subtypes). Most (94·7%; 18 of 19) thoracic soft tissue sarcomas occurred in women treated with radiotherapy; thus, radiotherapy was associated with a significantly increased risk of developing a thoracic soft tissue sarcoma (relative risk [RR] 8·1 [95% CI 1·1-60·4]; p=0·0052), but there was no association with prescribed dose, fractionation, or boost. The RR of angiosarcoma after anthracyclines was 3·6 (95% CI 1·0-13·3; p=0·058). Alkylating agents were associated with an increased risk of developing other sarcomas (RR 7·7 [95% CI 1·2-150·8]; p=0·026). History of hypertension (RR 4·8 [95% CI 1·3-17·6]; p=0·017) and diabetes (5·3 [1·4-20·8]; p=0·036) were each associated with around a five-times increased risk of angiosarcoma. In the SEER cohort, 430 (0·1%) of 457 300 patients had subsequent thoracic soft tissue sarcomas (268 angiosarcomas and 162 other subtypes) after a median follow-up of 8·3 years (IQR 4·3-13·9). Most (77·9%; 335 of 430) cases occurred after radiotherapy; thus, radiotherapy was associated with a significantly increased risk of developing a thoracic soft tissue sarcoma (RR 3·0 [95% CI 2·4-3·8]; p<0·0001) and, for angiosarcomas, the RR for breast-conserving surgery plus radiotherapy versus mastectomy plus radiotherapy was 1·9 (1·1-3·3; p=0·012). By 10 years after radiotherapy, the cumulative incidence of thoracic soft tissue sarcoma was 0·21% (95% CI 0·12-0·34) in the KP cohort and 0·15% (95% CI 0·13-0·17) in SEER.Interpretation: Radiotherapy was the strongest risk factor for thoracic soft tissue sarcoma in both cohorts. This finding, along with the novel findings for diabetes and hypertension as potential risk factors for angiosarcomas, warrant further investigation as potential targets for prevention strategies and increased surveillance.Funding: US National Cancer Institute and National Institutes of Health. [ABSTRACT FROM AUTHOR]

MEDICAL care costs, EPIDERMAL growth factor receptors, BREAST cancer, HORMONE receptors, HOSPITAL costs, and CANCER treatment

Objectives: Policy makers increasingly seek to complement data from clinical trials with information from routine care. This study aims to provide a detailed account of the hospital resource use and associated costs of patients with advanced breast cancer in The Netherlands.Methods: Data from 597 patients with advanced breast cancer, diagnosed between 2010 and 2014, were retrieved from the Southeast Netherlands Advanced Breast Cancer Registry. Database lock for this study was in October 2017. We report the observed hospital costs for different resource categories and the lifetime costs per patient, adjusted for censoring using Lin's method. The relationship between patients' characteristics and costs was studied using multivariable regression.Results: The average (SE) lifetime hospital costs of patients with advanced breast cancer were €52 709 (405). Costs differed considerably between patient subgroups, ranging from €29 803 for patients with a triple-negative subtype to €92 272 for patients with hormone receptor positive and human epidermal growth factor receptor 2 positive cancer. Apart from the cancer subtype, several other factors, including age and survival time, were independently associated with patient lifetime costs. Overall, a large share of costs was attributed to systemic therapies (56%), predominantly to a few expensive agents, such as trastuzumab (15%), everolimus (10%), and bevacizumab (9%), as well as to inpatient hospital days (20%).Conclusions: This real-world study shows the high degree of variability in hospital resource use and associated costs in advanced breast cancer care. The presented resource use and costs data provide researchers and policy makers with key figures for economic evaluations and budget impact analyses. [ABSTRACT FROM AUTHOR]

Introduction En 2001 les autorités sanitaires de Mayotte, confrontées à une situation inquiétante, mettent en place un nouveau plan de lutte antipaludique dont le succès est immédiat mais transitoire dans certaines zones. En 2009 en effet, on observe une reprise de la transmission dans le principal foyer de l’île, la commune de Bandraboua, essentiellement dans des villages temporaires de forêt dénommés « villages de gratte ». Les investigations concluent à une défaillance de la politique de pulvérisation intradomiciliaire (PID) systématique menée jusqu’alors. Une expérience pilote, consistant en la substitution des PID par l’installation généralisée de moustiquaires à imprégnation durable (MID) débute donc en 2010 dans cette commune. L’objectif de l’étude est de décrire l’impact de cette modification majeure du programme de lutte antipaludique menée à Mayotte sur un foyer historique de transmission de l’île. Matériels et méthodes Toutes les fiches de notification de cas de paludisme établies de 2002 à 2016 par les médecins et biologistes de l’île pour des patients résidant à Bandraboua ont été analysées. Seuls les cas présumés autochtones, selon les critères de définition actuels, ont été retenus. Résultats Sur la période étudiée, 2009 cas autochtones ont été notifiés à Bandraboua où 2 foyers sont identifiés : le village de Dzoumogné avec 1228 cas (61 %) et celui de Bouyouni avec 684 cas (34 %). Au sein de la commune l’incidence annuelle est passée de 64 ‰ en 2002 (479 cas) à 0,1 ‰ en 2011 (1 seul cas notifié en janvier 2011 dans le village de Bouyouni). De 2012 à 2015, l’incidence est nulle (aucun cas). Ces 4 années consécutives sans aucun cas traduisent l’efficacité du programme de lutte en vigueur. En 2016 on assiste malheureusement à une reprise de la transmission avec 12 cas (incidence 1,8 ‰), tous survenus au sein d’un village de gratte de Bouyouni. L’enquête relève un défaut de suivi et de renouvellement des MID durant 6 années. L’efficacité après 3 ans de ces moustiquaires était pourtant incertaine. Conclusion Les MID, en substitution aux PID, ont prouvé leur efficacité dans le programme de lutte antipaludique menée à Mayotte et la généralisation de leur distribution à l’ensemble de l’île décidée en 2012 est légitime. Il est impératif que le programme MID fasse l’objet d’un suivi rigoureux avec renouvellement régulier des moustiquaires. Il ne faudrait pas qu’à l’instar de nombreux pays, satisfaites des bons résultats de leur programme de lutte, les autorités sanitaires de Mayotte baissent la garde face à la maladie. Le retour de bâton serait immédiat, à l’image de la situation à Bouyouni en 2016. La réactivation récente d’un comité technique de gestion du paludisme à Mayotte devrait permettre de redresser la barre. Depuis 2014, l’OMS classe Mayotte parmi les territoires en phase d’élimination du paludisme. L’espoir d’obtenir le statut de zone exempte de la maladie reste permis, malgré un environnement géographique peu favorable. [ABSTRACT FROM AUTHOR]

PATIENT satisfaction, MEDICAL quality control, BREAST cancer, MEDICAL communication, and AGE factors in disease

Objectives: The Medical University of South Carolina implemented a patient-centered multidisciplinary breast clinic program (MDBC) in August 2012. In this study, patient satisfaction with the MDBC care delivery model and communication with healthcare providers was examined to inform the refinement of the MDBC program. Methods: During the first 10 months of the MDBC, patients were asked to complete a 14-question postconsultation telephone survey. A statistical analysis was performed to explore potential associations between age, race, and stage with overall patient satisfaction scores. Results: Overall, patients (N = 52, 56% white, 42% African American, 2% Hispanic; mean age 61 years) rated the quality of care highly (mean 4.7, range [1 = poor to 5 = excellent]) and felt comfortable with their plan of care (mean 1.63, range [1 = extremely comfortable to 5 = not at all comfortable]). No statistically significant differences in overall satisfaction were found by age, race, or stage; however, patient responses were commonly not optimal (ie, either "no" or "yes, but not as much as I would like") when asked if the care team addressed the impact of their diagnosis on personal relationships (40.4%) or emotional health (28.9%). Conclusions: Patients were highly satisfied with the care they received in the MDBC program. Findings suggest that this model is well suited to a diverse patient population and have highlighted quality improvement targets such as increased emphasis on providers' communication about psychosocial issues. [ABSTRACT FROM AUTHOR]

SMELL disorders, COVID-19, CENTRAL nervous system viral diseases, ODORS, and OLFACTOMETRY

Anosmia has been recognized as a prevalent and early symptom by many COVID-19 patients. However, most researchers have recorded smell dysfunction solely as present or absent and based on subjective evaluation by patients. We described the results of 57 consecutive COVID-19 patients seen at FIOCRUZ, Rio de Janeiro, Brazil, from April to May 2020. Data about the presence of smell loss, the onset of smell loss and other COVID-19 symptoms such as ageusia and nasal congestion or rhinorrhea were recorded. All patients at the initial consultation and 34 healthy controls underwent the Q-SIT, which is a quick disposable three-item smell identification test, by a trained physician. We compared three groups: healthy controls, COVID+ patients with reported smell loss (COVID w/ SL) and COVID+ patients without smell loss (COVID+ w/o SL). The mean age of patients was 41.4 years (SD ± 10.4), and 54.4% were women. Smell loss was reported by 40.4% of COVID-19 patients. We observed a gradual effect with higher Q-SIT scores in healthy controls, followed by COVID+ w/o SL and COVID+ w/ SL (medians = 3, 2 and 0; respectively, p < 0.001). Anosmia or severe microsmia (Q-SIT≤1) was present in 11.1% (CI: 3.1%–26.1%) of controls, 32.4% (CI: 17.4%–50.5%) of COVID-19 w/o SL and 87% (CI: 66.4%–97.2%) of COVID+ w/ SL (p < 0.001). This study provides evidence that olfactory dysfunction in COVID-19 is common and more prevalent than what is perceived by patients. Q-SIT is a quick and reliable screening test for the detection of smell dysfunction during the pandemics. • Smell dysfunction is frequent in COVID-19 patients. • Subtle olfactory dysfunction is frequently not perceived by patients when inquired during medical visits. • Q-SIT is a quick and reliable screening test for the detection of smell dysfunction during the pandemics. [ABSTRACT FROM AUTHOR]

DENTAL arch, BRACKETS, CORRECTIVE orthodontics, PAIN perception, and ORAL surgery

The use of self-ligating brackets, in different brands, has significantly grown over the last decade. Are they really better than conventional brackets? The answer tends to be "yes", regarding the efficiency of initial alignment, the changes in arch-form, the global reduction of treatment time, less clinical appointments and less pain perception by the patient. The explanation to this is to be found in the development of light forces by these brackets, which make the tooth movements smoother due to lower friction. The cases shown have been treated with GAC's In-ovation R, C and L brackets. Some of the cases have had an accessory treatment with RPE (rapid palatal expander) or the use of mini-screws. Others are preparations to oral maxillary surgery. [ABSTRACT FROM AUTHOR]

ATTEMPTED suicide, BIPOLAR disorder, LOGISTIC regression analysis, SUICIDAL behavior, and MULTIPLE regression analysis

The purpose of the present study was to detect demographic and clinical factors associated with lifetime suicide attempts in Bipolar Disorder (BD). A total of 1673 bipolar patients from different psychiatric departments were compared according to the lifetime presence of suicide attempts on demographic/clinical variables. Owing to the large number of variables statistically related to the dependent variable (presence of suicide attempts) at the univariate analyses, preliminary multiple logistic regression analyses were realized. A final multivariable logistic regression was then performed, considering the presence of lifetime suicide attempts as the dependent variable and statistically significant demographic/clinical characteristics as independent variables. The final multivariable logistic regression analysis showed that an earlier age at first contact with psychiatric services (odds ratio [OR] = 0.97, p < 0.01), the presence of psychotic symptoms (OR = 1.56, p < 0.01) or hospitalizations (OR = 1.73, p < 0.01) in the last year, the attribution of symptoms to a psychiatric disorder (no versus yes: OR = 0.71, partly versus yes OR = 0.60, p < 0.01), and the administration of psychoeducation in the last year (OR = 1.49, p < 0.01) were all factors associated with lifetime suicide attempts in patients affected by BD. In addition, female patients resulted to have an increased association with life-long suicidal behavior compared to males (OR: 1.02, p < 0.01). Several clinical factors showed complex associations with lifetime suicide attempts in bipolar patients. These patients, therefore, require strict clinical monitoring for their predisposition to a less symptom stabilization. Future research will have to investigate the best management strategies to improve the prognosis of bipolar subjects presenting suicidal behavior. [ABSTRACT FROM AUTHOR]

Extensive use of endocrine disruptor compounds (EDCs) and their release through various pathways into the environment are emerging environmental concerns. In this context, H 2 O 2 and chlorine UV-based treatments were carried out to evaluate their efficiency in the removal of the bisphenol A (BPA), 17β-estradiol (E2) and 17α-ethinylestradiol (EE2) at 100 μg L−1 from ultrapure water and from wastewater treatment plants (WWTP). Photolysis was performed under different irradiation sources, i.e. UVC and UVA. The effect of H 2 O 2 (3 and 30 mg·L−1), free chlorine concentrations (1 and 2 mg·L−1) and pH (5, 7 and 9) were also investigated. Toxicity (Raphidocelis subcapitata) and estrogenic activity (yeast estrogen screen - YES assay) were assessed during the processes. Compound removal at optimal operating parameters reached 100% after 15 and 2 min for UVC/H 2 O 2 (pH 9 and 3 mg L−1 of H 2 O 2), and UVC/Cl (pH 9 and 2 mg L−1 of chlorine), respectively. Total organic carbon (TOC) removal achieved 37% and 45% for the H 2 O 2 and Cl-UV based process, respectively. The in vitro YES assay indicated that the formed by-products were non-estrogenic compounds, while the toxicity evaluation revealed high cell growth inhibition due to UVC/Cl byproducts. During the UV-based processes, 30 transformation products (TPs) were identified, in which three new chlorinated TPs from E2 and EE2 may be responsible for toxicity effects. EDC degradation by UV/Cl is faster than by UV/H 2 O 2 , although chlorinated toxic byproducts were also formed during the UV/Cl process. Unlabelled Image • The Cl/UV process is more efficient than H 2 O 2 /UV in removing E2, EE2 and BPA. • Both processes are capable of removing WWTP EDCs. • EDC degradation products do not display estrogenic activity. • The Cl/UV process produces high toxicity TPs. • Three new TPs were identified during the Cl/UV process. [ABSTRACT FROM AUTHOR]

PROTEIN-tyrosine kinase inhibitors, GENE transfection, EPIDERMAL growth factor, ENDOTHELIAL growth factors, TUMORS, PHARMACOKINETICS, and PATIENTS

Background: JNJ-26483327 is an oral, potent, multi-targeted tyrosine kinase inhibitor, inhibiting kinases of epidermal growth factor receptor (EGFR)-1, -2 and -4, rearranged during transfection (RET) receptor, vascular endothelial growth factor receptor (VEGFR)-3 and Src family (Lyn, Fyn, Yes) at low nanomolar concentrations. This phase I, accelerated titration study assessed maximum tolerated dose, safety, pharmacokinetics and pharmacodynamic effects of JNJ-26483327.Methods: Nineteen patients with advanced cancers received JNJ-26483327 continuous twice daily (BID) in escalating dose cohorts ranging from 100 to 2100 mg. Pharmacodynamic effects were assessed in paired skin biopsies and blood.Results: JNJ-26483327 was well tolerated in doses up to 1500 mg BID, with target-inhibition-related toxicity such as diarrhoea and skin rash, and other common reported toxicities being nausea, vomiting, anorexia and fatigue. At 2100 mg, two episodes of dose-limiting toxicity were observed, consisting of grade 3 anorexia and a combination of grade 3 anorexia and fatigue, respectively. Pharmacokinetics were dose proportional up to 1500 mg in which plasma levels were obtained showing anti-tumour activity in xenograft mouse models. Pharmacodynamic analysis did not show a substantial effect on expression of Ki-67, p27(kip1), phosphorylated mitogen-activated protein kinase, phosphorylated Akt and EGFR, and serum levels of sVEGFR-2, VEGF-C and VEGF-D remained unchanged. Stable disease was noted in six patients (32%).Conclusion: JNJ-26483327 is well tolerated and shows a predictable pharmacokinetic profile; the recommended dose for further studies is 1500 mg BID. [ABSTRACT FROM AUTHOR]

RUBIACEAE, WEEDS, PLANT viruses, SEED industry, and ERIOPHYIDAE

Galium spurium L. (Rubiaceae), native to Europe, is an increasingly serious annual weed of cultivated crops in the prairie provinces of Canada. The gall mite Cecidophyes rouhollahi Craemer (Acari, Eriophyidae), originally found on the related plant species Galium aparine L. in southern France, was evaluated as a potential biological control agent for G. spurium. In greenhouse tests, C. rouhollahi caused severe stunting and complete prevention of seed production by G. spurium. Host specificity tests showed that C. rouhollahi developed only on three closely related annual Galium species in the Kolgyda section. No native North American Galium species were attacked, with the exception of G. aparine. A review of available information on G. aparine suggests that it is probably an introduced species in North America. It has been reported that a related gall mite attacking G. aparine might be associated with a plant virus. A series of tests on a greenhouse colony of G. spurium infested with C. rouhollahi showed no evidence of viral infection. On the basis of these results, C. rouhollahi has been approved for field release against G. spurium in Canada. [ABSTRACT FROM AUTHOR]

REPRODUCIBLE research, ULTRASONIC imaging, UTERUS abnormalities, COHORT analysis, LONGITUDINAL method, and COHEN'S kappa coefficient (Statistics)

Objective Purpose of this study is to determine the interobserver and intraobserver variability of 3D GIS in the assessment of intrauterine abnormalities. Study design Forty five 3D volumes were randomly selected from a larger prospective cohort study that studied the diagnostic accuracy of 3D GIS in addition to 2D GIS. To study interobserver agreement volumes were reviewed by two independent examiners. One examiner reviewed these samples twice with an interval of 1 month in a random order. Interobserver and intraobserver agreement were tested with Cohen's kappa coefficient and shown in Bland and Altman plots. Quality of the 3D volumes was evaluated. Results Cohen's kappa for interobserver variability for type of abnormalities (none, polyp, fibroid, other) was 0.64 and for presence of a fibroid (fibroid yes/no) 0.77. Agreement on type of fibroid was 0.59. Intraobserver agreement was almost perfect for type of abnormality (Cohen's kappa of 1.0) and good for fibroid diameter. Quality of the 3D volumes was poor in 11 out of 45 cases. Reproducibility increased when poor quality images were excluded. Conclusion Substantial interobserver and intraobserver agreement for 3D GIS in the diagnoses of intrauterine abnormalities was found. 3D GIS interobserver and intraobserver agreement are good for fibroid diameter and moderate for volume and protrusion. [ABSTRACT FROM AUTHOR]

The article discusses the issue of education youth and adults (EJA). The objective is to analyze, from the perspective of students, as Mossoro campus IFRN comes materializing the proposed curriculum of integrated technical course in Building the EJA modality, offered under the National Programme Vocational Education Integration with Basic Education in the Modality Youth and Adult education (PROEJA). Methodologically, the study is included in the exploratory-descriptive category, based on dialectics. The sources of information are the Pedagogical Project of the Course and the data (questionnaires and interviews) collected from students last semester of the first class of the course. Considering the pedagogical practices developed by teachers, it appears that there is no concrete evidence of an integrated curriculum in the course and, yes, that only a few didactic actions, very specific and not systematic or planned collectively contribute to this end. [ABSTRACT FROM AUTHOR]

Leachate, Landfills, Vermicomposting, Solid waste management, Eisenia, Earthworms, and Risk assessment

Leachate is difficult to biodegrade, and presents variable physical, chemical and biological characteristics, as well as high toxicological potential for soil, groundwater and water bodies. In this context, untreated leachate toxicity was evaluated through acute and chronic exposures in Eisenia andrei earthworms. Physico-chemical leachate characterizations indicate a complex composition, with high organic matter (COD – 10,634 mg L−1) and ammoniacal nitrogen (2388 mg L−1) concentrations. Metals with carcinogenic potential, such as Cr, As and Pb, were present at 0.60, 0.14 and 0.01 μg L−1, respectively and endocrine disrupting compounds were detected in estradiol equivalents of 660 ± 50 ng L−1. Acute tests with Eisenia andrei indicated an LC 50 (72 h) of 1.3 ± 0.1 μL cm−2 in a filter paper contact test and 53.9 ± 1.3 mL kg−1 in natural soil (14 days). The EC 50 in a behavioral test was estimated as 31.6 ± 6.8 mL kg−1, indicating an escape effect for concentrations ranging from 35.0 to 70.0 mL kg−1 and habitat loss from 87.5 mL kg−1 of leachate exposure. Chronic exposure (56 days) led to reproduction effects, resulting in a 4-fold decreased cocoon production and 7-fold juvenile decrease. This effect was mainly attributed to the possible presence of endocrine disrupting compounds. An estimated NOAEL of 1.7 mL L−1 and LOAEL of 3.5 mL L−1 were estimated for earthworms exposed to the assessed effluent. Extremely high-risk quotients (RQ ≥ 1) were estimated based on leachate application in irrigation. Thus, adequate municipal solid waste management is paramount, especially with regard to generated by-products, which can result in high toxicological risks for terrestrial organisms. [Display omitted] • Thirty metals and high COD and ammoniacal nitrogen were determined in leachate. • Leachate exhibited high estrogenic activity by the YES assay. • Leachate exposure resulted in Eisenia andrei earthworm escape and loss of habitat. • Reproduction effects were noted in leachate-exposed earthworms. • Leachate was considered as high environmental risk (RQ ≥ 1). [ABSTRACT FROM AUTHOR]

ULTRAVIOLET photolysis, WASTEWATER treatment, HYDROGEN peroxide, COMPOSITION of water, XENOESTROGENS, COST effectiveness, and BIOLOGICAL assay

In this study, UV based treatments were implemented at pilot scale to assess their ability to remove hormones from treated wastewater, especially with the view to equip small and medium size Wastewater Treatment Plants (WTPs). To this end, the degradation of a mixture of estrogenic hormones (Estrone (E1), β-Estradiol (E2), and 17α-Ethinyl Estradiol (EE2)) in waters by UV photolysis and UV/H 2 O 2 process was investigated in real conditions. A particular attention was paid at designing a well validated laboratory scale pilot in order to optimise oxidant concentrations and UV fluence. A Low pressure lamp (254 nm) was used in a flow through commercial reactor. The effects of water matrices (drinking water and treated wastewater) and H 2 O 2 concentrations (10, 40, and 90 mg/L) on the pilot efficiency were first determined. Only E1 could be partially degraded by UV photolysis whereas hormones were all well removed by UV/H 2 O 2 process in both matrices. The second part of the study focused on a chemical and biological assessment of UV photolysis and UV/H 2 O 2 process (30 and 50 mg/L). Degradation rate constants of hormones as well as changes in estrogenic activity (YES bioassay) and toxicity ( Vibrio fischeri ) were followed at the same time. UV photolysis could not remove neither estrogens nor estrogenic activity at relevant UV fluence in waters. However 80% of initial estrogenic compounds and estrogenic activity could be removed from treated wastewater by combining UV fluence of 423 and 520 mJ/cm 2 with 50 and 30 mg/L of H 2 O 2 , respectively. No high estrogenic or toxic by-products were detected by the two bioassays following UV photolysis or UV/H 2 O 2 process. Operating costs were estimated for a full scale pilot. H 2 O 2 was the major cost. By combining the appropriate concentration of H 2 O 2 and UV fluence, it could be possible to design a cost effective treatment for treating estrogens in small and medium size WTPs. [ABSTRACT FROM AUTHOR]

PHYSICAL activity, SKIN diseases, SPANIARDS, CHRONIC diseases, and METABOLIC equivalent

Background: To date there is limited literature on the prevalence of chronic skin conditions and its association with levels of physical activity (PA) in Spain. Aim: To determine the prevalence of chronic skin disease and to compare levels of PA between people with and without chronic skin disease in a large representative sample of Spanish adults aged 15–69 years. Methods: Data from the Spanish National Health Survey 2017 were analysed. Chronic skin disease was assessed using a yes/no question. PA was measured using the short form of the International Physical Activity Questionnaire. Total PA metabolic equivalent of task min/week were calculated, and PA was included in the analyses as a continuous and a five‐category variable. Results: This cross‐sectional study included 17 777 adult participants (52.0% women; mean ± SD age 45.8 ± 14.1 years), of whom 940 (5.3%) had chronic skin disease. After adjusting for several potential confounders, there was a negative association between chronic skin disease and PA (OR = 0.87, 95% CI 0.76–1.00, P = 0.05), which was significant for men (OR = 0.76, 95% CI 0.62–0.93, P = 0.01) but not for women (OR = 0.97, 95% CI 0.81–1.16, P = 0.72). Conclusions: In this large representative sample of Spanish adults, the prevalence of chronic skin disease was low. Levels of PA were lower in men with than in men without chronic skin conditions, but this association was not seen in women. [ABSTRACT FROM AUTHOR]

HUNTINGTON disease, YAP signaling proteins, HIPPO signaling pathway, HUMAN embryonic stem cells, and MEDICAL model

The Hippo pathway, a highly conserved signaling cascade that functions as an integrator of molecular signals and biophysical states, ultimately impinges upon the transcription coactivator Yes-associated protein 1 (YAP). Hippo-YAP signaling has been shown to play key roles both at the early embryonic stages of implantation and gastrulation, and later during neurogenesis. To explore YAP's potential role in neurulation, we used self-organizing neuruloids grown from human embryonic stem cells on micropatterned substrates. We identified YAP activation as a key lineage determinant, first between neuronal ectoderm and nonneuronal ectoderm, and later between epidermis and neural crest, indicating that YAP activity can enhance the effect of BMP4 stimulation and therefore affect ectodermal specification at this developmental stage. Because aberrant Hippo-YAP signaling has been implicated in the pathology of Huntington's Disease (HD), we used isogenic mutant neuruloids to explore the relationship between signaling and the disease. We found that HD neuruloids demonstrate ectopic activation of gene targets of YAP and that pharmacological reduction of YAP's transcriptional activity can partially rescue the HD phenotype. [ABSTRACT FROM AUTHOR]

HEAT equation, UNIQUENESS (Mathematics), NONLINEAR equations, CAUCHY problem, and INFINITE integrals

We study the existence of infinitely many solutions for the Cauchy problem associated with the nonlinear heat equation u t = ( u m − 1 u x ) x in the fast diffusion range of exponents −1 < m ≤ 0 with initial data u 0 ≥ 0, u 0 ≢ 0. The issue of non-uniqueness arises because of the singular character of the diffusivity for u ≈ 0. The precise question we want to clarify is: can we have multiple solutions even for initial data which are far away from the singular level u = 0, for instance for u 0 ( x ) ≡ 1? The answer is, rather surprisingly, yes. Indeed, there are infinitely many solutions for every given initial function. These properties differ strongly from other usual types of heat equations, linear or nonlinear. We take as initial data an arbitrary function in L loc 1 ( R ) . We prove that when the initial data have infinite integral on a side, say at x = ∞, then we can choose either to have infinite mass for all small times at least on that side, and the choice is then unique, or finite mass, and then we need to prescribe a flux function with diverging integral at t = 0, being otherwise quite general. Moreover, a new parameter appears in the solution set. The behaviour on both ends, x = ∞ and x = −∞ is similar and independent. [ABSTRACT FROM AUTHOR]

BRAIN physiology, ELECTROENCEPHALOGRAPHY, MEMORY, RECOGNITION (Psychology), STATISTICAL sampling, RANDOMIZED controlled trials, PROMPTS (Psychology), REPEATED measures design, and ONE-way analysis of variance

Items that are produced (e.g., read aloud) during encoding typically are better remembered than items that are not produced (e.g., read silently). This "production effect" has been explained by distinctiveness: Produced items have more distinct features than nonproduced items, leading to enhanced retrieval. The goal of the current study was to use electroencephalography (EEG) to examine the neural basis of the production effect. During study, participants were presented with words that they were required to read silently, read aloud, or sing while EEG data were recorded. Subsequent memory performance was tested using a yes/no recognition test. Analysis focused on the event-related brain potentials (ERPs) evoked by the encoding instruction cue for each instruction condition. Our data revealed enhanced memory performance for produced items and a greater P300 ERP amplitude for instructions to sing or read aloud compared with instructions to read silently. Our results demonstrate that the amplitude of the P300 is modulated by at least 1 aspect of production, vocalization (singing/reading aloud relative to reading silently), and are consistent with the distinctiveness account of the production effect. The ERP methodology is a viable tool for investigating the production effect. [ABSTRACT FROM AUTHOR]

HELP-seeking behavior, TINNITUS, and HEARING disorders

Knowledge on characteristics of people that seek help for tinnitus is scarce. The primary objective of this study was to describe differences in characteristics between people with tinnitus that seek help compared to those who do not seek help. Next, we described differences in characteristics between those with and without tinnitus. In this cross-sectional study, we sent a questionnaire on characteristics in different domains; demographic, tinnitus-specific, general- and psychological health, auditory and noise- and substance behaviour. We assessed if participants had sought help or planned to seek help for tinnitus. Tinnitus distress was defined with the Tinnitus Functional Index. Differences between groups (help seeking: yes/no, tinnitus: yes/no) were described. 932 people took part in our survey. Two hundred and sixteen participants were defined as having tinnitus (23.2%). Seventy-three of those sought or planned to seek help. A constant tinnitus pattern, a varying tinnitus loudness, and hearing loss, were described more frequently in help seekers. Help seekers reported higher TFI scores. Differences between help seekers and people not seeking help were mainly identified in tinnitus- and audiological characteristics. These outcomes might function as a foundation to explore the heterogeneity in tinnitus patients. [ABSTRACT FROM AUTHOR]

Endocrine disruptors, Suspended solids, Rivers, Endocrine glands, and Endocrine system

Endocrine disrupting chemicals (EDC) are exogenous substances that can potentially mimic hormonal substances and cause adverse effects on the endocrine system of living beings. The behavior and fate of these compounds in the environment is directly related to their physical-chemical properties, which indicate great affinity for solid and organic particles and suggest an inherent mechanism of fractionation between dissolved and particulate phases of aqueous matrices. However, few studies have been considering this fact when quantifying these pollutants and their effects through bioassays. In this study, the fractionation of estrogenic substances between dissolved and particulate phases in an urban stream was investigated via estrogenic activity evaluation by the YES assay. Two fractions of suspended solids (< 0.7 µm and between 0.45 and 0.7 µm) and the dissolved phase were considered and two approaches of SPE percolations were applied. Total estradiol equivalent (E2-Eq) values were observed in the 29–65 ng L−1 range, of which 35–62% were associated with the particulate phase. Most of the estrogenicity was associated with particles between 0.45 and 0.7 µm, whereas cytotoxicity was induced by extracts of particles greater than 0.7 µm. Results demonstrated the importance of solid fractions analysis towards the quantification of total estrogenic activity from aqueous environmental matrices and highlights the relevance of controlling fine suspended solids in sewage treatment plant effluents, regarding the control of endocrine disrupters in the environment. ga1 • High level of total estrogenic activity was quantified up to 65 ng L−1. • Phase distribution of estrogenic activity was highly influenced by SPM profile. • Cytotoxicity was recurrently associated with particles > 0.7 µm. • SPM < 0.7 µm in wastewaters might be of great concern due to associated EDC. [ABSTRACT FROM AUTHOR]

EXPERT evidence and PART-time employment

Background First-line afatinib significantly improved median progression-free survival (PFS) in pts with EGFRm+ NSCLC vs chemotherapy (CT) in LUX-Lung (LL) 3/6 (HR [95% CI]: 0.58 [0.43, 0.78]/0.28 [0.20, 0.39]), and vs gefitinib in LL7 (0.73 [0.57, 0.95]). We conducted a phase IIIb study of afatinib in a broader patient population, similar to real-world practice, of treatment-naïve or CT pre-treated pts with EGFRm+ NSCLC. Here we present an interim analysis. Methods EGFR TKI-naïve pts with locally advanced/metastatic EGFRm+ NSCLC and ECOG PS 0–2 received afatinib 40 mg/day; dose reduction was permitted (min. 20 mg/day). Primary endpoint: adverse events (AEs; descriptive fashion). Efficacy was assessed and post-hoc subgroup analysis conducted. Results 479 pts were included (data cut-off: 30/04/18): Caucasian/Asian: 97%/2%; female: 66%; 1st/2nd/≥3rd-line therapy: 78%/17%/5%; ECOG PS 0 or 1/2: 92%/8%; brain metastases: 17%; common/uncommon [C/U] mutations: 87%/13%. Median time on afatinib: 359 days. Objective response rate: 46%. Disease control rate: 86%. Median time to symptomatic progression (TTSP) and PFS were 14.9 (95% CI: 13.8, 17.6) and 13.4 (11.8, 14.5); subgroup analysis is in the table. Most common grade ≥3 afatinib-related AEs were diarrhea (16%) and rash (11%). AEs led to dose reduction in 258 (54%) pts (most frequently diarrhea 25%, rash 11%) and to afatinib discontinuation in 105 (22%) pts (malignant neoplasm progression 3%, diarrhea 3% [rash 0.8%]). Afatinib-related serious AEs occurred in 39 (8%) pts. Conclusions This analysis indicates a predictable and manageable safety profile for afatinib, consistent with the pivotal LL trials, and encouraging efficacy findings in this broad patient population. As expected, TTSP/PFS were longer for pts with ECOG PS 0/1 vs 2, and for pts with Del 19 or L858R mutations, vs those with uncommon mutations, which may be due to the high prevalence (44%) of pts with exon 20 insertions included in this study. Table: 482P   TTSP, mos   PFS, mos   Baseline characteristic (n)  Median  95% CI  Median  95% CI  Line of tx          1 (374)  15.6  14.1, 18.5  13.8  12.6, 15.2  2 (81)  14.7  11.3, 20.6  13.2  8.3, 17.7  ≥3 (24)  8.1  3.7, 14.4  6.6  3.2, 12.6  Mutations a           Del 19 b (232)  19.3  15.6, 21.8  15.9  13.9, 19.1  L858R b (162)  14.5  12.7, 17.9  13.1  11.5, 15.2  U c (84)  7.4  5.7, 9.0  6.0  4.2, 8.1  ECOG PS, inc. mutations          0–1 (442) a   15.8  14.4, 18.8  13.8  12.8, 15.2  C b (364)  18.2  15.5, 19.8  15.2  13.8, 17.7  U (77)  7.4  5.7, 9.7  6.6  4.6, 8.2  2 (36)  8.9  5.7, 13.2  6.2  2.5, 11.6  C b (30)  8.9  5.7, 13.9  7.7  3.9, 13.2  U (6)  7.0  0.9, 13.0  1.4  0.4, 6.0  Brain mets a           No (395)  15.8  14.1, 18.8  13.9  12.7, 15.5  Yes (83)  13.7  9.7, 17.2  10.1  8.2, 13.9    TTSP, mos   PFS, mos   Baseline characteristic (n)  Median  95% CI  Median  95% CI  Line of tx          1 (374)  15.6  14.1, 18.5  13.8  12.6, 15.2  2 (81)  14.7  11.3, 20.6  13.2  8.3, 17.7  ≥3 (24)  8.1  3.7, 14.4  6.6  3.2, 12.6  Mutations a           Del 19 b (232)  19.3  15.6, 21.8  15.9  13.9, 19.1  L858R b (162)  14.5  12.7, 17.9  13.1  11.5, 15.2  U c (84)  7.4  5.7, 9.0  6.0  4.2, 8.1  ECOG PS, inc. mutations          0–1 (442) a   15.8  14.4, 18.8  13.8  12.8, 15.2  C b (364)  18.2  15.5, 19.8  15.2  13.8, 17.7  U (77)  7.4  5.7, 9.7  6.6  4.6, 8.2  2 (36)  8.9  5.7, 13.2  6.2  2.5, 11.6  C b (30)  8.9  5.7, 13.9  7.7  3.9, 13.2  U (6)  7.0  0.9, 13.0  1.4  0.4, 6.0  Brain mets a           No (395)  15.8  14.1, 18.8  13.9  12.7, 15.5  Yes (83)  13.7  9.7, 17.2  10.1  8.2, 13.9  a Missing n = 1. b Del 19/L858R only. c Includes, n (%): ex 20 ins: 37 (44). Table: 482P   TTSP, mos   PFS, mos   Baseline characteristic (n)  Median  95% CI  Median  95% CI  Line of tx          1 (374)  15.6  14.1, 18.5  13.8  12.6, 15.2  2 (81)  14.7  11.3, 20.6  13.2  8.3, 17.7  ≥3 (24)  8.1  3.7, 14.4  6.6  3.2, 12.6  Mutations a           Del 19 b (232)  19.3  15.6, 21.8  15.9  13.9, 19.1  L858R b (162)  14.5  12.7, 17.9  13.1  11.5, 15.2  U c (84)  7.4  5.7, 9.0  6.0  4.2, 8.1  ECOG PS, inc. mutations          0–1 (442) a   15.8  14.4, 18.8  13.8  12.8, 15.2  C b (364)  18.2  15.5, 19.8  15.2  13.8, 17.7  U (77)  7.4  5.7, 9.7  6.6  4.6, 8.2  2 (36)  8.9  5.7, 13.2  6.2  2.5, 11.6  C b (30)  8.9  5.7, 13.9  7.7  3.9, 13.2  U (6)  7.0  0.9, 13.0  1.4  0.4, 6.0  Brain mets a           No (395)  15.8  14.1, 18.8  13.9  12.7, 15.5  Yes (83)  13.7  9.7, 17.2  10.1  8.2, 13.9    TTSP, mos   PFS, mos   Baseline characteristic (n)  Median  95% CI  Median  95% CI  Line of tx          1 (374)  15.6  14.1, 18.5  13.8  12.6, 15.2  2 (81)  14.7  11.3, 20.6  13.2  8.3, 17.7  ≥3 (24)  8.1  3.7, 14.4  6.6  3.2, 12.6  Mutations a           Del 19 b (232)  19.3  15.6, 21.8  15.9  13.9, 19.1  L858R b (162)  14.5  12.7, 17.9  13.1  11.5, 15.2  U c (84)  7.4  5.7, 9.0  6.0  4.2, 8.1  ECOG PS, inc. mutations          0–1 (442) a   15.8  14.4, 18.8  13.8  12.8, 15.2  C b (364)  18.2  15.5, 19.8  15.2  13.8, 17.7  U (77)  7.4  5.7, 9.7  6.6  4.6, 8.2  2 (36)  8.9  5.7, 13.2  6.2  2.5, 11.6  C b (30)  8.9  5.7, 13.9  7.7  3.9, 13.2  U (6)  7.0  0.9, 13.0  1.4  0.4, 6.0  Brain mets a           No (395)  15.8  14.1, 18.8  13.9  12.7, 15.5  Yes (83)  13.7  9.7, 17.2  10.1  8.2, 13.9  a Missing n = 1. b Del 19/L858R only. c Includes, n (%): ex 20 ins: 37 (44). Clinical trial identification NCT01853826. Editorial acknowledgement Christina Jennings of GeoMed, an Ashfield company, part of UDG Healthcare plc. Legal entity responsible for the study Boehringer Ingelheim. Funding Boehringer Ingelheim. Disclosure F. De Marinis: Honoraria (self): Roche; Honoraria (self): AstraZeneca; Advisory / Consultancy: Takeda; Research grant / Funding (institution): Boehringer Ingelheim. M. Hochmair: Advisory / Consultancy, Speaker Bureau / Expert testimony: Boehringer Ingelheim; Advisory / Consultancy, Speaker Bureau / Expert testimony: Merck Sharp & Dohme; Advisory / Consultancy: Novartis; Advisory / Consultancy, Speaker Bureau / Expert testimony: Roche; Speaker Bureau / Expert testimony: AstraZeneca; Speaker Bureau / Expert testimony: Bristol-Myers Squibb; Speaker Bureau / Expert testimony: Pfizer. M.R. Migliorino: Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Travel / Accommodation / Expenses: B.I.; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Travel / Accommodation / Expenses: ROCHE; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Travel / Accommodation / Expenses: MSD; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony, Travel / Accommodation / Expenses: AstraZeneca; Honoraria (self), Advisory / Consultancy, Speaker Bureau / Expert testimony: PFIZER. G.Z. Mukhametshina: Advisory / Consultancy: Association of oncologists of Russian Federation; Full / Part-time employment: State Autonomous Healthcare Institution «Republican Clinical Oncology Dispensary of the Ministry of Health of the Republic of Tatarstan». M. Schumacher: Honoraria (self), Advisory / Consultancy: BMS; Honoraria (self), Advisory / Consultancy: MSD; Honoraria (self), Advisory / Consultancy: Roche; Honoraria (self), Advisory / Consultancy: Pfizer; Honoraria (self), Advisory / Consultancy: AstraZeneca. S. Novello: Advisory / Consultancy, Speaker Bureau / Expert testimony: AstraZeneca; Advisory / Consultancy, Speaker Bureau / Expert testimony: BI; Advisory / Consultancy, Speaker Bureau / Expert testimony: MSD; Advisory / Consultancy, Speaker Bureau / Expert testimony: BMS; Advisory / Consultancy, Speaker Bureau / Expert testimony: Roche; Advisory / Consultancy, Speaker Bureau / Expert testimony: AbbVie; Advisory / Consultancy, Speaker Bureau / Expert testimony: Celgene; Advisory / Consultancy, Speaker Bureau / Expert testimony: Eli Lilly; Advisory / Consultancy, Speaker Bureau / Expert testimony: Pfizer; Advisory / Consultancy, Speaker Bureau / Expert testimony: Takeda. R. Dziadziuszko: Honoraria (self): Pfizer; Honoraria (self): Boehringer Ingelheim; Honoraria (self), Travel / Accommodation / Expenses: AstraZeneca; Honoraria (self), Travel / Accommodation / Expenses: Roche; Honoraria (self): MSD; Honoraria (self): Bristol-Myers Squibb. W. Tang: Full / Part-time employment: Boehringer Ingelheim. L. Clementi: Full / Part-time employment: Boehringer Ingelheim Italia SpA. A. Cseh: Full / Part-time employment: Boehringer Ingelheim. All other authors have declared no conflicts of interest. [ABSTRACT FROM AUTHOR]

ONCOLOGY, TUMORS, CANCER, AGE, and TUMORS in children

Background: To enhance risk stratification for Wilms tumour (WT) in a pre-operative chemotherapy setting, we explored the prognostic significance and optimal age cutoffs in patients treated according to International Society of Paediatric Oncology Renal Tumour Study Group (SIOP-RTSG) protocols. Methods: Patients(6 months-18 years) with unilateral WT were selected from prospective SIOP 93–01 and 2001 studies(1993–2016). Martingale residual analysis was used to explore optimal age cutoffs. Outcome according to age was analyzed by uni- and multivariable analysis, adjusted for sex, biopsy(yes/no), stage, histology and tumour volume at surgery. Results: 5631 patients were included; median age was 3.4 years(IQR: 2–5.1). Estimated 5-year event-free survival (EFS) and overall survival (OS) were 85%(95%CI 83.5–85.5) and 93%(95%CI 92.0–93.4). Martingale residual plots detected no optimal age cutoffs. Multivariable analysis showed lower EFS with increasing age(linear trend P<0.001). Using previously described age categories, EFS was lower for patients aged 2-4(HR 1.34, P = 0.02), 4-10(HR 1.83, P<0.0001) and 10–18 years(HR 1.74, P = 0.01) as compared to patients aged 6 months-2 years. OS was lower for patients 4–10 years(HR 1.67, P = 0.01) and 10–18 years(HR 1.87, P = 0.04), but not for 2–4 years(HR 1.29, P = 0.23). Higher stage, histological risk group and tumour volume were independent adverse prognostic factors. Conclusion: Although optimal age cutoffs could not be identified, we demonstrated the prognostic significance of age as well as previously described cutoffs for EFS (2 and 4 years) and OS (4 years) in children with WT treated with pre-operative chemotherapy. These findings encourage the consideration of age in the design of future SIOP-RTSG protocols. [ABSTRACT FROM AUTHOR]

HEMATOPOIETIC stem cell transplantation, HOMOGRAFTS, MYELODYSPLASTIC syndromes, ACUTE myeloid leukemia, BLOOD donors, AZACITIDINE, COMPARATIVE studies, and DISEASE risk factors

Standard first-line therapy for older patients with high-risk myelodysplastic syndrome (MDS) includes hypomethylating agents, such as azacitidine (AZA). However, the only approach with curative potential remains allogeneic hematopoietic cell transplantation (HCT). To date, no direct comparison of both strategies has been reported. The outcomes of 2 well-balanced cohorts of patients with high-risk MDS defined by age (60-70 years), performance status (Eastern Cooperative Oncology Group score ≤2), and donor availability (yes/no) were compared, including 103 patients undergoing HCT and 75 patients without this option who received AZA. The estimated 2-year overall survival after the start of treatment was 39% (95% confidence interval, 30%-50%) for the patients undergoing HCT and 23% (95% confidence interval, 14%-40%) for the patients receiving AZA therapy. In a multivariate Cox regression analysis of all patients (n = 178), Eastern Cooperative Oncology Group score (0 versus 1 versus 2; hazard ratio [HR], 2.9/3.9; P <  .001), cytogenetics (good versus intermediate versus poor; HR, 1.2/1.7; P = .026), and treatment (HCT versus AZA; HR, 0.3; P = .007) were associated with overall survival. This retrospective cohort analysis suggests a survival advantage for allogeneic HCT compared with AZA therapy in medically fit patients with high-risk MDS age 60-70 years. Prospective controlled studies are warranted. [ABSTRACT FROM AUTHOR]

HEADACHE, TURKS, DISEASE prevalence, PSYCHIATRY, ANXIETY, MENTAL depression, COMORBIDITY, and HEALTH

Purpose: The aim of this study was to evaluate the prevalence of headache in psychiatry clinics. Method: Three hundred and seventy two consecutive patients aged between 18 and 82 (Mean: 36.4±13.2) years were interviewed with a semi-structured interview form. All patients were asked whether they had headache or not. If they answered 'yes, the differential diagnosis of headache was made. Findings: Two-hundred and fifty- two patients (67.7%) did not complain any kind of headache. Migraine (13.7%, n=51) and tension type headaches (12.6%, n=47) were the most commonly seen headaches in psychiatry outpatient clinics. The frequency of migraine in subjects with anxiety disorder was higher than that in subjects with other psychiatric conditions including major depression. The frequency of tension type headache was higher in subjects with anxiety disorder in comparison to other psychiatric disorders, too. We found a statistically significant positive relationship between anxiety disorder or depression, and headache disorders (p<0.00). The tension type or chronic daily headache was seen at later ages but migraine in younger ages (p<0.00). The prevalence of migraine was similar in psychiatry clinics and in the general population of Turkey previously reported. The similar frequency of headache in psychiatry clinics is probably due to a comorbidity with psychiatric diseases. Discussion and Conclusion: We concluded that it was important to ask standard questions about headache in the course of the anamnesis in patients with major depression and anxiety disorder. [ABSTRACT FROM AUTHOR]

RHINITIS, WHEEZE, MILK allergy, EXERCISE-induced asthma, METERED-dose inhalers, FOOD allergy, and PROGNOSIS

Table of contents: WORKSHOP 4: Challenging clinical scenarios (CS01–CS06) CS01 Bullous lesions in two children: solitary mastocytoma S. Tolga Yavuz, Ozan Koc, Ali Gungor, Faysal Gok CS02 Multi‐System Allergy (MSA) of cystic fibrosis: our institutional experience Jessica Hawley, Christopher O'Brien, Matthew Thomas, Malcolm Brodlie, Louise Michaelis CS03 Cold urticaria in pediatric age: an invisible cause for severe reactions Inês Mota, Ângela Gaspar, Susana Piedade, Graça Sampaio, José Geraldo Dias, Miguel Paiva, Mário Morais‐Almeida CS04 Angioedema with C1 inhibitor deficiency in a girl: a challenge diagnosis Cristina Madureira, Tânia Lopes, Susana Lopes, Filipa Almeida, Alexandra Sequeira, Fernanda Carvalho, José Oliveira CS05 A child with unusual multiple organ allergy disease: what is the primer? Fabienne Gay‐Crosier CS06 A case of uncontrolled asthma in a 6‐year‐old patient Ioana‐Valentina Nenciu, Andreia Florina Nita, Alexandru Ulmeanu, Dumitru Oraseanu, Carmen Zapucioiu ORAL ABSTRACT SESSION 1: Food allergy (OP01–OP06) OP01 Food protein‐induced enterocolitis syndrome: oral food challenge outcomes for tolerance evaluation in a Pediatric Hospital Adrianna Machinena, Olga Domínguez Sánchez, Montserrat Alvaro Lozano, Rosa Jimenez Feijoo, Jaime Lozano Blasco, Mònica Piquer Gibert, Mª Teresa Giner Muñoz, Marcia Dias da Costa, Ana Maria Plaza Martín OP02 Characteristics of infants with food protein‐induced enterocolitis syndrome and allergic proctocolitis Ebru Arik Yilmaz, Özlem Cavkaytar, Betul Buyuktiryaki, Ozge Soyer, Cansin Sackesen OP03 The clinical and immunological outcomes after consumption of baked egg by 1–5 year old egg allergic children: results of a randomised controlled trial MerrynNetting, Adaweyah El‐Merhibi, Michael Gold, PatrickQuinn, IrmeliPenttila, Maria Makrides OP04 Oral immunotherapy for treatment of egg allergy using low allergenic, hydrolysed egg Stavroula Giavi, Antonella Muraro, Roger Lauener, Annick Mercenier, Eugen Bersuch, Isabella M. Montagner, Maria Passioti, Nicolò Celegato, Selina Summermatter, Sophie Nutten, Tristan Bourdeau, Yvonne M. Vissers, Nikolaos G. Papadopoulos OP05 Chemical modification of a peanut extract results in an increased safety profile while maintaining efficacy Hanneke van der Kleij, Hans Warmenhoven, Ronald van Ree, Raymond Pieters, Dirk Jan Opstelten, Hans van Schijndel, Joost Smit OP06 Administration of the yellow fever vaccine in egg allergic children Roisin Fitzsimons, Victoria Timms, George Du Toit ORAL ABSTRACT SESSION 2: Asthma (OP07–OP12) OP07 Previous exacerbation is the most important risk factor for future exacerbations in school‐age children with asthma S. Tolga Yavuz, Guven Kaya, Mustafa Gulec, Mehmet Saldir, Osman Sener, Faysal Gok OP08 Comparative study of degree of severity and laboratory changes between asthmatic children using different acupuncture modalities Nagwa Hassan, Hala Shaaban, Hazem El‐Hariri, Ahmed Kamel Inas E. Mahfouz OP09 The concentration of exhaled carbon monoxide in asthmatic children with different controlled stadium Papp Gabor, Biro Gabor, Kovacs Csaba OP10 Effect of vitamin D3 supplementation during pregnancy on risk of persistent wheeze in the offspring: a randomised clinical trial Bo Chawes, Klaus Bønnelykke, Jakob Stokholm, Lene Heickendorff, Susanne Brix, Morten Rasmussen, Hans Bisgaard OP11 Lung function development in childhood Henrik Wegener Hallas, Bo Chawes, Lambang Arianto, Hans Bisgaard OP12 Is the effect of maternal and paternal asthma different in female and male children before puberty? Maike Pincus, Thomas Keil, Andreas Reich, Ulrich Wahn, Susanne Lau, Linus Grabenhenrich ORAL ABSTRACT SESSION 3: Epidemiology—genetics (OP13–OP18) OP13 Lifestyle is associated with incidence and category of allergen sensitisation: the ALADDIN birth cohort Sara Fagerstedt, Helena Marell Hesla, Emelie Johansson, Helen Rosenlund, Axel Mie, Annika Scheynius, Johan Alm OP15 Maternal filaggrin mutations increase the risk of atopic dermatitis in children: an effect independent of mutation inheritance Jorge Esparza‐Gordillo, Anja Matanovic, Ingo Marenholz, Anja Bauerfeind, Klaus Rohde, Katja Nemat, Min‐Ae Lee‐Kirsch, Magnus Nordenskjöld, Marten C. G. Winge, Thomas Keil, Renate Krüger, Susanne Lau, Kirsten Beyer, Birgit Kalb, Bodo Niggemann, Norbert Hübner, Heather J. Cordell, Maria Bradley, Young‐Ae Lee OP16 Allergic multimorbidity of asthma, rhinitis and eczema in the first 2 decades of the German MAS birth cohort Thomas Keil, Hannah Gough, Linus Grabenhenrich, Dirk Schramm, Andreas Reich, John Beschorner, Antje Schuster, Carl‐Peter Bauer, Johannes Forster, Fred Zepp, Young‐Ae Lee, Renate Bergmann, Karl Bergmann, Ulrich Wahn, Susanne Lau OP17 Childhood anaphylaxis: a growing concern Filipe Benito Garcia, Inês Mota, Susana Piedade, Ângela Gaspar, Natacha Santos, Helena Pité, Mário Morais‐Almeida OP18 Indoor exposure to molds and dampness in infancy and its association to persistent atopic dermatitis in school age. Results from the Greek ISAAC II study Athina Papadopoulou, Despina Mermiri, Elpida Xatziagorou, Ioannis Tsanakas, Stavroula Lampidi, Kostas Priftis ORAL ABSTRACT SESSION 4: Pediatric rhinitis—immunotherapy (OP19–OP24) OP19 Associations between residential greenness and childhood allergic rhinitis and aeroallergen sensitisation in seven birth cohorts Elaine Fuertes, Iana Markevych, Gayan Bowatte, Olena Gruzieva, Ulrike Gehring, Allan Becker, Dietrich Berdel, Michael Brauer, Chris Carlsten, Barbara Hoffmann, Anita Kozyrskyj, Caroline Lodge, Göran Pershagen, Alet Wijga, Heinrich Joachim OP20 Full symptom control in pediatric patients with allergic rhinitis and asthma: results of a 2‐year sublingual allergen immunotherapy study Zorica Zivkovic, Ivana Djuric‐Filipovic, Jasmina Jocić‐Stevanovic, Snežana Zivanovic OP21 Nasal epithelium of different ages of atopic subjects present increased levels of oxidative stress and increased cell cytotoxicity upon rhinovirus infection Styliani Taka, Dimitra Kokkinou, Aliki Papakonstantinou, Panagiota Stefanopoulou, Anastasia Georgountzou, Paraskevi Maggina, Sofia Stamataki, Vassiliki Papaevanggelou, Evangelos Andreakos, Nikolaos G. Papadopoulos OP22 Cluster subcutaneous immunotherapy schedule: tolerability profile in children Monica Piquer Gibert, Montserrat Alvaro Lozano, Jaime Lozano Blasco, Olga Domínguez Sánchez, Rosa Jiménez Feijoo, Marcia Dias da Costa, Mª Teresa Giner Muñoz, Adriana Machinena Spera, Ana Maria Plaza Martín OP23 Rhinitis as a risk factor for asthma severity in 11‐year old children: population‐based cohort study Matea Deliu, Danielle Belgrave, Angela Simpson, Adnan Custovic OP24 The Global Lung Function Initiative equations in airway obstruction evaluation of asthmatic children João Gaspar Marques, Pedro Carreiro‐Martins, Joana Belo, Sara Serranho, Isabel Peralta, Nuno Neuparth, Paula Leiria‐Pinto POSTER DISCUSSION SESSION 1: Food allergy (PD01–PD05) PD01 Allergen‐specific humoral and cellular responses in children who fail egg oral immunotherapy due to allergic reactions Marta Vazquez‐Ortiz, Mariona Pascal, Ana Maria Plaza, Manel Juan PD02 FoxP3 epigenetic features in children with cow milk allergy Lorella Paparo, Rita Nocerino, Rosita Aitoro, Ilaria Langella, Antonio Amoroso, Alessia Amoroso, Carmen Di Scala, Roberto Berni Canani PD04 Combined milk and egg allergy in early childhood: let them eat cake? Santanu Maity, Giuseppina Rotiroti, Minal Gandhi PD05 Introduction of complementary foods in relation to allergy and gut microbiota in farm and non‐farm children Karin Jonsson, Annika Ljung, Bill Hesselmar, Ingegerd Adlerbert, Hilde Brekke, Susanne Johansen, Agnes Wold, Ann‐Sofie Sandberg POSTER DISCUSSION SESSION 2: Asthma and wheeze (PD06–PD16) PD06 The association between asthma and exhaled nitric oxide is influenced by genetics and sensitisation Björn Nordlund, Cecilia Lundholm, Villhelmina Ullemar, Marianne van Hage, Anne Örtqvist, Catarina Almqvist PD09 Prevalence patterns of infant wheeze across Europe Anna Selby, Kate Grimshaw, Thomas Keil, Linus Grabenhenrich, Michael Clausen, Ruta Dubakiene, Alessandro Fiocchi, Marek Kowalski, Nikos Papadopoulos, Marta Reche, Sigurveig Sigurdardottir, Aline Sprikkleman, Paraskevi Xepapadaki, Clare Mills, Kirsten Beyer, Graham Roberts PD10 Epidemiologic changes in recurrent wheezing infants Herberto Jose Chong Neto, Gustavo Falbo Wandalsen, Ana Carolina Dela Bianca, Carolina Aranda, Nelson Augusto Rosário, Dirceu Solé, Javier Mallol, Luis García Marcos PD13 A single nucleotide polymorphism in the GLCCI1 gene is associated with response to asthma treatment in children IvanaBanic, Matija Rijavec, Davor Plavec, Peter Korosec, Mirjana Turkalj PD14 Pollen induced asthma: Could small molecules in pollen exacerbate the protein‐mediated allergic response? Alen Bozicevic, Maria De Mieri, Matthias Hamburger PD15 A qualitative study to understand how we can empower teenagers to better self‐manage their asthma Simone Holley, Ruth Morris, Frances Mitchell, Rebecca Knibb, Susan Latter, Christina Liossi, Graham Roberts PD16 Polymorphism of endothelial nitric oxide synthase (eNOS) gene among Egyptian children with bronchial asthma Mostafa M. M. Hassan POSTER DISCUSSION SESSION 3: Mechanisms—Epidemiology (PD17–PD21) PD17 Pregnancy outcomes in relation to development of allergy in a Swedish birth cohort Malin Barman, Anna Sandin, Agnes Wold, Ann‐Sofie Sandberg PD18 Evolution of the IgE response to house dust mite molecules in childhood Daniela Posa, Serena Perna, Carl‐Peter Bauer, Ute Hoffmann, Johannes Forster, Fred Zepp, Antje Schuster, Ulrich Wahn, Thomas Keil, Susanne Lau, Kuan‐Wei Chen, Yvonne Resch, Susanne Vrtala, Rudolf Valenta, Paolo Maria Matricardi PD19 Antibody recognition of nsLTP‐molecules as antigens but not as allergens in the German‐MAS birth cohort Olympia Tsilochristou, Alexander Rohrbach, Antonio Cappella, Stephanie Hofmaier, Laura Hatzler, Carl‐Peter Bauer, Ute Hoffmann, Johannes Forster, Fred Zepp, Antje Schuster, RaffaeleD'Amelio, Ulrich Wahn, Thomas Keil, Susanne Lau, Paolo Maria Matricardi PD20 Early life colonization with Lactobacilli and Staphylococcus aureus oppositely associates with the maturation and activation of FOXP3+ CD4 T‐cells Sophia Björkander, Maria A. Johansson, Gintare Lasaviciute, Eva Sverremark‐Ekström PD21 Genome‐wide meta‐analysis identifies 7 susceptibility loci involved in the atopic march Ingo Marenholz, Jorge Esparza‐Gordillo, Franz Rüschendorf, Anja Bauerfeind, David P. Strachan, Ben D. Spycher, Hansjörg Baurecht, Patricia Margaritte‐Jeannin, Annika Sääf, Marjan Kerkhof, Markus Ege, Svetlana Baltic, Melanie C Matheson, Jin Li, Sven Michel, Wei Q. Ang, Wendy McArdle, Andreas Arnold, Georg Homuth, Florence Demenais, Emmanuelle Bouzigon, Cilla Söderhäll, Göran Pershagen, Johan C. de Jongste, Dirkje S Postma, Charlotte Braun‐Fahrländer, Elisabeth Horak, Ludmila M. Ogorodova, Valery P. Puzyrev, Elena Yu Bragina, Thomas J Hudson, Charles Morin, David L Duffy, Guy B Marks, Colin F Robertson, Grant W Montgomery, Bill Musk, Philip J Thompson, Nicholas G. Martin, Alan James, Patrick Sleiman, Elina Toskala, Elke Rodriguez, Regina Fölster‐Holst, Andre Franke, Wolfgang Lieb, Christian Gieger, Andrea Heinzmann, Ernst Rietschel, Thomas Keil, Sven Cichon, Markus M Nöthen, Craig E Pennell, Peter D Sly, Carsten O Schmidt, Anja Matanovic, Valentin Schneider, Matthias Heinig, Norbert Hübner, Patrick G. Holt, Susanne Lau, Michael Kabesch, Stefan Weidinger, Hakon Hakonarson, Manuel AR Ferreira, Catherine Laprise, Maxim B. Freidin, Jon Genuneit, Gerard H Koppelman, Erik Melén, Marie‐Hélène Dizier, A. John Henderson, Young Ae Lee POSTER DISCUSSION SESSION 4: Food allergy—Anaphylaxis (PD22–PD26) PD22 Atopy patch test in food protein induced enterocolitis caused by solid food Purificacion González‐Delgado, Esther Caparrós, Fernando Clemente, Begoña Cueva, Victoria M. Moreno, Jose Luis Carretero, Javier Fernández PD23 Watermelon allergy: a novel presentation Kate Swan, George Du Toit PD24 A pilot study evaluating the usefulness of a guideline template for managing milk allergy in primary care Mudiyur Gopi, Tim Smith, Edara Ramesh, Arun Sadasivam PD26 Efficacy and safety of cow's milk oral immunotherapy protocol Inês Mota, Filipe Benito Garcia, Susana Piedade, Angela Gaspar, Graça Sampaio, Cristina Arêde, Luís Miguel Borrego, Graça Pires, Cristina Santa‐Marta, Mário Morais‐Almeida POSTER DISCUSSION SESSION 5: Prevention and treatment—Allergy (PD27–PD36) PD27 Allergy‐protection by the lactic acid bacterium Lactococcus lactis G121: mode‐of‐action as revealed in a murine model of experimental allergy Stephanie Brand, Karina Stein, Holger Heine, Marion Kauth PD29 The relationship between quality of life and morning salivary cortisol after acute bronchiolitis in infancy Leif Bjarte Rolfsjord, Egil Bakkeheim, Johan Alm, Håvard Ove Skjerven, Kai‐Håkon Carlsen, Jon Olav Hunderi, Teresa Løvold Berents, Petter Mowinckel, Karin C. Lødrup Carlsen PD30 Randomised trial of the efficacy of MP29‐02* compared with fluticasone propionate nasal spray in children aged ≥6 years to <12 years with allergic rhinitis Ulrich Wahn, Ullrich Munzel, William Berger PD31 10 mg of oral bilastine in 2 to 11 years old children has similar exposure to the adult therapeutic dose (20 mg) Ulrich Wahn, Román Valiente, Valvanera Vozmediano, John C. Lukas, Mónica Rodríguez PD33 Daily symptoms, nocturnal symptoms, activity limitations and reliever therapies during the three steps of IOEASMA programme: a comparison Sebastiano Guarnaccia, Luigi Vitale, Ada Pluda, Emanuele D'Agata, Denise Colombo, Stefano Felici, Valeria Gretter, Susanna Facchetti, Gaia Pecorelli, Cristina Quecchia PD34 Sensitisation to an inert aeroallergen in weaning rats and longstanding disease, in a sensitisation‐tolerant and easily tolerisable rodent strain George Guibas, Evangelia Spandou, Spyridon Megremis, Peter West, Nikolaos Papadopoulos PD35 Bacterial and fungi exposure in school and allergic sensitisation in children João Cavaleiro Rufo, Joana Madureira, Inês Paciência, Lívia Aguiar, Patrícia Padrão, Mariana Pinto, Luís Delgado, Pedro Moreira, João Paulo Teixeira, Eduardo Oliveira Fernandes, André Moreira PD36 Comparative study of allergy rhinitis between two populations: children vs. adults Adriana Izquierdo Dominguez, Antonio Valero, Joaquim Mullol, Alfonso Del Cuvillo, Javier Montoro, Ignacio Jauregui, Joan Bartra, Ignacio Davila, Marta Ferrer, Joaquin Sastre POSTER VIEWING SESSION 1: Inflammation—Genetics—Immunology—Dermatology (PP01–PP09) PP01 Immune profile in late pregnancy: immunological markers in atopic asthmaticwomen as risk factors for atopy in the progeny Catarina Martins, Jorge Lima, Maria José Leandro, Glória Nunes, Jorge Cunha Branco, Hélder Trindade, Luis Miguel Borrego PP02 The impact of neonatal sepsis on development of allergic diseases Secil Conkar, Mehtap Kilic, Canan Aygun, Recep Sancak PP03 Clinical overview of selective IgE deficiency in childhood Athina Papadopoulou, Eleni Tagalaki, Lambros Banos, Anna Vlachou, Fotini Giannoula, Despina Mermiri PP04 Inverse relationship between serum 25(ΟΗ) vitamin D3 and total IgE in children and adolescence Athina Papadopoulou, Stavroula Lampidi, Marina Pavlakou, Maria Kryoni, Kostas Makris PP05 PP06 PP07 Asthma control questionnaire and specific IgE in children Snezhina Lazova, Guergana Petrova, Dimitrinka Miteva, Penka Perenovska PP08 Features of chronic urticaria of adolescents Aliya Klyucharova, Olesya Skorohodkina PP09 Cutaneous mastocytosis in children: a clinical analysis of 8 cases in Greece Dimitra Koumaki, Alkisti Manousaki, Maria Agrapidi, Lida Iatridou, Omima Eruk, Konstantinos Myridakis, Emmanouil Manousakis, Vasiliki Koumaki POSTER VIEWING SESSION 2: Food allergy—Anaphylaxis (PP10–PP47) PP10 Prognostic factors in egg allergy Maria Dimou, Maria Ingemansson, Gunilla Hedlin PP11 Evaluation of the efficacy of an amino acid‐based formula in infants who are intolerant to extensively hydrolysed protein formula Nitida Pastor, Delphine de Boissieu, Jon Vanderhoof, Nancy Moore, Kaitlin Maditz PP12 Anaphylaxis and epinephrine auto‐injector use: a survey of pediatric trainees Adeli Mehdi, Shaza Elhassan, Carolin Beck, Ahmed Al‐Hammadi PP13 Anaphylaxis in children: acute management in the Emergency Department Ioana Maris, Ronan O'Sullivan, Jonathan Hourihane, PP14 Understanding Cumbrian schools preparedness in managing children at risk of anaphylaxis in order to provide training and support which will create healthy and safe environments for children with allergies George Raptis, Louise Michaelis PP15 A new valid and reliable parent and child questionnaire to measure the impact of food protein enterocolitis syndrome on children: the FPIES Quality of Life Questionnaire (FPIESQL), Parent and Child Short Form Audrey DunnGalvin, Matthew Greenhawt, Carina Venter, Jonathan Hourihane PP16 An in‐depth case study investigation of the experiences of teenagers and young adults in growing up and living with food allergy with emphasis on coping, management and risk, support, and social and self‐identity Evelyn O'Regan, Duncan Cronin, Jonathan Hourihane, Anna O'Reilly, Audrey DunnGalvin PP17 Cow's milk protein allergy in Constantine. A retrospective study of 62 cases between 1996 and 2013 Foued Abdelaziz, Dounia Khelifi‐Touhami, Nihad Selim, Tahar Khelifi‐Touhami PP18 PP19 Cow's milk and egg oral immunotherapy in children older than 5 years Pablo Merida, Ana Mª Plaza, Juan Heber Castellanos, Adrianna Machinena, Montserrat Alvaro Lozano, Jaime Lozano, Olga Dominguez, Monica Piquer, Rosa Jimenez, Mª Teresa Giner PP20 Professionals' awareness of management of Cow's Milk Protein Allergy (CMPA) in North Wales Hospitals Konstantinos Kakleas, Manohar Joishy, Wendmu Maskele, Huw R. Jenkins PP21 PP22 Anaphylaxis: the great unknown for teachers. Presentation of a protocol for schools Mercedes Escarrer, Agustín Madroñero, Maria Teresa Guerra, Juan Carlos Julia, Juan Carlos Cerda, Javier Contreras, Eulalia Tauler, Maria Jesus Vidorreta, Ana Rojo, Silvia Del Valle PP23 Challenges facing children with food allergies and their parents in out of school activity sectors Niamh Flynn PP24 A review of food challenges at a Regional Irish Centre Gary Foley, Carol Harmon, John Fitzsimons PP25 The use of epinephrine in infants with anaphylaxis Krasimira Baynova, Ávila Maria Del Robledo, Labella Marina PP26 PP27 PP28 Mother's psychological state predicts the expression of symptoms in food allergic children Aaron Cortes, Alicia Sciaraffia, Angela Castillo PP29 The correlation between sIgE towards tree nuts and birch pollen in a Danish Pediatric Allergy Clinic Nanna Juel‐Berg, Kirsten Skamstrup Hansen, Lars Kærgaard Poulsen PP30 Food allergy in children: evaluation of parents' use of online social media Andreia Florina Nita, Ioana Valentina Nenciu, Adina Lazar, Dumitru Oraseanu PP31 The impact of food allergy on quality of life: FAQLQ questionnaire Rita Aguiar, Anabela Lopes, Maria J. Paes, Amélia S. Santos, M. A. Pereira‐Barbosa PP32 An unexpected cause of anaphylaxis: potato Hatice Eke Gungor, Salih Uytun, Umit Murat Sahiner, Yasemin Altuner Torun PP33 Is it clinical phenotype of allergic diseases determined by sensitisation to food? Mirjana Zivanovic, Marina Atanasković‐Marković PP34 PP35 Prescribing adrenaline auto‐injectors in children in 2014: the data from regional pediatricians Tina Vesel, Mihaela Nahtigal, Andreja Obermayer‐Temlin, Eva Šoster Križnik, Mirjana Maslar, Ruben Bizjak, Marjeta Tomšič‐Matic, Sonja Posega‐Devetak, Maja Skerbinjek‐Kavalar, Mateja Predalič, Tadej Avčin PP36 Who should have an adrenaline autoinjector? Adherence to the European and French guidelines among 121 allergists from the Allergy Vigilance Network Guillaume Pouessel, Etienne Beaudouin, Anne M. Moneret‐Vautrin, Antoine Deschildre, Allergy Vigilance Network PP37 Anaphylaxis by Anacardium Occidentale Marta Viñas, Bartolomé Borja, Nora Hernández, Mª José Castillo, Adriana Izquierdo, Marcel Ibero PP38 Anaphylaxis with honey in a child S. Tolga Yavuz, Ali Gungor, Betul Buyuktiryaki, Ozan Koc, Can Naci Kocabas, Faysal Gok PP39 Evaluation of courses adopted to children on prevention, recognition and management of anaphylaxis Tina Vesel, Mihaela Nahtigal PP40 Symptomatic dust mites and shrimp allergy: three pediatric case reports Filipa Almeida, Susana Lopes, Cristina Madureira, Tânia Lopes, Fernanda Carvalho PP41 Poor identification rates of nuts by high risk individuals: a call for improved education and support for families Camille Heming, Emily Garrett, Adam Blackstock, Santanu Maity, Rahul Chodhari PP42 DAFALL: database of food allergies in the Czech Republic Simona Belohlavkova, Eliska Kopelentova, Petr Visek, Ivana Setinova, Ivana Svarcova PP43 Serological cross‐reactivity between grass and wheat is not only caused by profilins and CCDs Sigrid Sjölander, Nora Nilsson, Malin Berthold, Helena Ekoff, Gunilla Hedlin, Magnus Borres, Caroline Nilsson PP44 Oil body associated proteins in children with nuts allergy. Allergens to consider in IgE‐mediated nuts allergy Loreto González Domínguez, Cristina Muñoz Archidona, Ana Moreira Jorge, Sergio Quevedo Teruel, Teresa Bracamonte Bermejo, Miriam Castillo Fernández, Fernando Pineda de la Losa, Luis Ángel Echeverría Zudaire PP45 PP46 Protective effect of helicobacter pylori infection against food allergy in children Olga Vrani, Antigone Mavroudi, Maria Fotoulaki, Maria Emporiadou, Kleomenis Spiroglou, Ioannis Xinias PP47 Anaphylaxis pathway: A road tryp‐tase to success? Helyeh A. Sadreddini, Mia Warnes, Donna Traves POSTER VIEWING SESSION 3: Miscellaneous (PP48–PP58) PP48 Surveillance study on safety of SLIT in pediatric population Ivana Djuric‐Filipovic, Zorica Zivkovic, Snežana Zivanovic, Gordana Kostić, Đorđe Filipovic PP49 Efficacy and safety of mixed mite subcutaneous immunotherapy among allergic rhinitis patients in the Northeastern Thailand Sawapon Sittisomwong, Siripong Sittisomwong PP50 Effect of inhaled beclomethasone or placebo on brain stem activity in a patient chronically treated with steroids: preliminary report Zygmunt Podolec, Marcin Hartel, Daria Panek, Magdalena Podolec‐Rubiś, Tomasz Banasik PP51 Sensitisation to aeroallergens in patients with allergic rhinitis, asthma and atopic dermatitis in Shiraz, Southwestern Iran Elham Abbasi, Mozhgan Moghtaderi PP52 Referring a child for allergy test: how appropriate are we? Phani Sanneerappa, Alina Deliu, Moosa Kutty, Nagabathula Ramesh PP53 EBV lymphoproliferative disease and cardiac lymphoma in a STK4 deficient patient Roya Sherkat, Mohammad Reza Sabri, Bahar Dehghan, Hamid Bigdelian, Nahid Raeesi, Mino Afshar, Hamid Rahimi, Christoph Klein PP54 A case study: the effect of massive honeybees attack on various body parameters atopic girl including allergy Mohemid Al‐Jebouri PP55 The role of TLR9, NLRP3 and proIL‐1β in activation of antiviral innate immunity Oxana A. Svitich, Daria O. Zubacheva, Dmitrii A. Potemkin, Ludmila V. Gankovskaya, Vitalii V. Zverev PP56 Overnight pulse oximetry, as a screening tool to diagnose obstructive sleep apnoea. How effective is it? Phani Sanneerappa, Elaine OB Doyle, Paul Gallagher, Nagabathula Ramesh PP57 The presentation and management of acute urticaria and allergic reactions in children in a multi‐ethnic, inner city Emergency Department (ED) Sherine Dewlett, Kin Man, Minal Gandhi, James Pocock, Anna Gerrardhughes PP58 Food allergens responsible for delayed‐type sensitisation in atopy patch test in children diagnosed with autism spectrum disorder Jolanta Wasilewska, Maciej Kaczmarski, Dariusz Lebensztejn POSTER VIEWING SESSION 4: Asthma—Rhinitis (PP59–PP87) PP59 Systematic review of incense as a trigger factor for asthma Chandramani Thuraisingham, Davendralingam Sinniah PP60 Increased risks of mood and anxiety disorders in children with asthma Yue Chen, Xiaomei Mei PP61 PP62 Asthma Control Test (ACT) and Pediatric Asthma Quality of Life Questionnaire (PAQLQ) association in children Sebnem Ozdogan, Pinar Karadeniz, Durdugul Ayyildiz‐Emecen, Ummuhan Oncul PP63 Seasonal and gender variations in vitamin D levels in children with asthma and its association with pulmonary function tests Sebnem Ozdogan, Gizem Sari, Sabanur Cavdar PP64 Defining treatment response in childhood asthma: rationale and design of the Pharmacogenomics in the Childhood Asthma (PiCA) consortium Niloufar Farzan, Susanne J. Vijverberg, Colin J. Palmer, Kelan G. Tantisira, Anke‐Hilseon Maitland‐van der Zee behalf of the PiCA consortium PP65 Prevalence of asthma and allergic disease in patients with inflammatory disease compared to celiac disease Fatma Yavuzyilmaz, Sebnem Ozdogan, Nafiye Urganci, Merve Usta PP66 A severe case with cystic fibrosis (CF) asthma Mehmet Hoxha, Maksim Basho PP67 Severe asthma exacerbation complicated with pneumothorax in a child with uncontrolled asthma due to poor treatment compliance Ioana Valentina Nenciu, Andreia Florina Nita, Adina Lazar, Alexandru Ulmeanu, Carmen Zapucioiu, Dumitru Oraseanu PP68 Evaluation of the Pediatric Quality of Life inventory (PedsQL) asthma module among low income asthmatic children and adolescents in Sao Paolo, Brazil Gustavo F. Wandalsen, Fernanda Monteiro, Dirceu Solé PP69 Early initiation of specific immunotherapy in asthma patients leads to higher benefits Blerta Lame, Eris Mesonjesi, Arjeta Sherri PP70 Treatment resistant asthma and rhinosinusitis with recurrent pulmonary infections. Is it primary ciliary dyskinesia? Alkerta Ibranji, Laert Gjati, Gjustina Loloci, Ardii Bardhi PP71 The comparison of sensitisation to animal allergens in children‐ and adult‐ onset patients with asthma Behnam Moghtaderi, Shirin Farjadian, Dorna Eghtedari PP72 Characterisation of children less than five years with wheezing episodes in Cali, Colombia Manuela Olaya, Laura Del Mar Vasquez, Luis Fernando Ramirez, Carlos Daniel Serrano PP73 Evaluation of the patients with recurrent croup Belgin Usta Guc, Suna Asilsoy, Fulya Ozer PP74 Obesity in adolescence compromising the asthma control Guergana Petrova, Sylvia Shopova, Vera Papochieva, Snezhina Lazova, Dimitrinka Miteva, Penka Perenovska PP75 Sleep behavior in children with persistent allergic rhinitis Gustavo F. Wandalsen, Jessica Loekmanwidjaja, Márcia Mallozi, Dirceu Solé PP76 Randomised trial of the safety of MP29‐02* compared with fluticasone propionate nasal spray in children aged ≥4 years to <12 years with allergic rhinitis William Berger, Ulrich Wahn, Paul Ratner, Daniel Soteres PP77 Safety and tolerability evaluation of bilastine 10 mg in children from 2 to 11 years of age with allergic rhinoconjunctivitis or urticaria Zoltán Novák, Anahí Yáñez, Kiss Ildikó, Piotr Kuna, Miguel Tortajada, Román Valiente, the Bilastine Pediatric Safety Study Group PP78 Sensitisation to Alternaria alternata: Is it a risk factor for severe rhinitis? Susana Lopes, Filipa Almeida, Tânia Lopes, Cristina Madureira, José Oliveira, Fernanda Carvalho PP79 Validation of the Patient Benefit Index (PBI) for the assessment of patient‐related outcomes in allergic rhinitis in children Julia Feuerhahn, Christine Blome, Meike Hadler, Efstrathios Karagiannis, Anna Langenbruch, Matthias Augustin PP80 Efficacy of sublingual tablet of house dust mite allergen extracts in adolescents with house dust mite‐associated allergic rhinitis Michel Roux, Shinji Kakudo, Efstrathios Karagiannis, Robert K. Zeldin PP81 Lung function improvement in a child treated with omalizumab for bronchial asthma Anna Sokolova, Tiago Milheiro Silva PP82 How to treat a child suffering from asthma, allergic rhinitis, allergy to peanuts and diabetes at the same time? Snezana S. Zivanovic, Vesna Cvetkovic, Ivana Nikolic, Sonja J. Zivanovic PP83 Nitric oxide in exhaled air in the relationship of the degree of sensitisation to aeroallergens Snezana S. Zivanovic, Ljiljana Saranac, Ivana Nikolic, Sonja J. Zivanovic, Zorica Zivkovic PP84 Clinical basis of diagnostic errors in pediatric asthma Zoia Nesterenko PP85 PP86 Childhood asthma control in Serbia and organised Asthma Educational Intervention (AEI) Snezana Radic, Branislava Milenkovic, Spomenka Smiljanic, Milka Micic‐Stanijevic, Olivera Calovic PP87 Experience from a group of adolescents with severe allergic asthma treated with Omalizumab Anne Marie Bro Hofbauer, Lone Agertoft THEMATIC POSTER SESSION 1: Prevention and Treatment—Epidemiology (TP01–TP18) TP01 A cost effective primary school asthma education program: pilot study from inner London schools Lucy Everson, Jessica Kearney, Jonny Coppel, Simon Braithwaite, Rahul Chodhari TP02 The prevalence of allergic diseases among 14–15 years old adolescents in two Danish birth cohorts 14 years apart Elisabeth S. Christiansen, Henrik Fomsgaard Kjaer, Esben Eller, Charlotte G. Mørtz, Susanne Halken TP03 Does pattern of sensitisation to phleum pratense change with age? Is it different in children with allergic rhinitis or asthma? Cristina Román India, Ana Moreira Jorge, Loreto González Domínguez, Cristina Muñoz Archidona, Sergio Quevedo Teruel, Teresa Bracamonte Bermejo, Juana Jiménez Jiménez, Luis Echeverría Zudaire TP04 Practicalities of prevention of peanut allergy: modelling a national response to LEAP Cathal O'Connor, Jonathan Hourihane TP05 Comparison of the influence of sunflower seed oil and skin care lotion on the skin barrier function of newborns: a randomised controlled trial Varvara Kanti, Lena Lünnemann, Günther Malise, Laine Ludriksone, Andrea Stroux, Wolfgang Henrich, Michael Abu‐Dakn, Ulrike Blume‐Peytavi, Natalie Garcia Bartels TP06 The effect of daily skin care on skin barrier properties in infants with dry skin and risk for atopic dermatitis Varvara Kanti, Lena Lünnemann, Laine Ludriksone, Marianne Schario, Andrea Stroux, Ulrike Blume‐Peytavi, Natalie Garcia Bartels TP07 Change in sum total aeroallergen skin prick test wheal diameters at 6 months predicts which children will respond to subcutaneous immunotherapy by three years Thorsten Stanley, Nicolien Brandenbarg TP08 Are mobile apps regarding adrenaline auto‐injectors accessed by adolescents for support and education in the community? Alia Boardman, Gary McGreevy, Emily Rodger, Katherine Knight, Victoria Timms, Trisha Taylor, Gemma Scanlan, Roisin Fitzsimons TP09 TP10 Prevention of early atopic dermatitis among low‐atopy‐risk infants by immunoactive prebiotics is not sustained after the first year of life Grüber Christoph, Ulrich Wahn, Margriet van Stuivenberg, Fabio Mosca, Guido Moro, Gaetano Chirico, Christian P. Braegger, Joseph Riedler, Yalcin Yavuz, Günther Boehm TP11 TP12 TP13 Treatment with Omalizumab in a 16‐year‐old Caucasian girl with refractory solar urticaria Stefania Arasi, Giuseppe Crisafulli, Lucia Caminiti, Federica Porcaro, Giovanni Battista Pajno TP14 Ultra‐pure soft water ameliorates skin conditions of adult and child patients with atopic dermatitis Akane Tanaka, Yaei Togawa, Kumiko Oida, Naotomo Kambe, Peter Arkwright, Yosuke Amagai, Naoki Shimojo, Yasunori Sato, Hiroyuki Mochizuki, Hyosun Jang, Saori Ishizaka, Hiroshi Matsuda TP15 Potential adjuvant effect of immunomodulator to improve specific immunotherapy in asthmatic child Wisnu Barlianto, Ery Olivianto, H. M. S. Chandra Kusuma TP16 How can Component Resolved Diagnosis (CRD) influence in Specific Immunotherapy (SIT) prescription, in a Spanish children population Ana Moreira Jorge, Cristina Román India, Loreto González Domínguez, Cristina Muñoz Archidona, Juana Jiménez Jiménez, Teresa Bracamonte Bermejo, Sergio Quevedo Teruel, Luis Echeverría Zudaire TP17 Mitochondrial dysfunction in food allergy: effects of L. rhamnosus GG in a mice model of peanut allergy Rosita Aitoro, Mariapia Mollica, Roberto Berni Canani, Giovanna Trinchese, Elena Alfano, Antonio Amoroso, Lorella Paparo, Francesco Amato, Claudio Pirozzi, Antonio Calignano, Rosaria Meli TP18 Prediction of atopic diseases in childhood: elevated blood eosinophils in infancy in a high risk birth cohort Siri Rossberg, Kerstin Gerhold, Kurt Zimmermann, Mohammad Zaino, Thomas Geske, Eckard Hamelmann, Susanne Lau THEMATIC POSTER SESSION 2: Food allergy—Anaphylaxis (TP19–TP38) TP19 TP20 TP21 Double‐blind provocation tests in non‐IgE mediated cow's milk allergy and the occurrence of placebo reactions Sarah Bogovic, Jochem van den Berg, Chantal Janssen TP22 Gradual introduction of baked egg (BE) in egg allergic patients under 2 years old Angela Claver TP23 Randomised controlled trial of SOTI with raw hen's egg in children with persistent egg allergy I: safety and efficacy of daily vs. weekly protocols of induction Mª Flor Martin‐Muñoz, C. Martorell, M. T. Belver, E. Alonso Lebrero, L. Zapatero, V. Fuentes, M. Piqué, A. Plaza, C. Muñoz, A. Martorell, Cristina Blasco, B. Villa, C. Gómez, S. Nevot, J. M. García, L. Echeverria TP24 Randomised controlled trial of SOTI with raw hen's egg in children with persistent egg allergy II: a randomised controlled trial to study a safer, more effective and easy to perform maintenance (daily vs. every two days) pattern of egg SOTI Mª Flor Martin‐Muñoz, C. Martorell, M. T. Belver, E. Alonso Lebrero, L. Zapatero, V. Fuentes, M. Piqué, A. Plaza, C. Muñoz, A. Martorell, Cristina Blasco, B. Villa, C. Gómez, S. Nevot, J. M. García, L. Echeverria TP25 Determining the safety of baked egg home reintroduction for children with mild egg allergy Brenda DeWitt, Judith Holloway, Donald Hodge TP26 Demographics, investigations and patterns of sensitisation in children with oral allergy syndrome in a London Teaching Hospital Sian Ludman, Merhdad Jafari‐Mamaghani, Rosemary Ebling, Adam T. Fox, Gideon Lack, George Du Toit TP27 Airborne peanut challenge in children: allergic reactions are rare Sofia Lovén Björkman, Caroline Nilsson, Natalia Ballardini TP28 The nutty question on Pediatric Wards: to be or "nut" to be? Supriyo Basu, Jenny Hallet, Jyothi Srinivas TP29 TP30 TP31 Allergy education in nursery schools Hazel Stringer, Nicola Jay TP32 Food allergy in the first year of life Tânia Lopes, Cristina Madureira, Filipa Almeida, Susana Lopes, Paula Fonseca, Clara Vieira, Fernanda Carvalho TP33 Prevalence and geographic distribution of oral allergy syndrome in Italian children: a multicenter study Carla Mastrorilli, Carlo Caffarelli, Riccardo Asero, Salvatore Tripodi, Arianna Dondi, Gianpaolo Ricci, Carlotta Povesi Dascola, Elisabetta Calamelli, Francesca Cipriani, Andrea Di Rienzo Businco, Annamaria Bianchi, Paolo Candelotti, Tullio Frediani, Carmen Verga, Paolo Maria Matricardi TP34 Are common standardised allergen extracts used in skin test enough in the diagnosis of nuts allergy? Cristina Muñoz Archidona, Loreto González Domínguez, Ana Moreira Jorge, Sergio Quevedo Teruel, Teresa Bracamonte Bermejo, Miriam Castillo Fernández, Fernando Pineda de la Losa, Luis Ángel Echeverría Zudaire TP35 Evaluation of IgE sensitisation in children with allergic proctocolitis and its relationship to atopic dermatitis Despina Mermiri, Paraskevi Korovessi, Skevi Tiliakou, Evaggelia Tavoulari, Kalliopi‐Maria Moraiti, Fotini Giannoula, Athina Papadopoulou TP36 Food allergy in children: are we managing them appropriately in the Emergency Department? Wan Jean Tee, Samir Deiratany, Raymond Seedhoo, Roisin McNamara, Ike Okafor TP37 Importance of oil body associated allergenic proteins in nuts suspected allergy children Loreto González Domínguez, Ana Moreira Jorge, Cristina Muñoz Archidona, Teresa Bracamonte Bermejo, Sergio Quevedo Teruel, Fernando Pineda de la Losa, Miriam Castillo Fernández, Luis Ángel Echeverría Zudaire TP38 Practical application of basophil activation test in children with food allergy Ekaterina Khaleva, Gennady Novic, Natalia Bychkova THEMATIC POSTER SESSION 3: Asthma (TP39–TP57) TP39 Effect of corticosteroid therapy upon serum magnesium level in chronic asthmatic children Amany Abd Al‐Aziz, Amany Fatouh, Ayat Motawie, Eman El Bostany, Amr Ibrahim TP40 ADAM33 in Bulgarian children with asthma Guergana Petrova, Dimitrinka Miteva, Snezhina Lazova, Penka Perenovska, Sylvia Andonova, Alexey Savov TP41 TP42 The impact of vitamin D serum levels in asthma and allergic rhinitis Maria Zoto, Marialena Kyriakakou, Paraskevi Xepapadaki, Nikolaos G. Papadopoulos TP43 Life‐threatening, first reported, paradoxical bronchospasm after nebulised Salbutamol in a 10 year old child Paraskevi Korovessi, Mariza Vassilopoulou, Athina Balaska, Lambros Banos, Stavroula Kostaridou, Despina Mermiri TP44 TP45 Asthma symptoms in children with treatment for allergic rhinoconjunctivitis Jorien Wartna, Arthur M. Bohnen, Gijs Elshout, David H. J. Pols, Patrick J. E. Bindels Erasmus MC, Rotterdam, The Netherlands TP46 Atopy increased the risk of developing exercise‐induced bronchoconstriction in young athletes Sven F. Seys; Ellen Dilissen, Sarah Van der Eycken, An‐Sofie Schelpe, Gudrun Marijsse, Thierry Troosters, Vincent Vanbelle, Sven Aertgeerts, Jan L. Ceuppens, Lieven J. Dupont, Koen Peers, Dominique M. Bullens TP47 The effect of higher BMI on risk for asthma and treatment outcome in overweight and obese children Ivana Banic, Sandra Bulat Lokas, Jelena Zivkovic, Boro Nogalo, Iva Mrkic Kobal, Davor Plavec, Mirjana Turkalj TP48 TP49 TP50 TP51 TP52 The impact of a multidisciplinary project intended to change the culture of nebulisers towards pressurised metered dose inhalers Georgeta Oliveira, Katharine Pike, Alda Melo, Tomás Amélia, José Carlos Cidrais Rodrigues, Cristina Serrano, José Manuel Lopes dos Santos, Carla Lopes TP53 TP54 TP55 TP56 Increased asthma control in patients with severe persistent allergic asthma after 12 month of nightly temperature controlled laminar airflow (TLA) Eckard Hamelmann, Uwe Schauer, Karl‐Christian Bergmann TP57 THEMATIC POSTER SESSION 4: Drug allergy—Dermatology (TP58–TP77) TP58 Should we proceed directly to provocation challenges to diagnose drug allergy? Our experience says yes Luis Moral, Teresa Toral, Nuria Marco, Beléns García Avilés, Mª Jesús Fuentes, Jesús Garde, Cristina Montahud, Javier Perona, Mª José Forniés TP59 Anaphylaxis to 13‐valent pneumococcal vaccine Esozia Arroabarren, Marta Anda, Maria Luisa Sanz, Maria Teresa Lizaso, Candida Arregui TP60 Intrapartum antibiotic exposure for treatment of group B streptococcus was not associated with the development of penicillin allergy in children Sara May, Martha Hartz, Avni Joshi, Miguel A. Park TP61 Evaluation of suspected drug hypersensitivity reactions in 169 children referred to the General Hospital Sonja Posega Devetak, Tina Vesel, Anja Koren Jeverica, Tadej Avčin TP62 Drug provocation testing: experience of a tertiary hospital Leonor Castro, Carolina Gouveia, Ana Carvalho Marques, Antonio Jorge Cabral TP63 Perioperative anaphylaxis: a growing concern in pediatric population Luis Amaral, Fabrícia Carolino, Eunice Castro, Madalena Passos, Josefina R. Cernadas TP64 Raising awareness of hypersensitivity to non‐steroidal anti‐inflammatory drugs in the pediatric age Fabrícia Carolino, Luís Amaral, Eunice Dias de Castro, Josefina R. Cernadas TP65 Perioperative anaphylaxis in young children: how to confirm the suspicion Josefina R. Cernadas, Fabrícia Carolino, Luís Amaral, Fernando Pineda, Armanda Gomes TP66 A case study of a child suspected to be penicillin allergic‐digging deeper Katherine Knight, Roisin Fitzsimons, Helen Brough TP67 Prevalence, characteristics and risk factors of hypersensitivity reactions to antibiotics in patients with cystic fibrosis Jobst Röhmel, Carsten Schwarz, Anne Mehl, Philippe Stock, Doris Staab TP68 Antibiotic drug hypersensitivity in cystic fibrosis: A pilot study using cellular allergy tests for diagnostics Jobst Röhmel, Carsten Schwarz, Christine Seib, Doris Staab, Philippe Stock TP69 Oral antibiotics challenges in children Anita Critchlow, Alyson Barber, Nicola Jay TP70 Hypersensitivity reaction to vancomycin: a new successful desensitization protocol Belen Delavalle, Teresa Garriga, Blanca Vilá, Cristina Blasco TP71 TP72 Clinical phenotypes according to FLG gene loss of function mutations in children with atopic dermatitis Francesca Cipriani, Annalisa Astolfi, Costanza Di Chiara, Elisabetta Calamelli, Iria Neri, Annalisa Patrizi, Gianpaolo Ricci TP73 TP74 Urticaria in children: clinical and epidemiological features Katerina Neskorodova, Asya Kudryavtseva TP75 TP76 Acute urticaria at the Pediatrics Emergency Department: is it allergy? Esozia Arroabarren, Jorge Alvarez, Marta Anda, Miriam Palacios, Marta Martinez‐Merino, Ibone Vaquero TP77 [ABSTRACT FROM AUTHOR]

AUTISM in children, AUTISTIC children, MEDICAL screening, AUTISM, COMMUNITIES, and TEACHING hospitals

The Indian Autism Screening Questionnaire (IASQ), derived from the Indian Scale for Assessment of Autism ISAA (the mandated tool for autism in India), is an autism screening instrument for use in the general population by minimally trained workers. While ISAA has 40 items with four anchor points, the IASQ is a 10-item questionnaire with yes/no answers. It was initially validated using the ISAA. During its development the ISAA was itself compared to the Childhood Autism Rating Scale version 1 (ISAA Manual). In the present study, we evaluated both the ISAA and the IASQ in relation to the Childhood Autism Rating Scale version 2 (CARS-2). Methods: Participants were recruited from three settings: a referral clinic for neurodevelopmental conditions run by the Department of Paediatrics of a tertiary care teaching hospital (NDC OPD), the outpatient department of an institute for disability and rehabilitation (NIEPID), and from the community (CGOC). Persons between ages 3–18 were recruited following consent or assent (parent and child/adolescent). The IASQ was administered by a minimally trained administrator. It was followed by ISAA and the CARS-2 (in alternating order, by different evaluators blind to each other) (CARS2 SV (Standard Version) and CARS2 HF (High Functioning) as applicable). Sensitivity, specificity and area under the Receiver Operator Characteristics (ROC) curve were calculated for IASQ and CARS2, as well as for ISAA and CARS2. Concordance between CARS2 and ISAA was calculated using kappa coefficient. Results: A total of 285 participants (NIEPD n = 124; NDC OPD, n = 4; CGOC n = 157) (a total of 70 with autism and 215 controls) participated. IASQ and CARS2 were administered on 285 participants, while IASQ and ISAA were administered on 264 participants. When IASQ was compared to CARS2, sensitivity was 97%, specificity 81%, PPV 63%, NPV 99% at cut off 1 while these values were 97%, 92%, 79% and 99% respectively at cut off 2. There was high concordance between CARS2 and ISAA (Kappa 0.907, p<0.0001). Conclusions: IASQ has satisfactory sensitivity, specificity and concordance when compared with CARS2; it can be used for screening children with autism in community. The ISAA also showed a high concordance with CARS2, as it had with the older version of CARS. [ABSTRACT FROM AUTHOR]

ARRHYTHMIA, CARDIAC pacing, CONFERENCES & conventions, and ELECTROPHYSIOLOGY

ANTIARRHYTHMICS P001 THE ANTI‐ARRHYTHMIC EFFECTS OF STATINS IN PATIENTS WITH CORONARY ARTERY DISEASE AND IMPLANTABLE CARDIOVERTER DEFIBRILLATORS Panattoni G; Papavasileiou LP; Della Rocca DG; Cioè R; Magliano G; Topa A; Sergi D; Santini L; Forleo GB; Romeo F Cardiology Department, University of Tor Vergata, Rome, Italy Introduction: A few studies have suggested that statins may have anti‐arrhythmic effects in patients with coronary artery disease. One proposed mechanism for the antiarrhythmic effect of statins is their antioxidant properties. The aim of our study was to determine whether statin therapy could reduce mortality, the occurrence of ventricular arrhythmias and appropriate or inappropriate intervention of the device in patients with implantable cardioverter defibrillators (ICDs). Methods: We investigated 244 consecutive patients with coronary artery disease who received ICDs at our institution between April 2003 and November 2010. Patients were subdivided into "statin" (n = 177, 153 males, age 67.4 ± 10.2 years) and "no‐statin" (n = 67, 56 males, age 71.4 ± 8.2 years) groups based on the use of statins. Results: Mean follow‐up was 20,6 ± 17,2 months and the two groups were homogeneous regarding antiarrhythmic therapy and ejection fraction. The overall incidence of non‐sustained (NSVTs) was lower among the statin group when compared with the no‐statin group (44 vs 31 patients, p = 0.02). No significant differences were found in the overall mortality (25 vs 12 patients, p = ns). The use of statin did not reduced significantly the occurrence of appropriate or inappropriate intervention of the device (31 vs 20 patients, p = 0.09 and 9 vs 3 patients, p = ns respectively) and of therapy. Conclusions: In our study statin therapy is associated with a lower incidence of non‐sustained ventricular tachycardias in patients with coronary artery disease and ICDs but does not influence overall mortality and appropriate or inappropriate intervention of the device. P002 QUINIDINE: AN "ENDANGERED SPECIES" DRUG APPROPRIATE FOR MANAGEMENT OF ELECTRICAL STORM IN BRUGADA SYNDROME Theofilogiannakos EK; Paraskevaidis S; Kamperidis V; Chatzizisis Y; Tsilonis K; Dakos G; Vassilikos V; Styliadis IH 1st Cardiology Department, AHEPA Hospital, Aristotle University Medical School, Thessalon The clinical manifestation of Brugada Syndrome (BS) varies from asymptomatic form to electrical storm and sudden cardiac death. We report two cases of BS that were presented with electrical storm. A 38‐year‐old man, who was treated with ICD implantation two years ago presented to our emergency department with electrical storm (i.e. three episodes of ventricular tachycardia in the same day) provoking shocks from the ICD. On admission, the patient was on a febrile status due to pneumonia that may was the predisposing factor that lead to the electrical instability. The second patient was a 75‐year‐old man, who was treated with ICD implantation nine years ago, was admitted for seven episodes of ventricular fibrillation within 24 hours that was successfully treated with ICD shocks. There was no predisposing factor that could lead to the electrical instability. Since the ICD implantation both patients did not receive any medication. Both patients were started on oral hydroquinidine (600 mg twice daily), remaining electrical stable for the rest of their hospitalization. After six months of hydroquinidine treatment the patients were also asymptomatic without any recorded ICD therapy. Recently, a discussion was initiated among electrophysiologists concerning quinidine shortage in the drug market. Quinidine is effective medical treatment for patients with short QT syndrome, BS and a subgroup of idiopathic ventricular fibrillation. Electrical storms in patients with the above syndromes should be treated with ICD. However, since ICD does not prevent the occurrence of arrhythmias, oral quinidine could be a reasonable choice for long‐term prevention of life‐threatening tachyarrhythmias. P003 SMALL NUMBER OF CANDIDATES FOR ANTIARRHYTHMIC DRUGS IDENTIFIED BY DATA FROM IMPLANTED PACEMAKERS Fisher JD; Yedlapati N; Rosal‐Greif V Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA Background: Modern pacemakers (pacers) quantify atrial fibrillation (AF) episodes and overall burden (% of time in AF). Many AF episodes are asymptomatic but still can be stroke risks. Records of 742 consecutive pacer checks were reviewed by a single investigator (JDF). Objective: To determine see how many patients (pts) had AF and might be candidates for antiarrhythmic drug (AAD) therapy. Methods: Charts were reviewed on or near the day of the in‐office pacer check. Pts were considered potential candidates for AAD therapy if they had dual chamber pacers (DDD), and electrograms showing AF or flutter burden between 1% and 99%, confirmed after 1 more month. 80% of patients had dual chamber pacers. Patients with single chamber pacers were excluded because in our practice these are used in AF patients when there is no intention of restoring sinus rhythm. Other exclusions were: Severe Co‐Morbidities – 9; Demented, aged – 10;Already on AAD – 8; MDs refused – 4;Patient refused – 17; AF disappeared – 8Chronic AF – 2; Language barrier – 13;Died – 1; SVT not AF – 2; Lost – 4; Moved – 2; Too Recent implant – 1 There were 11.3% non‐excluded DDD Patients with 1–99% AF. The Average% AF (Burden)was 24%. Conclusion: AF can be detected and quantified in DDD pacemaker patients, but only a low percentage go on to have appropriate antiarrhythmic drugs administered. P004 CHRONIC USE OF AMIODARONE IN ICD RECIPIENTS Santini L; Cioè R; Magliano G; Viele A; Minni V; Forleo GB; Mahfouz K; Sergi D; Topa A; Romeo F Department of Cardiology, University of Rome "Tor Vergata," Rome, Italy Purpose: Amiodarone is one of the most studied and used drug to treat life‐threatening ventricular arrhythmias. The aim of our study was to evaluate the influence of use of amiodarone on the outcomes of patients receiving implantable cardioverter defibrillator (ICD). Methods: We enrolled 428 consecutive patients (358 males, mean age 66,8 ± 11.3 years) who underwent ICD implantation at our Institute between September 2003 and January 2011. We subdivided patients in two groups regarding the used of amiodarone in chronic treatment. The Amiodarone + group (n = 161 patients, 139 males, 68.2 ± 10.6 years) and the Amiodarone‐ (n = 267, 219 males, 66.0 ± 11.6 years). Results: Groups resulted to be homogenous regarding age, sex, ejection fraction and underlying heart disease. After a mean follow‐up of 22,1 ± 18.0 months, 38 patients (23.6%) in Amiodarone + group experienced appropriate discharges versus 46 patients (17.2) in the Amiodarone − group (p = ns); while the incidence of inappropriate discharges was 5% (8 pts) and 6.7% (18 pts) respectively (p = ns). The incidence of TVNS was 26% (42 pts) vs 34% (91 pts) respectively (p = ns). No significant difference was found about mortality due to cardiovascular diseases (10/161 pts vs 18/267, p = ns). Conclusions: As reported by major clinical trials only the use of ICD influence mortality when compared to antiarrhythmic treatment. The chronic use of amiodarone in ICD recipients does not influence occurrence of major arrhythmic events, nevertheless reduces total number of events per patient. P005 ATRIAL TACHYARRHYTHMIA DECREASES VENTRICULAR MICROPERFUSION DURING AMIODARONE BUT NOT DURING DRONED‐
ARONE TREATMENT Hammwohner M; Bukowska A; Sixdorf A; Roehl FW; Lendeckel U; Goette A St.Vincenz Hospital Paderborn, Germany Atrial fibrillation (AF) is associated with an increased risk for acute coronary syndromes. AF‐induced ischemia seems to be related to disturbance of ventricular microcirculation. This study was conducted to evaluate the effects of dronedarone (DRO) and amiodarone (AMIO) infusion on ventricular macro‐ and microperfusion during rapid atrial pacing (RAP). Coronary flow reserve (CFR, microvascular perfusion marker) and fractional flow reserve (FFR, epicardial coronary artery flow marker) were determined in the left anterior descending artery in 30 pigs using a sensortipped thermodilution and pressure guidewire. Measurements were conducted at baseline, and after 6h of RAP with 600 bpm and/or DRO/AMIO infusion. RAP alone was performed in 6 pigs, 6 animals underwent RAP with DRO i.v. (10mg/kg) and 5 with AMIO i.v. (5mg/kg). 6 pigs were instrumented without intervention (Sham), 7 animals received DRO alone. FFR measurement (baseline = 100%) revealed a decreased FFR only in RAP and AMIO animals after 6h compared to all other groups (RAP:93 ± 6%; RAP + AMIO:82 ± 20%; p < 0.05). However, FFR did not drop below <0.8 in any animal. DRO infusion increased FFR compared to RAP after 6h (DRO:105 ± 5% vs RAP:93 ± 6%; p < 0.05). RAP and AMIO significantly decreased CFR (baseline = 100%) when compared with any other group (RAP:57 ± 11%; RAP + AMIO:54 ± 18% vs Sham:103 ± 14% vs RAP + DRO:96 ± 13% vs DRO:110 ± 17%; p < 0.05). DRO infusion abolished RAP induced decrease in CFR with a tendency towards an increased CFR compared to baseline (+10%). DRO infusion did not alter QTc compared to Sham. QTc increased in the DRO group (baseline Qtc 372 ± 10ms vs 6h DRO 408 ± 36ms). There were no significant differences in cardiac or systemic hemodynamic parameters between all groups. RAP impaires left ventricular microcirculation. DRO but not AMIO exerted vasodilatory effects in coronary arteries and improved microcirculation, thus abolishing RAP‐induced microvascular flow disturbances. P006 CONVERSION EFFICACY OF PROPAPHENONE IBOUTILIDE AND AMIODARONE IN MEN AND WOMEN WITH PAROXYSMAL ATRIAL FIBRILLATION OF RECENT ONSET Panageas V; Zika A General Hospital of Pyrgos Introduction: We aimed to determine whether the efficacy of antiarrhythmic agents is associated with sex, in patients with Paroxysmal Atrial Fibrillation of 3–48h. duration (PAFib). Methods used: We have observed 94 patients (64 men and 30 women). with PAFib. Patients were treated with Propaphenone (PR.), Ibutilide (IB) or Amiodarone (AMIO). If sinus rhythm was not restored with the first drug we used another one. Successful cardioversion was defined as arrhythmia termination within 48 hours. The results were analysed using Fisher's exact test. Summary of Results: Of 94 patients 89 were restored (95%). 60 men (93,75%) and 29 women (96,77%) were restored (p‐value = 1). As regards Propaphenone we used it as a 1st choice in 32 men (efficacy: 81,25%) and in 15 women (efficacy: 93,34%)(p = 0,6599). Propaphenone was never used as a 2nd choice). Amiodarone was used in 21 men as a 1st choice, with 90,5% efficacy and in 4 men as a 2nd choice, with 75% efficacy. In women it was used only as a 1st choice in 5 cases with 80% efficacy. (Amiodarone: p = 0,5153 as a first choice and 1,0000 as a 2nd choice). Finally, Iboutilide was used in 11 men and 10 women as a first choice and in 4 men and 1 women as a 2nd choice with efficacy 100% (in all of theme) (so p = 1,0000). Conclusions: In Southern‐West Greece the association between the gender and the conversion rate of antiarrhythmic drugs is not statistically significant. P007 ATRIAL EXCITATION PATTERNS OF REFRACTORY AND NON REFRACTORY TO PROPAPHENONE RECURRENT PAROXYSMAL ATRIAL FIBRILLATION Dakos G; Vassilikos V; Chouvarda I; Chatzizisis I; Mantziari L; Kamberidis V; Paraskevaidis S; Tsilonis K; Maglaveras N; Styliadis I 1st Cardiology Dept., Aristotle University of Thessaloniki, Greece The aim of this study was to associate the effects of propaphenone on the atrial excitation patterns of the recurrent paroxysmal atrial fibrillation (PAF), with P wave wavelet analysis. Methods: Thirty‐three PAF patients (20 males, mean age 60 ± 11 years) who received propaphenone, were divided into 2 Groups, after were followed for 2.3 ± 0.4 years. Nine patients (5 males, mean age 61 ± 7years) with multiple AF recurrences (>5 /year) were consisted Group A, while twenty‐four patients (15 males, mean age 60 ± 12 years) with less than 2 recurrences/year were consisted Group B. Two consecutive recordings were obtained, before and 37 ± 6 days after propaphenone administration with a 3 – channel digital recorder for 10 minutes and digitized with a 16–bit accuracy at a sampling rate of 1000 Hz. The P wave was analyzed using the Morlet wavelet and wavelet parameters expressing the mean and max energy of P wave were calculated in the three orthogonal leads (X, Y, Z) and in the vector magnitude (VM), in three frequency bands (1st: 200–160 Hz, 2nd: 150–100 Hz and 3rd: 90–50 Hz). The P wave duration was also measured in these axes and in the VM. Paired‐samples T‐test was used for comparing continuous variables. Results: After propaphenone administration, Group A patients showed higher mean and max energy values in the 2nd and 3rd frequency bands at Z axis, while Group B patients had shorter P wave duration at Z axis along with higher max energy values in the 1st and 3rd frequency bands at X axis and mean and max energy values in all frequency bands at Y axis. Conclusion: The refractory and non refractory to propaphenone recurrent PAF are associated with specific effects of propaphenone on the atrial excitation patterns, that can be revealed with P wave wavelet analysis. ATRIAL FIBRILLATION ABLATION P008 LONG‐TERM RESULTS OF BALOON CRYOISOLATION OF PULMONARY VEINS IN PATIENTS WITH PAROXYSMAL OR PERSISTENT ATRIAL FIBRILLATION Misikova S; Stancak B; Spurny P; Komanova E; Olexa P; Machacova Z; Sedlak J; Sudzinova A East Slovakia Institute of Cardiovascular Diseases, Kosice, Slovakia Introduction: Balloon cryoisolation of pulmonary veins is a novel method for treatment of atrial fibrillation. The aim of this study is to evaluate it's mid‐ and long term effectiveness in reducing the occurrence of atrial fibrillation. Patients and methods: We evaluated 95 patients with paroxysmal or persistent atrial fibrillation (mean age 58,6 ± 5,1 years, 62 men, 33 women) who underwent cryoisolation of pulmonary veins with 28 mm and 23 mm balloon size. The ablation protocol consisted of application of cryoenergy with duration of 900–1200 s into the ostium of each vein and check for the isolation with normal lasso or special microcircular catheter. The ambulatory evaluation via 24 Holter monitoring was repeated in 6 and 12 months. Results: We successfully isolated 361 (95%) pulmonary veins, veins without reach of balloon catheter were 19 (5%). Fluoroscopy time was 25 ± 10 min., procedural time 174 ± 79 min, average ACT during the ablation was 281 ± 38 s. The freedom of atrial fibrillation based on Holter data and patient's reports in 6 and 12 months was 68% and 65% respectively with more success in paroxysmal atrial fibrillation group. The phrenic nerve palsy was found in 5 patients, in 4 of them resolved within 6 months. Small pericardial effusion without the need of intervention was found in 1 patient, and femoral pseudoaneurysm managed by vascular surgeon in 1 patient. Conclusion: Balloon cryoisolation of pulmonary veins is fast, effective and safe ablation method. Long‐term success rate is comparable with conventional radiofrequency ablation especially in paroxysmal forms of atrial fibrillation. P009 PREVENTION OF POST OP ATRIAL FIBRILLATION WITH SURGICAL PULMONARY VEIN ISOLATION Ayala‐Paredes FA; Lavallee L; Lessard N; Teijeira J CHUS Universite de Sherbrooke Background: Post operative atrial fibrillation (Afib) is highly prevalent after CABG surgery; surgical pulmonary vein isolation, would reduce the risk of post operative AFib in patients (pts) with high risk. Methods & Results: Pts at least 65 years old with either hypertension or diabetes, but not previous Afib were randomized (1:1) to a CABG only (controls) or CABG + Cardioblate BP2 (Medtronic) to isolate four pulmonary veins (PV isolation) during the bypass surgery, plus left atrial appendage exclusion. A Reveal XT was implanted for long term monitoring. End point was any Afib lasting 2 min or longer before discharge. 42 pts were studied to date (from 50 expected), 88% men; with no complications and non significant changes in surgical times due to the addition of PV isolation. There were no differences in basal characteristics, diabetes or hypertension rates; beta –blockers or ACE/Ang II inhibitors use, but a marked reduction of new atrial fibrillation in patients with pulmonary vein isolation. In hospital Afib was present in 68.4% of controls versus 26.09% of PV isolation pts (p = 0.06). At 30 days Afib rate was 21.1% in controls versus 8.6% in PVI pts (p = 0.2). Most of patients (64.8%) with post op AFib received amiodarone for at least 30 days (47.4% group control vs 17.4%; (p = 0.049). Total surgical times were similar in both groups 206 (± 57 min) for controls versus 198.7 (± 30.3 min) in PVI pts (p = 0.8) as total hospital stay 8.21 (± 4.3 days) in controls versus 8.7 (± 3.9 days) in PVI pts (p = 0.7). Conclusion: A simple and time efficient surgical technique could significantly decrease the incidence of post operative atrial fibrillation, in pts with no history of atrial fibrillation, but high risk profile. This could decrease time to discharge and need of anti‐arrhythmic or anticoagulant therapy. This approach merits a wide scale validation as it could change the way CABG pts are managed. P010 PREVALENCE OF RIGHT ATRIAL THROMBUS ON THE TRANSEPTAL SHEATHS DETECTED BY INTRACARDIAC ECHOCARDIOGRAPHY DURING CATHETER ABLATION FOR ATRIAL FIBRILLATION WHILE ON THERAPEUTIC COUMADIN Di Biase L; Santangeli P; Bai R; Sanchez J; Mohanty P; Horton R; Lakkireddy DJ; Raviele A; Burkhardt JD; Natale A Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA Introduction: The reported prevalence of left atrial thrombus formation on the transseptal sheath detected by ICE ranged from 5 to 10.3% in patients undergoing pulmonary vein isolation (PVI) for atrial fibrillation (AF). Aim of our study was to report the prevalence of thrombus on the transeptal sheath placed in the right atrium (RA) before the transeptal access in patients undergoing PVI. Methods: Data from 4 centers performing catheter ablation of AF under ICE guidance and utilizing an open irrigated catheter have been collected. Before transeptal, a bolus of i.v. Heparin (10000 UI) was administered. Sheaths were continuously irrigated with heparinized saline and ACT was kept above 300 sec with additional bolus of i.v. heparin when required. Before administration of i.v. heparin, we assessed the prevalence of thrombus attached to the transeptal sheath placed in the RA. Results: Data from 2773 patients were analyzed. 1749 patients underwent PVI without Coumadin discontinuation with a mean INR of 2.46 + 0.32 while 1024 patients underwent PVI after Coumadin discontinuation 3 days preceding the PVI. In all patients the right thrombus was detected by ICE during transeptal access or immediately after the first transeptal puncture. The prevalence of right thrombus on the transeptal sheath was found in 9% (158 pts) of patients on 'therapeutic" Coumadin before PVI and in 8.6% (88 pts) of patients off Coumadin before PVI (p > 0,001). In all cases the right thrombus have not been aspirated but only monitored during the whole procedure by ICE. No parameter included in the baseline characteristics of the patients was found to be a predictor of this finding. Conclusions: Our study shows that thrombus on the transeptal sheaths is detected by ICE in about 9% of the patients undergoing PVI despite a therapeutic "INR". These results suggest that administration of i.v. heparin before transeptal access is required even in patients with "therapeutic" INR. P011 LEFT ATRIAL SPONTANEOUS ECHO CONTRAST IS CLINICAL PREDICTOR FOR THE RECURRENCE OF ATRIAL FIBRILLATION AFTER CATHETER ABLATION? Kim M‐N; Park S‐M; Shim W‐J; Choi J‐I; Park S‐W; Kim Y‐H Division of Cardiology, Department of Internal Medicine, Korea University College of Medicine Background: Left atrial spontaneous echo contrast (LASEC) is known as one of markers of thrombogenic milieu in patients with atrial fibrillation(AF). But it was not examined that SEC has a influence on the recurrence of AF after catheter ablation. Method: 229 patients with non‐valvular AF who underwent catheter ablation for AF were enrolled and performed trans‐thoracic echocardiography (TTE) and trans‐esophageal echocardiography (TEE) before procedure. SEC was diagnosed by TEE as the presence of smoke‐like echogenic materials which swirled in the cavities. And other 2D‐echocardiography parameters were measured. Result: Left ventricular ejection fraction (LVEF) of patients with (+) SEC was mildly decreased than in patients without SEC (55.5 ± 5.8% vs. 56.4 ± 3.7%, P = 0.003). E/e' ratio, the marker of diastolic function of the LV was larger in patients with (+) SEC than in patients without SEC (10.8 ± 5.9 vs. 8.7 ± 2.9, P = 0.004). Ablation time was longer in patients with (+) SEC than in patients without SEC (91 ± 59 min vs. 88 ± 34 min, p < 0.001). Patients with (+) SEC had a non‐significant, but higher incidence of AF recurrence after ablation (25.9 vs. 20.1%, P = 0.45). Conclusion: LASEC was closely associated with LV systolic and diastolic function as well, however, was not significantly related to clinical outcome after catheter ablation of AF. Further study including large number of the patients is warranted. P012 LONG TERM RESULTS OF ABLATION FOR LONE ATRIAL FIBRILLATION VIA RIGHT MINITHORACOTOMY: TOWARDS A RATIONAL REVISION OF TREATMENT PROTOCOLS Nasso G; Bonifazi R; Romano V; Visicchio G; Fiore F; Speziale G GVM Care & Research, Bari, Italy Objective: Despite continued technical improvements, the results of transcatheter radiofrequency ablation of atrial fibrillation may be suboptimal in some patients subgroups. The short‐term follow‐up results of the minimally invasive epicardial ablation of lone atrial fibrillation were encouraging. Methods: One‐hundred‐four patients with drug‐refractory lone atrial fibrillation underwent minimally invasive surgical ablation with a right 3–4 cm minithoracotomy by isolation of the pulmonary veins, and were followed‐up for average 17 months. Previous failed transcatheter ablation was not an enrolment criterion for this procedure in the last phase of our experience. Results: The procedure is confirmed to be safe (one case of procedure‐related morbidity, no operative deaths) and effective (89% overall freedom from recurrent arrhythmia at follow‐up with 96 freedom from arrhythmia for paroxysmal AF Type and 80% free for persisting AF).The results tend to improve with the expansion of the surgical experience. Cox hazards regression and Kaplan‐Meier analysis identified persisting type of atrial fibrillation and enlarged left atrium as the major predictors of recurrent atrial fibrillation at follow‐up. Health‐related quality‐of‐life is confirmed improved at the end of the follow‐up vs. baseline in the majority of the SF‐36 domains. Conclusions: The minimally invasive epicardial ablation of lone atrial fibrillation yields stable and gradually improving results. Earlier referral of patients to surgery is justifiable after a careful cardiologic work‐up. In order to define the relative roles of the minimally invasive ablation and the transcatheter ablation, which may be considered in the future as alternative therapies, a randomized trial of these two procedures is advisable. P013 A RANDOMISED CONTROLLED TRIAL OF CATHETER ABLATION VERSUS MEDICAL TREATMENT OF ATRIAL FIBRILLATION IN HEART FAILURE (THE CAMTAF TRIAL) Hunter RJ; Berriman TJ; Diab I; Baker V; Richmond L; Abrams D; Dhinoja M; Earley MJ; Sporton S; Schilling RJ Cardiology Research Department, St Bartholomew's Hospital Introduction: We sought to compare the impact of a catheter ablation strategy (CA) to a medical rate control strategy (MED) in patients with persistent atrial fibrillation (AF) and heart failure (HF). Methods: Patients with persistent AF, symptomatic HF, and a left ventricular (LV) ejection fraction (EF) < 50%, were randomised to CA or MED. HF medication and anticoagulation were optimised prior to baseline observations. For those with recurrent AF in the CA group, a repeat procedure was performed at the end of the 3 month blanking period and follow up re‐started. The primary end‐point was the difference in LV EF between groups on echocardiography at 6 months. Echocardiographic data were anonymized and core reported by a blinded collaborating centre. Results: 54 patients were randomised, but 5 were excluded (LV normalised during optimisation of medications prior to baseline tests in 2, and 3 withdrew un‐happy with their treatment allocation). Patients were 58 ± 11 yrs and 96% were male. Baseline EF was 31 ± 10% in the CA group and 33 ± 9% in the MED group. NYHA class was 2.5 ± 0.5 in both groups. Patients underwent 1.6 ± 0.7 procedures. There were 2 complications: 1 stroke and 1 tamponade. In the CA group 1 patient withdrew after a procedural stroke, and in the MED group 1 patient died. All 21 remaining in the MED group, and the 24 of 26 in the CA group that had reached 6 months follow‐up were included in the analysis of the primary end‐point. Freedom from AF was achieved in 21/24 (88%) off antiarrhythmic drugs. LV EF in the CA group at 6 months was 39 ± 10% compared to 32 ± 13% in the MED group (p < 0.05). NYHA class was also significantly lower in the CA group (1.7 ± 0.8 compared to 2.3 ± 0.6 in the MED group; p < 0.05). Conclusions: CA is effective in restoring sinus rhythm in patients with persistent AF and HF, and improves LV function and heart failure symptoms compared to medical treatment alone. P014 A NOVEL APPROACH TO MINIMALLY‐INVASIVE ABLATIVE MAZE SURGERY FOR REFRACTORY LONE ATRIAL FIBRILLATION Benussi S; Pozzoli A; Taramasso M; Dorigo E; Calabrese M; Nascimbene S; Anzil F; Alfieri O San Raffaele University Hospital, Cardiothoracic Surgery Department Purpose: One of the main limitations of the Maze is the requirement of median sternotomy. This, has limited the popularity for the surgical treatment of lone atrial fibrillation (AF) despite its recognized superior efficacy. We evaluated the outcomes of an original technique, devised to perform a complete MazeIII procedure with bipolar radiofrequency (RF), through a minimally‐invasive approach. Methods: The procedure was carried out through right minithoracotomy. Cardiopulmonary by‐pass was instituted through peripheral venous and arterial cannulation. After cross‐clamping, all Maze III ablations were performed using a new glidepath‐guided, articulated bipolar RF clamp, including a complete box around the 4 pulmonary veins. If needed, mitral and tricuspid connecting ablations, were completed using cryoenergy. Results: 14 patients were included (13 male; mean age 53 ± 9.6 years). All patients had highly symptomatic persistent (5/14 patients, 35%) or long‐standing persistent (9/14 patients, 65%) lone AF, refractory to a median number of 3 percutaneous ablations (min 1, max 5). The mean duration of AF before surgery was 117 ± 68.4 months, and mean hospital stay was 12 ± 6.7 days. Procedural success rate was 93% (13/14). There was no operative mortality or major complications. No patient required a permanent pacemaker. Follow‐up was complete for all patients, with a mean period of 13 ± 7.7 months and 13/14 patients were in stable sinus rhythm at latest follow‐up. Three months after surgery, left ventricular ejection fraction improved significantly (from 55.2%± 5.9% to 63%± 3.8%, p = 0.007). Furthermore, after surgery, EHRA score decreased by ≤ 2 in 9 patients (64%) and NYHA functional class also improved by ≥ 1 in 11 cases (78%). Conclusions: A MazeIII procedure can be reproducibly performed through right minithoracotomy using an articulated bipolar RF clamp and cryoenergy, with excellent mid‐term results. Maze surgery with bipolar RF can thus be performed through minithoracotomy safely, without compromising efficacy. P015 EVALUATION OF ECHOCARDIOGRAPHIC TECHNIQUES SENSITIVITY FOR GUIDING TRANSEPTAL PUNCTURE Ardashev AV; Zhelyakov EG; Rybachenko MS; Konev AV; Kuzovlev OP; * Belenkov YuN 83 Clinical Hospital of FMBA, * Lomonosov State University, Moscow, Russia Objective: to compare the sensitivity of transthoracic (TTE), transesophageal (TEE) and intracardiac (ICE) echocardiography for guiding transeptal puncture. Methods: The study concluded of 208 pts (48 female, mean age was 56.4 ± 11.3 years) who underwent RFA of left atrium because of atrial fibrillation. Transeptal puncture was performed after interatrial septum (IAS) visualization using TTE in 32 (15.4%), TEE – in 26 (12.5%), ICE – in 150 (72.1%) pts. ICE was preformed using the electronic phased‐array intracardiac ultrasound catheter sector imaging system (AcuNav, Siemens). Optimal contact of transeptal needle with IAS was defined as a tension of septum using echocardiographic techniques. Verification of tenting and following transeptal puncture with LA catheterization defined as a true positive result. Lack of visualization of tenting with successful transeptal puncture under fluoroscopy was defined as a false negative result. Results: Clear visualization of the IAS using TTE technique was demonstrated in 2 (6%) cases, and the sensitivity amounted for 6.7%. Obvious verification of IAS by TEE was revealed in 20 (77%) pts, and sensitivity of this technique was 86.9%. ICE control of septum puncture was performed in 127 pts. ICE allowed visualizing septum and tenting in 125 pts and the tension of septum was unable to be determined in 2 cases despite of the efforts of specialists. ICE sensitivity for IAS verification was 98.4%. Conclusion: In our study we estimated that ICE is the most sensitive ultrasound technique for obvious verification of optimal location of the transeptal needle in the region of IAS comparing with TTE and TEE. P016 ABLATION OF LONG‐LASTING PERSISTENT ATRIAL FIBRILLATION BY INTRAPROCEDURAL USING OF IBUTILIDE TO IDENTIFY PERSISTENT CFAES: RESULTS FROM A RANDOMIZED STUDY COMPARING TWO DIFFERENT STRATEGIES Rebecchi M; de Ruvo E; Sciarra L; De Luca L; Pitrone P; Guarracini F; Zuccaro LM; Dottori S; Verlato R; Calò L Policlinico Casilino, Rome, Italy. Introduction: Ablation of long‐lasting (LL)‐persistent atrial fibrillation (AF) is highly variable, with different strategies and outcome. We sought to compare RF ablation of CFAEs in right (RA) and left atrium (LA) identified by using endovenous low‐dose of ibutilide plus pulmonary veins isolation (PVI) with linear lesions in LA plus PVI. Methods: Fifty‐four symptomatic patients with LL‐persistent AF, refractory to AADs, were randomized to two different ablation approach. Twenty‐seven patients (group A; mean age 58.7 ± 7.4 years, 14 males) underwent PVI plus bi‐atrial ablation of CFAEs areas identified prior and post endovenous low‐dose of ibutilide (0.5 mg) administration. The remaining 27 patients (group B; mean age 58.6 ± 9.4 years, 14 males) underwent PVI and linear lesions (roof and mitral isthmus) in the LA. Results: All patients completed ablation procedure without complications. In the group A, the prevalence of CFAEs before ibutilide administration was higher in the LA than in the RA (35.4% vs 21.2% P = 0.016). After ibutilide administration, AF cycle lenght significantly decreased if compared with baseline (264.2 ± 51.9 vs 153.4 ± 33.9, P = 0.0001) and CFAEs prevalence was globally reduced of 69.4% (P = 0.001) in LA and of 81.7% (P = 0.001) in RA. Complete PVI was performed in all patients of both groups. Complete mitral isthmus and roof conduction block was observed in 15 (55%) and in 24 (88%) patients of group B, respectively. After a mean follow up of 13 ± 8 months, 22 (81.4%) patients of group A and 9 (33.3%) patients of Group B were free from AF recurrences (P = 0.001). Conclusion: In patients with LL‐persistent AF, PVI plus bi‐atrial ablation of CFAEs after ibutilide administration is safe and more effective in term of success rate if compared with PVI plus linear lesions approach. This study suggests the utility of intraprocedural use of ibutilide to perform ablation of persistent CFAEs that could be critical for the maintenance of AF. P017 CRYOBALLOON‐ABLATION TO TREAT PARO‐
XYSMAL ATRIAL FIBRILLATION USING ELECTROANATOMICAL VOLTAGE MAPPING:
WHAT IS THE LEVEL OF PULMONARY VENOUS ISOLATION? Catanzariti D; Maines M; Angheben C; Cirrincione C; Vaccarini C; Vergara G Division of Cardiology, S. Maria del Carmine Hospital, Rovereto (TN) – Italy Background: Balloon‐based technology and cryoenergy were recently introduced to increase the safety of procedure and to reduce discontinuity of circular lesions around pulmonary veins (PVs), by avoiding a major role in the outcome of the operatory dexterity. However relatively unknown remains the exact level of PVs isolation induced by cryoballoon‐ablation (CBA). Methods: In 22 consecutive patients undergoing CBA for paroxysmal or short standing persistent atrial fibrillation after prior MRI data acquisition, 3D reconstruction of the LA could be generated using the EnSite Verismo Software incorporating the 3D reconstruction of the LA created by MRI. This software was also used for measuring distances and the diameter of various anatomical structures and for reconstructing the complete "true" 65533 anatomy of PVs antra. Using preselected amplitude voltage limits of 0.05–0.5 mV and differential pacing techniques, the topographic extension of PVs isolation was assessed after CBA. Results: All 80 PVs of patients study were isolated by CBA (including 9 left common trunk and 1 right middle accessory veins). An antral level of isolation was observed in the vast majority of PVs with severe reduction of voltage outside the tubular portion of PV and at various extent proximal to the PV ostium. Indirect approaches to CBA were preferred in 42% of cryofreezes to enlarge the perivenous atrial lesions, while the coaxial approach was reserved in the remaining cases. Conclusion: CBA exerts its effects on electrical isolation at the antral level of PV ostia largely resorting to indirect approaches for achieving mechanical occlusion during cryoenergy delivery. P018 PVI IN 2011: IS IT NECESSARY TO PERFORM A DETAILED TIME CONSUMING ELECTROPHYSICAL MAPPING OR SHOULD WE FOCUS ON A RAPID AND SAFE THERAPY? A COMPARISON OF DIFFERENT ABLATION TOOLS Maagh P; Butz T; van Bracht M; Trappe HJ; Meissner A Department of Cardiology and Angiology, Cologne gGmbH, Hospital Merheim/Germany Background: PVI is an established treatment option in the field of drug refractory atrial fibrillation (AF). Different ablation tools are available, comparisons between procedure duration (PD) and fluoroscopy time (FT) are lacking. Objective: We compared PD and FT using I) the High Density Mesh Mapper (HDMM) with irrigated‐tip radiofrequency (RF) for antral ablation, and II) the single device RF technique of the High Density Mesh Ablator (HDMA), and III) the "single shot" device of the Arctic Front Cryoballoon with cryothermal energy. Methods: In our single center between August 2007 and March 2010, a series of 111 PVI procedures were performed in paroxysmal AF (PAF) and persistent AF (persAF) patients (mean age 59.7 ± 9.9 years with a 6.4 ± 4.4 years history of PAF (67 patients, 60.4%) and persAF (44 patients, 39.6%)). PD and FT were entered into a retrospective database. Results: The procedures included 42 PVIs with the HDMM (37.8%), 47 with the HDMA (42.3%) and 22 with the cryoballoon (19.8%). Comparing the 30 first procedures in groups of 10 in the HDMM and HDMA group, PD and FT fell in the HDMM group (257.5 to 220.9 min and FT from 80.5 to 67.3 min (both p < 0.005) as well as in the HDMA group (182.9 to 147.2 min and FT from 41.02 to 29.1 min). In the cryoballoon group, there was a steep learning curve with a steady state after the first 10 procedures (PD and FT decreased from 189.5 to 151.0 min and 36.9 to 33.0 min, p values 0.005 and 0.05 respectively). Severe complications did not occur. Conclusion: The cryoballoon technology had the shortest PD and FT. The strongest indicators of quality of ablation should include PD and FT as well as the efficacy to prevent AF recurrence. Further studies will show if we should adopt a "wait‐and‐see" attitude referring the AF recurrence or if the time for correct mapping of the PV potentials is a price we should be willing to pay. P019 INITIAL RESULTS OF PURSE‐STRING PV BOX ISOLATION PROCEDURE FOR NON‐MITRAL ATRIAL FIBRILLATION Imai K; Sueda T; Bagus H; Katayama K; Takahashi S; Takasaki T; Kurosaki T; Uchida N Department of Cardiovascular Surgery, Hiroshima University Hospital Introduction: Although less invasive procedure for atrial fibrillation (AF) such as catheter ablation or minimally invasive surgery diminished AF with high success rate, several problems still remain unsolved, including repeat sessions or uncertainly of ablation tools. We have performed surgical PV Box isolation (PVBI) for AF combined with mitral valve disease (MVD) with good success rate, however, PVBI for non‐MVD is invasive because of its incision line. We have developed less invasive surgical procedure, purse‐string PBVI with certain ablation line for non‐MVD AF. Method: Seven non‐MVD paroxysmal AF (pAF) cases (3 ASD, 2 AVR 1 TVR and 1 OPCAB) that have indication for surgical intervention, were received PVBI. Box ablation line was created by using bipolar radiofrequency surgical device which can create a long (about 7 cm) continuous transmural lesion. At first, bilateral epicardial PV isolation line was made and second, upper and lower connecting line was added without incision of left atrial wall using purse‐string technique: one‐half of ablation jaw was inserted into the left atrium through a purse‐string suture on the right PVs toward the left PVs. All patients were received continuous monitor ECG (in hospital) and Holter ECG of every 6 month (after discharge), AF recurrence was estimated by more than 5 minutes duration. Result: No complications or death were procedure related. At discharge, freedom from AF was 86%. In the patients of AF free at discharge, 100% of patients were free from pAF at averaged 13 months follow‐up. Conclusion: Purse‐string PVBI can be a less invasive and effective procedure for non‐MVD pAF. P020 PULMONARY VEIN ISOLATION WITH THE PULMONARY VEIN ABLATION CATHETER VERSUS CONVENTIONAL POINT‐BY‐POINT ABLATION USING THE CARTO SYSTEM: A LARGE, COMPARATIVE, SINGLE CENTRE STUDY De Greef Y; Segers V; Schwagten B; De Keulenaer G; Stockman D Department of Cardiology, Antwerp Cardiovascular Institute Middelheim, Belgium Aim: To compare pulmonary vein isolation (PVI) using the pulmonary vein ablation catheter (PVAC) with conventional PVI guided by CARTO. Methods: Two‐hundred consecutive patients with paroxysmal atrial fibrillation (AF) and left atrial (LA) diameter of <50 mm underwent either CARTO‐ (N = 100) or PVAC‐guided (N = 100) PVI. Follow‐up (symptoms and Holter) was performed at 1 month and every 3 months thereafter. Repeat ablation was guided by a circular catheter and CARTO to describe PV reconnection characteristics. Results: Clinical characteristics were similar. Successful PVI was obtained in 378 out of 390 (97%) veins in the PVAC vs. 393 out of 393 (100%) in the CARTO group. At 1 year follow up, 73 patients in the PVAC group were free of AF compared to 67 of CARTO patients (P NS). Procedure time was significantly shorter in the PVAC group (126 ± 44min vs. 201 ± 44, p < 0.0001). At repeat, the N (total (%)/per patient) of reconnected PV's was similar after PVAC (19 patients; 50 (66%)/2.7 ± 1.1) and CARTO (20 patients; 50 (63%)/2.4 ± 1.4) (P NS). Neither the N (total/per patient (PVAC N 44; 2.3 ± 0.9 vs CARTO N 59; 3.0 ± 1.6, P NS) nor spatial distribution of conduction gaps differed between both groups. PV stenosis occurred more significantly after PVAC (4 vs. 0, p < 0.05) while pericardial injury (8 vs. 0, p < 0.05) and LA tachycardia (9 vs. 3, p < 0.05) were more frequent after CARTO. Conclusions: Pulmonary vein isolation using the PVAC catheter is as efficient but significantly faster than the conventional approach. Whereas findings at repeat were similar, their safety profile differs significantly. P021 CATHETER ABLATION OF ATRIAL FIBRILLATION IN PATIENT WITH MECHANICAL MITRAL VALVE: PVAI VS. TRIGGER ABLATION Bai R; Di Biase L; Mohanty P; Santangeli P; Mohanty S; Pump A; Sanchez J; Burkhardt JD; Horton R; Natale A Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas, USA Background: It has not been reported whether trigger ablation prevents more arrhythmia recurrences than standard pulmonary vein antra isolation (PVAI) in patients with mechanical mitral valve (MMV) undergoing ablation of atrial fibrillation (AF). Methods: 109 patients with MMV who underwent ablation for either persistent (N = 70) or paroxysmal (N = 39) AF were divided into 2 groups: standard PVAI was performed in Group 1 (N = 45); in Group 2 (N = 64), in addition to PVAI, an isoproterenol challenge up to 30μg/min was performed and ectopic atrial beats or tachycardias (trigger activities) arising from extra‐PV foci were abolished. RF was delivered with a 3.5mm open irrigated‐tip catheter guided by CARTO map. The endpoint of procedure was complete PVAI (for both Groups 1 and 2) as well as elimination of all potential trigger sites (for Group 2). Patients were followed‐up by ECGs, transtelephonic monitoring, 7‐day Holters and office visit. Results: All patients (51 males; age 62 ± 10yrs) underwent the procedure successfully. INR on the day of ablation was 2.6 ± 0.3. There were 2 groin hematomas and 1 pericardial effusions in Group 2; while 1 diaphragmatic paralysis, 1 tamponade and 2 AV fistulae in Group 1. All except one patient in Group 2 had extra‐PV triggers. At 1‐year follow up, 39 (61%) patients in Group 2 and 7 (15%) patients in Group 1 were in sinus rhythm off AAD with single procedure (p < 0.0001). 85% of patients in Group 1 underwent redo ablation due to early recurrence of AF. Very late recurrence (32 ± 4 months) was observed in 12 (19%) patients in Group 2 and consisted of focal atrial tachycardia in 9 and atypical atrial flutter in 3 patients, which were treated with repeat ablation. Conclusion: Catheter ablation of AF in patients with MMV is feasible and safe. Trigger ablation in addition to standard PVAI was associated with less arrhythmia recurrence at follow‐up. Focal atrial tachycardia appeared to be the predominant cause of very late recurrences. P022 A FAST EVALUATION OF THE LEFT ATRIUM BEFORE ABLATION: ICETEE (INTRACARDIAC ECHOCARDIOGRAPHY PROBE USED FOR TRANSOESOPHAGEAL ECHOCARDIOGRAPHY) Schuster P; de Bortoli A; Chen J; Hoff PI Haukeland University Hospital, Department of Heart Disease, Bergen, Norway Aim: In high risk patients before atrial fibrillation (AF) radiofrequency ablation (RFA) we used nasogastrically an expired resterilized intracardiac echocardiography (ICE) probe (AcuNav, Siemens; 10 F) as a a simplified transesophageal echocardiography (TEE) procedure and registered the time consumption. Method: 25 patient (mean age 59 ± 9 years, 4 female) were examined without any form of sedation or anaesthesia using the ICEETEE method to exclude atrial thrombi and to determine left atrial (LA) appendage flow. 17 patients because of high CHADS2 score (>2), four paroxysmal AF patients not using preprocedural Warfarin, three patients admitted to RFA with AF unknown duration, one with unknown duration of a fast AFL and the purpose of DC conversion. Results: Due to previous painful and difficult gastroscopi one patient refused a conventional TEE before the RFA procedure. Despite good sedation, local anesthesia and an experienced operator including help of a gastroenterologist conventional TEE had failed in another patient. No difficulties during the nasogastric insertion of the probe were experienced in any patient. In all patients a good overview of the LA excluding thrombi and an acceptable LA appendage Doppler flow were demonstrated. The duration of the ICEETEE examination was 8 ± 2 min and a mean of 11 ± 5 loops were recorded. In the 24 RFA patients the ICEETEE procedure lasted 8 ± 3 min of the 208 ± 73 min of total procedure duration. No thrombembolic complications occurred during the RFA procedures. Conclusion: A simplified and fast risk stratification using an ICE probe nasogastrically as TEE is feasible and only 8 min (4%) of the total RF procedure time are needed to perform an ICEETEE examination. P023 EFFECT OF GENDER AND AGE ON RESULTS OF ABLATION OF PAROXYSMAL ATRIAL FIBRILLATION Rafla S; Kamal A; Kautzner J* Alexandria Univ. Cardiology Dept, Egypt and IKEM institute, Prague, Czech Republic* This analysis assesses the effect of gender and age on the results of ablation of paroxysmal AF. Methods: We studied 150 patients (pts) (86 males and 64 females) having a mean age of 51.3 yrs, who suffered from symptomatic drug refractory paroxysmal AF. Cardiac MSCT image integration to the 3D electroanatomic LA map was used in 106 pts (70.6%, however all of them underwent intracardiac echo guided imaging during the ablation procedure. 40 pts underwent manual RF ablation using CARTO, 40 pts underwent ablation using NavX system, 70 pts underwent robotic ablation using Sensui system. Pulmonary vein isolation was done to all pts using either pulmonary vein (PV) antral isolation in 116 (77.3%) or circumferential pulmonary vein ablation in 34 pts (22.7%). Circumferential PV ablation was usually associated with posterior wall ablation. Additional roof line was done in 28 pts (18.6%). All pts were followed at 3, 6, 9, and 12 months. Results: 34 patients (22.6%) developed early recurrence of AF after an initial blanking period of 3 months. We had 16 patients(10.6%) with treatment failure at short term follow up, this number increased to 18 patients (12%) at midterm follow up and further small increase to 20 patients(13.3%) at long term follow up, recurrences were any episode of AF and /or AFL/AT > 30 seconds after the blanking period. ECG during follow up: Normal SR 32 (80%), Atrial Tachycardia 4, PAF 2, A flutter 2. Complications rate: None in 92,5%, air embolism zero, cardiac tamponade zero, trivial pericardial effusion 1, groin hematoma 5%. There was no difference between males and females in success of ablation or complications. Those below age 50 and above 50 were not different in incidence of maintenance of SR or complications. Conclusions: Neither gender nor age had influence on success of ablation of AF or on incidence of complications. P024 A MIDTERM FOLLOW‐UP RESULT OF SIMPLIFIED MAZE PROCEDURE BASED ON RADIOFREQUENCY PV BOX ISOLATION Imai K; Sueda T; Bagus H; Katayama K; Takahashi S; Takasaki T; Kurosaki T; Uchida N Department of Cardiovascular Surgery Introduction: It has been reported that some less invasive modified Cox‐maze procedures were effective for limited patients. We report a midterm follow‐up result of our simplified procedure based on PV Box isolation for permanent/chronic atrial fibrillation (AF) combined with several type of organic heart disease. Methods: Among a total of 194 cases, we extracted 93 cases that received modified maze procedures; pulmonary vein box isolation (PVBI) or hybrid procedure (HBP). The HBP consisted of 1) circumferential isolation of four pulmonary veins (this is "PVBI") with monopolar or bipolar device, 2) radiofrequency ablation (RF) between PVBI‐line and mitral annulus (with monopolar or bipolar), 3) RF for RA isthmus (bottom line of Koch's triangle and between RA incision and coronary sinus orifice with monopolar or pen type bipolar) and 4) RF from IVC to RA incision line. We divided the patients based on their etiological background and analyzed the operative results in overall, every groups and between groups retrospectively. Results: Overall freedom from recurrent AF was 80% at latest follow up. The significant (p < 0.01) predicting factor of AF recurrence were AF duration, amplitude of V1‐f wave and LAD. In the patients of bi‐atrial strain (mitral regurgitation + tricuspid regurgitation), the AF free rate in the HBP group was significantly higher than that in PVBI (91% vs. 68%, p = 0.0307) without any differences of their backgrounds. Conclusions: For further improvement of operative outcomes with lesser invasion, it may be necessary to choose the tailored procedure based on the etiology. P025 USE OF PARTIALLY WITHDRAWN CORONARY SINUS CATHETER TO EVALUATE CAVOTRICUSPID ISTHMUS BLOCK DURING RADIOFREQUENCY CATHETER ABLATION Marinskis G; Aidietis A; Kaireviciute D; Jurkuvenas P; Bagdonas K Clinic of Cardiac and Vascular Diseases, Vilnius University Purpose: to assess feasibility of verification of cavotricuspid isthmus (CTI) block by evaluation of low right atrial activation sequence using coronary sinus (CS) electrode withdrawn to the inferior vena cava (IVC) orifice. Methods: in 167 patients (pts) who underwent CTI ablation for typical atrial flutter, presence of cavotricuspid block has been verified by halo catheter or evaluation of low lateral right atrial activation sequence by ablation catheter, and comparison of His bundle electrogram (HBE) and proximal coronary sinus (PCS) atrial activation timing. In all pts, decapolar CS catheters with 5 mm inter‐electrode space and 10 mm space between electrode pairs have been introduced using femoral approach. After prolongation of CTI conduction times, CS electrode was withdrawn to the IVC orifice and timing of atrial activation on the proximal (5th) pair and the 4th pair of electrodes has been compared. Results: when complete CTI block has been achieved, pacing lateral to ablation line has been accompanied by "bracketing" of low right atrial activation – activation on the proximal pair (closer to ablation line) was later than activation on the 4th pair. That was seen in 127 of patients with CTI block (sensitivity 76%, specificity 100%). In 40 pts with complete CTI block after extensive ablation close to CS ostium, either the signals on the proximal pair could not be appreciated, or atrial activation on this pair was the earliest. Conclusion: evaluation of low right atrial activation sequence by coronary sinus catheter partially withdrawn to the inferior vena cava helps to confirm cavotricuspid isthmus block after ablation. P026 SERUM n‐3/n‐6 POLYUNSATURATED FATTY ACID RATIO IS A STRONG PREDICTOR OF SINUS RHYTHM MAINTENANCE AFTER CATHETER ABLATION OF PAROXYSMAL ATRIAL FIBRILLATION Nakanishi H; Hirata A; Okada M; Kashiwase K; Nishio M; Asai M; Nemoto T; Matsuo K; Konishi S; Ueda Y Cardiovascular Division, Osaka Police Hospital, Osaka, Japan Purpose: Atrial fibrillation (AF) is the most common cardiac arrhythmia. Despite advances in rhythm control including catheter ablation (CA), the effect on secondary prevention of AF is not completely established. There have been some evidences that the n‐3 polyunsaturated fatty acids (PUFAs) have anti‐arrhythmic effects, however, these effects are controversial. The present study was designed to evaluate the effect of the serum n‐3/n‐6 PUFA ratio on the rate of SR maintenance after CA of paroxysmal AF (pAF). Methods: We assessed 38 patients with pAF. The serum n‐3/n‐6 PUFA ratio was defined as an eicosapentaenoic acid (EPA) / arachidonic acid (AA) ratio. All the serum samples were obtained before admission. In the procedure, all patients underwent bilateral extensive encircling pulmonary vein (PV) isolation. Additional procedures (left atrial (LA) linear [1 patient], complex fractionated atrial electrograms [3 patients], non‐PV foci [2 patients], or cavo‐tricuspid isthmus [15 patients]) were performed as necessary. The definition of AF recurrence was one more than 3 months after the procedure. In this study, no patients were taking purified EPA ethyl ester agent. Results: 27 patients maintained SR, while 11 patients had recurrence of AF. SR maintenance group had significant higher serum EPA/AA ratio (0.50 ± 0.20 vs. 0.29 ± 0.11, p = 0.002) than AF recurrence group. There were no significant differences between two groups in age (64.0 ± 10.6 vs. 59.3 ± 14.0 yrs, p = NS), gender (15 (56%) vs. 7 (64%) males %, p = NS), LA diameter (39.5 ± 4.4 vs. 42.5 ± 6.4 mm, p = NS), left ventricular (LV) ejection fraction (67.7 ± 5.9 vs. 68.3 ± 6.6%, p = NS), LV end‐diastolic dimension (49.1 ± 5.2 vs. 51.3 ± 4.2 mm, p = NS), CHADS2 score (0.7 ± 0.7 vs. 1.3 ± 1.1, p = NS), follow up period (11.7 ± 6.0 vs. 15.6 ± 7.8 mths, p = NS), and antiarrhythmic drugs after procedure (8 (30%) vs. 4 (36%), p = NS). Conclusions: Serum n‐3/n‐6 PUFA ratio is important for secondary prevention after CA of pAF. P027 RATIONALE AND DESIGN OF VATCAT: VIDEO‐ASSISTED THORACOSCOPIC PULMONARY VEIN ISOLATION VERSUS PERCUTANOUS CATHETER ABLATION IN ATRIAL FIBRILLATION TRIAL Velthuis BO; Stevenhagen J; Storm van Leeuwen RPH; Speekenbrink RGH; van der Palen J; Scholten MF; VATCAT Medisch Spectrum Twente Background: Recent studies have demonstrated that radiofrequency isolation of the pulmonary veins (PVI) and surgically video‐assisted thorascopic pulmonary vein isolation (VATS‐PVI) are acceptable or even superior alternatives to anti‐arrhythmic drug therapy in patients with symptomatically paroxysmal atrial fibrillation (AF). However, data comparing effectiveness in both interventions are limited. Objective: The primary objective is to compare the effectiveness of PVI and VATS‐PVI. The secondary objective is the comparison of duration and costs of hospitalization, discomfort during admission, experienced AF burden during follow‐up and time to recurrence. Methods: The Video‐Assisted Thoracoscopic pulmonary vein isolation versus percutaneous Catheter Ablation in atrial fibrillation Trial (VATCAT) is a prospective single center study. 160 patients with paroxysmal or persistent AF will be randomized to percutaneous PVI or VATS‐PVI. After a stabilization period of 90 days, which allows for a second procedure, 7‐day Holter‐ECG will be done at 3, 6 and 12 months. Treatment failure will be defined as reoccurrence of AF exceeding 30 seconds. Results: Inclusion started in August 2010, currently 40 patients are included. 22 patients were treated of which 9 received VATS therapy. Conclusion: This study should provide data on the effectiveness of either PVI strategy based on intensive rhythm observation. It is unique because, to the best of our knowledge, no previous randomized trial comparing both strategies has been published. P028 USEFULNESS OF CONTRAST INTRACARDIAC ECHOCARDIOGRAPHY IN PERFORMING PV BALLOON OCCLUSION DURING CRYO‐ABLATION FOR ATRIAL FIBRILLATION Maines M; Catanzariti D; Angheben C; Cemin C; Giovanelli C; Vergara G Division of Cardiology, S. Maria del Carmine Hospital, Rovereto (TN) Introduction: Cryoballoon ablation (CBA) has proven very effective for pulmonary vein (PV) isolation (PVI) if complete mechanical occlusion is achieved and conventionally assessed by angiographic injection of contrast within PV lumen. The aim of our study was to assess the usefulness of saline contrast intracardiac echocardiography (CE) in guiding CBA. Methods: Twenty consecutive patients with paroxysmal atrial fibrillation were assigned to fluoroscopy plus CFD (n = 10; group 1: iodinated medium as both an angiographic and an echographic contrast) versus CE plus CFD (n = 10; group 2: saline contrast) for guidance of CBA. CFD‐guidance was used only in pull‐down approaches (16% in the study) in both groups. Results: We evaluated 227 occlusion of 71 PVs. CE‐guided assessment of occlusion, defined as the loss of echocontrastographic back‐flow to the left atrium after saline injection regardless of the visualization of PV antrum, showed a high level of agreement with the angiographic diagnosis of occlusion. PVI rate was similar in both groups and effectively guided by CE (PVI using ≤ 2 double cryofreezes: 89% of PVs in gr. 1 vs 91% in gr. 2; P = n.s.). Group 2 patients (CE guidance) had significantly shorter procedure (128 ± 17 minutes vs 153 ± 18; P < 0.05) and fluoroscopy times (30 ± 11 minutes vs 42 ± 9, P < 0.05) and used lower iodinated contrast (90 ± 25 mL vs 191 ± 45, P < 0.05). Conclusion: PV occlusion and PVI during cryoablation can be effectively predicted by CE. This technique reduces radiological exposure and iodinated contrast use. P029 NO DIFFERENCE IN TRIGGER INDUCIBILITY DURING ATRIAL FIBRILLATION ABLATION PERFORMED WITH GENERAL ANESTHESIA Mountantonakis SE; Kondapalli L; Marchlinski F; Hutchinson M Electrophysiology Section, Division of Cardiology, University of Pennsylvania, Philadelphia, USA Background: General anesthesia (GA) has been increasingly utilized during catheter ablation of AF. When AF ablation is performed under GA, many operators do not intentionally elicit AF triggers with catecholamine infusion due to concern for either excessive medication‐induced hypotension or autonomic‐dependence of trigger induction. We sought to determine whether patients undergoing AF ablation with GA had fewer provocable triggers than patients whose procedures were performed under conscious sedation alone. Methods: 23 patients who underwent AF ablation under GA (Group 1) were matched for age, gender, ejection fraction, left atrial size and type of atrial fibrillation with 23 patients who underwent catheter ablation under conscious sedation (Group II). Patients in Group 1 were maintained under general anesthesia with intravenous propofol; those in Group 2 were anesthetized with boluses of midazolam and fentanyl without airway support. Both groups received escalating doses of isoproterenol (ISO) until either: 1) a maximal dose of 20 mcg/min was achieved or 2) AF was induced. We included only pulmonary vein or non‐pulmonary vein triggers which initiated AF in the analysis. If necessary, intravenous phenylephrine was administered via bolus (25 mcg) and/or continuous infusion (up to 200 mcg/min) to maintain a mean arterial pressure >60 mmHg. The incidence of AF triggers between the two groups was compared. Results: AF triggers were identified in 19/23 patients from Group I and 18/23 patients from Group II (83% vs. 78%; p = 0.9). There was no difference in trigger site or the total ISO required between the 2 groups (15.8 vs 14.8mcg/min, p 0.624). The use of phenylephrine was more frequent in Group I (83% vs. 52%, p = 0.028). Conclusion: The use of GA does not appear to inhibit the provocation of AF triggers. Although ISO‐induced hypotension is more often required in patients under GA, effective doses of ISO can be reliably achieved with phenylephrine infusion. P030 RADIOFREQUENCY CATHETER ABLATION OF ATRIAL FIBRILLATION IN RETIREED PATIENTS Ardashev AV; Konev AV; Zhelyakov EG; Rybachenko MS; *Belenkov YuN 83 Clinical Hospital of FMBA, * Lomonosov State University, Moscow, Russia Aim: To assess effectiveness and safety of radiofrequency catheter ablation (RFA) of atrial fibrillation (AF) in elderly pts with paroxysmal, persistent and permanent AF. Methods: Study was conducted on 214 pts who underwent primary RFA of AF. 76 of them were older than 60 years of age and underwent 93 procedures. The mean age was 68 ± 3.5 years (22 females). The mean duration for AF was 8.7 ± 6.5 years. 36 had paroxysmal, 19 had persistent AF and 21 had permanent AF despite use of 1.7 ± 0.4 antiarrhythmic drugs (AAD). All pts were divided into two groups. First group consisted of 60 pts ranged from 60 to 70 years old (mean age – 65.7 ± 3.5 years), second group concluded of 16 pts ranged from 71 to 83 years old (mean age – 73.7 ± 2.4 years). The ablation strategy consisted of wide‐area circumferential lines around pulmonary veins, roof lines and extensive RFA of the left atrial substrate modification using a three‐dimensional mapping system. Follow up consisted of 1, 3, 6 and 12 months out‐patient clinical visiting after de‐novo RF‐procedure and included of repetitive 24 hour Holter monitoring. Results: There were no complications associated with RFA. 24 (40%) pts of the first group vs 5 (31%) pts of the second subgroup had arrhythmia of the blanking period (p = 0.84) 10 (17%) pts of the first group vs 5 (31%) pts of the second group underwent redo procedures because of atypical atrial flutter, focal atrial tachycardia and atrial fibrillation in period from 6 to 12 months after primary RFA (p = 0.009) because of failure to sinus rhythm control using combined RFA and AAD approach. The incidence of stable sinus rhythm in the first/second groups were 60%/69%, 72%/69%, 83%/81% and 92%/75% at 1, 3, 6 and 12 months, respectively. Conclusion: RFA is a safe and effective treatment for elderly patients with AF. One year arrhythmia free survival rate was higher in patients ranged from 60 to 70 years old. P031 EVALUATION OF ESOPHAGEAL DISPLACEMENTS DURING PULMONARY VEIN ISOLATION IN PAROXYSMAL ATRIAL FIBRILLATION ABLATION Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A; Kamlofsky M; Banega R Instituto Cardiovascular de Buenos Aires (ICBA) Purpose: Catheter ablation represents a substantial achievement in AF treatment but this technique is not free from complications. Atrio esophagic fistula has been described as an infrequent but lethal complication. The aim of this study is describe esophagus position shifts using the shadow function. Methods: Single‐center prospective analysis of consecutive patients who underwent ablation of atrial fibrillation and received a MSCT‐64 prior to ablation between May 2009 and May 2011. A multislice 64 computed tomography was optimized for imaging of pulmonary veins. We performed the tridimensional reconstruction of the esophagus. We designed the left atrium shell and the esophagus position with a quadripolar EP catheter inside the esophagus lumen. We obtain the fiducially points from the pulmonary vein ostium and transport passively the esophagus acquired points obtained during shell construction. If esophagus tract fit with 3D Esophagus reconstruction its position was assessed by using the Nav X Shadow tool during the entire procedure. Significant displacements were defined as those presenting a more than 3 mm shift between the esophagus passive fusion and the 'in vivo' position determined by the shadow function. Results: 153 patients were included with a mean age 61 ± 9.7 yrs, 90% male and a mean BMI of 26.5 ± 6.4 kg/m2. 142 (93%) patients were in sinus rhythm at time of MSCT‐64. We determine the esophagus tract in 146 patients (95%). In 17 patients it was impossible to perform the reconstruction because of technique problems in acquisition image. Significant displacements were observed in 21 patients (15%) and 125 (85%) showed no significant position shifts (p value <0.05). Conclusions: The present study suggests that the Esophagus does not present significant position shifts during PVI. Shadows tool confirm that initial assessment of esophagus position after 3D reconstruction is safe and precisely to guide PVI procedure. P032 CONTINUATION OF VITAMIN K ANTAGONISTS AS ACCEPTABLE ANTICOAGULATION REGIMEN IN PATIENTS UNDERGOING PULMONARY VEIN ISOLATION Oude Velthuis B; Stevenhagen YJ; van Opstal JM; Scholten MF Medisch Spectrum Twente Background: Recent studies have demonstrated that radiofrequency isolation of the pulmonary veins (PVI) is an effective treatment for symptomatic atrial fibrillation. Based on these positive results, non‐ pharmacological therapy has been incorporated in the guidelines for drug refractory atrial fibrillation, resulting in an increased popularity. The prevention of thromboembolic complications remains an important issue. Methods: In January 2010, we adopted an anticoagulation strategy based on continuation of vitamin K antagonists (VKAs) and selective use of transesophageal echocardiogram (TEE). We retrospectively analyzed the results of this strategy in all patients referred for PVI treatment. VKAs were started for all patients 2 months prior to treatment. Discontinuation of oral anticoagulation was considered 3 months after treatment based on thromboembolic and bleeding risk profile. Bleeding and thromboembolic complications were registered during outpatient clinic follow‐up up until 3 months. Results: We performed 151 PVI procedures from January 2010 to March 2011. All patients were seen 6 weeks after discharge. No transient ischemic accident or ischemic cerebrovascular incident occurred pre‐, peri‐ or postprocedure. Four (2.7%) procedures were complicated by tamponade requiring pericardiocentesis. Conclusions: Our data support the increasing evidence for continuation of periprocedural administration of VKAs complemented by a selective TEE approach as a safe therapy for thromboembolic complications. P033 EFFECTIVNESS OF AF ABLATION STRATEGIES IN "YOUNG" AF‐ABLATION CENTER Chasnoits A; Goncharik D; Halianishcha V; Kovalenko O; Persidskikh Y; Plaschinskaya L Republican Scientific and Practical Center "Cardiology", Minsk, Belarus Purpose of the study: to estimate effectiveness and time consumption of 3 different strategies of ablation in patients with paroxysmal and persistent atrial fibrillation (AF) in condition of first starting AF‐ablation center. Methods: 35 consecutive patients underwent Carto XP Merge endocardial ablation procedure. Follow up period was 3 – 18 month. Data presented as Median (Q25; Q75). Summary: Patient divided into 3 groups: 1) ganglionary plexi (GP)‐ablation (n = 11 (4 females), age 55.0 (50.0, 58.0). AF duration 6,50 (4,0; 8,0) years; left atrium (LA) size 41,50 (36,50; 47,00) mm). 2) pulmonary vein (PV)‐isolation (n = 18 (5 females), age 52,50 (48,0; 62,0) years, AF duration 2,00 (1,00; 2,00) years, LA size 41,00 (40,0; 42,0) mm). 3) PV + GP ablation group. (n = 6 (1 female), age 54 (44,0; 59,0), AF duration 4,0 (3,0; 8,0) years, LA size 42,0 (37,0; 42,0) mm). Time of procedure does not significantly differ between groups 4,0 (5,0; 6,0) hour, 3,5 (4,88; 5,5) hour, and 4,0 (4,0; 6,0) hour respectively. After at least 3 month post procedure in GP‐group 5 patient out of 11 were in sinus rhythm (45,45%); in PV‐group 12 out of 18 were in sinus rhythm (66,66%); and in PV + GP‐group – all 6 patients (100%) were in sinus rhythm. Average effectiveness resulted as follows: 23 patients out of 35 (65,71%) were in sinus rhythm. Statistical analysis by Kruskal‐Wallis, Mann‐Whitney and Fisher exact p, two‐tailed tests showed significantly better effectiveness (p < 0,05) only in PV + GP‐group than in GP‐group. GP‐ablation and PV‐isolation groups do not differ in effectiveness by this number of patients. Conclusion: Effectiveness of GP‐ablation and PV isolation does not significantly differ in firs starting AF‐ablation center, but results in group PV + GP are significantly better than in just GP‐group, what is connected to size of myocardial critical mass, involved by PV + GP ablation. It does not take additional time to perform GP‐ablation, doing PV‐isolation. We suggest performing a GP + PV ablation technique. P034 SEQUENTIAL APPROACH FOR TREATMENT OF LONGSTANDING PERSISTENT ATRIAL FIBRILLATION Revishvili A; Matsonashvili G; Labartkava E; Serguladze S; Shmul A; Kvasha B Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia Nowadays surgical ablation of persistent atrial fibrillation (PAF) is thought to be the most effective approach. But still postablative atrial tachycardias (PAT) can be observed in a short period after intervention because of incomplete lesions. Subsequent percutaneous ablation can improve success rate by precise elimination of critical gap‐zones. From May 2007 to June 2011 55 consecutive patients (40 patients with concomitant valvular pathology and 15 patients with failed prior to surgery percutaneous ablations) with symptomatic PAF (mean arrhythmia duration 6 ± 2 years, mean age 56 ± 4 years, mean left atrial volume 180 ± 22 ml., mean EF 58 ± 5%), refractory to antiarrhythmic therapy, underwent bipolar modification of MAZE procedure (MAZE IV) using the Atricure system. Within 14 days after surgery PAT was observed in 7 cases (14%). These patients underwent electrophysiological (EP) study and radiofrequency ablation (RFA). During mean follow up of 14 ± 2 months 49 patients (98%) had stable sinus rhythm, 1 patient (2%) required dual chamber pacemaker implantation because of symptomatic sinus bradycardia. No peri‐operative complications were observed. In 7 patients with PAT during EP study next observations were registered: 1 patient with left atrial ectopic tachycardia because of restoration of conduction from left superior pulmonary vein (LSPV), 1 patient with typical atrial flutter with cycle length (CL) 235 ms and 5 patients with left atrial flutter (mean CL 240 ± 15 ms). During mapping critical sites of left atrial (LA) flutters were found at LA ridge (3 patients) and at LSPV‐LA roof junction(2 patients). All arrhythmias were successfully ablated and during mean follow‐up of 2 ± 1,2 years no evidence of any tachycardia was registered on repetitive Holter monitoring. Two‐step approach can improve long term success for maintaining sinus rhythm and can increase effectiveness of invasive methods of treatment of PAF. P035 DETECTION OF ATRIAL EXCITATION CHAN‐
GES FOLLOWING CIRCUMFERENTIAL PULMONARY VEINS ISOLATION USING WAVELET ANALYSIS Vassilikos V; Dakos G; Chouvarda I; Paraskevaidis S; Mantziari L; Hatzizisis I; Tsilonis K; Maglaveras N; Styliadis I 1st Cardiology Dept, Aristotle University of Thessaloniki, Greece The aim of this study was to investigate differences in P wave duration and excitation characteristics following circumferential pulmonary veins (CPV) isolation using P wave wavelet analysis. Methods: We studied 33 patients (20 males, mean age 52.5 ± 7 years) which underwent CPV isolation because of non‐responsive to drugs atrial fibrillation. The recordings were obtained during sinus rhythm before and after PV isolation with a 3 – channel digital recorder for 10 minutes and digitized with a 16–bit accuracy at a sampling rate of 1000 Hz. The PVs were isolated in pairs using the Nav‐X mapping system. The P wave was analyzed using the Morlet wavelet and wavelet parameters expressing the mean and max energy of P wave were calculated in the three orthogonal leads (X, Y, Z) in three frequency bands (1st: 200–160 Hz, 2nd: 150–100 Hz and 3nd: 90–50 Hz). Nonparametric Wilcoxon matched‐pairs signed‐rank test was used for comparing continuous variables, while p < 0.05 was considered significant. Results: Following CPV isolation, P wave duration at X, Y and Z axes was significantly shorter (96.8 ± 18 vs 86.7 ± 12msec, p < 0.001, 99.3 ± 14.7 vs 89.9 ± 13.8msec, p = 0.001 and 99.5 ± 17 vs 91.3 ± 15msec, p = 0.001, respectively), while mean and man energy in all frequency bands at X and Y axes along with mean energy in all frequency bands at Z axis were significantly lower. Conclusions: P wave wavelet analysis demonstrates significant differences in atrial conduction patterns following CPV isolation, as suggested by the shortening of P wave duration and the lower wavelet energies. P036 TNT DEMONSTRATES COMPARABLE IMPACT OF CIRCULAR MULTIELECTRODE AND IRRIGATED COOL TIP CATHETERS IN ATRIAL FIBRILLATION ABLATION Herstad J; Hoff PI; de Bortoli A; Solheim E; Lizhi S; Chen J; Schuster P Haukeland University Hospital, Department of Heart Disease, Bergen, Norway Aim: Comparing the level of myocardial injury by measuring TnT using non‐irrigated circular multielectrode or irrigated cool tip catheters. Method: 40 patients (mean age 53 ± 12 years, 10 females) underwent pulmonary vein isolation (PVI) for paroxysmal (n = 36) or persistent (n = 4) atrial fibrillation. A multielectrode low energy phased radiofrequency catheter (PVAC, Medtronic Ablation Frontiers Inc, USA; n = 20, group 1) or 3‐D mapping system, irrigated cool tip catheter and circular mapping catheter for demonstrating PVI (n = 20, group 2) were used. TnT (ng/L) was measured 15–22 hours post procedural. Results: No significant differences in age or sex were demonstrated between the groups and no complications were observed. In group 1 procedure time was significantly lower (150 versus 193 min, p < 0,05) and X‐ray duration shorter (26 versus 36 min, p < 0,05). The applied RF energy (43 min (group 1) versus 55 min (group 2), p = ns) resulted in a not significant different release of TnT between the groups (720 ± 352 versus 1397 ± 1134, p = 0,06). The time corrected TnT release per minute ablation (21 ± 12 versus 26 ± 17, p = ns) was similar. Conclusion: Signal controlled PVI using multielectrode radiofrequency catheters compared to irrigated cool tip catheters results in a similar myocardial injury suggesting comparable impact in shorter procedure time and shorter X‐ray duration. P037 THE LONG‐TERM SAFETY OF ANTICOAGULATION STRATEGY AFTER RADIOFREQUENCY CATHETER ABLATION OF ATRIAL FIBRILLATION Park JH; Ko KJ; Han PK; Lim RS; Jang JK; Park HC; Kim YH Korea University Arrhythmia Center Background: The purpose of this study was to investigate the safety and efficacy of standard anticoagulation (SA) over 3 months after radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) in comparison with the early‐stopped warfarinization (EW) within 3 months. Methods and Results: We compared safety between SA (n = 50) and EW (n = 59) group in 109 patients who underwent RFCA of AF (78 males, 55.9 ± 11 years old, paroxysmal AF 59.6%, CHADS2 score 1.5 ± 0.9, duration of follow up 693.1 ± 234.6 days, duration of AF 46.7 ± 42.5 months). Results: There was no significant difference in CHADS2 score (1.5 ± 0.9 vs 1.4 ± 0.8, P = NS) between SA and EW group. Compared to EW group, uninterrupted preprocedural warfarinization (70.6% vs 39.4%, P = 0.014) was greater in SA group, therefore, INR value (1.47 ± 0.51 vs 1.14 ± 0.28, P = 0.002) at the procedure was higher. However, the incidence of hemorrhagic complications (11.9% vs 6.0%, P = NS) or the thromboembolic events (1.7% vs 0.0%, P = NS) was not different between two groups. Conclusion: In patients with low to intermediate risk of thromboembolism (mean CHADS2 1.5) early stopped warfarinization within 3 months after catheter ablation of AF had comparable safety with warfarinization over 3 months. Further prospective study in large scale is warranted to determine long‐term safety of each anticoagulation strategy. P038 INCIDENCE OF SUPERIOR VENA CAVA ELECTRICAL ACTIVITY DURING ATRIAL FIBRILLATION RADIOFREQUENCY TREATMENT Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A Instituto Cardiovascular de Buenos Aires (ICBA) Introduction: It is widely known that almost 94% of atrial fibrillation triggers are located in pulmonary veins and only few are located in extrapulmonary vessels. Nevertheless, new ablation techniques including superior vena cava (SVC) isolation have demonstrated higher success rates. Objective: To determine the incidence of SVC electrical activity in patients elegible for pulmonary vein isolation (PVI) as a methodological approach to understand atrial fibrillation (AF) pathophisiology in a huge cohort of patients. Method: Single‐center analysis of consecutive patients who underwent pulmonary vein isolation ablation between may 2009 and january 2011. Electrical activity in SVC was assessed by placing a circular multipolar catheter (Optima, St. Jude medical) inside the vessel. The SVC electrical activity was defined as the registry of potentials inside this structure (impulse conduction between right atrium and SVC) as far as 5 cm by the Optima catheter during sinus rhythm or AF. Results: A total of 107 patients were included. Electrical activity in SVC was assessed in only 42 patients; 90.47% male; Mean age 48 ± 8,4 years; 73.80% presented as paroxysmal AF. A total of 16 patients (38.09%) showed SVC electrical activity. Conclusion: This study confirms a high prevalence, almost 40%, of SVC electrical activity in patients referred for PVI. If this finding become in a new goal in AF treatment has to be determine in future trials. P039 PREVALENCE, CHARACTERISTICS AND PREDICTORS OF PULMONARY VEIN NARROWING AFTER PVAC ABLATION De Greef Y; Tavernier R; Raeymaeckers S; Schwagten B; Desurgeloose D; De Keulenaer G; Stockman D; Duytschaever M Department of Cardiology, Antwerp Cardiovascular Institute Middelheim, Belgium Background: The risk and determinants of pulmonary vein narrowing (PVN) after pulmonary vein isolation (PVI) using a novel multi‐electrode ablation catheter (PVAC) are unknown. Methods and Results: PV diameters (PVD) and left atrial (LA) volume were compared by computed tomography before and 3 months after PVI using duty‐cycled phased RF energy (2:1 or 4:1 bipolar/unipolar ratio) in 50 patients. PVD was measured in a coronal and axial view at three levels (A = ostium, B = 1cm more distal, C = 2cm more distal). Moderate PVN was defined as a PVD reduction of 25–50%, severe PVN as > 50%. Axial PVD shortened by 17 ± 16%, 14 ± 16% and 8 ± 22% at level A, B and C respectively (p < 0,001 for all); coronal PVD decreased by 16 ± 14%, 13 ± 17% and 7 ± 19% (p < 0,001 for all). Moderate PVN occurred in 55/200 PVs (28%) in 36 patients (72%); severe PVN occurred in 8/200PVs (4%) in 7 patients (14%). The left superior PV and the number of 2:1 applications were predictors for PVN. LA volume decreased by 10 ± 18% (p < 0,001). Conclusions: PVAC ablation results in a consistent moderate reduction of the PVD predominantly at the ostium. PV narrowing occurred more frequently in the LSPV and was related to the number of 2:1 applications. Severe PVN in 14% of patients, raises concerns about the risk for clinical PV stenosis. P040 ATRIAL FIBRILLATION TREATED WITH PULMONARY VEINS ABLATION:PATIENTS PROFILE AND LIFE QUALITY Fernandez‐Oliver AL(1); Mgueraman‐Jilali R; (1) ELECTROPHISIOLOGY AND ARRHYTHM UNIT Universitary Hospital Virgen de la Victoria. Malaga. Spain Purpose. Atrial fibrillation (AF) is a highly prevalent arrhythmia with significant impact on patients' life quality. Pulmonary veins ablation (PVA) offer new treatment expectations. Purposes: 1. To assess daily living activities changes, the patient quality of life as a result of arrhythmia, and changes after PVA. 2. To get the profile of patients with AF those who perform PVA. Method. Quantitative, retrospective, descriptive study. Sample of 44 patients (56 procedures) underwent PVA (March 2008–August 2009). We custom‐assessment interview prior to the procedure and post‐ablation to 3,6 and 9 months for assessing the impact it was on issues as respiratory distress, palpitations, difficulty performing daily activities. Were also given to patients health questionnaire EQ‐5D to responses objectively. Also we discussed Holter records evaluation to verify presence of sinus rhythm or AF recurrence. Results. Mean age 51 years (19‐72), 66% men; 65% of patients improved significantly their quality of life, refer unwell without pain /discomfort, assessing their current health status markedly improved (39% according rating scale). 50% following a 15% to more than one and 19% waiting for a new procedure; 12% were asymptomatic before PVA. We obtained a profile highlighting: Overweight ‐ Obesity (86.3%) and Hypertension (43.2%). Emphasize that 22.7% have no CVRF, 29.5% have one, 31.8% two, 13.6% three, and 2.2% four CVRF. Detected greater success 72.4% males vs. 40% women (p = 0.03). Conclusions. Despite the information given on CVRF remains high prevalence assessing the need for modification, corrective strategies and approach to heart‐healthy living habits. We need to plan a continuity care program, information and control of CVRF. Care plans implementation and data transmission between hospital and primary health care centers increases the efficacy and safety of the PVA treatment, while increasing the patient perception of safety, quality and continuity of care. ATRIAL FIBRILLATION: EPIDEMIOLOGY, AETIOLOGY AND MANAGEMENT P041 MANAGEMENT OF ATRIAL FIBRILLATION IN EMERGENCY ROOMS OF 23 MIDDLE EASTERN HOSPITALS: FINDINGS FROM GULF RACE Zubaid M; Rashed W; Alsheikh‐Ali AA; AlMahmeed W; Shehab A; Sulaiman K; Al‐Zakwani I; Al Qudaimi A; Asaad N; Amin H; Gulf SAFE Registry Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait Purpose: To study emergency room (ER) management strategies of patients presenting with atrial fibrillation (AF) in the Middle East. Methods: We used data from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE), a prospective multinational registry of consecutive AF patients presenting to ERs of 23 hospitals in the Gulf region of the Middle East between October 2009 and June 2010. Results: Of 2043 patients enrolled, we analyzed data from 923 patients whose primary reason for ER visit was AF (age 52 ± 16, age ≥ 75 (9%), 56% male, 26% with diabetes, 48% with hypertension, 12% with history of heart failure, 6% with prior stroke/transient ischemic attack, 17% with history of significant valvular disease). Types of AF were: first attack 46%, paroxysmal 26%, persistent 11%, permanent 16% and not known 1%. Majority of patients (75%) presented to ER within 48 hours of symptom onset. While in ER, 98 patients (11%) had spontaneous cardioversion. Out of the remaining 825 patients the ER management strategy was rate control in 482 patients (59%) and rhythm control in 341 patients (41%). Cardioversion was attempted during ER stay in 226 patients (27%). Electrical cardioversion was used in 24 patients (11%) and pharmacological cardioversion in 202 patients (89%). The remaining 115 patients were admitted to hospital for cardioversion. Among those cardioverted pharmacologically in ER amiodarone was the drug used in the majority of patients (64%), propafenone was used in about one third of patients and all other antiarrhythmic drugs were used in only 5% of the patients. Majority of patients (76%) were admitted to hospital independent of the management strategy used and even after successful cardioversion in ER. Conclusions: Despite being relatively young with a short history of AF duration, most patients Admitted to ER Primarily for AF were not cardioverted and a majority got admitted to hospital. P042 HOW BENIGN IS ATRIAL FIBRILLATION? A LOOK AT THE ONSET (THE FIRST EPISODE) Fraile A; Goicolea L; Perea JA; Villanueva A; Kallmeyer C; Galán L; González‐Panizo J; González A; Zorita B; García‐Cosío F Hospital Universitario de Getafe, Madrid. Spain Chronic atrial fibrillation (AF) is often considered a benign arrhythmia in which attempts to recover and maintain of sinus rhythm might be deleterious, however some studies suggest a poor prognosis at the outset of the arrhythmia. Objective: To study the prognosis of patients after a first episode of AF in an industrial city in the center of Spain, 250000 in population, served by one public hospital. Methods: We registered all patients seen in the emergency room (ER) during the year 2010, with a previously undetected AF. Clinical evolution of admitted patients was obtained from clinical records. Discharged patients were followed in a dedicated clinic 15 ± days post discharge. Results: We registered 75 patients with a first episode of AF, 21 (28%) needed hospitalization: in 6 (28.6%) due to congestive heart failure, 4 chest pain (19′1%), respiratory insufficiency in 2 (9.5%), cerebrovascular accident in 2 (9.5%), poor ventricular rate control in 2 (9'5%), and in 5 (23.8%) other causes nonrelated to cardiovascular disease. The reason for ER visit among those discharged was: palpitations in 23 (42.6%), dyspnea in 7 (13%), chest pain in 6 (11.1%) and neurological symptoms in 6 (11.1%). In 10 patients (18.5%) AF was an incidental finding, and 2 (3.7%) patients consulted for other reasons. As compared to those discharged from the ER, hospitalized patients were older (71.2 vs. 63.9 y, p 0.043) with more associated disorders: hypertension (76.2% vs. 50%, p 0.011); valvular heart disease (23.1% vs. 16%, p 0.005); cerebrovascular accidents (19% vs. 9.2%, p 0.019). Two patients died during hospitalization: one from respiratory distress syndrome and another of aspiration pneumonia. Conclusions: The initial episode of AF prompts hospitalization in 28% of the cases. Advanced age, hypertension, structural heart disease and neurological complications are the factors associated with the more severe clinical pictures. Death is not rare during this first episode of AF (1.5%). P043 EFFECTS OF ATRIOVENTRICULAR NODE ABLATION IN PATIENTS WITH CHRONIC ATRIAL FIBRILLATION CANDIDATE FOR CARDIAC RESYNCHRONIZATION THERAPY Moghaddam M; Bagher Zadeh A; Moshkani Farahani M Jam Hospital, Tehran, Iran Objectives: Cardiac resynchronization therapy (CRT) is an important advance for the treatment of end stage heart failure (HF). The aims of this study were (i) to assess the clinical benefit of CRT in patients with Atrial Fibrillation (AF) and (ii) to evaluate the impact of Atrioventricular junctional (AVJ) ablation on the outcome of AF patients undergoing CRT. Method: A total of 68 permanent AF patients were included in this prospective study and CRT implantation. The patients randomized in 2 groups, 34 Patients received optimal medication to control ventricular rate and other 34 patients underwent an AVJ ablation and were followed up for 21 ± 11 months. Clinical parameters and echocardiographic parameters were compared at baseline and after a follow‐up of 1 and 6 months after and every 6 months thereafter. Patients were evaluated for the occurrence of cardiac death, hospitalization for HF, and responsiveness to CRT (improvement of 1 (NYHA) class at 6 months). Results: Although EF and NYHA class was improved with marginal significance, QRS duration and severity of Mitral Regurgitation was not significantly changed in Medical Therapy group but all of these parameters were significantly improved in AVJ ablation group. Although the clinical characteristics was somewhat improved in both groups after CRT implantation, the improvement was much higher in AVJ ablation group. Conclusion: Beneficial effects of CRT could be noticed in a significant number of AF patients, therefore these patients should not be excluded from CRT implantations. AF without AVJ ablation was an independent predictor of hospital admissions and non‐responsiveness to CRT. Performing AVJ ablation in AF patients undergoing CRT seems crucial to attain maximal clinical benefit. P044 SLEEP QUALITY IN PATIENTS WITH ATRIAL FIBRILLATION Kayrak M; Gul EE; Alibaşiç H; Abdulhalikov T; Gunduz M; Aribas A; Yazici M; Ozdemir K; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Although, AF was related with impaired quality of life (QoL), decreased functional physical activity, and elevated levels of anxiety and depression in clinical investigation, little is known about the level of sleep quality (SQ) in patients with AF. We aimed to examine self reported SQ of patients with AF. Methods‐Materials: Ninety‐one patients with a history of asymptomatic non‐valvular AF (mean age 62 ± 10 years) and 110 age and gender‐matched patients with sinus rhythm were recruited. Patients with heart failure, coronary heart disease, chronic kidney disease, severe valvular heart disease, and cerebrovascular accident were excluded from the study. Echocardiography was performed in all study population. SQ was measured using the Pittsburgh Sleep Quality Index (PSQI). The PSQI scoring yielded seven components: subjective SQ (C1), sleep latency (C2), sleep duration (C3), sleep efficiency (C4), sleep disturbances (C5), use of sleep medications (C6), and daytime dysfunction (C7). A global PSQI score > 5 indicated ''poor sleepers". Main Results: Demographic features were comparable between groups. Also, echocardiographic measurements were similar in two groups. The prevalence of '' poor sleepers" was significantly higher in patients with AF compared to patients with sinus rhythm (76% vs. 45%, p < 0.001). In addition, patients' global PSQI score was also increased in AF group compared with control group (9.4 ± 4.6 vs. 5.8 ± 4.1, p < 0.001, respectively). In a multivariate regression model, predictors of poor SQ was found as HT (odds: 1.9 (1.2–3.6 with 95% CI)) and AF (odds: 3.7 (1.9–6.8 with 95% CI)). However, age, gender, and BMI did not predict a poor SQ in this model. Nevertheless the effect of diabetes on SQ was in a trend of significance (p = 0.06). Conclusion: Poor SQ is a potentially important problem in patients with AF and may be determined with PSQI score, a simple screening tool. P045 CORRELATION BETWEEN WARFARIN PRESCRIPTION AND STROKE RISK AMONG MIDDLE EASTERN PATIENTS WITH ATRIAL FIBRILLATION: DATA FROM THE GULF SURVEY OF ATRIAL FIBRILLATION EVENTS (GULF SAFE) Zubaid M; Rashed W; Alsheikh‐Ali AA; AlMahmeed W; Shehab A; Sulaiman K; Al‐Zakwani I; Al Qudaimi A; Asaad N; Amin H; Gulf SAFE Registry Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait Purpose: To describe anticoagulation use among patients with non‐valvular atrial fibrillation (AF) in the Middle East and its relation to stroke risk. Methods: We used data from the Gulf Survey of Atrial Fibrillation Events (Gulf SAFE), a prospective multinational registry of consecutive AF patients presenting to emergency rooms of 23 hospitals in the Gulf region of the Middle East between October 2009 and June 2010. Results: Of 2043 patients enrolled, we analyzed data from 846 patients with previous history of non‐valvular AF (age 62 ± 15, 50% female, 37% with diabetes, 68% with hypertension, 35% with history of heart failure, 16% with prior stroke/transient ischemic attack, 3% with history of major bleed and 8% with renal impairment). Among these patients, 17% had CHADS2 score of 0, 24% had CHADS2 score of 1 and 59% had a CHADS2 score of 2 or more. Warfarin prescription increased with higher stroke risk categories: 27% in patients with CHADS2 score of 0, 38% in patients with CHADS2 score of 1 and 52% in patients with CHADS2 score of 2 or more (P‐trend < 0.01). However, warfarin was inappropriately used and underused in a large number of patients. About one in four patients considered at low risk for stroke (CHADS2 score 0) were prescribed warfarin (27%) while a substantial proportion of high risk patients (CHADS2 score of 2 or higher) were not prescribed warfarin (48%). Conclusions: There is significant misuse and underuse of warfarin among Middle Eastern patients with AF. Future studies should aim to understand determinants of anticoagulation patterns for stroke prevention among Middle Eastern patients with AF and strategies to improve them. P046 REVERSE BIATRIAL REMODELING IN PERSISTENT ATRIAL FIBRILLATION AFTER CARDIOVERSION van Bracht M; Christ M; Plehn G; Prull M; Meissner A; Butz T; Trappe HJ Department of Cardiology and Angiology, Marienhospital Herne, Ruhr University Bochum, Herne, Germany Background: Atrial fibrillation is the most common cardiac arrhythmia. Approximately 25% of those over forty will experience atrial fibrillation at least once in their life. It is well known that "atrial fibrillation begets atrial fibrillation" due to morphological and electrophysiological remodeling. In cardiac magnetic resonance imaging biatrial volumes and function can be measured with great accuracy. Our aim was to evaluate changing of atrial volumes and ejection fraction in patients with persistent atrial fibrillation after cardioversion. Methods: We examined 15 patients (8m,7f) with persistent atrial fibrillation directly after cardioversion and in a 4 weeks follow up. All scans were done in sinus rhythm. The images were performed with a 1,5 T Siemens Sonata scanner. SSFP sequences with a slice thickness of 5 mm and no gap were used. Image analysis was performed offline using CMR Tools (Imperial College London, UK). Results: Enddiastolic volumes (EDV) after cardioversion in the right atrium: 69,4 ml ± 15,1 (m), 67,9 ml ± 32 (f). At the four week follow up volumes decreased to 61,8 ml ± 31,7 (m), 60,5 ± 17,4 (f). Ejection fraction of the right atrium measured after cardioversion 19,4%± 11,1 (m), 20,7%± 8,6 (f), four weeks later 30,7%± 13,2 (m) and 27%± 16,9 (f). In the left atrium EDV decreased from 99,3 ml ± 32,5 (m) 96 ml ± 25,1 (f), to 99,2 ml ± 29,6 (m), 90,3 ml ± 27,4 (f) and ejection fraction increased from 22,4%± 12,6 (m), 17,6%± 6,4 (f) to 36,2%± 10,8 (m), 27%± 16,9 (f). Conclusion: Already 4 weeks after cardioversion the biatrial dilatation in persistent atrial fibrillation decreases and the atrial ejection fraction increases. Structural remodeling in persistent atrial fibrillation seems to be to some extent reversible. P047 ANATOMICAL CHARACTERISTICS OF LEFT ATRIUM AND LEFT ATRIAL APPENDAGE IN PATIENTS WITH STROKE/TRANSIENT ISCHEMIC ATTACK Park HC; Park YM; Ban JE; Park JH; Choi JI; Park SW; Kim YH Arrhythmia center, Korea University, Seoul, Korea Background: The left atrial appendage (LAA) has been identified as a frequent source of cardiac thrombus associated with systemic embolism in atrial fibrillation (AF). The aim of this study was to identify morphological characteristics of the LA and LAA that may confer higher stroke/TIA risk. Methods: We enrolled 119 patients with AF who underwent 3D‐CT examination. We assessed LA and LAA anatomy and categorized LAA morphology and LAA position, and counted the number of LAA lobes. Thirty one patients had a history of stroke/TIA (S group) and the others (88 patients) were free (NS group). There were no significant differences in age between two groups (63.0 ± 6.3 years in S, 63.5 ± 6.1 years in NS group, NS). Results: The LA size (41.9 ± 6.1 mm) and LA volume (108.2 ± 40.5 mm3) in S group were similar to those of NS group (42.3 ± 6.6 mm and 98.0 ± 35.8 mm3, p = 0.7 and p = 0.2, respectively). There were no significant differences in LAA volume (p = 0.8) and LAA neck diameter (p = 0.2) between two groups (22.3 ± 4.2 mm3 and 10.1 ± 3.4 mm in S, 22.6 ± 5.1 mm3 and 11.1 ± 5.0 mm in NS group). There were no significant differences in LAA morphology, LAA position and the number of LAA lobes between two groups. Conclusions: Morphological and dimensional characteristics of the LA and LAA did not determine the risk of stroke/TIA in patients with AF. Keywords: stroke/transient ischemic attack (TIA), 3D contrast‐computed tomography P048 INCIDENCE OF ATRIAL FIBRILLATION AFTER ATRIAL FLUTTER RADIOFREQUENCY ABLATION Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A Instituto Cardiovascular de Buenos Aires (ICBA) Introduction: Atrial fibrillation (AF) and atrial flutter (F) are frequently associated arrhythmias. Cavotricuspid isthmus (CTI) ablation for typical F is a proven effective treatment; nevertheless, AF can still be developed after this procedure. Objective: To determine the incidence of AF after CTI ablation in a cohort patients eligible for Atrial Flutter ablation, whether they presented or not prior AF. Method: Patients eligible for CTI ablation were included. Prior history AF was assessed. Telephonic follow up and Holter monitoring was performed to determine AF incidence after ICT ablation. Results: A total of 179 patients (77.09% male; Age 66 ± 8 years) were analyzed. Prior AF was observed in 80 patients (44.61%) of which 76 (95%) developed AF during the follow up. There was no history of prior AF in 99 patients (55.30%) of which 37 (37, 37%) presented AF after CTI ablation. Both groups' variables were analyzed. Atrial fibrillation predictors after CTI ablation were: Prior history of AF (p = 0.001); Male sex (p = 0.03); Valvular Heart disease (p = 0.04); Coronary heart disease (p = 0.01) and hypertensive heart disease (p = 0.003). Antiarrhythmic drug therapy with Class IC / III drugs was higher in the group with prior AF (90.01% vs. 24.6%). Conclusion: Atrial Flutter is a major risk factor to predict Atrial Fibrillation recurrence after CTI ablation. It occurs predominantly in males, with higher prevalence of cardiomyopathy. Radiofrequency treatment of atrial flutter may not be a suitable technique to reduce AF incidence in patients with these characteristics. Difference between real lone Atrial Flutter vs Atrial Fibrillation under Class I drugs treatment must be posed as differential entities. We emphasize the global treatment of this kind of patients. P049 PSYCHOLOGICAL DISTRESS AND IS ASSOCIATED INFECTION IS AN INDEPENDENT RISK OF ATRIAL FIBRILLATION RECURRENCES RATE IN LONE ATRIAL FIBRILLATION PATIENTS Hatzinikolaou‐Kotsakou E; Latsios P; Kotsakou M; Reppas E; Beleveslis T; Moschos G; Tsakiridis K Electrophysiology Department, Saint Luke's Hospital‐Thessaloniki, Greece Background: Depression is common after the first recurrence in lone atrial fibrillation (AF) patients (pts). While there is evidence that major depression (MD) is related to reduced natural killer cell cytotoxicity (NKCC) and enhanced cytokine production in healthy individuals. Its effect on recurrences rate in Lone AF pts is unknown. We examined the role of hostility, depression, somatic symptom, anxiety, overall psychological distress and associated infectious illness on long‐term recurrences in pts with lone AF. Methods: The study included 355 pts with lone AF, mean age 57 ± 14 years, after the cardioversion for the first recurrence episode of AF, followed prospectively with annual Kellner Symptom psychometric questionnaire at 8 weeks interviews. NKCC was measured by 3‐hour chromium release assay. We calculated the incidence rate of AF by quartiles of psychometric scores. We estimated the odds ratio (ORs) and 95% confidence intervals (CI), to represent the association between depression, anxiety, somatic symptom, and hostility scores and risk of AF. Results: After adjusting for non psychological risk factors, of AF, higher anxiety, depression hostility somatic symptom and total psychological distress were significantly associated with risk recurrences of AF. A higher quartile group was associated with a significant increase in risk. For each higher quartile group, adjusted odds ratio for total psychological distress was 2. 4 (CI, 1.4–4.3). Compared to those without psychological distress, depressed pts had diminished NKCC (22.1 ± 12 vs 13.4 ± 9.8%, p = 0.02). Conclusions: Among patients with lone AF, psychological distress in general is associated with reduced NKCC, increased infectious illness and with a dose‐response increase in the long‐term risk of AF recurrence rate. Cognitive behavioral therapy may hold promise for improving depression and for reducing AF recurrences in this population. P050 ATRIAL FIBRILLATION AFTER ISOLATED CORONARY SURGERY: COMPARISON BETWEEN OP‐ CABG AND CPB‐ CABG. INCIDENCE, TREATMENT AND LONG TERM EFFECTS Rostagno C; Blanzola C; Sclafani G; Codecasa R; Carone E; Giunti G; Rapisarda F; Stefano PL; Cardiologia Generale 1, Cardiochirurgia AOU – Careggi – Firenze Background: The effects of operative technique (off‐pump versus conventional cardiopulmonary assisted revascularization) on post‐operative AF is still unclear. Aim of present investigation was to compare the incidence of POAF and its prognostic role in patients undergoing respectively OP‐CABG and CPB –CABG. Methods and Results: We conducted a prospective study on 229 patients undergoing isolated CABG between January 1 2007 and December 31 2007. Patients with PO AF were followed up for an average period of 522 days (end of the study June 31 2008). The two groups did not show significant baseline difference with the exception that OP‐CABG were significantly older than CPB‐CABG patients (70.5 vs 64.9 years). 52/229 (22.7%) developed AF after coronary surgery. Incidence of POAF was not significantly different in patients undergoing CPB‐CABG (20/90‐ 22.2%) in comparison to those undergoing OP –CABG (32/139 – 23%). Hospital mortality was 0.4%(one death for cardiogenic shock after CPB‐CABG). Only in patients with POAF after CPB‐CABG length of hospitalization was significantly higher (7.55 days versus 5.9 in patients with PO‐AF after OP‐CABG P <.001). During follow up AF recurred in 6 patients, 3 for both groups, within 2 months after surgery. Hospitalization was required in 3. Three patients recovered SR after amiodarone, 1 required electrical cardioversion, 1 had spontaneous recovery of SR while in the last one AF persisted. Only one patient died during follow up. No strokes were recorded. Conclusions: Although we did not find any difference in the incidence of postoperative AF between OP‐ and CPB‐CABG however OP‐CABG patients were significantly older than CPB‐patients. Early and late mortality did not show relation with POAF probably due to immediate treatment with recovery of sinus rhythm before hospital discharge. Recurrence of AF occurred in 6/52 patients (11.5%) however only in one AF persisted. P051 THE USE OF ANTICOAGULATION THERAPY IN PATIENTS WITH PACEMAKER DETECTED ATRIAL FIBRILLATION Music L; Boskovic A Clinical Center of Montenegro Euro Heart survey have already demonstrated the suboptimal use of anticoagulation in patients with atrial fibrillation (AF). Recent generations pacemakers demonstrated the ability to detected episodes of AF by recording electrogram (egm). The aim of the study is to reveal appropriate use of anticoagulations in patients with AF episodes diagnosed by pacemaker EGM during routine pacemaker interrogation. These AF episodes are quantified on the basis of their duration. The medication regime was noted and control at the next scheduled pacemaker interrogation. Two hundred patients with dual chamber pacemaker were included in the study. Atrial fibrillation was diagnosed in 79 (40%). Anticoagulation by vitamin K antagonist was prescribed 51 (63%) with new detected AF on the risk factor – based point scoring system CHA2DS2VASc and antiplatelet agent prescribed in 30 (27%) Among patients with prescribed anticoagulation therapy, 35 (43%) had optimal value of international normalized ratio (INR) during regular control of 3 months and 6 months, 4 (5%) gave up because of discomfort of checking value of INR, 41 (52%). Patients had suboptimal value of INR. The majority of patients in this study received anticoagulation therapy according the current guidelines. But the values of INR were not satisfactory. Pacemakers provide the important information on cardiac rhythm and represent a useful tool of detecting subclinical AF. The rate of appropriate anticoagulation prescription and control of optimal INR may be improved through specific treatment recommendations and better compliance with patients and anticoagulation drugs. P052 THE EFFECT OF SINUS RHYTHM RESTORATION WITH ELECTRICAL CARDIOVERSION ON SELF REPORTED SLEEP QUALITY IN PATIENTS WITH ATRIAL FIBRILLATION Kayrak M; Gul EE; Alibaşiç H; Abdulhalikov T; Yildirim O; Aribas A; Yazici M; Ozdemir K; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Atrial fibrillation (AF) is the most common sustained cardiac rhythm disturbance encountered in clinical practice and associated with impaired quality of life. In patients with AF, sinus rhythm maintenance after electrical cardioversion or direct current cardioversion (DCC) provides improvement in functional capacity and decrease in symptoms. However, the effect of DCC on the sleep quality (SQ) is still unknown. Therefore, we aimed to examine the effect of sinus rhythm restoration after successful DCC on the SQ in patients with AF. Methods‐Materials: DCC was performed in eligible 53 patients with persistent AF. Electrical cardioversion was performed successfully (i.e., sinus rhythm restoration) in 48 patients. To eliminate the placebo effect of DCC, patients were divided into two groups; patients with sinus rhythm maintenance (n = 34) and recurrent AF patients (n = 14) according to sixth months follow up. SQ was assessed using the Pittsburgh Sleep Quality Index (PSQI) before DCC and sixth month later. The PSQI scoring yielded seven components: subjective sleep quality, sleep latency, sleep duration, sleeps efficiency, sleep disturbances, use of sleep medications, and daytime dysfunction. Patients with global PSQI score > 5 was defined as "poor sleepers." Thus increase in global PSQI score was considered as a marker of worsened SQ. Main Results: Demographic features and baseline PSQI scores were comparable in two groups. In sinus rhythm maintenance group, baseline global PSQI score was significantly improved compared to sixth month follow‐up (8.7 ± 4.1 vs. 7.2 ± 3.8, p < 0.001, respectively). However, global PSQI score did not change in AF recurrence group compared to baseline value (Table). The difference of intergroup change reached to statistical significance in repeated ANOVA analysis (p < 0.05). Conclusion: Maintenance of sinus rhythm after DCC may have favorable effect on SQ in patients with AF. P053 MINIMAL EXTRACORPOREAL CIRCULATION SIGNIFICANTLY REDUCES THE OCCURRENCE OF POSTOPERATIVE ATRIAL FIBRILLATION Jakubova M; Sabol F; Stancak B; Luczy J; Kolesar A; Hermely A; Torok P East Slovakia Institute of Cardiovascular Diseases, Kosice, Slovakia Introduction: Atrial fibrillation (AF) is the most common arrhythmia after cardiac surgery. The pathogenesis of postoperative atrial fibrillation is multifactorial. It has been hypothesized that atrial fibrillation might be related to extracorporeal circulation. Objectives: The aim of the study was to monitor preoperative, intraoperative, and postoperative factors and their relationship to the occurrence and duration of AF. Methods: 196 patients with coronary heart disease (152 men, age 62,7 ± 10,1 years) underwent surgical revascularization. Extracorporeal circulation was used in 64 patients and minimal extracorporeal circulation was used in 75 patients. 57 patients underwent surgery without using ECC. During the first 3 postoperative days, patients were monitored for the incidence and duration of AF. Laboratory markers of inflammation (CRP, leukocytes), and serum potassium were routinely measured. Results: Patients' preoperative characteristics did not differ between groups. The incidence of AF was 56% (110 patients). The highest incidence was in the ECC subgroup. The incidence of AF in patients operated using minimised circuit or operated off pump was significantly lower (75% vs. 47% vs. 46%, p < 0,001). The longest duration of AF was in patients operated with ECC, patients in group with minimal extracorporeal circulation and without extracorporeal circulation fibrillated significantly shorter (9,7 ± 11,6 vs. 4,9 ± 8,3 vs. 3,1 ± 5,2, p ≤ 0,001). The incidence of postoperative AF significantly correlated with elevation of inflammatory markers (Leukocytes and CRP) compared to patients free of AF (p ≤ 0,001, p ≤ 0,05). Conclusion: The use of minimal extracorporeal circulation lowers the incidence of postoperative AF in comparison to classical ECC. P054 THE ANTIARRHYTHMIC IMPACT OF RANOLAZINE IN PATIENTS WITH SICK SINUS SYNDROME AND PAROXYSMAL ATRIAL FIBRILLATION Leftheriotis D; Flevari P; Rigopoulos A; Rizos I; Anastasiou‐Nana M "Attikon" University Hospital, Department of Cardiology, Athens, Greece Background: It has been reported that Ranolazine (Ran) suppresses atrial fibrillation (AF), but its efficacy in patients with sick sinus syndrome (SSS) and paroxysmal AF is not clear. Besides, pacemakers that detect and store AF episodes can be useful tools for revealing asymptomatic AF recurrence. Therefore, we studied the antiarrhythmic impact of Ran on patients with paroxysmal AF, who had such pacemakers due to SSS. Methods: We studied 22 patients with SSS, paroxysmal AF under no antiarrhythmic medication, and stable coronary artery disease who had a dual chamber pacemaker with the capability to detect and store AF episodes (Altrua DR, Boston Scientific, MA, USA, and Sensia DR, Medtronic, MN, USA). The number and total duration of AF episodes within the last 6 months and QTc duration were assessed at baseline. Subsequently, Ran was administered (375 mgr, twice daily) for six months and AF episodes, total time in AF, and QTc were reassessed. Side‐effects related to Ran were reported. Results: Two patients missed their six‐month reevaluation. Among the remaining 20 patients, 7 (35%) discontinued Ran within the first three months due to side effects: constipation (3), abdominal pain (2), dyspnea and dizziness (1), and decreased urination (1). Compared to baseline, treatment with Ran was associated with a non significant trend towards a decrease in the number of AF episodes (16.5 ± 2.6 vs 15.9 ± 2.8, p = 0.3) and a significant decrease in the total AF duration (4.8 ± 2.9 vs 3.7 ± 2.5 hours, p = 0.01) without QTc prolongation (457 ± 2 vs 459 ± 3 ms, p = 0.2). Conclusions: In clinically stable patients with a pacemaker due to SSS, paroxysmal AF and coronary artery disease, Ran did not significantly reduced AF episodes, but it shortened the total time in AF. Although QTc was not significantly prolonged, a high rate of Ran discontinuation was observed, due to its side effects. P055 PRACTICAL ASPECTS OF CARDIOEMBOLIC STROKE PREVENTION IN PATIENTS ELIGIBLE AND UNELIGIBLE FOR WARFARIN THERAPY Timcenko M; Volceka D; Skorodumovs A; Sipacovs P; Kenina V; Miglane E; Millers A Paul Stradin's Clinical University Hospital Objectives: The aim of the study is to evaluate efficacy of warfarin (Wn) therapy in CS prevention and eligibility of Wn substitution with antiplatelet therapy (a/p) for CS secondary prevention if one is contraindicated. Methods: The trial is ongoing unicenter prospective. 94 cases of acute stroke classified as CS had been analysed. First, clinical record analysis was done. Then patient's telephone inquiry was used to recognize incidence of primary outcome (PO) (death, stroke, systemic embolism, hospitalization) or haemorrhage within 90 days from the stroke onset. 76 patients had completed trial. Results: None of patients used Wn prior stroke. Main source of embolism was atrial fibrillation (AF) in 86,2% of cases. In 77.8% of cases CHADS2 score prior stroke was >1. At discharge Wn was recomended in 55 (58,5%) cases, a/p was recommended in 35 (37,2%). Wn was avoided by these reasons: patient's incompliance in 30,8% (12), INR control inaccessibility in 15,4% (6), hemorrhagic risk in 28,2% (11), severe stroke in 25,6% (10). 90 days after discharge: Wn was continued in 35 cases (46,1%), but 41 patients (53,9%) were on a/p therapy. There was PO in a/p group in 18 (43,9%; confidence interval (CI) 29,9–59,0%), in Wn group in 2 (5,7%; CI 1,6–18,6%) (p = 0,0002); major haemorrhage in a/p group in 0 (0%; CI 0–8,6%), in Wn group 2 (5,7%; CI 1,6–18,6%) (p = 0,209); minor haemorrhage in a/p group in 1 (2,4%; CI 0,4–12,6%), in Wn group 5 (14,3%; CI 6,3–29,4%) (p = 0,0889); death in a/p group in 14 (34,2%; CI 21,6–49,5%), in Wn group in 0 (0%; CI 0–9,9%) (p = 0,0001) cases. Conclusion: Wn is used insufficiently for primary CS prevention. The incidence of PO and death within 90 days after CS is significantly higher in group of patients unable to use Wn for secondary CS prophylaxis. Wn is contraindicated after CS in almost half of cases, but risk of haemorrhage isn't the main contraindication. Wn is more effective in PO and death prevention in CS patients compared to a/p. P056 CLINICAL FLOW OF ATRIAL FIBRILLATION DEPENDING ON CONCOMITANT THYROID FUNCTION Lyzohub SV; Sychov OS; Romanova OM; Frolov OI; Mogilnitskiy YV NSC «Institute of Cardiology named after N.D.Strazhesko» of AMS of Ukraine Objective: To estimate amount of patients with atrial fibrillation (AF) with concomitant thyroid pathology (TP); to study frequency of new cases of TP in the patients receiving amiodarone; to study morphological and functional indices of cardio‐vascular system in the groups of patients with hyper‐ and hypothyroid function. Methods: We included 763 patients. All patients underwent clinical examination, including thyroid function evaluation, EchoCG, ECG HM, 24‐hours BP monitoring. Results: In thre patients with AF 90% had normal thyroid function, 10% (77 patinets) had thyroid disorders, including hypothyroid status in 29 patients (4%), and hyperthyroid status in 48 patients (6%). In hyperthyroidism and hypothyroidism groups patients did not significantly differ in age, concomitant CAD ot myocardiofibrosis, but significantly differed by concomitant CHF status – 4% in hyperthyroidism group compared to 41% in hypothyroidism group. We observed difference in appreciation of paroxysms severity by patients according to EHRA scale depending on thyroid function. Thus, in normal thyroid function group 50% had class II, while only 8% had class IV. In the groups with thyroid function impairment we observed increase of patients with class III to IV according to EHRA scale, which is probably connected to cardiovascular system function alterations and deepened by CNS dysfunction. Conclusion: • TP was found in 10% of patients. Hyperthyroidism was present in 6%, hypothyroidism – in 4% of patients.• Patients with concomitant hypothyroidism significantly differed from those with hyperthyroidism by lower LV EF, lower mean, maximal and minimal HR during 24 hrs, lower quantity of AF paroxysms, as well as higher amount of ventricular extrasystoles according to ECG HM data.• Significant difference in patients perception of AF paroxysms severity according to EHRA scale depending on thyroid function was observed, which is due both to hemodynamics and CNS alterations. P057 THE ROLE OF ATRIAL FIBRILLATION IN PATIENTS WITH IMPLANTABLE CARDIO‐
VERTER‐DEFIBRILLATOR Panattoni G; Papavasileiou LP; Della Rocca DG; Forleo GB; Topa A; Cioè R; Magliano G; Sergi D; Santini L; Romeo F Cardiology Department, University of Tor Vergata, Rome, Italy Purpose: Atrial fibrillation (AF) is common in patients with implantable cardioverter‐defibrillators (ICDs) and could lead to inappropriate shocks due to AF misclassification. The aim of our study was to evaluate the effects of AF on ICDs outcomes. Materials and Methods: We enrolled 428 consecutive patients (358 males, mean age 66.8 ± 11.3 years) who underwent ICD implantation at our institution. We excluded 322 patients without history of AF. Patients were divided in two groups: 45 patients (38 males, mean age 73.0 ± 8.8 years) with permanent AF (group A); 61 patients (48 males, mean age 69.4 ± 11.0 years) with history of paroxistical (83.3%) and persistent (16.7%) AF (group B). During follow‐up the occurrence of appropriate or inappropriate device therapy as well as mortality was noted. Results: During a mean follow–up of 24.8 ± 20.1 months, no significant differences were found in the overall mortality (12 vs 7 pts, p = ns). The presence of AF did not increase significantly the risk of appropriate therapy (13 vs 12 pts, p = ns) or of inappropriate therapy (5 vs 4 pts, p = ns). Type of treatment, with ATP or shock did not result to be statistically significant between groups (ATP: 7/13 vs 10/12 p = ns, shock: 6/13 vs 2/12, p = ns). Conclusion: In our study type of AF does not influence significantly the occurrence of appropriate or inappropriate device therapy and mortality. P058 PREVALENCE OF RISK FACTORS IN PATIENTS WITH A FIRST EPISODE OF ATRIAL FIBRILLATION Gonzalez A; Hinojar R; Perea JA; Zorita B; Goicolea L; Fraile A; Palma J; Romero R; Ruiz‐Polaina M; García‐Cosio F Hospital Universitario de Getafe, Madrid, Spain Background: Therapeutic failures in atrial fibrillation (AF) has turned the attention of clinical researchers toward chronic subclinical remodeling related to risk factors causing chronic atrial overload, in the hope that "upstream" therapy might improve prognosis. Objective: To study AF risk factors present in patients with a first episode of AF, who do not have significant structural heart disease, attending a public Spanish hospital that provides care to a population of 250000 people. Methods: From January 2008 to December 2010, patients attending the emergency room for a first episode of AF were registered. We excluded patients admitted to the hospital for coexistent structural heart disease. Follow‐up was done 10–20 days after discharge. Results: 170 patients were diagnosed and discharged, of which 50,6% were men. The mean age was 63.9 ± 13.9 years. 79 patients (46.5%) had hypertension, 11 (6.5%), were obese, 29 (17.1%), were diabetic, 10 (5.9%) had coronary artery disease, 11 (6.5%) chronic obstructive pulmonary disease, and 5 (2.9%) obstructive sleep apnea. Two patients (1.2%) practiced high level sports, 2 (1.2%) consumed alcohol in excessive quantities and 8 (4.7%), had history of hyperthyroidism. In 53 patients (31.2%), no risk factors were present. One risk factor was present in 47 patients (27.6%), 2 in 40 (23.5%), and 3 or more in 30 (17.7%). Conclusions: Most patients presenting with a first episode of atrial fibrillation have risk factors that could be corrected with the purpose of maintaining sinus rhythm once it has been achieved. A high percentage of patients have no risk factors and follow‐up should reveal if they have a better prognosis for AF control. In patients with no risk factors and recurrence of AF, it seems important to rule out triggering arrhythmias which could be treated with an ablation such as atrio‐ventricular tachycardias and arrhythmogenic foci in pulmonary veins. P059 INTERLEUKIN‐18 AMONG ATRIAL FIBRILLATION PATIENTS IN THE ABSENCE OF STRUCTURAL HEART DISEASE Guo Y; Luan Y; Li S; Yu B; Li S; Li N; Tian Z; Cheng J; Tian Y Department of Cardiology, the Second Affiliated Hospital of Harbin Medical University, Harbin 150086 Background: Inflammation plays a role in the genesis and perpetuation of atrial fibrillation (AF). Interleukin (IL)‐18 is a pleiotropic proinflammatory cytokine with a central role in the inflammatory cascade. We hypothesize that the circulating IL‐18 concentration is elevated in AF patients. Methods: In a case‐control study design, 56 cases with AF and 26 controls were enrolled. All AF cases were categorized into paroxysmal and persistent AF, or lone AF and AF with hypertension. Circulating levels of IL‐18, tumor necrosis factor‐α, high‐sensitivity C‐reactive protein (hs‐CRP), matrix metalloproteinase (MMP)‐9 and tissue inhibitor of matrix metalloproteinase‐1 were measured. Results: In adjusted analyses, only age, MMP‐9 and IL‐18 were independently associated with AF, in which IL‐18 had the most significant association [p = 0.0011, STB = 1.76, OR = 1.02; 95% CI (1.01–1.03)]. IL‐18 levels in persistent AF patients were higher than those in paroxysmal ones(p = 0.0011). Patients who developed AF within 24 hours prior to sampling displayed a higher level of IL‐18 than those with sinus rhythm (p = 0.0027). IL‐18 was positively correlated with left atrial diameter (LAD) (r = 0.33, p = 0.0117). Conclusions: This study is the first to document elevated IL‐18 in AF patients. IL‐18 may be superior to other inflammatory markers which are known to be elevated in AF. Keywords: Atrial fibrillation, inflammation, interleukin‐18, MMP‐9, hs‐CRP. P060 THE RELATIONSHIP BETWEEN VITAMIN D DEFICIENCY AND NONVALVULAR AF Demir M; Uyan U; Günay T; Özmen G; Keçeoğlu S; Doğanay K; Melek M Bursa Yüksek İhtisas Education and Research Hospital Cardiology Clinic Bursa/Turkey Aims: The role of vitamin D (vitD) deficiency suggests cardiovascular disease such as coronary artery disease, heart failure and hypertension.VitD deficiency actives renin‐angiotensin‐aldosterone system which affects cardiovascular system.For this reason, could be suggested relationship between vitD deficiency and atrial fibrillation (AF). In our study we compared 25‐ OH vitD levels, between nonvalvular‐valvular AF and control groups in sinus rhythm. Method: Patients with replacement therapy of vitD and who has a disease affect vitD levels were excluded. 102 patients with nonvalvular chronic AF without any other cardiovascular disease (42 male; average age 62,51 ± 5.88; Group I) and 96 patients with AF which is associated with mitral valve disease (38 male; mean age 61,51 ± 5; Group II) were included in our study. 100 age‐matched healthy people with sinus rhythm were accepted as control groups (40 male; mean age 61,35 ± 5,44). All groups underwent transthoracicechocardiography. Routine biochemical parameters, 25‐OH vitD and parathormon (PTH) levels were performed. Results: Baseline characteristics of the study groups were comparable. Group I patients had a lower vitamin D level than Group II and control group (6,51 ± 4,89; 9,24 ± 7,39 and 11,18 ± 6,98 ng/ml, p < 0.001, respectively). In Group I and Group II patients left atrium (LA) diameter and systolic pulmonary artery pressure (SPAP) is higher than the control groups. In nonvalvular AF patients, LA diameter (OR: 2.29; 95% CI: 1,850–2,984, p < 0.001)and 25 OH VitD level (0.86, 95% CI: OR: 0,786–0.940, p = 0.001) were found independent predictors for AF. In patients with valvular AF, LA diameter, SPAP and right atrium diameter were predictors for AF. Conclusion: As a result of our study revealed relationship between vitD deficiency with nonvalvular AF. But the vitD level were found similar in valvular AF patients with mitral valve disease and control group. This situation suggests that vitD deficiency may cause nonvalvular AF. P061 AGE RELATED PREDICTION OF RECURRENCE OF ATRIAL FIBRILLATION IN METABOLIC SYNDROME PATIENTS Borrello F; Nardi S; Cassadonte F; Pirrotta S; Ciconte VA; Maglia GP Cardiology and ICU Pugliese Hospital Catanzaro, Italy Background: Metabolic Syndrome (MS), already known as a concurring condition in atrial fibrillation (AF), is a worldwide cluster of multiple cardiovascular risk factors. To establish the recurrence of AF is important for selecting patients who will be undergoing catheter ablation, several studies respectively evaluated the risk factor of the recurrence of AF post‐ablation. Objective: To investigate the factors predicting the recurrence of AF after catheter ablation in MS population. To assess the specific weight of each risk factor contributing MS in each decades. Methods: Out of 500 patients undergone AF catheter ablation in 2 years in Catanzaro and Terni, 100 (53 ± 26 years, 56 male) fulfilled the criteria for MS, including 59 paroxysmal AF and 41 persistent AF who were studied. Clinical data before, during, at 6, and 12 month follow‐up were recorded. Statistical analysis was performed to determine the factor weight predicting late recurrence of AF (LRAF). Results: There were 38 patients who experienced LRAF at 12 month follow‐up. Metabolic syndrome was statistically associated with recurrence of LRAF in all the subpopulation examined (< 45 yrs, 45–65, 65–75 yrs). From 75 years of age on, recurrence of AF was independent from the presence of MS. In addition, in patients younger than 65 yrs of age, the more risk factors of MS, the more the recurrence of AF. Conclusion: Our data suggest that MS is associated with LRAF in paroxysmal and non‐paroxysmal AF in patients younger than 75 yrs of age. Below such age, the more risk factors determining MS, the higher the risk of AF recurrence. P062 AUTONOMIC OUTFLOW DURING PROVOCATIVE MANEUVERS IN PAROXYSMAL LONE ATRIAL FIBRILLATION Oliveira M; Laranjo S; Tavares C; Xavier R; Geraldes V; da Silva N; Santos S; Ferreira R; Rocha I Autonomic Nervous System Unit, Institute of Molecular Medicine; Cardiology, Sta Marta Hospital Autonomic dysfunction appears to play a role in paroxysmal atrial fibrillation (PAF), but the mechanisms linking autonomic nervous system activity with PAF are incompletely understood. Aim: to assess the RR‐intervals (RRI) and systolic blood pressure (BP) variability in lone PAF patients (P) during standard autonomic tests. Methods: 16P with PAF (8 men; 55 ± 17 years) and 16 healthy individuals (HI) (8 men; 54 ± 10 years) while on sinus rhythm. RRI and BP were continuously assessed and LF (low‐frequency), HF (highfrequency) and LF/HF calculated in response to head‐up tilt (HUT), handgrip (HG), cold pressure (CPT) and deep breathing (DB), by using the wavelets transform analysis. Results: In baseline RRI and BP were similar for both groups. HI showed larger mean RRI and maximum RRI during DB. During HUT, two BP profiles were observed: an increase in PAF P and a decrease followed by an increase and further recovery in HI. HG and CPT provoked an increase of BP with a delayed pattern in PAF P. DB elicited a modulation of systolic and diastolic BP in both groups, but a significant decrease occurred only in HI. PAF P showed lower LF in HUT, and decreased HF in basal and during tilting movement in RRI variability analysis, without differences regarding systolic BP variability. LF of BP variability increased earlier in PAF P, with higher values during the second minute of HG. During the CPT, LF for BP variability analysis increased significantly only in HI. There were no differences between groups for RRI variability during DB. Conclusions: P with PAF present modified cardiovascular responses during maneuvers evoking autonomic outflow. These data underscore the presence of autonomic disturbances in PAF. P063 ASSOCIATION BETWEEN NEUTROPHIL/LYMPHOCYTE RATIO AND RECURRENCE OF ATRIAL FIBRILLATION AFTER SUCCESSFUL ELECTRICAL CARDIOVERSION Kayrak M; Gul EE; Demir K; Duman C; Alibaşiç H; Akıllı H; Aribas A; Ozdemir K; Gok H; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Current evidence links Atrial Fibrillation (AF) to the inflammatory state. Inflammatory indexes such as C‐reactive protein, interleukin‐6, and high‐sensitivity C‐reactive protein (hs‐CRP) have been related to the development and persistence of AF. More recently, the neutrophil/lymphocyte (N/L) ratio, which can be easily derived from the WBC count and determines the state of inflammation (reflecting neutrophil) and poor general health (lymphopenia), has emerged as a potentially useful prognostic parameter and was related with postoperative AF. We hypothesized that an elevated N/L ratio would be associated with an increased incidence of AF recurrence after successful electrical cardioversion. Methods‐Materials: One hundred and forty nine patients with a history of symptomatic AF (mean age 62 ± 10 years) underwent cardioversion. Echocardiography, complete blood count, and hs‐CRP assay were performed prior to cardioversion.During a follow‐up period of sixth months, AF recurred in 46 patients (31%). Main Results: Baseline hs‐CRP levels were greater in patients with AF recurrence compared to those with sinus rhythm (8.0 ± 5.1 mg/dl vs. 5.1 ± 3.7 mg/dl, p = 0.007, respectively). Overall, baseline N/L ratio was comparable between groups (AF recurrence 2.9 ± 2.0 and SR 2.8 ± 1.5, p = 0.96). Duration of AF was significantly longer in AF recurrence group than SR group (19 ± 12 months vs. 12 ± 9 months, p = 0.012, respectively). In addition, left atrial diameter was enlarged in AF recurrence group compared to SR group (p = 0.002). There was no correlation between N/L ratio and echocardiographic parameters. There was a weak positive correlation between hs‐CRP levels and N/L ratio (r = 0.22, p = 0.05). Conclusion: Our data suggest N/L ratio was failed to predict of AF recurrence. It needs to future investigation to determine the role of N/L ratio in AF development and recurrence. P064 ANTI‐COAGULATION USE FOR STROKE PROPHYLAXIS IN ATRIAL FIBRILLATION IN A MULTI – ETHNIC POPULATION Neo S; Francis PJ; Li A; Chia P‐L; Foo D Department of Cardiology, Tan Tock Seng Hospital Aims: We evaluate the patterns and prevalence of anti‐coagulation amongst patients of different ethnic backgrounds presenting with atrial fibrillation (AF) to a tertiary hospital. Methods: We identified 588 patients with AF admitted to our institution between years 2006 to 2010 and performed a retrospective review of their medical records. Baseline demographics, stroke and bleeding risk stratification scores and anti‐coagulation use were evaluated. Results: The mean age was 63 ± 14 years and 33% were aged ≥75. 77.6% were Chinese, 4.8% Indians, 11.7% Malays. Hypertension (67.7%) was the commonest associated co‐morbid condition, with no statistically significant difference amongst the ethnic groups. The mean composite CHA2DS2‐VASc score was 3.1 ± 2.0. The mean composite HAS‐BLED score was 1.8 ± 1.3. 62.9% had no contraindications to anti‐coagulation. Although 45.1% had composite CHA2DS2‐VASc scores ≥2 and HAS‐BLED scores ≤2, only 26.7% received warfarin. The commonest reasons for physicians not starting warfarin were patients' refusal due to fear of adverse effects of bleeding and increased fall risks in the elderly. There was no statistical difference regarding lack of anti‐coagulation across the different ethnic groups. Patients with permanent AF have higher odds of receiving anti‐coagulation compared to those with paroxysmal AF (OR 2.3; 95% CI, 1.51‐ 3.36; p < 0.001). Conclusions: The prevalence of anti‐coagulation in elderly is low in our multi‐ethnic population. Both physician and public education is of importance to prevent increased health care costs and AF related stroke mortality and morbidity. P065 THE FEATURES OF AUTONOMIC HEART RATE CONTROL IN PATIENTS WITH PERMANENT ATRIAL FIBRILLATION IN RESPONSE TO ACTIVATION OF SYMPATHETIC NERVOUS SYSTEM Mamontov OV; Berngardt ER; Parmon EV; Treshkur TV; Shlyakhto EV Almazov Federal Heart, Blood and Endocrinology Centre, Saint‐Petersburg, Russia Background: Assessment of autonomic heart rate (HR) regulation in patients suffering from permanent atrial fibrillation (AF) remains an unresolved problem. Most methods are based on evaluation of dynamics of sinus rhythm (SR). At the same time, alteration of autonomic cardiac nerve tone in patients with AF can be realized by modification of atrioventricular (AV) conduction. Objectives: The aim of the study was to evaluate features of autonomic HR modulation in patients suffering from permanent AF in response to activation of sympathetic nervous system. Methods: The study enrolled 43 patients suffered from heart failure II‐IV functional class (NYHA), mean age 53,8 ± 7,2 yrs. 20 pts had ischemic, 16–nonischemic and 7–mixed cardiomyopathy. 30 pts had SR and 13 ones had permanent AF. All patients underwent a handgrip test (HGT) during which blood pressure (BP) was measured by continuous noninvasive method (Finometer, FMS) and high resolution ECG was recorded simultaneously. BP and HR were estimated initially and in 3 min from starting of the HGT. Results: During the HGT comparable augmentation of BP was registered in both groups: dBP systolic in AF and SR patients was 20.5 ± 11.4 and 19.5 ± 10.7 mmHg, respectively, p > 0.05; dBP diastolic (dBPD) 14.3 ± 5.2 and 11.2 ± 6.4 mmHg, p > 0.05 resp. HR increase significantly greater in AF group than in SR one: dHR 11.7 ± 7.0 and 5.7 ± 4.0 bpm, resp., p < 0.005. In AF group dHR was strongly correlated with dBPD (r = 0.62, p < 0.005) but in SR group this correlation was less significant (r = 0.36, p > 0.05). The difference in HR increase and its relation with dBPD between SR and AF groups explains the difference in intensity of modulating impact of arterial baroreflex on sinus node and AV conjunction that opposes sympathetic activation. Conclusions: Parallel with BP augmentation strongly marked HR is observed in patients with AF during a simpathotonic HGT. That may indicate weak limitative influence of vagal feedback on AV conduction. BASIC SCIENCE: FROM BENCH TO BEDSIDE P066 CHANGES IN THE AGING‐ASSOCIATED OF L‐TYPE CALCIUM CHANNEL OF THE LEFT ATRIA OF THE CANINES Tianyi G; GuoJun X; Xianhui Z; Baopeng T; Xia G; Yaodong L Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi, China Introduction: Action potential (AP) contours vary considerably between normal adult and aged left atrial fibers. The ionic and molecular bases for these differences remain unknown. So we investigate whether the L‐type calcium current (ICa.L) an L‐type calcium channel of left atria may be altered with age. Methods: We used whole‐cell patch‐clamp to record action potential (AP) and ICa.L in left atrial (LA) cells dispersed from normal adult (2–2.5 years) and older canines (>8 years).The a1c (Cav1.2) subunit of L‐type calcium channel mRNA and protein expression were assessed by real‐time quantitative RT‐PCR and Western blotting respectively. Results: Whereas resting potential, AP amplitude and Vmax did not differ with age, the plateau was more negative and AP duration was max longer in old tissue. Aged LA cells have lower peak ICa.L current densities than Adult LA cells (P < 0.05). In addition, Compared to the adult group,the Cav1.2 mRNA and protein expression of LA were decreased in aged group. Conclusions: The lower plateau potential of AP and the decreased ICaL of LA in aged canines may contribute to the slow conduction and discontinuous conduction of LA. While the decreased expression of Cav1.2 with age may be the basis of the decrease of ICaL with age. Atria; Calcium channel; Cellar electrophysiology; Aging P067 SINUS RHYTHM RESTORATION AFFECTS COLLAGEN TURNOVER IN PATIENTS WITH PERSISTENT ATRIAL FIBRILLATION Kallergis EM; Kanoupakis EM; Mavrakis HE; Goudis CA; Saloustros IG; Vardas PE Department of Cardiology, University Hospital of Heraklion, Crete, Greece Objectives: To evaluate the importance of serum markers of collagen turnover in predicting the outcome of electrical cardioversion (CV) of persistent atrial fibrillation (AF) and to clarify the relationship between AF and fibrosis. Background: Collagen turnover and atrial fibrosis have been implicated in the generation and perpetuation of AF. Methods: Serum C‐terminal propeptide of collagen type I (CICP) and C‐terminal telopeptide of collagen type I (CITP) were measured in 98 patients with AF before and two months after CV. Results: All patients were successfully cardioverted to sinus rhythm (SR) although in 27 of them AF recurred. Baseline CICP levels were comparable in patients in sinus rhythm 60 days after CV and in those who experienced a relapse of AF (82.464 ± 16.65 ng/ml vs. 86.45 ± 10.95 ng/ml, respectively, p = 0.18). Baseline CITP levels were significantly higher in patients with AF recurrence compared to those who remained in SR (0.47 ± 0.15 ng/ml vs. 0.33 ± 0.19 ng/ml, respectively, p = 0.001). The restoration and maintenance of SR resulted in a decrease of CICP but not of CITP levels. In the 75 patients who maintained SR, CICP levels were significantly lower at the end of the study as compared to baseline, (61.89 ± 14.18 ng/ml vs. 82.464 ± 16.65 ng/ml p < 0.001), while there was no difference in plasma CITP levels, (0.35 ± 0.20 ng/ml vs. 0.33 ± 0.19 ng/ml, respectively, p = 0.477). Conclusions: AF can result in alterations in atrial structure and architecture that make the atrial myocardium more susceptible to the maintenance of the arrhythmia. Sinus rhythm restoration could affect the fibrotic process occurring or exacerbating during AF course. P068 ASSESSMENT OF VENTRICULAR ELECTROPHYSIOLOGICAL CHARACTERISTICS AT PERI‐INFARCT ZONE OF POST MYOCARDIAL INFARCTION IN THE RABBITS FOLLOWING STELLATE GANGLION BLOCK Gu Y; Wang X; Wang L; Tang Y Cardiovascular Research Institute of Wuhan University Background: To investigate the characteristics of ventricular electrophysiology following stellate ganglion block at peri‐infarct zone in the rabbits with MI. Method and Results: Sixty‐four rabbits were randomly assigned into two groups: MI group (n = 32), ligation of the anterior descending coronary; SO, sham operation group (n = 32), without coronary ligation. Both MI group and SO group were divided into four subgroups according to the right or left SGB and the corresponding control (n = 8, each). After eight weeks, 90% of monophasic action potential duration (MAPD90) of epicardium, midmyocardium and endocardium, transmural dispersion of repolarization (TDR), effective refractory period (ERP), ventricular fibrillation threshold (VFT) were measured at the infarct border zone (MI group) and corresponding zone (SO group) following SGB. For SGB, 0.5ml of 0.25% bupivacaine was used.As compared with the corresponding control group, in both of the MI group and SO group, LSGB prolonged the MAPD90 of three layers, reduced the TDR, increased the ERP and the VFT (P < 0.05). However, RSGB shortened the MAPD90, increased the TDR, reduced the ERP and the VFT(P < 0.05). Conclusion: The results demonstrated that LSGB can increase the electrophysiological stability of ventricular myocardium. Keywords: Stellate ganglion block; transmural dispersion of repolarization; effective refractory period; ventricular fibrillation threshold; Myocardial infarction. P069 ELECTROPHYSIOLOGICAL EFFECTS OF WENXIN GRANULE IN RABBITS WITH CON‐
GESTIVE HEART FAILURE IN VIVO Tang YH; Liu MX; Lian ZM; Wang Xi; Wang T; Hu P Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan 430060, china To observe the effect of Wenxin Granule on electrophysiology in rabbits with congestive heart failure(HF). 32 rabbits were randomly divided into four groups, they are sham‐operated no‐drug group (sham group), sham‐operated Wenxin Granule group (SHAM‐Wenxin group), HF no‐drug group (HF group) and HF Wenxin Granule group (HF‐Wenxi Group). HF model was successfully produced by volume overload combined with pressure overload. The rabbits were feed by Wenxin Granule 8 weeks. Sinusatrial node function, atrial and ventricular myocardium monophasic action potential duration (MAPD), effective refractory period (ERP), transmural dispersion of repolarization (TDR) and ventricular fibrillation threshold (VFT) were record by monophasic action potential (MAP) technique. Results: 1. sinusatrial node conduction time (SACT), sinusatrial node recovery time (SNRT), cSNRT were all prolonged in HF group (P < 0.05). SACT was shorter in HF‐Wenxin group (P < 0.05). 2. Compared with sham group, MAPD50 and MAPD90, ERP were prolong in sham‐Wenxin group and HF‐Wenxin group (P < 0.05). But there were no significant difference between HF group and HF‐Wenxin group (P>0.05).3. Compared with sham group and HF‐Wenxin group, the MAPD90 of the middle layer myocardium of left ventricular was prolonged and TDR was larger in HF group (P < 0.05 respectively). 4. Compared with HF group, VFT were remarkably increased in HF‐Wenxin Granule group (P < 0.05). Conclusions: Wenxin Granule had no more negative effects on sinus node dysfunction in heart failure rabitts. APD became conformity in three layers myocardium of heart failure by using Wenxin Granule, to decrease TDR in left ventricular, Wenxin Granule can increase VFT of heart failure rabitts, there was protective function in heart failure accompaning with arrhythmia. P070 SINUS NODE DYSFUNCTION AND HYPER‐
POLARIZATION‐ACTIVATED (HCN) CHANNEL SUBUNIT REMODELING ASSOCIATED WITH ATRIAL FIBRILLATION Tianyi G; GuoJun X; Xianhui Z; Baopeng T; Xia G Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, China Background: Atrial fibrillation (AF) is frequently associated with Sinoatrial node (SAN) dysfunction. But underlying mechanisms remain poorly understood.The hyperpolarization‐activated cation current contributes significantly to sinoatrial node pacemaker function and possibly to ectopic arrhythmogenesis. This study examined the hypothesis that AF impair SAN function by altering hyperpolarization‐activated (HCN) channel expression and AF may lead to HCN channel of atria remodeling. Methods: We assessed expression of HCN1, 2, 4 and beta‐subunit minK in sinus rhythm (SR) beagle canines and canines subjected to 8‐week atrial tachypacing‐induced atrial fibrillation (AF). Realtime RT‐PCR and Western blot were used to quantify HCN subunit and beta‐subunit minK mRNA and protein expression in the right atrium (RA) and sinoatrial node. Results: AF canines have longer sinus node recovery time than SR canines, which reflects impaired SAN function.HCN2 and HCN4 expression was greater at both protein and mRNA levels in sinoatrial node than RA. AF significantly decreased sinus node HCN2,4 and beta‐subunit minK expression at both mRNA and protein levels,while increased HCN2,4 and beta‐subunit minK expression of RA. Conclusions: The decreased expression of HCN2,4 and beta‐subunit mink of sinoatrial node contribute to AF‐induced sinus node dysfunction; while upregulation of atrial HCN2,4 and beta‐subunit minK may help to promote maintaining of AF. Keywords: Atrial fibrillation; sinoatrial node; HCN channel; remodeling. BRADYARRHYTMIAS P071 PREDICTIVE VALUE OF ELECTROCARDIOGRAPHY AND ELECTOPHYSIOLOGICAL STUDIES IN CONDUCTION ABNORMALITIES AFTER CORE VALVE‐MEDTRONIC AORTIC VALVE IMPLANTATION‐ PRELIMINARY RESULTS Kostopoulou A; Karyofillis P; Livanis E; Voudris V 2nd Cardiology Department, Onassis Cardiac Surgery Center, Athens, Greece Aim: Surgical aortic valve replacement is associated with complete heart block (CHB) requiring permanent pacing in 3 to 6%. Reports have shown a higher incidence of conduction disease in patients (pts) undergoing percutaneous aortic valve implantation (PAVI). The purpose of our study was to assess the value of the surface electrocardiogram (ECG) and the electrophysiology study (EPS) as predictors of conduction abnormalities after PAVI. Methods: Twenty seven consecutive pts mean aged 81 ± 6 years with severe aortic stenosis and normal or slightly impaired left ventricular function (mean LVEF 53 ± 10%) who underwent Core Valve‐Medtronic implantation were included. The baseline 12‐lead surface ECG was analyzed for the recording of basic rhythm and conduction abnormalities. A basic EPS study was performed a day before for the measurement of the basic intervals PA, AH, HV, the effective refractory period (ERP) of the atrioventricular (AV) node and the Wenckebach cycle length (WCL). Results: At baseline evaluation 21 pts were in sinus rhythm and 6 in chronic atrial fibrillation. The mean PR and QRS were 185 ± 25 msec and 118 ± 27 msec. Six pts had a LBBB and 3 LAH. The basic EPS measurements were: AH 93 ± 17 msec, HV 51 ± 11 msec (34–90 msec), AV‐ERP 288 ± 59 msec, and WCL 386 ± 72 msec. All pts, except 1, had HV intervals <70 msec. Nine pts (33%) required permanent pacing due to CHB after PAVI. Seven pts developed LBBB during the first 4 days. Four of the 9 pts that had a pacemaker implantation had restored normal rhythm at first‐month follow‐up. Student's T test showed that in pts with pacemakers compared to those without, the AH interval was prolonged at significant levels. The HV interval and AV‐ ERP measurements were higher but not significantly whereas the QRS width did not differ. Conclusions: Preliminary data show that patients with pre‐existing conduction abnormalities revealed in an EPS study may be susceptible to development of complete AV block after PAVI. P072 HIGH PREVALENCE OF AMYLOID DEPOSITION IN SUBCUTANEOUS FAT TISSUE IN PATIENTS WITH BRADYARRHYTHMIA Omi W; Hanaoka R; Takatori O; Saeki T; Kasashima S; Kawashima A; Sakagami S Department of Cardiology, Kanazawa Medical Center, National Hospital Organization Background: Most of cases with amyloidosis progress asymptomatically, and is diagnosed when cardiac involvement is already at end stage. Additionally, the diagnosis is sometimes cumbersome and accompanied with complication. These factors make early diagnosis difficult. Aim: To assess the usefulness of subcutaneous fat sampling during pacemaker implantation and to validate the prevalence of systemic amyloidosis in patients with bradyarrhythmia who required permanent pacemaker. Patients and Methods: We enrolled 15 consecutive patients (79 ± 12 years old, 7 males) who required pacemaker implantation (containing 4 patients, generator exchange). Four patients had sick sinus syndrome and 11 had atrioventricular block. In all cases, echocardiography did not show typical findings suggesting cardiac amyloidosis. Pacemaker was inserted to infraclavicular precordia. Subcutaneous fat tissues were taken during surgery and specimens were evaluated by the pathologists. Results: Pacemaker implantation and subcutaneous fat sampling were performed successfully and safely in all cases, and interstitial amyloid deposition was confirmed in 9 cases (60%). Gastro and/or colon endoscopy were performed in 4 patients of them, and intestinal amyloid deposition was confirmed in 2 patients. Conclusion: Subcutaneous fat sampling during pacemaker implantation was safety and helpful for diagnosis of systemic amyloidosis. Our data suggests that systemic amyloidosis could be more frequent than we supposed, and that contribute to bradyarrhythmia even in the absence of other typical manifestation. P073 CASE REPORT: COMPLETE HEART BLOCK FOLLOWING PARAPHENYLENE DIAMINE (PPD) HAIR DYE POISONING Suliman AAA; Ibrahim GIA Alshaab Teaching Hospital – Khartoum‐Sudan Introduction: Paraphenylene diamine (PPD) [C6H4 (NH2)2] is an aromatic amine not found in nature and it is produced commercially by many industrial companies. It is widely used in industrial products. PPD is the most common constituent of hair dye formulations. PPD is commonly used in its raw form for cosmetic purposes in Africa, Middle East and Indian subcontinent while it is rarely used in the West. In Sudan, PPD is mixed with henna leaves of Lawsonia Alba, which is a non toxic herb used to decorate the hands and feet in special social events. PPD intoxication is a life threatening condition, commonly manifested as acute upper respiratory tract obstruction and acute kidney injury but seldomly affects the heart. Case Presentation: We are reporting this case of a 26 year old female from Aljazeera State in Sudan, who presented complaining of dizzy spells and severe fatigue following swallowing of hair dye intentionally (suicide attempt). She was seen initially at her local hospital where she was found to be bradycardic. Her HR was 40 bpm and she was referred to our cardiology department at AlShaab Teaching Hospital. Upon arrival, the patient looked fatigued but was fully conscious, BP 110/50, HR 40/min and her systemic examination was unremarkable. ECG showed complete heart block with wide complex escape rhythm of 38 bpm. Her blood tests showed mildly elevated renal profile and CPK with normal cardiac biomarkers. Echo showed normal systolic function. Temporary pacemaker wire was immediately inserted and kept under monitoring. Over the next two weeks she remained in complete heart block with intrinsic HR of 38bpm. After two weeks of temporary pacing, a DDDR pacemaker was inserted. Two years after initial presentation, the patient still remains in complete heart block and is pacemaker dependent. Conclusion: This is the first reported case of permanent complete heart block, requiring PPM implantation, following PPD intoxication without evidence of of myocardial injury. P074 BRADYCARDIA AS A CAUSE OF ANGINATHE NEW BRADYANGINA SYNDROME Duque M; Herrera AM; Múnera JS; Medina E; Marín J; Uribe W School of Medicine, Universidad CES – Department of Cardiology, Clínica CES, Medellín, Colombia Background: Angina is defined as a sensation of pressure or retrosternal pain with a rather specific pattern of irradiation, with physical or emotional stress, or even at rest, and secondary to a decrease in myocardial oxygen supply. Bradycardia is defined as a persistent or transitory decrease in heart rate below 60 beats per minute, due to primary, secondary, and reversible or irreversible causes. There is an association between heart rate and cardiac output. Could it be possible that a reduction in the heart rate results in a decrease in cardiac output to a point that it is responsible for myocardial ischemia, and as such, angina?Materials and Methods: This is a retrospective – prospective study of patients with angina of unknown origin and sinus bradycardia diagnosis that were admitted in our cardiology service between august 1st 2007 and august 31st 2009. Diagnostic approach included coronariography, or non invasive measures as stress echocardiography or myocardial perfusion test with radiotracers. Patients were treated with pacemaker implantation, discontinuation of medications with negative chronotropic effect and/or follow up in those with transitory or non pharmacologic causes of bradycardia. After performing the interventions, all patients were followed up and evaluated in search of the presence of angina or bradycardia, and persistence of symptoms. Results: A total of 60 patients were evaluated, 70% were men. Mean age of 52.5 ± 16.3 (SD) years. Pacemaker implantation was performed in 78.3% of patients. Medication associated with bradycardia was discontinued in 11.7% of patients. During follow up, 100% of patients did not report having new episodes of angina after the intervention was performed. Conclusion: With coronary disease discarded, the study of rhythm anomalies as a potential etiology of the symptomatology should be performed. The association between bradycardia and angina could be newly defined as "Bradyangina syndrome". P075 SINUS OF VALSALVA ANEURYSM AS A REVERSIBLE CAUSE OF COMPLETE HEART BLOCK (A CASE REPORT) Alasti M; Omidvar B; Mali S; Majidi S Department of Cardiology, Jundishapur University of Medical Sciences, Ahvaz, Iran A 43 year old lady was referred to our center for temporary intravenous pacemaker insertion. She had a history of dizziness and one episode of syncope since two days ago. She did not have any risk factor of coronary artery disease. There was no significant past medical illness. Laboratory data including serum potassium and cardiac enzyme levels and sedimentation rate were within normal limits. The ECG showed complete AV block with ventricular escape rate of 30–35 beat/min. The QRS complexes were wide with LBBB morphology pattern (Figure 1‐A). Transthoracic echocardiography showed mildly enlarged left ventricle with normal contractility, mild aortic regurgitation and an aneurysm of sinus of valsalva eroding into the upper part of interventricular septum (Figure 2‐A). 64‐slice CT scan disclosed a large sinus of valsalva aneurysm originating from right sinus of valsalva (Figure 2‐B). Right sided heart catheterization and selective coronary angiography showed normal pulmonary artery and wedge pressures and normal epicardial coronary arteries. Aortography in LAO and RAO projections showed a large aneurysm of right coronary sinus of valsalva and mild aortic regurgitation (Figure 3‐A&B). The patient underwent surgery and the mouth of aneurysm was closed with a Gortex patch. In addition, an epicardial pacemaker was implanted. The ECG taken two weeks later disclosed sinus rhythm with prolonged AV interval and bifascicular block and no pacing (Figure 1‐B). In rare cases, the aneurysm erodes into the interventricular septum. Direct pressure by the expanding aneurysm and low grade inflammation can lead to atrioventricular conduction defects. It is interesting in our patient that the rhythm returned to sinus after surgical decompressing of interventricular septum. It looks reasonable that unruptured sinus of valsalva aneurysm eroding into the interventricular septum is operated as soon as possible, preventing development of complications such as heart block. CARDIAC IMAGING P076 CLINICAL IMPLICATION OF EVALUATING LEFT ATRIAL ARTERY AND LEFT ATRIAL RIDGE BEFORE CATHETER ABLATION FOR ATRIAL FIBRILLATION WITH MULTIDETE‐
CTOR‐ROW CT Kimura R; Inoue K; Toyoshima Y; Doi A; Masuda M; Sotomi Y; Iwakura K; Fujii K Sakurabashi Watanabe Hospital Objective: The anatomy of the left atrial ridge (LAR) is important for deciding strategy of catheter ablation (CA) for atrial fibrillation (AF). The branch of the left atrial circumflex artery (AC) runs within LAR, and it could exert the cooling effect during CA. We studied the morphology of LAR and AC with multidetector‐row CT (MDCT). Methods: Twenty‐six patients (age 60 ± 12 years, male 16) undergoing CA for AF (13 with paroxysmal AF and 13 with persistent AF) were enrolled. MDCT was performed prior to CA. Results: The left atrial volume (LAV) (98.6 ± 46.8 ml vs. 58.9 ± 21.9 ml, P < 0.05) and the thickness of the LAR (3.15 ± 0.60 mm vs. 2.54 ± 0.85 mm, P < 0.05) was significantly greater in persistent AF group. AC was observed by MDCT in 4 cases (30.7%) in proximal AF group and in 2 cases (15.4%) in persistent AF group. There were no significant differences in LAV and the thickness of LAR between groups with and without visible AC. The time (21.7 ± 11.4 min vs. 18.2 ± 8.61 min) and the number of CA (37 ± 23 vs. 31 ± 13) for left pulmonary vein isolation were greater in the patients with visible AC, but this difference did not reach statistical difference. Conclusion: The evaluation of the LAR with MDCT was useful for deciding strategy of AF ablation. The clinical implication of AC in AF ablation needs further investigation. P077 MULTIDETECTOR COMPUTED TOMOGRAPHY CAN DETECT LEFT VENTRICULAR MECHANICAL DYSSYNCHRONY IN HEART FAILURE PATIENTS UNDERGOING CARDIAC RESYNCHRONIZATION THERAPY Kimura R; Koyama Y; Inoue K; Toyoshima Y; Doi A; Masuda M; Sotomi Y; Iwakura K; Fujii K Sakurabashi Watanabe Hospital Background: Cardiac resynchronization therapy (CRT) is widely accepted as the adjuvant treatment of patients with severe heart failure. However, approximately 30% of patients receiving CRT are non‐responders. In order to improve the efficacy of CRT, the selection of appropriate patients based on the preoperative evaluation of the extent of left ventricular dyssynchrony is important. Several echocardiographic indices for the evaluation of dyssynchrony are proposed, but recent study shows their limitations. Objective: We sought to determine the feasibility of MDCT (Multidetector CT) to detect left ventricular mechanical dyssynchrony in heart failure patients. Methods: Eight patients with heart failure (mean left ventricular ejection fraction 22.8%) who were the candidates for CRT underwent electrocardiogram‐gated contrast‐enhanced 64‐slice MDCT (Philips Brilliance 64, EBW Workstation) and axial multiphase reformats were constructed. With visual observation, patients are divided into two groups: group D (with apparent left ventricular dyssynchrony, 4 patients), and group N (without apparent dyssynchrony, 4 patients). The short‐axis image of the left ventricle at the level of papillary muscle was divided into 6 segments. We determined the time from R wave to maximal wall motion for each 6 segments and defined the maximum difference in time‐to‐maximal wall motion of all 3 pairs of opposing segments as wall motion delay (WMD). Echocardiographic measurements including septal‐to‐posterior wall motion delay (SPWMD) were performed in all patients. Results: WMD was significantly greater in group D compared with group N (32.5 ± 9.6% RR vs. 10.0 ± 7.1% RR, P < 0.05). SPWMD was greater in group D, but it did not reach statistical significance (233 ± 60 ms vs. 161 ± 93 ms, p = 0.12). Conclusion: MDCT is useful for the observation and the evaluation of left ventricular dyssynchrony with its ability to clearly visualize the cross‐sectional moving images of left ventricle. P078 COMBINED USE OF THREE‐DIMENSIONAL ROTATIONAL ANGIOGRAM OF LEFT ATRIUM AND CIRCULAR MULTI‐ELECTRODE ABLATION CATHETER FOR PULMONARY VEIN ISOLATION Tang M; Gerds‐Li J‐H; Kriatselis C; Zhang S Department of Arrhythmia, Fuwai Cardiovascular Hospital, Chinese Academy of Medical Science, Beijing Background: A novel circular pulmonary vein ablation catheter (PVAC) has been introduced for pulmonary vein isolation (PVI). Accurate delineation of left atrium‐pulmonary vein (LA‐PV) anatomy is important for this technique. The aim of this study was to test the 3‐dimensional rotational angiogram of left atrium (3D RTA) can facilitate PVI using PVAC technique. Methods: Twenty patients with paroxysmal atrial fibrillation (AF) were enrolled in this study. The 3D RTA was reconstructed and registered with live fluoroscopy in all the patients. AF ablation was performed with PVAC catheter in the navigation of registered 3D RTA. Results: The 3DRTA image was successfully reconstructed and registered with the live fluoroscopy in all patients (100%). The LA‐PV anatomy was delineated clearly in all patients. Navigation of the PVAC inside the registered 3D RTA, ensured accurate placement within the atrium to perform ablation, and the PVAC was correctly placed inside the PV ostium to verify the PVI. All the PVs were isolated. Total procedural time was 87.5 ± 12.1 minutes, and fluoroscopy time was 20.1 ± 6.3 minutes. Follow‐up after 7.1 ± 1.5 months showed freedom from AF in 70% (14/20) patients. No PV stenosis was observed. Conclusions: Intraprocedurally reconstructed and registered 3D RTA can clearly delineate the LA‐PV anatomy in real‐time, this study demonstrates the feasibility and reliability of combining use of 3DRA and PVAC in AF ablation procedure. CARDIAC RESYNCHRONISATION THERAPY P079 LONG TERM OUTCOMES IN ISCHEAMIC VERSUS NON‐ISCHEAMIC DILATED CARDIOMYOPATHY AFTER CARDIAC RESYNCHRONIZATION THERAPY Mantziari L; Vassilikos V; Kamperidis V; Paraskevaidis S; Dakos G; Chatzizisis Y; Giannakoulas G; Karvounis H; Styliadis IH First Cardiology Department, AHEPA Hospital, Aristotle University of Thessaloniki, Greece Background: Cardiac resynchronization therapy (CRT) is an established treatment for patients with heart failure. Response to CRT and long term survival may be affected by a plethora of factors, heart failure aetiology being one of them. Aim of this study was to assess differences between patients with ischemic cardiomyopathy (ICM) and non‐ischemic dilated cardiomyopathy (DCM) treated with CRT. Methods: Data from CRT implantations for standard indications were retrospectively analysed. Differences in baseline characteristics, clinical and echocardiographic response to CRT and long term outcomes were sought between ICM and DCM. Results: A total of 166 patients were included, 51% with ICM and 49% with DCM. Mean baseline EF was 24 ± 5% and baseline NYHA class 3.0 ± 0.2 and did not differ between ICM and DCM. DCM patients were younger (61 ± 11 vs 69 ± 9 years, P < 0.001) and included more females (24% vs 2%, P < 0.001). QRS duration was similar between ICM and DCM (169 ± 24 vs 163 ± 25, p = 0.162) but left bundle branch block (LBBB) morphology was more frequent in DCM (89% vs 77%, p = 0.035). Atrial fibrillation prevalence and LV lead implantation site were similar. At 6 months, clinical improvement, defined as reduction ≥1 NYHA class, was 76% in both groups, and LVEF increased ≥15% in 75% of DCM vs 70% of ICM patients (p = 0.770). After a mean follow up of 24 ± 21 months DCM patients showed better survival (log rank p = 0.006) and a trend for better event‐free survival (log rank p = 0.055). After adjusting for age, gender and QRS morphology, DCM remains an independent predictor of better survival. Conclusions: Patients with DCM treated with CRT are younger, are more frequently female and have higher prevalence of LBBB. Even though short‐term response to CRT is similar between ICM and DCM, long term survival is better for DCM patients. P080 MORLET WAVELET ANALYSIS OF THE QRS COMPLEX AS A NOVEL TOOL FOR PREDICTING RESPONSE TO CARDIAC RESYNCHRONIZATION THERAPY Vassilikos V; Mantziari L; Dakos G; Kamperidis V; Kalpidis P; Paraskevaidis S; Maglaveras N; Chouvarda I; Karvounis H; Styliadis IH First Cardiology Department, AHEPA Hospital, Aristotle University of Thessaloniki, Greece Background: Among eligible patients for cardiac resynchronization therapy (CRT), those with wider QRS and left bundle branch block (LBBB) are more likely to respond. The wavefront pattern of myocardial ventricular activation in LBBB may differ between responders and non responders. Aim of the present study was to explore the differences in the QRS complex components between responders and non‐responders. Methods: We conducted a pilot prospective study in 39 consecutive patients (age 64 ± 10 years, 31 males) with heart failure and LBBB treated with CRT according to established guidelines. Signal averaged electrocardiograms were recorded before implantation and QRS decomposition was performed using the Morlet wavelet transformation. Wavelet parameters expressing the mean and maximal (max) energy were calculated in three orthogonal axes (x,y,z) and in the vector magnitude (vm), in each of three frequency bands. Response was defined as clinical improvement by one or more NYHA classes at 6 months follow up. Results: Baseline QRS duration was 166 ± 23 ms, left ventricular ejection fraction (LVEF) 26 ± 7% and LV end systolic volume (LVESV) 163 ± 49 ml. Thirty patients (77%) were identified as responders and had wider baseline QRS (171 ± 22 vs 142 ± 11ms, p = 0.005) and lower mean and max energies in all frequency bands on x axis as compared to non‐responders. Wavelet parameters on x lead could predict response to CRT with 76–79% sensitivity and 83% specificity. Conclusions: This pilot study showed that wavelet transformation of the amplified QRS complex may contribute in discriminating among patients who are more likely to benefit from CRT. A larger prospective study is deemed necessary to validate our findings. P081 DEMOGRAPHIC PROFILE OF CARDIAC RESYNCHRONISATION THERAPY (CRT‐D/CRT‐P) RECEIPIENTS AT OUR CENTRE – FIVE YEARS (2006–2011) EXPERIENCE Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Cardiac resynchronization therapy (CRT‐D/CRT‐P) is the emerging and proven modalities of treatment in patients (pts) with severe left ventricular (LV) dysfunction. Our center evaluated demographic profile of CRT in our pts over five years. Objective: To evaluate demographic profile of pts being referred for CRT‐D/CRT‐P in our center. Population/Methods: We studied 352 pts with severe LV dysfunction who were implanted CRT‐P/CRT‐D from 2006–2011. We analysed distribution by% of pts who received CRT‐D/CRT‐P, their age, gender selection, NYHA class, QRS duration (QRSd), etiology and comorbid conditions. In pts with QRSd (120–150 msec), we analysed mechanical dyssynchrony with Tissue Doppler Imaging (TDI). Indices chosen were atrioventricular (AV), interventricular and intraventricular dyssynchrony. Pts with 2/3 dyssynchrony indices were included. Results: Out of 352 pts (85.6% males, 14.4% females); mean age of pts 62.9 ± 17 yrs, with no statistical difference in mean age (59.3 ± 11.6 yrs for males vs 57.9 ± 10.4 yrs for females). 79% were diabetic and 60% hypertensive. CRT‐P was given to 79%, CRT‐D to 21%. 69.6% had ischemic etiology, 30.4% idiopathic dilated cardiomyopathy. Mean ejection fraction (EF) 22 ± 9%, mean QRSd 146 ± 18 msec. 2% in NHYA class II, 68% in NYHA class III and 30%in ambulatory NYHA class IV as a group, in females 46% were in NYHA class III and 54%in ambulatory class IV and in diabetics 43% were in NYHA class III and 57% in ambulatory class IV. Conclusion: We analysed demographic profile of pts who received CRT‐D/CRT‐P. The rate of implantation in females in our center is lower than expected. Also, females were older with higher NYHA class. The guidelines must be implemented carefully to avoid gender selection biases. We also concluded that diabetics were older with higher NYHA class vs non‐diabetics and hypertensives. In this study 2% population got CRT in NYHA classII in accordance with recent European guidelines for CRT. P082 LEFT VENTRICULAR PACING USING ACTIVE FIXATION LEADS IN CHALLENGING CORONARY SINUS ANATOMY Ahmad Fazli AA; Azlan H; Surinder K; Zunida A; Tay GS; Noor Ashikin S; Razali O National Heart Institute, Kuala Lumpur, Malaysia Introduction: The placement of leads in the distal coronary sinus is required for left ventricular stimulation in cardiac resynchronization therapy as well as for ventricular pacing whereby the right ventricle is inaccessible. Challenging coronary sinus anatomy may lead to instability, lead dislodgements and phrenic stimulations. We hypothesise that usage of an active fixation lead mechanism will overcome these limitations with stable lead performances. Methods: Patients who had implantation of 4F active fixation leads (SelectSecure Model 3830, Medtronic Inc, Minneapolis, USA) due to failed conventional left ventricular leads from May 2009 until July 2011 were selected for the study. Pacing parameters were tested at implantation and if found unreasonable, the lead is then unscrewed and fixed at a new location until the pacing parameters were satisfactory. We analysed pacing parameters at implantation and follow up as well as monitoring for lead related complications in these patients. Results: A total of 28 patients received implantation of the 4F active fixation leads. Among these, 71.4% were due to lead instability, 14.3% were selected for recurrent dislodgements, and 14.3% for phrenic stimulations. All 28 patients had successful implantations. Pacing threshold at implantation was 1.37 ± 0.59V and lead impedance was 809 ± 393 ohms. There were no significant difference in the pacing thresholds and lead impedances at 1 month, 3 months and 6 months follow up. The lead thresholds were 1.35 ± 0.86V, 1.33 ± 0.77V and 1.65 ± 0.98 V respectively (p = NS). Impedances were 624 ± 188 ohms, 666 ± 252 ohms and 624 ± 202 ohms respectively (p = NS). No lead related complications were encountered. Conclusions: Obstacles in lead placement for left ventricular stimulation due to challenging coronary sinus anatomy can be safely overcome by the use of 4F active fixation leads with stable pacing parameters. P083 AV NODE ABLATION IS NOT A PREDICTOR OF MORTALITY IN PATIENTS WITH ATRIAL FIBRILLATION TREATED WITH CARDIAC RESYNCHRONIZATION THERAPY Trucco E; Tolosana JM; Borras R; Calvo N; Arbelo E; Berruezo A; Sitges M; Castel MA; Brugada J; Mont L Hospital Clinic, Thorax Institute, Cardiology Department, Barcelona, Spain Background: There is a controversy about whether the AVJ node ablation (AVJ) improves the response and reduces the mortality of patients with permanent atrial fibrillation (AF) treated with cardiac resynchronization therapy (CRT). The aims of our study were: 1) to analyze if AVJ ablation reduced the mortality of patients in AF treated with CRT; 2) to analyze the predictors of mortality in this group of patients. Methods: This is a prospective and observational study. A cohort of 154 consecutive patients with permanent AF treated with CRT from 2000 to 2010 in our center was analyzed. Patients were divided into two groups: group 1: patients with AVJ ablation or need for continuous ventricular pacing due to complete AV block and group 2: those without AVJ ablation and non AV block. Patients were seen at the outpatient clinic at 6‐month intervals and at any time they required further evaluation due to a worsened clinical condition. Results: Of 154 patients: 78 (50.6%) were classified in group 1 and 76 (49.4%) in group 2. Basal echocardiogram and clinical parameters were similar in both groups. At 12 months, overall mortality was 21/154 (14.2%); 9/78 (11.5%) group 1 vs. 12/76 (15.7%) group 2 (p 0.486). In a univariate analysis the predictors of mortality were: plasma creatinine levels and NYHA functional class IV. After adjusting for these variables in a Cox regression model, the independent predictors of mortality were: basal NYHA functional class IV (HR 3.73, 95% CI [1.45–9.59], p = 0.006) and plasma creatinine levels (HR 1.93, 95% CI [1.00‐ 3.70], p = 0.048). Conclusions: AVJ ablation did not decrease the mortality of patients in AF treated with CRT. Basal NYHA functional class IV and poor renal function were the independent predictors of mortality in this group of patients. P084 A PROSPECTIVE AND RANDOMIZED STUDY USING A NUMERICAL MODEL ABLE TO PERSONALIZE AV AND VV DELAYS IN CARDIAC RESYNCHRONIZARION THERAPY Di Molfetta A; Forleo GB; Minni V; Panattoni G; Cioè R; Papavasileiou LP; Magliano G; Santini L; Capria A; Romeo F Department of Cardiology, University of Tor Vergata‐Departement of Cardiovascular Engineer CNR, Rome AV and VV setting is a critical issue in CRT. A numerical model (NM) able to simulate patients condition and optimize AV and VV was developed. The aim of this study was to assess if the developed algorithm dedicated to CRT‐optimization could increase clinical, electrical and echocardiographic outcome. Forty patients (PT) were enrolled in a prospective study and randomized into two groups. Group A (B) contains PT programmed by NM (commercial ones). PT were studied before CRT, 3 (_3) and 6 (_6) months after CRT to evaluate: left ventricular end systolic and end diastolic volumes (Ves, Ved), QRS, 6 minute walking test (S) and total Minnesota scores (M). In group A the AV and VV were changed at each follow up according to NM indications. No significant statistical differences were observed at the baseline (Ves_A = 194 ± 102 ml, Ves_B = 157 ± 56 ml; Ved_A = 252 ± 113 ml, Ved_B = 213 ± 72 ml; QRS_A = 156 ± 44 ms, QRS_B = 150 ± 43; S = 127 ± 88 m, S_B = 132 ± 90; M_A = 29 ± 19, M_B = 33 ± 21) A significant statistical difference in left ventricular remodeling concerning the reduction of Ved (A_3 =−25%, B_3 =−10%, p = 0.001; A_6 =−30%, B_6 =−10%, p = 0.0009) and Ves (A_3 =−23%, B_3 =−12%, p = ns; A_6 =−35%, B_6 =−12%, p = 0.002) were observed. A more evident increase of S distance was observed in A (A_3 =+219 m, B_3 =+198 m; A_6 =+279 m, B_6 =+195 m). No significant statistical difference in the reduction of QRS width was reported (A_3 =−16%, B_3 =−10%; A_6 =−9%, B_6 =−18%) and in M (A_3 =−8.9, B_3 =−14.25; A_6 =−9.25, B_6 =−16). A dynamic and personalized CRT can improve ventricular remodeling, without affecting QRS decreasing. Moreover, NM can be a support to select candidates to CRT estimating in advance the benefit effect of CRT on a specific patient. P085 THE EFFECT OF CARDIAC RESYNCHR‐
ONIZATION THERAPY ON THE LEFT VENTRICULAR FUNCTION: EVALUATION OF ELECTROCARDIOGRAPHIC AND ECHOCARD‐
IOGRAPHIC CHANGES Marinskis G; Maneikiene V; Jonaityte D; Zasytyte I; Aidietis A Clinic of Cardiac and Vascular Diseases, Vilnius University, Faculty of Medicine Aim: To evaluate the effect of cardiac resynchronization therapy on the left ventricular function by analyzing changes in left ventricular ejection fraction (LVEF) and QRS complex width. Patients and methods: A retrospective study was held in Vilnius University Hospital Santariskiu clinics. We analyzed 55 patients (18 women, 37 men, age 61.5 ± 14.5 years) who had biventricular pacing system implantation because of II‐IV NYHA heart failure. Primary implantation was performed for 45 patients, system upgrade – for 10. We analyzed the data of electrocardiograms and heart ultrasound before and after implantation (QRS width, LVEF and clinical status). Microsoft Excel and STATISTICA software was used for data processing and statistical analysis. Student t‐test was used to evaluate the difference between continuous variables in two groups. Pearson correlation coefficient was used to measure the correlation between the changes of QRS width and LVEF. p ≤ 0.05 was considered statistically significant. Results: QRS width average before implantation was 185 ± 26 ms, after – 152 ± 19 ms (P < 0.05). QRS width decreased by mean value of 31 ± 22 ms (P < 0.05). QRS width remained the same in 4 patients. LVEF mean value before implantation was 26 ± 10%, after – 31 ± 9% (P < 0.05). On average LVEF after the implantation increased by 6 ± 10% (P < 0.05). Changes in QRS width correlated with LVEF changes (r =−0.276, p = 0.048). The broader QRS complexes were before treatment, the more significantly they shortened after implantation of resynchronization system (r =−0.52, p = 0.00078). Clinical status (followed from 3 to 76 months after treatment) of 23 (42%) patients improved, 21 (38%) remained stable, 3 (5%) worsened, 8 patients (15%) died. Conclusions: In responders to cardiac resynchronization therapy, shortening of QRS complex correlates with improvement of left ventricular function. P086 PRESERVED CONTRACTILE AND CORONARY FLOW RESERVE ARE PREREQUISITE FOR POSITIVE RESPONSE AFTER CARDIAC RESYNCHRONIZATION THERAPY Djordjevic‐Dikic A; Nikcevic G; Raspopovic S; Jovanovic V; Tesic M; Djordjevic S; Milasinovic G Pacemaker Center, Institute for Cardiovascular Disease, Clinical Center of Serbia, Belgrade, Serbia Background: Cardiac resynchronization therapy (CRT) has become a mainstay in heart failure management, but still 30% of patients failed to respond to such therapy. In patients with non‐ischemic dilated cardiomyopathy, abnormal coronary flow reserve and absence of contractile reserve are independent prognostic markers of bad prognosis. Aim: The aim of this study was to investigate the potential impact of coronary flow reserve (CFR) and myocardial contractile reserve on left ventricular function recovery following CRT implantation. Method: Eighteen patients with heart failure (EF 26 ± 5%) and QRS duration of 159 ± 23 ms, underwent transthoracic Doppler echocardiography adenosine test to evaluate CFR and dobutamine echocardiography test to assess global contractile reserve (improvement in LVEF), before CRT implantation. Responders were defined by decrease in end‐systolic volume (ESV) ≥15%, 6 months after CRT. Results: Fourteen patients were responders, whereas 4 were nonresponders. At inclusion these groups did not differ in LVEF, ESV, EDV, QRS duration, 6 min walk test distance and coronary flow velocity at rest. Before CRT implantation, responders, compared with nonresponders, showed a greater increase in coronary flow velocity during hyperemia, and consequently higher CFR: 2,39 ± 0,74 vs. 1,68 ± 0.29, p = 0.03. During dobutamine test responders also had higher LVEF, p = 0.02, as well as after 6 months: 45 ± 12% vs. nonresponders 28 ± 8%, p = 0.013. By univariate analysis, LVEF during dobutamine infusion (p = 0.02) and coronary flow velocity during hyperemia (p = 0.04) were predictors for improvement of left ventricular function after CRT. Conclusion: Our results showed that prerequisite for positive response to CRT are preserved CFR and microcirculation and a presence of contractile reserve. P087 PREDICTORS OF THE RESPONSE TO CARDIAC RESYNCHRONIZATION THERAPY IN PATIENTS WITH NONISCHEMIC DILATED CARDIOMYOPATHY Vaikhanskaya TG; Kaptsiukh TM; Sidorenko IV; Kovalenko ON Republican Scientific and Practical Center of Cardiology, Minsk, Belarus Purpose: The aim of our study was to identify the significant finding of surface electrocardiogram (ECG) to predict the response to CRT in patients (pts) with nonischemic dilated cardiomyopathy (DCM). Metods: 34 pts with DCM nonischemic aethiology HF (82,4% male; 48,5 ± 10,7 years; NYHA class 3,0 ± 0,3; QRS 167 ± 21ms; LVEF 24,7 ± 2,8%) had CRT implanted. Pts were classified as symptomatic responder (CRT‐R) if they were experienced ≥5% absolute increase LVEF and improvement NYHA class ≥1 at 6 months after CRT. We (independent 3 doctors)assessed all the clinical characteristics including 12 lead ECG parameters before and after CRT and compared the findings between CRT‐R and non‐responders (CRT‐NR). Results: 15 pts (44,1%,14 male and 3 female) were CRT‐R and 19 pts (55,9%,3 female) were CRT‐NR. At baseline there were no significant differences in age, gender, NYHA, QRS width, 6‐MWT, maxV O2, LVEF, LV end‐diastolic and end‐systolic volume and pharmacology therapies between two groups. When compared width QRS,QR,RS,amplitude wave in 12 lead ECG after CRT, responders had a greater RS interval shortening in V1 lead (ΔRS in V1 −16 ± 4,5 ms vs. −8,4 ± 4,9 ms; p = 0,000) and increase R wave in V1 (ΔR in V1 1,4 ± 0,8 mm vs.0,6 ± 0,7 mm; p = 0,004), and at baseline width RS in V1 were significant differences between two groups (RS in V1 55,3 ± 12,4 ms vs. 43,2 ± 13,1 ms; p = 0,01). By multivariate logistic regression analysis identified presence reduction of RS interval and increase R wave in V1 during pacing as independent predictors of response to CRT. Conclusions: The reduction of RS interval and increase R wave in V1 lead during pacing CRT and baseline greater RS in V1 was significantly correlated with improvement of both LVEF and functional capacity. Future studies on larger population are needed to confirm that RS interval in V1 lead may reliable to predict CRT‐R in pts nonischemic DCM with indication to CRT. P088 VECTOR ELECTROCARDIOGRAPHIC AND HEMODYNAMIC RESPONSE TO ATRIOVE‐
NTRICULAR DELAY OPTIMIZATION IN HEART FAILURE PATIENTS RECEIVING CARDIAC RESYNCHRONIZATION THERAPY Ståhlberg M; van Geldorp I; van Deursen C; Strik M; Francois R; Francesco F; Auricchio A; Prinzen F Karolinska Institutet, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Introcuction: The purpose of this study was to evaluate the vector electrocardiographic (vECG) and hemodynamic response to atrioventricular delay (AVD) optimization in heart failure patients receiving cardiac resynchronization therapy (CRT). Methods: In 19 CRT recipients different AVDs were programmed in steps of 20 ms ranging from 60 ms to each patients maximal AVD before loss of capture during atrial overdrive pacing (90 bpm). ECG was recorded continuously for subsequent analysis of frontal plane vECG. At each AVD, stroke volume (SV) was measured using echocardiography (LVOT‐VTI, average of 10 beats in each setting). The AVD yielding the largest SV was considered optimal. Results: Mean maximal AVD was 270 ± 60 ms. Two different pattern of QRS response to AVD programming was observed. During CRT at short AVDs 8 patients (group 1) displayed a reduction in QRS width > 5% (mean: −23 ± 7%) while in 11 patients (group 2) no significant QRS shortening occurred (mean: +9 ± 15%). A significant, CRT induced, increase in SV over most AVDs was only observed in group 1 patients. Patients in group 2 had significantly shorter baseline QRS width (138 ± 22 vs. 170 ± 28 ms, p = 0.01) and significantly longer optimal AVDs compared to group 1 (220 ± 40 ms vs. 170 ± 50 ms, respectively, p = 0.02). Only in group 2 QRS width was shorter at optimal AVD than at short AVD (‐10 ± 10ms vs. +10 ± 10 ms in group 1, p = 0.02). In group 2 only, vector length was significantly shorter at AVDs > 230 ms compared to at AVD 60 ms which indicates fusion with intrinsic activation. Conclusions: Patients with relatively short QRS duration show little or no resynchronization (QRS reduction) with CRT at short AVD but may benefit from very long AVD, where QRS is reduced. This resynchronization is probably due to fusion with intrinsic activation, as indicated by vector length shortening on the vECG. P089 SINUS RHYTHM RECOVERY IN PATIENTS WITH CHRONIC ATRIAL FIBRILLATION AND DILATED CARDIOMYOPATY WHO UNDERWENT CRT IMPLANT (SIBILLA STUDY) Turco P (1); D'Onofrio A (2); Stabile G (3); Solimene F (4); La Rocca V (5); Cavallaro C (2); Iuliano A (3); Donnici G (4); Vecchione F (2); De Simone   (5); Sibilla Study (1) Hesperia Hospital, Modena, Italy. (2) Monaldi, Napoli, Italy. (3) C. Mediterranea, Napoli, Italy Cardiac resynchronisation therapy (CRT) has been demonstrated to be beneficial also in patients with atrial fibrillation (AF); in some patients sinus rhythm occur after CRT. In this patients we evaluate the feasibility of electrical cardioversion (EC) to restore sinus rhythm and the EC efficacy in preserving SR at follow‐up. We enrolled 41 consecutive patients with symptomatic heart failure despite optimal medical treatment, left bundle branch block (QRS duration ≥120 ms), left ventricular ejection fraction ≤35% and chronic (more than one year) AF, who underwent CRT‐D implant. In all patients, an atrial lead was used. We scheduled one or more internal, by means of device, or external EC in all eligible patients. Results: Major population characteristics are reported in the table. Mean ± SD orPercentageGender (Male)75%Age (Years)71,6 ± 9,2Ischemic Heart Disease54%Hpertension61%Diabetes24%NYHA functional class III/IV93%/ 7%QRS width (ms)138 ± 16LV ejection fraction (%)23,6 ± 5,7Left atrial diameter (mm)51,3 ± 7,8 At a mean of 2,7 ± 1,8 months 19/41 (46%) patients underwent at least one EC. No complications occurred. EC was effective in restoring SR in 13 patients (68%); an intention to treat analysis shows a success rate of EC procedure (SR) in 31% (13/41). Eleven among thirteen patients (85%) with effective EC remained in SR at a mean follow‐up of 9,2 ± 7,6 months. Spontaneous conversion was observed in two patients. Atria; Calcuim channel; Cellar electrophysiology; Aging EC was feasible in less than 50% of patients with chronic AF post CRT; however SR was persistent at six months in greater than 30% of population, suggesting an atrial lead may be considered at implant. P090 CEPHALIC VENOUS ACCESS FOR CRT WITH SUBCLAVIAN AND CEPHALIC VEIN TORTUROSITY AND ANOMALY Xu Y; Wang J; Qiao Q; Zhang S; Hua W Hangzhou 1st People's Hospital, Fu Wai Hospital, China Introduction: Subclavian venous access can be applied for the majority of cardiac resynchronization therapy (CRT) device implantation. However, puncture failure occurs occasionally. Case History: A 70‐years‐old man fulfilled CRT criteria. At first, several attempts were made to puncture the left subclavian vein, until arterial blood was aspirated. Puncture of subclavian vein then was abandoned out of concern for the risk of pneumothorax or hemothorax. Cephalic cutdown were performed. A 16‐gauge, 8.3‐cm angiocath was inserted into the cephalic vein, through which contrast was injected to perform venogram. Cephalic and subclavian venous anomalies were revealed. The proximal cephalic vein devided into two branches, the upper one joined the external jugular vein while the lower one, which was small and torturous, joined the axillary vein laterally at the level of superior border of the second rib, and subclavian vein was also small. A 150‐cm 0.89‐mm hydrophilic glide wire was introduced into the lower branch of the cephalic vein and advanced toward the heart under venographic guidance. A 9‐F 14‐cm sheath was then advanced over the glide wire, once the tip of the sheath unit was positioned in the superior vena cava, the dilator was removed and 2 other standard 50‐cm 0.97‐mm guidewires were introduced. The sheath was peeled away while the 3 guidewires were held in place. A left ventricular (LV) lead delivery system was advanced over the glide wire to position the LV lead. When an acceptable lead position had been attained, the delivery system was removed by tearing. A 8‐F sheath was advanced over one of the 50‐cm guidewires to position the atrial lead. This sheath was peeled away when a suitable position had been attained. Then a 8‐F sheath was placed over the final guidewire to position the right ventricular lead. All leads were fixed separately. A CRT device was implanted. Conclusion: Cephalic venous access is a feasible alternative to subclavian access for CRT. P091 TRANSAPICAL ENDOCARDIAL LV PACING FOR CRT, FIRST EXPERIENCE IN FIVE PATIENTS Karpenko Y; Volkov D Odessa State Medical University, Ukraine Background: CRT is approved method for HF treatment in selected groups of patients (pts). Transvenous method of implantation is common. Endocardial LV pacing seems promising by the fact of rapid physiologic LV depolarization pattern and absence of anatomical limits committed to the transvenous procedures. Life‐long taking of oral anticoagulants is obliged. Objective: To analyze experience of the few first LV endocardial pacing for CRT. Methods: 5 pts (4 men, age 57—74) with LBBB (QRS 170 ± 24 ms), advanced HF NYHA III (EF – 27 ± 9%) were implanted with DDD (3 pts) and DDDRV (2pts) for CRT with transapical endocardial LV lead placing as a part of the procedure. All of them had been on warfarin due to persistent‐permanent AFib. Two pts had repeated transvenous LV lead dislocations, one – no anatomical conditions for transvenous LV lead placement, one – LV lead exit block after repositioning and the last – deterioration after apical RV pacing. After thoracotomy the apex of LV was punctured and conventional screw‐in endocardial lead were inserted into LV by Seldinger method via pill‐away introduser using hemostatic purse‐string sutures. In 3 pts endocardial LV 3D activation mapping (NavX, S.J.M, USA) to find the optimal pacing site were done before final fixation. Then the electrode was tunneled to the pocket. Results: CRT was available in all pts with acute thresholds less than 1,5V,led to dramatic reduction of QRS duration (135 ± 17 ms) and good immediate and mid‐term clinical results (EF – 34 ± 12%). One patients had raise of LV capture threshold up to 3V with adequate pacing with 4,5V amplitude. LV 3D activation mapping during procedure revealed the "latest" point near LV apex in two pts with further implantations in that area which is discordant with existed theory of the best postero‐lateral regions for LV CRT delivery. Conclusion: Endocardial LV pacing for CRT is safe, useful and was at least as effective as traditional methods in our small group. P092 CARDIAC RESYNCHRONISATION THERAPY IN ATRIAL FIBRILLATION PATIENTS – ANY OUTCOME DIFFERENCES TO SINUS RHYTHM PATIENTS? Dusceac D; Iancu A; Capraru C; Bostan I; AlHassan A; Ciudin R "C.Davila" Univ of Medecine, "C C Iliescu" Institute of Cardiovascular Diseases, Bucharest, Romania Cardiac resynchronisation therapy (CRT) is been the therapy of choice in patients (pts) with severe heart failure (HF) and left bundle brunch (LBB) QRS morphology. Left ventricular ejection fraction (LVEF) less than 35%, optimal medical therapy and NYHA class III/IV are also major indications for CRT. Atrial fibrillation (AF) prevalence is high in pts with CRT indication but number of such pts enrolled in major CRT clinical trials is not so. We have study 94 pts who underwent CRT for severe HF and we have followed them for a mean of 3.2 years (from 9 years to 11 months). 60 pts had dilated non‐ischaemic etiology and 32 pts were of ischaemic etiology. 1 pt had hypertrophic non obstructive cardiomyopathy. 22 pts (23.4%) were in AF. We compare there outcome in terms of NYHA class, LVEF, mitral regurgitation degree, quality of life (QoL) and clinical and echo parameters evolution. There was no significant difference in NYHA class reduction or LVEF improvement between sinus rhythm (SR) and AF pts.Pts in SR have marginally done better in terms of mitral regurgitation reduction, 6 min walk test and QoL(Minnesota score). Non–responders percent was mainly the same: 26% in AF pts and 23% in SR pts group. If after 3 months following the initial implant the pacing percent was less than 80% despite optimal medical therapy we performed AVN ablation. We conclude that pts in AF can benefit from CRT almost as SR pts but more data and longer follow‐up period is needed. P093 THE CHOICE OF APPROACH TO LEFT VENTRICULAR LEAD IMPLANTATION FOR PERMANENT PACING Osadchy A; Marinin V; Kurnikova E; Lebedev D Almazov Federal Heart, Blood and Endocrinology Centre Objective: to improve surgical results of cardiac conduction disorder by prevention and correction of left ventricle dyssynchrony on the back of permanent pacing. Design and Methods: We observed 257 patients was exam and treated. Task 1 – to study the electrophysiological indices of LV lead, considering the delivery way (n = 80). Task 2 – to evaluate the effect of pacing on hemodynamics and CHF course, consider the lead position (n = 90). Task 3 – to study the anatomy of the venous system of the heart according to coronary angiography (CAG) (n = 107). In each task were formed comparable groups without significant clinical and demographic differences. Task 3 – by etiology patients were divided into 2 groups: 1 – with CHD, 2 – without CHD; we assess the effect of heart chambers enlargement to anatomy of cardiac veins. Venous anatomy was studied considering the zone of myocardial infarction. Results: Task 1 – in 1 group at 21% of cases problems with left ventricular lead was observed, but in 2 group these were absent. Differences in duration of operation, acute and chronic pacing thresholds were not obtained. Task 2 – ECHO: at 1 group ↑LVEDV, MR, ↓EF were significantly; at 2 and 3 group remodeling of heart chambers with normal EF were observed. At 1 group appearance of patients with IV f.cl. (NYHA), at 2 group ↓ quantity patients with III f.cl. were observed. At 3 group quantity patients with II f.cl. were decrease, patients with IV f.cl. weren't register. Task 3 – in all groups CS ostium, MCV, GCV were visualized at 100%. Conclusion: in patients before cardiac resynchronization device implantation is necessary to study the anatomy of cardiac veins and determination the optimal lead position (by tissue Doppler imaging). CAG allows to study the anatomy of cardiac veins and in combination with results of tissue Doppler imaging – permit to select the surgical approach (endovascular or thoracoscopical). P094 CARDIAC RESYNCHRONIZATION THERAPY IN POTENTIAL HEART TRANSPLANT CANDIDATES Sasov M; Liska B; Goncalvesova E; Margitfalvi P; Svetlosak M; Hatala R National Cardiovascular Institute, Bratislava, Slovakia Selected patients (pts) with end‐stage HF benefit from CRT and CRT might decrease or postpone the need for heart transplant (HTx). Aim of this study was to analyze in clinical practice the implementation of the latest ESC guidelines on CRT in HTx candidates. 311 pts with LVEF ≤ 35% referred for HTx eligibility in the years 1996 – 2009 at our institution were included in the analysis. This comprised 207 pts randomly selected from pts without realized HTx and 104 pts who finally underwent HTx (data taken from last evaluation prior HTx). Their mean age was 49.8 ± 11.4 years, 263 pts (85%) were male. The etiology was dilated CMP in 169 pts (54%), CAD in 87 pts (28%), hypertensive heart in 25 pts (8%), valvular disease in 11 pts (4%) and other in 19 pts (6%). Permanent atrial fibrillation (AF) was present in 50 pts (15%) and LBBB in 93 pts (30%). Results: In the entire cohort 110 pts (35%) fulfilled the criteria for CRT. Prevalence of CRT candidates in the subgroup of patients who finally underwent HTx was 51% (53 pts). In candidates for CRT, permanent AF was present in 14 pts (13%) and LBBB in 72 pts (65%). Optimal criteria for achieving CRT response (NYHA III/IV, QRS≥150 ms, LBBB, sinus rhythm) were fulfilled in the entire cohort by 43 pts (14%). Overall, CRT devices were implanted in 22 end‐stage HF pts (7%), 17 of them fulfilled optimal criteria for achieving CRT response. In multivariate analysis the presence of LBBB (P < 0.001) but not QRS duration was independent predictor for criteria fulfillment. Conclusions: More than 1/3 of chronic HF pts eligible for HTx fulfilled criteria for CRT. This proportion was higher (51%) in the subgroup of transplanted pts. CRT was underused in this specific patient cohort with only 20% of pts fulfilling actual indication criteria receiving a CRT device. However, this proportion increased to 40% when optimal criteria for achieving CRT response are considered. P095 FEATURES OF HOLTER MONITORING OF ECG IN CRT PATIENTS Basova VA; Rogacheva NM; Krasnoperov PV; Petruneva TS; Schneider YuA Medical Academy of Postgraduate Study Purpose: to assess the significance and features of Holter Monitoring of ECG in CHF patients with CRT devices. Methods: 112 ECG Monitoring records of patients with severe heart failure were analyzed before and after biventricular pacemaker implantation. 19 patients had coronary artery disease and 32 patients – nonischemic cardiomyopathy. 9 patients was in IV heart failure NYHA class, 32 – was in III NYHA class and 10 – was in II NYHA class. 38 CRT‐P and 13 CRT‐D devices were implanted in our clinic. Results: Holter Monitoring features in CHF patients before biventricular pacemaker implantation were distal type of LBBB (QRS > 170 ms in 13 cases), changing the degree of intraventricular conduction (Δ QRS = 30 ms), high ventricular ectopy (PVC > 100/hour – 7 patients (17%), paired PVC – 2 (4,8%), polymorphic PVC – 3 cases (7,3%), nonsustained VT–– 10 (24,4%), sustained VT – 5 patients (12,2%). Reduction in heart rate variability was registered in 34 patients (SDANN). Biventricular pacing percentage, existence and number of native QRS (own AV conduction) and fusion biventricular pacing with native QRS. The most of patients had biventricular pacing >90%. All patients were separate into 2 groups: "responders" (37) and "nonresponders" (14). Patients of the 1st group ("responders") reduced ventricular ectopy, increased heart rate variability (just in patients with sinus rhythm). However patients of the 2nd group ("nonresponders") had biventricular pacing <80% (3 cases), high ventricular ectopy (2 cases), existence of the fusion biventricular pacing with native QRS complexes > 20% of 24 hours recording (3 cases). Conclusions: It's important to pay attention for biventricular pacing percentage, existence and number of native QRS and fusion biventricular pacing with native QRS complexes during the ECG records analysis. Holter Monitoring of ECG is indicated to CRT patients who didn't response to the therapy. P096 TRIPLE‐SITE VENTRICULAR PACING IN PATIENTS WITH BORDERLINE NARROW QRS AND NYHA III‐IV CARDIAC FAILURE Calovic Z; Vicedomini G; Cuko A; Saviano M; Petreta A; Vitale R; Pappone C Villa Maria Cecilia Hospital, Cotignola, Italy Two‐fifths of heart‐failure patients who receive cardiac resynchronization therapy (CRT) are not benefitting clinically from the device therapy. Purpose: We hypothesized that among others, one of the possible reasons for this failure could be found in group patients who received CRT with a borderline QRS interval of 120 ms. (assuming they meet LVEF% requirements and other criteria). Materials and Methods: In 10 consecutive patients who fullfill "classic" criteria for CRT‐P/D, but borderline QRS duration of 120 ± 5 ms, NYHA III/IV class and echocardiography evidence of dyssynchrony, we performed CRT implantation placing additional CS lead over left ventricle and in that way obtained unify‐right with bifocal LV pacing. CS electrodes were implanted at two separate location of the LV, so the distance between the electrodes would be as far as possible. We use „Y connector" to connect two CS leads in one LV port of the pacemaker. RV electrode was implanted either in septal or apical portion of the heart. Six min hall‐walk test and echocardiography were performed 1 and 3 months after the implantation. Results: All implants were successful. No complications, either peri or post‐procedural, were observed in the patients. After 3 months follow‐up no patients died. Only one patient has no clinical improvement in hearth functional class. The rests of the 9 pts were improved at least one NYHA class, with the increase in LVEF (29,5% vs 38,9%). There was also significant increase in 6 min walking test (P < 0.05), 1 and 3 months, respectively. Conclusion: In our observational study, we found that triple‐site ventricular pacing is feasible and efficacious during 3 months pacing in patients with serious heart failure, borderline narrow QRS and significant ventricular dyssynchrony on TDI. Further bigger study and longer follow‐up is needed for pure clarification of this therapy. P097 PACING MODE SELECTION IN CRT PATIENTS: SEQUENTIAL OR SIMULTANEOUS BIVENTRICULAR PACING Krasnoperov PV; Rogacheva NM; Basova VA; Petruneva TS; Schneider YuA Medical Academy of Postgraduate Study Purpose: to study the results of sequential or simultaneous biventricular pacing in CRT patients, to assess is VV interval optimization need or not. Methods: 51 patients (M‐42, 59,7 ± 7,3 years) with cardiomyopathy (ischemic – 19, nonischemic – 32) were enrolled in the study. 38 CRT‐P and 13 CRT‐D devices were implanted. All patients had such examinations as clinical, ECG, two‐dimensional echocardiography, tissue Doppler imaging. Sequential or simultaneous biventricular pacing was programmed after operation before discharge. We optimized VV interval with LV outflow tract VTI. We particularly paid attention to clinical status: NYHA functional class, and echocardiographic parameters: LV volumes, LV ejection fraction (EF) at baseline, before discharge and in a 6 month after CRT implantation. Patients with improvements of ≥1 NYHA class at 6‐month follow up were classified as clinical responders. Patients with reduction of >15% in LV end‐systolic (LVESV) or/and end‐diastolic volume (LVEDV) and improvement in the LVEF of >5% were classified as echocardiographic responders. Results: 51 patients were separated depending into 2 groups depending on pacing mode. The 1st group – 29 patients with sequential biventricular pacing. VV interval was optimized after CRT implantation. The 2nd subgroup – 22 patients with simultaneous biventricular pacing. The results of 6 month follow up showed significant reduction of LV sizes and volumes in patients of the both groups. But the 1st group demonstrated biventricular pacing more systolic function improvement: EF, dP/dt, EPSS. Conclusions: Biventricular pacing is effective method of treatment patients with congestive HF. Sequential and simultaneous biventricular pacing lead to reverse LV remodeling. Systolic function increase significantly with sequential biventricular pacing. VV interval optimization is indicated to non‐responders. P098 COMPARATIVE STUDY OF INTERVENTRICU‐
LAR DELAY OPTIMIZATION IN CARDIAC RESYNCHRONIZATION THERAPY USING ELECTROCARDIOGRAPHY VERSUS USING ECHOCARDIOGRAPHY An C; Yang D; Chen K; Xu J; Fang X; Sun N; Liu F; Su H; Huang X; Yan J; Department of Cardiology, Anhui Province Hospital Anhui Institute of Cardiovascular Disease Objective: To assess ECG‐optimized Interventricular Delay Interval (V‐V) in cardiac resynchronization therapy. Methods: 30 CRT patients with dilated cardiomyopathy and ischemic cardiomyopathy, NYHA class III ∼IV, were studied, aging from 42 to 79 (63.3 ± 10.6) years. After one month follow‐up, the patients were programmed to only LV (Left ventricle) pacing and only RV (Right ventricle) pacing, respectively. V‐V interval optimization was performed by ECG as follows: calculating the time from pacing spike to beginning of earliest deflection of QRS complex in precordial leads, first activating epicardial LV lateral wall (named as T1) and secondly during RV pacing (named as T2). Difference between T1 and T2 was regarded as a surrogate measurement of interventricular delay and defined as the best optimal V‐V interval. Echocardiography was performed to measure the optimal V‐V interval using maximal aortic VTI. Results: By echocardiography, there were 20 patients and 5 patients showed the optimal LV synchrony with LV preactivation at 30 ms, 70 ms respectively, while 3 patients gained the most benefit from simultaneous pacing at 0∼5 ms, 2 patient achieved the maximum benefit with RV preactivation at 30 ms. With ECG, 19 patients and 5 patients benefited the most with LV preactivation at 30 ms, 70 ms, respectively. 4 patients got the best benefit with simultaneous pacing at 0∼5 ms, and 2 patients benefited most with RV preactivation at 30 ms. Good concordance was found between the ECG‐optimized and echocardiography‐optimized V‐V interval (K = 0.937). Conclusions: For CRT patients, the optimal V‐V interval can be achieved by ECG which shows a good correlation with UCG. Key words: cardiac resynchronization, electrocardiography, echocardiography. P099 EFFICACY OF CRT IN CHF WITH ATRIAL FIBRILLATION WITHOUT ABLATION OF AV NODE, BUT ACHIEVED STRICT RATE CONTROL Mareev YV; Golitsin SP; Sapelnikov OV; Kiktev VG; Latypov RS; Grishin IR; Saidova MA; Shitov VN; Akchurin RS Russian Cardiology Research Complex, Moscow, Russian Federation Aim of our study was to compare effect of CRT therapy in CHF patients with low EF and wide QRS in sinus rhythm (which have been proven) and permanent atrial fibrillation without ablation of AV node. Our hypothesis was that patients with atrial fibrillation and good pharmacological rate control with indication for CRT by EF and QRS duration would have comparable effect from CRT as patients with sinus rhythm. Methods: We used The Minnesota Living_with_Heart_Failure_Questionnaire, 6 minutes walk test, measurement of EF by echocardiography (GE Vivid 7). Percent of biventricular pacing we calculated by using of 24 hours ambulatory monitor. We examined patients before implantation of CRT and after six month. Statistical significance was evaluated with Wilkokson analysis. Results: We included 24 patients: 8 patients with permanent atrial fibrillation and 16 patients with sinus rhythm. 7 of 8 patient with permanent atrial fibrillation had >85% biventricular pacing. This patient had algorithm VSR – his "fusion" complex has same Doppler VTI as biventricular complex. There ware no death in both groups of patients. Functional class by NYHA decreased from 3.1 to 2 (P < 0.05) in group of permanent AF and from 2.9 to 1.6 (P < 0.05) in group of sinus rhythm. MLHFQ decreased from 55 to 39 (P < 0.05) in patients with permanent AF and from 49 to 35 (P < 0.05) in patients with sinus rhythm. 6 minutes walk test increased from 306 to 384m (by 66 m, p< 0.05) in patients with permanent AF and from 368 to 408 (by 40 m, P < 0.05) in patients with sinus rhythm. EF increased from 26.6% to 31.6% (by 5%) in group of permanent atrial fibrillation and from 23.3% to 33.4%(by 10.1%, P < 0.05) in group of sinus rhythm. Conclusion: Patients with permanent AF without ablation of AV node have comparable effect from CRT as patients with sinus rhythm. Limitation: We exclude from study patients with mean heart rate more than 95 bpm. P100 LOSS OF CARDIAC RESYNCHRONIZATION THERAPY: INCIDENCE, CAUSES AND OUTCOMES Colchero T; Arias MA; Domínguez‐Pérez L; Jiménez‐López J; Puchol A; Pachón M; Lázaro‐Salvador M; Rodríguez‐Padial L Department of Cardiology, Hospital Virgen de la Salud, Toledo, Spain Background and Objectives: The benefits OF cardiac resynchronization therapy (CRT) are directly related to the maintenance of continuous biventricular pacing. The loss of the TRC is a common clinical problem that limits the potential benefits of this therapy in patients with heart failure. We describe the experience in our center by identifying the causes, incidence and results of loss of CRT. Method: Retrospective, observational study of all patients who were implanted with a CRT device for a period of 43.2 months. Results: We analyzed data from 97 patients. 64.4% were male and mean age was 66 years. The indication for CRT was ischemic dilated cardiomyopathy in 41.8% of cases. 63,2% of patients were implanted with a cardioverter defibrillator system added. During a mean follow‐up of 43,2 months, 15 patients died and a total of 37 (37.8%) patients experienced transient or permanent loss of CRT. Six patients had more than one reason for loss of CRT. The most frequent cause was the presence of atrial tachyarrhythmias (12.3%), followed by dislodgement of the LV electrode (8.2%), increased threshold of the LV electrode (7.2%), extracardiac stimulation (4.1%), increased threshold for the VD electrode (4.1%), ventricular oversensing (3.1%), atrioventricular sensing (3.1%), infection (1%) and clinical intolerance to CRT (1%). The loss of the CRT was resolved in 79.1% (n = 34) of cases and was permanent in 20.9% (n = 9). Univariate analysis was performed to identify possible predictors of loss of CRT but there was no statistically significant difference in any of the variables. Conclusions: Despite technical advances in CRT, the loss of it is a very common clinical condition and difficult to solve in an appreciable percentage of cases. A close monitoring of patients with CRT is essential to identify and solve all the problems associated with this therapy. P101 A NOVEL 3D ELECTROMAGNETIC NAVIGATION SYSTEM REDUCES FLUOROSCOPY TIME AND RADIATION EXPOSURE IN LEFT VENTRICULAR LEAD PLACEMENT Heist EK; Valderrabano M; More R; Ryu K; Greenberg S Massachusetts General Hospital, Boston, MA Introduction: CRT implantation is often associated with extended fluoroscopy time and results in radiation exposure to physicians, patients, and staff. A novel 3D electromagnetic navigation system (MediGuide™, St. Jude Medical, St. Paul, MN) can be utilized to facilitate lead delivery with minimal fluoroscopy using specialized sensor‐enabled delivery tools. We report on our initial experience with the MediGuide™ system and tools, and its effect on reducing fluoroscopy time and radiation exposure during placement of left ventricular (LV) leads. Methods: In six canines, LV lead placement was performed by three operators in one or more coronary sinus (CS) branches using both Conventional (Conv) and MediGuide™ approaches in random order. The Conv implant used traditional tools – 0.014 CPS Courier® Guidewire, CPS Aim® inner and CPS Direct® outer catheters (St. Jude Medical, Sylmar, CA) and the MediGuide™ system implant used sensor‐enabled equivalent tools. Total fluoroscopy time, radiation exposure and lead delivery time were recorded from the time of CS cannulation to the time of final LV lead placement. For statistical evaluation, two‐sided Wilcoxon Signed Rank Sum Test was used. Results: The LV lead was successfully placed in 11 CS branches in 6 canines (1.8 ± 0.8 branches/canine) using both methods. The MediGuide™ system resulted in a 93% reduction in median values of fluoroscopy time (P = 0.001, 0.9 ± 2.0 [median = 0.1] vs 2.2 ± 2.0 [median = 1.5] min) and a 94% reduction in median values of radiation exposure (P = 0.005, 13.8 ± 32.5 [median = 1.7] vs 49.5 ± 45.3 [median = 27.2] uGym2), as measured by dose‐area product. Lead delivery times were similar (MediGuide™:237 ± 193 vs Conv: 186 ± 117 sec, P = 0.27) between the two methods. Conclusions: The MediGuide™ navigation system significantly reduced total fluoroscopy time and radiation exposure during LV lead implantation without compromising final lead location or total procedure time compared to the Conv implant strategy. P102 A NOVEL 3D ELECTROMAGNETIC NAVIGATION SYSTEM IS ACCURATE AND RELIABLE FOR LEFT VENTRICULAR LEAD PLACEMENT WITHOUT FLUOROSCOPY GUIDANCE Valderrabano M; Greenberg S; More R; Ryu K; Heist EK The Methodist Hospital System, Houston, TX Introduction: Fluoroscopic exposure during left ventricular (LV) lead placement remains a major concern. A novel 3D electromagnetic navigation system (MediGuide™, St. Jude Medical, St. Paul, MN) was developed to minimize fluoroscopic exposure by displaying the real‐time location of sensor embedded delivery tools superimposed on pre‐recorded coronary sinus (CS) venograms. We report on the accuracy and reliability of the MediGuide™ system in an in vivo setting with varying heart rates and C‐arm angulations. Methods: In six canines, CS venograms were obtained in three different fluoroscopic projections (RAO, LAO, AP) at three different heart rates (range: 60–140 bpm) for each projection. A MediGuide™ sensor embedded into a 0.014 guidewire was then introduced sequentially into two distinct CS branches. Location of the guidewire sensor detected by MediGuide™ was projected in real time on the pre‐recorded venograms and recorded as a movie file during pacing at the same rates that were used for venogram acquisition. The performance of the MediGuide™ system was assessed by analyzing the displacement between the projected sensor icon and the CS target branch on individual movie frames over three consecutive cardiac cycles. Results: In all six canines, the MediGuide™ sensor‐enabled guidewire could be visualized and tracked without fluoroscopy. The sensor icon was displayed within 1.7 mm of the target branch 90% of the time for all C‐arm angulations and heart rates. The MediGuide™ system accuracy was not affected by heart rate variations up to ± 30 bpm from the original rate that was used to acquire the venogram. In addition, the accuracy results were not affected by various C‐arm angulations (90% Quantiles – RAO: 1.3 mm; LAO: 1.7 mm; and AP: 2.0 mm). Conclusions: The MediGuide™ system provided accurate and reliable tracking of sensor‐enabled tools at various heart rates and C‐arm angulations for LV lead placements without fluoroscopy guidance. CHANNELOPATHIES P103 LIMITED VALUE OF INTRA‐CARDIAC ELECTROPHYSIOLOGICAL STUDY (EPY) IN SCD RISK EVALUATION IN PATIENTS WITH INHERITED ARRHYTHMIAS Zaklyazminskaya EV; Podolyak DG; Shestak AG; Nechaenko AM; Dzemeshkevich SL Perovsky Russian Research Centre of Surgery RAMS Background: Intracardiac electrophysiological (EP) study is considered as one of the methods to evaluate the risk of malignant cardiac arrhythmias and sudden cardiac death (SCD). But the predictive value of this method is still under the question. Material and Methods: Invasive EP study with 3 consequent extra‐stimuli was performed using CardioLab 4,0 Pruca installation. Genetic screening included direct Senger sequencing of SCN5A, KCNQ1, KCNH2, KCNE1, TRPM4, MOG1 and KCNE2 genes. Results and Discussion: We did perform EP study in 4 index patients with inherited arrhythmic syndromes. One patient (21 y.o., female, SCD case in the family) had idiopathic ventricular tachycardia with moderate shortening of QT interval till 390 ms. Three patients (males 38 y.o., 40 y.o., and 44 y.o.) had genetically confirmed Brugada syndrome with spontaneous Brugada type‐1 ECG. Patients were carriers of p.Y87C, p.R893H, and p.S1787N mutations in SCN5A gene. We failed to induce ventricular tachycardia in those patients. Nevertheless, for 3 patients ICDs were implanted, and one patient with p.Y87C mutation in SCN5A refuse the ICD implantation. During 1 year of follow‐up female patient had 2 appropriate shocks, male patients with Brugada syndrome did not experienced any shocks for now. Conclusion: We suspect that patients with lack of inducible ventricular tachycardia during EP study cannot be definitely considered at low‐risk of SCD. Presence of strong familial history of sudden death or genetic confirmation of diagnosis has to be taken into account in decision‐making about ICD implantation. This study was partly supported by grant No02740110783, Russian Ministry of Education and Science. P104 FAMILIAL SUDDEN NOCTURNAL CARDIAC DEATH ASSOCIATED WITH J WAVES AND ST SEGMENT ELEVATION PREDOMINANTLY IN INFERIOR AND LATERAL LEADS: EARLY RIPOLARIZATION SYNDROME OR BRUGADA VARIANT? Menichetti F*; Ottonelli AG; Svetlich C; Lilli A; Magnacca M; Chioccioli M; Casolo G Cardiology Unit, Versilia Hospital, Italy. *Cardiology Unit, University of Pisa, Italy A 43‐year‐old man with a family history of sudden nocturnal death (his father, his brother and his cousin died respectively at the age of 35, 49 and 50 year‐old) was presented to our Hospital for cardiologic evaluation. Before any further examination, the cardiologist drew the family tree and observed some correspondences: all died patients were male and had experienced SCD during night‐time. The authors could examine the ECG for one of them, revealing an ER pattern with prominent J waves in infero‐lateral leads. This ECG alteration was also observed in other six living family members who started a medical screening for arrhythmogenic cardiomyopathy: no structural heart disease was found at MRI scan. All these features are very similar to those which belong to Brugada Syndrome patients (sudden death syndrome associated with right bundle branch block and ST elevation in V1 trough V3), except that J wave and ST segment elevation was not seen in the right precordial leads, but rather in the inferior and lateral leads. All patients were tested with sodium channel blockers (Ajmalina) infusion, but none ECG conversion was observed. After one year, all patients were free from syncope, chest pain and palpitations, but a very close follow up is still going on and they were referred for improved genetic analysis, looking for specific channel mutations. A growing number of case reports and case‐control studies indicate that at some instances, ER is associated with increased risk of idiopathic ventricular fibrillation. Our report further strengthens the hypothesis of a causal relationship between ER and family sudden nocturnal death and suggests to consider ER as a variant of Brugada syndrome. The authors hope that his case report can stimulate investigators to address the many unresolved questions in this rapidly evolving field. P105 A CASE REPORT OF BRUGADA SYNDROM PATIENT WHO TAKES QUININE AFTER BEING IMPLANTED ICD Dong J; Sun J; Zhang Z; Yuan Y; Feng L; Deng Z Department of Cardiology Zhong Shan People's Hospital, Guangdong, China Background: The Brugada syndrome (BrS) is regarded as a rare genetic disease importantly because of the mutation of SCN5A nowadays. It easily causes unexpected sudden cardiac death by malignant ventricular arrhythmia. The effective treatment is the Implantation of ICD which is an external cardiac defibrillator automatically. Quinidine is the effective durg which is an Ito retardant of sodium channel. Quinine is a levorotatory form of Quinidine. Methods: To observe occurrence of malignant ventricular arrhythmia in one patient with Brugada syndrome who was implanted ICD in Jun in 2006. From Jun of 2006 to July of 2009, metoprolol and Amiodarone had been regularly taken also. During that time, there were total 15 times Ventricular tachycardia or ventricular fibrillation events. So metoprolol and Amiodarone were stopped by the patient himself. Then Quinine which is regarded as Quinidine by himself was took. It was regularly took from 200 mg to 600 mg each day. The patient voluntarily takes it about 2 years for no recurrence of malignant ventricular arrhythmia. The Quinine is produced by Actavis in England. Results: Malignant ventricular arrhythmia never recurs from July in 2009 by now and his ECG is changed. Conclusions: Quinine is possibly as effective as Quinidine to Brugada syndrome. But it is need to make further investigation. ECG P106 ALTERATIONS IN ATRIAL ELECTROPHYSIOLOGY AFTER HEMODIALYSIS: AN ANALYSIS OF THE P WAVE DURATION AND P WAVE DURATION AMONG CHRONIC KIDNEY DISEASE PATIENTS IN THE UNIVERSITY OF SANTO TOMAS HOSPITAL (USTH) Ona RL; Ramirez MF University of Santo Tomas Hospital, Espana, Manila, Philippines Hemodialysis causes significant changes in hemodynamic status and metabolic milieu in chronic kidney disease (CKD) patients. Electrocardiographic parameters which reflect atrial electrophysiology, exemplified by p wave duration and p wave dispersion, may indirectly reflect these hemodynamic and metabolic changes. Prolonged P‐wave duration (Pmax) has been shown in some studies to be a useful predictor of atrial fibrillation development in various clinical settings. This study aimed to determine the effect of hemodialysis on the p wave duration and p wave dispersion among patients with CKD. This is a prospective study of patients undergoing hemodialysis at the USTH. A 12 L ECG at a standard rate of 25 mm/sec was taken before and immediately after the hemodialysis. P wave duration (Pmax) was measured with electronic digital caliper in all 12 leads by one observer. P wave dispersion (Pwd) was measured. Pmax and Pwd were compared pre and post dialysis using paired student's T‐test. A total of 43 CKD patients with mean age of 55.23 ± 14.3 (age range 22–86 years old), 20 males and 23 females were included in the study. Mean pre‐dialysis Pmax was 72.44 ± 6.58. Mean Post dialysis Pmax was 75.39 ± 8.86. The mean difference between pre‐dialysis and post dialysis Pmax was −2.95 ± 5.55 (P 0.001). Mean pre‐dialysis Pwd was 15.51 ± 5.64. Mean post dialysis Pwd was 19.51 ± 7.29. The mean difference between pre‐dialysis and post‐dialysis Pwd was‐4 ± 6.2 (P0.0001). Among CKD patients undergoing hemodialysis, in our study p wave duration and p wave dispersion significantly increased after hemodialysis indicating prolongation of atrial conduction time. Longer duration of hemodialysis and increase in the amount of ultrafiltrate significantly increase the maximum p wave duration and p wave dispersion. These findings may suggest that the observed p wave prolongation is most likely due to changes in metabolic milieu rather than effect of extracellular volume changes. P107 THE 12‐LEAD ECG IN PERIPARTUM CARDIOMYOPATHY Tibazarwa K; Lee G; Mayosi BM; Carrington MJ; Stewart SS; Sliwa K Hatter Institute for Cardiovascular Research in Africa, University of Cape Town Background: The prognostic value of the 12‐lead electrocardiogram (ECG) in the deadly syndrome of peripartum cardiomyopathy (PPCM) is unknown. Aim: To determine the prevalence of major and minor ECG abnormalities in PPCM patients on diagnosis, and to identify any ECG correlates of persistent LV dysfunction and/or clinical stability at six‐months follow‐up, where available. Methods: 12‐Lead ECGs were performed on 78 consecutive PPCM patients presenting to two tertiary centres in South Africa on diagnosis, and 44 cases at six‐month follow‐up. Blinded Minnesota coding identified major ECG abnormalities and minor ECG changes. Results: The cohort mainly comprised young Black‐African women (mean age 29 ± 7 years and median body mass index of 24.3 [IQR 22.7–27.5]kg/m2). The majority of cases (n = 70, 90%) presented in sinus rhythm (mean heart rate 100 ± 21 beats/min). At baseline, at least one ECG abnormality/variant was detected in 96% of cases. Major ECG abnormalities and minor variations were detected in 49% (95%CI 37–60%) and 62% (95%CI 51–74%) of cases, respectively; the most common being T‐wave changes (59%), p‐wave abnormality (29%) and QRS‐axis deviation (25%). Of the 44 cases (56%) reviewed at 6‐months, normalisation of the 12‐lead ECG occurred in 25%; the most labile ECG features being heart rate (mean reduction of 27 beats per min; P < 0.001) and abnormal QRS‐axis (36% vs. 14%; p = 0.014). On adjustment, major T‐wave abnormalities on the baseline 12‐lead ECG were associated with lower left ventricular ejection fraction (LVEF) at baseline (average of −9%, 95%CI −1 to −16; p = 0.03) and at six‐months (‐12%; 95%CI −4 to −24; p = 0.006). Similarly, baseline ST‐segment elevation was associated with lower LVEF at six‐months (‐25%; 95%CI −0.7 to −50; p = 0.04). Conclusions: This unique study shows almost all women with PPCM have an "abnormal□ 12‐lead ECG. Pending more definitive studies, the ECG appears useful as both a screening and prognostic tool in resource‐poor settings. P108 INFLAMMATION MODULATES VENTRICULAR REPOLARIZATION IN CHILDREN WITH KAWASAKI DISEASE Fujino M; Kuriki M; Horio K; Omeki Y; Uchida H; Eryu Y; Boda H; Miyata M; Hata T; Yamazaki T Fujita Health University Introduction: The instability of myocardial repolarization is generally mediated by myocardial failure. We assessed the hypothesis that transmural dispersion of repolarization is increased in the inflamed myocardium in patients with acute‐phase Kawasaki disease. Method: Consecutive 27 infants (M:F = 15:12) with Kawasaki disease aged 2.6 ± 2.2 years and age‐matched control infants were included. RR interval, QT interval and Tp‐e time (CM5 lead) were calculated using analysis software (Acqknowledge Ver. 3.9, Biopac Systems Inc., CA, USA). Tp‐e time was corrected by Fridericia equation (Tp‐eC). These parameters were compared in the acute phase (6.9 ± 3.0 days after onset) and recovery phase (23.0 ± 13.3 days after onset) or control. The relationship between Tp‐e/QT, Tp‐eC and C reactive protein, body temperature on admission were evaluated by regression analysis. Results: 1) The Tp‐e/QT in the acute phase were significantly higher than that in the recovery phase and control group (P < 0.05, P < 0.005, respectively).2) The Tp‐eC in the acute phase was significantly higher than that in the recovery phase and control group (P < 0.05, P < 0.01, respectively).3) In acute phase, significant positive correlation was observed between Tp‐e/QT and C reactive protein or body temperature (r = 0.677 and 0.672, respectively). Further, between Tp‐eC and C reactive protein or body temperature (r = 0.482 and 0.583, respectively). Conclusions: Transmural dispersion of repolarization assessed by Tp‐e/QT and Tp‐eC was increased by inflammation in the acute phase of Kawasaki disease, which exhibits the sub‐clinical lability of ventricular repolarization. These repolarization properties of the myocardium were considered a useful indicator to assess arrhythmogenesis in patients with Kawasaki disease. P109 FRAGMENTED ECG IN CHAGAS' CARDIOMYOPATHY (FECHA STUDY) Rodriguez C; Baranchuk A; Femenia F; Lopez‐Diez JC; Muratore C; Valentino M; Retyk E; Galizio N; Di Toro D; Alonso K; on behalf of the FECHA Study Investigators IECTAS Maracaibo, Venezuela Background: Implantable cardioverter defibrillators (ICD) proven to be an effective therapy to prevent sudden death in patients with CChC. Identification of predictors of appropriate therapies delivered by the ICD remains a challenge. Aims: To determine whether surface fragmented ECG helps in identifying patients with CChC and ICDs at higher risk of presenting appropriate ICD therapies. Methods: Retrospective study involving 14 centers from Latin America. All patients with CChC and ICDs were analyzed. Pacing dependent patients were excluded. Clinical demographics, surface ECG and ICD therapies were collected. Bivariate and multivariate analyses analysis were performed. Results: A total of 98 patients from 14 Latin American centers were analyzed. Four cases were excluded due to pacing dependency.63.8% were male, mean age was 55.4 ± 10.4 years old (26/75), mean LVEF was 39.6 ± 11.8%. Secondary prophylaxis was the reason for implanting in 71.3% of the cases. Fragmented surface ECG was found in 56 patients (59.6%). Location of fragmentation was inferior in 57.1%, lateral 35.7% and anterior 44.6%. Rsr pattern was the more prevalent (57.1%). Predictors of appropriate therapy in the multivariate model were: increased age (p = 0.01), secondary prevention indication (p = 0.01) and ventricular pacing >50% of the time (p = 0.004). Male gender presented a positive trend (p = 0.07). The presence of surface ECG fractionation did not identify patients at higher risk of presenting appropriate therapies delivered by the ICD (p = 0.87); regardless of QRS interval duration. Conclusions: Fragmented surface ECG is highly prevalent among patients with CChC. It has been found to be a poor predictor of appropriate therapies delivered by the ICD in this population. P110 THE ASSOCIATION BETWEEN MYOCARDIAL IRON LOAD AND VENTRICULAR REPOLARIZATION PARAMETERS IN ASYMPTOMATIC BETA‐THALASSEMIA PATIENTS Kayrak M; Gul EE; Acar K; Abdulhalikov T; Ozbek O; Kaya Z; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Previous studies have demonstrated impaired ventricular repolarization in patients with β‐TM. However, the effect of iron overload with cardiac T2* magnetic resonance imaging (MRI) on cardiac repolarization remains unclear yet. We aimed to examine relationship between repolarization parameters and iron loading using cardiac T2*MRI in asymptomatic β‐TM patients. Methods‐Materials: Twenty‐two β‐TM patients and 22 age and gender matched healthy controls were enrolled to the study. From the 12‐lead surface electrocardiography, regional (QT duration, corrected QT duration, QT dispersion, corrected QT dispersion) and transmyocardial (T peak to T end interval, T peak to T end dispersion, and [T peak‐T end]/QT ratio) repolarization parameters were evaluated digitally by two experienced cardiologists. All patients were also undergone MRI for cardiac T2* evaluation. Main Results: Of the QT parameters, QT duration, corrected QT interval, and QT peak duration were significantly longer in the β‐TM group compared to the healthy controls. Tp‐Te and Tp‐Te dispersion were significantly prolonged in β‐TM group compared to healthy controls (p = 0.02 and p = 0.03, respectively). Only (Tp‐Te)/QT was similar between groups (p = 0.32). There was no any correlation between cardiac T2* scores and repolarization parameters. Conclusion: Although repolarization parameters were prolonged in asymptomatic β‐TM patients, this prolongation were not correlated with cardiac iron overload. P111 ELECTROCARDIOGRAPHIC LATE POTENTIAL RATES ARE SIGNIFICANTLY INCREASED IN RHEUMATOID ARTHRITIS PATIENTS FREE OF ATHEROSCLEROTIC RISK FACTORS WITH PRESERVED LEFT VENTRICULAR FUNCTION Canataroglu A; Tekin K; Cagliyan CE; Ortoglu G; Tufan MA; Sahin DY; Koc M; Sakalli H Adana Numune Training and Research Hospital, Departement of Rheumatology Aim: Sudden cardiac death (SCD) and conduction disturbances due to atherosclerosis is a common manifestation of Rheumatoid Arthritis (RA). Objective of this study is to investigate electrocardiographic late potentials (LP) by using signal averaged electrocardiogram (SAECG) in patients with RA with no traditional atherosclerotic risk factors. Presence of LP's had been considered as a substrate for increased SCD in patients with cardiovascular disease. There is no previous study investigating LP's in RA patients. Methods: A total of 34 patients with RA (RA Group) and 32 healthy controls had been included in our study. All of the RA patients and controls had neither history of cardiovascular disease nor cardiac risk factors. SAECG recordings and calculations were made due to Simson method in all of them. Individuals positive for the following 2 of 3 criteria were considered to have electrocardiographic late potential (LP): 1. Filtered QRS duration (FQRS) > 110 ms 2. Root mean square voltage (RMS) in the last 40 ms < 25 mV and 3. Low amplitude duration (LAD) < 40 mv of > 38 ms. Results: SAECG calculations were made from a mean of 350 cardiac cycles and mean noise level was 0.79 ± 0.22 mV. Continous variables were compared by using t test.FQRS levels were significantly higher (82.14 ± 11.6 mV vs 77.00 ± 8.4 mV; p: 0.044) in the RA group. RMS levels were lower (63.51 ± 43.7 vs 82.87 ± 35.6 mV; p: 0.052) and LAD levels were higher (28.93 ± 12.0 vs 25.25 ± 6.5 ms; p: 0.124) in RA group, and the differences weren't statistically significant. Electrocardiographic LP's were observed in 12 patients with RA whereas none of the controls had LP'S (35.3% vs 0%; P < 0.001). Conclusion: Cardiac LP's seem to be significantly increased in RA patients free of traditional atherosclerotic risk factors with preserved left ventricular function. Carefully designed prospective studies including higher numbers of this patient group are needed for more accurate results. P112 ELECTROCARDIOGRAPHIC P WAVE CHARACTERISTICS IN PATIENTS WITH THALASSEMIA MAJOR: P‐INDEX AND INTERATRIAL BLOCK Kayrak M; Acar K; Gul EE; Abdulhalikov T; Ozbek O; Ucar R; Alibaşiç H; Cardiology/Arrhythmia Selcuk University, Meram School of Medicine, Cardiology Department, Konya, Turkey Background: Although previous studies have documented a variety of electrocardiogram abnormalities in beta‐thalassemia major (β‐TM), little is known about P‐wave indices (P max, P min, and P dispersion), an independent risk factor for development of atrial fibrillation (AF). P index (Pi) and interatrial block (IAB) as novel parameters may more accurately predict AF and has not been previously investigated in β‐TM patients. We aimed to examine relationship between P‐wave parameters (traditional and novel) and iron loading using cardiac T2*MRI in asymptomatic β‐TM patients. Methods‐Materials: Twenty‐two β‐TM patients and 22 age and gender‐matched healthy controls were enrolled to the study. P‐wave duration was measured in all 12‐leads of the surface ECG. The difference between maximum and minimum P‐wave durations was defined as Pd. The standard deviation of the P‐wave duration across the 12 ECG leads accepted as a Pi. P wave duration above and equal 110 milliseconds was defined as interatrial block (IAB). All P‐wave parameters were evaluated digitally by two observers. All patients were also undergone MRI for cardiac T2* evaluation. Cardiac T2* score under 20 msec was considered as iron overload status. Main Results: P max, P min, and P index were significantly prolonged in the β‐TM group compared to the healthy controls (p = 0.005, p = 0.014, and p = 0.034, respectively). Only P disp was found similar between groups (p = 0.46). The prevalence of IAB was 41% and 73% in patients with β‐TM and healthy controls (p = 0.033). P‐wave parameters of patients with cardiac T2*<20 msec and T2*≥ 20 msec were comparable in patients with β‐TM. There was no correlation between P‐wave parameters and cardiac T2*MRI values. Conclusion: The present study demonstrated that Pi and IAB frequency were increased in patients with β‐TM. These novel parameters may be useful measurement tools in predicting AF in the recent group. P113 ASSOCIATION OF P WAVE DURATION AND DISPERSION WITH BLOOD PRESSURE RESPONSE TO EXERCISE IN NON‐HYPERTENSIVE PATIENTS Yao RC; Mancera JR; Asido CD; Ramirez MF University of Santo Tomas Hospital Objective: We hypothesize that hypertensive blood pressure responses to exercise stress test may be associated with prolonged P‐wave indices among non‐hypertensive patients. Methodology: Non‐hypertensive patients without known structural heart disease 18 years old and above with negative stress tests were included. Resting 12‐lead ECG at a paper speed of 25mm/s and 1mV/cm were recorded. An electronic caliper was used to measure P‐wave duration and dispersion. Patients were classified into normal systolic blood pressure (SBP), normal diastolic blood pressure (DBP), hypertensive SBP, and hypertensive DBP groups. Mean P‐wave indices were compared using independent samples T test. Results: 76 patients were eligible with mean age of 43.77 ± 12.16. 46% were male; 12.7%, smokers; 7.6%, diabetic; and 21.5%, dyslipidemic. Mean P‐wave dispersion in the hypertensive SBP group was higher than the normal SBP group (0.0512 ± 0.0234 vs 0.0386 ± 0.0200 P = 0.032). No significant difference in P‐wave dispersion between the hypertensive DBP and normal DBP groups was seen. P‐wave duration was prolonged in the hypertensive DBP group (0.113 ± 0.0147 vs 0.103 ± 0.0142 P = 0.031). Conclusion: Among non‐hypertensive patients, hypertensive systolic blood pressure response to exercise was associated with more prolonged P‐wave dispersion while hypertensive diastolic blood pressure response to exercise was associated with more prolonged P‐wave duration. P114 INFLUENCE OF THE ELECTRICAL AXIS OF THE HEART TO QRS DURATION AFTER BIVENTRICULAR PACEMAKER IMPLANTATION Kazakevicius T; Zabiela V; Kazakevicius L; Sileikis V; Sedlickaite D; Puodziukynas A Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania Background: Biventricular (BiV) pacing is indicated for treatment of heart failure patients with interventricular or intraventricular dyssynchrony and left bundle branch block (LBBB). Shortening of QRS duration is expected during implantation of BiV pacemaker. We observed differences in changes of QRS morphology, duration and electrical axis before and during simultaneous, left and right ventricle pacing. Aim of our study was to find correlation between these parameters. Methods: Electrical axis of the heart (QRS vector) was calculated using mathematical formula of P.N.Singh and M.Sajjad Athar Tanθ== (I+2III)/(I√3) before pacemaker implantation, during left (LV), right (RV) and simultaneous (BiV) ventricle pacing. Correlation was calculated between axis and duration of QRS complex. Results: Duration of QRS complex changed in all 27 consecutive patients with statistically significant (P < 0.001) mean difference 43.7 ± 10.6 ms. Observed correlation between QRS complex width during BiV pacing and following parameters: 1Electrical axis of preoperative (initial) QRS complex (correlation coefficient was −0.87),2Preoperative duration of QRS complex (correlation coefficient was +0.92),3Duration of QRS complex during LV pacing (correlation coefficient was +0.93). Best results (narrowness of QRS) were achieved when QRS axis before implantation was between 60° and 76°– normal or slightly to the right axis (37.5% of patients) then the QRS with LBBB and left axis morphology. Conclusions: According to our data LBBB and normal axis morphology of preoperative QRS complex predispose greater narrowing of QRS complex after implantation of biventricular pacemaker. Duration of preoperative and LV pacing QRS depends on ventricular conduction properties and has influence for postoperative QRS duration. P115 DAILY MONITORING OF ELECTROCARDIOGRAM IN DIAGNOSTICS OF PARASYSTOLES IN CHILDREN Dolgikh VV; Zurbanov AV; Denisova TV; Rychkova LV Scientific Centre of Family Health and Human Reproduction Problems of Siberian Brunsh of RAMS The Aim: To evaluate the frequency of parasystoles in the structure of the heterotropic heart rhythm disorders among children and adolescents. Materials and Methods: We surveyed 125 children aged 7–17 years with the idiopathic extrasystoles. All patients were examined by electrocardiography (ECG) in 12 standard leads and it was done 24‐hour monitoring ECG. The Results: According to the results of standard ECG in 81 children was found supraventricular extrasystoles, in 44 children – ventricular extrasystoles. Parasystolic signs, namely: the coupling interval variability, fusion complexes, multiplicity of interectopic intervals were found on standard ECG with 15 children (12%). Ectopic inflow in this group registered in atrioventricular node in one child (0.8%). 14 (11.2%) children has the diagnosis of ventricular parasystole. It should be noted that the multiplicity of the interectopic intervals on the standard ECG happened only among 3 people. Long‐term ECG recording complemented our group of surveyed with parasystoles, which con‐sisted of 4 children with ventricular and 1 child with atrial parasystole and parasystoles from atrio‐ventricular node. Thus, the total number of patients with parasystoles was 21 (16.8%). According to the daily monitoring, the number of registered parasystoles, with account fusion complexes was from 5 to 13 thousand per day. The coupling interval variability had increased significantly compared to the standard ECG and ranged from 100 to 230 msec, an average of 140 msec. Conclusion: therefore, the results showed a significant prevalence of parasystoles, as well as advantage of daily monitoring in the diagnosis of this dysrhythmia. P116 ACUTE EFFECTS OF ENERGY DRINK ON CARDIOVASCULAR FUNCTION AND ELECTROCARDIOGRAPHIC PARAMETERS AMONG HEALTHY YOUNG ADULTS Elcano JW; Ramboyong RE; Ramirez MF The Medical City Background: Energy drinks are consumed by teens, young adults, athletes and medical students at an alarming rate despite their unproven safety. The reported association of energy drinks to arrhythmias after its consumption remain controversial. The purpose of this study was to determine if consumption of energy drink among healthy young adults was associated with any acute cardiovascular physiologic effects as measured by blood pressure (BP), heart rate and electrocardiographic (ECG) parameters that are markers of increased arrhythmia risk. Method: A total of 103 healthy young adults were randomized to either an energy drink or placebo. Heart rate, blood pressure and ECG were taken immediately before, thirty minutes, one hour and two hours after consumption of the assigned beverage. P wave dispersion (PWD), P wave variability, QT interval, corrected QT interval (QTI rc), RR interval, QRS duration and morphology, and the presence of ST changes relative to the isoelectric line, T wave inversions, Atrial premature complexes (APCs) and Ventricular premature complexes (PVCs) were accounted for. Results: Both systolic and diastolic blood pressure were significantly increased in the treatment compared to placebo group at thirty minutes, one hour, and two hours, but there was no significant difference in the heart rate for all time frames. The PWD values were significantly longer in the treatment group at thirty minutes. There were no statistically significant differences in the QRS duration and QT interval between placebo and treatment. Two subjects developed premature ventricular complexes at one hour and two hours post energy drink ingestion. There were no ST segment shifts nor T wave inversions noted. Conclusion: These results suggest that acute ingestion of energy drink can cause systolic and diastolic BP elevation but no significant change in heart rate. No significant arrhythmia was observed in our study. P117 ST SEGMENT DEPRESION MORPHOLOGIES DURING SUPRAVENTRICULAR TACHYACRDIA Scazzuso FA; Rivera S; Gomez L; Albina G; Laino R; Sammartino V; Giniger A Instituto Cardiovascular de Buenos Aires (ICBA) Objetive: ST segment depression is a known high risk marker in coronary syndromes. It's value remains unknown in the presence of certain arrhythmias. The aim of this study is to determine the different morphologies in ST depression and its prevalence during supraventricular tachycardia (SVT). Method: Patients selected for paroxysmal SVT radiofrequency ablation were included. Only nodal re‐entrant tachycardia was included without bundle Branch block or other arrhythmias. CAD history and coronary risk factors were analyzed. ST segment depression was defined as equal or greater than 0.1 mv measured 80 ms after J deflection in more than one contiguous leads. Horizontal and descendent morphologies were considered pathologic and ascendant ST depression as normal. We compared the group which developed pathologic ST segment depression and normal. Results: A total of 162 patients, (age 48 ± 17 years, 67.6% female, 41.89% showed coronary risk factors and 8.78% coronary artery disease history); 39.86% presented STD (10.13% ascendant, 6.81% descendent and 25.67% horizontal). The group that did not developed STD presented a higher mean age, coronary risk factors and coronary artery disease history. The group that developed STD were younger (45 ± 17 vs. 50 ± 16 years, p = 0.05) with less CRF (49.51% vs.25%, p = 0.04) and the arrhythmia had a shorter cycle length (258.99 mseg vs. 343.46 mseg, p = 0.05). Pathological STD was observed in 44 cases (29.72%); those presenting this condition were even younger compared to the ones with non pathological STD or without STD (43 ± 17 vs. 50 ± 16 years, p = 0.03) and had a higher prevalence of female sex (78% vs. 63%, p = 0.09). Conclusion: These results suggest that STD is a length cycle phenomenon and it is most commonly seen in healthier populations, questioning its value as a high risk marker in certain arrhythmias. This result should be analyzed in further prospective trials. P118 HAVE FRAGMENTED QRS ANY PROGNOSTIC VALUE IN CRT‐D PATIENTS? Cipolletta L; Luzi M; Brambatti M; Guerra F; Matassini MV; Capucci A Cardiologic Clinic, Università Politecnica delle Marche, Ancona, Italy Fragmented‐QRS on electrocardiogram (ECG) is a marker of depolarization abnormality that can be correlated with a higher risk of sudden cardiac death. The purpose of this study is to analyze the responsiveness to CRT‐D and cardiac event rate in patients with fragmented‐QRS. We studied 58 patients, candidated to CRT‐D(mean age 70.8 ± 6.8 years, mean EF 24 ± 9%, NYHA III) with an echocardiogram and a 12‐lead ECG before and after implant. 3 readers, blinded to clinical outcome, analyzed ECG. Fragmented‐QRS in narrow QRS were defined as: presence of a notching in R or S wave in two or more contiguous leads. Fragmented‐QRS in patients with wide QRS were defined as ≥2 notches in the R or the S wave. Non‐responders were defined as patients with no improvement of NYHA class and no increase of ejection fraction (EF) at 3 months >10% than baseline. Interventricular dyssynchrony was measured considered an aorto‐pulmonary pre‐ejection delay >40 msec. Spontaneous fragmented‐QRS prevalence was 66% in all patients; stimulated fragmented‐QRS prevalence was 52% in ischemic and 59% in non‐ischemic patients. Elderly (≥65 years) have a 2.8‐fold higher risk to have a stimulated fragmented‐QRS (p = 0.005). At 6 months follow‐up, the incidence of non‐responders to CRT is higher in patients with stimulated fragmented‐QRS (88% vs 45%; p = 0.031). Patients with spontaneous non‐fragmented‐QRS have a greater reduction of left ventricular dyssynchrony (‐34.9 ± 11.7 ms vs −11.3 ± 26.0 ms, p = 0.030); patients without stimulated fragmented‐QRS showed a greater increase of left‐ventricular EF (12.9 ± 12.3% vs 6.23 ± 9.7%, p = 0.009) at 6 months. In our study fragmented‐QRS is not predictive of arrhythmic events. Non‐fragmented QRS is associated with an improvement of echocardiographic parameters, thus it could be a good marker in identifying responders. Instead, the persistence of stimulated fragmented‐QRS is associated with lack of response to CRT making this subgroup less likely to benefit from CRT. GENETICS P119 COMMON NOS1AP GENETIC VARIANT IS ASSOCIATED WITH SUDDEN CARDIAC DEATH IN DCM AND ALL‐CAUSE DEATH IN ICM Pei J; Che J; Zhan Y; Pu J State Key Lab Translational Cardiovascular Medicine, Cardiovascular Institute and Fu Wai Hospital Background: QT interval duration was an intermediate phenotype for sudden cardiac death (SCD) and a surrogate marker of SCD risk. Recent studies have shown that genetic variations in affecting QT interval and occurrence of cardiac events in healthy subjects and CAD respectively. Objective: We set to investigate whether the affecting QT interval gene variants are related to SCD in patients with CHF in a prospective study of Chinese Han populations. Methods: Using haplotype tagging SNPs (htSNPs) to choose 6 SNPs of three candidate‐genes (KCNJ2, KCNJ11, NOS1AP) in modulating QT interval. 6 marker SNPs were genotyped to assess the effect of variant alleles on QTc and the association with SCD risk in patients with CHF. Results: The successful follow‐up rate was 86.06%(1117 cases) including 303 (85.59%) cases of DCM and 814 (86.29%) cases of ICM with the median follow‐up time of 48 months (0.58∼70 months). 298 (26.68%) cases died in total, including 133 cases of DCM and 215 cases of ICM. Of them 60 cases (45.11%)of DCM and 67 cases (40.6%)of ICM had SCD. We found that the A allele of rs12567209 in NOS1AP was significantly not associated with adjusted QT interval in additive model but involved in the prognosis of CHF. After adjusting for age, gender, and suspected risk factors, patients carrying the A allele of rs12567209 had an increased risk of SCD (HR with 4.165 for 95% CI 2.052–10.382) and cardiac death (HR with 1.893 for 95% CI 1.205–3.887) in DCM. However, in ICM patients carrying the A allele of rs12567209 was only associated with cardiac death (HR with 1.524 for 95% CI 1.278–1.78). Conclusions: The A allele of rs12567209 in NOS1AP is associated with increased risk of SCD in patients with DCM and all‐cause death in ICM. The A allele of rs12567209 in NOS1AP is an independent protective factor against SCD in patients with DCM. Key words: genetics variant; QT interval; sudden cardiac death; predictor P120 A PROTECTIVE ROLE OF KCNE1 G38S POLYMORPHISM AGAINST SUDDEN CARDIAC DEATH IN PATIENTS WITH DILATED CARDIOMYOPATHY Galati F; Galati A; Massari S Department of Biological and Environmental Science and Technologies, University of Salento, Lecce, I Introduction: Dilated cardiomyopathy (DCM) is a myocardial disease with a multifactorial etiology. During recent years it has become evident that genetic factors can play a crucial role in its etiology, pathogenesis and prognosis. So we decided to investigate the effects of G38S polymorphism in the KCNE1 gene, that encodes for the β subunit of Iks potassium channel, in ischemic and idiopathic DCM (EF ≤ 35%). Methods: G38S polymorphism was genotyped by RFLP‐PCR in 132 subjects with idiopathic and ischemic DCM, treated with an ICD for primary prevention of sustained ventricular tachycardia (TV) or ventricular fibrillation (FV). Patients were followed at 6‐month intervals. Results: During a median follow‐up time of 47 ± 13 months, 60 patients (45,5%) developed almost one episode of TV/FV. We observed a prevalence of SS genotype in subjects without life‐threatening arrhythmias, although not statistically significant. Hypertension and diabetes could increase mortality and morbidity in DCM. So we divided our population into two groups, depending on the presence (I group – 78 pts) or absence (II group – 54 pts) of these diseases. Group I didn't show any difference in the distribution of alleles. In group II only 1/25 of homozygous carriers of the S38 allele developed severe ventricular arrhythmias, while 48,00% of GG38 patients (12/25) experienced at least one episode of TV/FV: this distribution was statistically significant (P < 0,05). So the incidence of TV/FV was lower in SS homozygotes (1/10; 10% vs 90%) than in G carriers (24/44; 55% vs 45%– P < 0,025). Conclusion: These results suggest that S38 allele can act as protective factor against malignant arrhythmias in patients with DCM without hypertension and/or diabetes. IMPLANTED CARDIOVERTER DEFIBRILLATORS P121 SURVIVAL, INCIDENCE AND TIME‐DEPENDENCE OF APPROPRIATE THERAPY IN PATIENTS RECEIVING ICDS FOR PRIMARY PREVENTION: LONG‐TERM FOLLOW‐UP IN A TERTIARY SINGLE CENTER Kanoupakis EM; Koutalas EP; Mavrakis HE; Kallergis EM; Saloustros IG; Goudis CA; Psathakis E; Petousis S; Vardas PE Cardiology Dpt, University Hospital of Heraklion Crete Introduction: Despite the increased utilization of ICDs for primary prevention of sudden cardiac death, there is a limited number of long‐term follow‐up data regarding outcomes of this population in a routine clinical practice, outside the context of controlled clinical trials. In the present, analysis we examined the survival, the incidence and time‐dependence of appropriate ICD therapy for ventricular arrhythmias in patients who underwent ICD implantation at our institution. Methods and Results: We acquired data from patients with ischaemic, non‐ischaemic dilated and hypertrophic cardiomyopathy as well as patients with inherited channelopathies who received an ICD from 1996 to 2009 for primary prevention. Of 377 ICD recipients 44 deaths were observed (11.7%). Median survival was 8.9 years (95% CI: 86–95). 87 patients (23.1%) had appropriate ICD therapy. Median shock time was 6.9 years (95% CI: 41–72). Incidence of first appropriate ICD therapy was 7.7% in the first year postimplant, increased to 12.5% in year 2, while in year 5 it was 58.3%. Comparing Kaplan‐Meier curves between ischemic and nonischemic patients, nonischemic patients seem to receive shocks at a significantly higher rate than ischemic patients (p = 0.04). Conclusion: In a routine clinical practice primary prevention population, mortality rate remains low. The risk of first appropriate ICD therapy persists over long lifetime and necessitates continuing device therapy irrespective of shock‐free intervals. P122 INTRAVASCULAR DEFIBRILLATOR (INNERPULSE PICD): IMPLANTATION AND REMOVAL TECHNIQUES Merkely B; Geller L; Molnar L; Neuzil P; Reddy V; Tondo C; Natale A; Bednarek J; Bartus K; Sanders WE, Jr Heart Center Semmelweis University, Budapest, Hungary Background: A percutaneously placed, implantable intravascular defibrillator has been developed (PICD). This is the first defibrillator for which removal techniques were developed in conjunction with a femoral vein implantation method. Objective: This study evaluated the initial implant techniques and tools as well as the acute removal procedure in a canine model. Methods: Ten hounds were anesthetized and a custom sheath was introduced into the femoral vein. Two guidewires were placed in the jugular vein and the PICD advanced via the femoral vein over a wire into the vasculature. Utilizing a delivery catheter the device was positioned such that the titanium electrodes (cathodes) were located in the superior vena cava and the inferior vena cava (IVC). A self‐expanding Nitinol anchor was advanced to the jugular via the second wire and deployed to secure the PICD in the vasculature. With a lead placement catheter the RV coil electrode (anode) was positioned in the RV apex. The catheters and wires were removed with an average implant time of under 18 minutes. For removal, the IVC segment of the PICD was snared utilizing a custom catheter. The RV lead was separated from the body of the PICD by cutting the lead inside a protective sheath. A novel catheter with a surgical cutting wire was then advanced over the device. The PICD was used as a rail to advance the cutting wire to the anchoring region. The silicone segment of the PICD was detached from the Nitinol anchor by the cutting catheter and the entire device was removed via the femoral vein. The RV lead was then snared. A cutting wire was positioned at a specific detachment region at the tip and the lead was cut and removed through the femoral vein. Results: Each procedure, both implant and removal, required less than 20 minutes. All implants and removals were successful with no complications. Conclusions: The PICD can be rapidly and safely implanted and removed in canines. P123 LONG‐TERM RESULTS OF ICD IMPLANTATION Revishvili A; Lomidze N; Neminushiy N Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia Purpose of Study: Is to analyze the efficacy of ICD during long‐term follow‐up, estimate survival of patients with ICD, evaluate complication rate in the immediate and late postoperative periods. Material: 426 ICDs were implanted in our clinic in 1990–2010. Primary implantation was performed in 301 patients, in 125 cases the ICD were replaced because of battery depletion. Second and fourth generation of ICDs with epicardial leads were implanted in 11 patients with help of open chest surgery, for 2 patients from them (IV generation ICD) this methodic was used because of impossibility of transvenous implantation. Results: We evaluated long‐term results of 292 patients (237 male, age 12–82 years, average 50,5 ± 15,3 years, follow‐up period 1–178 months, average 39,9 ± 34,5). During this period 168 pts (57,5%) received ICD therapy, the interval between the implantation and the first therapy was 0,2 – 70 month, average follow‐up time in this group was 24,1 ± 19,3 month, in group of patients who did not get an ICD therapy – 15,5 ± 12,2 month (p = 0,04). Most of episodes of VT were terminated by electrical shocks (156) that were determined by tachycardia behavior and hemodynamic condition of patients. ATP was successful in 68 patients. Multifactorial analysis revealed that the only variable which influenced rate of ICD therapy was left ventricle ejection fraction (LVEF) which in group of patients who got ICD therapy was in the average 41,3 ± 16,8%, and in group of patients who did not get ICD therapy– 57,4 ± 15,7% (P < 0,03). Most important factor effecting survival was LVEF. Generally LVEF was 46,8 ± 15,7%, in deceased – 30,3 ± 16,9% (p = 0,001). Total cumulative proportional survival (Kaplan‐Meier) was 73% during 150 month. Conclusions: In our opinion LVEF is the most significant factor influencing: survival, occurrence of VT, VT number and accordingly occurrence of ICD therapy. P124 SPRINT FIDELIS DEFIBRILLATION LEAD: A NINE‐CENTRE EXPERIENCE IN SPAIN Domínguez‐Pérez L; Arias MA; Jiménez‐López J; Toquero J; Jiménez‐Candil J; Díaz‐Infante E; Tercedor L; Olagüe J; García Fernández J; Rodríguez‐Padial L Department of Cardiology, Hospital Virgen de la Salud Introduction and Objectives: Sprint Fidelis defibrillation leads are prone to early failure. Most of the series reported come from a single institution. This paper describes the clinical experience in nine Spanish hospitals. Methods: Clinical, implant, and follow‐up visits data of all patients with Sprint Fidelis lead were analyzed. All cases of lead failure were identified, medium‐term lead survival was calculated and possible predictors for lead failure were determined. Results: A total of 378 leads in 376 patients were studied. The mean age (male 85.7%) was 64.9 ± 13.6 years. The majority of patients (59.8%) had ischemic heart disease. Mean left ventricular ejection fraction (LVEF) was 0.334 ± 0.1445%. Left subclavian vein puncture was used in 74.8%. During a mean follow‐up of 30.9 ± 14.0 months, 16 lead failures have occurred with a lead survival of 96.1% at 36 months after implantation. Eleven of 16 lead failures were caused by failure of pace/sense conductors, 3 failures were caused by defects in the high‐voltage conductor, and 2 cases were caused by defects in both types of conductors. A less depressed LVEF was associated with an increased probability of lead failure (0.424 ± 16% vs. 0.330 ± 0.143%, p = 0.011). Three hospitals presented a rate of lead failure higher than 10%, being less than 5% in the remaining 6 hospitals. Conclusions: In this multicenter series of 378 leads, the three‐year estimated survival was higher than that reported in prior series. Clinical presentation of lead failures was similar to that reported previously. LVEF and hospital of implantation were variables associated to lead failure. P125 IMPLANTABLE CARDIOVERTER DEFIBRILLATOR THERAPY REDUCES ARRHYTHMIC MORBIDITY AND MORTALITY IN HIGH RISK PATIENTS WITH PRESERVED EJECTION FRACTION Tsiachris D; Gatzoulis KA; Dilaveris P; Arsenos P; Archontakis S; Sideris S; Kartsagoulis E; Vouliotis A; Kallikazaros I; Stefanadis C First Cardiology Clinic, University of Athens Medical School, Hippokration Hospital, Athens, Greece Background: Current guidelines for the primary prevention of sudden cardiac death have used a left ventricular ejection fraction (LVEF) ≤ 35% as a critical point to justify implantable cardioverter defibrillator (ICD) implantation in post myocardial infarction patients and in those with nonischemic dilated cardiomyopathy. We compared mortality and ICD activation rates among different ICD group recipients using a cut‐off value for LVEF ≤ 35%. Methods: We followed up for a mean period of 41.1 months 495 ICD recipients (442 males, 65.6 years old, 68.9% post myocardial infarction patients, 422 with LVEF ≤ 35%). Prevention was considered primary in patients who fulfilled guidelines criteria or had inducible ventricular arrhythmia during programmed ventricular stimulation for patients with LVEF > 35%. Results: Over the course of the trial, 84 of 495 patients died; 69 experienced cardiac death (6 sudden) and 15 non cardiac death. ICD recipients with LVEF ≤ 35% compared to those with preserved LVEF (mean LVEF = 43%) had a greater incidence of total mortality (18% vs. 11%, log rank p = 0.028) and cardiac death (15.4% vs. 5.5%, log rank p = 0.005). There was no difference in the cumulative incidence for appropriate therapy between patients with LVEF ≤ 35% and those with LVEF > 35% (56.9% vs. 65.8%, log rank p = 0.93). Similarly, no difference was observed between the two groups in the incidence of ICD shocks or antitachycardia pacing (34.6% vs. 45.2%, log rank p = 0.35 and 50.2% vs. 57.5%, log rank p = 0.98, respectively). In the multivariate analysis the presence of advanced New York Heart Association stage predicted both total mortality (HR = 2.69, 95% CI 1.771–4.086) and cardiac death (HR = 3.437, 95% CI 2.163–5.463). Conclusions: ICD therapy may protect heart failure patients at early stages from arrhythmic morbidity and mortality, based on an electrophysiology‐guided risk stratification approach. P126 PREDICTORS OF INAPPROPRIATE THERAPY IN PATIENTS WITH IMPLANTABLE CARDIOVERTER‐DEFIBRILLATORS AND CHAGAS' CARDIOMYOPATHY Rodriguez C; Miranda R; Femenia F; Lopez‐Diez JC; Serra JL; Muratore C; Valentino M; Retyk E; Galizio N; Baranchuk A; on behalf of the FECHA Study Investigators IECTAS Maracaibo, Venezuela Introduction: Implantable cardioverter defibrillators (ICD) proven to be an effective therapy to prevent sudden death in patients with Chagas' Cardiomyopathy (CChC). Identification of predictors of inappropriate therapy delivered by the ICD would allow implementing medical or ICD programming interventions. Methods: Retrospective study involving patients with CChC and ICD from 14 centers in Latin America, follow up of 33 ± 20 months. Demographics, surface ECG and clinical and ICD follow up were collected. ICD therapies were reviewed by 2 independent investigators. Chi‐square and logistic regression were performed. Results: A total of 94 patients were analyzed. Mean age 55 ± 10 years old (26/75), 62 male (63.8%). Mean left ventricular ejection fraction (LVEF) was 39.6 ± 11.8%. Secondary prophylaxis was the reason for implanting an ICD in 71.3% of the cases. During a follow up of 33 ± 20 months, 19 patients (20%), presented inappropriate therapies. Univariate analysis can be seen in Figure 1. Multivariate analysis adjusted by age and LVEF showed that paroxysmal atrial fibrillation (AF) (OR 2.4, 1.2–3.6; p = 0.01), QRS>150 ms (OR 1.6, 1.1–2.3; p = 0.04) and B‐Blocker therapy (OR 0.93, 0.84–0.97; p = 0.04) remained statistically significant. Conclusion: In patients with CChC and ICD, paroxysmal AF and QRS>150 ms increased the risk of inappropriate therapies. The use of B‐blockers therapy was protective. P127 VENTRICULAR TACHYCARDIA WENT UNDETECTED BY ICD? A CASE REPORT Tan VH 1; Lee LL 1; Goh YS 1; Tong KL 1; Chow J 1; Tan BY 21 Changi General Hospital, Singapore; 2National Heart Centre, Singapore Introduction: ICD shock occurred in about 10–20% of patients who received ICD therapies. However, there is paucity of data on ventricular arrhythmia undetected by ICD. We attempt to describe a case of VT which was undetected by ICD and subsequent management. Case Description: 53 years old man, a sudden cardiac arrest survival (developed VT at rate of 168 bpm or 357 ms cycle length). He was later diagnosed to have arrhythmogenic right ventricular dysplasia (ARVD) and underwent ICD implantation (Medtronic Maximo VR 7232) in November 2010. Initial ICD setting include VT zone (430 ms, 140 bpm), FVT via VF (250 ms, 240 bpm), VF zone (320 ms, 188 bpm), wavelet threshold, onset, stability and SVT discrimination were on. He was on oral sotalol 40 mgbd. He started to feel lethargy 1 day prior to admission in June 2011. He went to seek general practitioner advice and ECG was done which showed VT and was immediately referred to hospital. On arrival at emergency department, ECG showed VT (176 bpm, 341 ms). He was given intravenous amiodarone for an hour but unsuccessfully cardioverted. He subsequently underwent synchronised cardioversion and returned to sinus rhythm. ICD interrogation revealed VT occurring at rate of 390–430 ms. It was recognized by the device as gradual onset tachycardia and therefore no shock was given. R wave sensitivity was 0.3 mv. Defibrillation threshold check was normal. Blood investigations showed no evidenced of sepsis or electrolytes abnormality. Adjustment was made in which the onset and stability was off. He did not experienced further ventricular arrhythmia during hospitalization and was subsequently discharged from hospital with sotalol 80 mgbd. He was follow up 2 weeks later at outpatient and ICD check showed 1 episode of VT with appropriate shock. Conclusion: ARVD patient who received ICD for secondary prevention and receiving high dose sotalol may required minimum detection enhancement to avoid undetected VT episode. P128 SELECTION OF ICD RECIPIENTS – GENDER DISCRIMINATION SINGLE CENTER EXPERIENCE OF FOUR YEARS (2007 – 2011) Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: In clinical trials of primary and secondary prevention of sudden cardiac death, mainly male patients (pts.)have been selected to be implanted with a cardioverter defibrillator (ICD), which can be explained only in part by a lower prevalence of coronary disease in women, in younger age groups. Objective: To evaluate the gender distribution of ICD implantation from a single center in Indian population with left ventricular (LV) dysfunction. Population/Methods: We studied 252 pts with moderate to severe LV systolic dysfunction that were implanted ICD in our department (from 2007–2011) in New Delhi. We analyzed the distribution by gender, age and etiology. Results: Out of 252 pts (90.8% were males and 9.2% were females); the mean age of pts was 63 ± 15 yrs however there was no significant difference regarding mean age (56.5 + 9.8 years for males vs. 55.4 + 9.6 years for females). 66.4% had ischemic etiology, 29.5% had idiopathic dilated cardiomyopathy, 3.1% had hypertrophic cardiomyopathy, 1.0% had arrhythmogenic right ventricular cardiomyopathy. Indication for primary prevention was in 32.5%, while 67.5% of pts. had the ICDs implanted for secondary prevention as a whole group, out of which 91% of females had the ICDs implanted for secondary prevention. The mean ejection fraction (EF) was 26%± 9% as a whole group, while the mean EF for females was 24%± 5%. 15% of patients were in NYHA functional class I, 49% in class II and 36% were in class III as a group, while in the female population, 40% were in class II and 60% were in class III. Conclusion: The rate of implantation of ICDs in females in Indian population is lower than theoretically expected. Also, the female population was older with higher NYHA class. The guidelines must be implemented carefully to avoid gender selection biases. P129 CLINICAL OUTCOMES IN IMPLANTED CARDIOVERTER DEFIBRILLATOR POPULATION: SINGLE CHAMBER VS DUAL CHAMBER Forleo GB; Vecchio F; Papavasileiou L; Mahfouz K; Topa A; Ticchi C; Schirripa V; Magliano G; Santini L; Romeo F Division of Cardiology, Department of Internal Medicine, University of Rome "Tor Vergata" Introduction: Implanted cardioverter defibrillator (ICD) has been demonstrated to offer life‐saving therapies in patients with high risk of sudden cardiac death. The type of ICDs implanted could influence the occuence of inappropriate discharges due to supraventricular tachycardia misclassification. The aim of our study was to evaluate the outcomes of patients implanted with dual‐chamber (DC) versus single chamber (SC) devices. Methods: We analyzed 285 consecutive patients underwent ICDs implantation at our Institution between September 2003 and November 2010. We subdivided patients into "single chamber device" (n = 164, 147 males, age 64.4 ± 12.2 years) and "dual chamber device" (n = 121, 102 males, age 66.8 ± 11,1 years) groups based on the type of device implanted. Results: After a mean follow‐up of 24.1 ± 18.4 months, no significant differences were found in the incidence of appropriate discharges (40 vs 25 patients, p = ns) and in the occurrence of inappropriate therapy (11 vs 7 patients, p = ns). The type of ICD does not influence the incidence of TVNS (50 vs 28 patients, p = ns). Surprising our analysis shows a significant lower mortality in single chamber device group (13 vs 26 patients, p = 0.004). Further analysis would be necessary to explain such a data which should be confirmed in a wider population study. Conclusions: In our experience type of device does not influence the occurrence of ICD therapies and the incidence of ventricular arrhythmias. P130 IMPLANTABLE CARDIOVERTER DEFIBRILLATORS AN D QUALITY OF LIFE Forleo GB; Cioè R; Magliano G; Panattoni G; Papavasileiou LP; Minni V; Topa A; Mahfouz K; Santini L; Romeo F Department of Cardiology, University of Rome "Tor Vergata," Rome, Italy Purpose: Implantable cardioverter defibrillators (ICDs) reduce mortality in patients at high risk for sudden cardiac death. Quality of life (QoL) of these patients is often reduced, however, due to clinical, social problems, behavioral factors and psychological distress. The aim of the study is to evaluate the quality of life of patients with ICDs. Materials and Methods: We investigated 65 consecutive patients (56 males, age 65.68 ± 6.6 years) who received ICDs between December 2005 and August 2010 at our institution. All subjects were interviewed after a mean follow up of 14.59 ± 13.93 months, using the Short‐Form Health Survey (SF‐36). The SF36 includes eight independent scales. For each variable item scores are coded, summed, and transformed on to a scale from 0 (worst possible health state measured by the questionnaire) to 100 (best possible health state). Results: The SF36 shown a score of 51.44 ± 28.98 for physical functioning, a score of 35.98 ± 40.46 for role limitations due to physical problems, a score of 33.33 ± 45.86 for role limitations due to emotional problems, a score of 50.00 ± 22.77 for energy/fatigue, a score of 59.70 ± 21.16 for emotional well being, a score of 67.05 ± 26.13 for social functioning, a score of 70.80 ± 26.55 for pain and a score of 49.24 ± 16.48 for general perception of health. Conclusion: The study show that from a patient's perspective, QoL of subjects with ICDs is compromised, both psychologically and physically. They have difficulty performing the work or other activities, as a result of their clinical and psychological status. Often their psychosocial involvement is caused by fear of shocks and fear of death. The results suggest the importance of dialogue between the physician and the patients, which should be reassured and helped to overcome their limitations. P131 PROGNOSTIC FACTORS IN PATIENTS AFTER CARDIAC DEFIBRILLATOR IMPLANTATION Raspopovic S; Kircanski B; Nikcevic G; Jovanovic V; Pavlovic S; Zivkovic M; Milasinovic G Pacemaker Center, Clinical Center of Serbia Introduction: The aim was to establish different prognostic factors of patients after implantation of an ICD, including all cause mortality and occurrence of appropriate ICD therapy and new hospitalization rate. Method: All patients with ischemic and non‐ischemic cardiomyopathy(CMP), low left ventricular ejection fraction (LVEF ≤ 35%) and only ICD implanted during 2006 and 2007 in our center, and at least one follow up (FU) examination were included in the study. Patients baseline characteristics were over‐viewed, including etiology of CMP, QRS duration, New York Heart Association (NYHA) functional class, presence of hypertension, atrial fibrillation (AF), diabetes, hyperlipidemia, previous myocardial infarction (MI), QRS duration. Follow up charts were examined, regarding the last FU date, occurrence of arrhythmia, appropriate ICD therapy, death and new hospitalization due to heart failure(HF), arrhythmia episodes or upgrade of the system. Results: A total of 77 patients fulfilled inclusion criteria, 88,3% male, average age 62,4 years and 65% with ischemic CMP. Hypertension was found in 66%, AF in 36%, previous MI 58,4. There were 19,5% with diabetes and 42.9% with hyperlipidemia. NYHA class≥II had 91% and QRS≥120 ms was present in 44%. Mean FU was 34 months. Overall mortality rate was 25%(SCD 11%, nonSCD 68%, non cardiac death 21%). Arrhythmia episodes (VT/VF) showed in 52%, ICD therapy experienced 53% of patients, appropriate in 95% of cases. Hospitalization rate after ICD implantation was 21%. There were no significance between subgroups regarding mortality in patients with ischemic/non ischemic CMP (p>0,05, diabetes, and atrial fibrillation. There were significance between subgroups regarding mortality in patients with hypertension and wide QRS. Conclusion: Identifying different prognostic factors is very important for outcome in a specific population like ICD patients. P132 PROBLEMS OF ICD THERAPY IN CHILDREN RELATED TO LEAD IMPLANTATION TECHNIQUE Ivanitskiy EA; Kropotkin EB; Tsaregorodtsev AP; Kasimtseva TA The Federal Centre of Cardiovascular Surgery The aim of this study was to analyze the problems of ICD therapy in children according to our own experience. Methods: Four patients were enrolled in the study, age 5 – 13 years. Two ICDs were implanted for primary prevention and two ICDs – for secondary prevention of sudden cardiac death. One patient had corrected triad of Fallot, one patient had long QT syndrome and sick node syndrome, one patient had Brugada syndrome and one patient had dilated cardiomyopathy before the ICD implantation. Two ICDs were implanted by using transvenous approach with endocardial leads. One ICD was implanted via sternotomy by using two epicardial pacing leads and one epicardial shock patch. One ICD was implanted via left thoracotomy by using epicardial pacing leads. The shock lead in the last patient was positioned subcutaneously in the fifth intercostal space. Results: There were problems related to sensing disorders, ineffective shocks and inappropriate shocks in one patient who had endocardial leads. In this patient all endocardial leads were then removed by using laser extractor. New endocardial leads were successfully implanted via transvenous approach in this case. Conclusion: Epicardial approach for ICD implantation in children seems to be attractive because of less problems with leads and ICD therapy. Sometimes it is very effective to use both epicardial and subcutaneous approach for ICD leads implantation. In elder age in this category of patients we still have a possibility to use transvenous approach when lead and/or device replacement is needed. P133 ELECTROCARDIOGRAPHIC FINDINGS, COMORBIDITIES AND DEVICE THERAPIES IN OCTOGENARIAN IMPLANTABLE DEFIBRILLATOR RECIPIENTS IN INDIAN POPULATION ‐FOUR YEARS EXPERIENCE (2007–2011) Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Sudden cardiac death (SCD) is significant cause of mortality. Large, multicenter, randomized trials have shown efficacy of implantable cardioverter‐defibrillator (ICD) for primary and secondary prevention of SCD. The incidence of SCD increases with age. Many elderly patients (pts.) qualify for ICD, pts aged ≥80 years (octogenarians) are underrepresented in clinical trials of ICD as comorbidities in old age may negate the beneficial effects of ICD.Many pts who meet standard criteria for an ICD are older than those included in clinical trials of ICD, its use in these patients requires further definition. Objective: To assess baseline ECG findings, arrhythmia episodes, and severe nonarrhythmic illness or death in patients aged ≥80 years at ICD implantation, and to compare them with younger pts. Population/Methods: We studied 86 pts, ≥70 years old who underwent ICD implantation with respect to comorbidities, ECG findings and device therapies. Pts were divided in 3 groups based on age: age 70–74 (group 1; 38 pts), age 75–79 (group 2; 26 pts), and age ≥80 (group 3; 22 pts). Results: ECGs: Octogenarians were more likely to have sinus bradycardia (SB) and left bundle branch block (LBBB) compared to younger pts. There was no difference among groups in the proportion of pts with atrial fibrillation or any degree of AV block. Therapies: There was no difference in any appropriate or inappropriate therapy per patient‐year. Nonarrhythmic Death/Morbidity: There was no difference in time to death or serious illness. Conclusion: This was the study to evaluate the therapies received by octogenarians after ICD in Indian population at our centre. The higher incidence of SB and LBBB might influence the number of pacing sites in octogenarian patients. These pts have similar rates of arrhythmic episodes and development of severe comorbidities as septuagenarians, and they should not be denied ICD implantation based solely on age. P134 INTRAOPERATIVE DEFIBRILLATION THRE‐
SHOLD TESTING AND POSTOPERATIVE LONG‐TERM EFFICACY OF IMPLANTABLE CARDIOVERTER‐DEFIBRILLATOR IMPLANTATION Tianyi G; Yu Z; Baopeng T; Jinxin L; Xianhui Z; Guojun X; Yanyi Z; Yaodong L; Jianghua Z Department of Cardiology, First Affiliated Hospital, Xinjiang Medical University, Urumqi, China Introduction: To determine the defibrillation threshold of implantable cardioverter‐defibrilla‐
tors and outcomes of treatment. Methods: Sixty‐four patients received implantable cardioverter‐defibrillators implantation. During implantation, defibrillation threshold was determined by defibrillation safety margin. All patients were followed‐up for 12–48 months after the implantation. Results: The overall defibrillation threshold was 14.27 ± 2.56 J and defibrillation safety margin was 18.40 ± 1.89 J. Malignant ventricular arrhythmias occurred in 42 patients after implantable cardioverter‐defibrillators implantation including 500 episodes of non‐sustained ventricular tachycardia and 289 episodes of persistent ventricular tachycardia. Following antitachycardia pacing treatment, 265 episodes were treated successfully by one antitachycardia pacing treatment (91.69%), 12 episodes were treated successfully by two antitachycardia pacing treatment (4.15%). 12 episodes were converted by low energy electrical cardioversion (4.15%). A total of 175 ventricular fibrillation episodes were identified. of which 18 episodes automatically terminated before treatment.146 episodes were converted by one cardioversion with defibrillation energy of 13.21 ± 2.58 J and 11 episodes were converted by two cardioversions with defibrillation energy of 16.19 ± 2.48 J. Conclusions: It is safe and feasible to determine defibrillation threshold by defibrillation safety margin measurement during implantable cardioverter‐defibrillators implantation. Keywords: Implantable cardioverter‐defibrillator, defibrillation threshold, ventricular arrhythmia PACING P135 ASSESSMENT OF LEFT VENTRICULAR FUNCTION AND SYNCHRONY IN PATIENTS WITH RIGHT VENTRICULAR OUTFLOW TRACT AND APICAL PACING‐ AN INTERMEDIATE TERM FOLLOW UP STUDY Sharma G; Varghese MJ; Salahuddin S; Seth S; Juneja R; Bahl VK All India Institute of Medical Sciences, New Delhi, India Introduction: Pacing from the right ventricular outflow tract (RVOT) may preserve left ventricular function and dyssynchrony compared with right ventricular apical (RVA) pacing. We evaluated permanently paced patients from the two sites at 6 months post implantation. Methods: 30 consecutive patients with baseline normal LV function were evaluated. Detailed echocardiographic (VIVID 7, GE Medical Systems) assessment was done to assess left ventricular ejection fraction (LVEF) and ventricular dyssynchrony, during forced ventricular pacing. Dyssynchrony parameters assessed were interventricular mechanical delay (IVMD), septal‐posterior wall mechanical delay (SPWMD) and tissue Doppler parameters including dyssynchrony index and maximum time delay in peak tissue velocities in twelve left ventricular segments (MaxTPV). Results: 20 patients had pacemaker leads in the RVOT position. Mean age of the population was 57 ± 12 years (22 males). The mean time to echocardiographic assessment at follow‐up, from the time of pacemaker insertion was 246 ± 77 days. At follow‐up, there was no significant difference in LVEF between the two groups (61.7 ± 5.8% vs 61.8 ± 8.6%; RVOT vs RVA groups respectively, P‐0.97). The RVOT group showed a trend towards improvement in interventricular synchrony with IVMD of 28.7 ± 16.4 msec as compared to 39.1 ± 10.5 msec in the RVA group (p‐0.08). Similarly, the SPWMD showed a trend towards benefit in the RVOT group (22.9 ± 1.4msec vs 29.6 ± 4.30msec, p‐0.07). Tissue Doppler parameters of LV synchrony were also significantly better in the RVOT group (Dyssynchrony index: 3.9 ± 2.2 vs 6.2 ± 3.4, p‐0.03; Max TPV: 19.65 ± 4.9msec vs 36.5 ± 16.1msec, p‐0.0002; for RVOT vs RVA groups respectively). Conclusion: At an intermediate term follow up, patients with RVA pacing have significant ventricular dyssynchrony as compared to RVOT pacing. The left ventricular systolic function in the relatively short follow up is preserved in both sites of pacing. P136 AN ATRIOVENTRICULAR CONDUCTION TEST AT 90 BPM IDENTIFIES THE PATIENTS WITH A LOW RIGHT VENTRICULAR PACING PERCENTAGE Stazi F; Mampieri M; Verde M; Cardinale M Dipartimento Apparato Cardiocircolatorio, A. O. San Giovanni Addolorata. Roma. °CLI Foundation Introduction: High percentages of right ventricular pacing (RVP) are associated with increased mortality and heart failure. The use of the algorithms of RVP reduction such as AAISafeR® (Sorin Group) and MVP® (Medtronic) allows to obtain very low percentage of RVP in patients with preserved atrioventricular conduction. Picking out the patients that can take advantage of these algorithms it would be therefore very useful. Aim of the study was to assess if an atrioventricular conduction test at 90 beats per minute (bpm) enables to identify the patients who can have a low RVP percentage using the algorithms of RVP reduction. Methods: One hundred thirtythree patients (82 M, 51 F, age 75 ± 11 years, AAISafeR®= 121, MVP®= 12) underwent an atrioventricular (AV) conduction test at 90 bpm during atrial pacing at the time of the pacemaker (PM) (n = 113, 52 for sinus node disease, SND, and 61 for atrioventricular block of any degree, AVB) or defibrillator (ICD) (n = 20) placement, both provided of an algorithm of RVP reduction. Results: One hundred patients (65 M and 35 F, age 75 ± 12) who underwent PM (n = 80, 51 for SND and 29 for AVB) or ICD (n = 20) placement had 1:1 AV conduction (group 1) while thirtythree subjects (17 M and 16 F, age 78 ± 9) all with PM placement (32 for AVB and 1 for SND) had AV conduction defects (group 2). 73 ± 209 days after the procedure the mean RVP percentage was 6 ± 17% in group 1 and 76 ± 35% in group 2 (P < 0,0001). Conclusions: An 1:1 AV conduction during atrial pacing at 90 bpm identifies the subset of patients who will have a low RVP percentage with the RVP reduction algorithms. P137 PERFORMANCE OF ACTIVE VERSUS PASSIVE FIXATION LEADS IN PACEMAKER RECIPIENTS – ACUTE AND CHRONIC PARAMETERS; OUR CENTER EXPERIENCE OF TEN YEARS (2001–2011) Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Innovation in pacemaker technology has lead to development of steroid eluting fixation leads‐ active(screw‐in) & passive(tined) leads leading to significant reduction in acute & chronic pacing thresholds, lead impedance & decrease in rate of lead dislodgement. For unknown reasons, screw‐in leads are used more often, despite that tined leads have lower chronic thresholds. This may have significance in pacemaker battery longevity and avoiding early replacements. We compared basic parameters of two leads at our center over ten years of follow up. Objective: To examine time course of atrial(A), ventricular(V), or A+V pacing threshold, P & R amplitude and impedance in patients (pts) who underwent single or dual chamber pacemaker implant respectively (rly) between 2001–2011. Population/Methods: We studied 3568 pts. A & V acute & chronic pacing thresholds at 0.4 ms, P & R amplitude & impedance were measured at implantation & 6 months. Results: At implantation, mean acute A & V threshold for tined & screw‐in lead‐ 0.53 ± 0.23V, 0.68 ± 0.4 V; 0.83 ± 0.25V, 0.88 ± 0.33V rly. P & R amplitude 3.8 ± 1.6mV, 11.1 ± 4.2mV; 2.9 ± 1.8mV, 10.7 ± 3.9mV rly & impedance 578 ± 93Ω, 693 ± 98Ω 602 ± 103Ω, 703 ± 98Ω rly. Mean chronic A & V threshold for tined & screw‐in lead‐ 0.33 ± 0.18V, 0.49 ± 0.1V; 0.76 ± 0.2V, 0.79 ± 0.28V rly. P & R amplitude 4.2 ± 1.6mV, 13.8 ± 4.0mV; 3.2 ± 1.5 mV, 11.9 ± 2.9mV rly & impedance 498 ± 76Ω, 608 ± 85Ω 546 ± 96Ω, 612 ± 88Ω rly. Conclusion: We concluded that acute & chronic atrial and ventricular pacing threshold with screw‐in lead was significantly higher than with tined lead. There was significant increase in chronic P and R‐wave amplitude with tined vs screw‐in lead, also decrease in chronic impedance was noticed in tined vs screw‐in lead but not statistically significant. Henceforth, one should give good thought in selection of leads as this may have great impact on pacemaker longevity and on economic aspect of health care. P138 LONG TERM OUTCOME OF VDD AND DDD PATIENTS: A SINGLE CENTER EXPERIENCE Campana A; Manzo M; Brigante MR; Melchiorre G; Matrone A; Avallone B Heart Department A.O.U. San Giovanni di Dio e Ruggi D'Aragona. Salerno, Italy Background and Objective: VDD/VDDR pacing is used less frequently than recommended by guidelines. Aim of the present study was to demonstrate that VDD pacing is effective and safe, if performed in indicated patients, and to compare long‐term follow‐up results of VDD versus DDD pacemaker patients in terms of: reliability, rate of atrial fibrillation (AF) onset and device replacements during observation period. Methods and Results: A retrospective analysis was conducted on 364 patients who underwent their first implantation of DDD/DDDR or VDD/VDDR pacemaker in our center between January 1995 and December 2000. Main indication for pacemaker implantation was sinus node disease and/or advanced A‐V conduction dysfunction in 177 patients with DDD/DDDR pacemaker (Group D) and advanced atrioventricular block in 187 patients with VDD/VDDR pacemaker (Group V). The median follow‐up was 8 years (25th‐75th percentile: 4–10). Twenty‐six patients (15%) in Group D and 20 (11%) in Group V developed persistent or permanent AF. The incidence of AF was 2.2 per 100 patient‐years in Group D and 1.5 in Group V (p = 0.176). Pacemakers were replaced during follow‐up in 96 patients (54%) in Group D and in 43 patients (23%) in Group V (P < 0.001). In total, 163 patients died during follow‐up: 92 in Group D (52%) and 71 in Group V (39%). The risk of death proved to be significantly higher in Group D than in Group V (V vs D: HR = 1.48, 95%CI 1.08–2.01, p = 0.014). Conclusions: In our cohort, VDD pacing proved just as reliable as DDD pacing, more long‐lasting and no more arrhythmogenic. P139 ADVERSE EFFECTS OF SUSTAINED ATRIAL OVERPACING IN SICK SINUS NODE PATIENTS WITH PAROXYMAL ATRIAL FIBRILLATION Menezes A Jr; Rassi S; Moura MC Catholic University Of Goias Background: The atrial Dynamic overpacing for atrial tachyarrhythmias prevention is an attempt to pace the atrium with a higher rate than the coupling episodes of atrial premature beats of the patients, inhibiting their focus and avoiding the occurrence of short‐long cycle. Instead, some authors have been demonstrating that the increase in atrial and ventricular stimulation may determine the development of persistent atrial fibrillation. (GILLS, A. HRS, 2009). Objective: Observe the evolution of paroxysmal atrial fibrillation in patients with DDD device and the overpacing algorithm on, initially to persistent or permanent atrial fibrillation (characterized as adverse effect of pacing mode). Methods: An observational, prospective, evaluating 35 patients with SSS and paroxysmal atrial fibrillation, pacemaker DDD, followed for 48 months. Rating telemetry, 24 hours Holter and transesophageal echo every 6 months. Results: The mean age was 67 ± 8 years, 65% male, 77% patients with Chagas' heart disease. Clinical evaluation showed a significant increase in complaints of palpitations, AF burden and MS (Mode Switch) with a significant increase after 36 months with P value < 0.003. Transesophageal echocardiography with a significant increase of Left Atrim (volume, dimension) (p <0.05). Seven patients were submitted to AV node ablation (for better control of symptoms). Conclusions: Dynamic atrial overpacing when continuously accomplished, instead of prevent atrial tachyarrhythmias might develop a worsening of atrial fibrillation in SSS pacemaker patients. P140 ABNORMAL SINUS NODE RESPONSE TO ADENOSINE PREDICTS THE OCCURRENCE OF SYNCOPE OR PRESYNCOPE IN PATIENTS WITH SICK SINUS SYNDROME Fragakis N; Antoniadis A; Koskinas K; Pagourelias E; Kyriakou P; Skeberis V; Geleris P Cardiology Unit, 2nd Propedeutic Department, Hippokration Hospital, Thessaloniki, Greece Background: Intravenous adenosine administration is a noninvasive diagnostic test for sick sinus syndrome (SSS). However, whether its effect on sinus node is associated with the clinical presentation of SSS remains elusive. We hypothesized that the sinus nodal inhibition by adenosine is more pronounced in SSS patients with previous syncope or presyncope as compared to SSS patients without syncopal or presyncopal attacks. Patients and Methods: We studied 44 patients with SSS, 33 with a history of syncope or presyncope and 11 without such history. Controls were 29 subjects undergoing electrophysiological studies for supraventricular tachycardia or unexplained syncope, none of whom had sinus nodal dysfunction. We calculated the corrected sinus node recovery time after 0.15 mg/kg intravenous adenosine (ADSNRT) and after overdrive atrial pacing (CSNRT). CSNRT values >525 msec were considered abnormal. Results: SSS patients with a history of syncope or presyncope had notably prolonged ADSNRT as compared to SSS patients without such history (median: 4900, IQR: 920 – 8560 msec vs. median: 160 IQR 0–563 msec; P < 0.001). Also, SSS patients with a history of syncope or presyncope had significantly longer ADSNRT than CSNRT (median: 4900, IQR: 920–8560 msec vs. median: 680 IQR: 359–1650 msec, P < 0.01). On the other hand, SSS patients without a history of syncope or presyncope showed no difference between ADSNRT and CSNRT values (median: 160 IQR: 0 – 563 msec vs. median 380, IQR: 200–455 msec, p = 0.72). The sensitivity of CSNRT in the diagnosis of SSS was 57% and the specificity 100%. A cut‐off of 1029 msec for ADSNRT yields the same sensitivity with a specificity of 96.4%. Conclusions: Patients with SSS and a history of syncope or presyncope exhibit an exaggerated sinus nodal suppression by adenosine. Prolonged ADSNRT is suggestive of a more severe underlying sinus node dysfunction, and this may be useful in the risk‐stratification and effective management of patients. P141 CARDIAC PACING TRENDS IN SOUTH KOREA FOR THE LAST 10 YEARS: CHANGES FROM SINGLE CHAMBER PACING TO DUAL CHAMBER PACING Jang SW; Rho TH; Choi MS; Shin WS; Kim JH; Oh YS; Lee MY; Cho EJ; Kim DB; Kim JH Devision of Cardiology, Department of Internal Medicine, The Catholic University of Korea A nationwide cardiac pacing survey has been undertaken annually in South Korea. We compared the 2010 survey with the 2000 one. Data were collected from the cardiac implantable electronic device manufacturers and distributors. The implantable cardioverter defibrillator was not included in this survey. In 2010, the number of total implants, new implants, and replacements were 2932, 2153, and 779, respectively. Those numbers are 162%, 133%, and 295% increases, respectively, as compared with the 2000 data. A number of new implants per million population was increased from 19 to 43. However, according to the 2009 world survey, it was still lower than other Asian Pacific countries including Japan (272), Taiwan (172), Hong Kong (124), and Singapore (94). As for the pacing mode, VVI(R) was decreased from 38% to 26%, and DDD(R) was increased from 44% to 60%. The major indications for new implants were a sinus node dysfunction (41%) and an advanced atrioventricular block (54%), and female patients constituted 59% of total implants, which were similar to the 2000 survey. Possible reasons for a small number of cardiac pacing implantation in South Korea, as compared with other Asian countries with similar economic background, could be differences in population profiles, physician's attitudes, cultural backgrounds, reimbursement problems, and a low incidence of conduction system disorders. In summary, the cardiac pacing implantation has markedly increased for the last 10 years. The dual chamber pacing has been replacing the single chamber pacing. Why the implants in South Korea are small is still questioning. P142 ADVERSE EVENTS RELATED TO TINED VERSUS SCREW‐IN LEADS IN PATIENTS RECEIVING DEVICE IMPLANTS – GENDER DIFFERENCES Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Devices‐Implantable cardioverter defibrillators (ICDs) & pacemakers (PMs) have reduced morbidity & mortality. However, gender differences may exist in adverse events attenuating benefits. Females unlike males are at high risk for procedural complications like high rates of bleeding, stroke & in‐hospital mortality after invasive procedures.Less is known about differences in complications in device recipients. Choice of lead (tined/screw‐in) may have major role. We addressed the issue in our patients (pts). Objective: To examine gender specific, adverse events related to type of lead in pts with device implants (2001–2011). Population/Methods: We studied 4398 pts & followed them for adverse events for three years after implantation. Results: PMs: 3568; 71.3% males, 28.7% females; mean age 62 ± 15yrs‐no significant gender difference (59.7 yrs males vs 60.1 yrs females). Females significantly got more tined vs screw‐in leads; males got nearly same. ICDs: 830; 91%males, 9%females; mean age 63 ± 14 yrs‐ significant gender difference (54.7 yrs males vs 60.1 yrs females). Females & males got more screw‐in vs tined leads. Females have more heart failure (78% vs 72%), worse NYHA class III (60% vs 51%), differences mainly found in females receiving ICDs. Females have more any adverse event (3.9% vs 3.0%) & major adverse events (1.4% vs 1.0%). The% of adverse events‐higher with screw‐in vs tined leads; females receiving tined leads in PMs or ICDs showed lesser major adverse events. Conclusion: In our center device related adverse events in females were multifactorial: Older age, higher% of comorbidities & risk factors, after adjusting these variables‐ smaller body size & anatomy such as thinner right ventricular wall, smaller blood vessel diameter; thus clear that screw‐in lead caused more adverse events in females vs males. Hence, choice of leads is a strong & independent factor associated with adverse events & one should exercise great efforts in choosing the leads especially in females. P143 ANTICOAGULATION PROTOCOLS FOR PERMANENT PACING IMPLANTATION: LESSONS TO LEARN? Sandhu K; Raju P; Ugni S; McIntosh R; Furniss S; Sulke AN; Lloyd GW; Patel NR Eastbourne District Hospital; East Sussex; England Please may we submit the following work to present as a poster at your conference?Introduction: High risk of complication in patients with anticoagulation is well recognised in patients undergoing permanent pacemaker implantation (PPM). We sought to investigate current practice in London and the South East. We focused on two different types of patient sub groups, those patient with atrial fibrillation and patient with metallic mitral valves. We looked at the number of days prior to device implantation warfarin was stopped, the INR that devices were implantations, what alternative anticoagulants were used prior to implantation after stopping warfarin and how soon after implantation warfarin was restarted. Method: A telephone survey of device implanting hospitals was undertaken in November 2009, detailing current practice with respect to anticoagulant use before and after implantation in two different sub groups. Results: 34 hospitals (London 22, South East 12), 27 NHS Trusts (London 19, South East 8) were sampled. Data was collected from registrars (19) and nurses (15) we have comprehensive images to reflect protocols in different hospitals that are within the same geographic region within the UK. Conclusion: Anticoagulant prescription protocol around PPM implantation varies widely in different NHS hospitals. The most common anticoagulant used before PPM was Enoxaparin in AF group and Unfractionated Heparin Infusion in MVR group. However no alternative anticoagulants were used in significant proportion in AF group before PPM but surprisingly an equal proportion had low molecular weight heparin in MVR group. In significant proportion of hospitals, anticoagulation was restarted after 24 hours in post PPM patients, which could increase the length of stay. It would be valuable to correlate complication rates with anticoagulation practice and produce guidance for a nationally agreed approach to anticoagulation in high risk groups. P144 SELECTIVE SITE PACING. IS IT BETTER TO STIMULATE THE LEFT THAN THE RIGHT VENTRICLE IN PATIENTS WITH CONVENTIONAL PACEMAKERS? Sapelnikov OV; Latypov RS; Grishin IR; Saidova MA; Akchurin RS Cardiology Research Center, Moscow Introduction: There are a lot of contradictory works dedicated to selective site pacing. Furthermore, BELIEVE and recent Bi‐LEFT trials showed no advantages of biventricular pacing in comparison with isolated LV‐pacing in patients with CRT‐indications. Materials: 4 groups of patients were included in this study. The 1st included 25 consecutive ventricular pacing lead implants in the interventricular septum (IVS), the 2nd – 14 patients with RVOT pacing, the 3d – 34 patients with right ventricle apex pacing and the 4th 8 patients with LV‐pacing. Patients in the last group were initially with LBBB. All the measurements were made after the procedure and in 6,12,24 months after the operation.In the period of study we observed the mean percent of ventricular pacing of 82 ± 5%. LV dyssynchrony was measured by means of Doppler investigation and tissue myocardial imaging (TMI). Results: Mean QRS duration in group 1 was 116 ± 11 ms before and 124 ± 14 ms two years after the procedure. In 2 group of patients these figures were 104 ± 10 ms and 120 ± 11 ms, and in 3 group of patients these figures were 106 ± 12 ms and 171 ± 15ms. In 4 group QRS‐duration was significantly wider (159 ± 15 ms before and 165 ± 14 ms after procedure), but the ECG pattern transformed from LBBB to RBBB. Immediately after implantation the values of electromechanical delay between IVS and left ventricle lateral wall (basal segments) were significantly higher during apical pacing (35 ± 5 ms in group 1, 30 ± 5 in group 2, 29 ± 5 group 4 and 54 ± 6 ms in group 3). In two years after implantation the difference between groups still was observed (38 ± 6 ms, 34 ± 5 ms, 27 ± 5 ms vs 68 ± 5 ms). Conclusions: The IVS and RVOT pacing allow an improvement in functional and hemodynamic parameters in acute study and shows stable effect in two years period of follow‐up. Despite of wider QRS‐duration, LV‐pacing demonstrates slightly lower parameters of interventricular dyssynchrony, especially in patients with initial LBBB. P145 POSSIBILITY TO SHORTEN PROGRAMMABLE AV DELAY BY CLOSER POSITIONING THE ATRIAL AND VENTRICULAR LEADS IN THE SEPTAL REGIONS Volkov D; Karpenko Y Institute of General and Urgent Surgery, AMS of Ukraine, Kharkov Objective: Fact of potentially negative effects of right ventricle's (RV) apical pacing on the pumping function is widely recognized in pacemakers (PM) practice. Strategies for overcoming this situation are using of alternative areas of implantation and special pacing algorithms. Nonetheless programming shortest possible AV delay (AVD) is preferring. The purpose of this study was checking the hypothesis that shortest paced and sensed AV‐conduction times recognized by PM are committed to a minimum distance between the electrodes in the right atrium (RA) and RV. Methods: The study included patients with Class I and II indications for DDD(R) pacing with intact 1:1 AV‐conduction during evaluation (n = 55, F‐21, age 65 ± 21). Patients with AV block II‐III degrees were excluded. Electrodes were implanted in four variants: RA appendage (RAA) – RV apex (RVA), n = 18; RAA – RV outflow tract (RVOT), n = 21; RA low septum (LAS) – RVA, n = 7; LAS – RVOT, n = 12. AV‐conduction defined as distance between PM channels' markers during RA sensing and pacing with programmed long AVD and three‐fold sensitivity threshold to RA and RV signals. Results: The electrodes were successfully implanted in all patients. AV conduction during RA sensing, ms: RAA – RVA 192 ± 40; RAA – RVOT 185 ± 32; LAS – RVA 156 ± 38; LAS – RVOT147 ± 35. AV conduction during RA pacing, ms: RAA – RVA 251 ± 37; RAA – RVOT 239 ± 44; LAS – RVA 215 ± 45; LAS – RVOT – 206 ± 39. Implantation of electrodes in the septal RA and RV areas led to a shortening of the AV conduction recognized by PM (LAS and RVOT positions). That was more dependent on the position of RA than RV leads. Conclusion: The position of the electrodes in the heart's chambers can influence the PM detection and thus AVD programming. Minimal distance between the electrodes at their location in the septal areas gave a combination of delayed detection in RA and stimulation the area close to the AV node and early detection in the RV. P146 IMPLANTABLE DEVICES‐RELATED INFECTI‐
ONS‐ANYTIME A POSSIBLE COMPLICATION? LONG TERM FOLLOW‐UP IN A SINGLE LARGE IMPLANTING CENTER Ciudin R; Mihaila M; Capraru C; Petre M; Bostan I; Ginghina C "C. Davila" University of Medecine, "C. C. Iliescu" Inst. of Cardiovascular Diseases Bucharest, Romania Infections involving implantable antiarrhythmic devices are often challenging to treat. Methods: From September 1997 to April 2010 we have implanted 4900 implantable devices and we identify from our records 36 patients (pts) presenting with late (>30 days following the implant) device‐related complications. Initial diagnosis of infection ranges from 30 days to 4.8 years following the primary implant, with a mean of 577 days. There were 18 male and the age group was 65,47 ± 17 years, ranging from 15 to 85 years old. Results: Device‐related late complications were diagnosed on 29 VVI, 3 DDD, 1 AAI pacemakers and 3 ICD (1 pt up‐graded to CRT‐D. In 5 pts there was a lead repositioning and in 3 pts a generator replacement. All the others were a primary implant.In 25 pts there was only a pocket related infection and in 9 pts we diagnosed as having an infective endocarditis (IE) as well. 2 pts had only IE. Staphylococcus Aureus (SA) was a probably cause for infection in 50% of the pts, in 21.3% methylino‐resistant SA was identify, Gram negative bacteria in 21.3% and Staphylococus epidermitis in 7.4%. Our treatment had included antibiotics for a mean of 10 days, device explantation for 16 pts and reimplantation on the other side in 11 pts, subpectoral in 4 pts and same site 1 pt. In 9 pts were extracted the leads as well. 4 pts with IE received a tricuspid prosthesis and the others epicardial leads. There were 2 postsurgery deaths. Late device‐related infections rate in our group was 0.73%. Implanted Cardioverter Defibrillators Devices‐related infections can complicate anytime a pacemaker/ICD implant. Incidence in our study was 0.73%. Treatment of device infections is often difficult to achieve and needs individualised hybrid antibiotics, intervention or surgical approach. P147 SUBCLAVIAN VEIN OBSTRUCTION IN PATIENTS WITH PERMANENT PACEMAKER Murat Y; Serdar B; Erdinç A; Selim E; Erdal G; Sefa S; Nursen P İzmir Atatürk Teaching Hospital Introduction: The number of patients with permanent pacemaker has increased exponentially recently. Complications associated with the implantation procedure are uncommon, but also include venous thrombosis. Device‐associated venous thrombosis generally presents as unilateral arm edema. Treatment includes extremity elevation and anticoagulation. Venous thrombosis at the access site may be silent and may be detected during re‐implantation of a new lead due to lead failure or infection. This study investigated the incidence of silent venous thrombosis in patients who underwent pacemaker re‐implantation for various reasons. We also investigated risk factors for venous thrombosis in this patient population. Method: Fifty‐three patients who underwent pacemaker pulse generator and/or lead reimplantation in our institution were enrolled between 2007–2010. Prior to exchange procedure, patients underwent subclavian venography through the ipsilateral cubital vein. Results: Complete obstruction of the ipsilateral subclavian vein was detected in 5 patients. Of these 5, only 2 patients required implantation of a new pacemaker lead. Ipsilateral venous puncture was thought impossible in these patients. In these patients, pacemaker system was removed and reimplantation was performed through the contralateral subclavian vein. Comparison of basal characteristics of patients with or without subclavian vein obstruction (SVO) revealed nonsignificant difference. There was not significant difference between patients with or without SVO according to age, gender, number of previous replacements, number of leads, systolic function, Concomitant antiplatelet and anticoagulant medications were found comparable in both groups. Significantly increased history of pacemaker pocket erosion incidence was found in patient group with SVO (P < 0.05). Conclusion: The results of this preliminary study demonstrates that prior pacemaker pocket erosion creates a predisposition for ipsilateral SVO. P148 THE PREDICTOR FOR ATRIAL PACING DEPENDENCY AND NEED FOR RATE RESPONSE FUNCTION IN PATIENTS WITH HEART BLOCK Suga C; Hirahara T; Sugawara Y; Nakajima J; Wakaba H; Ako J; Momomura S Department of Cardiology, Jichi Medical University Saitama Medical Center, Saitama, Japan Background: Even patients with heart block (HB) sometimes develop to atrial pacing dependency suitable for rate response function. The purpose of this study was to determine if there was any predictor for atrial pacing dependency in HB patients. Methods: This study included 145patients (64males, mean age 71.7 ± 9.1 years) undergoing a dual chamber pacemaker (PM) implantation for sinus node dysfunction (SND) or HB from 2008 to July, 2010. Atrial pacing dependency at 6 months after PM implantation was compared between SND and HB. We compared patient characteristics, atrial rate, blood pressure (BP), echocardiographic measurements before PM implantation, lead location, and lower pacing rate according to atrial pacing dependency ≥20% or <20% in HB patients. Results: Though the number of HB patients with atrial pacing dependency ≥20% (39.8%) was fewer than SND patients (87.1%, P < 0.0001), 10.8% of HB patients had ≥50%, and 3.6% had ≥80% atrial pacing dependency. There were no significant differences between HB patients with atrial pacing dependency ≥20% and <20% in patient characteristics, BP, LV dimension, LVEF, and ventricular lead location. HB patients with atrial pacing dependency ≥20% had greater LAD (46.4 ± 5.5 vs 42.0 ± 6.9[mm], p = 0.0038), faster atrial rate (82.9 ± 13.7 vs 73.9 ± 14.3[bpm], p = 0.0055), more frequent RA appendage lead placement (72.7 vs 46%, p = 0.016), and greater lower pacing rate (60.6 ± 2.4 vs 58.8 ± 3.3[bpm], p = 0.0082). Multivariate analysis showed that LAD (OR: 0.907, 95%CI: 0.827–0.995, p = 0.0391), atrial rate (OR: 1.05, 95%CI: 1.002–1.1, p = 0.0408), and atrial lead location (OR: 0.253, 95% CI: 0.074–0.861, p = 0.0278) were independent predictors for atrial pacing dependency. Conclusions: A considerable number of HB patients developed atrial pacing dependency. HB patients who had enlarged LA and relatively slower atrial rate prior to PM implantation may develop to atrial pacing dependency and may benefit from rate response function. P149 A TECHNIQUE FOR IMPLANTING A RIGHT VENTRICULAR ELECTRODE IN PATIENTS SUFFERING FROM LEFT SUPERIOR VENA CAVA PERSISTENCE USING A CONVENTIONAL J GUIDE Mora G Universidad Nacional de Colombia Background: Locating pacemaker electrodes can become complicated by congenital abnormalities including alterations of the systemic upper veins, such as left superior vena cava (LSVC) persistence. Materials and Methods: The study was carried out from June 2001 to June 2009 involving all patients who were admitted to the Hospital Universitario Mayor, Instituto de Corazon de Bogota and Hospital Universitario Clinica San Rafael (Bogota‐Colombia) to have a pacemaker or cardiac defibrillator implanted. LSVC was diagnosed by fluoroscopic observation (anterior‐posterior view) of the course of the guide. The following technique was used for gaining access to the right ventricle. The electrode was initially introduced with a straight guide as far as the right atrium, this was then changed for a J guide and the electrode was pushed towards the lateral or anterolateral wall of the RA. The electrode tip was thus lying against the tricuspid valve. Once in this position, the guide was withdrawn 3–5 cm and the tip passed spontaneously into the right ventricle. If it were wished to leave it in the apex, then an anticlockwise rotation would have been needed before withdrawing the guide; on the contrary, if it were wished to place it in the septum or in the outflow tract, then it would have had to be rotation clockwise. Results: A total of 1,048 patients were admitted for pacemaker or cardiac defibrillator implant during the 8‐year study period, 974 received a left subclavian venous approach. There were 508 males and 466 females. LSVC persistence was found in four patients (0.46%) Fluoroscopy time for implanting the ventricular electrode ranged from 1 to 4 minutes, 40 to 92 minutes being taken to complete the whole procedure. Conclusions: We present a simple and rapid technique for electrode placement in patients with LSVC using usual J guide and active fixation electrodes with good success. P150 PACING IN TRICUSPID PROSTHESIS PACIENTS – WHAT ARE THE IMPLANTING OPTIONS? A 9 PATIENTS SERIES EXPERIENCE FOLLOW UP Ciudin R; Bolog M; Capraru C; Mihaila M "C Davila" Univ of Medecine, "C C Iliescu" Instit of Cardiovascular Diseases, Bucharest, Romania Tricuspid prosthesis (TP) patients (pts) having bradyarrhythmias pacing indication represent a difficult option for implanting technique. We present a such 9 pts series in whom we had to choose the implanting technique according with the underlying heart disease. Methods: There were 4 male and 5 women, mean age of 43.4 yars old (range from 24 to 61 years) in whom a TP was implanted for valvulopathy (mitral and TP 3 pts; aortic, mitral and TP 1 pt; TP only in 2 pts) and 3 pts receiving TP following infective endocarditis. Results: 5 pts had metallic TP and 4 pts tricuspid bioprosthesis (TbP). In all pts with TbP we implanted a trans TbP active fixation lead into the right ventricle. 2 Pts with TP have received a coronary sinus (CS) lead for left ventricle pacing and one pt a CS lead following a surgical implanted epicardial lead high threshold. 2 pts had only a surgical epicardial right ventricle lead. During our series follow‐up 1 pt had a high threshold in an active fixation trans TbP right ventricle lead and had to be replaced and 1 pt with CS lead had an intermittent high threshold. Conclusions: Choosing the implanting technique in tricuspid prosthesis pts is not an easy option and it depends of TP type and underlying cardiac diseases. Technical pacing problems could complicate evolution of pts with TP. P151 PATIENT PROFILE AND IMPLANTATION TRENDS IN RECIPIENTS OF PACEMAKERS AND IMPLANTABLE CARDIOVERTER DEFIBR‐
ILLATORS IN INDIA AT OUR INSTITUTE: 2006–2011 Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Early clinical success and advances in technology in implantable cardiac rhythm management devices(pacemakers [PM] and implantable cardioverter defibrillators [ICDs])have resulted in expansion of indications with dramatic increase in access and utilization. The indications for pacemaker have also expanded beyond treatment of bradyarrhythmias to cardiac resynchronization therapy in patients (pts) with heart failure and electromechanical dyssynchrony. Objective: We evaluated trends in cardiac rhythm management device implantation. Trends in primary device implantation and burden of device replacement, defined as ratio of replacement procedures to total number of primary and replacement procedures for all pts from 2006–2011 were analysed. Methods: All pts receiving PM and ICD over a period of five years were studied. Results: Total 1900 pts and 604 pts received PMs and ICDs respectively; 1680 received primary PMs and 530 ICDs; there were 220 PMs and 54 ICDs replacement. Women comprised 29% of PM and 9% of ICD pts. The mean ICD replacement burden was 8.9% (range 4–12%)and that of PMs was 11.5%, (range 8.2–15.6%). ICD pts had more comorbidities than PM pts. Conclusions: Firstly, rate of implantation of ICDs in females in our population is lower than expected. Also, females were older with higher NYHA class. Secondly, there has been marked increase in rate of ICD implants.The ICD pts were older, with greater comorbidities, while age of PMs pts has remained stable, with slower rate of increase in comorbidities. Analysis also revealed that replacement burden for PMs has remained constant, while that for ICDs has decreased, which may be ascribed to relative stability of the patient receiving PMs and on the other hand expanding indications for ICD implantation,resulting in increased number of primary ICD implants.These data suggest that monitoring is required, given the changing populations, their disparate clinical outcomes, and implications to the health care system. P152 EPICARDIAL DUAL CHAMBER PACEMAKER (DDD) IMPLANTATION WITHOUT STERNO‐
TOMY IN INFANCY Mitropoulos F; Tsoutsinos A; Kiaffa M; Rammos S Onassis Cardiac Surgery Center Congenital complete heart block (CHB) is a rare conduction anomaly occurring in 1/11.000 to 1/20.000 live births. The most common association is with maternal systemic lupus erythematosus. Usually the surgical strategy for epicardial dual chamber pacemaker implantation include sternotomy or partial lower sternotomy. We report the implantation of epicardial pacemaker in an 18 months old female infant, with CHB, without sternotomy, or cardiopulmonary bypass. Materials and Methods: The infant was born with complete heart block, (minimum heart rate 45 beats per minute) and normal cardiac anatomy. Gradually she developed symptomatic bradycardia (heart rate 25–45) with ventricular dysfunction. Through a 5cm curvilinear skin incision the pericardium was opened and the heart was visualized. The sternum was elevated with a retractor and the diaphragmatic surface or the right ventricle was exposed. An epicardial steroid eluding unipolar ventricular electrode was sewn through diaphragmatic surface of the right ventricle with 5–0 prolene. Then the right atrium was retracted in a caudal direction and a unipolar electrode was sawn to the right atrial appendage with 5–0 prolene.Through the same incision a pocket was created in the left upper quadrant below the left rectus abdominis muscle and a St. Jude generator was implanted. The infant tolerated the procedure without any hemodynamic compromise. The infant remained one day in the CTICU and she was discharged on postoperative day 5. At the first pacemaker check after implantation the parameters measurements were good. Conclusion: Non sternotomy, dual chamber epicardial pacemaker implantation can be achieved. Although technically more challenging it is feasible and safe and the aesthetic result is very gratifying. P153 PERMANENT PACING IN PATIENTS WITH PROLONGED ASYSTOLE AT THE HEAD UP TILT TEST Santini L; Capria A; Papavasileiou LP; Scarfò IS; Smurra F; Viele A; Schirripa V; Magliano G; Forleo GB; Romeo F Cardiology Department, University of Tor Vergata, Rome, Italy Introduction: Dual chamber pacemakers with rate drop response pacing algorithm (DDDR‐RDR) may be a therapeutic option for neutrally mediated cardioinhibitory syncope assessed trough a positive Head‐up tilt test (HUTT) in patients older than 40 years with a history of syncope. Aim of our study was to evaluate the outcome of such a therapeutic strategy. Methods: We selected 22 patients who underwent HUTT, aged 42–70 years. Patients were divided into two groups. Group A: 11 pts with cardioinhibitory syncope (asystole >4 seconds or atrio‐ventricular dissociation with heart rate lower than 30 bpm) addressed to PMK implantation; Group B: 11 pts with a milder cardioinhibitory response, in this group conservative treatment was preferred. A clinical follow‐up was performed after three years. Results: 9 pts in the group A accepted PMK implantation, 2 pts preferred conservative treatment. In patients with PMK cumulative atrial pacing was found to be greater than ventricular pacing (AP 40.28 vs 3.5% VP, P < 0.05). In addition, 254 episodes of rate drop response were adequately recognized and treated. Follow‐up was concluded in 67% of PMK pts. None of them presented new episodes of syncope. Regarding patients left with conservative treatment, follow‐up was concluded in 11 pts: syncope occurred in 3 pts; 2 patients were lost in the follow‐up. Conclusions: The higher percentage of cumulative atrial pacing shows in the more severe patients group a basal vagal hypertonic pattern which modulates sinus node function but not affecting the basal AV conduction. DDDR‐RDR pacing is a valid and effective option in selected patients with history of neurally mediated syncope and a severe tilt test‐induced cardioinhibitory syncope. Patients with a milder cardioinhibitory response at the HUTT seem to have a good response to conservative treatment. P154 AN UNUSUAL CAUSE OF CHRONIC INFECTIVE ENDOCARDITIS FOLLOWING A PACEMEKER IMPLANT‐AN ACHILE'S TENDON PROSTHESIS ABSCESS Ciudin R; Avram AM; Arama V "C Davila" Univ of Medecine, "C C Iliescu" Instit of Cardiovascular Diseases, Bucharest, Romania Device‐Related infection are often challenging as primary cause and there treatment is not always easy. We present a 67 years old male patient with 18 months history of fever and antibiotic treatment for infective endocarditis following his DDD pacemaker implant. He had undergone 4 previous pocket interventions with no obvious results. During his admission in our center the patient was stil having positive blood cultures with Gram negative germs including Pyocianic, recurrent septicemia, dermatitis and urinary infection. Pacemaker was removed and the 2 leads were extracted mechanically. We implanted a new system on the other side after antibiotic therapy but after a relatively afebrile period of 45 days he came back with recurrent fever. During his second admission we identified a local Achille's tendon abscess where the pt had a plastic orthopedic prosthesis many years before the implant. The abscess was opened, clean and debridment of inflammatory tissue was done. He had a very good recovery following his new antibiotic treatment. Conclusion: Unusual metastatic infection sites or abscesses could be the cause of recurrent infection or endocarditis resistant to antibiotic therapy in pts with device‐ related infections complications. P155 ROLE OF AF PREVENTIVE PACING ALGORITHMS IN LONG TERM MAINTENANCE OF LOW AF BURDEN AS PART OF HYBRID THERAPY IN SICK SINUS SYNDROME Simeonidou E; Papandreou A; Spyroulias G; Varounis C; Dagres N; Anastasiou‐Nana M; Manolis AS 2nd University Cardiology Dept, Attikon Hospital, Athens, Greece Among the non‐pharmacologic therapeutic modalities for management of atrial fibrillation (AF), atrial pacing for AF prevention presented an attractive strategy. Because of limited data regarding its long‐term impact, it still remains as controversial pacing indication. Aim of the study was to determine the long‐term efficacy of preventive pacing algorithms (AFPPA)on AF burden (AFB) in patients (pts) with sick sinus syndrome (SSS) and drug refractory paroxysmal AF. Methods: Study population: 51 pts (10 w, 41 m), mean age 61 ± 9 yrs with SSS, who apart from conventional indications of pacing suffered frequent episodes of AF, refractory to at least 2 antiarrhythmics (AAMs) and they received a PPM with incorporated AFPPA plus AAMs, group A. Another 51 pts (41m) with SSS and frequent AF, who received a conventional DDDR plus AAMs served as controls, group B. Mean LA:43 ± 8 mm. Atrial pacing LR was programmed at 70 bpm. There was an effort to promote native AV conduction by relevant pacing settings. Different AFPPAs were activated in each pt according to the AF onset mechanism. All pts underwent fu in regular basis and interrogation of the stored diagnostic AF data every 6 mos. AFB overtime was compared annually in the same group and between the 2 groups. Two‐way ANOVA for repeated measurements was used to assess the effects of AFPPA on AFB in the 2 groups. Logarithms were used for non‐normally distributed AFB. Results:Average time of fu: 50 ± 8 mos. Five pts in A 10%) and 10 pts (22%) in B group were progressed to permanent AF. Median AFB in A and B groups at baseline, 1 yr and 4 yrs were 3.0, 1.0, 1.2 h/day and 3.8, 3.2, 6.8 h/day respectively and differed between both groups over time (F = 15.88, P < 0.001. AFB improved significantly in the 1st yr only in group A and after 4 yrs deteriorated significantly only in group B. Conclusions: Although AFPPAs efficacy is slightly reduced over time they are useful in AF management of selected SSS pts, as part of hybrid therapy. PUBLIC HEALTH ISSUES P156 TRANSESOPHAGEAL ELECTROPHYSIOLOGICAL STUDY AND PACING – STILL THE OPTION FOR EMERGING COUNTRIES? Volkov D Institute of General and Urgent Surgery of Ams of Ukraine Background: Endocardial EP study and catheter ablation of supraventricular arrhythmias are the golden standards of medical care nowadays. Transesophageal electrophysiological study (TEEPS) and pacing (TEP) couldn't be an alternative, but useful supplement, especially in centers where EP service is absent or not fully available. Atrial flutter (AFl) is second common arrhythmia after atrial fibrillation (AFib), catheter ablation is the first line therapy for typical AFl, but there're a lot of local restrictions in Ukraine to apply this method widely. TEP can be used to interrupt AFl. Methods: We've been using CardioLab+ system (XAI Medica, Ukraine) for TEEPS and TEP by programmed and rapid pacing successfully in 293 tachycardia patients (pts) over last 5 years. Among them TEP for AFl were done in 95 pts (typical AFl – 76 pts). Diagnosis were established based on regular and transesophageal ECGs, AV conduction gaps, RP intervals during tachycardia and patterns of initiations and cessations by pacing and drugs. Results: AFls were converted to sinus rhythm in 86% of pts. 1) cardioversion to sinus rhythm during procedure – 61 pts; 2) induction of AFib with restoration of sinus rhythm up to 2 days – 21 pts; 3) induction and persistence of AFib – 6 pts; 4) recovery of AFl – 7 pts. Most unsuccessful results occurred in atypical AFl's pts. In remaining 198 pts different types of existed tachycardia were evaluated depending on listed above criteria of differentiation: AVRT – 91, AVNRT – 96, ectopic atrial tachycardia – 3, AFl and Afib – 8. No complications were observed. Near a half of pts had catheter ablations afterward. Conclusion: TEEPS is very cheap and useful tool for initiation and investigation of supraventricular arrhythmias in pts with non‐documented palpitations to establish indication for catheter ablation and to control its efficacy if needed. TEP is safe and effective instrument of sinus rhythm restoration in pts with AFls. P157 INTERACTION OF PORTABLE METAL DETECTOR USED IN AIRPORT CONTROLS WITH IMPLANTABLE PACEMAKERS AND CARDIO‐
VERTER DEFIBRILLATORS Tzeis S; Andrikopoulos G; Jilek C; Rassias I; Kolb C; Theodorakis G Cardiology Department, Henry Dunant Hospital, Athens, Greece Aim: Proper function of pacemakers (PMs) or implantable cardioverter‐defibrillators (ICDs) may be impaired due to interaction with electrical devices. Portable metal detectors generate an electromagnetic field that may interfere with PMs or ICDs. In the present study we sought to investigate whether a commercially available portable metal detector routinely used in airport controls interacts with PMs and ICDs. Methods: A total of 75 patients (28 ICD and 47 PM recipients) were tested with and without telemetry communication for electromagnetic interference when exposed to the electromagnetic field generated by a portable metal detector (PD140V – magnetic field Br.m.s. 2.71 μT, electric field Er.m.s. 2.2 V/m) placed over the implanted system under continuous ECG recording. Results: No interference with proper device function (sensing and pacing) was observed in any of the 75 patients tested. Telemetry interference was observed in 83% of patients with 12% of patients presenting a "pseudo‐oversensing" type of telemetry interference (noise recording on online print‐outs without impairment of proper pacing function documented with continuous ECG recording), 59% presenting loss of detection and 12% presenting both types of telemetry interference. Conclusion: Routinely used hand‐held metal detectors may frequently cause telemetry interference with ICDs and PMs without though interfering with proper device function. These findings support the safety of using portable metal detectors for control of PM and ICD recipients. SUDDEN CARDIAC DEATH P158 MULTIRESOLUTION WAVELET ANALYSIS OF HEART RATE VARIABILITY RISK STRATIFIES HEART FAILURE PATIENTS FOR BOTH SUDDEN CARDIAC DEATH AND TOTAL MORTALITY Arsenos P; Gatzoulis K; Manis G; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Kartsagoulis E; Aggelis A; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To evaluate the performance of non‐invasive predictors in arrhythmia risk stratification of heart failure patients (pts). Methods: We prospectively screened 230 patients (age: 64.5 ± 13.4 years, male: 83%, NYHA class: 2.3 ± 0.5, LVEF:32.6 ± 10.1, CAD: 82%,DCMP: 18%) with ECG, SAECG, ECHO and 24‐hour HOLTER. After 17 ± 16.1 months of follow up, pts were classified into the High risk (52 pts, mean Left Ventricular Ejection Fraction (LVEF): 29 ± 10.2%) and the Low risk (174 pts, mean LVEF:33.7 ± 9.9%, p = 0.003) groups according to three SCD surrogates: 1. clinical VT/VF (17 pts) 2.ICD's appropriate activation (22 pts) 3.confirmed SCD (13 pts).Total mortality (TM) was also considered as an end point and 37 deaths were recorded (arrhythmic = 13, pump failure = 17, non cardiac = 7). LVEF, filtered QRS (SAECG), NSVT > 1/24 hours, VPBs > 240/24 hours, Decelaration Capacity (DC) of heart rate, mean Heart Rate (HR), SDNN/HRV, QTc and the scale dependent wavelet‐ coefficient standard deviation [σwav (m)] of multiresolution wavelet analysis (MWA – Haar 8) of HRV were calculated and statistically analyzed for the two groups. Results:σwav (m) was a statistically significant predictor of SCD (Long rank test p = 0.0006). After Cox regression analysis adjusted for LVEF, gender, fQRS, NSVT episodes >1/24hours, VPBs > 240/24 hours, DC, HR, and SDNN, the σwav (m) remained an important and independent SCD predictor with HR:0.991 (P < 0.001) 95% CI: 0.986–0.995. Considering TM as end point σwav (m) was again a statistically significant predictor of TM (Long rank test = 0.0001) and after a new analysis of the same multivariable Cox model for TM, σwav(m) remained an important and independent TM predictor with HR: 0.990 (p = 0.003) 95% CI:0.983–0.996. Conclusions: In this heart failure pts cohort with a short term follow up, σwav (m) was an important and independent predictor both for SCD and TM. P159 PROGRAMMED VENTRICULAR STIMULATI‐
ON AS COMPARED TO THE NON INVASIVE RISK STRATIFIERS FOR SUDDEN CARDIAC DEATH PREDICTION AMONG SEVERE HEART FAILURE PATIENTS Gatzoulis K; Arsenos P; Dilaveris P; Gialernios T; Kartsagoulis E; Sideris S; Archontakis S; Tsiachris D; Aggelis A; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To examine the prediction ability of VT/VF inducibility on Programmed Ventricular Stimulation (PVS) for Sudden Cardiac Death (SCD) among Heart failure (HF) patients (pts). Methods: We screened 114 HF pts (age: 67 ± 11 years, male: 83%, LVEF: 29 ± 9.5, NYHA: 2.4 ± 0.5, CAD: 72%, DCMP: 28%) under optimum treatment with ECG, SAECG, ECHO and 24 hour HOLTER. All pts underwent also a PVS. After 14.1 ± 12.6 months of follow up the sample divided to the HIGH risk (24 pts) and the LOW risk (90 pts) groups according to three SCD events/surrogates: 1. clinical VT/VF 2. ICD's appropriate activation 3. confirmed SCD. Data calculated and statistically analyzed for the two groups. Results:HIGH RISKLOW RISKp(n = 24)(n = 90)valueLVEF (%)27.9 ± 9.5 30.3 ± 10.00.2QRS (ms)120 ± 33125 ± 320.6FQRS (ms)146 ± 29146 ± 300.9QTc (ms)471 ± 51469 ± 570.9Heart Rate69.7 ± 9 69.9 ± 9 0.9NSVT (episodes nb) 4.2 ± 7.7  22.2 ± 107.30.4VPBs (nb) 1483 ± 3355 2437 ± 41390.3VT/VF on PVS (nb/%)18 (75%)46 (51%) 0.03 After multiple logistic regression analysis adjusted for male, age, LVEF, and VT/VF on PVS the only independent and important SCD predictor was VT/VF inducibility on PVS with OR: 3.101 (p = 0.03, 95%CI: 1.101–8.731). Conclusions: In this small and preliminary HF sample the non invasive risk factors from electrocardiography and echocardiography failed to predict SCD on medium term follow up. On the contrary the induction of VT/VF on PVS was the only significant SCD predictor with sensitivity 75% and specificity 48%. P160 NORMOBARIC INTERMITTENT HYPOXIA TRAINING AS A METHOD OF SUDDEN CARDIAC DEATH PRIMARY PREVENTION IN THE PATIENTS WITH ISCHEMIC CARDIO‐
MYOPATHY Dubovik TA; Rachok LV; Shket AP; Khudnitskaya VS Republican Scientific and Practical Center of Cardiology The purpose of this research was to study the efficiency of using a course of normobaric intermittent hypoxia training (NIHT) before coronary bypass surgery (CABG) in the patients with ischemic cardiomyopathy (ICMP) and chronic heart failure (CHF) and its influence on the character of reperfusion complications and life‐ threatening arrhythmias development. Materials and Methods: Cohort of 60 patients with ICMP (n = 30 in the main and control groups) were included into the research. All patients had depressed left ventricle systolic function (LVEF) less than 35%. The main group patients underwent a NIHT before CABG. The indications for CABG were the presence of myocardium more than 50% with accumulation radiopharmaceutical over 50% during SPECT with 99 mTc‐MIBI. Functional state of LV was assessed by means of echocardiography and daily monitoring of the electrocardiogram. Results: The initial CHF severity of the patients in both groups was determined by depressed LVEF against the prevalence of sympathetic activity nervous system (NS). After a course of NIHT a shift in autonomic balance towards the prevalence of parasympathetic NS was marked (RMSSD increased from 28,6 ± 4,5 ms to 58,22 ± 6,1, p <0,05) as well as a reduction in the number of ventricular arrhythmias (VA) against the microcirculatory processes improvement. The main group were characterized with a more favorable recovery during the perioperative period after CABG. We revealed less frequent of ventricular fibrillation during cardiac resuscitation after artificial circulation, reduction of VA and high grade VA in the perioperative period in the main group. Conclusion: For the patients with ICMP and CHF with adequate mass of a viable myocardium, CABG is effective in SCD primary prevention. The use of NIHT in the preoperative period can increase the volume of the viable myocardium and thus helps to protect from reperfusion injury during CABG and provides a more favorable recovery during the perioperative period. P161 RISK STRATIFICATION OF SUDDEN CARDIAC DEATH IN PATIENTS WITH DILATED CARDIOMYOPATHY Vaikhanskaya TG; Melnikova OP; Gul LM; Frolov AV Republican Scientific and Practical Center of Cardiology, Minsk, Belarus Dilated Cardiomyopathy (DCM) is associated with risk of sudden death due to malignant ventricular arrhythmias. Objective: assessment of Holter monitoring predictors of life‐threatening ventricular arrhythmias (LTVA}: microvolt T‐wave alternans (mTWA) and heart rhythm turbulence(HRT) in patients (pts.) with nonischemic DCM. Materials and Methods: 67 pts. with DCM were examined (10,4% females, aged 44,3 ± 11,7 years) by Holter 24‐h (Oxford) and 7‐minute ECG recording (Intecard‐7, including 3 min of exercise test (25 Wt/m). Microvolt TWA detected by the software Intecard‐7 on a method modified moving average in 3 lead of ECG‐12 at exercise test. Results: Heart rhythm ventricular dysfunctions were revealed at 29 (43,3%) pts. with DCM: nonsustained ventricular tachycardia(VT)‐28 pts., sustained VT(1 pts.). On the basis of the received data the step‐by‐step discriminant analysis by which results following independent indicators have been included in mathematical model has been carried out: mTWA ≥ 56 mcV, pathological HRTS < 2,5 ms/RR, presence syncope and extQTc. For definition of risk LTVA for patient with DCM already at the first inspection it is possible to use classification equations. Definition of high risk LTVA for the individual patient is spent by substitution of the received indicators to each of two equations. The patient gets to that group for which classification function has the greatest value. Thus, the classification equations for risk revealing of LTVA in patients DCM look like: HI = 0,9 × mTWA+7,9 × HRTS + 7,3 × Syncope + 6,3 × QTc–31. Hit of the patient in 1 group testifies to high risk LTVA and more adverse forecast. Such category of patients is potential candidates for ICD/CRT‐D. Hit of the patient in 2 group testifies to more favorable forecast and low risk LTVA: LII = 0,6 × mTWA + 3,6 × HRTS + 9,2 × Syncope + 5,6 × QTc–42. In conclusion, sudden death risk stratification is of utmost importance for DCM as it is the main cause of death related to this disease. P162 REDUCED RMSSD FROM HEART RATE VARIABILITY ANALYSIS RISK STRATIFIES HEART FAILURE PATIENTS FOR SUDDEN CARDIAC DEATH Arsenos P; Gatzoulis K; Manis G; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Kartsagoulis E; Sideris S; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To estimate the performance of non invasive arrhythmia predictors in the risk stratification for sudden cardiac death (SCD) of heart failure (HF) patients (pts). Methods: We prospectively screened 230 pts (age: 64.5 ± 13.4 years, male: 83%, LVEF: 32.6 ± 10.1, NYHA class: 2.3 ± 0.5, CAD: 82%, DCMP: 18%) with ECG, SAECG, ECHO and 24 hours HOLTER. After 17 ± 16 months of follow up, pts were classified into the High risk [52pts, mean left ventricular ejection fraction (LVEF): 29 ± 10.2%] and the Low risk group (174 pts, mean LVEF: 33.7 ± 9.9%, p = 0.003) according to three SCD events/surrogates: 1. clinical VT/VF (17 pts) 2. ICD's appropriate activation (22 pts) 3. confirmed SCD (13 pts). LVEF, the filtered QRS (SAECG), NSVT episodes > 1 /24hours, VPBs > 240/24 hours, mean heart rate (HR), RMSSD and SDNN from heart rate variability (HRV) [24 hour HOLTER], were calculated and statistically analyzed for the two groups. Results: RMSSD was a statistically significant predictor of SCD (Long rank test p = 0.01). Furthermore after Cox regression analysis adjusted for LVEF, fQRS, NSVT>1/24 hours, VPBs > 240/24 hours, mean HR and SDNN, the RMSSD remained an important and independent SCD predictor with HR 0.974 (p = 0.01) 95% CI: 0.955–0.993. A cut off point of RMSSD < 46 (75th percentile) presented HR 2.491 for predicting SCD (p = 0.05) 95% CI: 0.969–6.405. Conclusions: In the present HF pts cohort with a short term follow up, RMSSD performed better (logrank p = 0.01) than the most commonly used SDNN (longrank p = 0.05) and it was an important and independent predictor of SCD. Further evaluation of the reduced RMSSD is guaranteed. P163 PREVALENCE OF RISK FACTORS OF SUDDEN CARDIAC DEATH IN TRYPANOSOME CRUZI SEROPOSITIVE PATIENTS Mora G Universidad Nacional de Colombia Chagasic patients with heart disease are at risk of sudden cardiac death (SCD) and sometimes it may be the first manifestation of the disease. The aim of this study was to assess the prevalence of some risk factors for MCS among carriers of antibodies to T. Cruzi with and without heart disease. Methods: 8 patients without heart disease taking (normal electrocardiogram and echocardiogram) were compared with 26 patients with heart disease. Echocardiogram was evaluated, number of premature ventricular contractions, heart rate variability determined by the SDNN, presence of ventricular extrasystoles and polymorphic duplet. Results: No significant differences were found in the different variables evaluated except for the number of extrasystoles in 24 hours (66 vs 369 p = 0.0084), being more common in patients with heart disease. Conclusions: factors commonly described as predictors of SCD are very common in patients with antibodies to T. Cruzi with or without heart disease. The only variable with a significant difference was the number of extrasystoles in 24 hours. P164 RISK STRATIFICATION USING MICROVOLT T‐WAVE ALTERNANS IS NOT FEASIBLE IN A LARGE PERCENTAGE OF POTENTIAL ICD RECIPIENTS Kraaier K; Wilde AAM; Scholten MF Medisch Spectrum Twente, Enschede, The Netherlands Purpose: Previous studies have demonstrated that microvolt T‐wave alternans (MTWA) screening in patients with ischemic and non‐ischemic cardiomyopathy is effective in identifying patients at high or low risk for sudden cardiac death. In this study we evaluated the feasibility of MTWA testing using an exercise protocol in the risk stratification of potential ICD recipients with ischemic or dilated cardiomyopathy. Methods: Medical charts of 180 primary prevention ICD recipients were reviewed to decide if patients were able to perform a MTWA exercise test or not. Contra‐indications for testing were: atrial fibrillation or flutter, pacemaker‐dependency, recent (cardiovascular) surgery (<1 month) and inability to exercise. Results: Fifty‐eight (35%) of the potential ICD recipients were not suitable for testing. Among which; 35 patients were excluded due to atrial fibrillation, 13 patients due to recent surgery, 6 patients due to co‐morbidity (NYHA class IV, paralysis or absence of lower extremities, balance problems, AVblock), and 3 patients due to pacemaker dependency. Conclusion: In several studies MTWA testing is a promising risk stratifier for predicting sudden cardiac death, however, 35% of the potential ICD candidates is not suitable for MTWA testing using an exercise protocol. Therefore alternative methods to estimate MTWA and their clinical value must be studied. P165 HOLTER DERIVED QTC INTERVAL RISK STRATIFIES HEART FAILURE PATIENTS FOR SUDDEN CARDIAC DEATH Arsenos P; Gatzoulis K; Manis G; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Kartsagoulis E; Sideris S; Stefanadis C; APRET First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To estimate the performance of current non invasive arrhythmia risk stratifiers in the prediction of sudden cardiac death (SCD) in heart failure (HF) patients (pts). Methods: We prospectively screened 230 pts (age: 64.5 ± 13.4 years, male: 83%, LVEF: 32.6 ± 10.1, NYHA class: 2.3 ± 0.5, CAD: 82%,DCMP: 18%) with ECG, SAECG, ECHO and 24‐hour HOLTER. After 17 ± 16 months of follow up, pts were classified into the High risk [52pts, mean left ventricular ejection fraction (LVEF): 29 ± 10.2%) and the Low risk (174 pts, mean LVEF:33.7 ± 9.9%, p = 0.003) groups according to three SCD events/surrogates: 1. clinical VT/VF (17 pts) 2. ICD's appropriate activation (22 pts) 3. Confirmed SCD (13 pts). LVEF, the filtered QRS (SAECG), the presence of NSVTepisodes> 1/24 hours, VPBs > 240/24 hours, mean Heart Rate (HR), SDNN from HRV and mean 24 hour QTc interval (24 hour HOLTER), were calculated and statistically analyzed for the two groups. Results: The Holter‐QTc was a statistically significant predictor of SCD (Long rank test p = 0.01). After Cox regression analysis adjusted for gender, LVEF, fQRS, NSVTepisodes > 1/24 hour, VPBs > 240/24 hour, mean Heart Rate and SDNN, Holter‐QTc remained an important and independent SCD predictor with HR 1.009 (p = 0.02) 95% CI: 1.001–1.017. A cut off point of QTc> 470ms (75th percentile) presented HR 1.825 for predicting SCD (p = 0.05) 95% CI: 0.993–3.335. Conclusions: In the present HF pts cohort with a short term follow up, Holter‐QTc was an important and independent predictor of SCD. Further evaluation of the Holter‐QTc in the prediction of SCD is guaranteed. P166 ARRHYTHMIAS IN NEUROMUSCULAR DISEASES: A Moroccan EXPERIENCE AND A LITERATURE REVIEW Bouhouch R*; Fellat I*; Zarzur J*; Oukerraj L*; Bennani R*; Birouk N**; Oudghiri FZ***; Cherti M* *Service de Cardiologie B, CHU Ibn Sina Rabat, MAROC Introduction: Neuromuscular Diseases are a heterogeneous molecular, clinical and prognosis group. Progress has been achieved in the understanding and classification of these diseases. Cardiac involvement in neuromuscular diseases, namely conduction disorders, ventricular arrhythmias and dilated cardiomyopathy with its impact on prognosis, is often dissociated from the peripheral myopathy. Therefore, close surveillance is mandatory in the affected patients. In this context, preventive therapy (beta‐blockers and angiotensin converting enzyme inhibitors) has been recently recommended in the most common Neuromuscular Diseases, Duchenne Muscular Dystrophy and Myotonic Dystrophy. Methods: We report a series of patients with neuromuscular diseases in whom we assessed cardiac involvement and initiated a therapy. From January 2007 to June 2011, 105 patients were referred to cardiology visit by a neurologist or pediatrician. Results: There were 49 female and 56 male with a mean age of 28 years old. Limb‐Girdle muscular dystrophies, Myotonic Dystrophy (MD), and Duchenne / Becker Muscular Dystrophy (DMD, BMD) are the major neuromuscular diseases in our series. Cardiac symptoms were found in 54 patients, ECG was often abnormal (96 patients): 41 patients had a conduction disorder, 42 patients had atrial or ventricular premature beats; Transthoracic Echocardiography found a left ventricular dysfunction in 10 patients. Therapy with beta‐blockers and angiotensin converting enzyme inhibitors was initiated in 37 patients and 5 patients required a Pace‐Maker or an Implantable Cardiovertor Defibrillator. Conclusion: A close collaboration between Cardiologists and referral physicians is mandatory for a better management of Cardiac involvement especially arrhythmias in patients with neuromuscular diseases. P167 MEAN HEART RATE FROM 24 HOUR HOLTER RECORDINGS PREDICTS TOTAL MORTALITY IN HEART FAILURE PATIENTS Arsenos P; Gatzoulis K; Dilaveris P; Gialernios T; Archontakis S; Tsiachris D; Kartsagoulis E; Sideris S; Aggelis A; Stefanadis C; Apret First Department of Cardiology, Medical School, National & Kapodistrian University of Athens, Greece Purpose: To estimate Electrophysiological indices derived from non invasive Electrocardiographic and Echocardiographic screening as Total Mortality (TM) predictors for Heart Failure (HF) patients (pts). Methods: We screened 279 HF pts (age: 67 ± 13.0, male: 83%, NYHA: 2.4 ± 0.5, LVEF: 31.4 ± 10.1, CAD: 80%, DCMP: 20%) under optimum treatment and with ECG, SAECG, ECHO and 24 hour HOLTER (HM). After 14.8 ± 13.3 months of follow up 48 deaths occurred (Sudden Cardiac Deaths: 16, Pump Failure Deaths: 26, Non Cardiac Deaths: 6). Differences of non invasive markers between survivors and non‐survivors analyzed with Log rank test. The correlation of the non invasive markers with mortality was searched through survival analysis method utilizing Kaplan Meier – survival curves adjusted for possible confounders under building of appropriate Cox statistical models. Results: After Cox regression model analysis adjusted for gender, age, LVEF, VPBs/24 hour, NSVT episodes/24 hour, mean Heart Rate and QTc interval the only important and independent predictor of TM was mean Heart Rate(24 hour) presented HR: 1.044 (p = 0.007, 95% CI: 1.011–1.077). Conclusions: Mean Heart Rate predicted TM in HF patients importantly and independently of gender, age, LVEF, VPBs, NSVT and QTc. A cut off point of Heart Rate > 70.5 bpm (50th percentile) presented sensitivity 58% and specificity 51% for predicting TM. SUPRAVENTRICULAR TACHYCARDIAS P168 CASE OF A LATVIAN FAMILY'S ATRIOVENTRICULAR NODAL REENTRY TACHYCARDIA Kupics K; Jubele K; Kalinins A; Sipacovs P Paul Stradin's Clinical University Hospital We would like to describe a case of potentially hereditary AVNRT within one family. Only a very limited number of reports are available in the literature describing inherited cases of AVNRT. In Latvia such cases have not been reported yet. In this family a mother and her two sons suffered from arrhythmia episodes. All of these diagnoses of typical AVNRT were established using intracardiac electrophysiological study. The mother's father also had had an unspecified kind of arrhythmia. In both the son's father and his family members had never occurred any episodes of arrhythmia. The mother and both her sons had had no other comorbidities diagnosed. Only the mother had been on medication – metoprolol 50mg bid, but that therapy had not reduced the number of arrhythmia episodes. The first patient to be treated at out clinic was the younger son, aged 18 (patient no 1). In his case arrhythmias had been occurring for 2 – 3 years at that time. After the younger son's successful treatment, the mother also approached us. She was 51 years old (patient no 2) and has had arrhythmias for over 20 years. The symptoms had worsened after childbirths. The last patient from this family to be treated was the older son, aged 22 (patient no 3). He has had arrhythmias for approximately 2 months. The mother and both son's were treated using radiofrequency catheter ablation of the "slow pathway" of the atrioventricular junction. After one year of regular observation no arrhythmias have reoccurred. This case hints at the possibility that in some cases the reason for changes in the atrioventricular junction that are responsible for AVNRT could be inherited, possibly in the form of an autosomal dominant type. P169 3D NONINVASIVE MAPPING AND RESULTS OF CATHETER ABLATION OF TACHYARRHY‐
THMIAS Revishvili A; Sopov O; Dzhordzhikiya T; Simonyan G; Lyadzhina O; Fetisova E; Kalinin V Bakoulev Scientific Center for Cardiovascular Surgery, Moscow, Russia Introduction: We evaluated facilities of the novel 3D surface ECG based mapping technology in patients with different atrial and ventricular arrhythmias. Methods: Before procedure noninvasive mapping using 240‐lead ECG combined with CT scan based anatomy (Amycard, RUS) was performed in 102 patients. Among them 48 patients (mean age 36,3 ± 14,6 years) were with ectopic non‐ischemic ventricular arrhythmias (VT/PVC), 35 patients (mean age 32,8 ± 10,3 years) with WPW syndrome, 19 patients (mean age 39,4 ± 16,6 years) with ectopic atrial tachycardias. The findings were compared with invasive 3D mapping and successful radiofrequency ablation. Results: In 48 patients with ventricular arrhythmias (95,9%) a location of ectopic focus was similar to the invasive data and arrhythmia was successfully eliminated by single radiofrequency (RF) application. Two focal VT (4,1%) located in interventricular septum could not be accurately identified by noninvasive mapping. Clinical target coincided in 54 (100%) patients with WPW syndrome and atrial tachycardis and successfully terminated by RF ablation. Mean distance between noninvasive target and effective point of ablation was 3,8 ± 2,5 mm. Time of fluoroscopy in group of patients that underwent noninvasive mapping was significantly lower 4,1 ± 2,5 min in comparison with average 10,3 ± 4,9 min (P < 0,05). Conclusion: Initial experience with a novel noninvasive 3D mapping system shows its clinical utility in various arrhythmias, feasibility of accurately locating the target and significant reduction of fluoroscopy and procedure time. P170 DIFFERENCES IN ANATOMICAL LOCATION AND CONDUCTION PROPERTIES OF ACCESSORY PATHWAYS IN SYMPTOMATIC WPW PATIENTS WITH AND WITHOUT CLINICAL DOCUMENTED TACHYCARDIAS Pastor A; Leguizamón J; Zorita B; Panizo J; Jiménez S Hospital Universitario de Getafe (Madrid), Spain Radiofrequency ablation is the preferred treatment for symptomatic WPW syndrome. Clinicians have to face symptomatic WPW patients (P) but with non‐documented ECG clinical tachycardia (CTa), in whom some therapeutic doubts arise, especially in case of presumed high risk ECG appearance (midseptal/perihisian location). Purpose: Analyse the anatomical location and conduction capabilities of accessory pathways (AccP) in P with symptomatic WPW with and without documented ECG CTa before ablation. Methods: 100 consecutive symptomatic WPW P considered for ablation. Group A consisted of 56 P with documented ECG CTa and Group B, 44 P with symptoms of palpitations, dizziness or syncope, but without documented ECG CTa. Results: Left‐sided AccP was more frequent in group A compared to group B (60% vs 34%, P < 0.01). Septal location, was found more frequently in group B compared to group A (50% vs (28%, P < 0.05), being located close to AV conduction system (midseptal o perihisian) in 6 (14%) and 6 (11%) respectively. Only anterograde conductive AccP was found more frequently in group B than in group A (36% vs 5%, P < 0.02). Orthodromic tachycardia inducibility rate was similar in group A and in group B P with bidirectional conduction of AccP(92% vs 86%). Conclusion: 1. An important subset of symptomatic WPW P (44%) considered for ablation have not documented ECG CTa before the procedure, being septal location in half of these P. 2. Exclusive anterogradely conductive AccP were found more frequent in non‐documented ECG CTa group compared to documented ECG CTa group. 3. In non‐documented ECG CTa, bidirectional conductive AccP were present in 64% and had similar rate of inducible orthodromic tachycardia compared to documented ECG CTa group, maintaining indication for ablation in the majority of these P, although careful consideration if "high risk" WPW ECG profile (septal location near AV system) or anatomical difficulties are anticipated. P171 RESULTS OF ELECTROPHYSIOLOGIC TESTING IN CHILDREN WITH ASYMPTOMATIC WPW SYNDROME Ivanitskiy EA; Kropotkin EB; Tsaregorodtsev AP; Kasimtseva TA The Federal Centre of Cardiovascular Surgery The aim of this study was to find out the strategy of management of children with asymptomatic WPW syndrome. Methods: 20 consecutive patients were enrolled in the study, age 3 – 15 years. There were all typical features of preexitation on the surface ECG, and no registered paroxysms of tachycardia on surface ECG or symptoms of palpitation in past. 18 patients underwent catheter ablation of accessory pathway (AP) after previous electrophysiological study. All procedures were performed under the general anesthesia. Results: Anterograde conduction via accessory pathway more than 220 beats per minute (bpm) and effective refractory period (ERP) less than 250 ms were revealed in 15 patients. Anterograde conduction via AP less than 180 bpm and ERP more than 300 ms were seen in three patients. But retrograde conduction via AP in these three patients was more than 220 bpm, ERP was less than 250 ms. Atrioventricular reciprocating tachycardia was induced in 14 patients. Atrial flutter was induced in one patient with 1:1 conduction via AP. All these patients underwent catheter ablation of AP. No major complications were seen after catheter ablations. Conclusion: Indications for AP ablation were revealed in 90% of patients after previous electrophysiological study. Electophysiological study is a crucial moment for taking a decision to perform ablation of AP in children with asymptomatic WPW syndrome. P172 CARDIOMYOPATHY INDUCED BY PAROXYSMAL TACHYCARDIA – AN UNDERDIAGNOSED CLINICAL ENTITY Bogossian H; Ninios I; Karosiene Z; Pechlivanidou E; Mijic D; Kloppe A; Zarse M; Lemke B Klinikum Luedenscheid, Germany Introduction: Cardiomyopathy due to a sustained tachycardia is a common clinical entity. The detrimental effects of self‐terminating tachycardias, however, have been less thoroughly investigated. We examined the effects of interventional ablative therapy on the systolic left ventricular ejection fraction (EF) of otherwise healthy patients (P) with paroxysmal tachycardias. Methods: 241 consecutive P without structural heart disease(no coronary heart disease, no valve disease, no ICD or pacemaker) presenting for ablation therapy due to paroxysmal tachycardias were examined. EF was determined by echocardiography before and 1–3 months after ablation. Incidence of tachycardia was determined by repetitive Holter ECG and according to described symptoms. Results: 241 P with the following tachycardias were included: AVNRT (n = 99), atrial flutter (n = 57), paroxysmal AF (n = 51), EAT (n = 6), AVRT (n = 14), idiopathic VT (n = 14). 24% of P demonstrated with a slightly decreased EF (48 ± 6%): 22% of AVNRT‐P(EF 51 ± 5%), 28% of atrial flutter‐P (EF 47 ± 8%), 25% of paroxysmal AF‐P (EF 48 ± 9%), 17% of EAT‐P (EF 54 ± 4%), 21% of AVRT‐P (EF 46 ± 8%), 21% of VT‐P (EF 43 ± 7%). Ventricular tachycardias proved to be more detrimental to EF than supraventricular tachycardias. After successful ablation left ventricular function normalized in all patients (EF: 61 ± 5%). Conclusions: Not only sustained but also paroxysmal tachycardias may cause EF deteriorations which are fully reversible after ablation therapy. Supraventricular tachycardias worsen EF independent of its diagnosis but clearly correlated to its incidence. In P with undetermined cause of reduced EF a sinus rhythm ECG does not exclude the possibility of a tachycardiomyopathy. Therefore also paroxysmal tachycardias have to be excluded. In patients with frequent episodes of paroxysmal tachycardias ablation therapy should be planned on a short term basis to prevent tachycardiomyopathy. P173 TACHYCARDIOMYOPATHY INDUCED BY FOCAL ATRIAL TACHYCARDIA: THE INCIDENCE, ELECTROPHYSIOLOGICAL PREDICTORS AND THE LONG TERM OUTCOME Ju W; Chen M; Yang B; Chen H; Zhang F; Yu J; Cao K Department of Cardiology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, 2100 Objectives: To report the incidence, clinical and electrophysiological characteristics, and the long term outcomes of the patients with focal ATs induced cardiomyopathy. Methods: Totally 186 cases of patients with focal atrial tachycardias but without pre‐exiting structural heart disease underwent catheter ablation from Jan 2005 to Apr 2011 in our institution were enrolled in the study. The data were retrospectively analyzed to characterize the clinical and electrophysiological profiles of patients with tachycardia induced cardiomyopathy, which was defined as the left ventricle ejection fraction ≤50%. Results: Twelve patients (9 males, the mean age 23.4 ± 16.0 years) were identified to have tachycardiomyopathy, giving an incidence of 6.5%. The patients with tachycardiomyopathy were younger (23.4 ± 15.9 vs 45.7 ± 17.1, P < 0.05) and more frequently males (9/12 vs 64/174, P < 0.05). The tachycardias in the cardiomyopathy group were more frequently incessant (10/12 vs 32/174, P < 0.05).The prevalence of symptoms, including the palpitations, shortness, and syncope or pre‐syncope was not different between the two groups, as well as the tachycardia cycle length and heart rate. The appendage was the most preferential site for the tachycardia to develop cardiomyopathy (8/12). In a 36.3 ± 20.1 months follow up, all of the patients with cardiomyopathy had their left ventricle ejection fraction improved by either catheter ablation or rate control using drug therapy (43.9 ± 5.8 vs 61.1 ± 3.5, P < 0.05). However, one patient suffered sudden death due to unauthorized withdrawal, which leading to uncontrollable heart failure. Conclusions: About 6.5% patients with focal atrial tachycardia developed to tachycardiomyopathy. The incessant nature was associated with the development of the myopathy. The appendage was the most preferential site. Most patients had benign long term outcome using either catheter ablation or rate control by drug therapy. P174 NONINVASIVE BEAT‐TO‐BEAT CARDIAC MAPPING FOR TOPICAL DIAGNOSIS OF ATRIAL AND VENTRICULAR TACHYARRHY‐
THMIAS Shlyakhto E; Lebedev D; Treshkour T; Chmelevsky M; Zubarev S Almazov Federal Heart, Blood and Endocrinology Centre, St. Petersburg, Russia Topical diagnosis of atrial and ventricular ectopy is a relevant issue in electrocardiology. Non‐invasive beat‐to‐beat epi‐ and endocardial cardiac mapping (NCM) is a fundamentally new method of solving this problem. NCM is based of solving the so‐called inverse electrocardiographic (ECG) problem: digital reconstruction of electrograms on the epicardium and endocardium based on the multichannel ECGs recorded on the torso surface. Accurate individual heart and thorax anatomical images derived from tomography studies are used for the calculations. Objective: To determine localization of focal atrial and ventricular tachyarrhythmias (SVTA and VTA) and to explore nature of spread of excitation, using NCM. Materials and Methods: 35 patients were examined, 5 with SVTA and 30 with VTA, average age 43 ± 12 years. Men/women – 21/14. VTA were presented by monomorphic ventricular ectopic complexes (VEC) in 19 cases and nonsustained ventricular tachycardia (VT) in 11 cases. Among patients with SVTA: 3 were with atrial premature beats, 2 – with atrial tachycardia. All patients were identified with indications for radiofrequency catheter ablation (RFCA). For topical preoperative diagnosis NCM with AMYCARD 01 C SYSTEM for Noninvasive EP studies was performed. 15 patients underwent RFCA tachyarrhythmias: 12 patients with VTA and 3 patients with pulmonary veins (PV) ectopia. In 9 cases electroanatomic mapping CARTO was applied and in 3 cases – with software module CARTO Merge. Results: The areas of early activation were defined by construction of potential and isochrone maps on epi‐ and endocardium. The first results showed a complete coincidences of early activation areas obtained using intraoperative mapping and NCM. Conclusions: NCM can improve accuracy of preoperative topical VTA and SVTA diagnosis, reduce time of intraoperative mapping and duration of the cateter ablation procedures. P175 RELATIONSHIP BETWEEN LEFT VENTRICULAR DIASTOLIC FUNCTION AND ABNORMAL REPOLARIZATION AFTER RADIOFREQUENCY CATHETER ABLATION IN PATIENTS WITH WOLFF‐PARKINSON‐WHITE SYNDROME Weng K‐P; Lin C‐C; Hsieh K‐S Kaohsiung Veterans General Hospital, Taiwan Purpose: To assess the serial changes in LV function after RF ablation of a manifest accessory pathway and the relationship between T‐wave changes and LV diastolic function. Methods: The subjects consisted of three groups with tachyarrhythmias. Group A (n = 20): manifest WPW syndrome. Group B (n = 20): concealed WPW syndrome. Group C (n = 20): AVNRT. All patients underwent a series of EKG and echocardiographic examination before and after the catheter ablation procedure. With regard to LV diastolic function parameters, E/A ratio, DT, IVRT, Tei index and tissue Doppler parameters were assessed. Results: In group A (12 ± 3 years), 13 patients had T‐wave changes after ablation. In group B (13 ± 2 years) and C (11 ± 5 years), none had T‐wave changes after ablation. In three groups, there were no significant changes in LVDD, LVSD, and EF before and after the ablation procedure. The cE/A ratio decreased after the ablation and began to improve after 1 month. The cDT increased after the ablation and decreased after 1 month. Left ventricular cIVRT improved in the late period. No statistically significant change was observed in the E/Em ratio. The Em/Am ratio, Tei index, and tissue Doppler parameters obtained from the lateral side of the mitral annulus using tissue Doppler was statistically different before and after the ablation procedure. There was no correlation between the presence of T‐wave changes and postablation echocardiographic findings. Conclusions: T‐wave change after RF ablation of manifest accessory pathway may result from abrupt alteration of the sequence of ventricular repolarization and are not a direct result of RF ablation. This conclusion is supported by no correlation between the presence of T‐wave changes and postablation echocardiographic findings. Key words: Radiofrequency ablation, T‐wave, diastolic function P176 SLEEP APNEA DOES NOT PREDICT ATRIAL FLUTTER RECURRENCE AFTER ATRIAL FLUTTER ABLATION van Oosten EM; Furqan MA; Redfearn DP; Simpson CS; Michael KA; Fitzpatrick M; Hopman WM; Baranchuk A Kingston General Hospital, Queen's University, Kingston, Ontario, Canada Background: Sleep apnea (SA) has been associated with atrial fibrillation (AF) and has been found as a predictor of AF recurrence after successful pulmonary vein isolation (PVI). However, no investigations have been carried out to determine the prevalence of SA in patients with atrial flutter (AFL) and the impact of SA on AFL recurrence after AFL ablation. Aim: To determine if SA is a predictor of recurrence of AFL and/or atrial arrhythmias in patients who have undergone AFL ablation. Methods: Retrospective electronic chart review analysis of consecutive right sided isthmus dependent AFL referred for ablation over a two year period. Recurrent atrial arrhythmias were classified as AFL, AF, or other atrial arrhythmias. SA prevalence was determined. Results: We included 122 consecutive patients undergoing AFL ablation between Jan. 2008 – Dec. 2009. Mean follow‐up was 28.3 ± 6.4 months. 20 patients were excluded due to atypical flutter, procedure abandonment, misdiagnosis, or PVI being the primary procedure. Male 75.4%, mean age 68.3 ± 10.4 years, hypertension 65%, and structural heart disease 42%. Prevalence of SA was 27% (33 patients). Recurrence of AFL was observed in 9.8%, recurrence of AF was observed in 22%, and other arrhythmias in 5%. SA was not a predictor of AFL recurrence (6.1% vs. 11.2%, p = NS). SA was neither a predictor of AF nor of other arrhythmia recurrences. Variables associated with AFL recurrence were: no history of pre‐ablation antiarrhythmic drugs (18.8% vs. 6.7%, p = 0.04) and lower BMI (27.07 kg/m2 vs. 30.87 kg/m2, p = 0.04). Variables associated with AF recurrence included: paroxysmal atrial flutter (vs. persistent) (26.7% vs. 9.4%, p = 0.04), higher BMI (32.6 kg/m2 vs. 29.7 kg/m2, p = 0.039), and lower right atrial volume index (23.9 mL/m2 vs. 32.2 mL/m2, p = 0.002). Conclusions: In this cohort prevalence of SA in patients with AFL was increased (27%). SA was not found to be a predictor of AFL recurrence after successful AFL ablation. P177 INTRACARDIAC ULTRASOUND‐GUIDED ABLATION OF CAVOTRICUSPID ISTHMUS Bencsik G; Pap R; Makai A; Klausz G; Chadaide S; Traykov V; Sághy L 2nd Department of Internal Medicine and Cardiology Center, University of Szeged, Hungary Aims: Our aim was to compare intracardiac echocardiography (ICE) guided ablation of cavotricuspid isthmus (CTI) with conventional fluoroscopy‐guided ablation (FGA) focusing on procedure and fluoroscopy times, radiation exposure and delivered radiofrequency energy (RFE). Patients and Methods: In our single center, prospective, randomized study we included 72 patients (mean age 64.6 ± 11.06, 13 women) scheduled for CTI ablation with documented typical flutter. We randomized patients (1:1 fashion) in two groups: one with conventional FGA (36 patients with 3 femoral punctures for 2 multipolar and 1 ablation catheter) and a second ICE‐guided group (36 patients) with 4 femoral punctures (additional puncture for ICE catheter placed in right atrium). Procedure time was counted from starting the punctures until withdrawal of the last sheath. Fluoroscopy times and radiation data (cumulated radiation and dose‐area product (DAP)) were registered by radiology system and RFE data (sum of delivered RFE) by EP system. The endpoint for ablation was bidirectional block on the CTI after a waiting period of 30 minutes. Results: We found a significantly shorter procedure time (105.0 ± 30.3 min vs. 67.2 ± 16.0 min, p = 0.005) and a significantly lower fluoroscopy‐time (19.1 ± 10.7 min vs. 5.6 ± 4.3 min, p = 0.001) in the ICE‐guided group. DAP was found to be significantly higher in the FGA group (1493.6 ± 1263.3 cGycm2 vs. 433.3 ± 435.8 cGycm2, p = 0.001) and the sum of delivered RFE was significantly higher in the FGA group (14481.4 ± 11035.0 Ws vs.10339.5 ± 6917.7 Ws, p = 0.011). Four vascular complications (groin haematoma) and steam pops (3 in each group) were equally distributed. Conclusion: ICE‐guided ablation of CTI significantly shortens the procedure and fluoroscopy time and markedly decreases radiation exposure in comparison with FGA without a risk of increasing a complication rate. Using ICE‐guidance the sum of delivered RFE was found to be significantly lower. P178 ECHOCARDIAGRAPHIC DYNAMIC IN PATIENTS WITH PAROXYSMAL ATRIOVENTRICULAR NODAL REENTRY TACHYCARDIA BEFORE AND AFTER RADIOFREQUENCY CATHETER ABLATION Ardashev AV; Rybachenko MS; Konev AV; Zhelyakov EG; Belenkov YuN* 83 Clinical Hospital of FMBA, * Lomonosov State University, Moscow, Russia Purpose: To assess hemodynamic parameters in pts with atrioventricular nodal reentry tachycardia (AVNRT) before and after slow pathway radiofrequency catheter ablation (RFA). Methods and Material: Study included of 81 pts who were divided into 2 groups. Study group consistent of 61 AVNRT pts (17 female, mean age 45.3 ± 15.1 years) who underwent RFA of AV node slow pathway. Control group comprised of 20 healthy volunteers (5 female, mean age 41.9 ± 5.3 years) without structural heart pathology. Hemodynamic parameters were accessed by means of transthoracic echocardiography before and 2, 6, 12 months after intervention. We used M‐mode, 2D‐mode to determine end diastolic dimension of the left ventricle (LV), end systolic dimension of LV, end diastolic volume of LV, end systolic volume of LV, ejection fraction of LV. Results: There were no significant differences of hemodynamic parameters in studied and control groups before and 2, 6, 12 months after RFA. In AVNRT pts parameters of hemodynamics did not undergo substantial changes during 12 months of follow up after RFA comparing with initial values. Minor anomalies of development of cardiac connective tissue were diagnosed in 28 (45%) AVNRT pts (mitral valve prolapse – 21 pts, left ventricle accessory chords – 7 cases) vs 2 cases (mitral valve prolapse in both cases) of control group (10%) (P < 0.01). Conclusion: Hemodynamic parameters of AVNRT pts characterized by normal values and don't differ from healthy population before and after RFA of AV node slow pathway. AVNRT might be associated with minor anomalies of development of cardiac connective tissue. P179 ELECTROANATOMICAL MAPPING OF AV NODE AND CRYOABLATION OF PARAHISIAN ATRIAL TACHYCARDIA Katsouras GE; Grimaldi M; Petruzzellis A; Sgueglia M; Langialonga T Cardiology Clinic, "F.Miulli" General Hospital, Acquaviva delle Fonti, Italy Introduction: Focal atrial tachycardia originating from the parahisian region is relatively rare. Ablation of this form of tachycardia may carry a potential risk of atrioventricular (AV) block with consequent pacemaker implantation. Methods: N/A. Results: A 37 y female, without previous diseases of note, presented with nausea, asthenia, and sense of imminent death! ECG showed frequent and repetitive atrial extrasystoles. An electrophysiologic study was performed, demonstrating numerous repetitive parahisian extrasystoles. Beta‐blockers, flecainide or sotalol were not efficient and the patient after 6 months gave informed consent to proceed with ablation of the focus. We introduced a decapolar catheter into the coronary sinus as a reference catheter and used a Navistar catheter to map the arrhythmia (CARTO system). We first constructed the right atrium and AV ring anatomy while performing a detailed mapping of the AV node, creating a cluster of points of 2 mm diameter. Each point corresponded to a His signal on the catheter. We circumscribed such points with a yellow line (Fig.) and proceeded with activation mapping of the extrasystoles. The tachycardia was arising from the midseptal region between the AV node and the AV ring. We introduced a 7 F 4 mm tip Medtronic CryoCath quadripolar catheter which was also shown on our map after regulating the CARTO system. However, we performed cryoablation excluding the CryoCath catheter from the CARTO system for incompatibility reasons. After ablation, we noted junctional beats different from the original tachycardia which had disappeared by the first month control. At one‐year follow up, the patient presented only 1 atrial extrasystole during 24 h Holter. Conclusions: To our knowledge, this is the first report of AV node mapping with the technique described above, as well as the first report of combined use of cryoablation with the CARTO system. P180 THE OCCURRENCE OF AV BLOCK AFTER SLOW PATHWAY ABLATION AND 12 MONTHS FOLLOW UP: TWO‐CATHETER APPROACH Kocijancic A; Mrdja S; Mujovic N; Marinkovic M; Potpara T; Polovina M; Simic D; Ostojic MC Clinic for Cardiology, Clinical Center of Serbia, Belgrade, Serbia Background: Radiofrequency ablation of the slow pathway has been recommended as first‐line therapy for the treatment of AVNRT. The purpose of this study is to show that incidence of AV block follow the slow pathway ablation is not higher with two‐catheter approach than with multi‐catheter approach, as referred in the literature. Methods: A total of 92 consecutive patients (aged 19–76, mean 51.9 ± 13.3 years) underwent RFA of the slow pathway, 59 (64.1%) were female. Electrophysiologic method with only two electrode catheters, one diagnostic, (placed in the high right atrium) and one ablation cathether ("two‐catheter approach") was used. The patients were followed at the outpatient clinic for 1, 6 and 12 months during the first year after the procedure. Results: RF ablation was acutely successful in 91 patients (98.9%); slow pathway ablation was achieved in 38 patients (41.3%) and slow pathway modification in 54 (58.7%). Transient AV block occurred in 4 patients (4.3%) during the procedure. After 12 months follow‐up complete AV block occurred in 1 patient (1,1%) required pacemaker implantation. Conclusions: The use of a "two‐catheter approach" (one diagnostic and one ablation) was as effective and safe as a multi‐catheter approach. The incidence of acute and late AV block showed results similar to those of previous studies. P181 RIGHT ATRIAL TACHYCARDIA DESPITE SILENT RIGHT ATRIUM Bogossian H; Ninios I; Karosiene Z; Pechlivanidou E; Guenesdogan B; Kloppe A; Mijic D; Zarse M; Lemke B Klinikum Luedenscheid, Germany We saw a 62 year old male patient suffering from severe palpitations during his atrial driven tachycardia with a heart rate of 105 bpm with 1:1 ventricular pacemaker (PM) stimulation (Cycle length 575 ms) for 8 weeks. A DDDR PM has been implanted due to intermittent AV‐Block III°. CHD has been ruled out via coronary angiography. Echocardiographic examination showed only slightly reduced systolic left ventricular function (EF 48%) without any major valvular dysfunction. Cardiac risk factors were hypertonus, hyperlipidemia and diabetes. Additionally the patient suffered from obstructive sleep apnea. Paroxysmal atrial fibrillation has been described. Before EP‐study, PM modus was changed from DDDR to VVI 30/min which caused a decrease in heart rate down to 53 bpm due to 2:1 block in ventricular answer. During EP study we saw a totally silent right atrium (RA) which showed neither electrical activity nor response to stimulation even with high output. Exclusively in the coronary sinus (CS) and directly adjacent areas, a rapid centrifugal activity was demonstrated. 3‐D electroanatomical mapping was employed after pacing‐manoevers including entrainment and post‐pacing intervals were measured to closer define the area of interest. At the defined hot spot RF‐energy was applied. However, only after adding a line up to an electrically isolated anchor‐point at the tricuspid‐valve circumference tachy was terminated, followed by an atrial electrical standstill which required DDDR‐Pacing. Long AV‐interval allowed for intrinsic AV‐conduction which immediately decreased clinical symptoms. Atrial electrical standstill in one atrial chamber with the other one demonstrating rather normal electrical activity is quite unusual. In our case the underlying pathophysiological mechanism might be connected to increase right atrial pressure due to obstructive sleep apnea. This effect might be aggravated by the underlying hypertension and paroxysms of atrial fibrillation. P182 GENDER DIFFERENCES IN THE CLINICAL CHARACTERISTICS AND ATRIOVENTRI‐
CULAR NODAL CONDUCTION PROPERTIES IN PATIENTS WITH ATRIOVENTRICULAR NODAL REENTRANT TACHYCARDIA (AVNRT) Singhal R; Jaswal A; Saxena A Fortis Escorts Heart Institute, New Delhi, India Introduction: Atrial fibrillation and WPW syndrome have higher incidence in men while Atrial tachycardia and Atrioventricular nodal reentrant tachycardia (AVNRT) occurs frequently in women. The electrophysiological (EP) characteristics of gender differences in AVNRT is still not clear. This study investigated gender‐related EP differences in patients (pts) undergoing radiofrequency (RF) ablation. Objective: The aim of study was to investigate gender‐related EP differences in pts undergoing RF ablation of AVNRT. Methods & Results: 580 AVNRT pts (men/women 210/370; 1.8:1); mean age‐45.6 ± 18.6 years old, who underwent RF ablation were enrolled in study over three years (2007‐2010). We evaluated gender differences in EP characteristics. Women had younger age of onset, higher incidence of multiple jumps, shorter AH interval, atrial effective refractory period (ERP), anterograde (AG) fast pathway ERP, AG slow pathway ERP, retrograde (RG) slow pathway ERP, and longer ventricular ERP than men. Incidence of baseline VA dissociation was lower in women than men. No gender differences in tachycardia cycle length of AVNRT was noted. Women needed less isoproterenol/atropine to induce AVNRT. No gender differences in radiation exposure time, complication rate, acute success rate or second procedure rate were noted. Typical AVNRT was more predominant in women and atypical AVNRT was more in men. In patients with atypical AVNRT, there was no significant gender difference in incidence of baseline VA dissociation; however, the RG slow pathway ERP was significantly shortin women than in men. Women of premenopausal age ≤50 years old had higher incidence of AG multiple jumps and RG jump phenomenon, and short AG slow pathway ERP and RG slow pathway ERP than those of women ≥50 years old. Conclusion: Gender differences in AG and RG AV nodal EP were noted in pts with AVNRT, which may be related to cyclical changes in hormonal milieu in premenopausal women vs men and postmenopausal women. P183 OUTCOME ON ATRIAL FLUTTER PATIENT WITH POOR EJECTION FRACTION WHO UNDERWENT SUCCESSFUL RADIOFREQUENCY ABLATION AT ONE YEAR Tan VH (1,2); Imran SS (1,3); Liew R (1); Tan BY (1); Chong D (1); Teo WS (1); Ching CK (1) 1. National Heart Centre of Singapore, 2. Changi General Hospital, 3. Khoo Teck Puat Hospital Introduction: There were limited studies on the outcome of patients with atrial flutter and poor left ventricular ejection fraction (LVEF) who underwent successful radiofrequency catheter ablation (RFCA). We report the 12 month outcome of patients with atrial flutter and depressed LVEF who underwent successful RFCA. Methods: Patients with atrial flutter and depressed LVEF ≤ 40% were included over a 15 months period. Clinical demographics, recurrence of atrial flutter at 12 months and change in NYHA status and LVEF were collected and analyzed. Results: There were 15 patients with atrial flutter and LVEF ≤ 40% during the period. Majority were male (86.7%) and mean age was 66.7 ± 8.5 years. 80% of patients had ischemic heart disease and 20% had prior stroke. Distribution of NYHA status at baseline was as follow: class I: 6.7%, class II: 53.3%, class III: 33.3% and class IV: 6.7%. All underwent successful RFCA. One patient developed pseudoaneurysm at puncture site post procedure. Mean EF before ablation was 24 ± 6.3%. Post ablation mean LVEF increased significantly to 37.6 ± 17.6% (P < 0.01). Improved ejection fraction (>40%) after ablation was noted in 46.7% of patient. Mean duration of repeat EF post ablation was 9.1 ± 7.2 months. The recurrence rate was 14% at 12 months. Comparing those who had improved LVEF (>40%) with poor LVEF (≤40%), there was no significant different in baseline characteristic and recurrence rate at one year. However, there was significant difference in NYHA class post ablation in which 4 (57%) patients were at NYHA class 1 in EF>40% group as compare to none at NYHA class 1 in EF≤40% group, p = 0.03. Conclusions: Atrial flutter ablation in patients with LVEF ≤ 40% was safe with a recurrence rate of 14% at 12 months follow‐up. LVEF was significantly improved post ablation. Of note those who attained LVEF >40% had significantly improved NYHA status. P184 ONE YEAR OUTCOME ON ISCHEMIC VERSUS NON‐ISCHEMIC CARDIOMYOPATHY WITH POOR EJECTION FRACTION IN ATRIAL FLUTTER PATIENT WHO UNDERWENT SUCCESSFUL RADIOFREQUENCY ABLATION Tan VH (1,2); Imran SS (1,3); Liew R (1); Tan BY (1); Chong D (1); Teo WS (1); Ching CK (1) 1. National Heart Centre of Singapore, 2. Changi General Hospital, 3. Khoo Teck Puat Hospital Introduction: Studies have shown that patients with atrial flutter and poor left ventricular ejection fraction (LVEF) who underwent successful radiofrequency catheter ablation (RFCA) have significant improvement in LVEF and NYHA class. We sought to determine if there were differences in LVEF improvement and changes in NYHA status between patients with ischemic (ICMP) and non‐ischemic cardiomyopathy (NICMP) ≤ 40% LVEF who underwent successful RFCA for atrial flutter. Methods: Patients with atrial flutter and depressed LVEF ≤ 40% were included over a 15 months period. Clinical demographics, recurrence of atrial flutter at 12 months and change in NYHA status and LVEF were collected and analyzed. Results: 15 patients with atrial flutter and LVEF ≤ 40% during the period were recruited. 80% (12 patients) have ICMP versus 20% (3 patients) with NICMP. Clinical demographics between the two groups were similar. Distribution of NYHA status (ICMP vs. NICMP) at baseline was as follow: class 1: 0% vs. 33.3%, class 2: 66.7% vs. 0%, class 3: 25.0% vs. 66.7% and class 4: 8.3% vs. 0%. One patient in NICMP group developed pseudoaneurysm at puncture site post procedure. There was significant improved in mean LVEF post ablation within both groups (ICMP: 22.6% vs. 32.3%, p = 0.03; NICMP: 29.7% vs. 58.7%, p = 0.04). NICMP group had a significant increase in magnitude of LVEF post ablation compared to ICMP (+29.0% vs. +9.7%, p = 0.04). There was improvement in NYHA class post ablation in both groups (ICMP vs. NICMP) and as follow: class 16.7% vs. 66.7%, class 2: 58.3% vs. 33.3%, class 3: 25.0% vs. 0% and class 4: 0% vs. 0%. The recurrence rate was 25% at 12 months in the ICMP group whereas there was no recurrence in the NICMP group (p = 0.5). Conclusions: LVEF and NYHA status improved significantly in patients who underwent successful RFCA of atrial flutter. Of note, patients with NICMP seemed to have greater improvement in LVEF compared to those with ICMP. SYNCOPE P185 HEART RATE VARIABILITY IN CHILDREN IN DEPEND ON THE TYPE OF RESPONSE TO HEAD‐UP TILT‐TEST Pogodina AV; Dolgikh VV; Valyavskaya OV Scientific centre of family health and human reproduction problems