171 Right ventricular free wall longitudinal strain (RVFWSL): a new outcome predictor in patients candidate for TAVI

Aims Right ventricular systolic dysfunction is considered an outcome predictor in various cardiac diseases, sometimes stronger than ejection fraction (EF). We assume that right ventricular dysfunction, calculated with echocardiography in patients candidate for trans-catheter aortic valve implantation (TAVI), could be an outcome predictor. To evaluate the prognostic value of pre-TAVI right ventricular free wall longitudinal strain (RVFWSL) in patients with severe aortic stenosis undergoing TAVI. Methods and results Retrospective analysis of 100 patients underwent transfemoral TAVI in our hospital from January 2015 to September 2019, with at least a pre-TAVI and post-TAVI echocardiography. For each patients we collected clinical and echo data before and after TAVI and during the follow-up; we measured RVFWSL off-line at the same time. We considered the value of [23.3]% the cut-off of normality for RVFWSL. The primary endpoint was a composite of death from any cause and hospitalization for heart failure. The median age of the patients was 81 years (79–83) and EF was preserved in most patients (median: 56%, 55–58.28%). At a median follow-up of 1023 days (630–1387), the univariate analysis demonstrated a predictive of a reduced RVFWSL before TAVI ( < [23.3]%, P = 0.015) and EF < 50% (P = 0.014). Cox regression analysis found that pre-TAVI reduced RVFWSL (HR: 2.875, CI 95%: 1.113–7.425; P = 0.03) and EF < 50% (HR: 2.511, CI 95%: 1.07–5.892; P = 0.03) were independently associated with composite endpoint of the study. Moreover, a reduced EF associated with RVFWSL < [23.3]% had an incremental value in predicting the outcome (P = 0.021). Conclusions Among patients with severe aortic stenosis undergoing TAVI, a reduced pre-implant RVFWSL is able to predict long-term outcome.

284 Worsening renal function as an outcome predictor in patients with new onset atrial fibrillation on direct oral anticoagulant

Aims In patients with atrial fibrillation (AF), baseline kidney function is used to guide oral anticoagulant (OA) selection and dosing, and chronic kidney disease (CKD) is a significant outcome predictor. However, the incidence of worsening renal function (WRF) and its prognostic role during treatment with direct oral anticoagulants (DOACS) has been poorly explored. To assess the prognostic role of WRF in terms of bleedings and major adverse cardiovascular events (MACEs) in a cohort of patients with newly diagnosed non-valvular AF (NVAF) treated with DOACs. Methods and results Between January 2017 and March 2019, we enrolled all the patients with newly diagnosed NVAF and OA indication, treated with DOACs. Renal function was assessed using the mean value of the estimated glomerular filtration rates (eGFR) calculated using Cockcroft–Gault (CG), modification of diet in renal disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulas. CHA2DS2-VASc and HAS-BLED scores were used at baseline to estimate the ischaemic and haemorrhagic risk, respectively. At follow-up, WRF was identified as a decrease in eGFR of at least 20% while bleedings were classified according to the international society of thrombosis and haemostasis (ISTH) criteria. Finally, we defined AF progression as the transition from paroxysmal to persistent or permanent AF or from persistent to permanent AF. 1009 patients with newly diagnosed NVAF started on DOAC were enrolled. They were followed-up for 21.6 ± 9.5 months. Overall, WRF was observed in 181 cases (18%). Patients with WRF had higher rates of progression of AF (18.5% vs. 11.8%, P = 0.02), MACEs (20.4% vs. 12.9%, P = 0.09) and major bleedings (MBs) (9.4% vs. 4.7%, P = 0.013). WRF did not correlate with all bleedings, stroke, or acute coronary syndrome (ACS). However, those who presented WRF using CKD-EPI formula had higher ACS incidence (6.1% vs. 2.5%, P = 0.015), and generally better-predicted MACEs. At multivariate analysis adjusted for age, hypertension, baseline HAS-BLED score and WRF, the latter emerged as an independent predictor of MB (OR: 1.9, 95% CI: 1.059–3.51). Conclusions In patients with newly diagnosed NVAF treated with DOACs, WRF is associated with AF progression and MACEs, and emerged as an independent predictor of major bleedings. WRF evaluated with CKD-EPI formula better predicted MACEs.

Unsupervised Clustering Identifies Sub-Phenotypes and Reveals Pre-Dialysis Hyperlactatemia as a Novel Outcome Predictor in Dialysis-Requiring Sepsis-Associated Acute Kidney Injury

BackgroundHeterogeneity exists in sepsis-associated acute kidney injury (SA-AKI). This prospective observational cohort study aimed to perform consensus cluster analysis and investigate the clinical relevance of identified sub-phenotypes of critically ill patients with dialysis-requiring SA-AKI.MethodsAll septic patients with dialysis-requiring SA-AKI, defined by the Sepsis-3 and Kidney Disease: Improving Global Outcomes AKI criteria, admitted to an intensive care unit in Taiwan between 2002 and 2018 were included. We employed unsupervised consensus clustering based on 22 clinical variables upon initialising renal replacement therapy. They were observed until death or 90 days after hospital discharge. The outcomes were mortality and being free of dialysis.ResultsIn total, 1,397 patients were enrolled (mean age of 63.8 ± 16.38 years and 69.7% were men). After a median follow-up period of 31 (interquartile range 8-123) days, all-cause mortality occurred in 911 patients (65.12%). Moreover, 133 (9.51%) survivors were dialysis dependent, where 355 (25.38%) survivors were free of dialysis. Unsupervised consensus clustering identified three sub-phenotypes associated with significantly different risks of mortality and being free of dialysis. This strategy led us to reveal that the pre-dialysis hyperlactatemia of ≥ 3.1 mmol/L was an independent predictor of mortality and being free of dialysis according to the competing risk modeling. Our results were validated in an independent multi-center AKI cohort.ConclusionsBy the data-driven clustering analysis, we identified sub-phenotypes in septic patients with dialysis-requiring SA-AKI and revealed pre-dialysis hyperlactatemia as a novel outcome predictor. This result represents a step towards precision medicine for septic patients.

SARS-CoV-2 blood RNA load predicts outcome in critically ill COVID-19 patients

Background SARS-CoV-2 RNA loads in patient specimens may act as a clinical outcome predictor in critically ill patients with COVID-19. Methods We evaluated the predictive value of viral RNA loads and courses in the blood compared to the upper and lower respiratory tract loads of critically ill COVID-19 patients. Daily specimen collection and viral RNA quantification by RT-qPCR was performed in all consecutive 170 COVID-19 patients between March 2020 and February 2021 during the entire ICU stay (4145 samples analyzed). Patients were grouped according to their 90-days outcome as survivors (n=100) or non-survivors (n=70). Results In non-survivors, blood SARS-CoV-2 RNA loads were significantly higher at the time of admission to the ICU (p=0.0009). Failure of blood RNA clearance was observed in 33/50 (66 %) of the non-survivors compared to 12/64 (19 %) of survivors (p<0.0001). As determined by multivariate analysis, taking sociodemographic and clinical parameters into account, blood SARS-CoV-2 RNA load represents a valid and independent predictor of outcome in critically ill COVID-19 patients (OR [log10]: 0.23 [0.12 – 0.42], p<0.0001) with a significantly higher effect for survival compared to the respiratory tract SARS-CoV-2 RNA loads (OR [log10]: 0.75 [0.66 – 0.85], p<0.0001). Blood RNA loads exceeding 2.51 x 10 3 SARS-CoV-2 RNA copies/ml were found to indicate a 50% probability of death. Consistently, 29/33 (88%) of the non-survivors with failure of virus clearance exceeded this cut-off value constantly. Conclusion Blood SARS-CoV-2 load is an important independent outcome predictor and should be further evaluated for treatment allocation and patient monitoring.