3rd International Spring School

THE SCIENCE AND PRACTICE OF VENOUS THROMBOEMBOLISM

Endorsed by:

WELCOME

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Dear Colleagues,

It is our great pleasure to welcome you at the Third International Spring School on THE SCIENCE

AND PRACTICE OF VENOUS THROMBOEMBOLISM. The School is organized by the Center for

Thrombosis and Hemostasis (CTH) at the University Medical Center Mainz, Germany, in

collaboration with the Leiden University Medical Center (LUMC), The Netherlands, and with

the Democritus University of Thrace, Greece, as the local host.

Venous thromboembolism (VTE) is not only the third most frequent cardiovascular disease,

but also an exciting field in which research is currently being translated into major

breakthroughs in clinical practice and improved patient outcomes. Based on your enthusiastic

support and the feedback that we received in 2013 and 2015, we have revised and updated

the 2017 program to include the most relevant and contemporary scientific topics related to

thrombosis and VTE. The program of the Third Spring School will feature:

State-of-the-Art Clinical Seminars as well as Moderated Poster Presentations in the

morning sessions

Breakout Workshops (parallel interactive practical sessions, from which the participants

will be able to choose among a total of 12 offered workshops) in the afternoon sessions

Keynote Lectures in the evening sessions

Young Investigator Awards and networking opportunities.

The purpose of the VTE Spring School is to provide interested early career scientists and

physicians across a broad spectrum of medical disciplines with a comprehensive overview of

what is, at present, the state of the art in the rapidly evolving science and practice of acute

venous thromboembolism and its chronic sequelae. The participants will have the opportunity

to benefit from the School’s interactive seminars and workshops to be moderated by some of

the most renowned experts and leaders in the field. Last but not least, the Spring School will

offer a unique opportunity for networking and for discussing future areas of research and

collaboration projects.

We wish you an exciting meeting!

With best regards

Stavros Konstantinides Menno V. Huismann Center for Thrombosis and Hemostasis Leiden University Medical Center Mainz, Germany Leiden, The Netherlands

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IMPRINT Publisher Center for Thrombosis and Hemostasis (CTH) University Medical Center Mainz Langenbeckstrasse 1, D- 55131 Mainz Editorial staff Nadine Heydenreich, PhD Sabrina Rump Phone +49(0)6131/17-8376 Fax +49(0)6131/17-3456 www.cth-mainz.de www.eurospringschool.eu

Triaena Tours & Congress S.A.

Phone: +30 210 74 99337

Μobil: +30 6932662850

Fax: +30 210 77 05752

Email: efip@triaenatours.gr

Website: www.triaenacongress.gr

facebook.com/TriaenaTours twitter.com/TriaenaTours

The following companies have provided sponsorship to support the VTE Spring School and may

be present at the event but have had no input into, or influence on, the choice of presenters or

topics. No entertainment costs have been covered by the sponsors.

CME Accreditation by EBAC

The Third European (International) Spring School on THE SCIENCE

AND PRACTICE OF VENOUS THROMBOEMBOLISM has been accredited

for 26 CME credit hours by the European Board for Accreditation

in Cardiology (EBAC).

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FACULTY

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Galit Aviram

Imaging Division – Computerized Tomography, Tel-Aviv Sourasky Medical Center, Israel

Benjamin Brenner

Rambam Health Care Campus, Haifa, Israel

Hugo ten Cate

Cardiovascular Research Institute Maastricht (CARIM), The Netherlands

Arina J. ten Cate-Hoek

Maastricht University Medical Center, The Netherlands

Jelena Čelutkiene

Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius,

Lithuania

George Chalikias

Department of Cardiology, Democritus University of Thrace, Greece

Sven Danckwardt

Center for Thrombosis and Hemostasis, University Medical Center of the Johannes

Gutenberg University Mainz, Germany

Marion Delcroix

Respiratory Division, University Hospitals Leuven, Belgium

Elie Fadel

Laboratory of Surgical Research and INSERM U999, University of Paris-Sud, Marie

Lannelongue Hospital, Le Plessis Robinson, France

Anna Falanga

Department of Immunohematology and Transfusion Medicine, and Hemostasis

and Thrombosis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy

Georgios Giannakoulas

Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece

Jana Grünewald

Center for Thrombosis and Hemostasis, University Medical Center of the

Johannes Gutenberg University Mainz, Germany

Veli-Pekka Harjola

Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki,

Finland

Menno V. Huisman Department of Thrombosis and Hemostasis, Leiden University Medical Center, The Netherlands

FACULTY

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David Jiménez

Respiratory and Medicine Department, Ramón y Cajal Hospital and Alcalá de Henares

University Madrid, Spain

Theodoros Karamitsos

Department of Cardiology, AHEPA University Hospital, Thessaloniki, Greece

Frederikus A. Klok

Department of Thrombosis and Hemostasis, Leiden University Medical Center, The

Netherlands

Stavros Konstantinides

Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg

University Mainz, Germany; Department of Cardiology, Democritus University of Thrace,

Greece

Matija Kozak

Department for Vascular Diseases, University Medical Center Ljubljana, Slovenia

Bernhard Lämmle

Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg

University Mainz, Germany; Department for Hematology, University Hospital Bern,

Switzerland

Irene Lang

Department of Cardiology, Medical University Vienna, Austria

Mareike Lankeit

Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg

University Mainz, Germany; Department of Cardiology, Campus Virchow Klinikum (CVK),

Charité University Medicine, Berlin, Germany

Eckhard Mayer

Department of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany

Guy Meyer

Université Paris Descartes, Hôpital Européen Georges Pompidou, Paris, France

Saskia Middeldorp

Academic Medical Center, University of Amsterdam, The Netherlands

Anton Vonk Noordegraaf

Vrije Universiteit Medisch Centrum, Amsterdam, The Netherlands

Marina Panova-Noeva

Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg

University Mainz, Germany

FACULTY

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Paolo Prandoni

2nd Chair of Internal Medicine, Department of Cardiologic, Thoracic and Vascular Sciences

Padova, Italy

Piotr Pruszczyk

Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw,

Poland

Marc Righini

Division of General Internal Medicine, Department of Internal Medicine, University Hospitals

of Geneva, Switzerland

Stephan Rosenkranz

Heart Center of the University of Cologne, Germany

Olivier Sanchez

Université Paris Descartes, Hôpital Européen Georges Pompidou, Paris, France

Katrin Schäfer

Center for Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg

University Mainz, Germany

Branislav Stefanovic

Clinical Center of Serbia, Coronary Care Unit, Emergency Center Belgrade, Republic of Serbia

Peter Verhamme

Department of Cardiovascular Sciences, University of Leuven, Belgium

Eric Vicaut

Hôpital Fernand-Widal, AP-HP; Université Diderot-Paris 7, Paris, France

Philip Wenzel

Center for Thrombosis and Hemostasis, and Center for Cardiology, Cardiology I, University

Medical Center of the Johannes Gutenberg University Mainz, Germany

Philipp Wild

Center for Thrombosis and Hemostasis, and Preventive Cardiology and Preventive Medicine,

Center for Cardiology, University Medical Center of the Johannes Gutenberg University

Mainz, Germany

PROGRAM

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TUESDAY, 9th May

19.00 Reception and Welcome

Wednesday, 10th May

Morning program Plenary Sessions and Abstract Presentations

08.45 – 09.00 S. Konstantinides, DE/GR

Welcome and Introduction

09.00 – 10.00 H. ten Cate, NL

Venous thromboembolism: Magnitude of the problem

and its impact on patients, societies, and health systems

10.00 – 11.00 A. Vonk Noordegraaf, NL

Pathophysiology of venous thromboembolism: Focus on right

ventricular dysfunction and failure

11.00—11.30 Coffee Break

11.30 – 12.30 P. Wenzel, DE

Venous thromboembolism seen from the perspective of cross

talk between thrombosis and inflammation

12.30 – 14.00 Abstract Session I – Thrombosis and Hemostasis

14.00 – 16.00 Lunch & Afternoon Break

Afternoon program Parallel Breakout Workshops

16.00 – 17.15 Interactive Workshops I/II/III

W-I S. Rosenkranz, DE / S. Konstantinides, DE/GR

How to perform and interpret right heart catheterization?

W-II J. Čelutkiene, LT / G. Giannakoulas, GR

Imaging of acute and chronic pulmonary embolism:

Echocardiography

W-III B. Lämmle, DE/CH / S. Danckwardt, DE

Role of the laboratory in the management of anticoagulated

patients with VTE: What can or should be monitored?

What are the pitfalls?

PROGRAM

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17.15 – 18.00 Coffee Break

18.00 – 19.15 Interactive Workshops IV/V/VI

W-IV P. Wild, DE / M. Panova-Noeva, DE

Progress in VTE research: Importance of large cohorts and

biodatabanking, contribution of platelet function testing

W-V G. Aviram, IL / T. Karamitsos, GR

Imaging of acute and chronic pulmonary embolism: CT and

MRI

W-VI E. Fadel, FR / K. Schäfer, DE

Animal models for studying venous thrombosis and CTEPH

Evening program

19.30 – 20.15 M. Righini, CH

Progress in the diagnosis of venous thromboembolism: Where are we three years after the ESC guidelines? What can we expect in the coming years?

PROGRAM

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Thursday, 11th May

Morning program Plenary Sessions and Abstract Presentations

09.00 – 10.00 B. Brenner, IL

Thrombosis risk and laboratory markers of thrombogenicity: What is new? What is clinically relevant?

10.00 – 11.00 A. Falanga, IT

The association between thrombosis and cancer: Pathophysiological

insights and clinical implications

11.00 –11.30 Coffee Break

11.30 – 13.00 Abstract Session II - Pulmonary Embolism

13.00 – 15.30 Lunch & Afternoon Break

Afternoon program I Career Workshop

15.30 – 16.00 J. Grünewald, DE

Early career opportunities and programs

Afternoon program II Parallel Breakout Workshops

16.00 – 17.15 Interactive Workshops IV/V/VI

W-IV P. Wild, DE / M. Panova-Noeva, DE

Progress in VTE research: Importance of large cohorts and

biodatabanking, contribution of platelet function testing

W-V G. Aviram, IL / T. Karamitsos, GR

Imaging of acute and chronic pulmonary embolism: CT and

MRI

W-VI E. Fadel, FR / K. Schäfer, DE

Animal models for studying venous thrombosis and CTEPH

PROGRAM

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17.15 – 18.00 Coffee Break

18.00 – 19.15 Interactive Workshops I/II/III

W-I S. Rosenkranz, DE / S. Konstantinides, DE/GR

How to perform and interpret right heart catheterization?

W-II J. Čelutkiene, LT / G. Giannakoulas, GR

Imaging of acute and chronic pulmonary embolism:

Echocardiography

W-III B. Lämmle, DE/CH / S. Danckwardt, DE

Role of the laboratory in the management of anticoagulated

patients with VTE: What can or should be monitored?

What are the pitfalls?

Evening program

19.30 – 20.15 G. Meyer, FR

Progress in the treatment of venous thromboembolism:

Where are we three years after the ESC guidelines?

What is there to expect in the coming years?

PROGRAM

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Friday, 12th May

Morning program Plenary Sessions and Abstract Presentations

09.00 – 10.00 M.V. Huisman, NL

Venous thromboembolism: How to manage and how to follow the

patient in the era of the direct oral anticoagulants?

10.00 – 11.00 P. Prandoni, IT

How long to anticoagulate after venous thromboembolism:

Do we finally have the answer?

11.00 – 11.30 Coffee Break

11.30 – 13.30 Abstract Session III - Chronic Thromboembolic

Pulmonary Hypertension

13.30 – 15.30 Lunch & Afternoon Break

Afternoon program I Career Workshop

15.30 – 16.00 J. Grünewald, DE

Early career opportunities and programs

Afternoon program II Parallel Breakout Workshops

16.00 – 17.15 Interactive Workshops VII/VIII/IX

W-VII M. Kozak, SI / M. Lankeit, DE

Tough calls in VTE management: What is this risk of this patient

with PE?

W-VIII P. Pruszczyk, PL / B. Stefanovic, RS

Tough calls in intermediate-risk PE: Thrombolysis or intervention?

W-IX A. ten Cate-Hoek, NL

Preventing and managing the post-thrombotic syndrome after VTE

PROGRAM

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17.15 – 18.00 Coffee Break

18.00 – 19.15 Interactive Workshops X/XI/XII

W-X E. Vicaut, FR / G. Chalikias, GR

Designing and interpreting clinical trials on VTE and beyond

W-XI D. Jiménez, ES / P. Verhamme, BE

Anticoagulation for VTE: Which regimens in vulnerable patients?

How to manage bleeding emergencies?

W-XII O. Sanchez, FR / F. Klok, NL

Acute pulmonary embolism or pre-existing CTEPH?

Evening program

19.30 – 20.15 I. Lang, AT

Progress in management of chronic thromboembolic pulmonary

hypertension: Where are we three years after the ESC guidelines?

What can we expect in the coming years?

PROGRAM

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Saturday 13th May

Morning program Plenary Sessions

09.00 – 10.00 V.P. Harjola, FN

Current management of acute right ventricular failure

10.00 – 11.00 S. Middeldorp, NL

VTE management in vulnerable populations

11.00 – 11.30 Coffee Break

11.30 – 12:30 E. Mayer, DE

Progress in the surgical and interventional treatment of chronic

thromboembolic pulmonary hypertension

12.30 – 13.00 Announcement – Young Investigator Award Winners

13.00 – 15.00 Lunch & Afternoon Break

Afternoon program Parallel Breakout Workshops

15.00 – 16.15 Interactive Workshops X/XI/XII

W-X E. Vicaut, FR / G. Chalikias, GR

Designing and interpreting clinical trials on VTE and beyond

W-XI D. Jiménez, ES / P. Verhamme, BE

Anticoagulation for VTE: Which regimens in vulnerable patients?

How to manage bleeding emergencies?

W-XII O. Sanchez, FR / F. Klok, NL

Acute pulmonary embolism or pre-existing CTEPH?

PROGRAM

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16.15 – 16.45 Coffee Break

16.45 – 18.00 Interactive Workshops VII/VIII/IX

W-VII M. Kozak, SI / M. Lankeit, DE

Tough calls in VTE management: What is the risk of this patient

with PE?

W-VIII P. Pruszczyk, PL / B. Stefanovic, RS

Tough calls in intermediate-risk PE: Thrombolysis or intervention?

W-IX A. ten Cate-Hoek, NL

Preventing and managing the post-thrombotic syndrome after VTE

Evening program

18.15 – 19.00 M. Delcroix, BE

Understanding the pathophysiology of chronic thromboembolic pulmonary hypertension: What are the implications for patient follow-up and care after PE?

20.00 – 23.00 Farewell Dinner

PROGRAM

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Sunday 14th May

09.00 – 10.00 All

How to optimize early career support and networking in the field of venous thromboembolism

10.00 – 11.00 All

Conclusions

11.00 Adjourn

Overview: ABSTRACT SESSION I

Thrombosis and Hemostasis

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Chairs: A. ten Cate-Hoek (NL), B. Lämmle (DE)

Time: Wednesday, 10th May, 12:30-14:00h

101 Investigation of potential interactions of platelet- and bacterial-derived polyphosphates

with human and murine neutrophils

J. Schöche, Mainz, DE

102 Inorganic polyphosphate: An inorganic polymer affecting the blood clotting pathway and

survival in live E. coli sepsis models

G. Stavrides, Mainz, DE

103 Defining modifiers of F2 expression dynamics with a potential role in thrombosis formation

by using an integrated animal and cell model system

L. Schott, Mainz, DE

104 Quercetin 3, 3’, 4’, 5, 7-O-pentasulfate reduces in vivo thrombus formation

N. Gupta, New Delhi, IN

105 Platelet phenotypic characteristics in acute venous thromboembolism – results from the

VTEval project

M. Paul, Mainz, DE

106 Prevalence of deep vein thrombosis in patients with confirmed pulmonary embolization

J. Maneikyte, Vilnius, LT

107 Comparison of trans-popliteal reflux in the limb with deep vein thrombosis and the limb

without thrombosis

L. Sarolo, Padua, IT

108 High recanalization rate in patients with proximal-vein thrombosis treated with the new

direct oral anticoagulants

L. Sarolo, Padua, IT

109 The YEARS algorithm for suspected pulmonary embolism leads to much shorter

diagnostic turnaround time than conventional algorithms

C.E.A. Dronkers, Leiden, NL

110 No further reduction in the number of required CT pulmonary angiograms when

implementing the ADJUST (age adjusted) D-dimer cut-off level in the YEARS algorithm

L.M. van der Pol, Leiden, NL

111 Value of electrocardiographic changes in suspected acute pulmonary artery

thromboembolism

E. Paleviciute, Vilnius, LT

Overview: ABSTRACT SESSION II

Pulmonary Embolism

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Chairs: M. Righini (CH), P. Prandoni (IT)

Time: Thursday, 11th May, 11:30-13:00h

201 Plasma D-Dimer in combination with shock index for identification of patients with acute

pulmonary embolism at risk of serious adverse events

M. Kozłowska, Warsaw, PL

202 Prognostic value of various glomerular filtration rate formulas in risk assessment of patients with

acute pulmonary embolism

M. Pływaczewska, Warsaw, PL

203 Prognostic impact of copeptin in normotensive pulmonary embolism – a European multicenter

validation study

K. Hellenkamp, Göttingen, DE

204 Prognostic value of MR-proANP in normotensive pulmonary embolism

N. Rogge, Göttingen, DE

205 Performance of the modified FAST score for risk stratification of normotensive pulmonary

embolism – a validation study

L. Hobohm, Mainz, DE

206 Sex-specific differences in pulmonary embolism

K. Keller, Mainz, DE

207 The empty heart in patients with active malignancy and acute pulmonary embolism

A. Milwidsky, Tel-Aviv, IL

208 Temporal trends in risk-adjusted management and outcome of patients with pulmonary

embolism – a single centre experience

M. Ebner, Berlin, DE

209 Prediction of 30-day major bleeding in patients with acute pulmonary embolism – validation of

the VTE-BLEED score in a real-world cohort

K.P. Kresoja, Berlin, DE

210 Patients are more adherent to treatment with LMWH nadroparin than enoxaparin for cancer

related venous thromboembolism

S.J. van der Wall, Leiden, NL

211 Continuation of LMWH treatment for cancer related venous thromboembolism – a prospective

cohort study in daily clinical practice

S.J. van der Wall, Leiden, NL

212 Efficacy of chest, abdomen and pelvis computed tomography in the screening of occult cancer

after unprovoked venous thromboembolism

S. Miranda, Rouen, FR

Overview: ABSTRACT SESSION III

Chronic Thromboembolic Pulmonary Hypertension

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Chairs: E. Mayer (DE), O. Sanchez (FR)

Time: Friday, 12th May, 11:30-13:30h

301 Follow-up after acute pulmonary embolism (FOCUS): A prospective observational multicentre cohort study

S. Barco, Mainz, DE

302 High sensitivity of a non-invasive screening strategy for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism

Y.M. Ende-Verhaar, Leiden, NL

303 Importance of Angiopoietin-2 (Ang-2) for the transition from pulmonary embolism to chronic thromboembolic pulmonary hypertension (CTEPH)

L. Hobohm, Mainz, DE

304 Osteopontin (OPN) and its potential role in the pathogenesis of chronic thromboembolic pulmonary hypertension (CTEPH)

S. Kölmel, Mainz, DE

305 Role of transforming growth factor-beta signalling for fibrotic remodelling in murine venous thrombi and human chronic thromboembolic pulmonary hypertension

M. Bochenek, Mainz, DE

306 Role of endoglin in endothelial colony forming cells (ECFCs) and vascular remodelling

C. Goyard, Paris, FR

307 Expression signature of endothelial cells in chronic thromboembolic pulmonary hypertension

M. Bochenek, Mainz, DE

308 What is the best endothelial progenitor cells delivery method for the treatment of chronic thromboembolic pulmonary hypertension induced right ventricle dysfunction?

F. Loisel, Le Plessis-Robinson, FR

309 Thyroid disease and treatment in patients with chronic thromboembolic pulmonary hypertension (CTEPH)

V. Krieg, Mainz, DE

310 Chronic thromboembolic pulmonary hypertension in a real world setting: experience from two expert centres

S.A. Mouratoglou, Thessaloniki, GR

311 Bilateral proximal CTEPH is associated with worse RV function and RV (mal)adaptation

D. Ruigrok, Amsterdam, NL

312 Factors predicting outcome after pulmonary endarterectomy

C. Tromeur, Brest, FR

313 Lack of correlation between ICU haemodynamics and 6-month follow-up after PEA in CTEPH

D. Ruigrok, Amsterdam, NL

314 Perioperative haemodynamic factors predicting outcome after pulmonary endarterectomy

C. Tromeur, Brest, FR

315 Riociguat use in patients with chronic thromboembolic pulmonary hypertension. Real life experience from a two centres in Northern Greece

S.A. Mouratoglou, Thessaloniki, GR

ABSTRACT SESSION I Thrombosis and Hemostasis

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Poster 101

Abstract Title Investigation of potential interactions of platelet- and bacterial-derived polyphosphates with human and murine neutrophils

Authors J. Schöche1, J. Röwe1, M. Strüve1, A. Mann1, S.A. Smith2, J.H. Morrissey2, M. Bosmann1

Affiliations 1Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; 2Department of Biochemistry, University of Illinois at Urbana-Champaign, United States

Abstract Background Polyphosphates (PolyP) are linear polyanionic molecules, in which inorganic phosphates are covalently linked via phosphoanhydride bonds. They are to be found in microbes as well as in platelets, varying in size. Microbial PolyP of >100-1000 Pi units (long-chained PolyP= L-PolyP), promoting bacterial metabolism and homeostasis, as well as PolyP in platelets (60-100 Pi units, short-chained PolyP= S-PolyP) have shown prominent capabilities as activators of the coagulation cascade. In this project, PolyP are investigated in the context of innate immunity (at the level of murine and human neutrophils), with particular interest in platelet-immune cell interplay. Direct influence of platelet-derived PolyP on neutrophils, as an example of immunothrombosis, is hypothesized. In addition, microbial PolyP could activate neutrophils, triggering their platelet-activating arsenal such as NET-(Neutrophil Extracellular Trap)-formation and cytokine production (e.g. CXCL4), thereby endorsing thrombus formation in sepsis.

Material and Methods Neutrophils are fast-dying, easily activatable cells, which produce cytokines and contain relatively low amounts of mRNA. High-quality extraction and rigorous purification (>98% purity) methods for human and murine neutrophils were established for analysing neutrophil functions by molecular biology techniques. For murine neutrophils, intraperitoneal injection and subsequent positive immunomagnetic (MACS) selection yielded a purity of 97-99% and a cellular viability of >95%. Human neutrophils were isolated via negative MACS isolation, performed on freshly drawn EDTA-blood from healthy volunteers, resulting in 98-99% purity and viability >99%. Purity was confirmed via flow cytometry analysis, viability via PI-/Annexin-V staining. Neutrophils were stimulated with L-PolyP, S-PolyP, each in co-stimulation with bacterial pathogen-associated molecular patterns (e.g. lipopolysaccharides [LPS], lipoteichoic acid [LTA]) or inactivated E. coli, and examined for different endpoints by ELISA, qPCR and flow cytometry.

Results Bacterial-sized L-PolyP influenced the production and secretion of various cytokines. In addition, phagocytosis of E. coli was significantly impaired in the presence of L-PolyP. Furthermore, L-PolyP regulated surface markers for cellular activation. Platelet-sized S-PolyP did not show significant effects on neutrophil functionalities in our preliminary experiments.

Conclusion While S-PolyP appeared not to significantly interfere with neutrophil functions, L-PolyP strongly interacted with neutrophil functions. The biological properties of bacterial PolyP will deserve further studies for evaluation as a potential therapeutic target in infection-associated immune disorders in future. Platelet-derived PolyP appear not to interfere with immune functions and selective blockade of platelet-derived PolyP in thrombotic disease is not expected to cause immunosuppressive side effects or inflammatory syndromes.

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Poster 102

Abstract Title Inorganic polyphosphate: An inorganic polymer affecting the blood clotting pathway and survival in live E. coli sepsis models.

Authors G. Stavrides1, J. Röwe1, M. Strüve1, A. Mann1, S. A. Smith2, M.J. Gray3, U. Jakob3, J.H. Morrissey2, M. Bosmann1

Affiliations 1Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; 2Department of Biochemistry, University of Illinois at Urbana-Champaign, Illinois, United States; 3Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, United States

Abstract Background Information Inorganic polyphosphate (PolyP) is a polymer, consisting of many orthophosphates, linked together by phosphoanhydride bonds. PolyP is found in all living organisms and its size varies from short chain polymers (SC), found in platelets, to long chain polymers (LC), found in prokaryotic cells, e.g. bacteria. Intracellular polyphosphate modulates energy metabolism, as Pi-storage for ATP Synthesis and as an energy reservoir in stress conditions. It was also found that PolyP plays an important role in the blood clotting pathway. It works as activator of Factor XII and as amplifier of the activation of factor XI, by enhancing the thrombin feedback and activation of Factor V. The enzymes participating in PolyP metabolism are polyphosphate kinase (PPK), which catalyses the synthesis of polymers from anionic phosphate monomers, and exopolyphosphatase (PPX), which catalyses the successive degradation of PolyP into monomers. The aim of our study is to demonstrate the influence of PolyP on thrombus formation and survival in mouse models during bacterial sepsis, after intraperitoneal injection of live E. coli. This study not only focuses on the resulting changes in coagulant and procoagulant factors, but also on the effect on immune modulating cells and cytokines.

Material and Methods The bacterial strains used were E. coli MG1655 (as wild type), E. coli MG1655∆PPK (a strain lacking the enzyme polyphosphate kinase, thus deficient in PolyP) and E. coli MG1655∆PPX (lacking the enzyme exopolyphosphatase, thus overexpressing PolyP chains). 8-12 week old male C57BL/6J mice were intraperitoneally injected with 8.5x108-2x109 CFUs of bacterial solution and long-chain PolyP (P700; 10mg/kg body weight). Blood plasma and peritoneal lavage were taken for further analysis, involving the qualitative and quantitative measurement of immune cells, bacterial cells, cytokines and coagulant factors. In companion studies, recombinant exopolyphosphatase from Saccharomyces cerevisiae (ScPPX) was evaluated during E. coli sepsis for interference with PolyP effects, altering sepsis endpoints and improving thromboembolic incidents.

Results The presence of long chain PolyP during sepsis resulted in a significant increase of mortality and immune cells such as neutrophils and macrophages, leukocyte-derived cytokines, thrombin-antithrombin complexes and platelet-derived mediators, confirming our hypothesis, that inorganic polyphosphate is an immune modulator of septic coagulopathy.

Conclusion According to our results in murine models, PolyP is an important mediator of thrombosis during inflammation. PolyP could serve as a future target in the fight against venous thromboembolism and inflammation, achieving better outcomes for human patients.

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Poster 103

Abstract Title Defining modifiers of F2 expression dynamics with a potential role in thrombosis formation by using an integrated animal and cell model system

Authors L. Schott1, S. Khokhar1, K. Mühlbach1, S. Tokalov1, S. Danckwardt1,2,3

Affiliations

1Center for Thrombosis and Hemostasis (CTH); 2Institute for Clinical Chemistry and Laboratory Medicine; 3Posttranscriptional Gene Regulation & Experimental Hemostasis, all at University Medical Center of the Johannes Gutenberg University, Mainz, Germany

Abstract Background The coordinated dynamics of F2 gene expression and protein secretion ensure the well-balanced equilibrium of the haemostatic system. Here, we set out to define regulatory mechanisms controlling F2, which may play a role in thrombosis formation.

Material and Methods For this purpose, we generated a genetic model that allows to interrogate and define regulatory principles controlling F2 gene expression and secretion in a spatiotemporal manner. By applying a multimodal genetic tagging strategy, we generated a novel constitutive knock-in mouse model based on fluorescence and luminescence reporters separated by P2A peptides for tailored multicistronic expression. This mouse model, termed D-Insight, allows the “visualization” of regulated F2 gene expression and protein secretion in its natural context, and the coupling between these processes real-time in vivo by the use of non-invasive optical imaging. Complementary, we generated primary hepatic cell lines derived from this mouse model. This cell line permits the deconvolution of F2 gene expression-, protein biosynthesis- and secretion dynamics in high resolution and in a scalable high-throughput format ex vivo with bioluminometry and fluorescence microscopy.

Results We confirm that this genetic model system faithfully recapitulates established (patho)physiologically relevant modifiers of F2 expression associated with thrombus formation (i.e. during sepsis). An update on potentially new modifiers playing an important role in the deregulation of the haemostatic system will be presented during the meeting.

Conclusion This newly generated experimental model system represents a versatile tool to interrogate regulatory mechanisms that may play a role in the endogenous control of F2 gene expression. It will help deciphering underlying mechanisms of disordered haemostasis, e.g. in response to pathophysiological cues such as septicaemia and other (environmental) perturbations leading to thrombus formation.

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Poster 104

Abstract Title Quercetin 3, 3’, 4’, 5, 7-O-pentasulfate reduces in vivo thrombus formation

Authors Q. Rashid1, N. Gupta1, I. Ahmad1, S. Bano1, M. Abid2, M.Z. Ashraf3, M.A. Jairajpuri1

Affiliations 1Protein Conformation and Enzymology Lab; 2Organic Synthesis Lab, Department of Biosciences, Jamia Millia Islamia, New Delhi, India; 3Defense Institute of Physiology & Allied Sciences, Timarpur, Delhi, India

Abstract Background Venous thromboembolism based complications are most common causes of morbidity and mortality worldwide. Current antithrombotic treatment strategies predominantly revolve around the use of heparin and its derivatives, however its polyanionic nature and multispecificity poses several complications including excessive bleeding. The quest for the design of new oral antithrombotic molecules with reduced side effects envisages chemical modification of already known scaffolds like natural flavonoid for imparting the in vitro anticoagulant activity. Several sulfated compounds have shown promise. However; their ability to reduce in vivo thrombus formation and molecular specificity largely remains unknown.

Methodology In the present study, the pentasulfated form of the widely known flavanoid Quercetin, i.e. Quercetin 3, 3’, 4’, 5, 7-O-pentasulfate (QPS), was chemically synthesized, characterized and evaluated for its in vivo antithrombotic potential using rat model for venous thrombosis. Male Sprague Dawley rats (250-270 g) were used for the study. Rats were injected with purified QPS at a dosage of 0.5 mg/kg, prior to thrombus induction and pro-thrombotic read outs (thrombus weight and length) were measured and compared to vehicle controls. Anti-platelet activity of test compound was determined by whole blood platelet aggregation assay.

Results Our in vivo observations demonstrated that intravenous administration of QPS, significantly reduced thrombus formation in a rat model of venous thrombosis. Further, the injection of rats with QPS prior to ligation also delayed activated partial thromboplastin time (APTT) with profound effect on prothrombin time (PT) as compared to non-sulfated Quercetin injected rats. The inhibition of ADP induced platelet aggregation in samples isolated from QPS injected rats also suggested its dual anticoagulant and antiplatelet mechanism of action.

Conclusion Current observations propose QPS as a lead antithrombotic agent.

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Poster 105

Abstract Title Platelet phenotypic characteristics in acute venous thromboembolism – results from the VTEval project

Authors M. Paul1,2, M. Nagler3,2, H. Lamparter3,2, J.H. Prochaska4,1,2, N. Arnold4,2, H.M. Spronk5, K. Jurk1, G. Weißer4, C. Espinola-Klein4, S. Konstantinides1, K.J. Lackner6,7,2, T. Münzel4,7,2, H. ten Cate5, P.S. Wild3,1,7,2, M. Panova-Noeva1,2

Affiliations 1Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; 2Center for Translational Vascular Biology (CTVB), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; 3Preventive Cardiology and Preventive Medicine, Center for Cardiology, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; 4Center for Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany; 5Laboratory for Clinical Thrombosis and Hemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, the Netherlands; 6Institute for Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany; 7DZHK (German Center for Cardiovascular Research), Partner Site Rhine Main, Mainz, Germany

Abstract Background Venous thromboembolism (VTE) is potentially a life-threatening disease associated with substantial morbidity and mortality rates. The potential role of platelets in the pathogenesis of VTE is receiving increasing attention. Presently however, limited information is available on platelet phenotypic characteristics in the acute phase of disease. This study aims to determine the levels of different platelet surface activation markers in patients with acute VTE in comparison to individuals from the population-based Gutenberg Health Study (GHS).

Material and Methods Whole blood flow cytometry was used to assess platelet surface expression of P-selectin and CD63 under resting conditions and integrin αIIbβ3 activation, after collagen/ADP stimulation, in 123 individuals from the VTEval study and 407 individuals from the GHS. The expression of platelet surface activation markers in VTEval cases (subjects with objectively confirmed VTE) was compared to 2 control groups: 1) GHS controls (individuals without cardiovascular risk factors or history of cardiovascular disease, n=69), and 2) VTEval controls (subjects with objectively excluded VTE, n=72).

Results VTEval subjects showed increased platelet surface expression of P-selectin (3.20% vs 2.20%, p<0.0001) and CD63 (8.62% vs 6.40%, p<0.0001) in comparison to platelets from GHS individuals. VTE cases presented with increased P-selectin (3.80% vs 2.20, p<0.0001) and CD63 (9.40% vs 6.40, p<0.0001) compared to GHS controls and without statistically significant differences to VTEval controls. The analysis based on provoked (n=18) or unprovoked (n=21) venous thrombosis showed that subjects with provoked VTE had marked expression of platelet integrin αIIbβ3 activation (66.3%) compared to unprovoked VTE (45.8%, p=0.0010).

Conclusion Platelets from subjects enrolled in the VTEval study showed increased P-selectin and CD63 surface expression compared to platelets from population-based controls. No significant differences were observed for these platelet activation markers between VTEval cases and controls. On the other hand, increased platelet reactivity to collagen/ADP platelet agonists was observed in patients with provoked compared to unprovoked venous thrombosis. Whereas these findings support the concept of platelet activation in acute VTE, future studies should answer if platelet activation markers at baseline have a predictive value for VTE outcome.

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Poster 106

Abstract Title Prevalence of deep vein thrombosis in patients with confirmed pulmonary embolization Authors J. Maneikyte1,2, V.V. Maneikiene1,2, D. Vajauskas3,4

Affiliations

1Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; 2Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Clinics, Vilnius, Lithuania; 3Department of Radiology, Nuclear Medicine and Physics of Medicine Vilnius University, Faculty of Medicine, Vilnius, Lithuania; 4Centre of Radiology and Nuclear Medicine, Vilnius University Hospital Santariskiu Clinics, Vilnius, Lithuania

Abstract Background Lower-extremity deep vein thrombosis is the most common type of venous thrombosis, with a prevalence of 1 case per 1000 population. According to the literature pulmonary embolism (PE) is the consequence of deep vein thrombosis (DVT) in 40-50% of the cases. The aim of our analysis was to evaluate the incidence of DVT in patients with confirmed PE in patients referred to university hospital.

Material and Methods We have retrospectively analysed a total of 113 consecutive patients’ clinical data who in 2016 underwent lung perfusion scintigraphy (performed in all patients) and contrast enhanced computed tomography (CECT) (performed in 67 [52.47%] patients) and leg deep vein ultrasound (performed for 40 [35.39%] patients) due to clinically suspected pulmonary embolism. Demographic data, symptoms, heart rhythm, laboratory tests were assessed in all patients. Statistical analysis was performed with SPSS v.16 software packages and the level of significance was indicated by a p-value of less than 0.05.

Results This analysis included 113 patients, mean age was 64.1 ± 13.2 years, 68.1% were females. PE was diagnosed in 66 (58.4%) patients by lung perfusion scintigraphy alone or together with CECT. Lung perfusion scintigraphy confirmed the PE diagnosis for 56/113 (49.56%) of patients, CECT – 25/67 (37.31%). Patients with radiologically confirmed PE more often felt dyspnea and chest pain (96.8% vs 85.1%, p=0.036 and 19.0% vs 4.3%, p=0.023). Despite the PE diagnosis lower extremity deep venous ultrasound was performed for 40 (35.39%) patients. These patients were included in to the further analysis. 33 of 40 (82.5%) patients who underwent deep venous ultrasound were diagnosed with PE and 7 (17.5%) had negative results. There were 14/40 (35.00%) patients with detected DVT, 11/14 (78.57%) cases were found in patients with PE. In 26/40 (65.00%) cases DVT was not detected, but PE diagnosis was confirmed radiologically in 22/26 (84.61%) patients. There was no significant difference between the incidence of DVT in patients with PE (33) and patients without PE (7) – 11 (33.3%) vs 3 (42.9%), p=0.679. Developing PE risk was higher for the patients with the DVT (OR = 1.393, 95%CI [0.362, 5.365], p>0.05). However, these results were statistically insignificant.

Conclusion Possibly small number of the patients who underwent all imaging modalities confirming PE and DVT brought us to statistically insignificant results, however according to our analysis results DVT was present for up to 33% of PE patients, potentially confirming close relationship of PE and the prevalence of DVT. Our results also presuppose a view that absence of DVT does not eliminate the PE diagnosis. Larger number of the patients’ analysis could be needed achieving statistically significant odds ratio for determining the risk of PE for the patients with the DVT.

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Poster 107

Abstract Title Comparison of trans-popliteal reflux in the limb with deep vein thrombosis and the limb without thrombosis

Authors L. Sarolo, G. Turatti, M. Milan, F. Bilora, P. Prandoni

Affiliations Department of Cardiovascular Sciences, Vascular Medicine Unit, University of Padua, Italy

Abstract Background Chronic venous insufficiency (CVI) leads to various consequences, including pain, swelling, oedema, skin changes and ulcerations. Venous reflux is the primary cause of CVI. In literature there is not much evidence on possible damages that thrombotic events may cause to the deep veins of the lower limbs. The aim of our study was to determinate whether deep vein thrombosis (DVT) may be cause of incompetence of the venous valves and then of the venous reflux.

Material and Methods In order to test the plausibility of the association between DVT and the PVI, we assessed the rate of PVI in 59 consecutive patients with previous proximal DVT (32 males; mean age, 57 years), and compared it with that detectable in the otherwise unaffected contralateral leg of the same patients. The presence of a retrograde flow through the popliteal valve after a standardized compression of the mid-thigh, persisting after repeating the manoeuvre with a tourniquet to prevent the influence of superficial vein reflux, was considered suggestive of valve incompetence.

Results PVI was detected in 17 patients (28.9%), and involved the leg with previous DVT in 14 cases (82.3%), the contralateral leg in 2 (11.8%), and both legs in 1 patient (5.9%). The odds ratio (OR) of PVI in the legs with previous DVT as compared to the unaffected legs was 6.40 (95% CI, 1.7 to 23.5).

Conclusion We conclude that after an episode of proximal DVT, trans-popliteal venous reflux is detectable in the leg with thrombosis much more frequently than in the otherwise healthy leg. Our study results make it plausible the association between DVT and the subsequent development of PVI.

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Poster 108

Abstract Title High recanalization rate in patients with proximal-vein thrombosis treated with the new direct oral anti-coagulants

Authors L. Sarolo1, W. Ageno2, N. Mumoli3, N. Zanatta4, D. Imberti5, A. Visonà6, M. Ciammaichella7, L. Simioni8, R. Cappelli9, E. Bucherini10, M. Di Nisio11, G. Avruscio12, R. Parisi13, S. Cuppini14, F. Noventa1, P. Prandoni1

Affiliations 1Department of Cardiovascular Sciences, Vascular Medicine Unit, University of Padua; 2Department of Clinical Medicine, University of Insubria, Varese; 3Department of Internal Medicine, Hospital of Livorno; 4Division of General Medicine, Presidio Hospital of Conegliano; 5Haemostasis and Thrombosis Center, Department of Internal Medicine, Hospital of Piacenza; 6Department of Angiology, S. Giovanni Apostolo Hospital, Castelfranco Veneto; 7Department of emergency, A.O. San Giovanni-Addolorata, Roma; 8Department of Medicine, Allergy Service, ULSS 2 di Feltre; 9Internal Medicine, Le Scotte Hospital of Siena; 10Department of Vascular Medicine, Hospital of Ravenna- Faenza; 11Department of Medical, Oral and Biotechnological Sciences, G. D'Annunzio University, Chieti; 12Unit of Angiology, Department of Cardiovascular Sciences, Vascular Medicine Unit, University of Padua; 13Unit of Angiology, Internal Medicine, SS Giovanni e Paolo Hospital, Venice; 14Department of Internal Medicine, Santa Maria della Misericordia Hospital, Rovigo

Abstract Background In patients with proximal deep venous thrombosis (DVT) of the lower extremities, the ultrasound persistence of residual vein thrombosis (RVT) has been reported to increase the risk of subsequent complications, such as recurrent venous thromboembolism and post thrombotic syndrome. With the use of standard anticoagulant therapy, the rate of RVT has consistently been reported to occur in approximately 50% of patients after three and six months. In an Italian registry, we sought to investigate the rate of RVT after three and/or six months in a wide series of consecutive patients with proximal DVT who were treated with the new oral anticoagulants (NOA). We compared this rate with a historical cohort of 1094 patients who had been treated with standard anticoagulation, made of LMWH followed by vitamin K antagonists (VKA).

Material and Methods 352 consecutive outpatients with proximal DVT, who had been treated with therapeutic doses of a NOA, alone or preceded by a few days of LMWH, were recruited in 14 centres in Italy, provided that they had not experienced an ipsilateral DVT in the previous two years. Of these patients, 282 had been treated with rivaroxaban, 28 with dabigatran and 42 with apixaban. In each patient the common femoral vein at the groin and the popliteal vein at the popliteal fossa were scanned in transverse plane at 3 and/or 6 months after the acute event. Veins were assessed during compression, and RVT was defined as the persistence of thrombotic material resulting in a diameter of at least 4 mm.

Results The mean age of the study patients was 65.4 as compared to 60.7 of the historical control (p=0.016); 55.1% were males as compared to 49.2% (p=0.053); 20% had a previous VTE as compared to 14.6% (p=0.017); 73% had an unprovoked event as compared to 47.3 (p=0.001). 75 patients had their RVT assessment after three months, 3 after six months and 272 after both three and six months. Residual venous thrombosis was detected in 143 patients treated with NOA (41.2%) after three months and in 58 patients (21.1%) after six months; the corresponding figure in patients treated with conventional anticoagulation was 52.3% and 54.5%, respectively. After adjusting for the baseline characteristics, the odds ratio of RVT in patients treated with the NOA as compared to those treated with conventional anticoagulation was 0.63 (95% CI 0.48 - 0.81) after three months and 0.17 (95% CI 0.11 -0.26) after six months.

Conclusion Our study results show for the first time that in patients with proximal DVT treated with the NOA the persistence of ultrasound detectable RVT occurs less frequently than in patients treated with conventional anticoagulation. Whether this observation has implications for the development of subsequent complications remains to be demonstrated.

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Poster 109

Abstract Title The YEARS algorithm for suspected pulmonary embolism leads to much shorter diagnostic turnaround time than conventional algorithms

Authors C.E.A. Dronkers1, L.M. van der Pol1,2, T. van der Hulle1, C. Tromeur1, C. Heringhaus3, A.T.A. Mairuhu2, M.V. Huisman1, F.A. Klok1

Affiliations 1Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands; 2Department of Internal medicine, HagaHospital, The Hague, The Netherlands; 3Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands

Abstract Background Recently, the safety and efficacy of the YEARS algorithm (Figure 1), designed to simplify the diagnostic work-up of PE, have been confirmed (YEARS study, 2016 ESC abstract 5727). We hypothesize that by design, due to the simultaneous assessment of pre-test probability and D-Dimer level, YEARS is associated with a faster diagnostic turnaround time at the emergency ward compared with the conventional algorithm.

Material and Methods To test our hypothesis, we selected consecutive outpatients with suspected PE included in the YEARS study (n=308) and the ADJUST-PE study (Righini M et al, JAMA 2014; n=233). Different time points of the diagnostic process were extracted from the electronic patients chart system. Patients who were initially evaluated for a different acute condition, i.e. myocardial infarction, were excluded from this analysis.

Results All predefined diagnostic turnaround times were significantly shorter after implementation of YEARS. Specifically, the time between start of the diagnostic algorithm and order for CT-scan decreased from 133 to 82 minutes (min) and patients were discharged earlier from the emergency ward: 271 versus 215 min for the complete study population. Importantly, patients diagnosed with PE by CTPA received the first dose of anticoagulants 46 min (95%CI 17-76) faster than those managed according to the conventional algorithm.

Conclusion YEARS was associated with a significantly shorter diagnostic turnaround time compared with the conventional diagnostic algorithm, leading to faster treatment initiation in case of confirmed PE.

Figure 1: The YEARS algorithm versus conventional algorithm

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Poster 110

Abstract Title No further reduction in the number of required CT pulmonary angiograms when implementing the ADJUST (age adjusted) D-Dimer cut-off level in the YEARS algorithm Authors L.M. van der Pol1,2, T. van der Hulle1, A.T.A. Mairuhu2, T. van Bemmel3, J. van Es4, L.M. Faber5, M. ten Wolde6, H. Hofstee7, M.M.C. Hovens8, M. Nijkeuter9, R.C.J. van Klink10, M.J.H.A. Kruip11, S. Middeldorp12, M.V. Huisman1, F.A. Klok1

Affiliations 1Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands; 2Department of Medicine, HagaHospital, The Hague, The Netherlands; 3Department of Medicine, Gelre Hospital, Apeldoorn, The Netherlands; 4Department of Pulmonology, OLVG Hospital, Amsterdam, The Netherlands; 5Department of Medicine, Red Cross Hospital, Beverwijk, The Netherlands; 6Department of Medicine, Flevo Hospital, Almere, The Netherlands; 7Department of Medicine, The Hague Medical Center, The Hague, The Netherlands; 8Department of Medicine, Rijnstate Hospital, Arnhem, The Netherlands; 9Department of Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; 10Department of Pulmonology, Alrijne Hospital, Leiden, The Netherlands; 11Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands; 12Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands

Abstract

Background The YEARS algorithm was designed to simplify the diagnostic work-up of pulmonary embolism (PE) and to reduce the number of necessary computer tomography pulmonary angiography (CTPA) scans. A recent outcome study confirmed the safety and efficacy of YEARS (2016 ESC abstract 5727). Another strategy to reduce the number of CTPAs is the age-adjusted D-Dimer cut-off in patients aged 50 or older. A combination of both diagnostic strategies might save additional CTPAs.

Material and Methods We performed a post hoc analysis of the YEARS study to compare the number of required CTPAs for the two D-Dimer cut-off scenarios, to investigate whether the age adjusted cut-off for D-Dimer in patients aged ≥ 50 provides incremental diagnostic value to YEARS in patients with suspected PE without jeopardizing safety.

Results Using YEARS, 1651 patients (48%) were managed without CTPA; PE was diagnosed in 456 (13%) patients at baseline and 18 (0.52%) venous thromboembolism (VTE) during 3-month follow-up in patients with initial normal testing. When applying the age adjusted D-Dimer cut-off, 1497 patients (43%) would have been managed without CTPA for an absolute difference of 4.4% (95%CI 2.1-6.8) (Table 1). However, 4 PE would have been missed at baseline in patients with ≥ 1 YEARS item.

Conclusion In our cohort, there was no added value of implementing the ADJUST (age adjusted) D-Dimer cut-off level into the YEARS algorithm due to both an increased required number of CTPAs for excluding PE and an increased 3-month VTE failure rate. Table 1: Overview of patients managed without CTPA and failure rate

Number of patients managed without CTPA

Failure rate

YEARS protocol 1651/3465 (48%) 18/3465 (0.52%)

Years combined with age adjusted D-Dimer 1497 /3465 (43%) 22/3465 (0.64%)

Total difference between both protocols + 154 CTPAs + 4 failures

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Poster 111

Abstract Title Value of electrocardiographic changes in suspected acute pulmonary artery thromboembolism

Authors E. Paleviciute1,2, M. Laukyte1,2, P. Budrys1,2, A. Mebazaa3, J. Celutkiene1,2, on behalf of GREAT network

Affiliations

1Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; 2Centre of Cardiology and Angiology, Vilnius University Hospital Santariskiu Klinikos, Vilnius, Lithuania; 3U942 Inserm, Hospital Lariboisière, Université Paris Diderot, France

Abstract Background Frequently, difficult diagnosis of pulmonary embolism (PE) requires an integrated approach using clinical findings, electrocardiography (ECG), blood investigations and imaging modalities. The value of the ECG for the diagnosis of pulmonary embolism (PE) is debatable. The aim of our study was to analyse the prevalence of the most common ECG changes in patients with suspected acute PE in modern era.

Material and Methods 428 dyspneic patients were prospectively enrolled in the observational study in our hospital’s Emergency Department during 20 months’ period. Due to suspicion of PE, chest computed tomography pulmonary angiography (CTPA) was performed in 77 patients. These patients were included in the ECG analysis; prevalence of typical for right ventricular overload changes (S1Q3T3 pattern, complete and incomplete RBBB, T wave inversions in leads V1-4 and II, III, aVF, right axis deviation, dominant R wave in V1) together with sinus tachycardia, atrial tachyarrhythmias, LBBB was compared between the two groups: group 1 with confirmed PE by CTPA and group 2 with excluded PE by CTPA.

Results Acute PE was confirmed by CTPA in 30 (38.9%) patients. Diagnosis of PE made 7% of the whole acute dyspnea population. Finally, 29 patients entered the 1st group and 44 the 2nd group (excluding patients with no ECG in database). The mean age of the patients in group 1 was 68.0 ± 15.9 years, 17 (58.6%) were men. In group 2, the mean age was 72.7 ± 11.4, 21 (47.7%) were men. The results are presented in Table 1.

Conclusion The majority of patients with acute PE demonstrate several ECG signs of right ventricular overload. With a compatible clinical picture, an ECG showing S1Q3T3, sinus tachycardia or T wave inversions may raise the suspicion of PE and prompt diagnostic testing.

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Table 1: Comparison of ECG changes in groups 1 and 2 *ECG sign of right heart overload; AF- Atrial fibrillation, LBBB - Left bundle branch block, RBBB – Right bundle branch block

ECG criteria Group 1: Acute PE (n=29) Group 2: Dyspnea, no PE (n=44) p-value

Normal ECG 0 3 (6.8%) 0.213

Number of ECG signs*:

0 4 (13.7%) 11 (25%) 0.246

1 AF 8 (27.6%) 1 (3.4%) 22 (50%)

14 (31.8%) 0.057

2-4 11 (37.9%) 8 (18.2%) 0.060

>=5 6 (20.7%) 3 (6.8%) 0.078

HR < 100 rpm 18 (62.1%) 34 (77.3%) 0.160

HR > 100 rpm: 11 (37.9%) 10 (22.7%) 0.160

sinus tachycardia

9 (31%) 2 (4.5%) 0.003

AF 2 (6.9%) 8 (18.2%) 0.170

AF total 5 (17.2%) 24 (54.5%) 0.001

S1Q3T3 pattern 10 (34.5%) 1 (2.3%) 0.001

T (-) II, III, aVF 12 (41.4%) 3 (6.8%) 0.001

T (-) V1-4 + II, III, aVF 7 (24.1%) 0 0.001

RBBB 3 (10.3%) 3 (6.8%) 0.450

Incomplete RBBB 5 (17.2%) 2 (4.5%) 0.083

LBBB 1 (3.4%) 8 (18.2%) 0.060

Pacemaker 1 (3.4%) 2 (4.5%) 0.654

Acknowledgment: The work was supported by the Research Council of Lithuania, grant No. MIP-049/2015 and approved by Lithuanian Bioethics Committee, No. L-15-01.

ABSTRACT SESSION II Pulmonary Embolism

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Poster 201

Abstract Title Plasma D-Dimer in combination with shock index for identification of patients with acute pulmonary embolism at risk of serious adverse events.

Authors M. Kozłowska1, M. Pływaczewska1, M. Koć1, S. Pacho1, A. Wyzgał1, O. Zdończyk1, A. Furdyna1, M. Ciurzyński1, K. Kurnicka1, M. Kostrubiec1, P. Palczewski2, B. Lichodziejewska1, K. Irzyk1, P. Pruszczyk1.

Affiliations 1Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland; 2Department of Radiology, Medical University of Warsaw, Warsaw, Poland

Abstract Background Prognostic assessment in acute pulmonary embolism is based on clinical evaluation using the simplified pulmonary embolism severity index which incorporates amongst other parameters heart rate and systolic blood pressure, followed by the assessment of the presence of right ventricle dysfunction (RVD) with biomarkers or imaging. The aim of this study was to assess the prognostic value of shock index (HR/SBP) in combination with plasma D-Dimer levels measured during diagnostic evaluation to create a new risk stratification tool for the prediction of early serious adverse events (SAE).

Material and Methods Into this single centre retrospective study 270 patients were included (144 F, median age 66 years (25th-75th percentile, 49-81)) with thromboemboli visualized in multi-slice computed tomography in at least segmental arteries. Patients underwent transthoracic echocardiogram for RVD, hsTnT was assayed at admission. Patients were treated according to ESC guidelines. The 30-day SAE included death, hemodynamic deterioration requiring rescue thrombolysis or cardio-pulmonary resuscitation, and major bleeding.

Results The group comprised of 54 low-risk patients classified according to ESC guidelines, 198 intermediate-risk patients, and 18 high-risk patients. Mean shock index and D-Dimer levels were significantly related to SAEs (SI 0.92 (0.75-1.37) vs 0.62 (0.54-0.78), p<0.001; DD 7247 ng/ml (4553-27750) vs 5156 ng/ml (2149-11229), p=0.004), RVD dysfunction (SI 0.60 (0.53-0.70) vs 0.71 (0.60-0.92), p<0.001; DD 6012 ng/ml (2810-16018.5) vs 4476 ng/ml (2486-7631), p=0.04), and signs of myocardial injury defined as cTnT > 0.014 ng/ml (SI 0.61 (0.54-0.74) vs 0.66 (0.56-0.86), p=0.007; DD 6346 ng/ml (3566-18558.5) vs 2751 ng/ml (1681-5236), p<0.001). The optimal cut-off point for D-Dimer levels was determined by ROC analysis leading to the selection of a threshold characterized by a NPV of 100% for SAE - 1350 ng/ml, the AUC for the ROC of DD for SAE was 0.672 (95%CI 0.559-0.785). The AUC in ROC analysis of SI alone for SAE was 0.807 (95% CI 0.707-0.908), the optimal cut-off point for shock index was determined using Youden’s index – the threshold of 0.7 was chosen. The sensitivity of SI> 0.7 for the prediction of SAE was 88%, specificity 65%, NPV 98%, PPV 21%, OR= 10.8 (95%CI 3.1-37, p=0.0002). Of the 270 studied patients, 105 had SI > 0.7 and 239 had D-Dimer levels > 1350 ng/ml. There were 25 SAE (14 deaths, 11 hemodynamic deteriorations) of which all occurred in the DD > 1350 ng/ml group and 22 occurred in SI>0.7 group. In the group of 100 patients with DD levels > 1350 ng/ml and SI > 0.7 22/25 SAE occurred (88%), OR=11.9 (95% CI 3.4-40.9, p=0.0001).

Conclusion D-Dimer levels measured during diagnostic evaluation for APE show prognostic value. DD levels > 1350 ng/ml in combination with SI> 0.7 allow for the identification of patients at increased risk of serious adverse events occurring within the first 30 days of treatment.

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Poster 202

Abstract Title Prognostic value of various glomerular filtration rate formulas in risk assessment of patients with acute pulmonary embolism.

Authors M. Pływaczewska, M. Kozłowska, O. Dzikowska-Diduch, M. Ciurzyński, P. Pruszczyk, M. Kostrubiec

Affiliations Department of Internal Medicine & Cardiology, Medical University of Warsaw, Poland

Abstract Background Acute pulmonary embolism (APE) impacts primarily the pulmonary circulation. However, there are disorders of other organs, including the kidney, due to the reduction of cardiac output, hypoxemia and increased venous pressure perfusion. Impaired renal function assessed by Glomerular Filtration Rate (GFR) is the risk factor of increased mortality and morbidity in many cardiovascular diseases.

Aim We compared prognostic values of creatinine clearance (GFR) calculated the MDRD formula (Modification of Diet in Renal Disease) and the Cockcroft-Gault formula in 646 patients with acute pulmonary embolism.

Material and Methods Six hundred forty-six patients (287 M/ 359 F, years 64 ±19) hospitalized with APE proven by spiral computer tomography were included to the study. The GFRs with MDRD and Cockcroft-Gault formula were estimated based on serum creatinine on admission. Echocardiography was performed within 48 hours of the admission to assess the risk according to European Cardiac Society guidelines.

Results The GFRs assessed by both, MDRD and Cockcroft-Gault formula, were highest in patients with low risk APE and the lowest in high risk APE (GFR according to MDRD 77,29 (10,25-187,8) in patients with low risk vs. 74,25 (9,22-184,8) in moderate risk vs. 60,23 (14,76-127,84) in high risk (p<0,0001); GFR calculated by Cockcroft-Gault formula 88,54 (6,43-246,9) vs. 74,25 (11,22-230,7) vs. 50,4 (13,6-152,5), p=0,001, respectively. Forty-one patients died during 30-day follow-up. The calculated GFR (both methods MDRD and Cockcroft-Gault formula) was significantly lower in non-survivors compared to survivors 54,18 (19,18-174,89) vs. 73,33 (9,22-187,89), p<0,00001 for MDRD and 44,98 (14,16-161,66) vs. 80,75 (6,43-246,9) for Cockcroft-Gault, (p=0,00) respectively. The GFRs ≤35 ml/min estimated by MDRD and Cockcroft-Gault formula were predictors of 30-day mortality (HR 2,13, 95% CI: 0,985-4,618, p=0,05 and HR 2,68, 95% CI: 1,219-5,910, p=0,01, respectively). The area under the ROC curve for GFR calculated with MDRD tended to be higher than for GFR estimated with Cockcroft-Gault formula 0,600 (95% CI: 0,561- 0,638) vs. 0,524 (95% CI: 0,484 -0,563) p=0,08 (Figure 1).

Conclusion The GFR assessed on admission in patients with APE by both, MDRD and Cockcroft-Gault formula, is a significant mortality predictor. However, the comparison of areas under the ROC curves tends to indicate that GFR calculated with MDRD has better prognostic value in APE than estimated with Cockcroft-Gault formula.

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Figure 1: ROC curve of GFR (MDRD and Cockcroft-Gault) for predicting 30-day mortality

34

Poster 203

Abstract Title Prognostic impact of copeptin in normotensive pulmonary embolism – a European multicentre validation study

Authors K. Hellenkamp1, P. Pruszczyk2, D. Jiménez3, A. Wyzgał2, D. Barrios3, M. Ciurzyński2, R. Morillo3, L. Hobohm4,5, K. Keller4, K. Kurnicka2, M. Kostrubiec2, R. Wachter1,6, G. Hasenfuß1,6, S. Konstantinides4, M. Lankeit1,4,7,8

Affiliations 1Clinic of Cardiology and Pneumology, Heart Center, Georg-August University of Göttingen, Germany;

2Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland; 3Respiratory Department and Medicine Department, Ramón y Cajal Hospital, Alcalá de Henares University, IRYCIS, Madrid, Spain; 4Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; 5Center for Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; 6German Cardiovascular Research Center (DZHK), partner site Göttingen, Germany; 7Department of Cardiology, Campus Virchow Klinikum (CVK), Charité University Medicine, Berlin, Germany; 8German Cardiovascular Research Center (DZHK), partner site Berlin, Germany

Abstract

Background The current 2014 guideline of the European Society of Cardiology (ESC) recommends risk stratification of patients with acute pulmonary embolism (PE), as this may influence treatment decisions. Vasopressin (AVP), and its more stable surrogate marker copeptin, reflects a promising new pathophysiological axis of PE severity since AVP is released upon stress and hypotension and may therefore indicate the systemic response to impaired hemodynamics due to RV failure. Indeed, in a prospective single-centre derivation study [1,2], we have shown in 268 normotensive PE patients that elevated copeptin levels were associated with a more than 5-fold increased risk of an adverse 30-day outcome. The aim of the present European multicentre study was to externally validate the prognostic value of copeptin in normotensive PE.

Material and Methods We performed a post-hoc analysis of 843 normotensive patients with confirmed PE prospectively included in three European cohort studies.

Results Within the first 30 days, 21 (2.5%) patients had an adverse outcome and 12 (1.4%) died due to PE. Patients with plasma copeptin levels above the predefined cut-off value of 24 pmol/l had a 6.3-fold increased risk for an adverse outcome (95%CI, 2.6-15.5; p<0.001) and a 7.6-fold increased risk for PE-related death (95%CI, 2.3-25.6; p=0.001). As shown in Figure 1, risk classification according to the 2014 European Society of Cardiology (ESC) guideline algorithm identified 248 (29.4%) intermediate-high risk patients with 5.6% adverse outcomes. In comparison, a stepwise biomarker-based risk assessment strategy (based on high-sensitivity troponin T [hsTnT], N-terminal pro-brain natriuretic peptide [NT-proBNP] and copeptin) identified 123 (14.6%) intermediate-high risk patients with 8.9% adverse outcomes. Importantly, the identification of patients at higher risk was even better when copeptin was measured on top to the 2014 ESC algorithm in intermediate-high risk patients (adverse outcome: OR, 11.1; 95%CI, 4.6-27.1; p<0.001 and PE-related death: OR, 13.5; 95%CI, 4.2-43.6; p<0.001; highest risk group vs. all other risk groups). Using this combined approach, 85 (10.1%) patients with 12.9% adverse outcomes were identified.

Conclusion Copeptin improves risk stratification of normotensive patients with PE, especially by identifying patients with an increased risk for an adverse outcome.

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Figure 1: Risk assessment strategies for normotensive PE patients A) Risk assessment using a biomarker-based strategy based on hsTnT, NT-proBNP and copeptin B) Risk assessment as proposed by the 2014 ESC guideline C) Adding measurement of copeptin in patients classified in the intermediate-high risk group by the 2014 ESC

algorithm helps to identify patients with an increased risk for an adverse outcome. References (1) Hellenkamp K, Schwung J, Rossmann H, Kaeberich A, Wachter R, Hasenfuß G, Konstantinides S, Lankeit M.

Risk stratification of normotensive pulmonary embolism: prognostic impact of copeptin. Eur Respir J. 2015; 46:1701-10.

(2) Hellenkamp K, Schwung J, Rossmann H, Kaeberich A, Hasenfuß G, Wachter R, Konstantinides S, Lankeit M. Investigation of a new pathophysiological axis for risk stratification of normotensive pulmonary embolism: prognostic impact of copeptin. Posterpresentation. Second European Spring School on VTE 2015. Sithonia, Chalkidiki, Greece.

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Poster 204

Abstract Title Prognostic value of MR-proANP in normotensive pulmonary embolism

Authors N. Rogge1, K. Hellenkamp1, K.P. Kresoja2, R. Wachter1, G. Hasenfuß1, B. Pieske2, A. Parwani2, M. Lankeit1,2.

Affiliations 1Clinic of Cardiology and Pneumology, Heart Center, Georg-August University of Göttingen, Germany; 2Department of Cardiology, Campus Virchow Klinikum (CVK), Charité University Medicine, Berlin, Germany

Abstract Background Risk stratification of patients with pulmonary embolism (PE) is mandatory to define the appropriate management strategy. However, identification of intermediate-high risk patients who may benefit from thrombolysis remains challenging. We aimed to investigate the prognostic value of midregional pro-atrial natriuretic peptide (MR-proANP) in normotensive PE patients.

Material and Methods MR-proANP concentrations were measured in venous plasma samples in 305 normotensive PE patients included in the Pulmonary Embolism Registry Göttingen (PERGO).

Results MR-proANP concentrations ranged from 15 to 989 (median, 148 [IQR, 75-267]) pmol/l, correlated with N-terminal pro-brain natriuretic peptide (NT-proBNP; r=0.72, p<0.001; n=255 [83.6%]), high-sensitivity troponin T (hsTnT; r=0.55, p<0.001; n=283 [92.8%]) and GFR (r=0.52, p<0.001; n=300 [98.4%]) and were higher in patients with renal insufficiency, chronic heart failure, coronary artery disease, RV dysfunction on echocardiography, tachycardia and syncope. During the in-hospital stay, 15 patients (4.9%) had PE-related complications and 11 patients (3.6%) died; of those 7 (63.6%) due to PE. Patients with PE-related complications and with PE-related death had higher MR-proANP levels compared to patients with a favourable clinical course (382 [233-567] vs. 134 [70-250], p<0.001 and 461 [296-567] vs. 142 [73-258], p=0.002, respectively). ROC analysis yielded an AUC of 0.83 (0.74-0.91) for MR-proANP, 0.87 (0.80-0.93) for NT-proBNP and 0.74 (0.65-0.82) for hsTnT. Overall, 171 patients (56.1%) had MR-proANP levels above the pre-defined cut-off value of 120 pmol/l; of those, 15 (8.8%) had PE-related complications and 7 (4.1%) died due to PE. All tested biomarkers were associated with an excellent sensitivity and negative predictive value (NPV; 100% each, respectively). The specificity (46%) and positive predictive value (9%) of MR-proANP ≥120 pmol/l was comparable to NT-proBNP ≥600 pg/ml (49% and 9%, respectively) and hsTnT ≥14 pg/ml (36% and 8%, respectively). A patient-cohort optimised cut-off value for MR-proANP of 209 pmol/l was associated with a higher specificity (67%) and positive predictive value (PPV, 12%) but lower sensitivity (87%) and NPV (99%). Elevation of MR-proANP ≥209 pmol/l was associated with an almost 13-fold increased risk for PE-related complications (OR, 12.9; 95% CI, 2.9-58.5; p=0.001) while odds ratios for established biomarker cut-off values were not calculable. In a multivariable logistic regression model also including renal insufficiency (OR, 6.7 [95% CI, 1.8-25.1], p=0.004), chronic heart failure (OR, 3.3 [1,1-9.6], p=0.031) and syncope (OR, 4.8 [1.5-15,3], p=0.008), MR-proANP ≥209 pmol/l emerged as the only independent predictor of PE-related in-hospital complications (ORcorr, 9.0 [1.0-78.3], p=0.046).

Conclusion MR-proANP may serve as a promising new biomarker for risk stratification of normotensive PE.

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Poster 205

Abstract Title Performance of the modified FAST score for risk stratification of normotensive pulmonary embolism – a validation study

Authors L. Hobohm1,2, C. Becattini3, S. Konstantinides1,4, F. Casazza5, M. Lankeit1,6

Affiliations 1Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; 2Center for Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Germany; 3Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy; 4Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece; 5Cardiology Department, San Carlo Borromeo Hospital, Milan, Italy; 6Department of Cardiology, Charité University Medicine, Campus Virchow Klinikum (CVK), Berlin, Germany

Abstract Background Recent studies demonstrate that the algorithm suggested by the ESC 2014 guideline improves risk stratification of patients with pulmonary embolism (PE). Additionally, the modified FAST (based on a positive troponin test, syncope and tachycardia) and the Bova score appear especially helpful to identify normotensive PE patients at highest risk for PE-related complications. We aimed to externally validate the prognostic performance of the

modified FAST score compared to other scores for risk stratification.

Methods Normotensive patients with confirmed PE included in the observational multicentre Italian Pulmonary Embolism Registry (IPER) between January 2006 and November 2010 were studied. Patients without an echocardiogram or troponin test on admission were excluded from analysis.

Results Overall, 868 normotensive PE patients (median age, 70 [IQR, 63-81] years; females: 55.2%) were included in the analysis. During the in-hospital stay, 27 patients (3.1%) had clinical worsening requiring at least one of the following: (1) i.v. catecholamine infusion, (2) endotracheal intubation, or (3) cardiopulmonary resuscitation. Additionally, 32 patients (3.7%) died and 12 deaths (1.4%) were related to PE. The ESC 2014 algorithm classified one third of patients in each risk class while the Bova and especially the modified FAST score classified more patients in low-risk classes (48.0% and 65.2%, respectively). The percentage of patients with clinical worsening was highest in the intermediate-high-risk classes of the ESC 2014 algorithm (5.7%) and the modified FAST score (5.3%) while the Bova score failed to identify patients at highest risk (intermediate-low- [4.7%] and intermediate-high-risk class [4.5%]). Accordingly, patients classified as intermediate-high-risk by the use of the ESC 2014 algorithm (compared to low- and intermediate-low-risk; OR, 3.1 [1.4-6.8]; p=0.004) and modified FAST score (compared to low-risk; OR, 2.8 [1.3-6.2]; p=0.009) had a higher risk of clinical worsening compared to the patients classified by the use of the Bova score (compared to low- and intermediate-risk; OR, 1.7 [0.7-3.9]; p=0.263). Using continuous risk classes, the AUC for prediction of clinical worsening was higher for the ESC 2014 algorithm (0.68 [0.59-0.78]) and the modified FAST score (0.67 [0.59-0.76]) compared to the Bova score (0.63 [0.53-0.73]). Regardless of the score or algorithm used, less than 1% of patients classified in low-risk classes died due to PE.

Conclusion We were able to externally validate the usefulness of the modified FAST score for risk stratification of normotensive PE in a large Italian multicentre cohort. While the ESC 2014 algorithm and the modified FAST score accurately stratified PE patients in different risk classes, the Bova score failed to identify patients at highest risk who need monitoring and possibly rescue reperfusion therapy.

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Poster 206

Abstract Title Sex-specific differences in pulmonary embolism

Authors K. Keller1; L. Rappold2; A. Gerhold-Ay1,3; G. Hasenfuß2; S. Konstantinides1; C. Dellas4; M. Lankeit1,2,5

Affiliations 1Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; 2Clinic for Cardiology and Pulmonology, Heart Centre, University of Göttingen (Georg-August University of Göttingen), Göttingen, Germany; 3Institute of Medical Biostatistics, Epidemiology and Informatics [IMBEI], Mainz, Germany; 4Department of Paediatric Cardiology, University of Göttingen (Georg-August University of Göttingen), Göttingen, Germany; 5Department of Cardiology, Campus Virchow Klinikum (CVK), Charité University Medicine, Berlin, Germany

Abstract Background Sex-specific differences regarding risk factors, symptoms and prognosis have been reported for several cardiovascular diseases (CVD). For patients with pulmonary embolism (PE), sex-specific data are limited and inconsistent.

Material and Methods Over a 10-year period (01/2003-09/2013), patients with confirmed symptomatic PE were enrolled in a prospective single-centre cohort study. Study follow-up data were collected 30 days after the PE index event and data were analysed post-hoc. Study outcomes were defined as an adverse 30-day outcome (PE-related death, need for mechanical ventilation, cardiopulmonary resuscitation or administration of catecholamines) and 30-day all-cause mortality.

Results We included 569 PE patients (318 women [55.9%]) in this analysis. Although 60% of the patients <50 years were female, in the overall cohort females were older (median, 71 [IQR, 55-79] years) compared to males (67 [53-75] years, p=0.008). Except a higher frequency of cancer (20.7% vs. 13.5%, p=0.024) in males, no relevant sex-specific differences with regard to symptoms and venous thromboembolism (VTE) risk factors were observed. Regarding relevant comorbidities, females more often had renal insufficiency (39.4% vs. 31.0%, p=0.042) and rheumatoid arthritis (9.5% vs. 4.4%, p=0.022), while males more frequently had coronary artery disease (25.1% vs. 13.5%, p=0.001). Women were more often diagnosed with tachycardia (42.3% vs. 31.6%, p=0.010), right ventricular (RV) dysfunction on echocardiography (56.6% vs. 44.6%, p=0.023) and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels ≥600 pg/ml (61.4% vs. 49.5%, p=0.015). Overall, 84 patients (14.8%) had an adverse 30-day outcome and 43 (7.6%) died within the first 30 days. Adverse 30-day outcome (p=0.636) and 30-day all-cause mortality (p=0.873) were comparable between both sexes. Interestingly, in 501 normotensive PE patients (88.0%), established risk stratification tools such as RV dysfunction on echocardiography, high-sensitive troponin T (hsTnT), NT-proBNP, the sPESI, Bova score and the algorithm proposed by the 2014 ESC guideline failed to predict an adverse 30-day outcome in male patients in contrast to females. Only the modified FAST score was able to predict an adverse 30-day outcome in women (≥3 points; OR, 32.6 [95% CI, 4.2-255.9], p=0.001) and men (OR, 5.1 [1.2-21.1], p=0.026).

Conclusion Although 30-day outcomes did not differ between both sexes, women presented more frequently with signs of RV dysfunction. Established risk stratification markers and scores failed to predict 30-day PE-related complications in male patients; only the modified FAST score was able to predict an adverse 30-day outcome in both sexes.

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Poster 207

Abstract Title The empty heart in patients with active malignancy and acute pulmonary embolism

Authors A. Milwidsky1,5, E. Soikher2,5, A. Bendet2,5, Y. Hadad2,5, T. Ziv-Baran4,5, S. Greenberg3,5, S. Berliner3,5, Y. Topilsky1,5, G. Aviram2,5

Affiliations Departments of 1Cardiology, 2Radiology and 3Internal Medicine "E" all at the Tel Aviv Medical Center, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 4Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 5This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

Abstract Background Clinical and computed tomography pulmonary angiographic (CTPA) characteristics of pulmonary embolism (PE) in patients with malignancy are poorly defined. The aim of the current study was to compare clinical and CTPA data of acute PE patients with and without active malignancy.

Methods We conducted a retrospective cohort study of 636 consecutive patients diagnosed on CTPA with acute PE between 1/2007-12/2010. Clot location, right ventricular (RV) and left ventricular diameters were assessed. Volumetric measurements of cardiac chambers were performed by fully automatic software. A multivariate logistic regression model adjusted to age, gender, and multiple comorbidities analysed associations between CT indices and 30-day mortality rates.

Results The mean age of the study population was 68±18 years, 280 (44%) patients were males and 219 (34%) had active malignancy. Age and gender were similar in patients with and without malignancy. Both atrial and RV volumes were smaller in patients with active malignancy (P ≤ 0.001), and their 30-day mortality rate was higher (27% vs. 6%, respectively, P < 0.001). A 10 ml smaller left atrial volume increased the mortality rate by 1.17 in patients with an active malignancy (95% CI [1.01-1.37], P = 0.04), and by 1.24 in patients without active malignancy (95% CI [1.01-1.53], P = 0.04).

Conclusion Acute PE patients with active malignancy have smaller cardiac chambers than those without malignancy. Short-term mortality rates in both groups were associated with a decrease in left heart chamber volumes rather than an increase in right heart chamber volumes.

Figure 1: An example of volumetric analysis of cardiac chambers in a 49-year-old woman with metastatic gastric carcinoma and acute pulmonary embolism who died within 30 days of PE diagnosis. Left: Axial image of CT pulmonary angiography. Right: volumetric model of the four cardiac chambers. Colour code: right ventricle = orange, right atrium = yellow, left ventricle = pink, and left atrium = purple. There are decreased cardiac

volumes in general especially of the left heart, (left ventricle [LV] =72 mL; left atrium [LA] = 44 mL; right ventricle [RV] = 90 mL; right atrium [RA] = 69 mL). RV/LV volume ratio = 1.3; RA/LA volume ratio = 1.6. Note, pulmonary emboli (white arrow) can be seen in a segmental branch in the right lower lobe, as well as enlarged para-oesophageal lymph nodes (black arrow).

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Poster 208

Abstract Title Temporal trends in risk-adjusted management and outcome of patients with pulmonary embolism – a single centre experience

Authors M. Ebner1, K.P. Kresoja1, K. Hellenkamp2, L. Hobohm3, K. Keller3, G. Hasenfuß2, B. Pieske1, S. Konstantinides3, M. Lankeit1,2,3

Affiliations 1Department of Cardiology, Campus Virchow Klinikum (CVK), Charité University Medicine, Berlin, Germany; 2Clinic of Cardiology and Pneumology, Heart Center, Georg-August University of Göttingen, Germany; 3Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany

Abstract Background Treatment of pulmonary embolism (PE) has evolved over the past decade. Current guidelines underline the importance of risk-stratification to identify patients with high risk for an adverse outcome and to guide treatment decisions. However, real world data on the impact of these advances on patient outcome are limited.

Material and Methods Consecutive PE patients enrolled in the prospective on-going Pulmonary Embolism Registry of Göttingen (PERGO) between September 2008 and August 2016 were included. Frequency of adverse outcome was assessed according to validated risk scores. Furthermore, we evaluated temporal trends in acute revascularisation (systemic thrombolysis, surgical thrombectomy and interventional approaches), adverse outcome (intubation, treatment with catecholamines, resuscitation or in-hospital PE-related death), 30-day and one-year all-cause mortality and length of in-hospital stay.

Results We analysed 605 patients (median age 70 years [IQR, 55-77] years, 53% female) with a high percentage of patients classified as high- and intermediate-high-risk (8.8% and 26.6%, respectively) according to the ESC 2014 risk classification. Acute revascularisation was performed in 9.4% with a stable rate throughout the study period (Figure 1). Additionally, 5.6% of patients were enrolled in the PEITHO trial. The ESC risk classification accurately identified patients at risk for an adverse outcome. Adverse events predominantly occurred in high- (71.2%) and intermediate-high- (11.8%) risk patients. Other risk scores (sPESI, Bova and modified FAST score) performed similar in normotensive patients. Overall, complication rates decreased from 19.4% in the first 2-year segment (09/2008 – 08/2010) to 11.7% in the last 2-year segment (09/2014 – 08/2016); however, case-fatality rate in high-risk patients increased over time despite an increase of revascularisation treatment. In-hospital death occurred in 7.0% and was mainly due to PE related death (66%). Median duration of in-hospital stay decreased from 10 days [IQR, 6-15.5] in the first 2-year segment to 7 days [IQR, 4-15] in the last 2-year segment. One-year mortality rate was 16.6% across all risk groups, and ranged from 1.4% in low-risk to 55.1% in high-risk patients (Figure 2).

Conclusion In our patient cohort, the rate of PE-related adverse outcomes and the length of in-hospital stay have decreased over time. However, mortality remains substantially high in high-risk patients.

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Figure 2: Probability of survival within one year after diagnosis of pulmonary embolism One-year mortality rate ranged from 1.4% in low-risk patients to 55.1% in patients classified as high-risk according to the ESC 2014 risk classification.

Figure 1: Revascularisation rate over time Percentage of patients who underwent revascularisation stratified according to the ESC 2014 risk classification. Acute revascularisation was defined as systemic thrombolysis, surgical thrombectomy or interventional procedures.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

09/2008-08/2010 09/2010-08/2012 09/2012-08/2014 09/2014-08/2016

Acute Revascularisation Rate

Low Risk Intermediate Low Risk Intermediate High Risk

High Risk All Patients

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Poster 209

Abstract Title Prediction of 30-day major bleeding in patients with acute pulmonary embolism – validation of the VTE-BLEED score in a real-world cohort

Authors K.P. Kresoja1, M. Ebner1, N. Rogge2, J. Reuter2, G. Hasenfuß2, B. Pieske1, M. Lankeit1,2

Affiliations 1Department of Cardiology, Campus Virchow Klinikum (CVK), Charité University Medicine, Berlin, Germany; 2Clinic of Cardiology and Pneumology, Heart Center, Georg-August University of Göttingen, Germany

Abstract Background Assessment of bleeding risk in patients with pulmonary embolism (PE) is challenging. Recently, the VTE-BLEED score, which is based on six different weighted variables, was shown to predict major bleeding events in patients with venous thromboembolism (VTE) on stable anticoagulation with both warfarin and dabigatran [1]. We aimed to validate the VTE-BLEED score in a real-world cohort of PE patients.

Material and Methods Consecutive PE patients prospectively included in the Pulmonary Embolism Registry Göttingen (PERGO) between September 2008 and November 2016 were eligible for the present analysis; patients included in the AMPLIFY or PEITHO study and patients treated with thrombolysis were excluded. The VTE-BLEED and the HAS-BLED score were calculated post-hoc; 30-day major bleeding was defined using the ISTH definition.

Results Overall, 522 patients (median age, 69 [IQR, 56-78] years, 53% female) were included in the present analysis; major bleedings occurred in 16 (3.1%) patients. Patients classified as high-risk (>2 points) by the VTE-BLEED score (n=305 patients; 58.4%) had major bleeding rate of 4.6% compared to 0.9% in 217 patients (41.6%) classified as low-risk (OR 5.2; 95% CI 1.1-23; sensitivity 88%, specificity 57%). ROC analysis yielded an AUC of 0.65 (95% CI 0.53-0.78) for the VTE-BLEED score which was larger compared to the HAS-BLED score (0.51; 95% CI 0.37-0.65). The HAS-BLED score failed to predict major bleeding events (3.2% in high-risk compared to 3.0% in low-risk patients, p=0.525; OR 1.1; 95% CI 0.4-3.0). Patients classified as high-risk by the VTE-BLEED score had a 6.7-fold (95% CI 1.6-29) increased risk of 30-day all-cause mortality. Bleeding events were more frequently observed in patients initially treated with unfractioned heparin (UFH) with a decrease of bleeding events over time (Figure 1); and UFH treatment tended to be associated with an increased risk of major bleeding (OR 3.4; 95% CI 0.95-12). In our cohort, the number of patients treated with non-Vitamin-K dependent oral anticoagulants (NOACs) at discharge has substantially increased over time (31% of patients treated with rivaroxaban and 46% treated with apixaban in the last 3-month segment, Figure 2).

Conclusion A VTE-BLEED score >2 points was associated with a 5.2-fold increased risk for 30-day major bleeding in a large real-world cohort of PE patients while the HAS-BLED score failed to adequately identifying patients at risk. A less frequent use of UFH for initial anticoagulation might have contributed to the decrease of bleeding events over time. The number of patients treated with NOACs at discharge increased over time. References [1] Klok FA et al. Prediction of bleeding events in patients with venous thromboembolism on stable anticoagulation treatment. Eur Respir J 2016; 48:1268-1270.

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Figure 1: Initial anticoagulation and major bleeding

Figure 2: a) Anticoagulation at discharge (overall); b) Anticoagulation at discharge (between 09/2014 and 11/2016)

a) b)

44

Poster 210

Abstract Title Patients are more adherent to treatment with LMWH nadroparin than enoxaparin for cancer related venous thromboembolism

Authors S.J. van der Wall1, F.A. Klok1, P.L. den Exter1, D. Barrios2, R. Morillo2, S.C. Cannegieter3, D. Jimenez2, M.V. Huisman1

Affiliations

1Department of Thrombosis and Hemostasis, Leiden University Medical Center, The Netherlands; 2Respiratory Department, Ramon y Cajal Hospital IRYCIS, Spain; 3Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands

Abstract Background Current guidelines recommend low-molecular-weight-heparins (LMWH) monotherapy for 3 to 6 months as first-line treatment for cancer-associated venous thromboembolism (VTE). In clinical practice nadroparin and enoxaparin are common agents used. However, differences in therapy adherence between these LMWHs have never been reported.

Material and Methods Consecutive patients with active cancer and objectively confirmed VTE, treated at three Dutch hospitals and one Spanish hospital, were included and followed during LMWH therapy with a maximum of 180 days to compare adherence to nadroparin and enoxaparin in patients with cancer-associated VTE. Cumulative incidences of discontinuation of both LMWHs were estimated and compared according to the Kaplan-Meier method, applying a competing risk analysis to correct for mortality.

Results 372 patients were analysed during LMWH treatment, of whom 284 patients (76%) were treated with enoxaparin and 88 (24%) with nadroparin. The overall cumulative incidence of discontinuation of enoxaparin and nadroparin treatment because of side effects was 30% (95%CI 24-36) and 10% (95%CI 2.7-17), respectively. Competing risk analysis revealed a higher number of patients discontinuing enoxaparin because of side effects (Hazard Ratio: 3.4, 95%CI 2.6-4.2). Unacceptable pain at the injection site was the most common reason of discontinuation in patients using enoxaparin, occurring in 32 patients, while it occurred in one patient using nadroparin.

Conclusion This analysis reveals that enoxaparin was associated with a higher risk of discontinuation because of side effects compared to nadroparin. Although this was a non-randomised comparison, our findings are relevant for choice of LMWH when treating cancer-associated VTE.

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Poster 211

Abstract Title Continuation of LMWH treatment for cancer related venous thromboembolism – a prospective cohort study in daily clinical practice

Authors S.J. van der Wall1, F.A. Klok1, P.L. den Exter1, D. Barrios2, R. Morillo2, S.C. Cannegieter3, D. Jimenez2, M.V. Huisman1

Affiliations 1Department of Thrombosis and Hemostasis, Leiden University Medical Center, The Netherlands; 2Respiratory Department, Ramon y Cajal Hospital IRYCIS, Spain; 3Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands

Abstract Background Current guidelines recommend low-molecular-weight heparin (LMWH) monotherapy for 3 to 6 months as first-line treatment for cancer-associated venous thromboembolism (VTE). However, although daily administration of LMWH injections over a course of several months may be burdensome, the number of patients who quit because of LMWH side effects is unknown. The aim of this study was to evaluate the continuation rate and complications of daily LMWH injections in cancer-associated VTE.

Material and Methods Consecutive patients with active cancer and objectively confirmed symptomatic proximal deep vein thrombosis (DVT) and/or pulmonary embolism (PE), treated at three Dutch hospitals and one Spanish hospital, were included to evaluate continuation LMWH therapy during LMWH treatment. Patients were excluded when they received other anticoagulants, were lost to follow up or experienced a venous catheter-associated thrombosis.

Results A total of 372 patients were analysed during LMWH treatment with a maximum of 180 days. The cumulative incidence of discontinuation was 21% (95% confidence interval [CI]: 17-25) after a median period of 90 days (interquartile range 60-120 days). Only female sex was found to be significantly associated with premature LMWH discontinuation (OR 1.6; 95%CI 1.03-2.5). Thirty patients (8.1%) developed recurrent VTE, 30 patients (8.3%) suffered a major bleeding and 106 patients (28%) died.

Conclusion Our study reveals that one out of five patients with cancer-associated VTE stopped LMWH injections because of side effects. This finding provides relevant background information to current clinical trials investigating the efficacy and safety of direct oral anticoagulants (DOACs) compared to LMWH.

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Poster 212

Abstract Title Efficacy of chest, abdomen, and pelvis computed tomography in the screening of occult cancer after unprovoked venous thromboembolism

Authors S. Adham, G. Armengol, H. Levesque, Y. Benhamou, S. Miranda

Affiliations

Department of internal medicine, University Hospital of Rouen, France

Abstract Background The relationship between VTE (venous thromboembolic event) and malignant disease has been demonstrated for years. So patients with cancer, have up to a 7-fold higher risk to develop VTE as compared to non-cancer patients. A review has reported a prevalence of occult cancer detection following diagnosis of VTE up to 10% of patients with unprovoked VTE while recent prospective studies have reported a rate lower than 5%. The optimal screening strategy is controversial, recently the SOME study did not support an extensive screening strategy. Since many years, the screening strategy of occult cancer in our centre include a thoracic, abdominal, and pelvic computed tomography (CT) in addition to clinical examination, routine laboratory-testing, and mammography. So we aimed to test the input of whole body CT in the screening strategy for detection of occult malignant disease in patients with unprovoked VTE.

Material and Methods All the medical records of patients hospitalized for venous thrombotic event (lower limb deep venous thrombosis and pulmonary embolism) from 2005 to 2014 in the department of internal medicine of the hospital of Rouen were retrospectively screened. All patients with unprovoked VTE were included.

Results 977 patients were assessed to eligibility. Patients with active cancer disease (34%), provoked VTE (40%), and patients who did not undergo a whole-body CT or whose CT result was not available (7.67%) were excluded. 456 patients were finally included. The mean age was 67.7 ± 16.3. 7 years. 83 (18.3%) patients had a diagnosis of cancer following the VTE. Among the patients with a diagnosis of cancer 35(42.1%) had a normal clinical examination and in the remaining population 18 (21.6%) had a normal paraclinic evaluation. So the limited strategy missed 18 patients with cancer. Among these patients CT found malignant diseases in 16 (19.2%). Considering the overall population, only 3.5% of occult cancer was diagnosed with CT. In univariate analysis, cancer was associated with age, male gender, current smoking and bilateral DVT. In multivariate analysis cancer was significantly associated with age (OR=1.03[1.01-1.06] p<0.001), current smoking (OR=2.78[1.23-6.32] p=0.015) and bilateral DVT (OR=3.37[1.69-6.69] p<0.001). In the subgroup of patients with bilateral DVT at presentation, the CT identified significantly more occult lesions 10.64% versus 2.68% in patients without bilateral DVT (p=0.017).

Conclusion The prevalence of occult cancer in a cohort of patients hospitalized in a tertiary care centre for idiopathic VTE appears to be higher than described in recent controlled studies. It appears that performing a CT scan to detect occult cancers provide a small benefit. However, CT might be useful in a selected population at very high risk of cancer and should be investigated in a prospective study.

ABSTRACT SESSION III Chronic Thromboembolic Pulmonary Hypertension

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Poster 301

Abstract Title Follow-up after acute pulmonary embolism (FOCUS): A prospective observational multicentre cohort study

Authors S. Barco1, A. Gerhold-Ay2, M. Lankeit1,5, P.S. Wild1,3,4, S.V. Konstantinides1,6 on behalf of the FOCUS investigators

Affiliations 1University Medical Center of the Johannes Gutenberg University Mainz, Center for Thrombosis and Hemostasis, Mainz, Germany; 2University Medical Center of the Johannes Gutenberg University Mainz, Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Mainz, Germany; 3University Medical Center of the Johannes Gutenberg University Mainz, Preventive Cardiology and Preventive Medicine, Center for Cardiology, Mainz, Germany; 4German Center for Cardiovascular Research (DZHK), Partner Site RheinMain, Mainz, Germany; 5Charité University Medicine, Campus Virchow Klinikum, Department of Cardiology, Berlin, Germany; 6Democritus University of Thrace, Department of Cardiology, Alexandroupolis, Greece

Abstract Background Acute pulmonary embolism (PE) increases the risk of future death and disability, including functional limitations. Data suggest that up to 50% of survivors complain of persistent/progressive dyspnea or poor functional status after first PE; of these, a small proportion will develop chronic thromboembolic pulmonary hypertension (CTEPH), a progressive vasculopathy resulting from incomplete resolution of pulmonary emboli. The true incidence, temporal pattern, and predictors of CTEPH and the broader syndrome of post-PE impairment (pPEI) remain largely unknown.

Study Design and Objectives The ongoing multicentre ´Follow-up after acute pulmonary embolism´ (FOCUS) observational study has set out to prospectively follow the clinical, echocardiographic, functional and hemodynamic course of 1,000 unselected patients admitted for confirmed acute symptomatic pulmonary embolism (PE). Clinical status, results of diagnostic and therapeutic procedures, and outcomes, are being collected at baseline, upon discharge, and at 3-, 12-, and 24-month follow-up visits (Figure 1). A multicentre biobanking sub-study (FOCUS BioSeq) is conducted within the FOCUS cohort study. The primary objective of FOCUS is to determine the incidence of CTEPH and persisting or progressive functional and/or hemodynamic pPEI over the long term. Secondary objectives are to assess predictors of death, major cardiovascular events, bleeding complications under anticoagulation, and indicators of quality of life.

Results (baseline data) A total of 611 acute PE patients have been included as of December 2016 in 19 high-volume sites, geographically distributed all over Germany, and 578 of them completed the first follow-up (discharge) visit. Mean age is 62.0 years, 323 patients (52.9%) are males; 103 patients (16.7%) had symptoms of concomitant deep vein thrombosis, and 58 (9.5%) active cancer at presentation. The majority of the patients was discharged on rivaroxaban (n=395) or apixaban (n=101) anticoagulation. Table 1 summarizes the main baseline characteristics of the patients included so far. Enrolment of the last patient is expected by the end of 2017.

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Figure 1: Data collection schedule

CTEPH, chronic thromboembolic pulmonary hypertension, DVT deep vein thrombosis, PE pulmonary embolism.

aDate of birth, gender, height, weight, bPresentation and symptomatology, vital signs; 12-lead ECG, cSerum creatinine, creatinine clearance [MDRD-estimate], TSH, O2-saturation [pulse oximetry], hematocrit,

thrombocytes, leucocytes, aPTT, PT, INR, troponin T or I, NT-pro-BNP, BNP, CRP, d-dimer, dWHO functional class, Borg dyspnea index, eCT pulmonary angiography, V/Q scan; selective pulmonary angiography, right heart catheterization fEQ-5D questionnaire, gPEmb-QoL questionnaire.

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Table 1: Baseline characteristics of the patients included in FOCUS with available follow-up discharge visit

Male sex 323 (52.9%)

Age (years), median (interquartile range) 65 (51-74)

Body Mass Index (BMI), median (interquartile range) 27.7 (24.6-32.2)

BMI>40 or Body weight >120 kg 53 (9.2%)

Active cancer 58 (9.5%)

Concomitant antiplatelet treatment 98 (17.0%)

Diabetes mellitus 62 (10.7%)

Chronic lung disease 95 (16.4%)

Chronic heart failure 32 (5.5%)

ESC risk stratification model

Low-risk 83 (14.4%)

Intermediate risk 101 (17.5%)

Intermediate-low 253 (43.8%)

Intermediate-high risk 125 (21.6%)

High-risk 16 (2.8%)

sPESI>0 333 (57.6%)

50

Poster 302

Abstract Title High sensitivity of a non-invasive screening strategy for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism

Authors Y.M. Ende-Verhaar1, D. Ruigrok2, H.J. Bogaard2, M.V. Huisman1, L. Meijboom3, A. Vonk Noordegraaf2, F.A. Klok1

Affiliations 1Department of Thrombosis and Hemostasis, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands; 2Department of Pulmonology, VU Medical Center, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands; 3Department of Radiology, VU Medical Center, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands

Abstract Background A non-invasive screening algorithm for chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE) (Figure 1) was recently constructed. We aimed to evaluate the sensitivity of the algorithm and assessed the reproducibility of the individual items of the algorithm.

Methods The algorithm was applied to 54 consecutive patients with confirmed CTEPH. Two independent researchers calculated the prediction score based on clinical characteristics at PE diagnosis, and evaluated the ECG and NT-proBNP level assessed at CTEPH diagnostic work-up. Interobserver agreement for assessment of the prediction score, RV/LV ratio measurement on CTPA as well as ECG reading was evaluated by calculating kappa statistics.

Results Median time between PE diagnosis and presentation with CTEPH was 8 months (interquartile range 5-13). 52 patients (96%, 95%CI 87-100%) had a high prediction score and/or CTEPH specific symptoms. The ECG/NT-proBNP combination was abnormal in 49 of 52 patients (94%, 84-99%). The sensitivity of the algorithm was 91% (79-97%), indicating that 27 of 30 cases of CTEPH would have been detected when applying the screening algorithm to 1000 random PE survivors with a 3% CTEPH incidence (projected negative predictive value 99.7%; 99.1-99.9%). The interobserver agreement for calculating the prediction score, RV/LV ratio measurement and ECG reading was excellent with a kappa of 0.96, 0.95 and 0.89 respectively.

Conclusion All components of the algorithm were highly reproducible. 91% of the CTEPH patients would have been identified by the algorithm, underlining its adequate sensitivity. Prospective validation of the algorithm in consecutive PE patients is required before clinical implementation.

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Figure 1: Screening algorithm for CTEPH after acute PE consisting of sequential application of the CTEPH prediction score (J Thromb Haemost 2016;14:121-8), assessment of CTEPH specific symptoms and the so called ‘Rule-out’ criteria (Thromb Res 2011;128:21-6)

52

Poster 303

Abstract Title Importance of Angiopoietin-2 (Ang-2) for the transition from pulmonary embolism to chronic thromboembolic pulmonary hypertension (CTEPH)

Authors L. Hobohm1,2, C. Niemann3, S. Kölmel1, P. Kümpers4, V. Krieg1, M. Bochenek2, S. Guth5, C. Liebetrau6, A. Lukasz3, C. Troidl6, P. Wenzel1,2, S. Konstantinides1, E. Mayer5, K. Schäfer2, M. Lankeit1,7

Affiliations 1Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University, Mainz, Germany; 2Center for Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; 3Clinic of Cardiology and Pneumology, Heart Center, University of Göttingen, Germany; 4Department of Medicine D, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Muenster, Germany; 5Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany; 6Department of Cardiology, Kerckhoff Clinic, Bad Nauheim, Germany; 7Department of Cardiology, Campus Virchow Klinikum (CVK), Charité University Medicine, Berlin, Germany

Abstract Background Incomplete thrombus resolution followed by vascular remodelling is considered the critical mechanism for the development of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE). Recent studies suggest that Ang-2, an antagonist of the Tie2 receptor, may lead to dysregulated thrombus resolution. Therefore, we aimed to investigate the role of Ang-2 in patients with acute PE and in CTEPH and in established mouse model of stagnant flow venous thrombosis by subtotal infrarenal vena cava (IVC) ligation.

Methods and Results First, we studied 182 PE patients (54.0% women; median age, 69 [IQR, 52-78] years) included in a single-centre prospective cohort study to investigate the prognostic performance of Ang-2 with regard to the prediction of CTEPH diagnosis in long-term follow-up (FU). Interestingly, patients diagnosed with CTEPH during FU (6 of 84 patients [7.1%]) had significantly higher Ang-2 plasma levels on admission for acute PE compared to those with favourable course (9.0 [4.7-19.6] vs. 2.0 [1.4-3.3] ng/ml, p=0.001). Plasma levels of Ang-2 ≥5.5 ng/ml were associated with a 93-fold increased risk for the diagnosis of CTEPH (OR, 92.5 [95% CI, 8.6-999.6]; p<0.001). Second, we studied 68 patients (51.5% women; median age, 63 [55-72] years) with confirmed CTEPH (median mean pulmonary arterial pressure [mPAP], 43.0 [33-52] mmHg; pulmonary vascular resistance [PVR], 6.4 [4.4-10.5]) transferred to pulmonary endarterectomy (PEA) at an expert centre. Ang-2 plasma concentrations (3.4 [2.1-7.2]) ng/ml) correlated with haemodynamic parameters (mPAP, r=0.430, p<0.001; PVR, r=0.588, p=0.001) and biomarkers indicating RV dysfunction (NT-proBNP, r=0.763, p<0.001). Of note, median Ang-2 plasma levels in CTEPH patients were higher compared to patients with acute PE (2.5 [1.6-4.4] ng/ml) and a healthy reference population (1.8 [1.1-3.4] ng/ml). CTEPH tissue material obtained during PEA was histomorpologically classified as fresh thrombus, early- and late-organized thrombus, myofibroblast-rich or vessel-rich regions, and fibrosis. Quantitative analysis showed Ang-2 positive cells in all areas of interest, with pronounced Ang-2 presence in late-organized thrombi (median, 7.1 [4.2-9.8] %) and vessel-rich regions (7.5 [354-11.4]%) as opposed to fresh thrombi (0.8 [0.3-1.5]%) and fibrosis (1.0 [0.3-2.2]%; p<0.001 each). Third, we induced thrombi using an established mouse model of stagnant flow venous thrombosis by subtotal IVC ligation. Wild type mice treated with recombinant Ang-2 showed larger thrombi compared to controls (4.2 [3.0-5.3] vs. 2.3 [1.4-3.1] mm²; p<0.001) with fewer newly formed microvessels detected as CD31 positive cells (0.5 [0.2-0.6] vs. 1.3 [0.9-1.6] %; p<0.001).

Conclusion Ang-2 might help to identify PE patients at risk for developing CTEPH. Moreover, our data suggest a potential role for Ang-2 contributing to misguided thrombus resolution by reduced angiogenesis and thus to the transition from PE to CTEPH.

53

Poster 304

Abstract Title Osteopontin (OPN) and its potential role in the pathogenesis of chronic thromboembolic pulmonary hypertension (CTEPH)

Authors S. Koelmel1, A. Kaeberich1,2, L. Hobohm1,2, V. Krieg1, M.L. Bochenek2, S. Guth3, C.B. Wiedenroth3, P. Wenzel1,2, S. Konstantinides1, E. Mayer3, K. Schäfer2, M. Lankeit1,4

Affiliations

1Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; 2Center for Cardiology, Cardiology I, University Medical Center Mainz, Germany; 3Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany; 4Department of Cardiology, Charité University Medicine, Campus Virchow Klinikum (CVK), Berlin, Germany

Abstract Background OPN represents a central mediator in organ fibrosis, angiogenesis, and inflammation. These biologic processes have been linked to the pathogenesis of CTEPH. However, the potential role of OPN in the development of CTEPH remains unknown.

Materials and Methods We aimed to investigate OPN and its upstream (sonic hedgehog [SHH]) and downstream markers (matrix metalloproteinase [MMP]-2 and MMP-9) in specimen from CTEPH patients obtained during pulmonary endarterectomy (PEA) and in the physiological process of venous thrombus resolution using a murine model of inferior vena cava (IVC) ligation.

Results Immunohistochemistry (IHC) analyses of human PEA specimen demonstrated the presence of OPN, MMP-2, MMP-9 and SHH positive cells throughout all histomorphological defined areas of interest. Fresh CTEPH thrombi (median, 0.6 [IQR, 0.4-1.0]%) and fibrotic areas (1.2 [0.6-2.4]%) stain sparsely OPN-positive, whereas organizing CTEPH thrombi (11.2 [6.6-18.4]%), myofibroblast-rich areas (13.0 [9.2-19.6]%), neovascularisations (19.2 [13.1-24.1]%) and profibrosis (9.9 [6.9-26.5]%) stain highly positive for OPN. High positive staining for OPN was paralleled by positive staining for MMP-9 in late organizing CTEPH thrombi (1.7 [0.6-4.3]%), myofibroblasts (4.4 [1.4-8.5]%), neovascularisations (3.0 [2.1-5.5]%) and profibrosis (8.8 [3.4-14.3]%) as well as for SHH in fresh CTEPH thrombi (3.3 [0.5-13.4]%) and neovascularisations (4.3 [0.9-14.0]%). In murine thrombi, OPN positive staining increased from day 3 to day 7 after IVC ligation (2.0 [1.0-3.6]% vs 9.7 [6.2-13.3]%; p=0.002) paralleled by an increase in MMP-2 positive staining from day 3 (2.0 [0.9-2.6]%) to day 7 (6.1 [4.6-8.3]%; p=0.024) and to day 14 (12.5 [5.1-16.5]%; p<0.001). From day 14 (6.1 [4.3-8.0]%) to day 21 (8.0 [4.3-8.6]%; p=0.891) OPN positive staining remains elevated whereas MMP-2 positive staining decreases from day 14 (12.5 [5.1-16.5]%) to day 21 (0.5 [0.2-1.1]%; p<0.001). Notably, fresh human CTEPH thrombi showed lower OPN (0.6 [0.4-1.0] vs 6.1 [2.1-10.0]%; p<0.001) and MMP-2 (0.1 [0.0-0.9] vs 4.6 [2.2-7.1]%; p<0.001) positive staining compared to fresh murine thrombi harvested 3 and 7 days after IVC ligation.

Conclusion Fresh CTEPH thrombi and fibrosis are characterised by low OPN, MMP-2, MMP-9 and SHH positive staining. While OPN positive staining was detected in all other areas of interest, MMP-2 positive staining was most pronounced in late organizing CTEPH thrombi and neovessels. MMP-9 positive staining was most pronounced in myofibroblasts, neovessels and profibrotic areas. Early stages of murine venous thrombus resolution are characterised by an immediate presence and time-dependent increase of OPN and MMP-2 positive staining. Overall, these results point to a potential involvement of OPN during early inflammatory processes of thrombus resolution and fibrotic vascular remodelling in CTEPH.

54

Poster 305

Abstract Title Role of transforming growth factor-beta signalling for fibrotic remodelling in murine venous thrombi and human chronic thromboembolic pulmonary hypertension

Authors M.L. Bochenek1,2,5, C. Leidinger1, N.S. Rosinus1,5, M. Lankeit2, E. Mayer3, T. Münzel1,5, S. Konstantinides2, M. Bosmann2,4, K. Schäfer1,5

Affiliations 1Department of Cardiology, University Medical Center Mainz, Germany; 2Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany; 3Thoracic Surgery, Kerckhoff Klinik, Bad Nauheim, Germany; 4Medical Clinic 3, Department of Hematology and Oncology, University Medical Center Mainz, Germany; 5German Center for Cardiovascular Research (DZHK e.V.)

Abstract Background Chronic thromboembolic pulmonary hypertension (CTEPH) represents an inadequate healing response to pulmonary embolism resulting in excessive thrombofibrotic remodelling and major artery obstruction. Defects of the profibrotic transforming growth factor-beta (TGFβ) pathway have been implicated in pulmonary arterial hypertension, whereas its role in CTEPH is unknown.

Purpose To investigate the role of TGFβ released from activated platelets and to determine whether it may promote pulmonary fibrosis in CTEPH via endothelial-to-mesenchymal transition (EndMT) and endothelial TGFβ II receptor.

Methods Pulmonary endarterectomy specimens (PEA) from CTEPH patients were processed for immunohistochemistry (including confocal microscopy) and quantitative real time PCR (qPCR). Endothelial cells outgrown from PEA specimens were ex vivo expanded and subjected to immunofluorescence and mRNA microarray analyses. Murine venous thrombi were induced by inferior Vena cava (IVC) ligation.

Results Dual immunofluorescence staining demonstrated cells simultaneously expressing endothelial (VE-cadherin, CD31) and mesenchymal (SMA, FSP1) markers thus confirming the presence of EndMT. Findings were confirmed on the mRNA level and also revealed upregulated expression of transcription factors, SLUG and TWIST, involved in EndMT. Treatment of HUVEC with recombinant TGFβ1 promoted EndMT. Microarray, qPCR and immunohistochemical expression analysis confirmed the expression of TGFβ ligands (TGFβ-1 and -2), receptors (TGFBRII, endoglin, BMPRII), and activated TGFβ signalling (phospho-SMAD2 and phospho-SMAD5) in CTEPH tissue. Furthermore, mice with platelet-specific TGFβ1 deletion (Pf4.Cre x TGFB1flox/flox) or inducible endothelial-specific deletion of TGFBRII (Tie2.CreERT2 x TGFβRIIflox/flox) were subjected to IVC ligation followed by ultrasound and histological examination over 3 weeks. Venous thrombi were smaller in mice lacking TGFβ in platelets (71 vs. 147% of initial thrombus area at day 7 and 86 vs. 120% at day 14; n=10 per group). On the other hand, endothelial-specific deletion of TGFβRII was associated with an increase in thrombus size at all points examined (157 vs. 76% at day 7; 166 vs. 90% at day 14 and 153 vs. 49% at day 21; n=6 per group). Confocal microscopy analysis demonstrated that EndMT did not occur in the absence of TGFβ released from platelets. Moreover, accumulation of fibrotic material in thrombi with platelet-specific deletion of TGFβ was significantly decreased.

Conclusion Our findings in cultivated cells, patient material (tissue, cells) and mice with cell-specific deletion of TGFβ1 or its receptor TGFBRII suggest that TGFβ signalling in endothelial cells contributes to chronic fibrotic remodelling following venous thrombosis and involves EndMT.

55

Poster 306

Abstract Title Role of endoglin in endothelial colony forming cells (ECFCs) and vascular remodelling

Authors C. Goyard1,3, E. Rossi1, D. Smadja1,2,3, B. Planquette1,3,4, P. Gaussem1,2,3, O. Sanchez1,3,4

Affiliations 1INSERM UMR-S1140, Innovative Therapies in Haemostasis, Paris Sorbonne; 2AP-HP, Service d’Hématologie, Hôpital Européen Georges Pompidou, Paris; 3Université Paris Descartes; 4AP-HP, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Européen Georges Pompidou, Paris

Abstract Background Pulmonary arterial hypertension (PAH) is a complex and rapidly progressive disorder leading to right heart failure and death. The whole pathophysiology is still unclear. An apoptosis-resistant endothelial phenotype seems to induce endothelial cells hyperproliferation, vessel obstruction and eventually occlusion, inducing neoangiogenesis and microvascular remodelling. ECFCs are involved in vascular remodelling and endothelial cell dysfunction has been already described in PAH. Moreover, these cells overexpress endoglin (Eng) at their membrane. Endogling, is an endothelial transmembrane protein that, in addition to act as an auxiliary partner protein in the TGF-β receptor complex, is involved in the cross-talk between endothelial cells and smooth muscle cells and plays a role in vessel stabilization. Haplo-insufficient mice (Eng +/-) are protected from PAH in a hypoxia model. We hypothesized that inhibition of endoglin in ECFCs can reduce vascular remodelling. First, we evaluated the role of endoglin in angiogenic potential of the ECFCs, and in cell-cell interactions in vitro. Then, we used an in vivo model of angiogenesis, the murine hindlimb ischemia, to identify the effect of endoglin’s inhibition on angiogenesis.

Material and Methods ECFCs were isolated from cord blood and endoglin silencing was performed by siRNA transfection. In vitro, a wound healing experiment was performed to evaluate the effect of endoglin inhibition on proliferation, adhesion and migration. The ECFCs angiogenic potential was measured by their ability to form tubes in a matrigel soluble membrane. An adhesion assay with different angiogenic cell monolayers (HAEC/HUVEC or MSC) was used to understand the role of endoglin in cell-cell interactions. Hindlimb ischemia was induced in nude mice by suturing the femoral artery, and revascularization was analysed with vascular Doppler at days 7 and 14 after ECFCs injection in the retro-orbital vein.

Results There was no significant difference in wound healing after silencing of endoglin in ECFCs, compared to scramble. Endoglin does not seem to play a role in ECFCs adhesion on coating, migration and proliferation. However, silencing of endoglin inhibits tubes formation in matrigel assay (p< 0,001) and reduces the ECFCs adhesion on mature endothelial cell monolayers (p< 0,001). Seven days after mice hindlimb ischemia, silencing of endoglin in ECFCs reduces revascularization compared to scramble (p< 0,05) and reduces the number of blood vessels and muscle regeneration at day 14.

Conclusion Endoglin is involved in angiogenic cell-cell interactions in vitro and silencing of endoglin inhibits angiogenesis in murine hindlimb ischemia model in vivo. This protein may therefore be a potential therapeutic target in vascular remodelling diseases.

56

Poster 307

Abstract Title Expression signature of endothelial cells in chronic thromboembolic pulmonary hypertension

Authors M.L. Bochenek1,2,6, K. Saar3, F. Marini4, A. Gerhold-Ay4, N. Hübner3, T. Münzel1,6, E. Mayer5, S. Konstantinides2, K. Schäfer1,6

Affiliations 1Department of Cardiology, Cardiology I, University Medical Center Mainz, Germany; 2Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany; 3Max-Delbrück-Center for Molecular Medicine, Berlin, Germany; 4Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Germany; 5Thoracic Surgery, Kerckhoff Klinik, Bad Nauheim, Germany; 6German Center for Cardiovascular Research (DZHK e.V.)

Abstract Background Thrombus neovascularization plays a crucial role during venous thrombus organization, as shown in mice. Avascular and endothelial cell-poor thrombi can be observed in patients with Chronic Thromboembolic Pulmonary Hypertension (CTEPH), a severe cause of pulmonary hypertension and right heart failure, characterized by thrombus non-resolution and fibrosis.

Purpose The objective of this study was to determine the genomic footprint of CTEPH endothelial cells and to compare them to ‘healthy’ endothelial cells in order to better understand the role of endothelial cells in the accumulation of thrombofibrotic material in CTEPH.

Methods Endarterectomy specimens were processed for cell culture, and visually identified endothelial cells outgrown from the tissue were submitted to RNA isolation and whole gene microarray analysis. As control, commercially available Human Umbilical Vein Endothelial cells (HUVECs) and Human Pulmonary Arterial Endothelial cells (HPAECs) were used.

Results Microarray analysis revealed that out of 26.808 genes examined, the expression of respectively 71 and 34 genes was mis-regulated in CTEPH vs. HUVECs and CTEPH vs. HPAECs (False Discovery Rate= 0.05). Markers of endothelial cells (VWF, CDH5, ICAM2) were expressed on the same level in the three groups confirming the endothelial identity of cells outgrown from CTEPH tissue specimens. Markers of apoptosis (CASP2, BAX, TP53, ANXA) also did not differ. On the other hand, particular proliferation markers (CCNA1, CCND1) were upregulated in CTEPH cells when compared to HUVECs or HPAECs. Pathway analyses in CTEPH endothelial cells were performed using two databases, i.e. Gene Ontology and Reactome. Overall, the signal intensity of diverse genes was most prominently misregulated in 14 pathways of biological processes. In brief, CTEPH endothelial cells profiling exhibited a ‘pro-fibrotic’, ‘pro-coagulable’ and ‘pro-inflammatory’ phenotype, as suggested by the upregulation of genes involved in extracellular matrix production (COL1A1, COL1A2, COL3A1, ACTA) and degradation (TIMP1, MMP1, FBN2, CD44, CTSS, CTSK), collagen catabolism (CTSS, CTSK, MRC2, ADAMTS2) or fibril organization (COL1A1, COL1A2, COL3A, ADAMTS2), cell-matrix adhesion (VCAM1, POSTN, APOD), pro-coagulable factors (F3, THBS2) and genes involved in platelet activation (ADAMTS18, MYL9) or the response to tumour necrosis factor (VCAM1, GATA3, POSTN, CYBA, CCL2, PLVAP, TNFAIP3, TNFSF15). Results were confirmed via qPCR on the cellular and by immunohistochemistry on the tissue level showing increased numbers of proliferating endothelial cells and vessels surrounded by extracellular matrix and collagen fibres in CTEPH specimens.

Conclusion Taken together, we expect that the microarray data will provide a useful basis for further analyses of selected molecules to determine the pathophysiology of CTEPH and the identification of novel biomarkers of this disease.

57

Poster 308

Abstract Title What is the best endothelial progenitor cells delivery method for the treatment of chronic thrombo-embolic pulmonary hypertension induced right ventricle dysfunction?

Authors *F. Loisel1,2, *B. Provost1, J. Guihaire1,3, D. Boulate1,3, N. Arouche2, B. Decante1, P. Dorfmüller1,5,6, B. Baudet7, F. Secatore7, E. Fadel1,4, G. Uzan2, O. Mercier1,6 *contributed equally to this work

Affiliations

1Research and Innovation Unit, Inserm UMR-S 999, Marie Lannelongue Hospital, Univ. Paris Sud, Paris-Saclay University, Le Plessis Robinson, France; 2Inserm 1197 Research Unit, 94807 Villejuif Cedex, France Univ. Paris Sud, Paris-Saclay University, France; 3Department of Cardiac Surgery, Marie Lannelongue Hospital, Univ. Paris Sud, Paris-Saclay University, Le Plessis Robinson, France; 4Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, Univ. Paris Sud, Paris-Saclay University, DHU TORINO, Le Plessis Robinson, France; 5Paris-Sud University and Paris-Saclay University, School of Medicine, Kremlin-Bicêtre, France; 6Department of Pathology, Marie Lannelongue Hospital, Le Plessis Robinson, France; 7Surgical Research Lab, Marie Lannelongue Hospital, Le Plessis-Robinson, France; Corresponding Author: Olaf Mercier, MD, PhD, Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Research and Innovation Unit, Marie Lannelongue Hospital, 133 Avenue de la Resistance, 92350, Le Plessis Robinson, France. Email: o.mercier@ccml.fr

Abstract

Background Right ventricle (RV) function is an important prognostic factor in pulmonary hypertension (PH). It has been demonstrated in an animal model that when RV failed there was a discrepancy between the decreased myocardial capillary density and the workload of the RV. Endothelial progenitor cells (EPC) are circulating cells which can induce angiogenesis. Hence, these cells may be good candidates for RV cell therapy to prevent PH induced RV failure. We aimed to evaluate the feasibility of different types of EPC delivery to the RV of a chronic thromboembolic pulmonary hypertension (CTEPH) piglet model.

Material and Methods Piglet CTEPH model was obtained in 3 animals by ligating the left PA and chronically embolising glue on the right lower lobe artery. After 5 weeks, right heart catheterization demonstrated pulmonary hypertension and CTEPH induced RV remodelling. Blood samples were collected at the time of the second embolization to isolate, culture and GFP or CFSE labelled EPC. To avoid immune reaction, autologous EPC were administrated. Three types of delivery were tested: (1) right intracoronary delivery using 8.106 EPC (2) intramyocardial delivery of 10.106 EPC via several injections of 250µL, and (3) polysaccharides patch containing 13.106 EPC. Piglets were sacrificed 24 hours after cell delivery for intracoronary and transmyocardial routes and 48 hours after patch placement. RV was harvested and cells engraftment was evaluated by immunochemistry.

Results After right intracoronary administration, EPC were found in the epicardium and we also found cells in the lungs, liver, spleen and kidneys at a lower level. After intramyocardial administration, we found EPC as different clusters at the injection sites localized in the myocardium. The patch delivery did not provide cells inside the myocardium as all the cells did not migrate from the patch to the heart meaning that the chemotactic signal may be too weak to stimulate rapid cell migration. No piglets died from injections which have been well tolerated as the level of troponin did not increase after delivery and no signs of myocardial infarction were found on pathology.

Conclusion In this study, we showed the feasibility of 3 different ways to deliver cells to the RV in a CTEPH animal model. Early cell retention rate was better in intracoronary and intramyocardiac delivery compared to the patch delivery. Myocardial cell delivery has also been proved to be well tolerated and safe. Further improvements are needed for the patch delivery as a sustainable delivery may be interesting in the future. In conclusion, these results are promising for the development of stem cell therapy to sustain RV function in PH.

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Figure 1: EPC engraftment 24h (a and b) after right intracoronary administration

Figure 2: EPC engraftement 24h after intramyocardial administration

59

Poster 309

Abstract Title Thyroid disease and treatment in patients with chronic thromboembolic pulmonary hypertension (CTEPH)

Authors V. Krieg¹, L. Hobohm1,2, C. Liebetrau3, S. Guth4, S. Koelmel¹, K. Pohl¹, C. Troidl5, L. Essmann5, H. Rossmann6, S. Konstantinides1, E. Mayer4, C. Wiedenroth4*, M. Lankeit1,7*

* contributed equally to this work

Affiliations 1Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Johannes Gutenberg University Mainz, Germany; ²Center for Cardiology, Cardiology I, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; 3Department of Cardiology, Kerckhoff Klinik GmbH, Bad Nauheim, Germany; 4Department of Thoracic Surgery, Kerckhoff Klinik GmbH, Bad Nauheim, Germany; 5Franz-Groedel-Institut, Kerckhoff KliniK GmbH, Bad Nauheim, Germany; 6Department of Laboratory Medicine, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Germany; 7Department of Cardiology, Charité University Medicine, Campus Virchow Klinikum (CVK), Berlin, Germany

Abstract Background CTEPH is a rare disease with poor prognosis if untreated and believed to result from incomplete thrombus resolution after pulmonary embolism (PE). Current data suggest that thyroid disease (TD) may contribute to CTEPH development and hypothyroidism was identified as a risk factor. The aim of the present study was to investigate the prevalence of thyroid disease in operable CTEPH patients.

Material and Methods Between 07/2014 and 11/2015, CTEPH patients scheduled for pulmonary endarterectomy (PEA) at a German referral centre were included in the present study. Venous blood samples were taken before PEA and laboratory measurements (TSH, fT3, fT4, TPO antibodies) performed. Thyroidal function was classified as euthyroidism, hypothyroidism (hypo) or hyperthyroidism (hyper) based on medical history and laboratory findings. Additionally, the impact of thyroid hormone replacement (THR) and suppression (TS) therapy was assessed.

Results Overall, 122 patients (median age, 63 [IQR, 53–72] years; 46.7% females; 71.3% NYHA class III/IV; median mean PA pressure, 43 [32-51] mmHg) were included in the analysis. PEA was successful in all patients and no patient died during PEA. Four (3.3%) patients died during the in-hospital stay and two further patients (36 and 566 days after PEA; overall mortality rate, 5.0%) during long-term follow-up (404 [320-511] days, n=119). Risk factors of CTEPH are shown in Figure 1. Overall, 28 patients (23.0%) had a known TD (hypo: n=20, 16.4%; hyper: n=8, 6.6%) and 25 patients (20.6%) received specific treatment (THR 14.8%, median levothyroxine dosage, 75 [50-100] mg/d; TS 3.3%; iodine 2.5%). Additionally, based on laboratory measurements, 4 patients with subclinical hypo and 1 patient with subclinical hyper were identified (in total, 33 patients [27.0%] with TD). Median level of TSH was 1.6 (0.9 -2.6) µU/ml, of fT3 2.8 (2.6 -3.0) pg/ml and of fT4 1.1 (1.0-1.2) ng/dl; thus, at the moment of blood sampling, 12 patients (9.8%) were identified with thyroidal dysfunction (hypo in 7 and hyper in 5 patients). Elevated levels ≥5.61 IU/ml of TPO antibodies were found in 19 patients (15.6%; median, 52.5 [19.8-95] IU/ml); of those, 7 patients (36.8%) had thyroidal dysfunction. fT4 levels correlated weakly with cardiac output (r=-0.191; p=0.039), were higher in patients who receive THR therapy (1.3 [1.2-1.4] vs 1.1 [1.0-1.2]; p<0.001) and in those who died in-hospital (1.4 [1.2-1.5] vs 1.1 [1.0-1.2] ng/dl; p=0.037) or during follow-up (1.4 [1.1-1.6] vs 1.1 [1.0-1.6] ng/ml; p=0.016). However, neither TD or TRH/TS therapy was associated with outcomes.

Conclusion In 122 operable CTEPH patients, thyroid disease/dysfunction and especially hypothyroidism was more common than previously reported. fT4 levels were higher in patients who died in-hospital or during long-term follow-up. However, probably explained by the low event rate, neither TD nor TRH/TS therapy was associated with outcomes.

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Figure 1: Frequency (%) of risk factors of CTEPH

61

Poster 310

Abstract Title Chronic thromboembolic pulmonary hypertension in a real world setting: experience from two expert centres

Authors M.A. Bazmpani1, A. Arvanitaki1, M. Toumpourleka1, G. Pitsiou2, E. Panagiotidou2, S.A. Mouratoglou1, G. Sianos1, S. Hadjimiltiades1, A. Pitsis3, E. Mayer4, I. Stanopoulos,2 H. Karvounis1, G. Giannakoulas1

Affiliations 1First Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Greece; 2Respiratory Intensive Care Unit, Aristotle University of Thessaloniki, G.H. “G. Papanikolaou”, Exohi, Thessaloniki, Greece; 3Agios Lukas Hospital, Thessaloniki, Greece; 4Kerckhoff Heart and Lung Center, Bad Nauheim, Germany

Abstract Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare, distinct pulmonary vascular disease, and, therefore, there is lack of data regarding its clinical presentation, diagnosis and management at a national basis. Our objective was to describe the demographics and management of CTEPH patients in Northern Greece.

Methods We conducted a retrospective, observational study with a joint collaboration from two pulmonary hypertension expert centres in Greece and included patients diagnosed with CTEPH. The patient population was divided into two groups based on operability.

Results Overall, 27 consecutive patients were included (59% female, mean age 59.3±15.1 years). Dyspnea and fatigue were the most common presenting symptoms. History of pulmonary embolism was present in 82%. Of all patients, 18 (67%) were assessed as operable, of whom 10 (55%) patients finally underwent pulmonary endarterectomy (PEA). There were no differences in symptoms, WHO functional class, six-minute walking test distance and hemodynamics between the operable and non-operable group. At the end of the follow-up, all non-operable, as well as operable patients that did not receive surgical treatment were treated with at least one PH specific drug.

Conclusion This is the first report which presents data of patients diagnosed with CTEPH in Greece. The percentage of patients that underwent surgical treatment is lower but approaches the reported rates in large registries. Taking into consideration that PEA is a relatively safe and potentially curative surgical procedure, we emphasize the need for establishing a designated PEA centre in Greece.

62

Poster 311

Abstract Title Bilateral proximal CTEPH is associated with worse RV function and RV (mal)adaptation

Authors D. Ruigrok1, M. Kreft1, A. Huis in 't Veld1, P. Symersky2, A. Vonk Noordegraaf1, L.J. Meijboom3, H.J. Bogaard1

Affiliations 1Department of Pulmonary Diseases, VU University Medical Center, Amsterdam, The Netherlands; 2Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam, The Netherlands; 3Department of Radiology, VU University Medical Center, Amsterdam, The Netherlands

Abstract Background Vascular obstructions in chronic thromboembolic pulmonary hypertension (CTEPH) are heterogeneous and vary from proximal occlusions to distal small vessel arteriopathy. Previous research showed no differences in baseline hemodynamic and functional parameters between patients with type 2 disease (thrombotic lesions in main, lobar and segmental vessels) and patients with type 3 disease (lesions in segmental and subsegmental arteries). However, right ventricular (RV) function was not taken into account in these studies and RV afterload was analysed based solely on pulmonary vascular resistance (PVR) and not by its pulsatile components. Proximal disease leads to increased wave reflection, thereby increasing pulmonary arterial stiffness and changing compliance and/or characteristic impedance, leading to increased RV afterload. We hypothesized that patients with bilateral proximal CTEPH present with worse RV adaptation than patients with bilateral distal CTEPH.

Methods We retrospectively analysed CT-pulmonary angiography (CTPA), cardiac MRI (RV end-diastolic volume (RVEDV), RV end-systolic volume (RVESV), RV ejection fraction (RVEF), LV ejection fraction (LVEF)) and hemodynamics (mean pulmonary artery pressure (mPAP), PVR, cardiac index (CI)) in 113 CTEPH patients presenting to our centre between 2010 and 2016. CTEPH subtype was determined for every lung and patients with bilateral proximal disease or bilateral distal disease were further analysed.

Results 33 patients with bilateral proximal CTEPH compared to 48 patients with bilateral distal CTEPH showed a significantly lower baseline RVEF and more maladaptive RV dilatation (higher RVEDVI and RVESVI). mPAP and PVR did not differ between groups. Calculated arterial compliance (SV/PP method) and RC time constant were not different between groups.

Conclusion Patients with bilateral proximal CTEPH have a significantly worse RV function in comparison to patients with bilateral distal CTEPH, despite similar mPAP and PVR. Also, no differences in compliance nor RC time constant were found between the two groups. When assuming a three-element “windkessel” model, a possible explanation for our findings could be a change in characteristic impedance, which will be subject of further analysis.

63

Table 1: Summary of results

Bilateral proximal CTEPH Bilateral distal CTEPH P-value*

RHC variables N = 33 N = 48

mPAP (mmHg) 45.2 (12.6) 43.7 (10.3) 0.574*

PVR (dyn.s/cm5) 628 (364-939) 555 (362-766) 0.399**

CI (L/min/m2) 2.3 (2.0-2.7) 2.5 (2-3) 0.375**

Cardiac MRI variables N = 15 N = 19

RVEDVI (mL/m2) 176 (118-206) 113 (87-147) 0.015**

RVESVI (mL/m2) 71 (45-86) 43 (29-60) 0.021**

RVEF (%) 28 (25-36) 48 (32-59) 0.015**

LVEF (%) 58 (51-69) 65 (62-74) 0.029**

Values stated as mean (SD) or median (IQR). Statistical tests: *Unpaired t test, ** Mann-Whitney test

Figure 1: Boxplots indicating significantly worse RVEF and more RV dilatation in bilateral proximal CTEPH

64

Poster 312

Abstract Title Factors predicting outcome after pulmonary endarterectomy

Authors C. Tromeur1,2,3, X. Jaïs4,5,6, O. Mercier4,6,7, D. Montani4,5,6, L. Savale4,5,6, O. Sitbon4,5,6, E. Fadel 4,5,6, D. Fabre4,6,7, S. Mussot4,6,7, P. Dartevelle4,6,7, M. Humbert4,5,6, F. Couturaud1,2,3, G. Simonneau4,5,6

Affiliations 1European Brittany University, Brest, France; 2Department of Internal Medicine and Chest Diseases, University Hospital Centre La Cavale Blanche, Brest, France; 3Groupe d’Etude de la Thrombose de Bretagne Occidentale (GETBO), EA 3878, CIC INSERM 1412, Brest, France; 4Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; 5AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire Sévère, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; 6INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; 7Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France

Abstract

Objective Few studies reported predictive factors of outcome after pulmonary endarterectomy (PEA) in chronic thromboembolic pulmonary hypertension. The purpose of this study is to determine factors influencing mortality and predictors of hemodynamic improvement after PEA.

Methods A total of 172 consecutive patients who underwent PEA between 2005 and 2009 were retrospectively reviewed. Among them, 150 were fully evaluated before and 7.5±1 months after PEA by NYHA class, 6-minute walk distance (6MWD), percentage of predicted carbon monoxide transfer factor (TLCO) and right heart catheterisation.

Results Mortality rate at 1 month, 1 year and 3 years was 2.8%, 6.9% and 7.5% respectively. Preoperative pulmonary vascular resistance (PVR) was a predictor of 1-month, 1- and 3-year mortality and age predicted mortality at 1 year and 3 years. A dramatic improvement in NYHA class and 6MWD was observed and PVR decreased from 773±353 to 307±221 dyn.sec.cm-5 (p<0.001). In 96 patients (64%), PVR decreased by at least 50% and/or was reduced to lower than 250 dyn.sec.cm-5. Preoperative cardiac output (CO) and TLCO predicted hemodynamic improvement.

Conclusion PEA is associated with an excellent long-term survival and a marked improvement in clinical status and hemodynamics. Some preoperative factors including PVR, CO, and TLCO can predict postoperative outcome.

65

Poster 313

Abstract Title Lack of correlation between ICU hemodynamics and 6-month follow-up after PEA in CTEPH

Authors D. Ruigrok1, H.J. Bogaard1, P.W.G. Elbers2, S. Kamminga3, R. Tepaske4, P.I. Bonta5, A. Vonk Noordegraaf1, P. Symersky6

Affiliations 1Department of Pulmonary Diseases, VU University Medical Center, Amsterdam; 2Department of Intensive Care Medicine, VU University Medical Center, Amsterdam; 3Department of Anesthesiology, VU University Medical Center, Amsterdam; 4Department of Intensive Care Medicine, Academic Medical Center, Amsterdam; 5Department of Pulmonary Diseases, Academic Medical Center, Amsterdam; 6Department of Cardiothoracic Surgery, VU University Medical Center, Amsterdam

Abstract Background Reported frequencies of residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA) range between 16 and 51%, depending on the definition used and time of measurement.

Aim The aim was to analyse the correlation between early postoperative and 6-month hemodynamic measurements and to determine the predictive value of early postoperative measurements for the presence of residual PH at 6 months.

Methods We retrospectively analysed ICU and 6-month post-PEA hemodynamics in 48 CTEPH patients. Pulmonary vascular resistance (PVR) was calculated assuming pulmonary arterial wedge pressure (PAWP) equal to central venous pressure (CVP) or using the preoperative PAWP. Patients on inotropes and/or vasopressors were not excluded.

Results Correlations were absent between postoperative and 6 month mPAP (r 0.28, p 0.05) and PVR (PAWP = CVP: r 0.27, p 0.07; PAWP = preoperative PAWP: r 0.11, p 0.50). Sensitivity of mPAP in the ICU for the diagnosis of residual PH (mPAP ≥ 25 mmHg) at 6 months was 0.33, specificity was 0.67. The negative predictive value (NPV) ranged from 0.63 (mPAP ≥ 25 mmHg criterion) to 0.91 (mPAP ≥ 30 mmHg criterion).

Conclusion mPAP and PVR 6 months after PEA do not correlate with mPAP and PVR measured post-operatively in the ICU. However, the NPV was high when using a cut-off of 30 mmHg, meaning mPAP < 30 mmHg in the early postoperative period makes residual PH at 6-month follow-up unlikely.

66

Table 1: Sensitivity, specificity, positive, and negative predictive values of ICU hemodynamics for the presence of residual PH after PEA in CTEPH

Used definition of residual PH

Sensitivity Specificity Positive predictive value

Negative predictive value

mPAP ≥ 25 mmHg 0.33 0.67 0.38 0.63

mPAP ≥ 30 mmHg 0.20 0.95 0.20 0.91

PVR ≥ 240 dynes.s.cm-5 (PAWP = CVP)

0.67 0.66 0.33 0.88

PVR ≥ 240 dynes.s.cm-5 (PAWP = PAWP pre-PEA)

0.40 0.65 0.25 0.79

mPAP ≥ 25 mmHg and PVR ≥ 240 dynes.s.cm-5 (PAWP = CVP)

0.22 0.77 0.20 0.79

Figure 1: Correlation analysis ICU mPAP and PVR versus 6-month follow-up mPAP and PVR, with reference lines indicating cut-offs for residual PH and a diagonal reference line indicating optimal correlation

67

Poster 314

Abstract Title Perioperative haemodynamic factors predicting outcome after pulmonary endarterectomy Authors C. Tromeur1,2,3, X. Jaïs4,5,6, O. Mercier4,6,7, D. Montani4,5,6, L. Savale4,5,6, O. Sitbon4,5,6, E. Fadel 4,5,6, D. Fabre4,6,7, S. Mussot4,6,7, P. Dartevelle4,6,7, M. Humbert4,5,6, F. Couturaud1,2,3, G. Simonneau4,5,6 Affiliations 1European Brittany University, Brest, France; 2Department of Internal Medicine and Chest Diseases, University Hospital Centre La Cavale Blanche, Brest, France; 3Groupe d’Etude de la Thrombose de Bretagne Occidentale (GETBO), EA 3878, CIC INSERM 1412, Brest, France; 4Univ Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin-Bicêtre, France; 5AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire Sévère, Hôpital Bicêtre, Le Kremlin-Bicêtre, France; 6INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France; 7Service de Chirurgie Thoracique et Vasculaire et de Transplantation Cardiopulmonaire, Hôpital Marie Lannelongue, Le Plessis Robinson, France

Abstract Objectives To identify perioperative predictive factors of survival, hemodynamics and NYHA functional class improvement after pulmonary endarterectomy (PEA) in chronic thromboembolic pulmonary hypertension.

Methods A total of 172 consecutive patients who underwent PEA between 2005 and 2009 were retrospectively reviewed. Among them, 150 were fully evaluated before and 7.5±1 months after PEA by NYHA class, 6-minute walk distance (6MWD), percentage of predicted carbon monoxide transfer factor (TLCO) and right heart catheterisation. Every patient underwent right heart catheterisation immediately after PEA.

Results Mean immediate postoperative mean pulmonary artery pressure (IPOmPAP) was 31+/-12 mmHg. Preoperative PVR was predictive of 1-month, 1- and 3-year mortality and age was the other predictor of mortality at 1- and 3-year. There was a trend towards a deleterious effect of high IPOmPAP on mortality at 1 month and 1 year. A normalization of IPOmPAP and a IPOmPAP under 30mmHg were identified as independent predictive factors of hemodynamic normalization and hemodynamic and NYHA functional class improvement.

Conclusion PEA is associated with an excellent long-term survival and a marked improvement in clinical status and hemodynamic in most cases. IPOmPAP is an additional and independent predictive factor of postoperative hemodynamic normalization or postoperative hemodynamic and NYHA functional class improvement.

68

Poster 315

Abstract Title Riociguat use in patients with chronic thromboembolic pulmonary hypertension. Real life experience from a two centres in Northern Greece.

Authors S.A. Mouratoglou1, G. Giannakoulas1, M.A. Bazmpani1, A. Arvanitaki1, M. Toumpourleka1, G. Pitsiou2, E. Panagiotidou2, D. Parcharidou1, T. Panagiotidis1, A. Koutsakis1, C. Feloukidis1, H. Karvounis1

Affiliations 11st Cardiology Department, “AHEPA University Hospital”, Aristotle University of Thessaloniki, Greece;

2Pulmonology Department, “G. Papanikolaou Hospital”, Aristotle University of Thessaloniki, Greece

Abstract Background Riociguat is a soluble guanylate cyclase stimulator used for the treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH). The aim of our study was to evaluate the efficacy and safety of riociguat administration in daily clinical practice.

Materials and Methods This was a retrospective, observational study. Patients diagnosed with inoperable and persistent or recurrent CTEPH after pulmonary endarterectomy who received riociguat were included. Riociguat dose uptitration was performed as per the summary of product characteristics (SPC) protocol. Efficacy and safety of the drug were evaluated.

Results In total 21 patients (mean age 62.5±13.9 years, 12 women) with CTEPH were included. Median time from administration of riociguat to re-evaluation was 30.3 (18.1-45.4) months. Only 3 patients received other advanced treatment for pulmonary hypertension before the initiation of riociguat. The majority of patients tolerated the maximal recommended dose of riociguat (Table 1). There was a significant difference in WHO functional class, 6-minute walk test distance, NT-proBNP, as well as in mean pulmonary artery pressure, cardiac index and systemic venous oxygen saturation before and after the administration of riociguat (Table 2). Vomiting, nausea, and diarrhea were the most common side effects. The development of side effects led to reduction of the riociguat dose in 3 patients and in drug discontinuation in two.

Conclusion Administration of riociguat was effective and safe in a contemporary cohort of patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension after surgical treatment.

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Table 1: Basic demographic data of patient population

TREATMENT

Concomitant advanced treatment

ERAs

Prostanoids

2 (9.5%)

1 (4.8%)

Maximal riociguat daily dose

3mg

4.5mg

6mg

7.5mg

1 (4.8%)

2 (9.5%)

2 (9.5%)

16 (76.2%)

Dose reduced (Y/N) 3/18

Riociguat discontinued (Y/N) 2/19

SIDE EFFECTS

Hypotension 2 (9.5%)

Headache 2 (9.5%)

GI-system 3 (14.3%)

Dizziness 2 (9.5%)

Peripheral oedema 1 (4.8%)

Allergy 1 (4.8%)

CTEPH: chronic thromboembolic pulmonary hypertension, ERA: endothelin receptor antagonist, GI-system: gastrointestinal system.

Table 2: Change in studied parameters after the administration of riociguat

pre post p

FUNCTIONAL CAPACITY

WHO functional class

I

II

III

IV

0

7(33.3%)

13 (61.9%)

1 (4.8%)

5(23.8%)

11 (52.4%)

5 (23.8%)

0

0.004

6MWD (m) 330.6±131.3 437.2±141.9 <0.0001

BIOCHEMISTRY

ΝΤ-proBNP (pg/ml) 483.7±281.0 277.5±87.9 <0.0001

HAEMODYNAMIC DATA

mPAP (mmHg) 44.4±11.0 35.3±11.3 0.049

RAP (mmHg) 8.6±4.2 7.0±3.9 0.133

CI (l/min/m2) 2.3±0.51 2.8±0.58 0.023

PVR (Woods) 9.3±4.6 5.2±2.5 0.348

SvO2 63.0±6.8 67.3±5.4 0.005

p: statistical significance, WHO: world health organization, 6MWD: 6-minute walk test distance, NT-proBNP: N- terminal pro B-natriuretic peptide, mPAP: mean pulmonary artery pressure, RAP: right atrial pressure, CI: cardiac index, PVR: pulmonary vascular resistance, SvO2: systemic venous oxygen saturation.

NOTH

NOTES

70

NOTE

71

NOTE

72

NOTE

73

NOTE

74

NOTE

75

NOTE

76

NOTE

77

NOTE

78

79

80