Recovery and prognostic value of myocardial strain in ST-segment elevation myocardial infarction patients with a concurrent chronic total occlusion

Objectives: Global left ventricular (LV) function is routinely used to assess cardiac function; however, myocardial strain is able to identify more subtle dysfunction. We aimed to determine the recovery and prognostic value of featuring tracking (FT) cardiovascular magnetic resonance (CMR) strain in ST-segment elevation myocardial infarction (STEMI) patients with a concurrent chronic total occlusion (CTO). Methods: In the randomized EXPLORE trial, there was no significant difference in global LV functio

Hønsefuglportalen. Oppsummering av drift og utvikling i perioden 2013-2018

Kvasnes, M., Pedersen, H.C., Kjønsberg, M., Rød-Eriksen, L., Eriksen, L.F., Bowler, D., Andersen, O, Berge, S.E., Hagen, B.R., Moa, P.F. & Nilsen, E. B. 2019. Hønsefuglportalen. Oppsummering av drift og utvikling i perioden 2013-2018. NINA Rapport 1664. Norsk institutt for naturforskning. Hønsefugler, og lirype især, er blant de mest ettertraktede viltartene i Norge. For å samle kunnskap om bestandene før jakt med sikte på å kunne regulere jakta bærekraftig, har lokale bestandsregistreringsprogrammer vokst fram. Disse har i de senere årene samlet seg om en enhetlig feltprotokoll og takseringsmetodikk; avstandsmetoden (eng: Distance sampling) ved bruk av stående fuglehund i august måned. I motsetning til de fleste storviltartene, har det ikke eksistert en helhetlig overvåkning av hønsefugl i Norge. Hønsefuglportalen ble etablert i 2012 for å skape et nasjonalt samlingssted for kvalitetssikring og ivaretagelse av data fra de lokale hønsefugltakseringene. Storfugl, orrfugl, lirype og fjellrype, samt observasjoner av smågnagere, hare og rødrev registreres av taksørene. Høsten 2013 ble en test-versjon av portalen utprøvd i utvalgte områder. Fra og med høsten 2014 har portalen vært tilgjengelig for rettighetshavere fra hele landet. I denne rapporten oppsummerer vi de første årene med drift. Vi beskriver portalens oppbygning og bruk, gjennomføring og omfang av takseringer. I tillegg viser vi eksempel på hvordan data fra hønsefuglportalen kan anvendes i statistisk modellering for å utvikle ny kunnskap om hønsefugl. I 2018 ble det registrert takseringer i 13 fylker, 80 kommuner og 188 områder i Hønsefuglportalen og de frivillige taksørene observerte om lag 50000 ryper og 2500 skogsfugl langs 8181 km med takseringslinjer. Det aller meste av takseringene gjennomføres basert på frivillig arbeid. Trøndelag og Hedmark har det klart største omfanget med henholdsvis 2411 og 2250 km takserte linjer i 2018. I Agder, hele Vestlandet, Telemark og Buskerud er takseringsinnsatsen veldig begrenset, til tross for mye egnet lirypeareal og stor avskyting i jakta. For å øke kvaliteten og forenkle prosessen med registrering av data ble det i 2017 utviklet en applikasjon for smarttelefoner der observasjoner registres direkte i felt. Denne ble testet ut i utvalgte områder i 2018 med lovende resultat og utprøving vil fortsette i 2019. Dette sammen med økt innsats for utdanning av taksører, er viktige tiltak for å bedre kvaliteten på data. Det er utviklet maler for analyser og rapportering av resultater fra takseringene. I rapportene fokuseres det på tre variabler; 1) tetthet av fugl, 2) tetthet av voksne fugler og 3) kyllingproduksjon. Hønsefuglportalens nettside har også en innsynsløsning med estimater av tetthet, kyllingproduksjon og innsats (antall kilometer taksert) fra offentlige områder. I løpet av de siste fire årene er innsynsløsningen besøkt over 60 000 ganger i de mest intense månedene august og september. Hønsefuglportalen er for øvrig hyppig omtalt i media i perioden før småviltjakta til noen uker etter oppstart. Spørreundersøkelser viser også at jegerne i stor grad ser nytten av bestandsregistreringer før jakt. Det viser seg også at noen jegere velger jaktområder basert på bestandstall fra Hønsefuglportalen. I 2015 ble det innført en ny prosedyre for beregning av kyllingproduksjon hos lirype. Et simuleringsstudie viste at det var en betydelig risiko for overestimering med den gamle metoden. Samtidig viser studien at den nye metoden kan ha en tendens til å underestimere kyllingproduksjonen. Det jobbes kontinuerlig med å forbedre analysemetodene. I de senere årene har vi demonstrert at data fra Hønsefuglportalen enkelt kan lastes ned i statistikkprogrammer for analyser. Vi har brukt disse prosedyrene for å utvikle populasjonsmodeller og habitatmodeller for lirype. Habitategnethetskart basert på habitatmodellene presenteres i denne rapporten. Dette er verktøy som kan benyttes i jaktforvaltning samt som kunnskapsgrunnlag ved vernesaker eller utbyggingssaker. Etter seks år med drift anses etableringen for vellykket og databasen slik den ble skissert i planleggingsfasen fungerer etter intensjonen. Det vil allikevel være et kontinuerlig behov for videre-utvikling av drift og utvikling også i tiden framover. Selv om omfanget av takseringer totalt sett er stort, er dekningsgraden særlig for skogsfugl for liten for å gi et representativt bilde av bestandssituasjonen nasjonalt. Vi foreslår endringer i feltregistreringene for å bedre kunne fange opp variasjoner i smågnagerbestandene. Det er også ytret ønsker fra brukerne om å utvikle hønsefuglportalen til en forvaltningsplattform med blant annet fellingsstatistikk.Kvasnes, M., Pedersen, H.C., Kjønsberg, M., Rød-Eriksen, L., Eriksen, L.F., Bowler, D., Andersen, O, Berge, S.E., Hagen, B.R., Moa, P.F & Nilsen, E. B. 2019. Hønsefuglportalen. Summary of project management and development 2013-2018. NINA Report 1664. Norwegian Institute for Nature Research. Tetraonids, and especially willow ptarmigan is among the most popular game species in Norway. Local, volunteer-based initiatives to survey pre-harvest population status of tetraonids has long traditions in Norway. Now, most of these initiatives follow a common field protocol and methodology; The Distance sampling methodology aided by free ranging pointing dogs. Contrary to other popular game species in Norway, the surveys of tetraonids has not been an integrated part of a common management system. As a direct response to this, Hønsefuglportalen: a common e-infrastructure, field protocols and coordination of tetraonid line transect sampling was established in 2012 to coordinate local and regional tetraonid line transect survey initiatives. A test version was launched in 2013 for a few selected areas and as of autumn, 2014, it has been available to stakeholders from all over Norway. This report summarize and describe the first six years of operation for Hønsefuglportalen; its structure and use, how surveys are conducted, the spatial extent of surveys and we will provide some examples of how the collected data can be applied to develop new knowledge of tetraonids. In 2018, surveys were conducted in 13 counties, 80 municipalities and 188 areas across Norway. The volunteer field workers observed 50000 ptarmigan and 2500 forest grouse along 8181 km of transect lines in 2018. Trøndelag and Hedmark had by far the largest extent of transect lines, with 2411 km and 2250 km, respectively. To increase the quality of data and to simplify the process of data registration, we developed an application for smartphones in 2017. The application was tested in selected areas in 2018 and testing is expected to continue in 2019. This, together with increased efforts in educating the volunteer personnel, are important measures to improve the quality of data. We have developed R-packages for analysing and reporting results to stakeholders. The reports focus on three variables; 1) density of birds, 2) density of adult birds and 3) juvenile production. In addition, results from many areas are accessible at Hønsefuglportalen’s website. The website represents an important channel of information to the public with 44000 and 22500 visits in August and September during the last four years. Surveys among hunters show that they in general appreciate and see the usefulness of density estimates before hunting and that some hunters use the numbers provided by Hønsefuglportalen when planning their hunting trip. Juvenile production estimates are one of the important parameters that are reported to stakeholders. The procedures for estimating juvenile production for willow ptarmigan was changed in 2015 due to suspicion of biased estimates (overestimation). We used simulations to evaluate the robustness of different approaches. The results show that there is a significant risk of overestimation of juvenile production with the methods used before 2015. Although the results also show biased estimates for the approached used after 2015, this approach has a low risk of overestimation. Hence, we regard this as a more sustainable approach for the management of the redlisted willow ptarmigan. In recent years, we have demonstrated that data from Hønsefuglportalen easily can be downloaded to statistical programs such as R. We have used these procedures to develop population- and habitat suitability models for willow ptarmigan. Such habitat suitability models can be used as decision-making tools in hunting management as well as in other land use matters. After six years of operation, we consider the implementation of Hønsefuglportalen into the tetraonid management system be successful and the database works according to the intention. Although the willow ptarmigan surveys have a large spatial extent, we acknowledge that there is a need to increase effort in some parts of Norway. The spatial extent of surveys in capercaillie and black grouse areas is too limited to monitor population status on a national level, and we suggest that an increase in survey effort is needed in forest areas. In addition, we suggest changes to the registration routines for small rodents

Recovery of right ventricular function and strain in patients with ST-segment elevation myocardial infarction and concurrent chronic total occlusion

The right ventricle (RV) is frequently involved in ST-segment elevation myocardial infarction (STEMI) when the culprit or concurrent chronic total occlusion (CTO) is located in the right coronary artery (RCA). We investigated RV function recovery in STEMI-patients with concurrent CTO. In EXPLORE, STEMI-patients with concurrent CTO were randomized to CTO percutaneous coronary intervention (PCI) or no CTO-PCI. We analyzed 174 EXPLORE patients with serial cardiovascular magnetic resonance imaging RV data (baseline and 4-month follow-up), divided into three groups: CTO-RCA (CTO in RCA, culprit in non-RCA; n = 89), IRA-RCA (infarct related artery [IRA] in RCA, CTO in non-RCA; n = 56), and no-RCA (culprit and CTO not in RCA; n = 29). Tricuspid annular plane systolic excursion (TAPSE), RV ejection fraction (RVEF), RV global longitudinal strain (GLS) and free wall longitudinal strain (FWLS) were measured. We found that RV strain and TAPSE improved in IRA-RCA and CTO-RCA (irrespective of CTO-PCI) at follow-up, but not in no-RCA. Only RV FWLS was different among groups at baseline, which was lower in IRA-RCA than no-RCA (− 26.0 ± 8.3% versus − 31.0 ± 6.4%, p = 0.006). Baseline RVEF, RV end-diastolic volume and TAPSE were associated with RVEF at 4 months. RV function parameters were not predictive of 4 year mortality, although RV GLS showed additional predictive value for New York Heart Association Classification > 1 at 4 months. In conclusion, RV parameters significantly improved in patients with acute or chronic RCA occlusion, but not in no-RCA patients. RV FWLS was the only RV parameter able to discriminate between acute ischemic and non-ischemic myocardium. Moreover, RV GLS was independently predictive for functional status

Recovery of right ventricular function and strain in patients with ST-segment elevation myocardial infarction and concurrent chronic total occlusion

The right ventricle (RV) is frequently involved in ST-segment elevation myocardial infarction (STEMI) when the culprit or concurrent chronic total occlusion (CTO) is located in the right coronary artery (RCA). We investigated RV function recovery in STEMI-patients with concurrent CTO. In EXPLORE, STEMI-patients with concurrent CTO were randomized to CTO percutaneous coronary intervention (PCI) or no CTO-PCI. We analyzed 174 EXPLORE patients with serial cardiovascular magnetic resonance imaging RV data (baseline and 4-month follow-up), divided into three groups: CTO-RCA (CTO in RCA, culprit in non-RCA; n = 89), IRA-RCA (infarct related artery [IRA] in RCA, CTO in non-RCA; n = 56), and no-RCA (culprit and CTO not in RCA; n = 29). Tricuspid annular plane systolic excursion (TAPSE), RV ejection fraction (RVEF), RV global longitudinal strain (GLS) and free wall longitudinal strain (FWLS) were measured. We found that RV strain and TAPSE improved in IRA-RCA and CTO-RCA (irrespective of CTO-PCI) at follow-up, but not in no-RCA. Only RV FWLS was different among groups at baseline, which was lower in IRA-RCA than no-RCA (− 26.0 ± 8.3% versus − 31.0 ± 6.4%, p = 0.006). Baseline RVEF, RV end-diastolic volume and TAPSE were associated with RVEF at 4 months. RV function parameters were not predictive of 4 year mortality, although RV GLS showed additional predictive value for New York Heart Association Classification > 1 at 4 months. In conclusion, RV parameters significantly improved in patients with acute or chronic RCA occlusion, but not in no-RCA patients. RV FWLS was the only RV parameter able to discriminate between acute ischemic and non-ischemic myocardium. Moreover, RV GLS was independently predictive for functional status

Value of the SYNTAX Score in ST-Elevation Myocardial Infarction Patients With a Concomitant Chronic Total Coronary Occlusion(from the EXPLORE Trial)

’To analyze the impact of additional coronary artery disease, quantified by the SYNTAX (SYNergy between PCI with TAXus and cardiac surgery) score, on left ventricular ejection fraction (LVEF) and long-term outcomes in a cohort of ST-elevated myocardial infarction (STEMI) patients with a concomitant chronic total coronary occlusion (CTO). A total of 302 STEMI patients were randomized to percutaneous coronary intervention of a CTO (CTO PCI) (n = 148) or conservative CTO treatment (n = 154). SYNTAX scores were calculated by an independent corelab (Cardialysis BV, Rotterdam) at two time-points: (1) at baseline, and (2) after primary PCI in the conservative CTO arm and after CTO PCI in the invasive arm (named ‘discharge SYNTAX score’). The population was divided in two groups (below or equal to the median SYNTAX score preprimary PCI, or above the median). At 4-month follow-up, the LVEF was significantly lower in patients in the group with a SYNTAX score above the group median (42.8% vs 48.5%, p = 0.001), and the SYNTAX score was an independent predictor for LVEF at 4 months (β-0.151 (SE 0.068), p = 0.028). In the group with a SYNTAX score above the group median the mortality rate was higher (10.1% vs 3.9%, p = 0.025), and there was a trend towards a higher MACE rate (15.4% vs 8.5%, p = 0.063). In conclusion, in this sub-analysis of the EXPLORE trial we observed a worse LVEF and a higher mortality rate for patients with a SYNTAX score above the median. We found that the SYNTAX score is an independent negative predictor for LVEF and an independent positive predictor for LVEDV at 4-month follow-up

Improved recovery of regional left ventricular function after PCI of chronic total occlusion in STEMI patients: A cardiovascular magnetic resonance study of the randomized controlled EXPLORE trial

Background: The Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) trial did not show a significant benefit of percutaneous coronary intervention (PCI) of the concurrent chronic total occlusion (CTO) in ST-segment elevation myocardial infarction (STEMI) patients on global left ventricular (LV) systolic function. However a possible treatment effect will be most pronounced in the CTO territory. Therefore, we aimed to study the effect of CTO PCI compared to no-CTO PCI on the recovery of regional LV function, particularly in the CTO territory. Methods: Using cardiovascular magnetic resonance (CMR) we studied 180 of the 302 EXPLORE patients with serial CMR (baseline and 4 months follow-up). Segmental wall thickening (SWT) was quantified on cine images by an independent core laboratory. Dysfunctional segments were defined as SWT < 45%. Dysfunctional segments were further analyzed by viability (transmural extent of infarction (TEI) ≤50%.). All outcomes were stratified for randomization treatment. Results: In the dysfunctional segments in the CTO territory recovery of SWT was better after CTO PCI compared to no-CTO PCI (ΔSWT 17 ± 27% vs 11 ± 23%, p = 0.03). This recovery was most pronounced in the dy

Improved recovery of regional left ventricular function after PCI of chronic total occlusion in STEMI patients: a cardiovascular magnetic resonance study of the randomized controlled EXPLORE trial

Background: The Evaluating Xience and left ventricular function in PCI on occlusiOns afteR STEMI (EXPLORE) trial did not show a significant benefit of percutaneous coronary intervention (PCI) of the concurrent chronic total occlusion (CTO) in ST-segment elevation myocardial infarction (STEMI) patients on global left ventricular (LV) systolic function. However a possible treatment effect will be most pronounced in the CTO territory. Therefore, we aimed to study the effect of CTO PCI compared to no-CTO PCI on the recovery of regional LV function, particularly in the CTO territory. Methods: Using cardiovascular magnetic resonance (CMR) we studied 180 of the 302 EXPLORE patients with serial CMR (baseline and 4 months follow-up). Segmental wall thickening (SWT) was quantified on cine images by an independent core laboratory. Dysfunctional segments were defined as SWT <45%. Dysfunctional segments were further analyzed by viability (transmural extent of infarction (TEI) <= 50%.). All outcomes were stratified for randomization treatment. Results: In the dysfunctional segments in the CTO territory recovery of SWT was better after CTO PCI compared to no-CTO PCI (Delta SWT 17 +/- 27% vs 11 +/- 23%, p = 0.03). This recovery was most pronounced in the dysfunctional but viable segments(TEI <50%) (.SWT 17 +/- 27% vs 11 +/- 22%, p = 0.02). Furthermore in the CTO territory, recovery of SWT was significantly better in the dysfunctional segments in patients with Rentrop grade 2-3 collaterals compared to grade 0-1 collaterals to the CTO (16 +/- 26% versus 11 +/- 24%, p = 0.04). Conclusion: CTO PCI compared with no-CTO PCI is associated with a greater recovery of regional systolic function in the CTO territory, especially in the dysfunctional but viable segments. Further research is needed to evaluate the use of CMR in selecting post-STEMI patients for CTO PCI and the effect of regional LV function recovery on clinical outcom

Predictors and outcomes of procedural failure of percutaneous coronary intervention of a chronic total occlusion—A subanalysis of the EXPLORE trial

Objective: To evaluate predictors of procedural success of percutaneous coronary intervention (PCI) of chronic total coronary occlusions (CTOs) in a non-infarct-related artery following ST-segment elevation myocardial infarction (STEMI), and demonstrate the effect on left ventricular functionality (LVF), infarct size (IS), and pro-arrhythmic electrocardiogram (ECG) parameters. Background: Predictors of unsuccessful revascularization of a CTO are numerous, although following STEMI, these are lacking. Besides, effects of failed CTO PCI (FPCI) on the myocardium are unknown. Methods: This is a subanalysis of the EXPLORE trial, in which 302 STEMI patients with a concurrent CTO were randomized to CTO PCI (n = 147) or no-CTO PCI (NPCI, n = 154). For the purpose of this subanalysis, we divided patients into successful CTO PCI (SPCI, n = 106), FPCI (n = 41), and NPCI (n = 154) groups. Cardiac magnetic resonance imaging and angiographic data were derived from the EXPLORE database, combined with ECG parameters. To gain more insight, all outcomes were compared with patients that did not undergo CTO PCI. Results: In multivariate regression, only CTO lesion length >20 mm was an independent predictor of procedural failure (OR 3.31 [1.49–7.39]). No significant differences in median left ventricular ejection fraction, left ventricular end-diastolic volume, IS, and the pro-arrhythmic ECG parameters such as QT-dispersion, QTc-time, and TpTe-intervals were seen between the SPCI and FPCI groups at 4 months follow-up. Conclusion: This subanalysis of the EXPLORE trial has demonstrated that a CTO lesion length >20 mm is an independent predictor of CTO PCI failure, whereas procedural failure did not lead to any adverse effects on LVF nor pro-arrhythmic ECG parameters

Long-term impact of chronic total occlusion recanalisation in patients with ST-elevation myocardial infarction

During primary percutaneous coronary intervention (PCI), a concurrent chronic total occlusion (CTO) is found in 10% of patients with ST-elevation myocardial infarction (STEMI). Long-term benefits of CTO-PCI have been suggested; however, randomised data are lacking. Our aim was to determine mid-term and long-term clinical outcome of CTO-PCI versus CTO-No PCI in patients with STEMI with a concurrent CTO