The MAGPI Survey -- science goals, design, observing strategy, early results and theoretical framework

© The Author(s), 2021. Published by Cambridge University Press on behalf of the Astronomical Society of Australia. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1017/pasa.2021.25We present an overview of the Middle Ages Galaxy Properties with Integral Field Spectroscopy (MAGPI) survey, a Large Program on ESO/VLT. MAGPI is designed to study the physical drivers of galaxy transformation at a lookback time of 3-4 Gyr, during which the dynamical, morphological, and chemical properties of galaxies are predicted to evolve significantly. The survey uses new medium-deep adaptive optics aided MUSE observations of fields selected from the GAMA survey, providing a wealth of publicly available ancillary multi-wavelength data. With these data, MAGPI will map the kinematic and chemical properties of stars and ionised gas for a sample of 60 massive (> 7 x 10^10 M_Sun) central galaxies at 0.25 < zPeer reviewe

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients : a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients’ clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward’s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients’ prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P &lt;.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27–3.62; HR 3.42, 95%CI 2.72–4.31; HR 2.79, 95%CI 2.32–3.35), and Cluster 1 (HR 1.88, 95%CI 1.48–2.38; HR 2.50, 95%CI 1.98–3.15; HR 2.09, 95%CI 1.74–2.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

Impact of renal impairment on atrial fibrillation: ESC-EHRA EORP-AF Long-Term General Registry

Background: Atrial fibrillation (AF) and renal impairment share a bidirectional relationship with important pathophysiological interactions. We evaluated the impact of renal impairment in a contemporary cohort of patients with AF. Methods: We utilised the ESC-EHRA EORP-AF Long-Term General Registry. Outcomes were analysed according to renal function by CKD-EPI equation. The primary endpoint was a composite of thromboembolism, major bleeding, acute coronary syndrome and all-cause death. Secondary endpoints were each of these separately including ischaemic stroke, haemorrhagic event, intracranial haemorrhage, cardiovascular death and hospital admission. Results: A total of 9306 patients were included. The distribution of patients with no, mild, moderate and severe renal impairment at baseline were 16.9%, 49.3%, 30% and 3.8%, respectively. AF patients with impaired renal function were older, more likely to be females, had worse cardiac imaging parameters and multiple comorbidities. Among patients with an indication for anticoagulation, prescription of these agents was reduced in those with severe renal impairment, p&nbsp;&lt;.001. Over 24&nbsp;months, impaired renal function was associated with significantly greater incidence of the primary composite outcome and all secondary outcomes. Multivariable Cox regression analysis demonstrated an inverse relationship between eGFR and the primary outcome (HR 1.07 [95% CI, 1.01–1.14] per 10&nbsp;ml/min/1.73&nbsp;m2 decrease), that was most notable in patients with eGFR &lt;30&nbsp;ml/min/1.73&nbsp;m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90&nbsp;ml/min/1.73&nbsp;m2). Conclusion: A significant proportion of patients with AF suffer from concomitant renal impairment which impacts their overall management. Furthermore, renal impairment is an independent predictor of major adverse events including thromboembolism, major bleeding, acute coronary syndrome and all-cause death in patients with AF

Clinical complexity and impact of the ABC (Atrial fibrillation Better Care) pathway in patients with atrial fibrillation: a report from the ESC-EHRA EURObservational Research Programme in AF General Long-Term Registry

Background: Clinical complexity is increasingly prevalent among patients with atrial fibrillation (AF). The ‘Atrial fibrillation Better Care’ (ABC) pathway approach has been proposed to streamline a more holistic and integrated approach to AF care; however, there are limited data on its usefulness among clinically complex patients. We aim to determine the impact of ABC pathway in a contemporary cohort of clinically complex AF patients. Methods: From the ESC-EHRA EORP-AF General Long-Term Registry, we analysed clinically complex AF patients, defined as the presence of frailty, multimorbidity and/or polypharmacy. A K-medoids cluster analysis was performed to identify different groups of clinical complexity. The impact of an ABC-adherent approach on major outcomes was analysed through Cox-regression analyses and delay of event (DoE) analyses. Results: Among 9966 AF patients included, 8289 (83.1%) were clinically complex. Adherence to the ABC pathway in the clinically complex group reduced the risk of all-cause death (adjusted HR [aHR]: 0.72, 95%CI 0.58–0.91), major adverse cardiovascular events (MACEs; aHR: 0.68, 95%CI 0.52–0.87) and composite outcome (aHR: 0.70, 95%CI: 0.58–0.85). Adherence to the ABC pathway was associated with a significant reduction in the risk of death (aHR: 0.74, 95%CI 0.56–0.98) and composite outcome (aHR: 0.76, 95%CI 0.60–0.96) also in the high-complexity cluster; similar trends were observed for MACEs. In DoE analyses, an ABC-adherent approach resulted in significant gains in event-free survival for all the outcomes investigated in clinically complex patients. Based on absolute risk reduction at 1 year of follow-up, the number needed to treat for ABC pathway adherence was 24 for all-cause death, 31 for MACEs and 20 for the composite outcome. Conclusions: An ABC-adherent approach reduces the risk of major outcomes in clinically complex AF patients. Ensuring adherence to the ABC pathway is essential to improve clinical outcomes among clinically complex AF patients

Impact of clinical phenotypes on management and outcomes in European atrial fibrillation patients: a report from the ESC-EHRA EURObservational Research Programme in AF (EORP-AF) General Long-Term Registry

Background: Epidemiological studies in atrial fibrillation (AF) illustrate that clinical complexity increase the risk of major adverse outcomes. We aimed to describe European AF patients\u2019 clinical phenotypes and analyse the differential clinical course. Methods: We performed a hierarchical cluster analysis based on Ward\u2019s Method and Squared Euclidean Distance using 22 clinical binary variables, identifying the optimal number of clusters. We investigated differences in clinical management, use of healthcare resources and outcomes in a cohort of European AF patients from a Europe-wide observational registry. Results: A total of 9363 were available for this analysis. We identified three clusters: Cluster 1 (n = 3634; 38.8%) characterized by older patients and prevalent non-cardiac comorbidities; Cluster 2 (n = 2774; 29.6%) characterized by younger patients with low prevalence of comorbidities; Cluster 3 (n = 2955;31.6%) characterized by patients\u2019 prevalent cardiovascular risk factors/comorbidities. Over a mean follow-up of 22.5 months, Cluster 3 had the highest rate of cardiovascular events, all-cause death, and the composite outcome (combining the previous two) compared to Cluster 1 and Cluster 2 (all P &lt;.001). An adjusted Cox regression showed that compared to Cluster 2, Cluster 3 (hazard ratio (HR) 2.87, 95% confidence interval (CI) 2.27\u20133.62; HR 3.42, 95%CI 2.72\u20134.31; HR 2.79, 95%CI 2.32\u20133.35), and Cluster 1 (HR 1.88, 95%CI 1.48\u20132.38; HR 2.50, 95%CI 1.98\u20133.15; HR 2.09, 95%CI 1.74\u20132.51) reported a higher risk for the three outcomes respectively. Conclusions: In European AF patients, three main clusters were identified, differentiated by differential presence of comorbidities. Both non-cardiac and cardiac comorbidities clusters were found to be associated with an increased risk of major adverse outcomes

P1698 Mitral valve endocarditis in hypertrophic obstructive cardiomyopathy

Abstract Introduction Endocarditis complicating hypertrophic cardiomyopathy (HCM) is not commonly reported but occurs almost universally in patients showing evidence of outflow tract obstruction. The estimated cumulative 10 year probability of developing endocarditis in obstructive HCM is &amp;lt; 5%. We report a rare case of mitral valve endocarditis in a young man with hypertrophic obstructive cardiomyopathy. Case report A 45 years old man was admitted to the emergency room after a 7 days history of weakness, thoracic discomfort, short of breath, cough and temperature up to 40 °C. He was treated with oral antibiotics in ambulatory setting, but symptoms persisted. He had no previous history of hypertension or known heart disease, family history of coronary heart disease and excessive smoker. On clinical examination, the patient was afebrile with a harsh systolic murmur. Initial blood tests showed normal inflammatory markers (C reactive protein 0.2 mg/l and fibrinogen 202 mg/dL) and normal blood sample. An ECG showed major left ventricular hypertrophy and abnormal lateral repolarisation. Transthoracic echocardiography showed localized septal hypertrophy (2.4 cm) and systolic anterior motion of the anterior mitral leaflet. Continuous wave Doppler ultrasound in the left ventricular cavity and outflow tract, had given a maximal predicted gradient of 73 mmHg. There was suspicion of vegetation on the anterior mitral valve leaflet and mitral regurgitation was quantified as moderate. Transoesophageal echocardiography confirmed the presence of vegetation on the anterior mitral valve leaflet, posterior leaflet prolapse and moderate mitral regurgitation. We found normal coronary arteries on coronary angio-CT. Treatment with intravenous antibiotics was initiated and the case was discussed with a microbiologist and a cardiothoracic surgeon. Discussion Infective endocarditis is a rare complication of hypertrophic cardiomyopathy (HCM). It is clear from morphological studies that systolic anterior motion of the anterior mitral valve leaflet is relevant to the pathogenesis of endocarditis. Pathogenesis of infective endocarditis in obstructive HCM can be explained by endocardium damage of the mitral or aortic valve, consequence of turbulence of blood flow during ejection and of the contact between the mitral anterior leaflet and the septum during systole as well as mitral regurgitation. Antibiotic therapy is the mainstay of the treatment. Surgery should be considered promptly whenever there is traditional indication (haemodynamic, emboli, persistent fever, abscess). Surgical procedure may consist of valve replacement or repair, and some authors reported relieve of outflow tract obstruction after mitral valve replacement which may be explained by the removal of systolic anterior motion of the mitral valve. Valve surgery combined with septal myectomy seems logical but requires great expertise and carries a higher operative mortality Abstract P1698 Figure. </jats:sec

P1701 Biatrial thrombus detection in a patient with atrial paroxysmal fibrillation and asymptomatic massive pulmonary embolism

Abstract Introduction Computed tomography (CT) is a noninvasive test for detection of LA and LAA thrombus.Although the transesophageal echocardiogram is the gold standart method, it can have rare but potential life threatening complications.Case report:A 62 y.o woman presented to the ER complaining of palpitations started less then 12h ago with no chest pain or dispnea.She was diagnosed with high rate paroxysmal atrial fibrillation (HR∼120/min).The ECG showed AF with no specific changes,the troponin I (TPI) level was negative and a TTE revealed a dilated left atria.The other lab results were within normal range(TBC and blood chemistry).Her past medical history included hypertension and diabetes type 2 for 10 years and 6 months respectively both on regular treatment and obesity.Also 2 months ago she was diagnosed with Hashimoto thyroiditis and close monitoring of TSH was recommended but no treatment.Subsequently,LMWH (enoxaparin) and amiodarone loading dose for cardioversion were started.After 24h the pt was still in AF,with a controlled heart rate and no complains.However ECG changes were noticed (evolutive T negative waves in leads D1,D2,aVL,V3-V6).A D-Dimer was requested and came back negative,O2 saturation was 97%.The asymptomatic pt was transferred to the Cardiology ward for further evaluation.TPI remained negative.Due to the cardiac risk factors and the ECG changes it was decided to perfom a coronary angiography which resulted normal.An electrical cardioversion was considered.Both TEE and pulmonary angio CT were requested prior.Because of the ECG changes the CT was performed first and showed central and peripheric bilateral pulmonary artery clots present also in both the left and right atrial auricles.Due to the massive thromboembolism(PE) unfractioned heparin was immediately started (aPTT 50-70s).A new TTE showed a PAP of 50 mmHg.Approximately 10h after the heparin infusion,the pt became hypotensive and started complaining of dyspnea,tachypnea,cough,pleuritic pain and fever(high temperature 39.5-40ᵒC).Considering the deteriorating conditions she was consulted by a cardiac surgery team and it was decided to perform an emergency surgical pulmonary embolectomy despite the high risk.Within 24h,the pt underwent a surgical embolectomy of the right and left pulmonary branches after incision of the pulmonary artery, as well as a clot embolectomy of the right and left atria auricles (confirmed by intraoperatory TEE).She was put on an iv heparin regimen and recovered well.She was discharged 2 weeks later in good condition,with a PAP of 40 mmHg,on acenocoumarol with persistent AF.1.5 years later she is in NYHA class I,in sinus rhythm taking rivaroxaban 20 mg/d.Discussion: Biatrial thrombus detection in both atrial auricles is rare as well as in this case a massive PE without a stroke.CT can be used as an alternative modality for detecting thrombus in selected high risk patients because it shows a good diagnostic accuracy with high sensitivity and specificity. Abstract P1701 Figure. Biatrial clots on CT and removed ones </jats:sec

P5245Cost-saving diagnosis approach by artificial intelligence tool in patients with suspected coronary artery disease. The co-operative ARTICA registry database

Abstract Background Although coronary tomographic angiography (CTA) has shown promise as a “gatekeeper” to invasive coronary angiography (ICA) in longitudinal cohort studies, it remains unknown whether the strategy of direct initial performance of CTA is cost-effective when compared with selected exercise treadmill testing (ETT) +/− functional cardiac imaging strategies in patients with suspected coronary artery disease (CAD). An innovative artificial intelligence (AI) Decision Support System (DSS) ESC guidelines based has been used at point of care for evaluating subjects with stable chest pain (SCP). Purpose The objective was to verify the cost-saving effect of the robotic AI DSS vs direct CTA by human standard care (SD) for diagnosing CAD in subjects presenting with SCP. Methods From October 2016 over three hospitals, 1017 subjects, 620 males, age 62±11 years, with clinically SCP being referred for CTA by SD received also a same day pre-scan AI DSS administration. All patients did not demonstrate significant CAD at CTA. CTA/ICA, or exercise treadmill test (ETT)/ stress echocardiography (SE), gated myocardial perfusion scintigraphy (gMPS) or Follow up/No tests (FNT) strategies by AI DSS were analyzed and compared to direct CTA SD. Pre-test likelihood (pt-lk) of CAD consider clinical risk factors into the model. Sensitivity and specificity of non-invasive diagnostic tests within our model were based upon a bivariate analysis of data from published multicenter trials. Costs of procedures were calculated by the sum of technical and professional components. Probabilistic sensitivity analysis was conducted to assess the impact of uncertainty in model parameters. Results The direct approach used performing direct CTA strategy by SD in all subjects costed 406.800 €. Costs of each procedure and distribution of AI DSS outputs are shown in the Table. Across the range of pt-lk of CAD, total costs of AI DSS strategy resulted 146.030€ with −65% vs SD approach. AI DSS tests distribution and costs pt-lk (pt/%) FNT (0€) ETT (90€) SE (350€) Stress gated MPS (750€) CCTA (400€) ICA (3.000€) High (29/2.8) 0 0 1 2 0 26 Int (371/36.5) 259 5 51 48 7 1 Low (612/60.7) 595 2 2 0 13 0 Total costs (€) 0 630 18,900.00 37,500.00 8,000.00 81,000.00 Conclusion These results from ARTICA registry seem to demonstrate that AI DSS is extremely cost-saving in subjects with stable chest pain across the whole range of pt-lk of CAD. </jats:sec

P839Lifetime cost-effectiveness of diagnostic artificial intelligence tool for evaluating individuals with stable chest pain. The co-operative ARTICA registry database

Abstract Background Non-invasive cardiac imaging testing has been often favored as an initial test for symptomatic patients with at least intermediate pre-test likelihood (pt-lk) of obstructive CAD. Despite this condition, uncertainty remains regarding the optimal testing strategies. It is known that intelligence applied with automatic decision support system (AI DSS) is able to correctly identify absence of significant CAD versus standard care (SD) in patients with stable chest pain (SCP). No evidence of long-term cost-effectiveness about AI DSS has been published in this setting. Purpose The aim is to determine the cost-effectiveness of AI DSS when applied to individuals without known CAD presenting with stable chest pain syndrome. Methods 1725 subjects, 982 males, age 61±12 years, with SCP were referred for clinical evaluation by human standard care (SD) and AI DSS administration during same day visit on a 2 years period. Exercise treadmill test (ETT), coronary tomographic angiography (CTA), invasive coronary angiography (ICA), stress echocardiography (SE)/gated myocardial perfusion scintigraphy (gMPS) and follow up/no tests (FNT) alone and combined strategies were analyzed. For the post-diagnosis follow up period of 16±3 months, we employed a Markov model based on 1-year cycle to account for outcomes for those correctly diagnosed with CAD. All subjects performed CTA to verify presence of CAD. CAD was defined as ≥70% stenosis in at least one major epicardial coronary artery vessels. Monte Carlo simulation was performed to derive mean values for costs and QALYs at different CAD prevalence of 15%, 50% and 80%. Results Data from ARTICA registry about lifelong costs based upon different diagnostic strategies in subjects with 15%, 50% and 80% CAD pt-lk are shown in Table. Lifelong costs related to strategies FNT (€) ETT-SE/gMPS-ICA (€) SE/gMPS-ICA (€) CTA-ICA (€) CTA-SE/gMPS-ICA pt-lk CAD 15% AI DSS 350 8,250 8,850 10,450 11,020 SD 1,015 11,100 12,715 12.215 12,215 pt-lk CAD 50% AI DSS 1,610 17,375 19,540 20,410 20,110 SD 1,855 19,650 21,340 22,950 22,115 pt-lk CAD 80% AI DSS 2,910 28,210 30,875 31,215 31,765 CD 4,110 32,715 34,815 35,755 35,660 Conclusion Data from ARTICA registry demonstrate that automatic use of AI DSS result in improved costs and enhanced effectiveness when compared with human SD in subjects with stable chest pain. </jats:sec