Therapeutic endoscopic ultrasound: European Society of Gastrointestinal Endoscopy (ESGE) guideline

Main Recommendations 1 ESGE recommends the use of endoscopic ultrasound-guided biliary drainage (EUS-BD) over percutaneous transhepatic biliary drainage (PTBD) after failed endoscopic retrograde cholangiopancreatography (ERCP) in malignant distal biliary obstruction when local expertise is available. Strong recommendation, moderate quality evidence. 2 ESGE suggests EUS-BD with hepaticogastrostomy only for malignant inoperable hilar biliary obstruction with a dilated left hepatic duct when inadequately drained by ERCP and/or PTBD in high volume expert centers. Weak recommendation, moderate quality evidence. 3 ESGE recommends that EUS-guided pancreatic duct (PD) drainage should only be considered in symptomatic patients with an obstructed PD when retrograde endoscopic intervention fails or is not possible. Strong recommendation, low quality evidence. 4 ESGE recommends rendezvous EUS techniques over transmural PD drainage in patients with favorable anatomy owing to its lower rate of adverse events. Strong recommendation, low quality evidence. 5 ESGE recommends that, in patients at high surgical risk, EUS-guided gallbladder drainage (GBD) should be favored over percutaneous gallbladder drainage where both techniques are available, owing to the lower rates of adverse events and need for re-interventions in EUS-GBD. Strong recommendation, high quality of evidence. 6 ESGE recommends EUS-guided gastroenterostomy (EUS-GE), in an expert setting, for malignant gastric outlet obstruction, as an alternative to enteral stenting or surgery. Strong recommendation, low quality evidence. 7 ESGE recommends that EUS-GE may be considered in the management of afferent loop syndrome, especially in the setting of malignancy or in poor surgical candidates. Strong recommendation, low quality evidence. 8 ESGE suggests that endoscopic ultrasound-directed transgastric ERCP (EDGE) can be offered, in expert centers, to patients with a Roux-en-Y gastric bypass following multidisciplinary decision-making, with the aim of overcoming the invasiveness of laparoscopy-assisted ERCP and the limitations of enteroscopy-assisted ERCP. Weak recommendation, low quality evidence.Cellular mechanisms in basic and clinical gastroenterology and hepatolog

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 <.001. Over 24 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 ml/min/1.73 m2 decrease), that was most notable in patients with eGFR <30 ml/min/1.73 m2 (HR 2.21 [95% CI, 1.23–3.99] compared to eGFR ≥90 ml/min/1.73 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 <.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

P324 Left atrial deformation analysis by 2D speckle tracking echocardiography in liver cirrhosis is a potential new tool for a better characterization of cirrhotic cardiomyopathy

Abstract Funding Acknowledgements “This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number PN-III-P1-1-TE-2016-0669, within PNCDI III” Background Cirrhotic cardiomyopathy (CCM) is defined as a cardiac dysfunction that includes mainly diastolic dysfunction (DD), generated by liver cirrhosis (LC). Its present diagnosis is based mostly on 2D conventional transthoracic echocardiography (TTE), with focus on diastolic dysfunction. However, there is no standardized algorithm for diagnosis of CCM. Role of the new methods, such as speckle tracking echocardiography (STE), for the diagnosis of CCM is still controversial. Aim. To assess left atrial (LA) function by STE in LC, on top of conventional TTE, in order to establish role of LA function for the diagnosis of CCM. Methods 107 subjects were assessed by TTE and STE: 52 patients with LC (57 ± 9 yrs, 23 males), free of any cardiovascular disease or diabetes, and 55 age-matched normal subjects. TTE was used to measure LV indexed volumes and ejection fraction (LVEF), E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP); STE to measure global longitudinal strain (GLS) and LA functions: reservoir function by strain from MVC to MVO (LASr) and positive strain rate (LASRr), conduit function by strain from MVO to onset of atrial contraction (LAScd) and early negative strain rate during conduit phase (LASRcd), LA pump function by negative strain at MVC (LASct) and late negative strain rate during atrial contraction phase (LASRct) (Figure). NTproBNP was measured in all patients. Results LC patients vs. controls had lower SBP (112 ± 15 vs. 122 ± 12, P &amp;lt; 0.001), higher LV volumes and NTproBNP, but similar LVEF. They had lower GLS, and higher E/E’, LAVi, and sPAP, suggesting higher LV filling pressure (Table). Meanwhile, they had lower LA reservoir, conduit, and pump functions(Table). By using current algorithm for the diagnosis of DD, 21% of LC patients had DD, 48% had no DD, and 31% had indeterminate grade. By adding assessment of LA reservoir function by STE (LASr &amp;lt; 35%) to the DD algorithm, 50% of patients had DD, without any indeterminate cases. Conclusion LC patients have longitudinal systolic LV dysfunction, diastolic dysfunction with higher estimated LV filling pressure, and lower LA reservoir, conduit, and pump functions. By adding LA deformation analysis by STE to the current diagnosis algorithm, better characterization of CCM is possible. Table Group (N) NTproBNP ng/ml GLS (%) E/E’ LAVi (ml/m2) sPAP (mmHg) LASr (%) LASRr LAScd (%) LASRcd LASRct LC (52) 215 ± 258 -20.8 ± 3 8.5 ± 2.3 44 ± 14 27 ± 9 28 ± 9 1.29 ± 0.4 14.7 ± 8.1 -1.2 ± 0.42 -1.64 ± 0.47 Controls (55) 44 ± 43 -22 ± 2 7.6 ±2.3 28 ±6.5 21 ± 8 35 ± 4 1.54 ± 0.4 18.3 ± 6.7 -1.7 ± 0.61 -1.93 ± 0.44 P value &amp;lt;0.001 0.05 0.05 0.001 0.003 0.011 0.002 0.014 0.001 0.002 Abstract P324 Figure </jats:sec

P1513 Myocardial work analysis is a potential novel tool to diagnose subclinical cardiac dysfunction in cirrhotic cardiomyopathy

Abstract Funding Acknowledgements This work was supported by a grant of Ministery of Research and Innovation, CNCS-UEFISCDI, project number PN-III-P1-1-TE-2016-0669, within PNCDI III Background Cirrhotic cardiomyopathy (CCM) is defined as systolic and/or diastolic cardiac dysfunction, associated with high preload and low afterload. Thus, assessment of cardiac dysfunction in these circumstances is still debatable. Left ventricular (LV) deformation is still load-dependent, and does not reflect directly myocardial energy consumption. Since myocardial work (MW)incorporates both deformation and afterload, it might be a better alternative for the assessment of LV function in CCM. Methods 80 subjects were assessed by 2D conventional and speckle tracking echocardiography (STE): 40 patients with liver cirrhosis (LC) (58 ± 8 years, 23 males), free of any cardiovascular disease or diabetes, and 40 age and gender matched normal, control subjects. Left ventricular ejection fraction (LVEF) and systolic/diastolic blood pressure (SBP/DBP) were measured. A new approach was used to evaluate myocardial work by 2DSTE: global constructive work (GCW), as the "positive" work of the heart; global wasted work (GWW), as the "negative" work of the heart; global work efficiency (GWE), as the GCW/(GCW + GWW) in %; and global work index (GWI), as the GCW added to GWW. E/E’ ratio, left atrial volume index (LAVi), and systolic pulmonary arterial pressure (sPAP) were also assessed. Results Patients with LC had significantly lower SBP/DBP than controls, with similar LVEF (Table). GCW and GWI were decreased in patients with LC, probably due to decrease in afterload, which shifts LV work to a lower level of energy. GWE and GWW were similar to controls. By segmental analysis (18 segments model), apical and mid antero-lateral segments were the first affected in terms of myocardial work, with higher WW, low WE, but without a compensatory increase in CW in other segments, suggesting a regional myocardial dysfunction. All patients with LC presented significantly elevated E/E’ ratio, LAVi, and sPAP, compared to controls (Table). Conclusion Myocardial global constructive work and global work index decrease in LC patients, compared to normal individuals, probably due to augmented peripheral vasodilatation. Apical and mid antero-lateral segments are the first affected. Assessment of global and regional MW might be a potential new tool to assess CCM, and to understand the relationship between LV remodeling and increased filling pressure under different loading conditions. Comparative myocardial work indices group SBP (mmHg) DBP LVEF (%) E/E’ LAVI sPAP GWI GWE (% ) GCW (mmHg % ) GWW (mmHg %) LC (40) 111 ±14 69 ± 12 59 ± 7 8.5 ± 2.5 45.9 ± 14.5 26 ± 9 1927 ± 379 95 ± 2 2068 ± 386 90.1 ± 49 Controls (40) 126 ± 14 76 ± 8 61 ± 7 7.5 ± 2.2 31.8 ± 6.8 21 ± 8 2123 ± 353 95± 2 2302 ± 335 94.4 ± 49 P value 0.001 0.004 0.3 0.05 0.001 0.009 0.01 0.9 0.005 0.7 Abstract P1513 Figure. Myocardial Work Cirrhotic Cardiomyopathy </jats:sec

P1334 Multimodal imaging assessment of a very rare cause of heart failure in adults

Abstract Introduction Congenitally Corrected Transposition of the Great Arteries (CCTGA) is a rare defect consisting in the abnormal twisting of the heart during fetal development. As a result, the two ventricles and their valves are reversed. CCTGA is frequently associated with other cardiac abnormalities. 25% of patients are developing heart failure, related to perfusion mismatch (the morphological left ventricle is supplied by a single coronary artery), and to the progressive deterioration of the structural right ventricle situated on the systemic side of the circulation. Case report A 45-year-old male was referred to our hospital for fatigue and dyspnea, occuring in the last five months. Physical examination revealed tachypnea, a slightly intense systolic murmur at the apex, and pulmonary congestion, in the absence of cyanosis, peripheral edema or jugular venous distension. Heart rate and blood pressure were normal. Usual laboratory work-up indicated increased levels of NT-proBNP, without any other abnormalities. ECG presented signs of pressure overload of the systemic ventricle (Figure Ia). Transthoracic echocardiography (TTE) highly suggested the diagnosis of CCTGA, due to atrioventricular valve displacement, with the morphological tricuspid valve closer to the apex in 4-chamber view (Figure Ib). TTE showed also dilated and dysfunctional left ventricle, mild left atrioventricular regurgitation, and normally functional right ventricle. Cardiac computed tomography emphasized a specific feature of CCTGA: the parallel emergence of aorta and pulmonary trunk, with the aortic arch crossing over the left pulmonary artery (Figure Ic). Cardiac magnetic resonance imaging confirmed dilatation and low ejection fraction of the systemic ventricle (20%), and displayed presence of trabeculations and the moderator band in the systemic ventricle (Figure Id). None of these evaluations found additional cardiac structural anomalies. Thus, patient was diagnosed with heart failure due to isolated CCTGA. Discussions and relevance of case report. This case emphasizes a very rare cause of heart failure in adults. CCTGA is reported in 0.5-1% of all congenital diseases, especially in males. Isolated CCTGA accounts for less than 10% of all cases, and represents the phenotype that is usually diagnosed in adulthood. In the absence of associated anomalies, the prognosis of these patients is particularly affected by the occurrence of heart failure in the 4th or 5th decade of life. Meanwhile, this case highlights the importance of a multimodal approach in CCTGA, and the specific contribution of each imaging method in the process of an accurate diagnosis. Abstract P1334 Figure I </jats:sec

Left atrial function assessed by 3-dimensional echocardiography is an independent predictor for mortality in heart failure with reduced ejection fraction

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Grant TE 137/2020 Background. Patients with heart failure and reduced ejection fraction (HFrEF) are at high risk for death. So far, left ventricular ejection fraction (LVEF) measured by 2-dimensional echocardiography (2DE) has been considered the main predictor of mortality in HFrEF. However, there are new echo parameters reflecting cardiac remodeling, assessed by 3-dimensional echocardiography (3DE), that might improve risk stratification in HFrEF. Aim. To assess comparative prognostic value of left heart function and remodeling parameters, measured by 2DE versus 3DE, in patients with HFrEF. Methods. 142 consecutive patients (60 ± 17 years, 91 males), diagnosed with HFrEF, in sinus rhythm, were assessed by 2DE, using dedicated views for the LV and left atrium (LA), and by 3DE, with full-volume multi-beat acquisitions of the LV and LA. Left ventricular volumes (LVVs) were measured from 2DE views, using the modified Simpson biplane method, and from 3DE using dedicated software. Maximal and minimal indexed LAVs were measured from 2DE, using the biplane area-length formula (2D_LAVmax and 2D_LAVmin); and from 3DE, using dedicated software package (3D_LAVmax and 3D_LAVmin). Patients were followed for 5 years (57 ± 11 months) after the index event. Primary outcome was mortality. Secondary outcomes were a composite endpoint (CE) of death and hospitalization for heart failure (HHF); HHF; and a composite cardiac events end-point (MACE) of death, HHF, myocardial infarction, coronary revascularization, arrhythmias, or cardiac resynchronization therapy. Results. At 5 years we recorded 52 deaths, 70 CE, 36 HHF, and 73 MACE. At baseline, mean 2DE and 3DE LVEFs were 32 ± 10% and 32 ± 9%, respectively.  There was no significant difference between the LVVs or LVEF by 2DE or 3DE between survivors and non-survivors. However, there was a significant difference for total and indexed 2D_LAVmax, 3D_LAVmax, and 3D_LAVmin (Table 1) between survivors and non-survivors. Similarly, there was no significant correlations with endpoints for the 2DE or 3DE LVVs. However, total and indexed 2D_LAVmax correlated with death, CE, HFH, and MACE, all with P &amp;lt; 0.03. Furthermore, total and indexed 3D_LAVmax, and 3D_LAVmin correlated with death, CE, HFH, and MACE, all with P &amp;lt; 0.05. In a linear multivariate regression model, that included 2DE and 3DE LVEF, indexed 2D and 3D LAV max and min, only indexed 3D_LAVmin was an independent predictor for death (p &amp;lt; 0.001), CE (p = 0.005), HFH (p = 0.009) and MACE (p = 0.006). Furthermore, by ROC analysis, an indexed LAV of 30 ml/m2 by 3DE was able to predict death ( Sb 94%, Sp 80%, AUC 0.70), CE (Sb 98%, Sp 80%, AUC 0.67), HFH (Sb 96%, Sp 80%, 0.67), and MACE (Sb 93%, Sp 76%, AUC 0.66). Conclusion. LVEF by 2DE and 3DE, while smaller in non-survivors, was unable to predict death in a small cohort of patients with HFrEF. However, LAVs, particularly by 3DE, were able to predict cardiac events, suggesting the potential key value of evolving cardiac substrate. Abstract Table 1 </jats:sec