Netherlands Heart Journal Supplements
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Netherlands Heart Journal Supplements
Netherlands Heart Journal Supplements Vo l u m e 2 4 Supplement 1 A p r i l 2 01 6 ISSN 1569-643X Journal of the Netherlands Society of Cardiology Abstracts Abstracts of the Scientific Spring Congress of the Netherlands Society of Cardiology 2016 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 1 31 March and 1 April 2016, NH Leeuwenhorst, Noordwijkerhout 09-03-16 10:40 Nieuw! De medisch specialist is (g)een alleskunner Over het functioneren van vrijgevestigde medisch specialisten en maatschappen Prof. dr. Douwe H. Biesma ISBN: 9789036810425 € 29,95 DE MEDISCH SPECIALIST IS (G)EEN ALLESKUNNER ‘De medisch specialist is (g)een alleskunner’ geeft een helder overzicht van de meest voorkomende werkzaamheden van vrijgevestigde medisch specialisten. Natuurlijk gaat het primair om kwalitatief goede zorg, om het medisch handelen, maar dat kan niet zonder goede context. De volgende competenties (volgens de CanMEDS-methode) komen aan bod: • Medisch handelen • Communicatie • Samenwerking • Kennis en wetenschap • Maatschappelijk handelen • Organisatie • Professionaliteit Biesma beschrijft per competentie enkele typerende voorbeelden aan de hand van de belevenissen van internist Berend en MDL-arts Marlies, gevolgd door korte commentaren en ontwikkelingen. Daarnaast laat hij enkele toonaangevende experts aan het woord over hun visie op de maatschap. Snel en eenvoudig bestellen? Ga naar www.bsl.nl NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 2 BSL_Adv. Lucide 210x280.indd 1 09-03-16 09:57 10:40 12-01-16 PREFACE Spring Congress of the Netherlands Society of Cardiology 2016 31 March and 1 April 2016, NH Leeuwenhorst, Noordwijkerhout Dear reader, We are pleased to present here the abstracts of the Scientific Spring Congress of the Netherlands Society of Cardiology which will be held on 31 March and 1 April in NH Leeuwenhorst, Noordwijkerhout. We hope that you will enjoy reading the abstracts. On behalf of the Chief Editorial Board Prof. Dr. E.E. van der Wall Netherlands Heart Journal, Volume 24, Supplement, April 2016 09:57 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 1 1 09-03-16 10:40 Abstracts Session 1: Cardiovascular Imaging DIFFERENCES IN ATHEROSCLEROTIC BURDEN BETWEEN SOUTH ASIANS AND CAUCASIANS WITH TYPE 2 DIABETES MELLITUS AND COMPARABLE 10 YEAR PREDICTED CARDIOVASCULAR RISK S.N. Gobardhan (LUMC, Leiden); A.C. Dimitriu-Leen (LUMC, Leiden); A.R. van Rosendael (LUMC, Leiden); E.W. van Zwet (LUMC, Leiden); C.J. Roos (LUMC, Leiden); P.V. Oemrawsingh (MCH, Den Haag); A.V. Kharagjitsingh (MCH, Den Haag); J.W. Jukema (LUMC, Leiden); M.J. Schalij (LUMC, Leiden); J.J. Bax (LUMC, Leiden); A.J.H.A. Scholte (LUMC, Leiden); Purpose: The aim of this study was to explore the association of 10 year predicted cardiovascular (CV) risk assessed with different risk models and the presence of coronary artery disease (CAD) and coronary artery calcium (CAC) score in South Asians with type 2 diabetes mellitus in comparison with matched Caucasians. Methods: Asymptomatic type 2 diabetic South Asians and Caucasians were matched on age, gender, BMI, hypertension and hypercholesterolemia. Several diabetes risk scores (UKPDS, FRS, ASCVD and JBS3) were calculated and the presence of CAC and obstructive CAD (≥50% stenosis) were assessed with coronary computed tomography angiography. In addition, the association of South Asian ethnicity with the presence of CAC and obstructive CAD was corrected for different CV risk models in multivariate analysis. Results: UKPDS, FRS and ASCVD showed no differences in estimated risk scores between 159 South Asians and 159 matched Caucasians. In contrast, JBS3 showed a significant higher risk score in South Asians (17.6% vs 13.7%, p<0.01). Higher presence of CAC score > 0 (69% vs 55%, p<0.05) and obstructive CAD (39% vs 27%, p<0.05) was observed in South Asians. In multivariate analysis, JBS3 corrected best for South Asian ethnicity in the predictive CV risk for the presence of CAC score > 0 and obstructive CAD (Figure 1). Conclusion: Asymptomatic South Asians with type 2 diabetes mellitus had more frequently CAC and obstructive CAD compared with matched Caucasians with similar predictive CV risk scores. JBS3 is recommended as predictive CV risk estimator in South Asians with type 2 DM. Figure 1 Association between the South Asian ethnicity adjusted for cardiovascular risk scores and the presence of coronary artery disease and coronary artery calcium on coronary computed tomography angiography WOMEN WITH SUSPECTED CORONARY ARTERY DISEASE BENEFIT MOST FROM CARDIAC CT: RESULTS FROM THE MULTICENTER, RANDOMIZED CRESCENT TRIAL Marisa Lubbers (Erasmus MC, Rotterdam), Adriaan Coenen (Erasmus MC, Rotterdam), Tobias Bruning (Maasstad ziekenhuis, Rotterdam), Tjebbe Galema (Erasmus MC, Rotterdam), Jurgen Akkerhuis (Sint Franciscus Gasthuis, Rotterdam), Boudewijn Krenning (Haven ziekenhuis Rotterdam), Paul Musters (Erasmus MC, Rotterdam), Mohamed Ouhlous (Erasmus MC, Rotterdam), Ahno Liem (Sint Franciscus Gasthuis, Rotterdam), Andre Niezen (Maasstad ziekenhuis, Rotterdam), Admir Dedic (Erasmus MC, Rotterdam), Ron van Domburg (Erasmus MC, Rotterdam), Miriam Hunink (Erasmus MC, Rotterdam), Koen Nieman (Erasmus MC, Rotterdam) Purpose: To assess the sex-based differences in the effectiveness and safety of a cardiac CT strategy versus standard functional testing in patients with symptoms suggestive of coronary artery disease (CAD). Background: Cardiac CT to detect CAD in women may provide an alternative strategy with potential benefits in terms of effectiveness and cost-efficiency. Methods: Patients with stable angina were prospectively randomized between cardiac CT and functional testing. The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test specific contra-indications were not excluded from study participation. Results: In this pre-specified sub-analysis of the CRESCENT trial, which randomized 350 patients (55% women) pre-dominantly middle-aged (55 ± 8 years) and the majority with an intermediate pre-test probability of CAD, women presented more often with atypical chest pain symptoms (58% vs. 46%, p=0.029). In both men and women CAD could be ruled out more frequently by cardiac CT (women 84% vs. 48%, p<0.001; men 71% vs. 55%, p=0.017). Women were more likely to have a zero calcium score (48% vs. 35%, p=0.036). After one year women randomized to CT reported fewer anginal symptoms in comparison to the functional testing group (40% vs. 22%, p=0.026). For both men and women randomized to CT the diagnosis was reached faster, with less frequently required additional diagnostic testing in women in the CT group (16% vs. 57%, p<0.001). For men this difference just failed to reach statistical significance (27% vs. 41%, p=0.057). This resulted in lower mean cumulative diagnostic costs for women (€270 vs. € 211, p<0.001). In men there was no difference in overall diagnostic costs. Conclusion: Cardiac CT is a safe, clinically more effective and cost-efficient alternative to functional testing in the diagnostic workup of suspected coronary artery disease in women. CAD = Presence of Coronary Artery Disease >50%. CAC = Presence of Coronary Artery Calcium, calciumscore >0. JBS3 = Joint British Societies for the prevention of cardiovascular disease. ASCVD = atherosclerotic cardiovascular disease. FRS = Framingham Risk Score. UKPDS = United Kingdom Prospective Diabetes Study. OR = Odds Ratio. Cl = Confidence interval LONG-TERM PROGNOSTIC VALUE OF DOBUTAMINE STRESS SPECT IN ELDERLY PATIENTS UNABLE TO PERFORM EXERCISE TESTING Figure 1. Kaplan-Meier curves for all-cause mortality. Event-free survival was significantly lower in patients with an abnormal SPECT compared to patients with normal SPECT. S. Roest (Erasmus MC, Rotterdam); H.J. Boiten (Erasmus MC, Rotterdam); R.T. van Domburg (Erasmus MC, Rotterdam); R. Valkema (Erasmus MC, Rotterdam); A.F.L. Schinkel (Erasmus MC, Rotterdam). Purpose: Dobutamine stress myocardial perfusion imaging (MPI) is a feasible alternative for the evaluation of coronary artery disease (CAD) in patients unable to perform an exercise test. However, no data exist regarding the long-term prognostic value of stress MPI in elderly patients unable to perform an exercise test. Methods: We examined the outcome of 247 elderly patients ≥65 years old who underwent dobutamine stress single-photon emission computed tomography (SPECT) MPI. End points were all-cause mortality, cardiac mortality, and nonfatal myocardial infarction (MI). Hard cardiac events were the combined endpoint of cardiac mortality and nonfatal MI. Kaplan-Meier curves were constructed and univariable and multivariable Cox proportional hazards regression models were used to examine the additional value of MPI parameters with the endpoints of interest. Results: During a mean follow-up of 8.2±5 years, 168 (68%) patients died (all-cause mortality), of which 56 (23%) were due to cardiac causes. Nonfatal MI occurred in 19 (8%) patients. Kaplan-Meier survival curves showed that MPI provided optimal risk stratification in patients with normal and abnormal MPI. Multivariable analysis identified an abnormal MPI as the strongest independent predictor of all-cause mortality [HR 1.85, (95% CI 1.28-2.69), P<0.001] and hard cardiac events [HR 2.66, (95% CI 1.54-4.61), P<0.001]. A reversible defect and the summed stress score (SSS) were also strong long-term predictors of cardiac events. Conclusion: Dobutamine stress MPI is useful in risk classifying elderly patients and provides incremental prognostic information for the prediction of long-term survival and cardiovascular outcomes in elderly patients, unable to perform exercise testing. 2 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 2 Netherlands Heart Journal, Volume 24, Supplement, April 2016 09-03-16 10:40 Abstracts Session 1: Cardiovascular Imaging (continued) ANOMALOUS CORONARY ARTERY ORIGINATING FROM THE OPPOSITE SINUS OF VALSALVA; FRACTIONAL FLOW RESERVE- AND INTRAVASCULAR ULTRASOUND-GUIDED MANAGEMENT IN 17 CONSECUTIVE PATIENTS B.W. Driesen (UMC Utrecht); G.J. Krings (WKZ Utrecht); P.A.F.M. Doevendans (UMC Utrecht); M. Voskuil (UMC Utrecht). Purpose: To describe the use of fractional flow reserve (FFR) and intravascular ultrasound (IVUS) in the assessment of anomalous coronary arteries originating from the opposite sinus of Valsalva (ACAOS). Methods: We retrospectively studied 17 consecutive patients with ACAOS who received IVUS- and FFRguided treatment at our institution between October 2010 and October 2015. FFR was performed using adenosine and if normal also dobutamine was given. IVUS was performed using Volcano Revolution catheter. Results: FFR was abnormal in only 3 patients. IVUS showed the typical slit-like anatomy of the origo in 12 patients. Based on either one of these measurements and the clinical presentation, intervention by unroofing of the coronary artery (n=6) was performed. No periprocedural complications occurred. In all other patients a conservative strategy was executed. No adverse events occurred after a mean of 20 months of follow-up. Conclusion: Conservative treatment is justifiable in patients with ACAOS in presence of non-significant FFR and IVUS results and absence of suspicious clinical symptoms. We recommend to use FFR and/or IVUS in standard work-up for ACAOS. Tabel Subject ACAOS Symptoms CPEX Scintigraphy. FFR IVUS Therapy 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 R R R R L R R R R R R R L R R R R Angina Angina, collapse Atypical Atypical Takotsubo Atypical Angina Atypical Routine CPEX Atypical Atypical Atypical Routine CPEX Atypical Atypical AVNRT with positive troponin Ventricular Fibrillation Positive Negative Not performed Not performed Not conclusive Negative Negative Not performed Positive Not performed Positive Negative Positive Negative Positive Not performed Not performed Not performed Not performed Not performed No ischemia Not performed Not performed Ischemia Not performed Not performed Not performed Ischemia Not performed Not performed Not performed Not performed Not performed Not performed 0.93 0.85 0,86 0,9 0,9 0,84 0,82 0,81 0,93 0,89 0,94 0,87 0,88 0,59 0,76 0,9 0,52 Slitlike orifice, coronary compression Slitlike orifice Slitlike orifice Mild atherosclerosis Slitlike orifice Slitlike orifice Slitlike orifice Slitlike orifice Slitlike orifice Slitlike orifice Mild atherosclerosis Slitlike orifice Mild atherosclerosis Slitlike orifice Slitlike orifice Normal Coronary compression Unroofing Unroofing Conservative Conservative Conservative Conservative Unroofing Conservative Conservative Conservative Conservative Conservative Conservative Unroofing Unroofing Conservative Unroofing SIMILAR OUTCOME AFTER A NEGATIVE TEST RESULT FOR ALL NON-INVASIVE CARDIAC IMAGING MODALITIES IN PATIENTS WITH SUSPECTED OR KNOWN CORONARY ARTERY DISEASE – A META-ANALYSIS M.W. Smulders (MUMC, Maastricht)*; C. Jaarsma (MUMC, Maastricht)*; P.J. Nelemans (MUMC, Maastricht); S.C.A.M. Bekkers (MUMC, Maastricht); J. Bucerius (MUMC, Maastricht); T. Leiner (UMC, Utrecht); H.J.G.M. Crijns (MUMC, Maastricht); J.E. Wildberger (MUMC, Maastricht); S. Schalla (MUMC, Maastricht). *these authors contributed equally. Purpose: The prognostic value is one of the most robust features of non-invasive cardiac imaging. However, comparison of prognosis between all available tests and the influence of the pretest probability has not been explored before in a single study. Methods: MEDLINE, EMBASE and Cochrane Library were searched for studies investigating the prognostic value of coronary computed tomographic angiography, cardiovascular magnetic resonance, exercise electrocardiographic testing, positron emission tomography, stressechocardiography, and single-photon emission tomography in patients with suspected or known coronary artery disease (CAD). Studies were included if a (derivable) annual event rate (AER) of non-fatal myocardial infarction and cardiac death for a negative test result was reported. Results: 165 studies (122,721 patients) were included. A negative test result was associated with an overall pooled AER of 0.94% (0.81-1.09) ranging from 0.32% [0.22-0.43] for computed tomography angiography to 1.66% [1.22-2.16] for stress-echocardiography during 2.7 years follow-up. A lower AER after a negative test result was significantly correlated with the baseline risk of events (Figure 1). After correcting for the baseline risk and presence of CAD (pre-test probability) using meta-regression analysis, the prognosis after a negative test result was similar between all non-invasive imaging modalities. Conclusion: This meta-analysis is the first study comparing all available non-invasive cardiac imaging modalities. It shows that a negative test result, regardless of the selected modality, conveys an excellent prognosis for patients with suspected or known CAD. Differences between modalities in the number of events after a negative test result may be explained by differences in pre-test probability. THE ASSOCIATION OF LEFT ATRIAL DIMENSIONS AND FUNCTION WITH AGE AND LEFT VENTRICULAR DIASTOLIC FUNCTION IN A HEALTHY DUTCH POPULATION R.W.J. van Grootel (Erasmus MC, Rotterdam); M.E. Menting (Erasmus MC, Rotterdam); A.E. van den Bosch (Erasmus MC, Rotterdam); J.S. McGhie (Erasmus MC, Rotterdam); W.B. Vletter (Erasmus MC, Rotterdam); M. Strachinaru (Erasmus MC, Rotterdam); M.L. Geleijnse (Erasmus MC, Rotterdam); J.W. Roos-Hesselink (Erasmus MC, Rotterdam). Purpose: Left atrial (LA) volume is associated with adverse cardiovascular events and outcome. We aim to determine the relationship between LA dimensions and function with anthropomorphic factors and left ventricular (LV) diastolic function, to propose normative values in a healthy Dutch population. Methods: A cohort of 155 prospectively recruited healthy subjects, aged 20-72 years (at least 28 subjects per decade, equally distributed for sex) underwent physical examination and 2D-echocardiography. LA minimum, maximum and pre-A volumes (PAV) were measured using the method-of-disk-summation-technique. LA reservoir, conduit and pump function were assessed with total, passive and active emptying volumes (TEV, PEV, AEV) and corresponding fractions (TEF, PEF, AEF). LV diastolic function was assessed with peak Eand A-velocities, TDI E’ and deceleration time. Results: 147 subjects were included (age 44±14 years, 50% female). Normal values are presented in figure per age group. Variables pertaining LA dimension and function were significantly correlated with age (LA-min r=0.252, PAV r=0.437, TEF r=-0.279, PEF r=-0.613, AEF r=0.281). This was also true for LV diastolic function parameters (E-wave r=-0.457, A-wave r=0.582, E/A-ratio r= -0.680, deceleration time r=0.313, E’(septal) r=-0.756, E/E’-ratio r=0.472). Multivariate analysis showed that age was an independent predictor for LA dimensions, function and LV diastolic function. Peak E- and A-velocities were strong independent predictors for LA conduit and pump function. Conclusion: This study provides echocardiographic reference ranges for LA dimensions and function which can be utilized to enhance accuracy of echocardiographic diagnostics. The results emphasize the need for age-specific assessment. Figure 1. Left atrial volume & function Figure 1. Correlation of the prognosis after a negative test result and the index risk of the referred population for all non-invasive cardiac imaging modalities. LA: Left Atrial. Volumes are indexed with BSA. *: p < 0.05. **: p < 0.001. Netherlands Heart Journal, Volume 24, Supplement, April 2016 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 3 3 09-03-16 10:40 Abstracts Session 1: Cardiovascular Imaging (continued) THE IMPACT OF HYBRID CORONARY CT ANGIOGRAPHY AND ADENOSINE STRESS CT PERFUSION IMAGING ON REFERRAL FOR CATHETERIZATION AND SUBSEQUENT REVASCULARIZATION IN PATIENTS WITH NEW-ONSET CHEST PAIN A.R. van Rosendael (LUMC, Leiden); A.C. Dimitriu-Leen (LUMC, Leiden); E.W. van Zwet (LUMC, Leiden); J.W. Jukema (LUMC, Leiden); J.J. Bax (LUMC, Leiden); L.J. Kroft (LUMC, Leiden); A.J. Scholte (LUMC, Leiden) Purpose: The aim of this study was to assess the impact of a protocol consisting of coronary artery calcium (CAC) score and coronary computed tomography angiography (CTA), added with adenosine stress computed tomography perfusion (CTP) in case of ≥ 50% stenosis (cardiac CT imaging protocol), on the downstream performance of catheterization and revascularization in patients presenting with new-onset stable chest pain. Methods: 384 patients with new-onset stable chest pain were enrolled in the cardiac CT imaging protocol. Patients with lesions ≥ 50% stenosis underwent subsequentially stress CTP. Perfusion scans were considered abnormal if a defect was observed in ≥ 1 segment. Downstream performance of catheterizations and revascularization was assessed within 3 months. Results: In total, 115 patients showed ≥ 50% stenosis on coronary CTA; the stress CTP was normal in 48 patients, abnormal in 38 patients and not performed in 29 patients. After normal stress CTP, 13 (27%) patients underwent catheterization and 8 (17%) underwent revascularization. After abnormal stress CTP, 36 (95%) underwent catheterization and 29 (76%) revascularizations were performed. No or non-obstructive CAD was observed in 269 patients among whom 8 underwent catheterization; none underwent revascularization. The rate of finding ≥ 50% stenosis at catheterization was 80%. Conclusions: The cardiac CT imaging protocol consisting of CAC score and coronary CTA, added with stress CTP in case of ≥ 50% stenosis effectively serves as a gatekeeper to catheterization and revascularization for patients with new onset chest pain. In patients with ≥ 50% stenosis, stress CTP could direct clinical decision making regarding downstream catheterization and subsequent revascularization. EKOSONIC ULTRASOUND ENDOVASCULAR SYSTEM FOR THE TREATMENT OF HEMODYNAMICALLY UNSTABLE PULMONARY EMBOLISM Hart, E (UMC Utrecht, Utrecht); Leenders, GEH (UMC Utrecht, Utrecht); Carpaij, N (UMC Utrecht, Utrecht); Klöpping, C (UMC Utrecht, Utrecht); Bronsveld, I (UM Utrecht, Utrecht); Stella, PR (UMC Utrecht, Utrecht); Voskuil, M (UMC Utrecht, Utrecht); Chamuleau, SAJ (UMC Utrecht, Utrecht); Kraaijeveld, AO (UMC Utrecht, Utrecht) Purpose: To assess the initial experience with the EkoSonic Ultrasound Endovascular System (EKOS), a novel local ultrasound assisted low-dose thrombolysis system for the treatment of hemodynamically unstable pulmonary embolism (PE). Methods: Patients with hemodynamically unstable PE that were treated with EKOS from December 2014 until February 2016 in the University Medical Center Utrecht were included in a registry. Efficacy outcomes were clinical improvement at discharge and reduction in right ventricular pressure and/or remission of PE as assessed by echocardiography or CT angiography (CTA), respectively. Safety outcomes were all-cause mortality, bleeding (International Society on Thrombosis and Haemostasis criteria), hospitalization time and PE recurrence. Results: Eight patients with CTA confirmed PE were included. All patients showed significant obstructive PE upon diagnosis. Following EKOS, 6 patients (75%) showed clinical improve ment, 2 patients (25%) died. One patient died from cerebral infarction accompanied by septic shock, 1 patient died due to right-sided heart failure. Six patients underwent CTA follow-up; all showed remission of pulmonary emboli. Of the two patients without CTA follow-up, 1 patient showed an echocardiographic decrease in right ventricular dilation and pressure and 1 patient showed no improvement. Two patients (25%) developed a bleed. One bleed consisted of a post-traumatic rib hematoma with a significant Hb drop of ≥1.24 mmol/L (major bleed), the other consisted of a post-traumatic periocular hematoma (clinically relevant non-major bleed). Median hospitalization time was 7 days, no recurrence of PE was observed. Conclusion: EKOS therapy for the treatment of hemodynamically unstable PE seems to be effective at reducing thrombus load without inducing clinically significant bleeding complications. 4 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 4 Netherlands Heart Journal, Volume 24, Supplement, April 2016 09-03-16 10:40 Abstracts Session II: Atrial fibrillation/Anticoagulants ECHOCARDIOGRAPHIC ASSOCIATES OF ATRIAL FIBRILLATION IN END-STAGE RENAL DISEASE PERIATRIAL EPICARDIAL ADIPOSE TISSUE DOES NOT PREDICT OUTCOME IN HYBRID ATRIAL FIBRILLATION ABLATION L.C.R. Hensen (LUMC, Leiden); V. Delgado (LUMC, Leiden); S.E. van Wijgaarden Leiden); M. Leung (LUMC, Leiden); M.K. de Bie (LUMC, Leiden); M.S. Buiten Leiden); M.J. Schalij (LUMC, Leiden); J.J. Van de Kerkhof (Bernhoven Medical Uden); J.W. Jukema (LUMC, Leiden); T.J. Rabelink (LUMC, Leiden); J.I. Rotmans Leiden); J.J. Bax (LUMC, Leiden) M.Vroomen (MUMC, Maastricht); B. Maesen (MUMC, Maastricht); V. L’Espoir (MUMC, Maastricht); S. Verheule (MUMC, Maastricht); M. La Meir (UZ Brussel, Brussel); U. Schotten (MUMC, Maastricht); J.G. Maessen (MUMC, Maastricht); H.J.G.M. Crijns (MUMC, Maastricht); L. Pison (MUMC, Maastricht). (LUMC, (LUMC, Center, (LUMC, Purpose: The prevalence of atrial fibrillation (AF) in end-stage renal disease (ESRD) patients is high. Changes in the atrium, such as an increased size and myocardial fibrosis, may lead to delayed conduction and are known substrates for AF. PA-TDI duration, a parameter derived from tissue Doppler imaging, measures delay between electrical conduction and mechanical activation of the atrial myocardium. This is a surrogate for detecting substrates in the left atrial wall. The present study evaluated whether atrial substrates differ between ESRD patients with and without AF. Methods: ESRD patients enrolled in the Implantable Cardioverter Defibrillators in Dialysis patients (ICD2) trial until June 2015 were included. Clinical and echocardiographic characteristics were evaluated. Based on ICD remote monitoring or clinical records, the occurrence of AF was detected. Results: Of 171 patients, 47 (27%) patients experienced AF. There were no differences in left ventricular ejection fraction or mitral regurgitation between ESRD patients with and without AF. However, patients with AF had significantly larger left atrial volume index (LAVI), reduced late diastolic mitral annular velocity and longer PA-TDI duration compared to patients without AF (Table 1). Larger LAVI and longer PA-TDI duration were independently associated with the presence of AF (OR 1.05, 95% CI 1.02-1.09, p=0.004 and OR 1.02, 95% CI 1.001.03, p=0.023) after correcting for age and left ventricular filling pressure. Conclusion: ESRD patients with AF show increased LAVI and delay of atrial conduction (based on PA-TDI duration) compared to ESRD patients without AF, suggesting more advanced changes in the LA substrate. Purpose: Epicardial adipose tissue volume (EAT-V) is greater in patients with a recurrence after a catheter ablation compared to those who maintained sinus rhythm. The aim of the present study is to explore the relation between periatrial EAT-V and outcome after a hybrid AF ablation (epicardial surgical and endocardial catheter ablation). Methods: Fifty patients referred for a hybrid ablation were studied. On preoperative CT-scans, left atrial (LA) and right atrial (RA) EAT-V were identified by a window of -30 to -190 Hounsfield Units, using custom-made imageJ. Also myocardial mass (10 to 120 Hounsfield Units) and LA volumes (LAV) were assessed. Follow-up in 49 patients (1 lost to follow-up) at 1 year was conducted according the HRS expert consensus statement. Results: Detailed results are depicted in the table. EAT-V was not significantly different between paroxysmal and persistent AF patients. EAT-V was not predictive of acute conduction block in the epicardial surgical box lesion, neither of AF recurrence at 1 year. LA EAT-V did not correlate with LAV determined on echocardiography (r=0.22, P=ns), but did correlate with LAV determined on CT (r=0.42, P<0.01). Overall, LAV determined on CT correlated to but was systematically smaller than LAV determined on echocardiography (r=0.40, P<0.01). Conclusion: In patient with a complex underlying AF substrate undergoing hybrid AF ablation, total EAT-V is not predictive of recurrence at 1 year. LA EAT-V does increase with LAV, and thus could fatty infiltration play a role in early substrate development, but less in the domestication of AF. Table Type of AF Table 1. Clinical and echocardiographic characteristics of ESRD patients with and without AF Variable AF (n=47) No AF (n=124) P value Heart rate (beats/min) 67 ± 10 72 ± 12 0.005 LVEF (%) 56 ± 8 54 ± 8 0.115 Moderate/severe MR, n (%) 8 (17) 12 (10) 0.165 LAVI (mL/m²) 29 ± 11 23 ± 10 0.001 Lateral A’ (cm/s) 7.1 ± 2.8 8.2 ± 2.4 0.012 PA-TDI (ms) 144 ± 30 131 ± 27 0.010 Acute block PAF (n=26) persAF (n=24) P Yes (n=32) EAT-V LA (mL) 7.0±4.3 8.1±5.1 0.41 7.8±5.2 EAT-V RA (mL) 9.5±5.1 10.6±5.7 0.44 9.6±5.3 Outcome 1 year No (n=7) P AF (n=6) 9.0±3.4 0.56 7.5±3.8 12.7±6.1 0.17 8.5±1.9 SR (n=43) P 7.5±4.9 0.99 10.3±5.7 0.45 Total EAT-V (mL) 16.5±8.9 18.8±9.8 0.39 17.4±9.9 21.8±8.7 0.28 15.9±5.4 17.8±9.9 0.67 EAT-V = Epicardial Adipose Tissue, LA = Left Atrium, RA = Right Atrium, AF = Atrial Fibrillation, PAF = Paroxysmal AF, persAF = persistent + long-standing persistent AF, SR = Sinus Rhythm. Continuous data are presented as mean ± SD. Categorical data are presented as numbers and percentages. LAVI, left atrial volume index; LVEF, left ventricular ejection fraction; MR, mitral regurgitation; TDI, tissue doppler imaging SURGICAL VERSUS PERCUTANEOUS AF ABLATION; A RANDOMIZED CONTROLLED TRIAL GALECTIN-3 DOES NOT REFLECT PROGRESSION OF THE FIBROTIC SUBSTRATE IN THE HUMAN ATRIA AND SERUM OF PATIENTS WITH ATRIAL FIBRILLATION A. Adiyaman (Isala Klinieken, Zwolle); L. Schreuder (Isala Klinieken, Zwolle); R. Beukema (Isala Klinieken, Zwolle); P.P. Delnoy (Isala Klinieken, Zwolle); J.J.J Smit (Isala Klinieken, Zwolle); H. Sie (Isala Klinieken, Zwolle); A.R. Ramdat Misier (Isala Klinieken, Zwolle); A. Elvan (Isala Klinieken, Zwolle). W.R. Berger (AMC, Amsterdam), B. Jagu (AMC, Amsterdam), N.W.E. van den Berg (AMC, Amsterdam), D.R.P.P. Chan Pin Yin (Spaarne Gasthuis, Zaandam), J. Neefs (AMC, Amsterdam), J.P. van Straalen (AMC, Amsterdam), A.H.G. Driessen (AMC, Amsterdam), S.P.J. Krul (AMC, Amsterdam), W. J. van Boven (AMC, Amsterdam), J.R. de Groot (AMC, Amsterdam) Purpose: The cornerstone of invasive AF treatment is pulmonary vein isolation (PVI). Both minimally invasive thoracoscopic epicardial PVI (MIPI) and percutaneously performed endocardial PVI are accepted treatments. As no randomized data is present for patients undergoing a first ablation, it is yet unclear which approach is most effective. Methods: We conducted a randomized controlled trial in patients with lone, paroxysmal or persistent AF, undergoing a first ablation. Patients were randomized to MIPI with LAA excision or percutaneous PVI (PVI). RF energy was used for all ablations. All patients were monitored with implanted continuous loop monitors from 6 months before up to 2 years after the procedure. The primary outcome measure was freedom of atrial tachyarrhythmia. Results were analyzed on an intention to treat basis. The safety endpoint was freedom of complications, and was analyzed on an as treated basis. Results: Between 2007 and 2013, fifty patients with drug-refractory AF were randomized to CA (n=25) or MIPI (n=25). Median age was 57 years (range 37-75), 78% were male and 74% had paroxysmal AF. All patients had 2 years of follow-up. No significant differences were present for the primary endpoint after 6 and 12 months follow-up. After 2 years, more patients were free of atrial tachyarrhythmia after PVI versus MIPI (12/27, 44% versus 6/22 27%, P=0.047). More procedure related major complications occurred after MIPI than after CA (0% versus 22%, p=0.016). Conclusion: Percutaneous PVI results in lower long-term AF recurrence rates than surgical PVI with LAA resection. Netherlands Heart Journal, Volume 24, Supplement, April 2016 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 5 Purpose: Galectin-3(Gal-3), a soluble lectin expressed in a variety of tissues, appears to be an important mediator of cardiac fibrosis, particularly in heart failure. Gal-3 levels are associated with increased risk of developing atrial fibrillation(AF) and may reflect atrial fibrotic remodeling. Therefore, Gal-3 may be a biomarker for AF progression. We investigated the relation between atrial fibrosis and Gal-3 concentrations in atrial tissue and serum of AF patients. Methods: Left atrial appendages(LAAs) and serum were collected from patients undergoing thoracoscopic pulmonary vein isolation (TPVI) for treatment of AF. Gal-3 concentrations in tissue and serum were measured with ELISA and normalized for total protein concentration. Picrosirius red staining was performed for quantification of interstitial collagen. Results: Ninety-eight patients(76% male, mean age 60±9 years) underwent TPVI for paroxysmal (PAF,n=44) or persistent AF(PeAF,n=54). The percentage of left atrial fibrosis was 5.1 and 5.0% (p=1.0), and did not correspond to local Gal-3 expression (93.6±28.6ug/l and 91.9±28.4ug/l, p=0.08 in PAF and PeAF respectively). Serum Gal-3 levels were not significantly different in PAF and PeAF (14.4±4.1 and 14.1±3.6 ug/l p=0.97) and did not correlate with tissue Gal-3 (p=0.3) or actual atrial fibrosis (p=0.2). Conclusion: Atrial fibrosis does not correspond to circulating Galecin-3 in patients with AF, and neither correlates with local Galectin-3 expression in atrial tissue. Our data suggest that changes in Galectin-3 may reflect remote processes and are not mechanistically related to AF progression. This may limit the clinical applicability of circulating Gal-3 as a biomarker for progression of the fibrotic substrate of AF. 5 09-03-16 10:40 Abstracts Session II: Atrial fibrillation/Anticoagulants (continued) SAFETY AND EFFICACY OF HYBRID ABLATION IN PATIENTS WITH LONGSTANDING PERSISTENT ATRIAL FIBRILLATION ADHERENCE TO NON VITAMIN K ORAL ANTICOAGULANTS IN ADULTS WITH CONGENITAL HEART DISEASE M.I.H. Al-Jazairi (UMCG, Groningen); T.J. Klinkenberg (UMCG, Groningen); J. Korenstra (UMCG, Groningen); M. Rienstra (UMCG, Groningen); I.C. Van Gelder (UMCG, Groningen); M. Mariani (UMCG, Groningen); Y. Blaauw (UMCG, Groningen) H. Yang (AMC, Amsterdam); G. Scognamiglio (Vincenzo Monaldi Hospital, Naples); M. Ladouceur (Hôpital Européen Georges Pompidou, Paris); F.J. Meijboom (UMCU, Utrecht); T. Konings (VU, Amsterdam); R.J.G. Peters (AMC, Amsterdam); B.J. Bouma (AMC, Amsterdam); B.J.M. Mulder (AMC, Amsterdam) Purpose: Catheter ablation of longstanding persistent atrial fibrillation (LS-AF) has high recurrence rates (even with multiple procedures). Safety and efficacy of combined surgical thoracoscopic and percutaneous ablation (hybrid), as a promising approach to treat LS-AF, are discussed. Methods: Consecutive patients undergoing single stage hybrid AF ablation (consisting of thoracoscopic PVI, roof, inferior line and SVC isolation, LAA exclusion by CHADS-VASc≥2, endocardial ablation by incomplete surgical lines, CTI-ablation, and CFAEs ablation if AF persisted). Efficacy was assessed using 3-day Holter at 3, 6 and 12 months. Major adverse events (MAEs) were prospectively assessed and included death, major bleeding, stroke, TIA, cardiac tamponade, myocardial infarction and major complications requiring surgical intervention. Results: Thirty-six patients, mean age was 55±8 years, 30 (83%) were men, 33 (92%) had symptomatic persistent AF, 18 (50%) had prior ablation(s) and total AF history was 5.1 years (2.1-8.7y). Mean BMI was 28.0±3.3, mean LAVI was 39±10ml/m2 and mean LVEF was 54±6%. Mean procedure time was 339±50 minutes. After a median follow-up of 7 months (3-10m), AF recurrence rate was 3% without AAD and 0% with AAD. Two (6%) patients had recurrence of atypical atrial flutter, neither requiring additional treatment. AADs were discontinued in 33 (92%) patients at 6±2 weeks. No re-interventions were performed or scheduled. Three (8%) patients developed MAEs; one had major bleeding necessitating sternotomy, one developed pericardial and pleural effusion requiring drainage and one developed pleural effusion requiring drainage. No death occurred. Conclusion: Our initial results of single stage hybrid AF ablation in patients with LS-AF demonstrate efficacy and safety. RESULTS FROM A DUTCH NOAC/VKA OBSERVATIONAL STUDY F.R. den Hartog (Ziekenhuis Gelderse Vallei, Ede); R.P. van ‘t Land (Trombosedienst Neder-Veluwe, Ede); P. van Mourik (Ziekenhuis Gelderse Vallei, Ede); M. Langedijk (Ziekenhuis Gelderse Vallei, Ede); D.J. Duits-Kroon (Trombosedienst Neder-Veluwe, Ede); J.Zimmerman (Ziekenhuis Gelderse Vallei, Ede) Purpose: In the Gelderse Vallei the introduction of NOAC for atrial fibrillation includes evaluation of clinical endpoints in our real life patients. The purpose is to attribute to the search for a good stratification of “real” patients to the right individual anticoagulation therapy. Methods: There was an active registration of thromboembolic events, severe bleeding and intra cranial bleeding, searched for in our cohorts (VKA 2014;NOAC 2015) as rigorous as in international NOAC trials. There was no randomization or correction for differences between our two cohorts. VKA results for 2015 will follow. The time in therapeutic range (TR) for VKA (INR) was around 85% for the long term patients. The TR was 2,0 – 3,5 INR for most of patients. Only around 4% of these INR’s was below 2,0. Results: Regardless of methodological differences and differences in patient characteristics the data show comparable event risks for our own VKA and NOAC cohorts, both of which in general perform better than both NOAC and warfarin in the NOAC trials (table, including 95% CI). Conclusions: 1. Our careful, protocolled introduction of NOAC performs better than NOAC and warfarin in NOAC trials. NOAC performs equal to VKA in our cohorts, set aside differences in characteristics. 2. VKA in our population performs better than warfarin in NOAC trials. 3. Our data support the recommendation for continued registration to confirm or reject these figures and to learn to stratify patients to the preferred anticoagulation therapy. Purpose: Adherence to non-vitamin K oral anticoagulants (NOACs) is of great concern due to lack of anticoagulation monitoring and devastating consequences of stroke. Recent data on patients with acquired heart disease using NOACs demonstrated that 70-75% were sufficiently adherent. However, adherence to NOACs and vitamin K antagonists (VKA) in adult congenital heart disease (ACHD) patients with atrial arrhythmias is currently unknown. Methods: Patients enrolled in the NOTE registry were included in this study. Adherence was measured using 1) pharmacy interrogation at 1-year follow-up (n=28) to calculate medication refill adherence (MRA) and 2) Morisky-8 questionnaire (MMAS-8), obtained at baseline, 6 months and 1-year follow-up (n=58). Adherence was classified as sufficient if MMAS-8 adherence was middle (6-7) to high (8) or MRA adherence was ≥80%. Chi-square test was used for comparisons. Results: A total of 58 ACHD patients were included (mean age 51y, 41.4% male, 84.5% moderate/ complex ACHD, median CHA2DS2-VASc 2). Pharmacy data revealed a high overall adherence of 98% (IQR 88.9-103), with 24 patients (86%) being sufficiently adherent. With MMAS-8 questionnaire, 70% of the patients scored sufficient adherence at 1-year follow up. In patients, who previously used VKA (n=37), 84% had sufficient adherence, which did not change at 6 months (87%, p=0.727) or at 1-year follow-up (81%, p=1.000). Main reason for low adherence (n=12) was polypharmacy. Conclusion: In this ongoing study, the first results regarding adherence to NOACs in ACHD patients are reassuring with sufficient adherence rates, equal to VKA adherence and higher than reported in patients with acquired heart disease. ENDO-EPICARDIAL DISSOCIATION OF THE RIGHT ATRIAL WALL DURING ATRIAL FIBRILLATION IN HUMANS J.M.E. van der Does (Erasmus MC, Rotterdam); A. Yaksh (Erasmus MC, Rotterdam); P. Knops (Erasmus MC, Rotterdam); E.A.H. Lanters (Erasmus MC, Rotterdam); C.P. Teuwen (Erasmus MC, Rotterdam); P.C. van de Woestijne (Erasmus MC, Rotterdam); J.A. Bekkers (Erasmus MC, Rotterdam); C. Kik (Erasmus MC, Rotterdam); A.J.J.C. Bogers (Erasmus MC, Rotterdam); M.A. Allessie (Erasmus MC, Rotterdam); N.M.S. de Groot (Erasmus MC, Rotterdam); Purpose: The purpose of this study is to provide evidence for the occurrence of endo-epicardial dissociation in human atrial fibrillation (AF) in support of the hypothesis of two layers acting as drivers for each other during AF. Methods: Intra-operative mapping of the endo- and epicardial right atrial wall was performed during (induced) AF in 14 patients with (N=10) and without (N=4) a history of AF. Before venous cannulation, a clamp made of two rectangular 8x16 electrode arrays (inter-electrode distance 2mm) was inserted into the incision in the right atrial appendage. Recordings of 10 seconds of AF were analysed to determine the incidence of asynchronous endoepicardial activation times (≥15ms) of opposite electrodes. Results: Patients were surgically treated for coronary heart disease (N=9), mitral valve (N=7), tricuspid valve (N=4) and/or aortic valve disorders (N=2). Patients with AF prior to surgery had paroxysmal (N=3), persistent (N=4) or longstanding persistent AF (N=3). Asynchronous endo-epicardial activation ranged between 0.9-55.9% and seems to occur more often in patients with AF than without AF (18.9% vs 5.2%). Focal waves appeared equally frequent at endocardium and epicardium (579 vs 620). Using strict criteria for breakthrough (presence of an opposite wave within 4mm and ≤14ms before the origin of the focal wave), the majority (65%) of all focal fibrillation waves could be attributed to endo-epicardial excitation. Conclusion: We provided the first evidence for asynchronous activation of the endo-epicardial wall during AF in humans. Endo-epicardial asynchrony may play a major role in the pathophysiology of AF. Tabel: Event risk / patient year in AF 6 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 6 Figure 1. Epi- and endocardial activation maps recorded during AF demonstrating endo-epicardial dissociation. Black/white arrows illustrate the direction of conduction. Isochrones are set at 5ms intervals. Thick black lines indicate conduction block (<18 cm/s). A focal wave appears at the white star. Four examples of corresponding endo-epicardial electrograms show the Netherlands Heart Journal, Volume 24, Supplement, April 2016 09-03-16 10:40 Abstracts Session III: Electrophysiology ANALYSIS OF CIRCADIAN REPOLARIZATION IDENTIFIES QTC DIURNALITY AS A NOVEL CLINICAL PARAMETER ASSOCIATED WITH HERG CHANNEL DYSFUNCTION AND VENTRICULAR ARRHYTHMIAS B.C. du Pré (UMC Utrecht, Utrecht); L.W. Van Laake (UMC Utrecht, Utrecht); M. Meine (UMC Utrecht, Utrecht); J.F. van der Heijden (UMC Utrecht, Utrecht); P.A. Doevendans (UMC Utrecht, Utrecht); M.A. Vos (UMC Utrecht, Utrecht); A.A.B Van Veen (UMC Utrecht, Utrecht); Purpose: Cardiac repolarisation abnormalities are among the major causes of ventricular arrhythmias and sudden cardiac death. In humans, cardiac repolarisation duration has a 24-hour rhythm and peaks in the early morning. Previous studies showed that in mice, the amplitude (diurnality) of this rhythm is associated with hERG channel dysfunction. Here, we investigated whether in man 1) 24-hour rhythms in repolarisation are associated with hERG channel dysfunction and 2) 24-hour rhythms in repolarisation are associated with ventricular arrhythmias. Methods: in 2 retrospective studies, 24-hour rhythms in repolarisation (QT and QTc diurnality) were derived from Holter analyses and compared between groups: 1) 5 genetic (LQTS2) and 16 drug (Sotalol)-induced hERG channel dysfunction patients vs 22 controls and 2) 64 postinfarct patients, 26 with and 38 without a history of ventricular arrhythmias. Results: QT and QTc diurnality were increased in patients with genetic or drug-induced hERG channel dysfunction. In post-infarct patients with a reduced (<35%) left ventricular ejection fraction, QT diurnality was 2-fold higher in patients with a history of ventricular arrhythmias compared to controls. Conclusion: QT and QTc diurnality present novel clinical repolarisation parameters that can be derived from Holter registrations. Both are associated with hERG channel dysfunction and ventricular arrhythmias in patients at risk. Figure 1. QTc diurnality in an example patient NON-INVASIVE TESTING CANNOT IDENTIFY A TYPICAL SUBSTRATE FOR LIFETHREATENING RE-ENTRY VT IN ATHLETES J. Venlet (Leids Universitair Medisch Centrum, Leiden); S.R.D. Piers (Leids Universitair Medisch Centrum, Leiden); M. De Riva Silva (Leids Universitair Medisch Centrum, Leiden;), Y. Naruse (Leids Universitair Medisch Centrum, Leiden); D.C.Q.M. BargeSchaapveld (Leids Universitair Medisch Centrum, Leiden); M.J. Schalij (Leids Universitair Medisch Centrum, Leiden); K. Zeppenfeld (Leids Universitair Medisch Centrum, Leiden). Purpose: Two electroanatomical (EA) scar pattern for VT from the RV have been identified: a dominant subtricuspid and an isolated epicardial RVOT scar, typical for endurance athletes with inferior axis VT. The latter pattern may not be identified by non-invasive testing. Methods: Consecutive symptomatic patients (pts) with scar-related re-entry VT from the RV, who underwent endocardial ± epicardial EA mapping were included. Results: Among 57 patients (48±15 years, 83% male) 46 (81%) had a dominant subtricuspid scar. All had features suggestive for structural heart disease (SHD); T-wave inversion (TWI) >V2 in 17 (37%), prolonged TAD 25/35, epsilon waves 10 (21%), wall motion abnormalities (WMA) 27 (59%), and 25/45 (56%) had an ARVC associated pathogenic mutation. Based on non-invasive testing, 33 had definite ARVC, 3 borderline ARVC, 5 cardiac sarcoidosis, 4 scar of unknown origin and 1 myocarditis. All 11 patients with isolated RVOT scar were endurance athletes (15 [IQR 10 – 20] hours/week); 9/11 (82%) presented with exercise related palpitations including syncope in 6 (55%). Only 1 had increased TAD, 2 (18%) TWI V1-V2, but none TWI > V2, epsilon waves, WMA, or a pathogenic mutation. Based on noninvasive testing the diagnosis was idiopathic RVOT VT in 8/11 (81%) and possible SHD based on additional minor criteria in 3. Conclusion: The majority of endurance athletes with isolated RVOT scar has no features for SHD on non-invasive testing and may be misdiagnosed as idiopathic VT. Considering the potentially life threatening VT EA mapping should be considered in symptomatic athletes. AGE AND GENDER RELATED DIFFERENCES IN CORRECTED QT INTERVAL IN CHILDREN AND ADOLESCENTS WITH LQT1 AND LQT2 A.S. Vink (AMC, Amsterdam); S.A.B. Clur (AMC, Amsterdam); R.B. Geskus (AMC, Amsterdam); A.C. Blank (UMCU, Utrecht); C.C.A. de Kezel (ETZ, Tilburg); R.R. Loontjens (AMC, Amsterdam); M. Bruijn (MCA, Alkmaar); N. Hofman (AMC, Amsterdam); A.A.M. Wilde (AMC, Amsterdam); and N.A. Blom (AMC, Amsterdam). Purpose: Children and adolescents constitute an important risk group in patients with congenital Long QT Syndrome (LQTS). Age-, gender- and genotype related differences in QTc intervals have been observed in young LQTS patients, but these observations were only based on the comparison of baseline QTc interval measurements between large age groups. Therefore, we aimed to evaluate age and gender related differences in QTc intervals in a longitudinal cohort of children and adolescents with LQTS type 1 and 2 (LQT1 and LQT2). OUTPATIENT TREATMENT WITH THE WEARABLE CARDIOVERTER DEFIBRILLATOR; CLINICAL EXPERIENCE IN 2 CENTERS V.F. van Dijk (St Antonius, Nieuwegein); A.F.B.E. Quast (AMC, Amsterdam); A.A.M. Wilde (AMC, Amsterdam); L.V.A. Boersma (St Antonius, Nieuwegein); R.E. Knops (AMC, Amsterdam) Purpose: An implantable cardioverter defibrillator (ICD) is indicated for the prevention of sudden cardiac death in patients at risk of ventricular arrhythmia. In case of a possible transient ICD indication or if an ICD temporarily cannot be implanted, a wearable cardioverter defibrillator (WCD) can be an alternative to long-term hospitalization. Methods: All patients treated with the WCD were included from both centers and retrospectively analysed. Events and compliance were collected from the home monitoring system and adjudicated by the investigators. Results: Between 2009 and 2016, 79 patients were treated with a WCD. Most common indications were awaiting improvement of left ventricular function after either revascularization or de novo cardiomyopathy diagnosis in 46 patients (58,2%), or bridge to implant in 33 patients (41,8%). Two patients (2,6%) received an appropriate shock(calculated appropriate annual shock rate 13,%), there was 1 inappropriate shock. In 21 patients (26,6%) ICD indication proved to be transient. 14(17,7%) patients did not receive an ICD for other reasons. A total of 44 patients were implanted with ICD’s after WCD(55,7%). The WCD was worn for 70±6,41 days. As bridge to implant, the WCD saved 79±10,59 admission days. Methods: All available electrocardiograms of genetically confirmed LQT1 and LQT2 patients born after January 1985 were retrospectively collected. QTc intervals were measured and analysed using a linear mixed-effect model. Results: All 2116 electrocardiograms of 278 patients from 100 different families were analysed. The study population consisted of 130 LQT1 patients (54% females) and 148 LQT2 patients (55% females) with a median follow-up duration of 4 years (IQR 1-9). LQT1 females had significantly longer QTc intervals after the age of 10 compared to LQT1 males. LQT2 males had significantly shorter QTc intervals during the first years of life and significantly longer QTc intervals between the ages of 8 - 11 years compared to LQT2 females (Figure 1). Conclusion: There is an age- depended gender difference in QTc interval among LQT1 and LQT2 patients, with different patterns in both genotypes. Our data suggests that changes in these gender differences occur after the age of 10-11 years which correspond with the onset of puberty. Figure 1 Age and gender related changes in QTc interval among LQT1 and LQT2 patients. Solid lines are males and dashed lines are females. 95% confidence intervals in grey. Conclusion: The WCD is a safe and effective treatment in patients in whom the indication for an ICD is to be postponed or device implantation is temporarily contra-indicated. Table 1. Results WCD therapy. Results Patients (n = 79) Number of days WCD is worn (median, IQ1-IQ3) 70,00 (43,00 – 94,00) Average hours a day WCD is worn (median, IQ1-IQ3) 23,30 (22,62 – 23,71) Appropriate therapy given by WCD (n, %) 2 (2,6%) Inappropriate therapy given by WCD (n,%) 1 (1,3%) Number of altered ICD indications after WCD (n,%) 21 (26,6%) Number hospitalization days prevented in ‘bridge-to-ICD patients’ (median) 79,00 (54,75 – 102,25) Netherlands Heart Journal, Volume 24, Supplement, April 2016 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 7 7 09-03-16 10:40 Abstracts Session III: Electrophysiology (continued) QRS-COMPLEX FRAGMENTATION IS ASSOCIATED WITH SUDDEN CARDIAC DEATH IN ADULTS WITH CONGENITAL HEART DISEASE PREDILECTION SITES FOR ELECTROPATHOLOGY DURING SINUS RHYTHM IN PATIENTS WITH A CONGENITAL HEART DISEASE J.T. Vehmeijer (Academisch Medisch Centrum, Amsterdam); Z. Koyak (Academisch Medisch Centrum, Amsterdam); B.J.M. Mulder (Academisch Medisch Centrum, Amsterdam); B.J. Bouma (Academisch Medisch Centrum, Amsterdam); J.R. de Groot (Academisch Medisch Centrum, Amsterdam) E.A.H. Lanters (Erasmus Medical Center, Rotterdam); C.P. Teuwen (Erasmus Medical Center, Rotterdam); A. Yaksh (Erasmus Medical Center, Rotterdam), P. Knops (Erasmus Medical Center, Rotterdam), J.W. Roos-Hesselink (Erasmus Medical Center, Rotterdam), P.C. van de Woestijne (Erasmus Medical Center, Rotterdam), A.J.J.C. Bogers (Erasmus Medical Center, Rotterdam), M.A. Allessie (Erasmus Medical Center, Rotterdam), N.M.S. de Groot (Erasmus Medical Center, Rotterdam) Purpose: Sudden cardiac death (SCD) is a major cause of mortality in adult congenital heart disease (ACHD) patients. However, identification of high-risk patients remains challenging. Fragmented QRS-complexes (fQRS) are a marker for SCD in patients with acquired heart disease, but data in ACHD patients is lacking. We evaluated the prognostic value of fQRS for SCD in ACHD patients. Methods: This was a multicenter case-controlled study. From a cohort of 25,790 ACHD patients, we included 165 SCD cases and 310 matched controls. We defined fQRS as ≥1 additional notch in the QRS-complex, not part of a bundle branch block, in two contiguous ECG-leads. We calculated odds ratios (OR) with corresponding P-values using generalized linear mixed models. Results: For 150 SCD cases (66% male, median age at death 34 years), and 271 controls, the ECG was of sufficient quality. fQRS was present in 49% of cases and 34% of controls (OR 1.9, P=0.002). In multivariable analysis, adjusted for QRS-duration, heart failure symptoms and impaired systemic ventricular function, fQRS was independently associated with SCD (OR 1.7, P=0.026). fQRS in the anterior leads was more strongly associated with SCD (21% in cases vs. 11% in controls; OR 2.1, P=0.02), compared to lateral (12% vs. 7%; OR 1.3, P=0.44), inferior (28% vs 23%; OR 1.2, P=0.48) and other leads (14% vs. 15%; OR 0.8, P=0.53). Conclusion: fQRS is associated with SCD in ACHD patients. Independently, its prognostic value is too limited to warrant ICD implantation. However, when combined with other clinical parameters, it may contribute to the indication for ICD implantation. Figure 1. Multivariable logistic regression of fQRS and SCD, corrected for QRS width >120ms, heart failure symptoms and impaired systemic ventricular function (SVF): ejection fraction ≤ 39% or at least moderately impaired. Purpose: Congenital heart diseases (CHD) such as atrial septal defects are associated with right atrial (RA) volume overload and subsequently atrial stretch resulting in intra-atrial conduction abnormalities which may be involved in the pathophysiology of atrial tachyarrhythmias. We tested the hypothesis that heterogeneity in conduction during sinus rhythm (SR) in CHD patients with RA overload occurs mainly in the right atrium. Methods: Intra-operative, high-resolution (128/192 electrodes, inter-electrode distances 2mm) epicardial mapping studies of the RA, Bachmann’s Bundle(BB), left atrioventricular groove(LAVG) and pulmonary vein area(PVA) during SR were performed in 12 CHD patients with RA volume overload. Three patients had paroxysmal atrial fibrillation. Unipolar voltages, conduction delay(CD) and conduction block (CB) were quantified per 1 cm2 quadrants. Results: Unipolar signals were recorded from 22,965 sites (1,914±329 signals/patient). Median atrial voltage was 2.5;2.5(1.4-3.5)mV; there were no differences between unipolar voltages/cm2 of the RA, BB, LAVG and PVA(P=0.461). Voltages ≤0.5mV were measured in 6(50%) patients at 12(2.9%) quadrants, mainly at the superior RA(N=5) and at BB(N=4). Median amount of CD and CB were 1.6;1.3(0.9-2.9)% and 1.6;1.3(0.7-3.5)% respectively. CD and CB occurred most frequently at BB(52% and 41% respectively). Also, the amount of CD (2.4%, P=0.027) and CB (3.2%, P=0.004) was highest at BB. Conclusion: In CHD patients with RA volume overload, low voltages and conduction disorders during SR occurred throughout the entire atria, showing considerable regional differences. A predilection site was observed at BB. Consequently, the arrhythmogenic substrate involved in the pathogenesis of atrial tachyarrhythmias may not only be confined to the RA. REASONS FOR ‘FAILING’ AUTOMATED EXTERNAL DEFIBRILLATORS OPERATED BY LAY RESCUERS J.A. Zijlstra (Academisch Medisch Centrum, Amsterdam); L.E. Bekkers (Academisch Medisch Centrum, Amsterdam); M. Hulleman (Academisch Medisch Centrum, Amsterdam); S.G. Beesems (Academisch Medisch Centrum, Amsterdam); R.W. Koster (Academisch Medisch Centrum, Amsterdam) CARDIOLOGY UNLIMITED : TOWARDS A SMART AED? VF WAVEFORM ANALYSIS TO PREDICT DEFIBRILLATION SUCCESS IN CARDIAC ARREST R. Starreveld (Radboudumc, Nijmegen); J. Nas (Radboudumc, Nijmegen); J.L. Bonnes (Radboudumc, Nijmegen); J. Thannhauser (Radboudumc, Nijmegen); G. Meinsma (University of Twente, Enschede); P.M. van Grunsven (Ambulance Emergency Services Gelderland-South, Nijmegen); M.J. de Boer (Radboudumc, Nijmegen); Marc A. Brouwer (Radboudumc, Nijmegen) Purpose: Recent studies have demonstrated that information from the VF waveform can be used in AEDs to contribute to the prediction of survival during out-of-hospital cardiac arrest (OHCA). A combined measure of amplitude and frequency, the Amplitude Spectral Area (AMSA), is regarded the most promising predictor of early shock success. Its impact in later phases of the resuscitation is unknown. We therefore sought to investigate whether the AMSA is able to predict shock success during early (shock 1–2) and later stages of a resuscitation (shocks > 2). Methods: Paddle-ECG recordings of OHCA patients from the Nijmegen area (2008–2011) with VF as first observed rhythm were studied (n=108, 392 shocks). The AMSA was calculated from three-second chest compression free segments of VF prior to each shock. Univariate analysis and receiver operating characteristic curves were used to evaluate the association of the pre-shock AMSA with shock success (i.e. return of organized rhythm). Results: For shock 1–2 (success 44%), the AMSA was significantly higher prior to successful compared to unsuccessful shocks. The discriminative value of the AMSA for shock success of shock 1 and 2 was 0.72 (p<0.001). The AMSA prior to shock 3–8 (success 53%) did not differ between successful and unsuccessful shocks. Also, the discriminative value of the AMSA was lower (0.58, p=0.054) for these shocks. Purpose: In The Netherlands, an increasing number of apparently failing automated external defibrillators (AEDs) is reported: AEDs not giving a shock or other malfunction. We assessed to what extent AEDs are ‘failing’ and whether this had a device-related or operator-related cause. Methods: We studied analysis periods from AEDs used between January 2012 and December 2014. For each analysis period we assessed the correctness of the (no)-shock advice (sensitivity/ specificity) and reasons for an incorrect (no)-shock advice. If no shock was delivered after a shock advice, we assessed the reason for no-shock delivery. Results: We analyzed 1114 electrocardiograms with 3288 analysis periods (1080 shock advices; 2208 no-shock advices). Sensitivity for coarse ventricular fibrillation and specificity for nonshockable rhythm detection was both 99%. The AED gave an incorrect shock advice in 3% (33/1080) of all shock advices (false positive rate), due to device-related (n=11) and operator-related errors (n=21) (one unknown error). Of these 33 shock advices, 22 shocks were given with one causing a harmful rhythm change. In 1% (21/2208) of all no-shock advices, this advice was incorrect (false negative rate), due to device-related (n=16) and operator-related errors (n=5). In 5% (52/1080) of the analysis periods, a shock advice was given but no shock was delivered: operator failed to deliver shock (n=26), electrodes were removed (n=16), operator pushed ‘off’ button (n=8) and other reasons (n=2). Conclusions: Errors associated with AED use occur in ≤5% of cases and are mainly caused by the operator. Fully automated AEDs may prevent the majority of these errors. Figure 1 Erroneously detecting a (non)-shockable heart rhythm (AED analysis, left part) and no shock delivery after a shock advice (operator performance, right part). Conclusion: The present analysis demonstrates that during OHCA, the predictive value of the AMSA for shock success is restricted to the early phase of resuscitation. This challenges the concept of continuous ECG waveform analysis for guidance of the entire resuscitation. Table 1. Median AMSA and corresponding p-values, C-statistic of ROC analysis ROOR + ROOR - P-value C-statistic AMSA Shocks 1-2 (n=186) 11.8 (IQR 8.0-16.1) 8.0 (IQR 5.4-11.0) <0.001 0.72 (95% CI 0.64-0.79) AMSA Shocks 3-8 (n=190) 9.2 (IQR 6.5-13.2) 7.7 (IQR 5.5-12.3) 0.054 0.58 (95% CI 0.50-0.66) 8 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 8 Netherlands Heart Journal, Volume 24, Supplement, April 2016 09-03-16 10:40 Abstracts Session IV: Valvular and aortic disease RATIONALE AND DESIGN OF THE EDWARDS SAPIEN-3 PERIPROSTHETIC LEAKAGE EVALUATION VERSUS MEDTRONIC COREVALVE IN TRANSFEMORAL AORTIC VALVE IMPLANTATION (ELECT) TRIAL: A RANDOMIZED COMPARISON OF BALLOONEXPANDABLE VERSUS SELF-EXPANDING TRANSCATHETER AORTIC VALVE PROSTHESES M. Abawi (UMC-Utrecht, Utrecht); P. Agostoni (UMC-Utrecht, Utrecht and St. Antonius Hospital, Nieuwegein); P. Stella (UMC-Utrecht, Utrecht). Background: Differences between transcatheter balloon-expandable and self-expanding heart valves have been suggested where a reduction of periprosthetic aortic regurgitation (PPR) seems to be crucial. Objective: The current randomized study aims to evaluate potential differences between the balloonexpandable Edwards SAPIEN-3™ and self-expanding Medtronic CoreValve® system with main focus on post-TAVI PPR by novel imaging endpoints and additional focus on other clinical endpoints. Primary endpoint of this study is quantitative assessment of difference in the severity of post-TAVI PPR, using different novel imaging modalities ((3D) transesophageal echocardiography, x-ray contrast angiography and magnetic resonance imaging). Secondary objectives of the study include clinical outcomes including cerebral and kidney injury related to TAVI and quality of life. Methods and design: The ELECT study is a single-center, prospective, two-arm randomized controlled trial. For the purpose of this study, 108 consecutive adult patients will be randomly allocated to receive the SAPIEN- 3 (n= 54) or the CoreValve system (n= 54). Randomization will be performed using sealed envelopes. Only patients with aortic annulus diameter between ≥18 and ≤29 mm and anatomy suitable for transfemoral TAVI will be included. Discussion: The ELECT-trial is the first randomised controlled trial to quantitatively compare the extent of post-TAVI PPR between SAPIEN-3 and CoreValve. Furthermore, it will evaluate potential differences between the two prostheses with regard to mid-term clinical outcome and quality of life. (ClinicalTrials.gov number NCT01982032). CLINICAL PERFORMANCE OF A NOVEL BIOENGINEERED DRUG-ELUTING STENT WITH A SHORT DURATION OF DUAL ANTIPLATELET THERAPY IN PATIENTS AT RISK FOR MAJOR BLEEDING, FIRST RESULTS OF THE COMBO-TAVI REGISTRY R. Rozemeijer (Universitair Medisch Centrum Utrecht, Utrecht); Masieh Abawi (Universitair Medisch Centrum Utrecht, Utrecht); M. Voskuil (Universitair Medisch Centrum Utrecht, Utrecht); A.O. Kraaijeveld (Universitair Medisch Centrum Utrecht, Utrecht); P.R. Stella (Universitair Medisch Centrum Utrecht, Utrecht). Purpose: Currently, DES require mandatory prolonged dual antiplatelet therapy(DAPT). We studied the clinical performance of a novel bioengineered DES with a short DAPT regimen(1 month) in patients at high risk for bleeding. Methods: From April 2015 to January 2016, 22 coronary lesions in 16 patients at risk for major bleeding were treated by PCI with the bioengineered Combo Dual Therapy Stent prior to TAVIprocedure. The bioengineered Combo Stent is designed to combine pro-healing endothelialprogenitor-cell-capture technology for rapid endothelial strut coverage along with sustainedrelease of sirolimus to control neointimal proliferation. Coronary lesions were treated with standard interventional techniques and use of FFR, without any restrictions(lesion type/ lesion length). After index-PCI, 8 patients received triple therapy for 1 month whereas the remainder received 1-month of DAPT prior to TAVI-procedure followed by 3 months of DAPT after TAVI-procedure. Patients were evaluated during regular hospital visits and by medical records. The Combo Stent showed a technical success rate of 100% and procedural success rate of 87.5%. According to (B)ARC, no stent thrombosis occurred and 1 patient suffered from a significant bleeding BARC≥3 bleeding. The major adverse cardiac event-free survival (any death/-myocardial infarction/-target-vessel revascularization/-bleeding BARC≥3 bleeding) was 75% after a median follow-up of 4 months [interquartile range 2.5-7.5] and included the TAVI-procedure. FIRST CLINICAL EXPERIENCE WITH THE 3RD GENERATION TRIGUARD® DEVICE FOR CEREBRAL EMBOLIC PROTECTION DURING TRANSCATHETER AORTIC VALVE IMPLANTATION M. Abawi (UMC-Utrecht, Utrecht); M. Voskuil (UMC-Utrecht, Utrecht); P. Stella (UMCUtrecht, Utrecht); F.C. Riess (AlbertinenHeart Center, Hamburg, Germany). Background: Silent brain infarcts are seen in 60 to 100 % of patients undergoing transcatheter aortic valve implantation (TAVI) and are associated with neurocognitive decline, a 2 fold risk of dementia and a >3 fold risk of stroke. The TriGuard cerebral embolic protection system is a highly flexible nitinol frame and mesh that is positioned in the aortic arch to cover all major cerebral branches to prevent cerebral embolization. The 1st and 2nd generation has been tested in clinical trials. Aim: To evaluate the clinical performance of the 3rd generation TriGuard device in 2 centers in Europe. Methods and Preliminary Results: The device was used in 31 patients ( 78.8± 8.7 yrs, 45.2% male) with symptomatic aortic valve stenosis, who underwent transfemoral TAVI because of high risk for open heart surgery (EuroSCORE II 7.6±6.3, STS Score 2.4±0.9). The TriGuard covered all 3 vessels with no device interference in all patients. Pre-TAVI balloon dilatation was performed in 67.7%, post dilatation in 22.6%, valve in valve implantation in 9.7% of patients. In 29% the Medtronic Core Valve/Evolute R, in 67.7% the Edwards SAPIEN, and in 3.2% the Boston Scientific Lotus valve was used. Conclusions: The 3rd generation TriGuard device is safe with improved performance and ease of use, 100% of the cases had 3 vessel coverage and no strokes. GENOTYPE IMPACTS SURVIVAL IN MARFAN SYNDROME Romy Franken (AMC, Amsterdam), Groenink M. (AMC, Amsterdam), de Waard V (AMC, Amsterdam), Feenstra HM (AMC, Amsterdam),, Scholte AJ (LUMC, Leiden), van den Berg MP (UMCG, Groningen), Pals G (VUMC, Amsterdam), Zwinderman AH (AMC, Amsterdam), Timmermans J (Radboud MC, Nijmegen), Mulder BJ (AMC, Amsterdam). Purpose: The aorta in Marfan syndrome (MFS) patients is variably affected. We investigated the assumed genotype-effect on protein production as a risk factor for a severe aortic phenotype in adult MFS patients. Methods: We collected clinical and genetic data from all 570 adults with MFS who had been included in the Dutch CONgenital CORvitia registry since the start in 2001. Mean age was 36.5 ± 13.5 years (51.2% male, 28.9% prior aortic surgery, 8.2% prior aortic dissection). Patients were prospectively followed for a mean duration of 8.2 ± 3.1 years. Results: Men had more frequently aortic surgery at baseline (38.0 vs. 19.4%, P < 0.001) and during follow-up (24.0 vs. 15.1%, P = 0.008) compared with women. After 10-year follow-up cumulative survival was 93.8% and dissection-free survival was 84.2%. We found a pathogenic FBN1 mutation in 357 patients, of whom 146 patients (40.9%) were positive for a mutation causing haploinsufficiency (reduced fibrillin-1 protein) and 211 (59.1%) for a mutation leading to a DN effect (abnormal fibrillin-1 protein). Corrected for age, sex, and previous aortic complications, patients with a haploinsufficient (HI) mutation had a 2.5-fold increased risk for cardiovascular death (hazard ratio, HR: 2.5, 95% CI: 1.0-6.1, P = 0.049), a 2.4-fold increased risk for the combined endpoint comprising death and dissection (HR: 2.4, 95% CI: 1.4-4.2, P < 0.001) and a 1.6-fold increased risk for any aortic complication compared with patients with a DN mutation (HR: 1.6, 95% CI 1.1-2.3, P = 0.014). Conclusion: Marfan syndrome patients with an HI mutation are at increased risk for cardiovascular death and aortic dissection compared with patients with a DN mutation. Figure 1 Conclusion: This prospective registry will provide more insight in the clinical performance and accelerated healing strategy of the Combo Stent, that aims to lower the risk of in-stent restenosis, stent thrombosis and may have the potential to safely reduce the regiment of DAPT, thereby minimizing bleeding complications in a fragile population scheduled for TAVIprocedure. Netherlands Heart Journal, Volume 24, Supplement, April 2016 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 9 9 09-03-16 10:40 Abstracts Session IV: Valvular and aortic disease (continued) PROGNOSIS OF AORTOPATHY IN ADULTS WITH CONGENITAL HEART DISEASE PREDICTORS AND PROGNOSIS OF THE POST PERICARDIOTOMY SYNDROME J.M. Kuijpers (AMC, Amsterdam); D.R. Koolbergen (AMC, Amsterdam); M. Groenink (AMC, Amsterdam); S.M. Boekholdt (AMC, Amsterdam); B.J.M. Mulder (AMC, Amsterdam); B.J. Bouma (AMC Amsterdam) D. van Osch (University Medical Center Utrecht, Utrecht); J.M. Dieleman (University Medical Center Utrecht, Utrecht); J.J.H. Bunge (Erasmus Medical Center, Rotterdam); D. van Dijk (University Medical Center Utrecht, Utrecht); P.A.F.M. Doevendans (University Medical Center Utrecht, Utrecht); W.J.L. Suyker (University Medical Center Utrecht, Utrecht); H.M. Nathoe (University Medical Center Utrecht, Utrecht) Purpose: Proximal aortic dilatation is frequently found in adults with bicuspid aortic valve (BAV), aortic coarctation with/without BAV (CoA-BAV/CoA), tetralogy of Fallot (ToF) and transposition of the great arteries (TGA). We aimed to prospectively determine the contemporary risk of aortic dissection, and effect of aortic replacement on prognosis in these patients. Methods: All patients with a native proximal (neo-)aorta and a main diagnosis of BAV (n=1378), CoABAV (n=617), CoA (n=849), ToF (n=1179) or TGA (n=593) were selected from the CONCOR database. Incidence of aortic dissection (cases/person-time lived with native proximal aorta) was calculated using Poisson regression. Survival was calculated using the KaplanMeier estimator, with time of inclusion (non-operated group) or time of aortic replacement in follow-up (operated group) as time zero. Purpose: Post Pericardiotomy Syndrome (PPS) is associated with short-term adverse events, however the long-term prognosis and predictors of PPS are largely unknown. Methods: We performed a cohort study in 822 patients undergoing valve surgery. Possible predictors of PPS were evaluated using multivariable logistic regression analysis. We also compared the incidence of reoperation for tamponade at one year between patients with and without PPS. Main secondary outcomes were hospital stay, mortality and quality of life. Results: During 28881 person-years in 4616 patients (61.4% male, median age 31.6years), 5 aortic dissections occurred (incidence rate=1.73/10.000person-years;95%CI,0.62-3.72); CoA, 2 cases (3.99;0.66-12.31); CoA-BAV, 1 (2.36;0.13-10.40); BAV, 1 (1.66;0.09-7.32); TGA, 1 (2.27;0.13-10.00). No dissections occurred in ToF patients. Three dissections were lethal (60%). During follow-up, 121 native proximal aortic replacements occurred (BAV,82; CoABAV,20; ToF,11; CoA,5; TGA,3), with 1 death <30days after surgery (0.83%). The Figure shows ten-year survival after proximal aortic replacement was similar to that of unoperated patients. Results: Of the 822 patients, 119 (14.5%) developed PPS. A higher Body Mass Index (BMI) (OR per point increase: 0.93, 95% CI 0.88-0.99) and preoperative corticosteroid use (OR 0.15, 95% CI 0.04-0.53) decreased the risk of PPS, whereas preoperative treatment for pulmonary disease increased the risk of PPS (OR 2.86, 95% CI 1.44-5.68). The incidence of reoperation for tamponade at one year in PPS versus no PPS was 20.2% versus 2.4% (OR 14.26, 95% CI 6.88-29.56), with all rethoracotomies taking place within the first 2 months. One year mortality in PPS versus no PPS was 3.4% versus 5.3% (OR 0.69, 95% CI 0.232.08). Median hospital stay was 13 days (IQR 9-18) versus 11 days (IQR 8-15) (p<0.001), respectively. Quality of life at 1 year did not differ significantly between the two groups (p=0.343). Conclusions: In contemporary practice, reflecting current guidelines for prophylactic aortic replacement, the risk of aortic dissection in adults with predisposing CHD is low. Proximal aortic replacement is associated with low peri-operative mortality and good long-term outcome in these patients. Conclusion: Despite of a longer hospital stay and more rethoracotomies, patients with PPS had an excellent long-term prognosis and quality of life. A higher BMI and preoperative corticosteroid use decreased the risk of PPS, whereas treated pulmonary disease increased the risk of PPS. Figure. Adults with CHD predisposing to aortopathy: survival after proximal aortic replacement versus that of patients with a native proximal aorta Figure 1. Survival free of rethoracotomy for tamponade LONG-TERM MORTALITY AND MORBIDITY IN PATIENTS AFTER PERCUTANEOUS MITRAL VALVE REPAIR J.F. Velu (Academisch Medisch Centrum, Amsterdam), B.J. Bouma (Academisch Medisch Centrum, Amsterdam), J. Baan (Academisch Medisch Centrum, Amsterdam) Purpose: High-risk patients suffering from Mitral Regurgitation (MR) can be treated by a percutaneous mitral valve repair with the MitraClip. Long-term mortality and morbidity after a MitraClip treatment has not been extensively investigated yet. However, knowledge about long-term follow-up is required to assess the sustainability of the outcome after percutaneous mitral valve repair in order to improve clinical decision making. Methods: The mortality of patients treated with a MitraClip was analyzed. The morbidity was quantified with the NYHA classification and MR grade at baseline and during follow-up. A riskmodel for mortality was developed to improve clinical decision making. Results: 140 patients received a MitraClip in the Academic Medical Center Amsterdam (AMC), the Netherlands. Mean age was 75 years, 54% was male and 30% had a poor LV function (<30%). The cumulative mortality was 4% after 30 days, 20% after 1 year and 58% after 5 years. The 1-year mortality of patients with severe MR is 57%, if left untreated. At baseline, 81% of the patients were classified in NHYA class > III/IV and 96% had MR grade ≥ 3. During follow-up, 27% were classified in NHYA class > II/IV and 36% had MR grade ≥ 3. Patients with NYHA class IV, NT-proBNP levels >5000 ng/L, creatinine >200 µmol/L, previous valve surgery or TR grade ≥ 3 prior to MitraClip had significantly higher mortality rates in multivariate analysis. 10 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 10 Conclusion: The cumulative mortality is 58% after 5 years. The founded predictors may improve clinical decisions making in order to optimize patient selection. Table 1 Predictors for 5-year survival in univariate and multivariate analysis (Cox model). Outcome Age > 80 years Univariate analysis Multivariate analysis n Death, % HR p-value HR 59 41 1.4 0.266 LVEF <30% 42 36 1.0 0.925 Functional etiology 89 38 1.0 0.942 NYHA class IV 18 56 2.3 0.017 2.4 p-value 0.020 NT-proBNP >5000ng/L 25 52 2.8 0.002 2.5 0.011 Creatinine >200 µmol/L 13 69 3.1 0.003 2.5 0.034 Previous valve surgery 13 77 4.0 <0.001 4.0 0.001 TR > grade 2 36 47 2.1 0.014 2.2 0.012 HR: hazard ratio; LEVEF: left ventricular ejection fraction; NYHA: New York Heart Association; TR: tricuspid regurgitation Netherlands Heart Journal, Volume 24, Supplement, April 2016 09-03-16 10:40 Abstracts Session IV: Valvular and aortic disease (continued) Session V: Heart failure/ Coronary artery disease FILTER BASED CEREBRAL EMBOLIC PROTECTION WITH TRANSCATHETER AORTIC VALVE IMPLANTATION: THE RANDOMIZED MISTRAL-C TRIAL STRUCTURED CARDIAC RESYNCHRONISATION THERAPY PATHWAY BASED ON LEAN SIX SIGMA METHODOLOGY; A FIRST EVALUATION OF OPERATIONAL OUTCOMES N.M. Van Mieghem (Erasmus MC, Rotterdam); L. van Gils (Erasmus MC, Rotterdam); H. Ahmad (Erasmus MC, Rotterdam); F. van Kesteren (AMC, Amsterdam), H.W. van der Werf (UMC Groningen); G. Brueren (Catharina Ziekenhuis, Eindhoven); M. Storm (Erasmus MC, Rotterdam); M. Lenzen (Erasmus MC, Rotterdam); J. Daemen (Erasmus MC, Rotterdam); A.F.M. van den Heuvel (UMC Groningen); P. Tonino (Catharina Ziekenhuis, Eindhoven); J. Baan (AMC, Amsterdam); P.J. Koudstaal (Erasmus MC, Rotterdam); M.E.I. Schipper (Erasmus MC, Rotterdam); A. van der Lugt (Erasmus MC, Rotterdam); P.P.T. De Jaegere (Erasmus MC, Rotterdam) A.M.W. van Stipdonk (MUMC+, Maastricht), A. Rao (Liverpool heart and chest hospital, Liverpool), R. Videbaek (Rigshospitalet, Copenhagen), Helen H Petersen (Rigshospitalet, Copenhagen), C. Knackstedt (MUMC+, Maastricht), I. A. Colin (Medtronic, Tolochenaz), J.M. Morgan (Southampton University Hospitals, Southampton), W. Mullens (Ziekenhuis Oost-Limburg, Genk), K. Vernooy (MUMC+, Maastricht)J12 Purpose: To determine whether use of the filter-based Sentinel Cerebral Protection System (CPS)™ during transcatheter aortic valve implantation (TAVI) can affect the early incidence of new brain lesions as assessed by diffusion-weighted magnetic resonance imaging (DW-MRI) and neurocognitive performance. Methods: From January 2013 to July 2015 65 patients were randomized 1:1 to transfemoral TAVI with or without the Sentinel CPS at four Dutch centers. Patients underwent a DW-MRI scan and extensive neurological examination including neurocognitive testing by study blinded neuro-radiologists and neurology specialists one day before and five to seven days after TAVI. Results: Follow up DW-MRI and neurocognitive testing was completed in 57% and 80% respectively. New brain lesions were found in 78% of patients with follow up MRI. Patients with Sentinel CPS had numerically less new lesions and a smaller total lesion volume (95 mm3 (IQR 10 – 257) vs. 197 mm3 (95 – 525). Overall 27% of Sentinel CPS patients and 13% of control patients had no new lesions. Ten or more new brain lesions were found only in the control cohort (in 20% vs. 0% in the Sentinel CPS cohort, p=0,03). Neurocognitive deterioration was present in 4% of patients with Sentinel CPS vs. 27% in patients without (p = 0.017). Thrombotic and tissue derived debris was present in 87% and 100% of patients with Sentinel CPS protection. Conclusion: Filter-based embolic protection with the Sentinel CPS captures debris en route to the brain in all patients undergoing TAVI. Its use results in less and overall smaller new brain lesions by MRI and preserves early postoperative neurocognitive performance. Purpose: Cardiac resynchronisation therapy (CRT) reduces mortality and morbidity in specific heart failure patients. Care for these patients is complex and puts a significant burden on health care resources. Care pathways are increasingly used to structure complex interventions; supporting evidence based medicine, as well as optimizing resource utilisation. Objective of this study is to design and implement a structured care. Methods: To design and implement a care pathway in the Maastricht University Medical Centre (MUMC+) we used Lean Six Sigma methodology. After evaluating current, usual care (UC) and comparing it to an expert consensus based best practice care pathway, UC processes were mapped and caveats were identified. Then a stepwise implementation of care pathway processes (Figure 1.) was performed with the help of standardized aides (checklists). Results: A total of 101 patients were included in this analyses. Referral-to-treatment time was reduced from 64 to 51 days (p=ns) and the number of pre-implantation consultations was reduced from 1.8 to 1.6 (p=ns). Though implementation of the pathway was only 60%. When excluding patients not treated accordingly, number of pre-implantation consultations were further reduced to 1.4 (p=0.03). Length of in-patient stay was reduced from 2.1 to 1.2 days (p<0.0001) Conclusion: This study shows the feasibility of the design and implementation of a structured CRT care pathway. Preliminary results show significant improvement of organisational outcomes. Figure 1. Process overview in CRT care pathway. Summarizing processes for Usual Care and Care after implementation of the CRT care pathway. INCREASED REFERRAL OF STABLE HEART FAILURE TO PRIMARY CARE IN THE CONNECT HEART FAILURE PROGRAM M Niesing-Lut (Alrijne Zorggroep, Leiderdorp); P. van Pol (Alrijne Zorggroep, Leiderdorp); J. Eysink Smeets (Lupine praktijk, Alphen a/d Rijn), A. van Haarlem (Alrijne Zorggroep, Leiderdorp), J. Flaman (Alrijne Zorggroep, Leiderdorp), C. Lucas (Alrijne Zorggroep, Leiderdorp) Purpose: The Connect Heart Failure Program has recently started in the Netherlands. Major goal of this program is to optimize shared care for heart failure patients between primary and secondary/tertiary care. One of the goals is to refer stable heart failure (HF) patients back to primary care. The first region where the program is running is the region of Alphen a/d Rijn, which is connected to the Alrijne Hospital where since 2000 a dedicated outpatient HF clinic has been available. Methods: Comparison was made between number of stable patients being referred back to primary care before and after the connect program was started in this region. Furthermore follow-up data of these patients after referral have been collected. Results: From 2000 until 2013 heart failure care responsibility was taken by primary care for 100 HF patients. In 2014 and 2015 when the new program was running, 74 patients in total were discharged from the outpatient clinic to the general practitioner. Five because of recovered myocardial function, 22 because of stable heart failure, 13 for end-stage heart failure, 22 because of frailty, 12 for other reasons. Sixteen patients of this 74 deceased, 3 were re-hospitalized for recurrent heart failure. None of the remaining 55 patients have been sent back to the HF outpatient clinic. Conclusion: Application of the Connect heart failure program results in increased referral of HF patients to primary care so far in short-term not resulting in readmissions or referral back to secondary care. Long-term follow-up data will be collected. Netherlands Heart Journal, Volume 24, Supplement, April 2016 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 11 11 09-03-16 10:40 Abstracts Session V: Heart failure/ Coronary artery disease (continued) QRS FRAGMENTATION IS ASSOCIATED WITH RIGHT VENTRICULAR FAILURE IN ADULTS WITH TETRALOGY OF FALLOT IMPROVEMENT OF LONG-TERM SURVIVAL OVER TIME IN PATIENTS WITH ACUTE HEART FAILURE: DATA FROM THE PERIOD 1985-2008 J.P. Bokma (Academisch Medisch Centrum, Amsterdam); M.M. Winter (Academisch Medisch Centrum, Amsterdam); K.C. de Wilde (Academisch Medisch Centrum, Amsterdam); H.W. Vliegen (Universitair Medisch Centrum, Leiden); M. Groenink (Academisch Medisch Centrum, Amsterdam); B.J.M. Mulder (Academisch Medisch Centrum, Amsterdam); B.J. Bouma (Academisch Medisch Centrum, Amsterdam) J.C. van den Berge (Erasmus MC, Rotterdam); K.M. Akkerhuis (Erasmus MC, Rotterdam); A.A. Constantinescu (Erasmus MC, Rotterdam); J.A. Kors (Erasmus MC, Rotterdam); R.T. van Domburg (Erasmus MC, Rotterdam); J.W. Deckers (Erasmus MC, Rotterdam) Purpose: Limited data is available to identify tetralogy of Fallot (TOF) patients at risk for right ventricular (RV) function deterioration and subsequent heart failure. Recently, fragmentation of QRS complexes (fQRS) was related to regional RV fibrosis and all-cause mortality. Our objective was to determine whether fQRS was associated with RV failure. Methods: This dual center study included all adult TOF patients with two cardiovascular magnetic resonance (CMR) investigations from the Concor registry. Notches in the QRS complex in ≥2 contiguous leads on standard 12-lead electrocardiograms (ECG), not related to right bundle branch block, were defined as fQRS. Extent of fQRS was classified as none, moderate (≤4 leads) or severe (≥5 leads). The change in RV ejection fraction (EF) between first and second CMR (3.3±1.8 years later) was calculated. Results: A total of 175 TOF patients (age at inclusion: 33±11 years, 51% male) were included. The extent of fQRS at inclusion was classified as none in 55% of patients, moderate in 32% and severe in 13%. Baseline RV EF was 47±10%. The number of fQRS leads was negatively correlated with baseline RV EF (R=-0.24, p=0.002). Average change in RV EF was +0.4±8.8%. After correction for baseline RV EF, fQRS extent was associated with RV EF deterioration (β=-2.2%/class, p=0.004). Furthermore, fQRS extent was associated with increasing odds for RV EF<35% at follow-up CMR (OR:2.97/class, p=0.006). Conclusion: In adult TOF patients, fQRS extent was associated with progressive RV dysfunction. These findings may improve selection of patients for therapy to prevent heart failure. Purpose: Acute heart failure (AHF) has a poor prognosis. However, limited data is available regarding their long-term mortality. We investigated the trends in short- and long-term mortality of AHF patients in the period 1985 thru 2008. We also determined the influence of major prognostic factors. Methods: In this prospective consecutive registry, we included patients admitted for AHF at the Intensive Coronary Care Unit of our tertiary referral hospital in the period of 1985 until 2008. Patients were classified into four aetiology categories: ischemic cardiomyopathy, other cardiomyopathy, valvular heart disease, and other/unknown. The time window was split up in periods of 1985-1989, 1990-1999 and 2000-2008. Results: We identified 1810 patients (age 64 years, 64% male). The overall cumulative mortality at one and ten years was respectively 32% and 73%. In the last decade, the number of patients with a history of coronary revascularization therapy and diabetes increased significantly. Mortality was lowest in the last decade (Figure). Compared to valvular heart disease, ischemic cardiomyopathy was associated with a higher mortality (HR 1.22; 95% CI 1.041.30). Other parameters associated with poor outcome were advanced age (HR 1.027; 95% CI 1.023-1.032), male sex (HR 1.27; 95% CI 1.13-1.42), previous heart failure (HR 1.57; 95% CI 1.41-1.75), and diabetes (HR 1.19; 95% CI 1.05-1.36). Conclusion: Patients admitted with AHF continue to have very high short- as well as long-term mortality. However, their prognosis has improved in the last decade. Patients with AHF due to ischemic cause has the worst outcome. Figuur. Kaplan-Meier Figure 1: Leads V2 and V3 of an ECG in a tetralogy of Fallot patient (1A) with a wide right bundle branch block and evident fragmentation (arrows) of the QRS complexes compared to a tetralogy of Fallot patient (1B) with a wide right bundle branch block without fragmentation of QRS complexes. MECHANICAL CIRCULATORY SUPPORT (MCS) IN THE NETHERLANDS: LONG TERM RESULTS FROM THE UNIVERSITY MEDICAL CENTER UTRECHT (UMCU) SERIAL MEASURES OF CLINICAL PARAMETERS PREDICT PROGNOSIS IN PAH-CHD M.T.U. Schuijt (AMC, Amsterdam); I.M. Blok (AMC, Amsterdam/NHI, Utrecht); A.C.M.J. van Riel (AMC, Amsterdam/NHI, Utrecht); A.H. Zwinderman (AMC Amsterdam); B.J.M. Mulder (AMC, Amsterdam/NHI, Utrecht); B.J. Bouma (AMC, Amsterdam). Purpose: Adult patients with pulmonary arterial hypertension due to congenital heart disease (PAHCHD) suffer from a high mortality. This underlines the importance of adequate risk stratification to guide treatment decisions. Several cross-sectional clinical variables have been associated with mortality, but nowadays longer follow-up is available. Therefore we investigated the prognostic relevance of serial measurements in patients with PAH-CHD. Methods: In this prospective observational cohort study, we included consecutive adult patients with PAH-CHD between 2005 and 2015. Control visits on the outpatient clinic were standardised, including WHO functional class (WHO-FC), six-minute walk distance (6-MWD) and NT-proBNP. All patients were treated with bosentan following the first visit. We evaluated prognosis of PAH-CHD patients who met the following criteria: first time worsening to WHO-FC 4, a 6-MWD decrease of 25 meters and an NT-pro-BNP increase of 200 ng/L during follow-up. Results: Sixty-six patients with PAH-CHD were included (mean age 44 years, 33% male, 33% Down, 71% Eisenmenger). During a mean follow-up of 5.5 years (SD 3.2), 21 patients died (32%). In our risk stratification model during follow-up (Figure 1), worsening to WHO-FC 4 occurred in 10 patients, a 6-MWD decrease of 25 meters in 47 patients and an NT-pro-BNP increase of 200 ng/L in 33 patients. The time from onset of these criteria until 25% of patients died, differed between WHO-FC (0.08 yrs), 6-MWD (4.5 yrs) and NT-pro-BNP (2.1 yrs). Conclusion: Serial measurements of WHO-FC, 6-MWD and NT-pro-BNP during semi-annual control visits, each have specific implications for the prognosis. Figure 1. Prognosis of PAH-CHD patients based on serial measures of clinical status 12 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 12 S.E.A. Felix (UMC Utrecht, Utrecht); F.Z. Ramjankhan (UMC Utrecht, Utrecht); F.de Heer (UMC Utrecht, Utrecht); M.P. Buijsrogge (UMC Utrecht, Utrecht); W.J.L. Suyker (UMC Utrecht, Utrecht); N. Hulstein (UMC Utrecht, Utrecht); C. Klöpping (UMC Utrecht, Utrecht); J.H. Kirkels (UMC Utrecht, Utrecht); P.A. Doevendans (UMC Utrecht, Utrecht); N. de Jonge (UMC Utrecht, Utrecht). Purpose: MCS improves survival and quality of life in selected patients with end-stage heart failure, refractory to medical therapy. Currently, Heartmate II (HM-II)®, Heartmate 3 (St.Jude Medical) and HVAD® (HeartWare) are most widely used MCS devices. In the Netherlands, the waiting list for heart transplantation increases as a result of shortage of donor hearts. Consequently, experience is built on longer term support, of which our single center results are presented. Methods: Data of all patients who received MCS between March 2006 and January 2016 were prospectively collected in a database. It includes baseline clinical characteristics as well as complications defined according to INTERMACS. Data were extracted to SAS for statistical analysis. Results: In the UMCU 203 patients received MCS (160 HM-II, 2 HM 3 and 41 HVAD). Heart transplantation was performed in 67 patients and in 7 patients MCS was explanted. Actuarial survival at 5 years is 68%. Death was most often caused by neurological complications and sepsis. Gastro-intestinal bleeding and intracerebral complications (hemorrhage and stroke) both occurred 0.15 times per patient year. Twenty-seven replacements were performed, most often due to pump thrombosis or driveline problems. Conclusion: 5-year survival in MCS patients is 68%. It is a promising therapy that might be a good alternative for heart transplantation in selected patients. However, further optimization of therapy by technical improvements, as well as management of long term complications is required. Figure 1. Kaplan Meier survival curve Netherlands Heart Journal, Volume 24, Supplement, April 2016 09-03-16 10:40 Abstracts Session V: Heart failure/ Coronary artery disease Session VI: General Cardiology (continued) PROGNOSTIC VALUE OF N-TERMINAL PRO-B-TYPE NATRIURETIC PEPTIDE IN ADULTS WITH CONGENITAL HEART DISEASE BNP CONCENTRATIONS AFTER PROLONGED MODERATE-INTENSITY EXERCISE IN INDIVIDUALS WITH CARDIOVASCULAR DISEASE AND RISK FACTORS V.J.M. Baggen (Erasmus MC, Rotterdam); A.E. van den Bosch (Erasmus MC, Rotterdam); J.A. Eindhoven (Erasmus MC, Rotterdam); J.A.A.E. Cuypers (Erasmus MC, Rotterdam); M. Witsenburg (Erasmus MC, Rotterdam); M. de Waart (Erasmus MC, Rotterdam); E. Boersma (Erasmus MC, Rotterdam); J.W. Roos-Hesselink (Erasmus MC, Rotterdam). V.L. Aengevaeren (Radboudumc, Nijmegen); M.T.E. Hopman (Radboudumc, Nijmegen); MJ de Boer (Radboudumc, Nijmegen); D.H.J. Thijssen (Radboudumc, Nijmegen; LJMU, Liverpool); T.M.H. Eijsvogels (Radboudumc, Nijmegen; LJMU, Liverpool) Purpose: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is related to echocardiographic measurements and exercise capacity in adults with congenital heart disease (CHD). Followup data are yet very limited in this patient group. This study aims to investigate the association between NT-proBNP and adverse outcomes in adults with CHD. Methods: In this prospective cohort study, consecutive stable adults with CHD who visited the outpatient clinic between April 2011 and April 2013 underwent NT-proBNP level measurement and extensive echocardiography. Multivariable Cox proportional hazards regression was performed to identify associations with clinical outcome events, independently of age, sex and systemic ventricular function. Results: We included 602 patients (median age 32 [IQR 25-41] years, 58% male, 90% NYHA class I): congenital aortic stenosis (n=138), aortic coarctation (n=112), arterial switch operation (n=24), tetralogy of Fallot (n=179), Mustard operation (n=65), congenitally corrected transposition of the great arteries (n=21), Fontan (n=36) or other (n=27). Patients were followed-up during a median of 3.5 [IQR 3.0-3.8] years. In multivariable analysis, a two-fold increase in NT-proBNP was independently related to an increased risk of death (n=12, HR 2.68 [95%CI 1.54-4.67], p=0.001), hospitalization for cardiac reasons (n=125, HR 1.74 [95%CI 1.52-2.00], p<0.001), heart failure (n=46, HR 2.23 [95%CI 1.75-2.85], p<0.001), arrhythmia (n=90, HR 1.52 [95%CI 1.30-1.77], p<0.001) and re-intervention (n=89, HR 1.68 [95%CI 1.44-1.96], p<0.001). Conclusion: NT-proBNP measured on a single random moment in the clinical course of adults with CHD is strongly associated with adverse outcomes, independently of age, sex and systemic ventricular function. Figure 1 Kaplan-Meier curves demonstrating the heart failure-free survival (A) and event-free survival (B) according to quartiles of NT-proBNP. Per two-fold increase in NT-proBNP the risk of death or heart failure (n=50, HR 2.18 [95%CI 1.73-2.74], p<0.001) and any adverse event (n=165, HR 1.55 [95%CI 1.38-1.75], p<0.001) significantly increased. MARKED GENDER DIFFERENCES IN THE PREDICTIVE VALUE OF THE HEART SCORE FOR MAJOR ADVERSE CARDIAC EVENTS IN PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH ACUTE CHEST PAIN I.E.M. Bank (UMC Utrecht); V.C. de Hoog (UMC Utrecht); D.P.V. de Kleijn (UMC Utrecht & NUS, Singapore); G.P. Pasterkamp (UMC Utrecht); H.M. den Ruijter (UMC Utrecht); P.A.F. Doevendans (UMC Utrecht); T.X. Wildbergh (Meander MC, Amersfoort); A. Mosterd (Meander MC, Amersfoort); L. Timmers (UMC Utrecht) Purpose: BNP concentrations are known to increase in athletes performing prolonged exercise, but whether this also occurs in less-trained individuals with cardiovascular diseases (CVD) or risk factors (CVRF) performing prolonged exercise is unknown. Therefore, we aimed to determine BNP concentrations in rest and after four consecutive days of 30-50 km/day walking exercise in participants with CVD, CVR and healthy controls. Furthermore, we aimed to identify predictors of the exercise-induced increase in BNP. Methods: Serum BNP concentrations were measured in 203 participants (60±1 yrs) of the Nijmegen Marches before (baseline) and immediately after each walking day. We selected age, gender, height, weight, BMI, CVD, CVRF, exercise duration, distance, intensity, walking speed and baseline BNP as potential predictors for ΔBNP and post-exercise BNP. Results: Participants walked 484±6 min/day at 65±1% of their maximum heart rate (Table 1). Baseline BNP levels were higher for CVD participants compared to CVRF participants and controls. BNP increased from 19.5±2.1 to 23.4±2.7 pg/ml post-exercise (p = 0.002), whilst no cumulative effect was observed across days (p=0.22). Comparing the 3 groups, postexercise BNP concentrations were elevated in CVD participants (p = 0.003), but not in CVRF participants (p=0.06) or controls (p=0.15). Predictors for ΔBNP (R2=0.15) and post-exercise BNP (R2=0.77) were baseline BNP, history of CVD and age. Conclusion: Moderate-intensity walking exercise increases BNP concentrations in subjects with CVD, but not in subjects with CVRF or healthy controls. 77% of post-exercise BNP and 15% of ΔBNP concentrations could be predicted using baseline BNP, history of CVD and age. Table 1 Cohort characteristics Total CVD CVRF Controls N 203 63 45 95 P-Value Age, years 60.2±0.8 65.9±1.0*† 61.3±1.3† 55.9±1.3 .000 Gender Male, n(%) 132 (65) 57 (91) *† 32 (71) † 43 (45) .000 Female, n(%) 71 (35) 6 (9) 13 (29) 52 (55) Height, cm 175±0.6 177±0.9 175±1.3 173±0.9 Weight, kg 78.1±1.0 83.6±1.7† 82.2±2.3† 72.6±1.3 BMI, kg/m2 25.5±0.3 26.6±0.5† 26.6±0.6† 24.2±0.3 .000 Walking distance, km 36.6±0.5 33.7±0.7*† 37.6±1.1 38.1±0.6 .000 Walking duration, min 484±6 465±7† 493±15 493±8 NS Walking speed, km/h 4.6±0.1 4.4±0.1† 4.7±0.1 4.7±0.1 .02 Baseline BNP, pg/mL 19.5±2.1 40.2±5.6*† 12.2±2.3 9.3±1.2 .000 BNP post-ex day 1, pg/mL 23.4±2.7 49.5±7.1 15.6±3.0 10.0±1.3 .000 BNP post-ex day 2, pg/mL BNP post-ex day 3, pg/mL † *† .004 .000 24.6±2.9 53.2±7.9 *† 15.2±2.7 10.2±1.4 .000 24.2±2.8 50.8±7.4*† 14.3±2.7 11.2±1.4 .000 BNP post-ex day 4, pg/mL 23.6±2.5 46.9±6.4*† 16.0±3.0 12.1±1.5 .000 HR/max HR, % 64.9±0.7 60.4±1.3*† 66.6±1.4 67.0±0.9 .000 † Data are presented as mean±SEM; BNP data were ln-transformed for analyses. CVD = cardiovascular disease, BMI = body mass index, ex = exercise, HR = heart rate * = significantly different from CVRF group, †= significant different from controls Purpose: The HEART score is a simple and effective tool to exclude short-term major adverse cardiac events (MACE) in patients presenting to the emergency department (ED) with acute chest pain. As it is suggested that diagnosing ischemic heart disease is more difficult in women than men, we evaluated the performance of the HEART score in men vs. women. Methods: The HEART score was assessed retrospectively in 1927 patients presenting with acute chest pain to the ED (MINERVA cohort, n=1093 men and n= 834 women), assigning them to a low, intermediate, or high risk category. Primary outcome was the occurrence of MACE, defined as myocardial infarction, coronary revascularization or all-cause death, within 6 weeks. Results: Compared to women, men were less frequently assigned to the low risk category (34.2% vs 40.4%, p=0.006, HEART score 0-3), and more frequently assigned to the high risk category (8.0% vs 3.8%, p<0.001, HEART score 7-10). The incidence of MACE was two times higher in men than in women (10.0 vs 20.6%, p<0.001). Within each HEART risk category, the MACE incidence was significantly higher in men as compared to women. (Figure 1) The c-statistic for the HEART score was similar across sexes. However, the negative predictive value of a low HEART score (proposed policy: early discharge) was 93.6% in men vs. 97.9% in women (p<0.008). Conclusion: The HEART score is less accurate and less efficient in ruling out MACE (without additional testing) in men than women who present to the ED with acute chest pain. Figure 1. Incidence of MACE in men and women within the HEART score risk groups Netherlands Heart Journal, Volume 24, Supplement, April 2016 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 13 13 09-03-16 10:40 Abstracts Session VI: General Cardiology (continued) VALIDATION OF THE PSYCHOSOCIAL SCREENING INSTRUMENT OF THE EUROPEAN SOCIETY OF CARDIOLOGY E. van Montfort (Tilburg University, Tilburg); J. Denollet (Tilburg University, Tilburg); J. Widdershoven (Elisabeth-TweeSteden ziekenhuis, Tilburg); N. Kupper (Tilburg University, Tilburg) Purpose: Examining the validity of the European Society of Cardiology’s’ psychosocial screening instrument. Methods: 508 (sub-)acute (67%) or elective (33%) percutaneous coronary intervention (PCI) patients administered the 15-item ESC screening interview and established self-report questionnaires for reputable psychosocial risk markers, i.e. depression (PHQ-9), anxiety (GAD-7) and Type D personality (DS14) during or close after hospital admission (n=353366; 63±10 years; 79% male). Results: Factor Analysis identified five components: emotional distress, work stress, hostility, social resources and social stress. Chi-square tests revealed high true negative rates for anxiety (95%) and depression (92%), indicating consistent absence of anxiety and depression on both screener and questionnaire. True positive scores were lower, indicating that respectively 43% and 70% of patients scoring above the clinical threshold for anxiety and depression were identified by the screener. For negative affectivity and social inhibition true negative rates were 76% and 72%. From participants reporting negative affectivity, the screener identified 74%. For social inhibition, this was 48%. Screening results were hardly affected by PCI indication (elective vs. (sub-)acute). Conclusion: The ESC screener is helpful as an early stage detector of emotional distress in both elective and (sub-) acute PCI patients. It can be used in the clinic to make a first subdivision of cardiac patients who may need psychosocial help and patients who do not need additional psychosocial care. Lower true positive scores indicate that more in-depth diagnostic assessment is needed as a second step. Future research is necessary for further validation of the other psychosocial screening components. Table 1. Rotated component matrix for ESC screener components Items I.M. van Hagen (Erasmus MC, Rotterdam); M.R. Johnson (Imperial College School of Medicine, Chelsea and Westminster Hospital, London, UK); R. Hall (Norwich Medical School, University of East Anglia, Norwich, UK); J.W. Roos-Hesselink (Erasmus MC, Rotterdam). Purpose: Maternal cardiovascular disease is known to be associated with increased risks of obstetric and fetal adverse events. During preconception counselling it is important to recognize women at highest risk. We aimed to validate the modified WHO classification and also studied the underlying diagnoses and clinical parameters for prediction of separate events. Methods: ROPAC is a worldwide ongoing prospective registry that has enrolled 2966 pregnancies from January 2008 up to April 2014. The majority (2742 women) had a pre-pregnancy diagnosis of structural heart disease and were included in this analysis. Results: Mean age was 28.2±5.5 years, 45% were nulliparous and 66.6% came from developed countries. Diagnoses included congenital heart disease (CHD 58.2%), valvular heart disease (31.4%), cardiomyopathy (5.9%), ischemic heart disease (0.6%), aortopathy (3.7%) and pulmonary hypertension (0.3%). Obstetric events occurred in 8.4% of women. Offspring events occurred in 23.7% of pregnancies. The modified WHO classification had a poor performance for obstetric events (c-statistic=0.596) and offspring events (c-statistic=0.561). Multivariable analysis of separate endpoints were performed to provide more insights (Figure 1). Aortic valve disease was associated with pre-eclamptic toxaemia. CHD was associated with spontaneous preterm birth. Complex CHD was associated with small-for-gestational-age offspring. Conclusion: In our study the modified WHO classification was a poor predictor of obstetric and offspring events. Maternal complex CHD was independently associated with fetal growth restriction, while in aortic valve disease there was a higher rate of pre-eclamptic toxaemia. Pathophysiological mechanisms of these associations are to be elucidated. Figure 1 Multivariable analysis: predictors of obstetric outcome Components 1 Negative affectivity .71 Depression: mood .71 Anxiety: worry .60 Depression: anhedonia .58 Anxiety: tension .54 2 4 5 .46 .79 .78 .58 Hostility: other people .81 Hostility: other things .81 Relationship: problems .80 Relationship: confidant .61 .36 Social: living alone .79 Social: highest education .67 Social inhibition 6 .38 Work: control demands .35 3 .46 Work: physical Work: reward vs. effort PREDICTORS OF OBSTETRIC AND OFFSPRING COMPLICATIONS IN WOMEN WITH HEART DISEASE: DATA FROM THE REGISTRY OF PREGNANCY AND CARDIAC DISEASE .85 RETROSPECTIVE ANALYZE OF CARDIOVASCULAR DISEASES IN A WOMEN OUTPATIENT CLINIC IN OLVG WEST C.A.M. Sijtsema (OLVG West, Amsterdam); B. Torensma (OLVG West, Amsterdam) J.M. Schroeder-Tanka (OLVG West, Amsterdam) Purpose: Cardiovascular diseases are the number one cause of death for women. In previous years women were underrepresented in many cardiovascular clinical trials. However recent studies show gender- differences in clinic presentation, pathophysiology, risk factors and diagnostics of cardiovascular diseases. In the Netherlands cardiological outpatient clinics are developed especially for women. The aim of this study was to sketch a profile of the women who visited the women outpatient clinic in OLVG West. Methods: This study concerned a retrospective analysis of 123 pre and post-menopausal patients between 45-65 years old with or without cardiovascular diseases. The study included patients with possible cardiovascular complaints and/or cardiovascular risk factors. Data was obtained through electronic patients files and a questionnaire filled in by the patients. Results: Results showed that 42,5% of the women suffered cardiovascular diseases. The complaint ‘chest pain’ was the most common complaint (66,7%), followed by ‘dyspnoe d’effort’ (58,5%) and ‘palpitations’ (50,4%). Four complaints was the most common (33,3%). There was a significant deviation of SBP (>140mmHg), abnormal ECG results and a history of cardiac diseases in women with cardiovascular disease. Regression analysis showed an increased risk of cardiovascular diseases by continue SBP (OR1,033) and a history of cardiac diseases (OR 5,631). Conclusion: This study showed similar to higher rates of diagnoses, compared with previous studies, suggesting that the women output clinic has been effective and representative. In the future, well conducted studies with significance variables are required to improve the prevention and the clinical management of cardiovascular diseases in women. 14 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 14 Netherlands Heart Journal, Volume 24, Supplement, April 2016 09-03-16 10:40 Abstracts Session VI: General Cardiology (continued) THE BENEFICIAL EFFECT OF BOSENTAN AND MACITENTAN IN CONGENITAL HEART DISEASE PATIENTS: ARE THE OUTCOMES COMPARABLE? I.M. Blok (AMC, Amsterdam/NHI, Utrecht); A.C.M.J. van Riel (AMC, Amsterdam/NHI, Utrecht); A.P.J. van Dijk (Radboud UMC, Nijmegen); B.J.M. Mulder (AMC, Amsterdam/NHI, Utrecht); B.J. Bouma (AMC, Amsterdam). Background: Macitentan, a novel endothelin receptor antagonist and successor of the widely applied bosentan, improves WHO functional class (WHO-FC) and six-minute walk distance (6-MWD) of patients with pulmonary arterial hypertension due to congenital heart disease (PAHCHD). The initial treatment effect of macitentan in therapy naïve PAH-CHD patients has never been compared to that of bosentan. Methods: Consecutive new PAH-therapy naïve PAH-CHD patients were started on macitentan 10 mg once daily. This cohort was compared to our historical cohort of therapy naïve patients starting bosentan between 2005-2013. All patients underwent standardized follow-up including determination of WHO-FC, NT-pro-BNP and 6-MWD. Change in variables between baseline and six months follow-up was compared between bosentan and macitentan starters with chi square statistics, and Mann-Whitney U test. Results: Six PAH-CHD patients (mean age 37 years, 33% male, 17% Down syndrome, 100% Eisenmenger syndrome) started macitentan. They were matched with a historical cohort of 12 PAH-CHD patients who started bosentan, based on age, sex, Down syndrome, baseline NT-pro-BNP, WHO-FC, and 6-MWD. After six months of therapy in both cohorts, patients on macitentan showed larger benefits in 6-MWD (+24 vs. +1, p=0.031) and similar benefit on WHO-FC (17 vs. 25% improvement, p=0.622). The improvement of NT-pro-BNP seemed better in the macitentan cohort, although non-significant (-27 vs. +34, p=0.151), however, more patients on macitentan improved their NT-pro-BNP levels (83% vs. 25%, p=0.019). Conclusion: Our historical cohort study shows larger treatment effect of macitentan compared to bosentan in therapy naïve PAH-CHD patients during the first six months. MOBILE HEALTH IN PATIENTS WITH CONGENITAL HEART DISEASE M.J. Schuuring (Haga, the Hague); B.J. Bouma (AMC, Amsterdam); D.R. Koolbergen (AMC, Amsterdam); A.P.C.M. Backx (AMC, Amsterdam); D. Robbers – Visser (AMC, Amsterdam); J. Vriend (Haga, the Hague); M. Groenink (AMC, Amsterdam); S.M. Boekholdt (AMC, Amsterdam); R. de Winter (AMC, Amsterdam); B.J. Mulder (AMC, Amsterdam) Purpose: Many adults with congenital heart disease (CHD) are affected by unpredictable arrhythmias and heart failure, putting them at risk of premature death. Mobile devices are an opportunity to monitor them. Currently, there are nearly 100,000 mobile health applications (‘apps’) available. However, none of these smartphone applications are adopted in clinical cardiology. There is a lack on data which patients are willing to use mobile health and which parameters to monitor. Methods: A survey on outpatient clinic in adults with CHD. Patients with mental retardation are excluded. Results: Preliminary data shows that 86% owned a smartphone (mean age 36 ± 14 years old, 64% male, predominantly NYHA II). Whereas currently a small minority (17%) of patients with CHD uses a smartphone health application, a majority (75%) of patients indicates that he or she wants to use a smartphone health application, see Figure 1. Furthermore, the majority of patients with CHD wants to receive health information on their smartphone and are willing to fill in questionnaires regarding vitals, life style and symptoms. More importantly, the majority wants to receive advice from their treating cardiologist in case of aberrant parameters and progression of symptoms, want to receive stimulating (lifestyle) messages and want to receive medication reminders. Conclusion: The majority of patients with CHD are willing to use mobile health. Results from an extended patient population with a more detailed characterization (severity of defect, corrected analysis on gender / NYHA class, etc) are available soon. Table 1. Historical comparison of clinical outcome during 6 months therapy with bosentan and macitentan WITHDRAWAL OF ANTIHYPERTENSIVE MEDICATION INCREASES BLOOD PRESSURE IN ONLY 50% OF PATIENTS Martine M.A. Beeftink (UMC Utrecht), Margreet F. Sanders (UMC Utrecht), Michiel Voskuil (UMC Utrecht), Pieter Doevendans (UMC Utrecht), Michiel Bots (UMC Utrecht), Wilko Spiering (UMC Utrecht) SECUNDUM ATRIAL SEPTAL DEFECTS AND ASTHMA-LIKE DYSPNOEA: THE IMPACT OF TRANSCATHETER CLOSURE M. Nassif (AMC, Amsterdam); C.B.B.C.M. Heuschen (AMC, Amsterdam); H. Lu (AMC, Amsterdam); B.J. Bouma (AMC, Amsterdam); R.P. van Steenwijk (AMC, Amsterdam); P.J. Sterk (AMC, Amsterdam); B.J.M. Mulder (AMC, Amsterdam); R.J. de Winter (AMC, Amsterdam). Purpose: Patients with atrial septal defects (ASD) are often misdiagnosed as asthma patients and receive erroneous bronchodilator treatment accordingly. In order to characterize their symptoms of dyspnoea to explain this clinical observation, we investigated the prevalence of asthma-like symptoms in patients with secundum ASD who then underwent successful percutaneous closure. Methods: A total of 80 ASD patients (74% female, mean age 46.7±16.8 years, median follow-up 3.0 [2.0-5.0] years) retrospectively completed dyspnoea questionnaires determining the presence and extent of cough, wheezing, chest tightness, effort dyspnoea and bronchodilator use on a 7-point scale (0=none, 6=maximum) before and after ASD closure. The Mini Asthma Quality of Life (Mini-AQLQ) and Asthma Control Questionnaire with bronchodilator use (ACQ6) were administered. Results: A total of 48 (60%) patients reported cough, 27 (34%) wheezing, 26 (33%) chest tightness and 62 (78%) effort dyspnoea. Symptom resolution or reduction was found in 64 (80%) patients after ASD closure. Asthma symptom scores decreased significantly on MiniAQLQ and ACQ6 (both P<0.001). The number of patients using bronchodilators decreased from 16 (20%) to 8 (10%) patients after ASD closure (P=0.039) with less frequent use of bronchodilators (P=0.015). Purpose: We observed unanticipated reductions in blood pressure after withdrawal of antihypertensive medication. To quantify this observation, we performed a structured analysis to investigate blood pressure changes after withdrawal of antihypertensive medication. Methods: We reviewed the medical records of the patients who were evaluated for hypertension at the UMC Utrecht between 2010 and 2015. Lifestyle parameter, laboratory results and prescribed antihypertensive medication were collected for all patients who had a 24-hour blood pressure measurement (ABPM) performed at referral (with medication), as well as after withdrawal of antihypertensive medication. Results: We included 163 patients with a mean age of 56.3 years (SD 13), a median of 3 antihypertensive drugs with a mean daily defined dose of 5.1 (SD 2.9). Eighty-seven patients (53,4%) demonstrated an increase of at least 5 mmHg after withdrawal of medication, whereas blood pressure remained stable (i.e. less than 5 mmHg change) in 40 patients (24,5%) and blood pressure decreased more than 5 mmHg in 36 patients (22,1%). The amount of withdrawn medication was highest in the group that experienced a decrease in blood pressure (-3.8 DDD when BP decreased, -4.3 DDD for stable BP and -5.2 when BP increased, p = 0.02). We also found a significant difference in 24-hour urinary sodium excretion (116 mmol/24hrs when BP decreased, 151 mmol/24hrs for stable BP and 155 mmol/24hrs when BP increased, p= 0.003). Conclusion: Withdrawal of antihypertensive medication fails to increase blood pressure in almost 50% of patients. The causes for this remarkable observation remain to be elucidated, but may include decreased sodium intake and poor medication adherence. Figure 1. Change in Systolic 24-hour blood pressure after withdrawal of antihypertensive medication. Conclusion: A high prevalence of asthma-like symptoms and bronchodilator use is present in ASD patients, higher than would be expected based on the amount of patients with bronchial asthma in this study population. The presence of an ASD should be considered in the differential diagnosis of patients with asthma-like symptoms, after which significant symptom relief can be achieved by ASD closure. Netherlands Heart Journal, Volume 24, Supplement, April 2016 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 15 15 09-03-16 10:40 VERKORTE PRODUCTINFORMATIE ATOZET® Voor de volledige en meest recente productinformatie verwijzen wij naar de goedgekeurde SPC op www.cbg-meb.nl NAAM VAN HET GENEESMIDDEL: ATOZET 10 mg/10 mg, 10 mg/20 mg en 10 mg/40 mg FARMACEUTISCHE VORM: Filmomhulde tablet KWALITATIEVE EN KWANTITATIEVE SAMENSTELLING: Per filmomhulde tablet 10 mg ezetimibe en 10, 20 of 40 mg atorvastatine. FARMACOTHERAPEUTISCHE GROEP EN WERKINGSMECHANISME: HMG-CoA-reductaseremmers in combinatie met andere antilipemica. Ezetimibe remt intestinale absorptie van cholesterol en atorvastatine is een selectieve, competitieve HMG-CoA-reductaseremmer. THERAPEUTISCHE INDICATIES: Aanvullende therapie naast dieet bij volwassenen met primaire (heterozygote familiaire (HeFH) en niet-familiaire) hypercholesterolemie of gemengde hyperlipidemie waar een combinatieproduct aangewezen is; bij patiënten onvoldoende onder controle met statine alleen of die al met een statine en ezetimibe worden behandeld; aanvullende therapie naast dieet bij volwassenen met homozygote familiare hypercholesterolemie (HoFH). CONTRA-INDICATIES Overgevoeligheid voor de ingrediënten; zwangerschap en borstvoeding; bij vruchtbare vrouwen die geen adequate anticonceptiemaatregelen treffen; actieve leverziekte of onverklaarde persisterende verhogingen van serumtransaminasen (>3xULN) BELANGRIJKSTE WAARSCHUWINGEN EN VOORZORGEN BIJ GEBRUIK: Myopathie en rabdomyolyse zijn postmarketing gemeld, meestal bij statines i.c.m. ezetimibe, zeer zelden bij ezetimibe monotherapie of i.c.m. andere middelen met verhoogd risico op rabdomyolyse. HMG-CoA-reductaseremmers incl. atorvastatine hebben invloed op skeletspieren en veroorzaken soms myalgie, myositis en myopathie, soms als (mogelijk levensbedreigende) rabdomyolyse (creatinekinase (CK) >10xULN), myoglobinemie en myoglobinurie, mogelijk leidend tot nierfalen en levensbedreigend). Vóór behandeling voorzichtigheid betrachten bij predisponerende factoren voor rabdomyolyse. Meet het CK vóór start behandeling bij nierfunctiestoornis, hypothyreoïdie, eigen/familiaire voorgeschiedenis van erfelijke spieraandoeningen, voorgeschiedenis van spiertoxiciteit met statine/fibraat, voorgeschiedenis van leverziekte en/of overmatig alcoholgebruik, leeftijd >70 jaar met factoren voor rabdomyolyse, bij risico op toename plasmaconcentraties (interacties, speciale populaties incl. genetische subpopulaties). In dit geval overweeg de voordelen/risico’s van behandeling en klinische controle wordt aanbevolen. Stel behandeling niet in als CK bij baseline-meting significant is verhoogd (>5xULN). CK mag niet worden gemeten na zware lichamelijke inspanning of andere plausibele oorzaak van CK-verhoging, wegens interpretatieproblemen. Als het CK bij baseline >5xULN, meet binnen 5-7 dagen opnieuw om resultaten te bevestigen. Tijdens behandeling: Verzoek patiënten spierpijn, -kramp of -zwakte direct te melden, vooral indien gepaard met malaise of koorts. Meet het CK als deze symptomen optreden tijdens behandeling met ATOZET. Staak behandeling als deze waarden >5xULN). Als spiersymptomen ernstig zijn met dagelijks ongemak, zelfs als CK verhoogd is ≤5xULN, overweeg behandeling te staken . Als symptomen verdwijnen en CK normaliseert, overweeg herstart van ATOZET of start van andere statines in de laagste dosis, met zorgvuldige controle. Staak behandeling met ATOZET indien CK klinisch significant is verhoogd (>10xULN), of bij (vermoeden van) rabdomyolyse. Zeer zelden is immuungemedieerde necrotiserende myopathie gemeld tijdens of na statinebehandeling, incl. atorvastatine (klinisch gekarakteriseerd door proximale spierzwakte en een verhoogd serumcreatinekinase, aanhoudend na staken van de statine). Atorvastatine verhoogt het rabdomyolyserisico bij gelijktijdig gebruik van geneesmiddelen die atorvastatineconcentraties kunnen verhogen, zoals krachtige CYP3A4-remmers of transporteiwitremmers (bijv. ciclosporine, telitromycine, claritromycine, delavirdine, stiripentol, keto/vori/itra/posaconazol en hiv-proteaseremmers). Het myopathierisico kan verhoogd worden door fibrinezuurderivaten (incl. gemfibrozil), boceprevir, erytromycine, niacine, telaprevir, of de combinatie van tipranavir met ritonavir. Alternatieve behandelingen moeten (zonder interactie) worden overwogen. Indien gelijktijdig gebruik van ATOZET nodig is, moeten de voordelen en risico’s zorgvuldig worden afgewogen. Bij geneesmiddelen die plasmaconcentraties atorvastatine verhogen, wordt een lagere maximum dosis ATOZET aanbevolen. Overweeg bij krachtige CYP3A4-remmers tevens een lagere aanvangsdosis en geschikte klinische controle is aanbevolen. Gelijktijdig gebruik met fusidinezuur wordt niet aanbevolen; overweeg tijdelijk staken van ATOZET tijdens gebruik van fusidinezuur. In gecontroleerde onderzoeken naar co-administratie van ezetimibe met atorvastatine, zijn opeenvolgende verhogingen van transaminasen (≥3x ULN) waargenomen. Leverfunctiecontrole wordt aanbevolen vóór start van behandeling en regelmatig daarna, en ook bij ontwikkeling van tekenen van leverbeschadiging. Als serumtransaminasespiegels stijgen, moeten controles worden uitgevoerd totdat afwijkingen zijn verdwenen; bij aanhoudende stijging tot 3xULN wordt dosisverlaging/staken van ATOZET aanbevolen. ATOZET met voorzichtigheid toepassen bij patiënten die aanzienlijke hoeveelheden alcohol consumeren en/of leverziektehistorie hebben. Vanwege het onbekende effect van verhoogde blootstelling aan ezetimibe bij een matige of ernstige leverinsufficiëntie, wordt ATOZET hierbij niet aanbevolen. De veiligheid en werkzaamheid van ezetimibe met fibraten zijn niet vastgesteld; gelijktijdige toediening wordt niet aanbevolen. Betracht voorzichtigheid bij co-administratie van ATOZET met ciclosporine; controleer ciclosporineconcentraties. Controleer INR bij gebruik van warfarine, andere coumarine-anticoagulantia of fluindion. In een post-hoc-analyse van subtypes van beroerte zonder coronaire hartziekte maar met recent doorgemaakte beroerte of TIA was er een hogere incidentie van hersenbloedingen bij patiënten die waren gestart met 80 mg atorvastatine vergeleken met placebo. Een verhoogd risico werd vooral gezien bij patiënten die eerder een hemorragische beroerte of lacunair infarct hadden gehad. Bij eerder doorgemaakte hemorragische beroerte of lacunair infarct is risico-batenbalans van 80 mg atorvastatine onduidelijk, en moet het potentiële risico op hersenbloeding worden afgewogen alvorens de behandeling te beginnen. Uitzonderlijke gevallen van interstitiële longziekte zijn gemeld bij sommige statines, vooral bij langdurige behandeling (kenmerken zijn o.a. dyspneu, niet-productieve hoest en afname algehele gezondheid (vermoeidheid, gewichtsverlies, koorts)). Bij vermoeden van interstitiële longziekte moet de statine worden gestaakt. Er zijn aanwijzingen dat statines bloedglucose verhogen en bij sommige patiënten met hoog risico op toekomstige diabetes een mate van hyperglykemie kunnen veroorzaken, die formele diabeteszorg vereist. Dit risico weegt minder zwaar dan verlaging van het vasculaire risico en moet geen reden zijn om de statine te stoppen. Controleer patiënten met dit risico (nuchter glucose 5,6 tot 6,9 mmol/l, BMI > 30 kg/m2, verhoogde triglyceriden, hypertensie) klinisch en biochemisch volgens de landelijke richtlijnen. ATOZET bevat lactose. Zie SPC voor interacties. BIJWERKINGEN: Vaak: diarree, myalgie. Soms: griep, depressie, slapeloosheid, slaapstoornis, duizeligheid, dysgeusie, hoofdpijn, paresthesie, sinus-bradycardie, opvlieger, dyspneu, abdominaal ongemak, abdominale distensie, buikpijn, pijn in de onderbuik, pijn in de bovenbuik, constipatie, dyspepsie, flatulentie, frequente darmbewegingen, gastritis, misselijkheid, maagongemak, acne, urticaria, artralgie, rugpijn, spiervermoeidheid, spierspasmen, spierzwakte, pijn in extremiteit, asthenie, vermoeidheid, malaise, oedeem, abnormale leverfunctietest, verhoogd ALAT en/of ASAT, verhoogde alkalische fosfatase, gamma-glutamyltransferase of leverenzymen, verhoogd CK in bloed, gewichtstoename. Zie SPC voor postmarketing gemelde bijwerkingen. REGISTRATIEHOUDER: Merck Sharp & Dohme Ltd., Hertford Road, Hoddesdon, Hertfordshire, EN11 9BU, UK. LOKALE VERTEGENWOORDIGER: MSD BV, Waarderweg 39, 2031 BN Haarlem, 0800 9999 000, [email protected] REGISTRATIENUMMER(S): RVG 114373/4/5 VERGOEDING: Volledig vergoed. AFLEVERSTATUS: UR. DATUM SPC: Oktober 2014. ATOZET SPC 85x110 Neth. Heart journal.indd 1 VAKINFORMATIE KOOP JE BIJ DE SPECIALIST • Meer dan 2.000 producten voor professionals en studenten in de zorg • Boeken, tijdschriften, e-books, vragenlijsten, testen, e-learnings, web-tv’s en meer Ga direct naar www.bsl.nl BAANBREKEND. BETROUWBAAR. 28-01-15 11:52 MAAK VANDAAG NOG EEN JOB ALERT AAN VOOR JOUW IDEALE BAAN! Vind actuele vacatures Solliciteer direct! Maak een Job Alert aan Medische banenbank • Actuele vacatures in de gezondheidszorg • Gemakkelijk zoeken, ook met smartphone of tablet • Ontvang dagelijks de nieuwste vacatures per email Het actuele vacatureaanbod voor de gezondheidszorg! Bekijk alle vacatures op medischebanenbank.nl BAANBREKEND. BETROUWBAAR. BSL_MBB__adv_167 x 114.indd 1 NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 16 21-01-15 09:54 09-03-16 10:40 BSL_ ON D ON DEMAND ONLINE NASCHOLING EMA ND 2015 Update over Atriumfibrilleren Live uitzending gemist? Kijk nu wanneer het u uitkomt! De behandeling van patiënten met boezemfibrilleren is vaak lastig. Er zijn veel mogelijkheden, en welke therapie is voor de individuele patiënt de beste strategie? Tijdens deze nascholing geven de sprekers u een duidelijk en actueel overzicht van de mogelijkheden. ONDERWERPEN • A personalized medical appproach to AF • A personalized ablation approach in AF SPREKERS • Dr. Joris R. de Groot, AMC (moderator) • Prof. dr. Isabelle C. van Gelder, UMCG • Dr. Yuri Blaauw, UMCG ACCREDITATIE Deze nascholing is geaccrediteerd voor 1 punt door de NVVC. Neem gratis deel via www.nvvc.nl/AF2015 432NL15PR12424-01 23-10-2015 15.ELI.21.153 NVVC web-tv wordt mede mogelijk gemaakt door: BSL_NVVC_web-tv_adv_210x280.indd NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 1 17 08-02-16 09-03-16 13:50 10:40 52% VAN DE HVZ-PATIËNTEN HEEFT EEN LDL > 2,5 MMOL/L*: DENK VERDER DAN STATINE MONOTHERAPIE * Gebaseerd op het rapport “Cardiovasculair risicomanagement in Nederland van 2009 tot 2013: the state of the art”: % HVZ-patiënten in CVRM-zorgprogramma bij wie uitkomst indicatoren CVRM zijn vastgelegd in 2013 (totaal aantal patiënten: 97.825).1 CARD-1109934-0032 Referentie: 1. Vijf jaar cardiovasculair risicomanagement in Nederland: the state of the art. Subtitle “Cardiovasculair risicomanagement in Nederland van 2009 tot 2013: the state of the art”, uitgave van de Hartstichting i.s.m. Platform Vitale Vaten en De Hart & Vaatgroep, augustus 2014. Raadpleeg de volledige productinformatie (SPC) alvorens Atozet voor te schrijven. Voor de verkorte productinformatie zie elders in dit blad. Postbus 581, 2003 PC Haarlem. Tel. 0800-9999000 e-mail: [email protected], www.msd.nl NHJ 1604 Abstracts NVVC incl omslag_proef5.indd 18 CARD-1109934-0032 Atozet advertentie 210x280.indd 1 (ezetimibe/atorvastatine, MSD) 09-03-16 10:40 26-05-15 12:59