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AbstractBackgroundLimited data are available regarding the demographics, disease associations, and long‐term prognosis of patients with inappropriate sinus tachycardia (IST).ObjectiveTo establish epidemiologic data for patients with IST, including symptom onset, comorbid disease, and long‐term outcomes.MethodsWe retrospectively reviewed all patients with an IST diagnosis at the Mayo Clinic (Rochester, MN) during a 20‐year period (1998‐2018). We extracted demographic data and clinical outcomes compared to an age and gender‐matched control group with atrioventricular nodal reentry tachycardia (AVNRT).ResultsWithin the study period, a total of 305 patients with IST were identified (mean follow‐up 3.5 years) with 92.1% female and mean age 33.2 ± 11.2 years. The most frequently identified circumstances triggering the condition included pregnancy (7.9%) and infectious illness (5.9%) while the most common comorbid conditions were depression (25.6%) and anxiety (24.6%). At diagnosis, the mean left ventricular ejection fraction (LVEF) was 62.3 ± 6.2%, with 77 patients having follow‐up echocardiographic data. No significant difference in LVEF was seen after a mean 4.9 ± 4.3‐year follow‐up (baseline LVEF 59.8 ± 10.7% vs subsequent 61.4 ± 8.1%; P = .2971). Two deaths occurred within the study period, with one related to myocardial infarction and the other noncardiac; compared to an age and gender‐matched AVNRT control group there was no excess mortality during the follow‐up period.ConclusionsIn our study cohort, IST predominately affects young females with structurally normal hearts and modest coexistent psychiatric disease. In most cases of IST, a major event occurring just before or at the time of diagnosis could not be identified, although nearly 8% of patients first noted symptoms during or shortly after pregnancy. In our cohort, there was no evidence of cardiomyopathy or mortality related to IST.

Abstract Abstract 4319 C-type natriuretic peptide (CNP) is known to exert pleiotropic effects on a variety of cell types through binding to its receptor, natriuretic peptide receptor type B (NPR-B) and activation of the cytoplasmic intracellular guanylyl cyclase domain. Although nitric oxide-mediated activation of cyclic guanosine monophosphate (cGMP) is known to induce megakaryocyte apoptosis and regulate platelet activation, the effects of CNP on these cells is yet to be defined. In this study for the first time we have addressed the potential role of CNP and NPR-B in megakaryocyte and platelet biology. We identified NPR-B on murine megakaryocytes by immunostaining demonstrating co-localization of CD41 and NPR-B. CNP induced cGMP production in megakaryocytes compared to a mutant form of CNP containing a single amino acid substitution (Lbab) (67.24 ± 10.65 fmol/well vs. 17.18 ± 2.089 fmol/well; P<0.05). Subsequently, CNP was shown to reduce megakaryocyte colony formation compared to Lbab and this effect was dose-dependent: Lbab 500nM 26.75 ± 5.618 CFU-M vs. 15.25 ± 2.750 CFU-M for CNP 500nM and Lbab 1000 nM 27.50 ± 2.102 CFU-M vs. 12.25 ± 1.493 CFU-M for CNP 1000nM; P<0.05). Furthermore, CNP also resulted in smaller-sized colonies, with altered cell morphology. To verify these findings, wild-type C57/BL6 mice were treated with daily injections of either saline, 1uM CNP or 1uM Lbab for one week, following which megakaryocytes were isolated and cultured. Colony formation was diminished in mice injected with CNP compared to mice receiving saline or Lbab peptide (125.3 ± 18.54 CFU-M for saline; 107.0 CFU-M ± 20.04 for Lbab and 20.00 ± 3.674 CFU-M for CNP; P<0.05). In addition platelet numbers were measured in the aforementioned mice and the CNP treated mice had significantly lower platelet counts compared to the mice treated with Lbab (832.0 ± 13.19 ×103/ul for CNP vs. 778.0 ± 12.00 ×103/ul for Lbab; P<0.05). Taken together, these data indicate that CNP may play a role in the development, maturation and/or survival of megakaryocytes. Using flow cytometry we identified that 47% of CD41+ murine platelets co-express NPR-B. In addition, this expression of NPR-B was confirmed by immunocytostaining and western blotting in both human and murine platelets. Interestingly, despite the expression of NPR-B, and unlike megakaryocytes, CNP (similar to the mutant peptide) did not increase cGMP production in platelets (1.652 ± 0.016 fmol/well for CNP and 1.606 ± 0.01550 fmol/well for Lbab). Further, although preliminary results did not indicate that CNP alters platelet secretion or aggregation, exposure to the peptide profoundly inhibited adhesion of platelets to collagen (53 ± 5 adhered platelets with Lbab, 32 ± 3 with CNP, relative reduction 42%; P<0.05). In summary, these results provide for the first time evidence that the NPR-B receptor is expressed on both megakaryocytes and platelets. Our studies suggest that CNP might have both cGMP dependent and independent functions in megakaryocytes and platelets and further studies will assist in delineating the mechanisms by which CNP exerts its actions on these cells. Disclosures: No relevant conflicts of interest to declare.

AbstractBackgroundRecipients of implantable cardioverter defibrillator (ICD) generator replacement with multiple medical comorbidities may be at higher risk of adverse outcomes that attenuate the benefit of ICD replacement. The aim of this investigation was to study the association between the Charlson comorbidity index (CCI) and outcomes after ICD generator replacement.MethodsAll patients undergoing first ICD generator replacement at Mayo Clinic, Rochester and Beth Israel Deaconess Medical Center, Boston between 2001 and 2011 were identified. Outcomes included: (a) all‐cause mortality, (b) appropriate ICD therapy, and (c) death prior to appropriate therapy. Multivariable Cox regression analysis was performed to assess association between CCI and outcomes.ResultsWe identified 1421 patients with mean age of 69.6 ± 12.1 years, 81% male and median (range) CCI of 3 (0‐18). During a mean follow‐up of 3.9 ± 3 years, 52% of patients died, 30.6% experienced an appropriate therapy, and 23.6% died without experiencing an appropriate therapy. In multivariable analysis, higher CCI score was associated with increased all‐cause mortality (Hazard ratio, HR 1.10 [1.06‐1.13] per 1 point increase in CCI, P < .001), death without prior appropriate therapy (HR 1.11 [1.07‐1.15], P < .0001), but not associated with appropriate therapy (HR 1.01 [0.97‐1.05], P = .53). Patients with CCI ≥5 had an annual risk of death of 12.2% compared to 8.7% annual rate of appropriate therapy.ConclusionsCCI is predictive of mortality following ICD generator replacement. The benefit of ICD replacement in patients with CCI score ≥5 should be investigated in prospective studies.

INTRODUCTION The human cerebral cortex has undergone an extraordinary increase in size and complexity during mammalian evolution. Cortical cell lineages are specified in the embryo, and genetic and epidemiological evidence implicates early cortical development in the etiology of neuropsychiatric disorders such as autism spectrum disorder (ASD), intellectual disabilities, and schizophrenia. Most of the disease-implicated genomic variants are located outside of genes, and the interpretation of noncoding mutations is lagging behind owing to limited annotation of functional elements in the noncoding genome. RATIONALE We set out to discover gene-regulatory elements and chart their dynamic activity during prenatal human cortical development, focusing on enhancers, which carry most of the weight upon regulation of gene expression. We longitudinally modeled human brain development using human induced pluripotent stem cell (hiPSC)–derived cortical organoids and compared organoids to isogenic fetal brain tissue. RESULTS Fetal fibroblast–derived hiPSC lines were used to generate cortically patterned organoids and to compare oganoids’ epigenome and transcriptome to that of isogenic fetal brains and external datasets. Organoids model cortical development between 5 and 16 postconception weeks, thus enabling us to study transitions from cortical stem cells to progenitors to early neurons. The greatest changes occur at the transition from stem cells to progenitors. The regulatory landscape encompasses a total set of 96,375 enhancers linked to target genes, with 49,640 enhancers being active in organoids but not in mid-fetal brain, suggesting major roles in cortical neuron specification. Enhancers that gained activity in the human lineage are active in the earliest stages of organoid development, when they target genes that regulate the growth of radial glial cells. Parallel weighted gene coexpression network analysis (WGCNA) of transcriptome and enhancer activities defined a number of modules of coexpressed genes and coactive enhancers, following just six and four global temporal patterns that we refer to as supermodules, likely reflecting fundamental programs in embryonic and fetal brain. Correlations between gene expression and enhancer activity allowed stratifying enhancers into two categories: activating regulators (A-regs) and repressive regulators (R-regs). Several enhancer modules converged with gene modules, suggesting that coexpressed genes are regulated by enhancers with correlated patterns of activity. Furthermore, enhancers active in organoids and fetal brains were enriched for ASD de novo variants that disrupt binding sites of homeodomain, Hes1, NR4A2, Sox3, and NFIX transcription factors. CONCLUSION We validated hiPSC-derived cortical organoids as a suitable model system for studying gene regulation in human embryonic brain development, evolution, and disease. Our results suggest that organoids may reveal how noncoding mutations contribute to ASD etiology. Summary of the study, analyses, and main results. Data were generated for iPSC-derived human telencephalic organoids and isogenic fetal cortex. Organoids modeled embryonic and early fetal cortex and show a larger repertoire of enhancers. Enhancers could be divided into activators and repressors of gene expression. We derived networks of modules and supermodules with correlated gene and enhancer activities, some of which were implicated in autism spectrum disorders (ASD).

Background— The effectiveness of implantable cardioverter-defibrillators (ICDs) for primary prevention of sudden death in patients with an ejection fraction (EF) ≤35% and clinical heart failure is well established. However, outcomes after replacement of the ICD generator in patients with recovery of EF to >35% and no previous therapies are not well characterized. Methods and Results— Between 2001 and 2011, generator replacement was performed at 2 tertiary medical centers in 253 patients (mean age, 68.3±12.7 years; 82% men) who had previously undergone ICD placement for primary prevention but subsequently never received appropriate ICD therapy. EF had recovered to >35% in 72 of 253 (28%) patients at generator replacement. During median (quartiles) follow-up of 3.3 (1.8–5.3) years after generator replacement, 68 of 253 (27%) experienced appropriate ICD therapy. Patients with EF ≤35% were more likely to experience ICD therapy compared with those with EF >35% (12% versus 5% per year; hazard ratio, 3.57; P =0.001). On multivariable analysis, low EF predicted appropriate ICD therapy after generator replacement (hazard ratio, 1.96 [1.35–2.87] per 10% decrement; P =0.001). Death occurred in 25% of patients 5 years after generator replacement. Mortality was similar in patients with EF ≤35% and >35% (7% versus 5% per year; hazard ratio, 1.10; P =0.68). Atrial fibrillation (3.24 [1.63–6.43]; P <0.001) and higher blood urea nitrogen (1.28 [1.14–1.45] per increase of 10 mg/dL; P <0.001) were associated with mortality. Conclusions— Although approximately one fourth of patients with a primary prevention ICD and no previous therapy have EF >35% at the time of generator replacement, these patients continue to be at significant risk for appropriate ICD therapy (5% per year). These data may inform decisions on ICD replacement.

Background The Purkinje network appears to play a pivotal role in the triggering as well as maintenance of ventricular fibrillation. Irreversible electroporation ( IRE ) using direct current has shown promise as a nonthermal ablation modality in the heart, but its ability to target and ablate the Purkinje tissue is undefined. Our aim was to investigate the potential for selective ablation of Purkinje/fascicular fibers using IRE . Methods and Results In an ex vivo Langendorff model of canine heart (n=8), direct current was delivered in a unipolar manner at various dosages from 750 to 2500 V, in 10 pulses with a 90‐μs duration at a frequency of 1 Hz. The window of ventricular fibrillation vulnerability was assessed before and after delivery of electroporation energy using a shock on T‐wave method. IRE consistently eradicated all Purkinje potentials at voltages between 750 and 2500 V (minimum field strength of 250–833 V/cm). The ventricular electrogram amplitude was only minimally reduced by ablation: 0.6±2.3 mV ( P =0.03). In 4 hearts after IRE delivery, ventricular fibrillation could not be reinduced. At baseline, the lower limit of vulnerability to ventricular fibrillation was 1.8±0.4 J, and the upper limit of vulnerability was 19.5±3.0 J. The window of vulnerability was 17.8±2.9 J. Delivery of electroporation energy significantly reduced the window of vulnerability to 5.7±2.9 J ( P =0.0003), with a postablation lower limit of vulnerability=7.3±2.63 J, and the upper limit of vulnerability=18.8±5.2 J. Conclusions Our study highlights that Purkinje tissue can be ablated with IRE without any evidence of underlying myocardial damage.

Background The decision to initially implant an implantable cardioverter-defibrillator (ICD) is informed by robust randomized controlled trials, but no such data exist to guide the decision to replace an ICD generator. In this study, we aimed to determine outcomes after ICD generator replacement. Methods All patients with ischemic or nonischemic cardiomyopathy who underwent ICD generator replacement from 2001 to 2011 at Mayo Clinic, MN, or Beth Israel Deaconess Medical Center, MA, were included. Outcomes included (1) appropriate therapy after generator replacement and (2) death before appropriate therapy after generator replacement. Cox proportional hazards modeling was used to determine the associations between patient characteristics and outcomes. Results In 1421 patients undergoing ICD generator replacement (mean±SD age 69.6±12.1 years, 81% male), appropriate therapy occurred after replacement in 435 patients (30.6%) over a mean follow-up of 2.7±2.6 years. Associated factors included lower left ventricular ejection fraction and history of appropriate therapy before generator replacement. Death before appropriate ICD therapy occurred in 336 (23.7%) patients. Older age, lower left ventricular ejection fraction, and noncardiac comorbidities, including diabetes mellitus, chronic lung disease, peripheral vascular disease, lower hemoglobin, and lower glomerular filtration rate, were associated with greater risk of death before appropriate therapy. A progressive increase in mortality was observed with aggregation of these noncardiac comorbidities. Conclusions The decision to replace the ICD should take into consideration not only left ventricular ejection fraction and history of ventricular arrhythmias, but also comorbid illnesses that may impact the duration and the quality of life.