The impact of percutaneous left atrial appendage closure on left ventricular diastolic function and natriuretic peptide levels

OBJECTIVE

Although the efficacy and safety of left atrial (LA) appendage (LAA) closure in patients with atrial fibrillation (AF) have been well documented in randomized controlled trials and real-world experience, there are limited data in the literature about the impact of LAA closure on diastolic functions. The study aimed to examine the impact of LAA closure on diastolic function and natriuretic peptide levels in patients with AF.

PATIENTS AND METHODS

Twelve non-valvular AF patients with high risk for developing cardioembolic stroke and contraindications to warfarin underwent LAA occlusion with the WATCHMAN device (Atritech Inc., Plymouth, MN, USA). B-type natriuretic peptide levels and detailed diastolic parameters (mitral inflow velocities, deceleration time (DT), flow propagation velocity (Vp), isovolumetric relaxation time (IVRT), mitral annular e', TE-e', IVRT/TE-e', E/Vp, E/e', pulmonary vein flow parameters consisting of S, D, and S/D) were evaluated at baseline and 45 days after LAA closure.

RESULTS

The median age of the patients was 69 (54-78) years and 75% (n: 9) of them were male. All patients completed forty-five days of follow-up. Compared to the baseline values, E/Vp ratio and BNP levels (1.95 (0.94-3.32) vs. 2.37 (1.09-4.46), p= 0.015; 290.0 (90-1271) pg/ml vs. 322.00 (106-1635) pg/ml, p=0.018, respectively) increased, and pulmonary vein S wave and S/D ratio (0.67 (0.33-0.92) vs. 0.38 (0.23-0.91) m/sec, p=0.048; 1.62 (0.86-5.75) vs. 1.33 (0.11-3.35), p=0.019, respectively) decreased after LAA closure.

CONCLUSIONS

In the present study, we demonstrated that patients with AF have shown impaired diastolic functions and elevated BNP levels after the percutaneous closure of the LAA.

The harm of anticoagulation in patients with low-risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc: inferences from TRAF cohort

OBJECTIVE

There is a gap in the knowledge concerning oral anticoagulation (OAC) in atrial fibrillation (AF) patients with a non-high risk of stroke. CHA2DS2VASc and CHADS2 scores generated imprecise risk estimates for low risk patients. We aimed to assess OAC in patients with low risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc.

PATIENTS AND METHODS

In this study, retrospective nationwide population-based study, data were obtained from the Turkish claims and utilization management system. Patients with non-valvular AF (n=451,113) between 2007 and 2012 sub-divided into those with a CHA2DS2VASc≥1 and CHADS2=0 (n=41,273) who were off-warfarin (n=29,448) and on-warfarin (n=11,825). Stroke and systemic embolism, major bleeding, all-cause mortality, net clinical benefit (NCB) and ultimate NCB (UNCB) were assessed.

RESULTS

Of the total cohort (mean age 66.1 ± 14.1 years, 56.1% female), CHA2DS2VASc improved the net reclassification index of observed 5-year composite thromboembolic endpoint by 6.9% (p<0.05). CHA2DS2VASc reclassified 9.7% low risk patients as high risk. Among reclassified-high-risk category (patients with a CHA2DS2VASc score of ≥1 and CHADS2 score of 0), major bleeding for that prescribed warfarin was 3% and higher than the rate of thromboembolism among those off-warfarin. NCB (-0.035) and UNCB (-0.021) were negative. Death and hospitalization at 1 year were significantly higher for on-warfarin group.

CONCLUSIONS

Clinical outcomes, net clinical benefit indices are negative; rates of death and hospitalization were significantly higher for OAC in reclassified category. This emphasizes the importance of greater attention to balancing the risks and benefits of OAC in patients with low risk by CHADS2 and reclassified as high-risk by CHA2DS2VASc.

Targeted septal branch microcirculatory embolization with tris-acryl gelatin microspheres in hypertrophic obstructive cardiomyopathy

Background

Alcohol septal ablation (ASA) has been shown to be an effective treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM) who are refractory to medical treatment. ASA may cause some life-threatening complications including conduction disturbances, hemodynamic compromise, ventricular arrhythmias, distant and massive myocardial necrosis. Tris-acryl gelatin microspheres provide consistent and predictable results for effective targeted microcirculatory embolization.

Purpose

We aimed to report our initial experience in tris-acryl gelatin microspheres for septal ablation in HOCM.

Methods

Microspheres are biocompatible, hydrophilic, non-resorbable microspheres which are available in a range of calibrated sphere sizes. In our method, after the cannulation of the left anterior descending by a 6F-7F guiding catheter, a 0.014-inch guidewire is introduced through the catheter and advanced into the septal branch. This septal artery is selectively cannulated with a 4F catheter over the guidewire. Selective angiography of the septal artery is performed to show the anatomy and collateral branches to other coronary arteries. Contrast echocardiography is performed to make sure that the pertinent septal artery is the target vessel supplying the hypertrophied septum. A microcatheter is then advanced deep enough into the septal artery through the 4F catheter. Microspheres/contrast solution infused slowly under fluoroscopic guidance into the targeted septal branches initially using coronary arteriolar sized small particles (diameter 100–300 μm); then the particle size was stepped up to larger particles (diameter 300–500 μm) until a complete block of the arteriolar flow is achieved.

Results

Septal ablation with tris-acryl gelatin microspheres was performed in 6 patients (mean age = 47.8±11.5; 5 males). Immediately after the procedure peak left ventricular outflow (LVOT) gradient reduced significantly both for direct catheter (69.0±13.8 vs. 8.2±3.7 mmHg, P&lt;0.001) and Doppler echocardiographic measurements (78.8±19.9 vs. 12.0±5.1 mmHg, P&lt;0.001). Post-procedure peak serum CK- MB fraction concentration was 82±22 ng/ml (reference range is 0 - 4.9 ng/mL) and peak serum troponin T concentration was 1.2 ng/ml [(interquartile range, 0.4–1.4), (reference range is 0 - 0.017 ng/mL)]. LVOT tract gradient reduction persisted after 6 months follow-up. There was no significant complication during the procedure and within a 6 months follow-up period.

Conclusions

The novel strategy by targeted septal branch microcirculatory embolization with tris-acryl gelatin microspheres seems to be an efficient and safe approach to HOCM. Further experience is needed in order to assess the long-term efficacy and safety of this technique.

Funding Acknowledgement

Type of funding source: None

Effects of bisphosphonate and calcium carbonate on normal aortic valve and cholecalciferol induced in vivo rabbit aortic stenosis model

Background

Calcific aortic valve disease (CAVD) is the most common valvular heart disease. Bisphosphonates are stable analogs of pyrophosphates and commonly prescribed in the treatment of osteoporosis. The effects of bisphosphonate treatment on CAVD are not clearly known and there are inconsistent results. Similarly, the effect of calcium supplementation on CAVD remains controversial.

Purpose

The aim of this study was to assess the effects of bisphosphonate therapy on the normal aortic valve and vitamin D induced in vivo rabbit aortic stenosis (AS) model.

Methods

The impact of calcium supplementation on the rabbit AS model was also evaluated. A total of 30 New Zealand white rabbits were divided into five equal groups: no treatment (Group I); 25,000 IU/day vitamin D3 (cholecalciferol) (Group II, rabbit AS model); 25,000 IU/day cholecalciferol plus 2500 mg/day calcium carbonate (Group III); 20 μg/kg/week intravenous alendronate (Group IV) and 25,000 IU/day cholecalciferol plus 2500 mg/day calcium carbonate plus 20μg/kg/week alendronate (Group V). Echocardiography was performed at baseline and after 12 weeks of treatment. The left ventricular mass index (LVMI), aortic valve area (AVA), transvalvular velocities and gradients were recorded. Radiologic and histopathologic examination was performed at the end of the 12th week. Control animals displayed no abnormalities of the aortic valve.

Results

There was no echocardiographic change in Group IV. In Groups II, III and V, there was a significant decrease in AVA and increases in transvalvular velocities and gradients. However, these stenotic changes were significantly prominent in Group V (p=0.001 for all, via repeated measures ANOVA). Moreover, LVMI was only increased in Group V (p&lt;0.05). Calcification of aortic valvar complex was detected in 14 (46.7%) cases by radiologic imaging and 10 (33.3%) cases by histopathologic examination. Most frequent calcification was found in Group V (5 for each method, 83.3%). Agatston, volume and equivalent mass scores of calcific foci in Group V were significantly higher than other groups (p&lt;0.05 for all). There was no significant difference between groups regarding with presence of osteoclasts in calcific foci.

Conclusion

Calcium supplementation has no effect on the in vivo rabbit AS model. Alendronate treatment aggravates the stenosis and increases the calcification in the rabbit AS model. Alendronate treatment has no effect on the normal valve in which there was no osteogenesis and osteoclastogenesis. Based on these findings, in patients with CAVD, alendronate treatment should be given with regular echocardiographic follow-up or may not be preferred.

Central figure

Funding Acknowledgement

Type of funding source: None

Prolonged Tp-e interval and Tp-e/QT ratio in patients with mitral annulus disjunction

Background

Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point. MAD has been associated with mitral valve prolapse (MVP) and arrhythmic events. T-wave peak to T-wave end interval (Tp-e) and Tp-e/QTc are electrocardiographic (ECG) indices to predict ventricular tachyarrhythmia and cardiovascular mortality.

Purpose

We aimed to evaluate ventricular repolarization dispersion by using the Tp-e interval and Tp-e/QT ratio in patients with MAD and healthy controls.

Methods

A total of 35 patients with MAD (age 40.4±8.2 years; 66% female) and 37 healthy controls (age 37.6±9.5 years; 68% female) were enrolled. All subjects were evaluated by 12 lead standard ECG, 24-hour ambulatory ECG, and transthoracic echocardiography. The MAD distance was measured from the left atrial wall-mitral valve leaflet junction to the top of the left ventricular wall during end-systole in the parasternal long-axis view. The standard 12-lead electrocardiograms were analyzed; QTc, Tp-e and Tp-e/QTc were calculated. The Tp-e interval was defined as the interval from the peak of the T wave to the end of the T wave from precordial leads. Finally, the Tp-e/QT ratio was calculated from these measurements. The normality assumption was checked with the Shapiro-Wilk test and the Mann–Whitney U test was used for inter-group comparisons.

Results

Tp-e interval (61.9±6.0 ms vs. 77.1±5.9 ms, p&lt;0.001) and Tp-e/QT ratio (0.14±0.01 vs. 0.17±0.02, p&lt;0.001) were significantly prolonged in patients with MAD than in the control group. MVP was present in 24 (69%) patients with MAD. The prevalence of 30 premature ventricular contractions / hour were higher in MAD subgroup without MVP than those MAD with MVP (54.5% vs 16.7%, p=0.041). Mean MAD distance measured by echocardiography was 5.7±1.5 mm. The Spearman's rank-order correlation analyses revealed positive correlations of MAD distance with Tp-e interval (r=0.620, p=0.001) and Tp-e/QT ratio (r=0.372, p=0.028).

Conclusions

The patients with MAD had a prolonged Tp-e interval and Tp-e/QT ratio compared with normal subjects. Furthermore, this prolongation was well correlated with MAD distance. Patients with MAD, particularly with higher MAD distance, should be followed closely for arrhythmic outcomes.

MAD distance and Tp-e interval

Funding Acknowledgement

Type of funding source: None

Focal laser ablation as clinical treatment of prostate cancer: report from a Delphi consensus project

PURPOSE

To define the role of focal laser ablation (FLA) as clinical treatment of prostate cancer (PCa) using the Delphi consensus method.

METHODS

A panel of international experts in the field of focal therapy (FT) in PCa conducted a collaborative consensus project using the Delphi method. Experts were invited to online questionnaires focusing on patient selection and treatment of PCa with FLA during four subsequent rounds. After each round, outcomes were displayed, and questionnaires were modified based on the comments provided by panelists. Results were finalized and discussed during face-to-face meetings.

RESULTS

Thirty-seven experts agreed to participate, and consensus was achieved on 39/43 topics. Clinically significant PCa (csPCa) was defined as any volume Grade Group 2 [Gleason score (GS) 3+4]. Focal therapy was specified as treatment of all csPCa and can be considered primary treatment as an alternative to radical treatment in carefully selected patients. In patients with intermediate-risk PCa (GS 3+4) as well as patients with MRI-visible and biopsy-confirmed local recurrence, FLA is optimal for targeted ablation of a specific magnetic resonance imaging (MRI)-visible focus. However, FLA should not be applied to candidates for active surveillance and close follow-up is required. Suitability for FLA is based on tumor volume, location to vital structures, GS, MRI-visibility, and biopsy confirmation.

CONCLUSION

Focal laser ablation is a promising technique for treatment of clinically localized PCa and should ideally be performed within approved clinical trials. So far, only few studies have reported on FLA and further validation with longer follow-up is mandatory before widespread clinical implementation is justified.

Computerized dynamic pupillometry indices mirrors the heart rate variability parameters

OBJECTIVE

Dynamic pupillometry (DP) is a simple, non-invasive computerized assessment of pupillary light response which provides data concerning both branches of the autonomous nervous system (ANS). Heart rate variability (HRV) analysis assess cardiac health and the ANS modulation on the heart. In this study, we aimed to evaluate the utility of DP as a predictor of cardiac autonomic activity assessed by HRV.

PATIENTS AND METHODS

A total of 44 consecutive healthy subjects (mean age = 35.9 ± 7.4 years, 24 males) were enrolled. Pupil diameters (R0, R1, R2 and R%): latency (Lc), amplitude (Ac), velocity (Vc) and duration of pupil contraction (Tc): latency (Ld), velocity (Vd) and duration of pupil dilatation (Td) were measured in DP. Time and frequency domain indices of HRV were obtained from 24-h ambulatory electrocardiographic monitoring.

RESULTS

There were strong significant correlations of Vc with LF/HF (r = -0.672, p = 0.001) and a measure of HRV: RMSDD (r = 0.654, p = 0.001). R% significantly correlated with PNN50 (r = -0.432, p = 0.003) and RMSDD (r = -0.422, p = 0.004) and LF/HF (r = 0.340, p = 0.024). Vc (β = 0.647, p = 0.011) and Ac (β = 0.320, p = 0.013) were found as independent predictors of RMSSD. Vc (β = 0.578, p = 0.036) was found to be only significant predictor of PNN50. Vc (β = -0.617, p = 0.008) and R% (β = 0.309, p = 0.038) were found to be significant predictors of LF/HF.

CONCLUSIONS

Pupillary autonomic functions assessed by DP correlates with cardiac autonomic functions evaluated by HRV. Among the DP parameters analyzed, Vc was a predictor of parasympathetic indices, and R% was a predictor of sympathetic indicators of cardiac autonomic functions.

Assessment of the relationship between dynamic pupillometry and exercise heart rate recovery among healthy subjects

OBJECTIVE

Dynamic pupillometry (DP) is a simple, non-invasive computerized technique for assessment of pupillary light response which provides data concerning the balance of both branches of the autonomous nervous system (ANS). Heart rate (HR) recovery (HRR) after graded exercise reflects cardiac autonomic activity and predicts cardiovascular events. In this study, we aimed to evaluate the utility of DP as a predictor of cardiac autonomic activity assessed by HRR.

PATIENTS AND METHODS

A total of 62 consecutive healthy subjects (mean age = 33.7 ± 8.6 years, 39 males and 23 females) were enrolled. Pupil diameters (R0, R1, R2 and R%): latency (Lc), amplitude (Ac), velocity (Vc) and duration of pupil contraction (Tc): latency (Ld), velocity (Vd) and duration of pupil dilatation (Td) were measured in DP. HRR indices were calculated by subtracting 1st (HRR1), 2nd (HRR2) and 3rd (HRR3) minute HR from the maximal HR during treadmill exercise stress test.

RESULTS

HRR1 was 32.9 ± 8.0 bpm, HRR2 was 55.1 ± 11.6 bpm and HRR3 was 58.3 ± 12.7 bpm, respectively. Correlation analysis revealed significant positive correlations of HRR1 with Vc (r = 0.660, p = 0.001), Ac (r = 0.559, p = 0.001) and Vd (r = 0.412, p = 0.001). HRR had significant negative correlations with Lc (r = -0.442, p = 0.001), R% (r = -0.384, p = 0.002) and Ld (r = -0.286, p = 0.025). Vc [β = 3.995 (1.040 to 6.951, 95% CI, p = 0.009)] and Lc [β = -0.032 (-0.056 to -0.008, 95% CI, p = 0.01)] were found to be significant independent predictors of HRR1.

CONCLUSIONS

Pupillary autonomic functions assessed by DP correlates with cardiac autonomic functions evaluated by HRR. Among the DP parameters analyzed, Vc and Lc were independent predictors of cardiac autonomic functions.

Comparative Effects of CT Imaging Measurement on RECIST End Points and Tumor Growth Kinetics Modeling

Quantitative assessments of tumor burden and modeling of longitudinal growth could improve phase II oncology trials. To identify obstacles to wider use of quantitative measures we obtained recorded linear tumor measurements from three published lung cancer trials. Model-based parameters of tumor burden change were estimated and compared with similarly sized samples from separate trials. Time-to-tumor growth (TTG) was computed from measurements recorded on case report forms and a second radiologist blinded to the form data. Response Evaluation Criteria in Solid Tumors (RECIST)-based progression-free survival (PFS) measures were perfectly concordant between the original forms data and the blinded radiologist re-evaluation (intraclass correlation coefficient = 1), but these routine interrater differences in the identification and measurement of target lesions were associated with an average 18-week delay (range, -20 to 55 weeks) in TTG (intraclass correlation coefficient = 0.32). To exploit computational metrics for improving statistical power in small clinical trials will require increased precision of tumor burden assessments.

Assessment of cardiac arrhythmias in patients with ankylosing spondylitis by signal-averaged P wave duration and P wave dispersion

OBJECTIVE

Aortic regurgitation, conduction disturbances, increased myocardial fibrosis and pericarditis could be seen in ankylosing spondylitis (AS). However, less attention has been paid to supraventricular arrhythmias (SVA) and atrial conduction system changes. We aimed to assess SVA and conduction system changes in patients with AS.

PATIENTS AND METHODS

Twenty-eight patients (24 men; mean age, 28.7 ± 5.7 years) with AS and 30 healthy volunteers (26 men; mean age, 29.3 ± 5.8 years) were enrolled. All subjects were evaluated by 24-hour ambulatory electrocardiogram, 12 lead standard electrocardiogram (ECG) for P wave dispersion (Pd), and signal-averaged ECG (SAECG) for P wave duration (SAPWD).

RESULTS

SVAs were detected in 9 patients with AS (32%) and 3 controls (10%; p =0.02). Mean SAPWD (115.7±28.6 ms vs. 100.2 ± 18.7 ms, p =0.017) and mean Pd (11.9±4.8 ms vs. 9.3±3.6 ms, 0.023) was longer in patients with AS than the control group. When patient with AS were divided into 2 subgroups as patients with or without SVA, the Pd (16.2±5.0 vs. 9.9±3.2, p =0.001), SAPWD (151.4±7.8 vs. 98.7±16.1, p =0.001) and Bath ankylosing spondylitis disease activity index (BASDAI) (5.1±1.6 vs. 3.7±1.0, p =0.014) were significantly greater in the subgroup with arrhythmias compared to the subgroup without arrhythmias. There was a moderate positive correlation between BASDAI and SAPWD (r=0.622, p =0.001). There was also a moderate positive correlation between BASDAI and Pd (r=0.479, p =0.01).

CONCLUSIONS

SVA were detected more frequently in AS than control group. SAPWD and Pd were prolonged in patients with AS. Clinical severity assessed with BASDAI had a positive correlation with prolongation of SAPWD and Pd.

DW-MRI of liver lesions: can a single ADC-value represent the entire lesion?

AIM

To evaluate whether focal liver lesions (FLLs) exhibit a homogeneous appearance on apparent diffusion coefficient (ADC) maps and whether there is inter-section variation in the calculated ADC values of FLLs (inter-section range).

MATERIALS AND METHODS

Eighty-eight patients with 128 FLLs (70 benign, 58 malignant) who underwent abdominal magnetic resonance imaging (MRI) including diffusion-weighted (DW)-MRI were included. Two observers evaluated variation of signal intensity of each FLL within each ADC map image (intra-section) and among different ADC map images through the lesion (inter-section). ADC values of each FLL and neighbouring liver parenchyma were measured on all sections. The inter-section range of FLLs was compared with the neighbouring liver parenchyma.

RESULTS

Intra-section inhomogeneity was noted in 39.8% (97/244 sections) and 38.9% (95/244) of benign lesions, and 61% (114/187 sections) and 61.5% (115/187) of malignant lesions, by observer 1 and observer 2, respectively. Inter-section inhomogeneity was noted in 25.7% (18/70) and 27.1% (19/70) of benign lesions, and 51.7% (30/58) and 50% (29/58) of malignant lesions, by observer 1 and observer 2, respectively. The inter-section range for both benign (0.28 × 10(-3) mm(2)/s) and malignant (0.25 × 10(-3) mm(2)/s) FLLs were significantly greater than that of liver parenchyma surrounding benign (0.16 × 10(-3) mm(2)/s, p < 0.001) and malignant (0.14 × 10(-3) mm(2)/s, p = 0.01) FLLs.

CONCLUSION

Due to intra-/inter-section variations in ADC values of benign and malignant FLLs, a single ADC value may not reliably represent the entire lesion.