A Call to Consider an Aortic Stenosis Screening Program

Aortic stenosis (AS) is the most common age-related valvular condition with a prevalence of 13.1% in patients older than 75 years of age. Based on the severity of AS and symptoms, current guidelines recommend interval monitoring with transthoracic echocardiogram (TTE). However, no guidelines exist regarding screening asymptomatic persons for AS. Prevalence of AS is comparable to conditions such as colorectal cancer, lung cancer, breast cancer, and abdominal aortic aneurysm where dedicated screening programs are offered resulting in reduction of overall morbidity and mortality. We review recent advancements in treatment options, and we propose an AS screening program for high-risk individuals without known history of AS including all persons over age 75 and persons aged 70 years and older with dialysis dependent end-stage renal disease (ESRD).

Delayed cervical cancer diagnosis: a systematic review

OBJECTIVE

Cervical cancer (CC) is a preventable women's cancer. Vaccination and routine Pap smear screening have reduced cervical cancer-related mortality by 70-80% in the world. The eradication of CC depends on identifying the disease early and removing barriers to its timely detection. This review study was designed to determine diagnostic delay and factors related to delayed CC diagnosis in the world.

MATERIALS AND METHODS

A comprehensive search was carried out in databases including Medline, Web of Science, Core Collection (Indexes = SCI-EXPANDED, SSCI, A & HCI Timespan), and Scopus for articles published up to December 2021. Publications were included if they reported data on the delayed CC, and factors related to diagnosis of CC in women. There was no time restriction in this review.

RESULTS

In total, 45 articles were entered into the study. In studies, advanced stages of CC (IIB to IV) varied from 10.2% to 87.9% due to delayed diagnosis. A delayed CC diagnosis was reported in 4.3%-89.1% of patients. The median and mean days of delayed diagnosis were 59-210 days and 2.92-10.5 months, respectively. Factors related to delayed CC diagnosis were categorized into three components including patient, medical history, and health system delay. Patient delay included socio-demographic, husband/ partner, and knowledge. Medical history included medical issues, obstetrics, and family history. Health system delays included health facilities and levels of accessibility.

CONCLUSIONS

There is an urgent need to shorten the diagnostic journey of CC patients by addressing all the components of diagnostic delay and developing strategies to modify the factors associated with these delays.

Prognostic Value of Coronary Artery Calcification Identified by the Semi-quantitative Weston Method in the Emergency Room or Other Hospitalized Patients

Background: Coronary artery calcification (CAC) may provide insight to the patients' coronary artery disease (CAD) risks and influence early intervention. With increasing use of non-gated CT scans in clinical practice, the visual coronary artery scoring system (Weston Method) could quickly provide clinicians with important information of CAC for patient triage and management.

Methods: We retrospectively studied the available CT imaging data and estimated CAC burden using the Weston method in 493 emergency room or other hospitalized patients. The Weston scores were calculated by the sum of the score for each vessel including the left main, left anterior descending, left circumflex artery and right coronary artery (range 0–12). The primary endpoint was a composite of the major adverse cardiac events (MACEs), including cardiac death, myocardial infarction, stroke, and coronary revascularization.

Results: During a median follow-up of 85 months, a total of 25 (5.1%) MACE were recorded and 57 (11.2%) patients died from any causes. Detectable CAC was most common (96%) in the left anterior descending coronary arteries. Multivariable analysis showed that CAC total scores were independent predictors for MACE and all-cause mortality. Receiver operating characteristic analysis showed that CAC total score ≥5 was the optimal cutoff value for predicting MACEs.

Conclusions: In the emergency room and hospitalized patients, the semi-quantitation of CAC burden using the Weston score system was related to the long-term cardiovascular outcomes including mortality. Clinicians and radiologists should maximize the value of non-contrast chest CT images by reporting CAC details.

Ascending Aortic Stenting for Acute Supraaortic Stenosis From Graft Collapse

A 78-year-old man with remote type-A dissection presented with acute-onset dyspnea. Twenty-two years prior, treatment for his aortic disease required replacement of ascending and arch aneurysms with a polyester graft (Dacron) using the graft inclusion technique. He presented currently in cardiogenic shock. Echocardiography demonstrated new severe hypokinesis of all apical segments. Left-heart catheterization revealed a 120 mm Hg intragraft gradient. Computed tomography arteriography was unrevealing, but intraaortic ultrasound demonstrated critical intragraft stenosis. A balloon expandable stent (Palmaz stent, Cordis, Milpitas, CA) was deployed in the stenotic region with gradient resolution. The patient later underwent aortic root replacement and ascending aneurysm repair (Bio-Bentall technique) and is doing well at 24 months.

AXSIS: Exploring the frontiers in attosecond X-ray science, imaging and spectroscopy

X-ray crystallography is one of the main methods to determine atomic-resolution 3D images of the whole spectrum of molecules ranging from small inorganic clusters to large protein complexes consisting of hundred-thousands of atoms that constitute the macromolecular machinery of life. Life is not static, and unravelling the structure and dynamics of the most important reactions in chemistry and biology is essential to uncover their mechanism. Many of these reactions, including photosynthesis which drives our biosphere, are light induced and occur on ultrafast timescales. These have been studied with high time resolution primarily by optical spectroscopy, enabled by ultrafast laser technology, but they reduce the vast complexity of the process to a few reaction coordinates. In the AXSIS project at CFEL in Hamburg, funded by the European Research Council, we develop the new method of attosecond serial X-ray crystallography and spectroscopy, to give a full description of ultrafast processes atomically resolved in real space and on the electronic energy landscape, from co-measurement of X-ray and optical spectra, and X-ray diffraction. This technique will revolutionize our understanding of structure and function at the atomic and molecular level and thereby unravel fundamental processes in chemistry and biology like energy conversion processes. For that purpose, we develop a compact, fully coherent, THz-driven atto-second X-ray source based on coherent inverse Compton scattering off a free-electron crystal, to outrun radiation damage effects due to the necessary high X-ray irradiance required to acquire diffraction signals. This highly synergistic project starts from a completely clean slate rather than conforming to the specifications of a large free-electron laser (FEL) user facility, to optimize the entire instrumentation towards fundamental measurements of the mechanism of light absorption and excitation energy transfer. A multidisciplinary team formed by laser-, accelerator,- X-ray scientists as well as spectroscopists and biochemists optimizes X-ray pulse parameters, in tandem with sample delivery, crystal size, and advanced X-ray detectors. Ultimately, the new capability, attosecond serial X-ray crystallography and spectroscopy, will be applied to one of the most important problems in structural biology, which is to elucidate the dynamics of light reactions, electron transfer and protein structure in photosynthesis.

Physiologic Guidance of Infrainguinal Vascular Interventions Using the Pressure Wire

OBJECTIVES

To assess the relationship between the resting (RG) and hyperemic (HG) translesional peripheral gradients, with the functional and anatomic parameters before and after an infrainguinal endovascular procedure.

BACKGROUND

RGs and HGs are objective tools in defining the hemodynamic significance of an arterial stenosis.

METHODS

In 25 subjects with infrainguinal arterial stenosis, RG and HG were measured via a pressure wire before and after angioplasty. Before and after the procedure, all subjects had an ankle-brachial index (ABI) and Duplex ultrasound evaluation, recording prelesion and in-lesion peak systolic velocity (PSV-L), and calculating a peak systolic velocity ratio (PSV-R). A Pearson R correlation coefficient was calculated.

RESULTS

The mean age was 73 ± 12 years, 70% were men, median Rutherford class 3. At baseline and after angioplasty, mean ABI was 0.78 ± 0.2 and 0.99 ± 0.1, mean PSV-L was 459 ± 110 cm/s and 126 ± 35 cm/s, and mean PSV-R was 6.7 ± 4 and 1.2 ± 0.5, respectively. RG and HG significantly improved (P<.001) from baseline to after angioplasty (28.7 ± 20.5 mm Hg to 5 ± 13 mm Hg and 40.2 ± 21.4 mm Hg to 10 ± 13 mm Hg, respectively). RG before and after the procedure correlated well with ABI (r = -0.58; r = -0.41), PSV-L (r = 0.40; r = 0.52), and PSV-R (r = 0.46; r = 0.42). An improvement of 9 mm Hg in RG predicted a change of 0.1 in ABI.

CONCLUSIONS

Improvement in RG during endovascular intervention in superficial femoral artery correlates well with the improvement in ABI, PSV-L, and PSV-R. A postprocedural decrease in RG of 9 mm HG predicts an improvement in ABI of 0.1.

Aortic dissection presenting as acute subtotal left main coronary artery occlusion: a case approach and review of the literature

Aortic dissection is the most common fatal condition of the aorta, yet it is often missed on initial clinical presentation. Aortic dissection associated with acute coronary syndrome (ACS) is relatively rare, but if it occurs, it can be diagnostically challenging, and the condition can be fatal. Here we describe a case of aortic dissection presenting as ST-segment elevation myocardial infarction (STEMI) managed via the transradial approach. We describe the current literature on the subject.

Tips and tricks for antegrade recanalization of chronic total occlusions using the CrossBoss catheter

OBJECTIVES

To provide new strategies and techniques for the successful recanalization of chronic total occlusions (CTOs) with the sole use of the CrossBoss catheter. In addition, some common CTO scenarios are illustrated in detail.

BACKGROUND

CTOs are one of the most challenging complex coronary lesion subsets to intervene upon. Even with the innovation of specialized catheters, the success rate of antegrade recanalization remains low.

METHODS

Between June and December 2013, a retrospective analysis of 50 consecutive patients who presented with a planned percutaneous intervention (PCI) of a CTO was performed. In all patients, the CrossBoss catheter was used. No additional reentry devices were necessary. Procedural success was defined as <20% residual stenosis and TIMI-3 distal blood flow of the treated vessel at the end of the procedure.

RESULTS

The majority of the patients were male (72%), with an average age of 68 years. Thirty percent of patients presented with prior CTO-PCI failure. The average fluoroscopy time was 45.9 minutes and the average amount of contrast use was 273.8 mL. No patient suffered a coronary perforation from the CrossBoss catheter.

CONCLUSIONS

With increased experience using the CrossBoss catheter, the antegrade success rate of CTOs can be improved. Some tips include identifying the likely course of the artery with the aid of retrograde injection, proper guidewire selection and manipulation, and redirecting the CrossBoss catheter if there is substantial deviation from the original path.

Outcomes of patients undergoing elective percutaneous coronary interventions in the ambulatory versus in-hospital setting

OBJECTIVES

To compare outcomes of elective percutaneous coronary interventions (PCI) in same-day discharge and overnight hospital stays.

BACKGROUND

Advances in PCI techniques and equipment have allowed same-day discharge after elective PCI. In this study, we investigated the safety of same-day discharge ambulatory PCI in patients according to age, creatinine, and ejection fraction (ACEF) scores.

METHODS

The ambulatory PCI group consisted of all PCIs with same-day discharge, while the overnight-stay group consisted of all elective PCIs with in-hospital observation and discharge the following day. Patients were stratified into tertiles based on ACEF score: low (<1.08), mid (≥1.08 and <1.31), and high (≥1.31). The primary endpoint was 30-day major adverse cardiac events, defined as readmission, all-cause mortality, non-fatal myocardial infarction, and target lesion revascularization. Propensity score matching was done to evaluate outcomes based on similar baseline characteristics.

RESULTS

There were 16,407 elective PCIs, of which 21.2% were in the ambulatory group. Patients who stayed overnight had similar 30-day composite outcomes as their same-day discharge counterparts in the high ACEF score (odds ratio [OR], 1.213; 95% confidence interval [CI], 0.625-2.355; P=.57) and mid ACEF score (OR, 0.636; 95% CI, 0.356-1.134; P=.13) comparisons, but had worse outcomes in the low ACEF score comparison (OR, 1.867; 95% CI, 1.134-3.074; P=.01).

CONCLUSIONS

In this single-center registry, patients who underwent same-day discharge ambulatory PCI had no worse outcomes, and in some cases better outcomes, than overnight-stay patients; this result was found in the group as a whole, as well as in all ACEF score subcategories.

Low-density lipoprotein levels in patients with acute heart failure

Statins do not appear to have a significant benefit in heart failure (HF) as they do in coronary artery disease (CAD). Significant evidence exists that low serum cholesterol levels may be harmful in HF. This study sought to determine the optimal low-density lipoprotein (LDL) level in patients hospitalized with acute HF. Patients were included if they presented to the hospital with acute HF and had a lipid panel drawn during admission. The primary outcome was all-cause mortality, and secondary outcomes were rates of major cardiovascular (CV) events, left ventricular assist device (LVAD) implantation, and orthotopic heart transplantation (OHT). A total of 2428 patients were followed for a mean of 2.9±2.2 years. For the entire cohort, when compared with those with LDL levels >130 mg/dL, all-cause mortality was higher in those with LDL levels <71 mg/dL (hazard ratio, 1.68; 95% confidence interval, 1.31-2.167; P<.01). Results were similar when analyzing patients with LVEF ≤40%, HF of ischemic etiology only, and in statin users. The rates of CV events, LVAD implantation, or OHT in any comparison did not differ. Low LDL levels (<71 mg/dL), similar to low total cholesterol levels, were associated with a poorer prognosis and higher overall mortality in patients with HF, regardless of etiology and systolic function.

Coronary artery disease in a large renal transplant population: implications for management

Coronary artery disease (CAD) accounts for approximately one-half of the sizable mortality in patients with end-stage renal disease who have undergone transplantation. The study was a retrospective review of 1460 patients who underwent renal transplantation at the Mount Sinai Medical Center from January 1, 2000 to October 31, 2009. Noninvasive stress testing was performed in 848 patients (88.1%) with 278 patients (32.8%) having abnormal results. Cardiac catheterization was performed in 357 patients (37.1%) and of these, 212 patients had obstructive disease (59.4%). At 5 years posttransplant, there was no statistically significant difference between those with nonobstructive CAD and those who required percutaneous or surgical interventions (adjusted hazard ratio [aHR], 1.243; CI 95%, 0.513-3.010; p = 0.630). Those with medically managed obstructive CAD had significantly higher rates of death at the 5-year period when compared to those who received percutaneous intervention (aHR, 3.792; CI 95%, 1.320-10.895; p = 0.013) or those who received coronary artery bypass grafting (aHR, 6.691; CI 95%, 1.200-37.323). Because noninvasive imaging is poorly predictive of coronary disease in this high-risk population, an anatomic diagnosis is recommended. Revascularization may result in improved long-term outcomes.

Modeling and characterization of the amino propeptide of collagenα1(XI), a regulatory domain in collagen fibrillar architecture

Connective tissues such as cartilage, tendon, skin, bone, and arteries are composite bio-materials that contain predominantly water, collagen, proteoglycans and hyaluronic acid. Like any composite material, the components themselves and their interactions dictate the properties of the material. Fibrillar collagens are the principal structural molecules of the connective tissues and require regulated assembly and growth. Previous work from our lab indicates that the amino propeptide (Npp) domain of collagen type XI α1 chain regulates fibril diameter growth. Npp is a globular domain that is thought to sterically hinder the dense packing assembly of collagen molecules in fibrils. This mechanism of regulating collagen fibril assembly may be more complex than steric hindrance. We hypothesize that the Npp domain has a more dynamic role in establishing the structure/function relationship of collagen fibrils in connective tissues. In this study, the molecular structure of Npp was predicted by modeling. The model predicted putative binding sites for heparan sulfate and divalent cations. These predicted binding sites were evaluated empirically by fluorescence spectroscopy and surface plasmon resonance.

Initial experience of removal of 10-French sheaths using the 8-French Angio-Seal vascular closure device

OBJECTIVES

We studied the use of 8 Fr Angio-Seal in closure of access sites up to 10 Fr.

BACKGROUND

The use of larger French catheters for procedures such as valvuloplasty and percutaneous valve replacement has required the use of better methods for arterial closure. The use of 6 and 8 Fr Angio-Seal hemostatic devices (St. Jude Medical, St. Paul, Minnesota) has been well described and are routinely used for diagnostic and interventional procedures up to 8 Fr in size. However, no data are available for the use of an 8 Fr Angio-Seal device in the closure of access sites up to 10 Fr.

METHODS

In our center, we evaluate the incidence of vascular complications following the use of an 8 Fr Angio-Seal device with 10 Fr sheaths in patients undergoing aortic valvuloplasty.

RESULTS

Of 53 procedures, there was only 1 vascular complication, a ruptured pseudoaneurysm, which required vascular repair.

CONCLUSIONS

Our data suggest that an 8 Fr Angio-Seal device can be utilized effectively and safely in procedures requiring larger access sites up to 10 Fr.

Structural model of the amino propeptide of collagen XI alpha1 chain with similarity to the LNS domains

Fibrillar collagens are the principal structural molecules of connective tissues. The assembly of collagen fibrils is regulated by quantitatively minor fibrillar collagens, types V and XI. A unique amino-terminal propeptide domain of these collagens has been attributed this regulatory role. The structure of the amino terminal propeptide has yet to be determined. Low sequence similarity necessitated a secondary structure-based method to carry out homology modeling based upon the determined structure of LNS family members, named for a common structure in the laminin LG5 domain, the neurexin 1B domain and the sex hormone binding globulin. Distribution of amino acids within the model suggested glycosaminoglycan interaction and calcium binding. These activities were tested experimentally. Sequence analyses of existing genes for collagens indicate that 16 known collagen alpha chains may contain an LNS domain. A similar approach may prove useful for structure/function studies of similar domains in other collagens with similar domains. This will provide mechanistic details of the organization and assembly of the extracellular matrix and the underlying basis of structural integrity in connective tissues. The absolute requirement for collagen XI in skeletal growth is indicated by collagen XI deficiencies such as chondrodystrophies found in the cho/cho mouse and in humans with Stickler syndrome.