Successful percutaneous mitral valve leaflet repair for primary mitral regurgitation results in functional improvement and positive cardiac reverse remodelling

Funding Acknowledgements

Type of funding sources: None.

Background

Percutaneous mitral valve leaflet repair can be an effective treatment for primary mitral regurgitation (MR) patients deemed high-risk for surgery. Accurate assessment of cardiac reverse remodelling is essential to optimise future patient selection. Cardiovascular magnetic resonance (CMR) is the reference standard for cardiac volumetric assessment and compared to transthoracic echocardiography (TTE) provides superior reproducibility in MR quantification. Prior CMR studies have analysed cardiac reverse remodelling following percutaneous intervention in combined cohorts of primary and secondary MR patients. However, as aetiology of MR can significantly impact outcomes, focused studies are warranted.

Purpose

Assess cardiac reverse remodelling and quantify changes in MR following percutaneous mitral valve leaflet repair for primary MR using the reference standard (CMR).

Methods

12 patients with at least moderate-severe MR on TTE were prospectively recruited to undergo CMR imaging and 6-minute walk tests (6MWT) at baseline and 6 months following percutaneous mitral valve leaflet repair (MitraClip). CMR protocol involved: left-ventricular (LV) short axis cines (bSSFP, SENSE-2, 10mm, no gap), transaxial right-ventricular (RV) cines (bSSFP, SENSE-2, 8mm, no gap), two and four chamber cines and aortic through-plane phase contrast imaging, planned at the sino-tubular junction. MR was quantified indirectly using LV and aortic stroke volumes.

Results

12 patients underwent percutaneous mitral valve leaflet repair (MitraClip) for posterior mitral valve leaflet prolapse, however 1 patient declined follow up after single-leaflet clip detachment resulting in 11 patients (age 83 ± 5years, 9 male) completing follow up imaging. At 6-months: significant improvements occurred in New York Heart Association functional class (Table 1) and 6MWT distances (223 ± 71m to 281 ± 65m, p = 0.005) and significant reductions occurred in indexed left ventricular end-diastolic volumes (LVEDVi) (118 ± 21ml/m2 to 94 ± 27ml/m2, p = 0.001), indexed left ventricular end-systolic volumes (58 ± 19ml/m2 to 48 ± 21ml/m2, p = 0.007) and quantitated MR volume (55 ± 22ml to 24 ± 12ml, p = 0.003) and MR fraction (49 ± 9.4% to 29 ± 14%, p= <0.001). There were no statistically significant changes in left ventricular ejection fraction (LVEF), right ventricular dimensions/ejection fraction or bi-atrial dimensions (Table 1). All patients demonstrated decreased LVEDVi and quantified MR (Figure 1).

Conclusion

Successful percutaneous mitral valve leaflet repair for primary MR results in reduction in MR, positive LV reverse remodelling, preservation of LVEF, and functional improvements. Larger CMR studies are now required to further guide optimal patient selection.

Testosterone in chronic heart failure

Chronic heart failure is common and can be described as a syndrome characterized by impairment of cardiac function associated with a maladaptive metabolic and neurohormonal axis. The thesis that testosterone replacement therapy may be helpful as a treatment for chronic heart failure may seem at first to be unlikely. Testosterone therapy is widely believed to be deleterious to the cardiovascular system and there is a common misconception that the excess of ischaemic heart disease in young and middle-aged males compared to females is a direct effect of endogenous serum testosterone levels. In this chapter we will present the published evidence of the effects of endogenous and therapeutic testosterone on the heart and the human cardiovascular system with an emphasis on the pathologic syndrome of chronic heart failure. There is developing evidence that of all morbid populations, patients with chronic heart failure in particular are likely to benefit from testosterone treatment since the natural history is that of progressive disordered metabolism with catabolic excess and androgen imbalance.

Investigation of anthropometric and work-rate profiles of Rugby Sevens players

BACKGROUND

To describe anthropometric and match performance profiles of international Rugby Sevens players and explore correlations between anthropometric characteristics and work-rates in matches.

METHODS

Profiles were compared by means of multivariate analysis and correlation techniques.

SETTINGS

measurements were made on players participating in the 1996 International Rugby Sevens tournament in Uruguay.

SUBJECTS

Thirty male players.

MEASURES

work-rate analysis during matches (n = 30) and a comprehensive anthropometry profile of 27 of the 30 players.

RESULTS

Forwards had more mass (whole-body, adipose tissue, muscle) than backs, jogged more frequently and paused more often. High intensity activity was negatively correlated with muscle mass and with mesomorphy.

CONCLUSIONS

Anthropometric features are related to components of match play in Rugby Sevens but do not necessarily determine whether a game is won or lost.

Hip flexion contracture in cerebral palsy. The association between clinical and radiologic measurement methods

Hip flexion contracture was examined in 51 spastic cerebral palsy patients by three clinical methods and two radiologic methods. An extremely low association was found between the clinical and radiologic methods with no particular method, clinical or radiologic, showing a higher association. The method of clinical examination should be chosen by convenience. Radiologic measurements by the methods used did not add useful information.

[Fractures of the proximal femur]

907 patients were operated on for fracture of the proximal femur in 1986-1987 and were then followed for an average of 7 months. There was a relatively high rate of complications in those over the age of 71, in whom mortality reached 15.5%, while the overall mortality was 6.8%. There was also a high rate of complications in those operated 3 or more days after the fracture had occurred. In those up to the age of 60, the ratio of males to females was almost 1 to 1, but in those over 80 the ratio was 1 to 4. The mortality of males was higher (9.2%) than that of females (5.5%). In trochanteric fractures treated by various methods of rigid fixation there were no problems of union or delayed union. Early mobilization and early discharge from hospital reduced mortality and complications.

Blood levels of vitamin D metabolites in gonarthrosis

The blood levels of the active metabolites of vitamin D3 25-hydroxycholecalciferol [25(OH)D3]. 1,25-dihydroxycholecalciferol [1,25(OH)2D3], and 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were determined in 27 patients suffering from arthrosis of the knee, including 4 patients with non-insulin-dependent diabetes mellitus. The blood level of 24,25-dihydroxycholecalciferol was found to be significantly lower in patients with gonarthrosis than in patients with coxarthrosis. With the exclusion of the diabetic patients, the mean value for this metabolite was lower than in the coxarthrosis group, but the difference was not significant statistically.

Preoperative and postoperative gait evaluation in cerebral palsy

The purpose of the study was to evaluate objectively and quantitatively the possible effects of surgical correction for equinus deformity on the gait of children with cerebral palsy (CP). Evaluation criteria selected were based on time and distance parameters of stride during gait. Ten children with confirmed diagnoses of CP took part in the study. They were tested before surgery and after surgery at four-month intervals for a period of up to one year. Results were compared to published data obtained on able-bodied, growing children to determine whether progress after the operation was faster than that expected in normal growth. Gait improvement was demonstrated by a decrease in support time and an increase in walking speed and stride length. Overall improvement was sometimes preceded by an initial, temporary deterioration. Results indicate that the time and distance parameters of stride can provide reliable objective evaluation of gait improvement after tendo Achilles lengthening in children with CP.

Blood levels of active metabolites of vitamin D3 in fracture repair in humans. A preliminary report

Blood levels of the active metabolites of vitamin D3, 25-hydroxycholecalciferol [25(OH)D3], 1,25-dihydroxycholecalciferol [1,25(OH)2D3] and 24,25-dihydroxycholecalciferol [24,25(OH)2D3] were determined in seven patients. Two subjects suffered from delayed union of tibial fractures; one showed a delayed union after a proximal tibial osteotomy; one patient suffered from bilateral femoral neck fractures, of which one failed to unite and the other united late; two patients had multiple fractures that united normally; and one patient exhibited staged bilateral femoral neck fractures whose occurrence was separated by a short interval and which united without undue delay. The blood levels of 25(OH)D3 were within the normal range. A relative decrease in 24,25(OH)2D3 values was noted in all patients, whereas in three subjects the decrease was absolute, to non-detectable levels. A decrease in 1,25(OH)2D3 levels was noted in only two patients. We postulate that these changes reflect the consumption of these metabolites during healing at the fracture site.

Active metabolites of vitamin D in patients with coxarthrosis and with aseptic loosening of total hip endoprostheses

The blood levels of the active metabolites of vitamin D--25-hydroxycholecalciferol (25(OH)D), 1,25 dihydroxycholecalciferol (1,25(OH)2D), and 24,25 dihydroxycholecalciferol (24,25(OH)2D)--were determined in 15 patients suffering from arthrosis of the hip and in 13 patients with aseptic loosening of total hip endoprostheses. Normal values were found in all but one patient with aseptic loosening, in whom 24,25(OH)2D was not detectable. The difference between the two groups of patients was not statistically significant.

Computerized tomography in the diagnosis and treatment of osteoid osteoma

Thirteen cases of osteoid osteoma demonstrated with computerized tomography are reported. Twelve patients underwent definitive surgery and were relieved of their symptoms. The histological examination confirmed the preoperative diagnosis in 11 cases. Six lesions were located in the proximal femur, three in the neck of the talus, two in the proximal tibia, and one each in the proximal humerus and the calcaneus. Radionuclide technetium 99m MDP scans were performed in 11 cases and showed an increased uptake in the vicinity of the lesions. Computerized tomography showed the precise location of the nidus, thus helping in the preoperative planning of the surgical approach and enabling us to perform a precise and economic resection.

Lateral patellar release and bone grafting of the tibial plateau in total condylar knee arthroplasties. A technical note

In a review of 50 primary total condylar knee arthroplasties in 25 female and in 14 male patients the factors affecting the necessity of lateral patellar release and bone grafting of the medial tibial plateau were established. Lateral patellar release was performed in 18 of 33 arthroplasties in female patients, in only two of 17 operations in male patients, and on all but one of the knees with preoperative valgus deformity. Bone grafting of the medial tibial plateau was necessary mainly in small knees, i.e., for six of 18 small prostheses in contrast to one of 15 standard-sized implants in female patients and in none of the operated knees in males.

Progressive valgus deformity after juxta-epiphyseal fractures of the upper tibia in children

Four cases of progressive valgus deformity following a juxta-epiphyseal fracture of the proximal end of the tibia are presented. We suggest that the deformity is due to asymmetrical growth of the physis. Since this type of fracture tends to create a deformity, an anatomical or even overcorrected reduction is required. Long follow-up is necessary.

Disruption of the symphysis pubis and fatigue fractures of the pelvis in a patient with rheumatoid arthritis. A case report

A 40-year-old woman, who suffered from severe rheumatoid arthritis causing avascular necrosis of the femoral head and protrusio acetabuli of the right hip, developed a severe spontaneous disruption of the symphysis pubis concomitant with a stress fracture of the left ilium adjacent to the left sacroiliac joint. After successful total hip arthroplasty, the symphysiolysis improved, but a new stress fracture of the left superior pubic ramus developed. Fourteen months after operation both stress fractures are healed. Altered hip and pelvic girdle mechanics acting on osteoporotic bone may account for this sequence of events.

The total condylar knee prosthesis: a review of 71 operations

Seventy-one operations are reviewed, in which knees were replaced with the total condylar prosthesis. The follow-up period ranged between 1 and 7 years, with an average of 3.25 years. Osteoarthritis was diagnosed preoperatively in 53 knees and rheumatoid arthritis in 18. The results obtained in cases of osteoarthritis were better than those in cases of rheumatoid arthritis. The prognosis was adversely affected by obesity, preoperative flexion contracture of 30 degrees or more, wound-healing problems, wound infection, and postoperative manipulation under general anesthesia. The overall results were excellent in 48% of cases (34 knees), good in 28% (20 knees), fair in 11.3% (eight knees), and poor in 4.3% (three knees). Failure was experienced in 8.4% of cases (six knees).

Total hip arthroplasty and acetabular bone grafting for unreduced fracture-dislocation of the hip

Functional restoration after chronic persistent fracture-dislocation of the hip was achieved by total hip arthroplasty (THA) in two patients with history of severe multiple injuries. Acetabular deficiency was corrected by use of the femoral head as an autologous bone graft. A 24-year-old man and a 42-year-old woman were treated for persistent fracture-dislocation of the hip two years and one year, respectively, after the accidents. In both, total hip arthroplasty in combination with acetabular bone grafts, with the femoral head, produced satisfactory clinical results at follow-up periods of 59 and 55 months.

Bone grafting in total hip replacement for acetabular protrusion. A review of 11 operations

In 11 total hip replacement operations performed on nine patients with acetabular protrusion, the deficient acetabulum was reinforced with a bone graft from the femoral head in ten operations and in one from the greater trochanter and the femoral medullary canal. Acetabular meshes were used in two operations and a fine wire mesh in one. At follow-up, averaging 18 (8-28) months postoperatively, a solid bone socket for the acetabular component had formed in all hips without evidence of loosening or infection.

The inverted Y approach to the talus and ankle joint

A case of a comminuted fracture of the body of the talus and the medial malleolus is reported. The inverted Y approach was used to expose the talus and ankle joint, facilitating reduction and internal fixation.

Fatigue fracture of the pubic ramus following total hip arthroplasty with unusual delayed healing

A 73-year-old woman with fatigue fracture of the right pubic rami following total hip arthroplasty had a long delay to union. Discrepancy in leg lengths due to nonunion of an intertrochanteric osteotomy of the contralateral hip may have contributed to the fatigue fracture of the pubic rami. The postarthroplasty fatigue fractures in patients reported in the literature were of the compression type and healed within a few weeks. In the patient reported here, the fracture was of the distraction type and was characterized by failure of callus formation with slow healing requiring two years to union.

Epiphyseometaphyseal cupping of the distal femoral epiphysis following scurvy in infancy

Bilateral epiphyseometaphyseal cupping of the distal femoral epiphysis occurred in a 9-year-old girl with a history of infantile scurvy. This rare condition is characterized by a cup-shaped depression of the metaphyseal end, growth disturbance at the distal femoral epiphysis and knee flexion contracture which develops slowly over many years of bone growth. Conservative treatment by corrective plasters and back slabs brought about recovery of the right knee flexion contracture and halted the growth disturbance. However, in the left knee, extension supracondylar femoral osteotomies had to be performed and severe growth disturbance of the distal femoral epiphysis led to premature epiphyseal fusion.

Osteoporosis, scurvy, and siderosis in Johannesburg bantu

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