Transcatheter tricuspid valve-in-valve: evolution of tricuspid hydraulic performance and respective changes of right ventricular anatomy and function

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter tricuspid valve-in-valve replacement (TVIV) is an emerging therapy for dysfunctional surgically implanted bioprostheses. There are few data about the evaluation of hydraulic performance of these valves.

Purpose

Purpose of this single-center study was to evaluate the evolution of the right ventricular anatomy and function and the respective changes of TVIV hydraulics.

Methods

Six patients who underwent Sapien S3 TVIV (size 29mm) were studied (age 57 ± 11years, 3/6 in sinus rhythm, all in NYHA class III/IV). Inspiratory (insp) and expiratory (exp) TV mean gradients (mGR) , respective heart rate (HR), right ventricular end-diastolic diameter (RVEDd mm), RV fractional area change (FAC%) and RV free wall longitudinal strain (RV strain) were estimated at baseline (B), 1 month (1m) and later than 6 months (>6m).

Results

NYHA class fell by at least 1 scale at 1m and remained either stable or further improved at 6m.

RVEDd increased early at 1m (B: 33.5 ± 5.3mm vs 1m: 41.3 ± 3.3mm, p = 0.018) and remained unchanged at >6m (>6m: 41 ± 4.2mm vs 1m: 41.3 ± 3.3mm, p = ns). FAC improved late at 6m (B: 42.6 ± 2.8% vs 6m: 56 ± 6.2% p = 0.04). RV strain remained unchanged (B: -17 ± 5.5% vs 1m: 16 ± 7% vs >6m: -20 ± 6%, p = ns).

The improvement in both mGR-exp and mGR-insp was evident at 1m and remained unchanged afterwards: (mGR-exp: B 9 ± 4mmHg, 1m: 3 ± 2, >6m: 5 ± 1, both p < 0.05 vs B, mGR-insp: B 15 ± 5mmHg, 1m: 6 ± 2, >6m: 8 ± 2, both p < 0.05 vs B). The respective heart rates during measurements at inspiration and expiration were similar (HR-exp: B 72 ± 22bpm, 1m: 81 ± 22bpm, >6m: 65 ± 9bpm, HR-insp: B 75 ± 27bpm, 1m: 79 ± 18bpm, >6m: 69 ± 3bpm)

Absolute values for both mGR-insp and mGR-exp, despite progressive improvement, showed variations exceeding the conventional cut-off for TV prosthetic valve dysfunction of 6 mmHg, despite preserved clinical improvement. Variations of mGR were not related with the respective HR.

Conclusion

Following TVIV, early clinical improvement was related with a concomitant increase in RV volume, whereas RV functional indices showed a delayed response. Conventional echocardiographic hydraulics showed variability, often exceeding threshold for definition of prosthetic valve dysfunction. Thus, the significance of TV gradient after TVIV should be interpreted in the clinical context, taking into account respiratory changes.

O-173 Decline in anti-Müllerian hormone (AMH) concentrations following radioactive iodine (RAI) treatment in women with differentiated thyroid cancer (DTC): a systematic review and meta-analysis

Study question

Does radioactive iodine (RAI) treatment in premenopausal women with differentiated thyroid cancer (DTC) affects ovarian reserve, as evaluated by anti-Müllerian hormone (AMH), antral follicle count (AFC) and follicle-stimulating hormone (FSH)?

Summary answer

AMH concentrations decreased at three, six and 12 months following RAI treatment in women with DTC, whereas no difference was observed regarding FSH.

What is known already

Thyroid cancer is the third most common type of female malignancy and DTC is the most common histopathological type. Thyroidectomy constitutes the mainstay of treatment for DTC, followed by administration of RAI, which acts as an adjuvant therapy to destroy residual cancerous thyroid tissue. However, the effect of RAI on ovarian reserve of these women, as assessed by AMH, AFC and FSH, remains controversial.

Study design, size, duration

A systematic review and meta-analysis was performed aiming to identify studies evaluating the effect of RAI treatment on ovarian reserve in women with DTC. For this purpose, a literature search in the electronic databases PubMed, Scopus and CENTRAL was carried out until 06/12/2020. The primary outcome measure was the effect of RAI on ovarian reserve, as evaluated by AMH, AFC and FSH.

Participants/materials, setting, methods

Studies were eligible if they included premenopausal women with DTC, treated with a single RAI dose and assessed for at least one marker of ovarian reserve repeatedly within 12 months post-RAI.Meta-analysis of weighted data was performed using random effects model. Results were reported as weighted mean difference (WMD) with 95% confidence interval (CI).

Main results and the role of chance

Four prospective eligible studies, published between 2005 and 2020, were eligible for the meta-analysis, evaluating a total of 154 women. The number of participants ranged from 24 to 50. The single dose of RAI used to treat DTC ranged from 50 to 150 mCi. AMH concentrations decreased at three (WMD -1.66 ng/ml, 95% CI -2.42 to -0.91, p < 0.0001; I2 0%), six (WMD -1.58 ng/ml, 95% CI -2.63 to -0.52, p = 0.003; I2 54.7%) and 12 months (WMD -1.62 ng/ml, 95% CI -2.02 to -1.22, p < 0.0001; I2 15.5%) following a single RAI dose compared with baseline (three studies; n = 104). With respect to FSH concentrations, no difference was observed at six (WMD +3.29 IU/l, 95% CI -1.12 to + 7.70, p = 0.14; I2 96.8%) and 12 months (WMD +0.13 IU/l, 95% CI -1.06 to + 1.32, p = 0.83; I2 55.2%) post-RAI compared with baseline (two studies; n = 83). No data on AFC was available.

Limitations, reasons for caution

The small number of studies and patients included, as well as the lack of data on AFC may have compromised the validity of the conclusions drawn. Moreover, subgroup analysis according to female age was not feasible, due to the lack of relevant data.

Wider implications of the findings

The negative effect of RAI on ovarian reserve in premenopausal women with DTC, as indicated by the decreased AMH, should be confirmed by data on AFC, which are currently not available. These findings necessitate close monitoring of ovarian reserve in such women, counselling them regarding the need for fertility preservation.

Trial registration number

N/A

Transcatheter management of valvular regurgitation beyond the aortic valve (mitral - tricuspid valve): Literature overview and future perspectives

The growth of the available transcatheter treatment approaches for the mitral and tricuspid position was accompanied by important clinical trials and studies through the last years. The selection of appropriate candidates for transcatheter techniques requires significant insight into anatomical limitations of each patient undergoing clinical evaluation. Furthermore, technological characteristics of the available devices, and risks and benefits of each potential therapy, play the most important role in a physician's decision. This knowledge should be valuable to both interventional cardiologists and researchers. This paper aims to offer a concise overview of the technological advances in this field of Interventional Cardiology. Trials and studies announced at the major interventional cardiology congresses during 2018 and 2019 were systematically reviewed. Moreover, a literature search in PubMed for the same period identified an amount of publications eligible for inclusion, based on their relevance to the subject, and their potential impact on current guidelines of good clinical practice.

Absorbed dose estimation to cohabitants and co-travelers of patients treated with radioiodine for differentiated thyroid carcinoma

OBJECTIVE

Thyroid remnant ablation with radioiodine is a well-established treatment for patients with differentiated thyroid carcinoma (DTC) after thyroidectomy. After hospitalization of approximately 2-4 days, these patients return home presenting a possible radiation hazard to the people around them. This work aims to estimate the possible radiation burden to people (co-travelers and cohabitants) which came in contact with the patients after their release from the hospital, analyzing data obtained during their hospitalization.

MATERIALS AND METHODS

Data from 1065 patients were used to estimate the possible radiation burden to family members and people that came in contact with the patients, grouping them according to their age, type of contact with the patient (co-traveler, cohabitant) and patient family status, assuming different exposure scenarios for each group and based on the written precautions given to all patients before discharge. Relations between the iodine effective half-life (T_eff), estimated from patient dose rate measurements during hospitalization, patient age and the method used for thyroid preparation for ablation (thyroid hormone withdrawal-THW or administration of recombinant human thyroid stimulating hormone-rhTSH) were also investigated.

RESULTS

Median absorbed dose to adult cohabitants was estimated to be 8.3μSv (0.1-117.2μSv), to babies (0-5yr) 15.7μSv (1.2-196.1μSv), to young children (5-10yr) 13.1μSv (0.8-100.7μSv), to children (10-18yr) 8.4μSv (0.5-116.8μSv) and to co-travelers 4.8μSv (0.2-114.9μSv). The highest doses to cohabitants were estimated in the few cases where the patient was a single parent of one or more children (median children dose 28.9μSv, range 11.2-279.4μSv). A statistically significant difference in median T_eff between THW (15.1h) and rhTSH (13.9h) patient groups was found.

CONCLUSION

Provided necessary precautions are followed, radiation burden to the family members and co-travelers of DTC patients treated with radioiodine following thyroidectomy can be kept well below the corresponding dose limits and constraints.

Quality & safety aspects of nuclear medicine practice: Definitions and review of the current literature

Current literature records a glaring discrepancy between the rapid developments and progress of medicine and the simultaneous deterioration of the quality and safety of the provided health care services. Bibliographic data as far as perceptions of quality and safety in nuclear medicine departments are concerned, are limited and frequently ambiguous. Most nuclear medicine departments provide the same types of services, but not the same quality of service, while patients' perceptions are not always matched by the perceptions of health care providers. The multidimensional nature of quality and safety, deriving from the different criteria and standards by which different groups of the population attempt to interpret and evaluate them, justifies these discrepancies, over most of quality's and safety's dimensions studied. Nuclear medicine's unique characteristic of using radiopharmaceuticals, exposing to ionizing radiation affects dramatically these perceptions, irrespective of whether quality and safety assurance measures already cover radiation protection, instrumentation maintenance, radiopharmaceutical handling, and the management of all the other aspects of patient care. On the other end of the spectrum, patient-centred practice, communication and proper information play as a well decisive role in ensuring patients' satisfaction.

Serum leptin, adiponectin and ghrelin concentrations in post-menopausal women: Is there an association with bone mineral density?

OBJECTIVE

Adipokines and ghrelin exert well-documented effects on energy expenditure and glucose metabolism. Experimental data also support a role in bone metabolism, although data from clinical studies are conflicting. The purpose of this cross-sectional study was to investigate the association of serum concentrations of leptin, adiponectin and ghrelin with bone mineral density (BMD) in post-menopausal women.

METHODS

BMD in lumbar spine and femoral neck, and circulating leptin, adiponectin and ghrelin concentrations were measured in 110 healthy post-menopausal women. Patients with secondary causes of osteoporosis were excluded.

RESULTS

Osteoporosis was diagnosed in 30 (27%) women and osteopenia in 54 (49%). Serum leptin concentrations were positively correlated with both lumbar spine (r=0.343, p<0.01) and femoral neck BMD (r=0.370, p<0.01). Adiponectin concentrations were negatively associated with BMD at both sites (r=-0.321, p<0.01 and r=-0.448, p<0.01 respectively). No significant correlation between ghrelin concentrations and BMD was found. Osteoporotic women had lower body weight, body mass index (BMI) and leptin concentrations, but higher adiponectin concentrations compared with non-osteoporotic women. In multivariate stepwise regression analysis, the association of adiponectin concentrations with BMD remained significant only for femoral neck, after adjustment for body weight or BMI.

CONCLUSIONS

An inverse association between adiponectin and femoral neck BMD was found in post-menopausal women, independently of body weight. The positive association between leptin and BMD was dependent on body weight, whereas no effect of ghrelin on BMD was evident.

Complex association between body weight and fracture risk in postmenopausal women

Osteoporosis is a common disease, characterized by low bone mass with micro-architectural disruption and skeletal fragility, resulting in an increased risk of fracture. A substantial number of studies has examined the possible relationship between body weight, bone mineral density and fracture risk in post-menopausal women, with the majority of them concluding that low body weight correlates with increased risk of fracture, especially hip fracture. Controversies about the potential protective effect of obesity on osteoporosis and consequent fracture risk still exist. Several recent studies question the concept that obesity exerts a protective effect against fractures, suggesting that it stands as a risk factor for fractures at specific skeletal sites, such as upper arm. The association between body weight and fracture risk is complex, differs across skeletal sites and body mass index, and is modified by the interaction between body weight and bone mineral density. Some potential explanations that link obesity with increased fracture risk may be the pattern of falls and impaired mobility in obese individuals, comorbidities, such as asthma, diabetes and early menopause, as well as, increased parathyroid hormone and reduced 25-hydroxy-vitamin D concentrations.

Multivessel spontaneous dissection of the left coronary tree in the postpartum period: case report and review of the literature

Spontaneous coronary artery dissection is a rare cause of myocardial infarction predominantly associated with young women during the third trimester of pregnancy or during the postpartum period. Multivessel spontaneous coronary artery dissection is an even less frequent condition with limited reports in medical literature. Hormonal changes as well as hemodymanic stress are some of the factors that have been implicated in the etiology of this condition. However, the exact pathophysiological process leading to spontaneous coronary artery dissection has not yet been elucidated. The spectrum of clinical presentation ranges from mild symptoms to cardiac arrest. Herein, we report the case of a 39-year-old woman with spontaneous two coronary vessel dissection during her postpartum period presented with ST elevation myocardial infarction on electrocardiogram complicated with pulmonary edema and cardiorespiratory arrest.

New strategies in the treatment of coronary bifurcations

Despite major improvements in stent technology (i.e., drug-eluting stents, DES), treatment of coronary bifurcations is an ever occurring problem of the interventional cardiology. While stenting the main branch with provisional side branch stenting seems to be the prevailing approach, in the era of DES various two-stent techniques emerged (crush) or were re-introduced (V or simultaneous kissing stents, crush, T, culottes, etc.) to allow stenting in the side branch when needed. New techniques in imaging like optical coherence tomography help in better understanding bifurcation anatomy and, thus, have the potential to help us better treat this challenging subset of lesions. In addition, new dedicated bifurcation stents have been proposed in an attempt to overcome limitations associated with current approaches, and they showed promising results in early studies; however, the safety and the efficacy of these devices remain to be seen in the ongoing and upcoming trials. This review focuses on the current approaches and the development of new techniques employed for the treatment of bifurcation disease.

Complex coronary artery anatomy in a patient with prolapsing left atrial myxoma

The case of an asymptomatic patient with prolapsing left atrial myxoma, in whom preoperative coronary angiography revealed a rare coronary artery anatomy in the absence of atherosclerotic obstructive disease, is presented. There was a type IV dual left anterior descending (LAD) artery with intraseptal course of the right aortic sinus-connected (long) LAD artery and an ectopic left circumflex artery originating from the right aortic sinus and having a retroaortic course. The patient underwent successful surgical excision of the mass which was confirmed by histology to be cardiac myxoma. This particular coronary artery anatomy has only been described once, and this is the first reported case of its combination with cardiac myxoma. This report highlights the importance of differentiating between the possible courses of such ectopic coronary arteries. The angiographic signs which enabled differentiation of the intraseptal course of the long LAD artery from the malignant interarterial course with which it is frequently confused are presented.

Isolated right ventricular infarction during percutaneous coronary intervention

Isolated right ventricular infarction (RVI) is an increasingly recognized cause of precordial ST-segment elevation (STE). A patient is described who developed STE in leads V1-V5 secondary to occlusion of the right ventricular branch during stent angioplasty to the right coronary artery. The pattern of precordial STE was thought to be suggestive of anteroseptal myocardial infarction because of progressive STE toward lead V3. Repeat angiography disclosed a patent left anterior descending artery. Subsequent scrutiny of the electrocardiogram (ECG) revealed that leads V2 and V3 were switched and ECG interpretation considering this technical error revealed STE in V2>V3, which favored RVI. Furthermore, the mean spatial ST vector was approximately +120° in the frontal plane producing ST-segment depression in lead I which argued against anteroseptal myocardial infarction and indicated right ventricular epicardial injury. This report highlights that analysis of the ECG using vector concepts is a useful adjunct to pattern recognition for the diagnosis of RVI.

Anosmia after general anaesthesia: a case report

Although anaesthetic drugs are included among the aetiological factors of anosmia, limited reports exist of anosmia induced by general anaesthesia. We present the case of a 60-year-old female patient with a 3-month history of altered smell and taste immediately after recovery from general anaesthesia for a urological operation. The anaesthetic drugs used were fentanyl, propofol and sevoflurane. Clinical examination and a computed tomography brain scan did not reveal any pathology. Psychophysical testing showed anosmia and normal taste function. Imaging studies using single photon emission computed tomography of the brain were performed twice: as a baseline examination; and after odour stimulation with phenyl ethyl alcohol. Normal brain activity without reaction to odorous stimuli suggested peripheral dysfunction or stimuli transmission problems. The patient, after four months of olfactory retraining, demonstrated significant improvement. The onset of the dysfunction in relation with the imaging findings may imply that anaesthetics could induce the olfactory dysfunction.

Treatment of bifurcation lesions with two stents: one year angiographic and clinical follow up of crush versus T stenting

OBJECTIVES

To compare long term outcomes of the crush versus the T technique in bifurcation lesions.

DESIGN

182 consecutive patients were identified who underwent percutaneous coronary interventions for bifurcation lesions with drug eluting stents between April 2002 and January 2004. Two techniques were used according to the operator's discretion: crush (group C, n = 121) or T (group T, n = 61).

RESULTS

In-hospital outcome differed significantly between the two groups. Angiographic follow up was available for 142 (78%) patients. Groups C and T did not differ significantly regarding late loss (0.42 (0.39) mm v 0.34 (0.35) mm, p = 0.52) and rate of restenosis (16.2% v 13.0%, p = 0.80) in both the main and the side branch without final kissing balloon post-dilatation. However, when final kissing balloon post-dilatation was performed, group C had significantly lower late lumen loss (0.23 (0.21) mm v 0.37 (0.33) mm, p = 0.02) and restenosis rate (8.6% v 26.5%, p = 0.04) in the side branch. At one year's clinical follow up, group C compared with group T had lower rates of target lesion revascularisation (14.0% v 31.1%, p = 0.01) and target vessel revascularisation (16.5% v 32.8%, p = 0.02).

CONCLUSIONS

In non-selected bifurcation lesions treated with drug eluting stents, the restenosis rate remains relatively high in the side branch. Compared with the T stenting technique, crush stenting with kissing balloon post-dilatation is associated with a reduced rate of restenosis in the side branch.

Somatostatin receptor expression in vivo and response to somatostatin analog therapy with or without other antineoplastic treatments in advanced medullary thyroid carcinoma

The long-term treatment of metastatic medullary thyroid carcinoma (MTC) with somatostatin (SST) analogs was evaluated in 22 patients with persistant or relapsed disease and with in vivo positive SST receptor (SSTR) tumors. After surgical intervention all patients but one, initially or at a later time, had persistenly (15) or after relapse (7) elevated serum calcitonin (CT, 252-69482 pg/ml) and carcinoembryonic antigen (CEA, 8-1130 ng/ml) concentrations; also, all of them showed positive uptake in 111In-pentetreotide scanning. Daily doses of 0.4-1.0 mg octreotide subcutaneously, or monthly doses of 20-30 mg long-acting octreotide (LAR) intramuscularly for 3-21 months were administered. Systemic chemotherapy (Ch) with or without external radiotherapy (eRT) was given to 13 patients simultaneously. A beneficial effect on pre-existing diarrhea was observed in 8 patients (subjective partial remmission, sPR 36.4%); 10 other patients showed stable disease, while in 4 a worsening of pre-existing diarrhea was observed. CT and CEA concentrations decreased more than 25% in 4 out of 22 patients (18%) and 11 patients showed a decrease of less than 25% (biological SD). No objective response in tumour growth was demonstrated. Patients (10 survivors in group B) treated with Ch+eRT plus Octerotide showed higher sR (92.5%), lower mortality (23.1%), longer mean time to death (130 months) and longer mean total survival (mts) time (145 months) in comparison to group A patients who had 66.7% sR, 33.3% mortality, only 88.5 months mean time to death and 101 months mts-time. Long-term octreotide and octreotide-LAR treatment offers a subjective and biological partial remission in one third and in one fourth of the MTC patients respectively, but it does not improve the natural course of the tumor. It remains to be answered if these drugs, combined with other antineoplastic therapies, have a synergistic effect relating to treatment response and to patient survival and mortality.

Heart rate is the major determinant of diastolic filling pattern during growth: a radionuclide ventriculography assessment

Left ventricular diastolic filling is a fundamental constituent of cardiac performance. Diastolic function in both adults and children can be routinely assessed by radionuclide ventriculography (RNV). It has previously been shown that factors such as heart rate (HR) and age can significantly modify diastolic performance in adults, thus limiting the clinical applicability of RNV diastolic indices. The aim of this study was to investigate various factors that may affect diastolic function in childhood. Seventy-nine children, aged 40 days to 15 years, were enrolled in the study; their HR ranged from 45 to 160 beats per minute (bpm). All had intact cardiac function and were submitted to baseline RNV prior to chemotherapy initiation for malignancies. Using stepwise linear regression analysis, HR was identified as the major factor affecting RNV diastolic indices during growth. Applying univariate regression models, diastolic indices were corrected for a referrence HR of 100 bpm; this substantially reduced variability of RNV diastolic indices along age increments, allowing for the establishment of reference ranges. In conclusion, HR was shown to be the major determinant of RNV diastolic indices during growth. Adjustment for this variable alone can offer reference ranges for the assessment of left ventricular filling in childhood.

Change in the epidemiology of Reiter's syndrome (reactive arthritis) in the post-AIDS era? An analysis of cases appearing in the Greek Army

OBJECTIVE

During the last 5 years we observed a significant decrease in the incidence of newly established cases of Reiter's syndrome (reactive arthritis) in Greek Army personnel. Our study was initiated to validate this observation and to evaluate a possible change in the prevalence of Reiter's syndrome (RS) associated infections.

METHODS

The case records of patients with reactive arthritis (ReA) admitted during the periods 1980-83 and 1989-92 at a large Army Hospital were studied retrospectively and the cases of RS were reviewed. In addition, the prevalence of cases with urethritis and dysentery that presented to the hospital in the same periods was studied in retrospect, as these infections are known to participate in the etiopathogenesis of RS.

RESULTS

A significant decrease in the overall incidence of the randomly presented RS cases during the second 4 year period was detected (27 versus 4 cases, p < 0.0001, chi 2 test). A similar significant decrease in the number of cases with gonococcal and nongonococcal urethritis was observed while the prevalence of dysentery was not significantly altered during the defined intervals.

CONCLUSION

We suggest that the anti-AIDS campaign which began after the years 1984-85 is the principal cause of the observed change of epidemiology of RS cases appearing in the Greek Army.