There is more than just longitudinal strain: prognostic significance of biventricular circumferential mechanics

 

Global longitudinal strain is a well-established predictive parameter of adverse outcomes in several cardiac diseases, therefore, it is widely used in clinical practice. Despite the significant contribution of circumferential shortening to the global ventricular function, data are scarce concerning the biventricular circumferential strain phenotypes and their prognostic value on long-term mortality.

Accordingly, the aim of our study was to assess both left (LV) and right ventricular (RV) global circumferential strain (GCS) using 3D echocardiography in order to determine the prognostic importance of the deterioration of biventricular circumferential mechanics.

Three hundred and sixty-four patients with various established left-sided heart diseases were retrospectively identified (age: 64.8±15.0 years, 69% males) with a median follow-up of 41 months. All patients underwent clinically indicated transthoracic echocardiography and left (LV) and right ventricular (RV) ejection fractions (EF) were measured by 3D analysis. 3D LV and RV GCS were also quantified by dedicated softwares. In order to determine the prognostic power of the different patterns of biventricular circumferential mechanics, we divided the patient population into four groups using the median values of LV and RV GCS (absolute values of 27.1% and 17.9%, respectively). Group 1 consisted of patients with both LV and RV GCS above median values; Group 2 was defined as patients with LV GCS above the median, while RV GCS below the median, whereas in Group 3 patients had LV GCS values below the median, while RV GCS was above median. Group 4 was defined as patients with both LV and RV GCS below the median. The primary endpoint of our study was all-cause mortality.

Fifty-five patients (15.1%) met the primary endpoint. The overall patient population showed balanced values of LV and RV EF (49.0±15.7 and 48.2±9.4%, respectively). Comparing the population separated into the above-mentioned four groups based on LV and RV GCS values enabled a detailed risk stratification as shown on the Kaplan-Meier curve (Figure 1.) When comparing Group 1 vs. Group 4, patients who had lower LV and RV GCS values the risk of all-cause mortality was more than 5 times higher than in patients with both LV and RV GCS above the median (HR, 5.240 [95% CI, 2.750–9.985], p<0.001). By comparing Group 2 with Group 3, the associated risks for all-cause mortality did not show a difference (HR, 0.461 [95% CI, 0.178 to 1.194], p=NS) as shown on the Kapan-Meier curve (Figure 2).

Based on the different phenotypes of LV and RV GCS, decreased biventricular circumferential shortening was associated with a significantly increased risk of long-term all-cause mortality. Interestingly, decreased RV GCS with maintained LV GCS showed a similar risk of adverse outcomes than decreased LV GCS with maintained RV GCS. Our results emphasize the importance of the assessment of biventricular circumferential mechanics.

Funding Acknowledgement

Type of funding sources: None.

Assessment of right ventricular segmental volumes and ejection fractions using a 15-segment model: three-dimensional echocardiographic study in healthy volunteers

Funding Acknowledgements

Type of funding sources: None.

On top of global ventricular function, segmental metrics may bear clinically relevant information. Concerning the left ventricle (LV), standardized segmentation is widely performed in different cardiovascular imaging modalities mainly to correlate regional dysfunction with coronary perfusion territories, or to appreciate and quantify distinct patterns in LV myocardial function. The same applies to the right ventricle (RV); as pulmonary hypertension, or arrhythmogenic cardiomyopathy are just two clinical examples among several others, where established regional dysfunction exists. Nevertheless, only a few options are available for the comprehensive and quantitative assessment of the segmental RV function due to its complex three-dimensional (3D) shape.

Therefore, our aim was to develop a 3D echocardiographic software solution for volumetric partitioning of the RV using a 15-segment model and to investigate a large number of healthy volunteers to describe the normal segmental pattern.

One hundred and fifty healthy adults with a balanced age range and an equal sex distribution were investigated (15-15 women and men in each age groups: 20-29, 30-39, 40-49, 50-59, 60+). Beyond standard two-dimensional echocardiographic protocol, full volume 3D datasets were acquired. Using commercially available software, we reconstructed the 3D mesh model of the RV and measured end-diastolic (EDV), end-systolic volumes and ejection fraction (EF). The 3D model was post-processed using the ReVISION method to calculate regional and segmental volumes and EFs. Fifteen standard segments were separated and quantified (Figure).

Increasing age resulted in significantly lower RV stroke volume (r=-0.17; p < 0.05) and tended towards lower RV EDV (r=-0.15, p = 0.06). EDVs of inflow tract and outflow tract segments decreased during aging (r=-0.21, p < 0.05 and r=-0.26, p < 0.01, respectively). Between the pre-specified age groups, there was no difference concerning global RVEF (ANOVA p = NS). In the 50-59 age group, regional EF of septal segments and also free wall segments were significantly lower compared to subjects in the 30-39 and 40-49 age categories (both p < 0.05). Global RV EDV was significantly lower in women (women vs. men: 95 ± 20 vs. 125 ± 28 ml; p < 0.05) along with a higher RV EF compared to men (62 ± 4 vs. 59 ± 4; p < 0.05). However, segmental EFs of apical, septal mid anterior, free wall mid posterior, free wall mid lateral, septal basal anterior and inflow tract segments were comparable between genders.

The ReVISION method allows a volumetric partitioning of the RV 3D models to investigate segmental geometry and function in a 15-segment model. We have explored segmental differences between different ages and genders. Further studies are warranted to justify the importance of segmental assessment of the RV in different cardiac diseases.

Abstract Figure. Separation of 15 standard RV segments

[Sensory nerve function after unilateral digital vascular-nerve injury: nerve repair with and without arterial repair]

PURPOSE

This study compares the clinical results of microsurgical nerve repairs in unilateral digital arterial-nerve-injuries with and without repair of the finger artery.

PATIENTS AND METHODS

Between January 2000 and May 2007 a total of 81 patients with unilateral digital vascular nerve bundle lesions, including concomitant soft-tissue tendon lesions, were operated on the emergency day. Forty of the 56 patients treated with a nerve repair alone took part in a follow-up after an average of 47 (7-87) months. Twenty of the 25 patients treated with a microsurgical arterial and nerve repair took part in a follow-up after an average of 12 (6-66) months; 3 patients were excluded due to a negative digital Allen-test. In addition to anamnestic data, peripheral nerve function was evaluated by the static and the moving two-point discrimination test, and by Semmes-Weinstein pressure aesthesiometer in the autonomous zone of the affected side of the injured finger. Stereognosis also was examined. The patency of the reconstructed digital artery was tested by a digital Allen-test.

RESULTS

No statistically significantly worse results were found in patients with a nerve repair alone compared to patients with additional repair of the finger artery.

CONCLUSION

Repair of the finger artery therefore appears to offer no improvement of the clinical outcome following nerve repair in unilateral injury of a digital arterial-nerve bundle.

Benchmarking with Spine Tango: potentials and pitfalls

The newly released online statistics function of Spine Tango allows comparison of own data against the aggregated results of the data pool that all other participants generate. This comparison can be considered a very simple way of benchmarking, which means that the quality of what one organization does is compared with other similar organizations. The goal is to make changes towards better practice if benchmarking shows inferior results compared with the pool. There are, however, pitfalls in this simplified way of comparing data that can result in confounding. This means that important influential factors can make results appear better or worse than they are in reality and these factors can only be identified and neutralized in a multiple regression analysis performed by a statistical expert. Comparing input variables, confounding is less of a problem than comparing outcome variables. Therefore, the potentials and limitations of automated online comparisons need to be considered when interpreting the results of the benchmarking procedure.

[Working ability after tendon interposition arthroplasty for degenerative arthritis of the thumb trapeziometacarpal joint]

Trapeziometacarpal arthrosis is the second most common disorder in the field of degenerative joint diseases of the hand, appearing ten to fifteen times more often in females older than 50 than in men of the same age group. Thus, an age group is afflicted where the hands are needed for occupational activity in addition to the physical strain of constant housework. However, no systematic data concerning the postoperative ability to perform household and or occupational activities have been reported. The aim of this study is to give better advice to future patients during office visits prior to the operation. For this, we evaluated different professions, postoperative working ability, occupational rehabilitation (housework or occupational activity), remaining discomfort and complications. We used a list of questions including the DASH questionnaire and sent it to patients after performing a tendon interposition arthroplasty. Forty-seven of the 52 patients of working age and under the age of 60 years returned the questionnaire. Patients were, according to their profession, classified into 4 different groups: manually heavy work, manually light work, office work and housework. Judging from the recorded data, we conclude that approximately 90% of the patients regained their preoperative working ability. Patients were unable to work for an average period of 8 weeks postoperatively and could only work part-time (50%) for another 8 weeks. There is a positive correlation between incapacity and the kind of work to be performed. Housewives/-men returned approximately to their preoperative status of working ability after a period of three months. Light pain is possible. The risk of disability pension due to persistent painful inability to use the hand is rather low despite the operation. Manually light working people evaluate the outcome of the operation as less good than manually heavy working people, office workers or housewives/-men.

Harris lines of the tibia across centuries: a comparison of two populations, medieval and contemporary in Central Europe

OBJECTIVE

To determine the incidence of Harris lines in two medieval populations which inhabited the Canton of Berne, in Central Switzerland, and to compare the results with those of a contemporary population living in the same geographical area. A simplified method is described for measuring the age of the individual at the time of formation of Harris lines, with possible future applications.

DESIGN AND PATIENTS

Radiographs of 112 well-preserved tibiae of skeletons of two medieval populations from the eighth to fifteenth centuries were reviewed for the incidence of Harris lines. The results were compared with those of 138 current patients living in the same geographic location in Central Switzerland. Age and gender of the medieval individual were determined using known anthropological methods. Age of bone at the time of formation of Harris lines was estimated according to the method of Maat.

RESULTS

Harris lines were found in 88 of 112 (80%) of the examined medieval skeletons and in 28 of 138 (20%) of the living individuals. Higher incidences of Harris lines were found at the age of 2 years and at ages between 8 and 12 years in both populations. No gender difference was found regarding the incidence of Harris lines. In both populations the occurrence of Harris lines was associated with certain diseases such as degenerative bone disease, trauma, osteoporosis, rheumatoid arthritis, peripheral vascular diseases, rickets and bony deformities.

CONCLUSION

A high incidence of Harris lines was found in the medieval population, perhaps reflecting difficult living and hygienic conditions, but also the poor care and neglect of the children population. Measuring the age of the individual at the time of formation of Harris lines is simple and may have future clinical applications in the paediatric population for medico-legal purposes. The application of Harris lines as a marker in follow-up of osteoporosis may need further evaluation.

Acute stroke care in non-urban emergency departments

OBJECTIVE

To evaluate the practice patterns for stroke care in rural emergency departments (ED).

METHODS

The authors prospectively evaluated clinical practice decisions for all ED patients in two non-urban East Texas communities using active and passive surveillance methods. Data collected included demographics, risk factors, symptoms, and treatment. Data analysis consisted of descriptive statistics and logistic regression analysis.

RESULTS

During the study period, 429 patients presented with validated strokes. Risk factors included hypertension (65%), previous stroke (41%), coronary artery disease (33%), diabetes (25%), current smoking (17%), and atrial fibrillation (11%). In the ED, neurology consultation occurred in 32%, head CT in 88%, and ECG in 85%. Heparin was used in 9%, and 5% received aspirin. Blood pressure was lowered in 19% from a mean high of 189(+/-38)/97(+/-26), average reduction 34 points (18%) systolic. Motor symptoms were more likely to prompt a neurology consultation (OR = 2.47). Heparin was used more commonly for patients with atrial fibrillation (OR = 2.93). Socioeconomic factors did not alter care. IV recombinant tissue plasminogen activator was used in 1.4% of ischemic stroke cases.

CONCLUSIONS

Acute stroke care in this representative non-urban community frequently does not follow published guidelines or clinical trial results. Whereas a high percentage of patients receive CT, aggressive blood pressure treatment occurs commonly and at pressures below current recommendations. The use of heparin is common, more so than aspirin treatment. These facts argue for educational interventions aimed at non-urban physicians to improve evidence-based medical practice.

Activation of emergency medical services for acute stroke in a nonurban population: the T.L.L. Temple Foundation Stroke Project

BACKGROUND AND PURPOSE

Activating emergency medical services (EMS) is the most important factor in reducing delay times to hospital arrival for stroke patients. Determining who calls 911 for stroke would allow more efficient targeting of public health initiatives.

METHODS

The T.L.L. Temple Foundation Stroke Project is an acute stroke surveillance and intervention project in nonurban East Texas. Prospective case ascertainment allowed chart abstraction and structured interviews for all hospitalized stroke patients to determine if EMS was activated, and if so, by whom.

RESULTS

Of 429 validated strokes, 38.0% activated EMS by calling 911. Logistic regression analysis comparing those who called 911 with those who did not activate EMS found that individuals who were employed were 81% less likely to have EMS activated (OR 0.19, 95% CI 0.04 to 0.63). Of the 163 cases in which 911 was called, the person activating EMS was: self (patient), 4.3%; family member of significant other, 60. 1%; paid caregiver, 18.4%; and coworker or other, 12.9%. Significant associations between the variables age group (P=0.02), insurance status (P=0.007), and living alone (P=0.05) with who called 911 was found on chi(2) analysis.

CONCLUSIONS

Educational efforts directed at patients themselves at risk for stroke may be of low yield. To increase the use of time dependent acute stroke therapy, interventions may wish to concentrate on family, caregivers, and coworkers of high-risk patients. Large employers may be good targets to increase utilization of EMS services for acute stroke.

Stroke in Hispanic Americans

The Hispanic American population is the fastest growing minority group with increasing representation among the older age strata. Current ethnic-specific cerebrovascular disease data regarding stroke outcomes and risk factor status reveal significant differences compared with other race/ethnic groups. The authors discuss the literature on stroke incidence and mortality among Hispanic populations. Traditional risk factors, access to care and stroke mechanism differences are also discussed. Advances in Hispanic American specific stroke prevention and treatment efforts demand further investigation to better define Hispanic American stroke prevention and acute treatment strategies.