Echocardiography is inferior to computed tomography in predicting balloon expandable transcutaneous implantation valve size in routine clinical setting-single centre study

Funding Acknowledgements

Type of funding sources: None.

Background

Transcatheter aortic valve replacement (TAVR) became standard of care for selected patients with severe aortic stenosis. Computed tomography (CT) and 2D/3D echocardiography (ECHO) are used for aortic annulus sizing. As a result of increasing number of TAVR more imaging specialists participate in pre-procedural TAVR assessment.

Purpose

The aim of this study was to compare accuracy of ECHO aortic annulus measurements vs CT based parameters for Edward Sapiens TAVR in such environment.

Methods

Data of 145 consecutive patients with TAVR (Sapiens XT or Sapiens 3S) were analysed retrospectively. One radiologist and six echocardiographers trained in aortic annulus size measurements participated in pre-procedural aortic anulus assessment. Aortic annulus area and area derived diameter were measured/calculated in each patient from 3D ECHO data set acquired from mid-oesophageal view and from CT data set, using multiplanar reconstruction. 2D ECHO aortic annulus size was measured from mid-oesophageal 120º view in early systole. 

Results

139 (96%) patients had favourable TAVR result (max. mild aortic regurgitation, single valve implanted). 3D ECHO aortic anulus area and area derived diameter were smaller than corresponding CT parameters (464 ± 99 vs 479 ± 88 mm2, p < 0.001 and 24.2 ± 2.7 mm vs 25.0 ± 5.5, p = 0.002, respectively) and differed between echocardiographers (p < 0.001). 2D ECHO anulus measurement were smaller in comparison to both CT and 3D ECHO area derived diameter (22.6 ± 2.9 vs 25.0 ± 5.5mm, p = 0,013 and 22.6 ± 2.9 vs 24.2± 2.7mm, p < 0.001, respectively). In implanted valves with favourable procedure result, concordance of CT and 3D ECHO aortic annulus area with manufacturer recommended ranges was 79.4% vs 61% (p= 0.001) and for area derived diameter 80.1% vs 61.7% (p = 0.001). Using 3D ECHO measurements 33% of the patients would have hypothetically received inappropriate valve size.

Conclusion

3D ECHO aortic annulus measurements are generally smaller then CT ones. If 3D ECHO based parameters only were used for TAVR (Edward Sapiens) size selection, it would have resulted in underestimation of the valve size in up to 1/3 of the patients. CT aortic annulus size assessment should be preferred method over 3D ECHO in daily practice. Abstract Figure 1  Abstract Table 1

Lipoprotein-associated phospholipase A₂ mass level is increased in elderly subjects with type 2 diabetes mellitus

OBJECTIVE. Lipoprotein-associated phospholipase A₂ (Lp-PLA₂) is extensively expressed by advanced atherosclerotic lesions and may play a role in plaque instability. We selected a group of elderly subjects that underwent transcatheter aortic valve implantation (TAVI) or balloon angioplasty (BA) and separated them into two groups, diabetic and nondiabetic, to compare the level of Lp-PLA₂ mass between them. METHODS. 44 patients aged 79.6 ± 5.6 years with symptomatic severe aortic valve stenosis underwent TAVI (n = 35) or BA (n = 9). 21 subjects had confirmed type 2 diabetes mellitus. Lp-PLA₂ mass was measured using an enzyme-linked immunosorbent assay kit (USCN Life Science, China) before and 3 days after the procedure. RESULTS. Lp-PLA₂ mass was significantly elevated in this population (1296 ± 358 ng/mL before TAVI; 1413 ± 268 ng/mL before BA) and further increased after TAVI (1604 ± 437 ng/mL, P < 0.01) or BA (1808 ± 303 ng/mL, P < 0.01). Lp-PLA₂ mass was significantly increased on the diabetic group before these interventions. CONCLUSION. Lp-PLA₂ may be a novel biomarker for the presence of rupture-prone atherosclerotic lesions in elderly patients. Levels of Lp-PLA₂ in diabetic patients may accompany the higher amount of small dense LDL particles seen in these subjects.

Failure of noninvasive prediction of pulmonary hypertension in patients with idiopathic pulmonary fibrosis

BACKGROUND

Pulmonary hypertension (PH) in patients with advanced idiopathic pulmonary fibrosis (IPF) is a complication connected with unfavorable prognosis. Great efforts have been made in attempting to establish a reliable non-invasive method which would enable detection of this complication. In this context a formula using pulmonary function parameters was published with outstanding results.

METHODS

We tested the formula in 27 IPF patients who underwent a lung function examination, cardiac ultrasonography and catheterisation on the same day.

RESULTS

Pulmonary hypertension was detected by catheterisation in 17 patients (63%). In our group, contrary to the published data, the aforementioned formula was neither useful for detecting patients with a high probability of PH nor as a means of calculating the mean pulmonary artery pressure in individual patients (p = 0.502 and p = 0.833, respectively). Ultrasound examination reached borderline correlation with the values measured by catheterisation when we compare patients with relevant results (r = 0.531, p = 0.051). However, the examination gave no usable results in 13 patients (48%).

CONCLUSION

Our data suggests that no reliable, noninvasive method is currently available for detecting and confirming PH in IPF patients. We did not confirm the usefulness of the published formula. Further carefully organised studies will be necessary to verify or refute it.

[Bicuspid aortic valve--ethiopathogenesis and natural history]

Bicuspid aortic valve is a disease with autosomal dominant inheritance with small penetration. The population of patients with bicuspid aortic valve is heterogenous. In the absence of dilatation of ascending aorta, valvular lesion or degenerative changes of valve leaflets patients are considered to belong to the low risk population. On the other hand patients with the above mentioned characteristics compose a high risk group. Dilatation of the ascending aorta in patients with bicuspid aortic valve has a progressive feature and continues even after replacement of the aortic valve. With progression of aortic dilatation the risk of aortic dissection and rupture increases. The main reasons for aortic dilatation are changes in quality of aortic wall and possibly mechanical stress of aortic wall during asymmetrical and turbulent flow. The progression of aortic dilatation or aortic valve disease is not essentially influenced by farmacologic treatment. Surgery is the treatment of choice. Physiology and pathophysiology of bicuspid and tricuspid aortic valves, prevalence of bicuspid aortic valve in general population and in the group of patients operated on for aortic valve disease, phenotypes of bicuspid aortic valve and follow-up of asymptomatic patients with normal bicuspid valve are reviewed in this article. Indications for operation of dilated ascending aorta according to american, european and czech guidelines are discussed.

Neutrophil apoptosis by Fas/FasL: harmful or advantageous in cardiac surgery?

Polymorphonuclear leukocytes or neutrophils are the main executors of cellular death, both in septic inflammation during bacterial infection and in sterile inflammation during trauma or surgery. Whereas in septic inflammation neutrophils perform a useful function to fortify the host's defense against infection, in sterile inflammation, by contrast, they contribute to unwelcome tissue damage. Regardless of the situation, activated neutrophils exhibit a prolonged lifespan and delayed apoptotic death which, under normal conditions, is a prerequisite for their natural renewal. Traditionally, delayed neutrophil apoptosis was considered to promote trauma or surgical injury. According to the results of recent studies, however surprising they may appear, the reverse might be in keeping with what happens IN VIVO. Apoptotic signaling in neutrophils could, by contrast, contribute to intrinsic protection of the host's tissues. This review article, aimed preferentially but not exclusively at the cardiac surgeon, presents some new information in support of this viewpoint, which fits in with our own observations.

[Increase in troponin levels after coronary angioplasty (PTCA) in stable angina pectoris]

GOAL

To determine frequency of elevated troponin levels following PTCA in patients with stable angina pectoris. To identify risk factors related to troponin elevation.

METHOD

Multicentric prospective study. Troponin I level (cTnI) was determined in a group of 261 patients treated for stable angina pectoris with coronary angioplasty (PTCA) 12 hours after the intervention. A group of patients with cTnI levels above the upper level of a normal range was compared to patients without troponin elevation. Clinical, angiography, and peri-procedural indicators were assessed and frequency of their incidence in both groups of patients was compared.

RESULTS

Elevation of cTnI levels above the upper levels of the normal range was identified in 32 patients (12.3%). There were no differences in age, risk factors for ischemic heart disease (IHD), nor number of impaired coronary arteries between this group of patients and the rest of them. Associated antithrombotic treatment (acetylsalicylic acid + ticlopidine 87.5% vs. 86.9%, p = NS; low-molecular heparin for PTCA 46.9% vs. 57.2%, p = NS) was comparable in both groups. On angiography, according to ACC/AHA, lesions were worse in patients with elevated cTnI (2.73 vs. 2.33, p = 0.02). Troponin elevation was significantly more often connected with calcification of coronary arteries (37.5% vs. 17%, p = 0.03), with intracoronary thrombus on angiography (15.6% vs. 2.2%, p = 0.05), and with increased number of implanted stents (1.13 vs. 0.90, p = 0.03). Incidence of peri-procedural complications (temporarily occluded artery, arterial dissection type C and worse, forced administration of inhibitors GP IIb/IIIa) was comparable. Chest pain after PTCA was accompanied with consecutive elevation of cTnI in 40%, while in absence of chest pain cTnI was elevated only in 8% of patients.

CONCLUSION

Elevation of troponin after PTCA in stable angina pectoris is significantly related to angiography findings in treated lesion. Elevation of cTnI is comparable both in use of unfractionated heparin during PTCA and in use of low-molecular heparin during PTCA. A combined antiaggregation treatment with acetyl salicylic acid (ASA) and ticlopidine did not lead to a lower incidence of cTnI elevation compared to treatment only with ASA. Heaviness in chest after PTCA has low positive and high negative predictive value for cTnI elevation.

[Surgical myocardial revascularization in a female patient with bilateral occlusion of the common carotid arteries]

Concurrent stenosis of the coronary and carotid circulation is one of the most serious disease. The authors describe the case of a 74-year old female patient with ischaemic heart disease with concurrent bilateral occlusion of the common carotid arteries. Surgical revascularization of the myocardium was made using extracorporeal circulation under general normothermia with protection of the heart muscle from ischaemia by the method of warm blood cardioplegia. In the discussion the authors analyze contemporary possibilities of surgical treatment of ischaemic disease (MIDCAB, OPCAB, operations with extracorporeal circulation) and emphasize the advantages and risks of different procedures.

[Primary PTCA in the treatment of acute myocardial infarct. Experience at the Faculty Hospital in Hradec Kralove]

INTRODUCTION

Primary coronary angioplasty is at present a fully accepted and worldwide method of treatment of acute myocardial infarction. As proved by a number of randomized studies, this treatment is associated with a higher rate of coronary patency, a smaller infarction focus an better clinical results as compared with thrombolytic treatment.

METHOD

The authors analyzed a register of 233 consecutively treated patients with primary coronary angioplasty in the Faculty Hospital in Hradec Králové with elevation of the ST sections on electrocardiographic examination during the period from September 1997-January 2001.

RESULTS

Acute success defined as a residual stenosis < 30%, normal flow through the vessel (TIMI III) and survival for the first 24 hours was 91.0% and without patients with cardiogenic shock even 96.0%. The total mortality on hospitalization was 9.1%. The mortality of patients without cardiogenic shock was only 1.9%. A high mortality was recorded in patients in cardiogenic shock (74.0%). A stent was implanted in 65.0% patients, subacute thrombosis of the stent occurred in 1.9%. During a 6-month follow up the total mortality was 10.3%. The percentage of patients without any cardiovascular even (event free survival, EFS) after discharge from hospital was 81.0%.

CONCLUSIONS

The authors provided evidence that primary coronary angiolpasty is a safe and highly effective method in the treatment of acute myocardial infarction. It is associated with a total hospitalization mortality of ca 10% and a mortality of less than 2% in patients without cardiogenic shock. Cardiogenic shock, on the other hand, remains a problem despite intensive treatment such as inotropic support, mechanical reperfusion and intraortal balloon counterpulsation. In the presented work the mortality of patients with cardiogenic shock was 74.1%. Implantation of a stent does not involve a major risk for the patient, the incidence of subacute thrombosis of the stent is low and does not differ from elective procedures. The fate of patients during the follow up after primary angioplasty is favourable. In the presented work the total 6-month mortality was 10.3% and EFS was 81.0%.

[The post-perfusion syndrome after operations performed with extracorporeal circulation]

Postperfusion syndrome (PPS) is a dreaded complication of cardiac surgery operation in extracorporeal circulation (ECC). Four factors play a key role in its pathophysiology: 1. contact of blood with the material of ECC, 2. release of activated leucocytes from pulmonary bed after the release of aortic cross-clamp, 3. translocation of endotoxin due to gut ischemia and its consequent reperfusion, 4. activation of coagulation, fibrinolytic, kallikrein-kinin and complement systems. The occurrence of PPS can be limited by reducing the ECC time and/or cross-clamp time, by using membrane oxygenator in the system of ECC, by using polyester or polypropylene in the set of ECC, by using heparin-coated set or leucocyte filter in the system of ECC, by application of pharmacological dosis of corticosteroids prior to the ECC, by early enteral nutrition. In eligible patients it is possible to eliminate the risk of PPS completely by using the operation without ECC. The experience of the authors with above mentioned problems is given and confronted with literature.

[Percutaneous rescue transluminal coronary angioplasty]

Rescue angioplasty is an operation performed in the acute stage of myocardial infarction where systemic thrombolysis did not lead to opening of the artery. Investigations made in recent years indicate the benefit of rescue angioplasty only in those patients where the infarcted artery is patent several hours after evidence that thrombolysis failed. At the same time they provide evidence of the increasing safety and technical success of the operation. The authors present a brief review of the literature pertaining to the development of views, and emphasize the need of early and correct indication.

Hemothorax--a complication of subclavian vein cannulation

Massive bleeding into pleural cavity after subclavian vein cannulation is a rather rare but very serious complication. Usually laceration of the venous wall is the cause. In patients where conservative treatment, i.e. pleural drainage, maintaining the circulatory volume, treatment of possible coagulopathy, etc. is ineffective, surgery has to be performed. Bleeding can be surgically managed either from posterolateral thoracotomy or direct subclavian vessel revision is possible after partial resection of the clavicle. Brachiocephalic vein bleeding can be approached and managed through median sternotomy. We present a case report of 22-year old man with hemothorax after subclavian vein cannulation. In our patient only complex surgical procedure enabled proper management of bleeding complication.

Concomitant coronary and asymptomatic carotid artery disease in patients prior to myocardial revascularization

The authors report on the results of ultrasound examinations of the carotid arteries in 525 patients with ischemic heart disease, hospitalized at the Department of Cardiac Surgery in Hradec Králové, prior to myocardial revascularization. Only 213 patients (40.6%) had intact carotid bed. The remaining 312 patients (59.4%) were found to have asymptomatic sclerotic changes of varying degrees of severity. Haemodynamically significant stenoses of over 50% were found in 64 cases (12.2%). 19 patients (3.6%) had critical stenoses of over 85% or occlusions of one or both internal carotid arteries. Comparison between patients younger than 65 and older than 65 showed significant increase of sclerotic changes in the older group. The authors prefer to perform myocardial revascularization procedure in hypothermic CPB with alpha-stat regime before carotid artery surgery. Combined procedures are preferred only in cases with concomitant neurologic and coronary symptomatology or in cases with severe carotid stenoses or occlusions of both arteries.