Mitral valve gradient changes associate with outcomes of patients undergoing transcatheter edge-to-edge repair

INTRODUCTION

Transcatheter edge-to-edge repair (TEER) is typically used to treat mitral regurgitation (MR) in patients with high surgical risk. Increased post-procedural mitral valve gradient (MVG) may impact mortality and hospitalizations. We aim to evaluate and compare the absolute postprocedural MVG and the change in the MVG effect on outcomes for patients undergoing TEER therapy.

METHODS

Patients who underwent TEER for severe MR were divided into two groups, initially by postprocedural absolute MVG, TTE-based at discharge, and then by the difference between preprocedural and postprocedural MVG. Primary endpoints included all-cause mortality and heart failure hospitalization (HFH) during one year after the procedure.

RESULTS

The study included 100 patients. The mean MVG increased from 3.39 mmHg immediately after the procedure to 4.83 mmHg the following day, an increase of 1.44 mmHg (p < 0.001). First stratification was by MVG on the day following the procedure - MVG ≤5 mmHg (n = 70) and MVG >5 mmHg (n = 30). There was no significant difference in rates of survival (88.6%, 93.3%, p = 0.716) or HFH (18.6%, 33.3%, p = 0.178). Second stratification was by the difference in preprocedural and postprocedural MVG- delta MVG <3 mmHg (n = 55) and delta MVG ≥3 mmHg (n = 45). While survival rates did not significantly differ (87.3% vs. 93.3%, p = 0.503), delta MVG ≥3 mmHg correlated with higher HFH rates (12.7% vs. 35.6%, p = 0.014).

CONCLUSIONS

The MVG of patients undergoing TEER usually increases on the day after the procedure compared to the immediate post-procedure MVG. Higher delta MVG is associated with higher HFH rate.

Urgent transcatheter edge-to-edge repair for severe mitral regurgitation with flail leaflet in critically Ill patients

Introduction

Degenerative mitral valve disease (DMR) is a common valvular disorder, with flail leaflets due to ruptured chordae representing an extreme variation of this pathology. Ruptured chordae can present as acute heart failure which requires urgent intervention. While mitral valve surgery is the preferred mode of intervention, many patients have significantly elevated surgical risk and are sometimes considered inoperable. We aim to characterize patients with ruptured chordae undergoing urgent transcatheter edge-to-edge repair (TEER), and to analyze their clinical and echocardiographic outcomes.

Methods

We screened all patients who underwent TEER at a tertiary referral center in Israel. We included patients with DMR with flail leaflet due to ruptured chordae and categorized them into elective and critically ill groups. We evaluated the echocardiographic, hemodynamic, and clinical outcomes of these patients.

Results

The cohort included 49 patients with DMR due to ruptured chordae and flail leaflet, who underwent TEER. Seventeen patients (35%) underwent urgent intervention and 32 patients (65%) underwent an elective procedure. In the urgent group, the average age of the patient was 80.3, with 41.8% being female. Fourteen patients (82%) received noninvasive ventilation, and three patients (18%) required invasive mechanical ventilation. One patient died due to tamponade, while echo evaluation of the other 16 patients demonstrated successful reduction of ≥2 in the MR grade. Left atrial V wave decreased from 41.6 mmHg to 17.9 mmHg (p < 0.001), and the pulmonic vein flow pattern changed from reversal (68.8%) to a systolic dominant flow in all patients (p = 0.001). After the procedure, 78.5% of patients improved to New York Heart Association (NYHA) class I or II (p < 0.001). There was no significant difference in the overall mortality between the urgent and elective groups, with similar 6 months survival rates for each group.

Conclusion

Urgent TEER in patients with ruptured chordae and flail leaflets can be safe and feasible with favorable hemodynamic, echocardiographic, and clinical outcomes.

Metabolic and Renal Effects of Mammalian Target of Rapamycin Inhibitors Treatment After Liver Transplantation: Real-Life Single-Center Experience

BACKGROUND

Mammalian target of rapamycin (mTOR) inhibitors following liver transplantation (LT) are used to minimize calcineurin inhibitor (CNI)-related nephrotoxicity. Data about metabolic effects of mTOR inhibitors are still limited.

AIM

This study aims to determine the renal and metabolic effects of different mTOR inhibitor-based protocols in real-life LT patients.

METHODS

This is a retrospective cohort study of patients treated with mTOR inhibitors after LT. Demographics, treatment protocols, glomerular filtration rate (GFR), and metabolic parameters were collected over a period of 4 years. Initiation of blood pressure (BP), diabetes mellitus, and lipid medications was also noted.

RESULTS

Fifty-two LT recipients received mTOR inhibitors. GFR improved significantly (by 1.96 mL/min/year), with greater improvement in patients with baseline renal dysfunction (+13.3 mL/min vs +4.5 mL/min at 3 years). Conversion to an mTOR inhibitor during the first post-transplant year resulted in a more durable improvement in GFR (for 4 years vs only 1 year for later conversion).No significant weight gain or new-onset diabetes mellitus was observed. However, there was some increase in total cholesterol (+7 mg/dL) and blood pressure (+2 mm Hg during the third year and +8 mm Hg in the fourth years), followed by initiation of lipid-lowering and BP medications in 25% and 13% of patients, respectively.

CONCLUSIONS

Treatment with an mTOR inhibitor following LT resulted in improved kidney functions without significant negative metabolic effects such as weight gain or new-onset diabetes mellitus. This makes mTOR inhibitors a valuable immunosuppressive option in the face of the growing incidence of nonalcoholic steatohepatitis as a leading cause for LT.

Empirical validation of statistical parametric mapping for group imaging of fast neural activity using electrical impedance tomography

Electrical impedance tomography (EIT) allows for the reconstruction of internal conductivity from surface measurements. A change in conductivity occurs as ion channels open during neural activity, making EIT a potential tool for functional brain imaging. EIT images can have  >10 000 voxels, which means statistical analysis of such images presents a substantial multiple testing problem. One way to optimally correct for these issues and still maintain the flexibility of complicated experimental designs is to use random field theory. This parametric method estimates the distribution of peaks one would expect by chance in a smooth random field of a given size. Random field theory has been used in several other neuroimaging techniques but never validated for EIT images of fast neural activity, such validation can be achieved using non-parametric techniques. Both parametric and non-parametric techniques were used to analyze a set of 22 images collected from 8 rats. Significant group activations were detected using both techniques (corrected p  <  0.05). Both parametric and non-parametric analyses yielded similar results, although the latter was less conservative. These results demonstrate the first statistical analysis of such an image set and indicate that such an analysis is an approach for EIT images of neural activity.

Functional hyposplenism is an important and underdiagnosed immunodeficiency condition in children

AIM

Few studies have focused on paediatric hyposplenism/asplenism, in which splenic phagocytic activity is diminished or absent in an anatomically present spleen. This study aimed to evaluate clinical findings, laboratory tests and prognosis of children with functional hyposplenism/asplenism.

METHODS

The study group comprised 74 children who had liver/spleen technetium-99m sulphur colloid scintigraphy from 2002 to 2008. Information collected included demographic features, background diseases, blood smear findings, indications for scintigraphy and outcome. Children with functional hyposplenism were followed until 2012.

RESULTS

We found that 34 patients had functional hyposplenism/asplenism. The main indications for scintigraphy in the hyposplenic patients were persistent thrombocytosis and recurrent infections. Associated conditions included immunodeficiencies, autoimmune diseases, malignancies and genetic disorders. Main infections were sinopulmonary infections, bacteraemia and sepsis. The major pathogens were Streptococcus pneumoniae and Haemophilus influenza group A. There was no correlation between the presence of Howell-Jolly bodies in blood smear with clinical disease severity or scintigraphic findings. Repeated scintigraphy showed spontaneous normalisation in 40% of patients.

CONCLUSION

Functional hyposplenism is an important and underdiagnosed immunodeficiency condition in children, associated with various clinical conditions including prolonged unexplained thrombocytosis, immune deficiency and autoimmunity. Technetium-99m sulphur colloid scintigraphy is the method of choice for evaluating splenic function.

A novel method for recording neuronal depolarization with recording at 125-825 Hz: implications for imaging fast neural activity in the brain with electrical impedance tomography

Electrical impedance tomography (EIT) is a recently developed medical imaging method which has the potential to produce images of fast neuronal depolarization in the brain. Previous modelling suggested that applied current needed to be below 100 Hz but the signal-to-noise ratio (SNR) recorded with scalp electrodes during evoked responses was too low to permit imaging. A novel method in which contemporaneous evoked potentials are subtracted is presented with current applied at 225 Hz to cerebral cortex during evoked activity; although the signal is smaller than at DC by about 10×, the principal noise from the EEG is reduced by about 1000×, resulting in an improved SNR. It was validated with recording of compound action potentials in crab walking leg nerve where peak changes of -0.2% at 125 and 175 Hz tallied with biophysical modelling. In recording from rat cerebral cortex during somatosensory evoked responses, peak impedance decreases of -0.07 ± 0.006% (mean ± SE) with a SNR of >50 could be recorded at 225 Hz. This method provides a reproducible and artefact free means for recording resistance changes during neuronal activity which could form the basis for imaging fast neural activity in the brain.

Design of electrodes and current limits for low frequency electrical impedance tomography of the brain

For the novel application of recording of resistivity changes related to neuronal depolarization in the brain with electrical impedance tomography, optimal recording is with applied currents below 100 Hz, which might cause neural stimulation of skin or underlying brain. The purpose of this work was to develop a method for application of low frequency currents to the scalp, which delivered the maximum current without significant stimulation of skin or underlying brain. We propose a recessed electrode design which enabled current injection with an acceptable skin sensation to be increased from 100 muA using EEG electrodes, to 1 mA in 16 normal volunteers. The effect of current delivered to the brain was assessed with an anatomically realistic finite element model of the adult head. The modelled peak cerebral current density was 0.3 A/m(2), which was 5 to 25-fold less than the threshold for stimulation of the brain estimated from literature review.

Phase-averaged characterization of respiratory sinus arrhythmia pattern

A method for the accurate time-domain characterization of respiratory sinus arrhythmia (RSA) pattern is presented and applied to two groups of healthy subjects to lay the baseline of RSA patterns and to underlay their features: response to standing, stability in successive recordings, and individuality of the shape of RSA pattern. RSA pattern is evaluated by selective averaging of heart rate (HR) changes from multiple respiratory cycles over the respiratory phase and represents the complete modulating function of HR by respiration. The RSA pattern is evaluated with free respiration and even in cases of severe arrhythmia. Estimation error is 6–8% in magnitude, phase resolution is 0.2 rad, and sensitivity margin for respiratory-related HR variability (HRV) components is 1%. RSA magnitude, phase lag, and expiration-to-inspiration time ratio are derived in addition to the entire pattern. In a group of 10 healthy young adults, a phase lag difference of 11.4 ± 8.5% (mean ± SD, P < 0.004) was observed between supine and standing postures, possibly ascribed to breathing mechanics. A second group of 15 healthy young adults at supine rest showed stability of the RSA pattern in successive recordings (several weeks apart) as well as individuality among subjects. This may suggest a nonscalar individual long-term index for cardiorespiratory coupling. The method is complementary to the existing statistical and spectral methods. It allows the complete characterization of the primary RSA components and may provide new insight into the effects of vagal activity and changes in clinical conditions.

A Herpesvirus Associated with Mass Mortality of Juvenile and Adult Koi, a Strain of Common Carp

A herpesvirus was isolated from adult koi, a strain of common carp Cyprinus carpio, suffering mass mortality in two outbreaks-one in the mid-Atlantic region of the United States and the second in Israel. The principal external signs of dying fish were pale and irregularly colored gills. There were few consistent internal signs in either outbreak. The most prominent microscopic lesions were in the gills, where hyperplasia and necrosis of the epithelium were severe. Other lesions included interstitial nephritis, splenitis, and enteritis. Affected cells often contained nuclei with marginated chromatin and faint intranuclear inclusions. Typical herpesvirus particles were present in branchial epithelial cells, hepatocytes, and among circulating leukocytes. Inoculations of the koi fin (KF-1) cell line with tissue extracts from the gill and kidney-spleen resulted in cytopathic effects characterized by severe vacuolation first detected after 7 d incubation at 20°C. Exposures of adult koi to the herpesvirus as propagated in KF-1 cells by bath or intraperitoneal injections resulted in 80-100% mortality during a 26-d period, and the virus was reisolated from the gill, kidney, liver, spleen, intestine, and brain of dead fish. The viral agents from koi in Israel and the United States appear to be similar if not identical; both could be distinguished from Herpesvirus cyprini by indirect fluorescent antibody tests with rabbit anti-H. cyprini serum. Other factors should be examined but we strongly suspect that this newly recognized koi herpesvirus (KHV) has the potential to be a significant cause of mortality among koi and presumably common carp.

Presbycusis: the aging ear. Part I

The aging ear is a particularly vexing problem. This review of the literature covers much of the pertinent information and leads to some suggested research which we hope to pursue. It seems to us that research directed toward increased knowledge of the auditory blood supply and a better understanding of the function of the stria vascularis will add much to our understanding of the aging ear.

Consultation between child psychiatry and otolaryngology: a case of esophageal stenosis

In contrast to traditional “interdisciplinary” methods of consultation where independent assessment and treatment are carried out by different treating agencies, the “ecological” approach involves continuing cooperation between all systems affecting the maintenance of the symptom in the patient-biological, psychological, individual, familial, social and community. The present case demonstrates how such an ecological approach resulted in the effective removal of symptoms in a 9-year-old child with intermittent esophageal stenosis. While there had been earlier consultations in the “interdisciplinary” sense by both the Department of Ear, Nose and Throat and the Department of Child Psychiatry, it was only when the family and all disciplines working with them were brought together on the same physical premises face to face that directives became fused and united. This enabled the family to mobilize its resources and effectively deal with its problems, resulting in the alleviation of the manifest symptoms.