Utility and futility of MitraClip implantation in secondary mitral regurgitation in a real-world population: the role of 3D transthoracic echocardiography

Introduction

Two recent prospective trials have been published, reporting opposite results on the efficacy and utility of the MitraClip (MC) procedure in patients with secondary mitral regurgitation (SMR). A ratio between the effective regurgitant orifice area (EROA) and left ventricular end-diastolic volume (LVEDV) ≥0.150 by two-dimensional (2D) transthoracic echocardiography (TTE) has been proposed to identify patients with disproportionate SMR, who would benefit from MC.

Purpose

To assess the prognostic role of clinical and echocardiographic parameters in a real-world population of SMR patients undergoing the MC procedure at our Institute.

Methods

Ninety-two patients underwent MC implantation. We retrospectively reviewed their clinical, and laboratory data, as well as 2D and three-dimensional (3D) TTE, and intraoperative transoesophageal echocardiography (Figure 1). The primary endpoint was a composite of cardiovascular death and/or hospitalisation for heart failure within 12-months follow-up.

Results

Thirty-one patients reached the endpoint (EP+), 61 did not (EP−). Demographics and anti-remodelling drugs were similar in EP+ and EP. Among comorbidities and laboratory data, EP+ significantly differed from EP− in smoking history, and extracardiac artery disease prevalence (65% vs. 39%, and 39% vs. 16%, respectively); EuroScoreII (12.2% vs. 5.2%); NYHA class ≥3 (94% vs. 69%); haemoglobin (12±2 vs. 13±2 g/dL), and brain natriuretic peptide levels (855 [426–1500] vs. 357 [170–902] pg/mL). At 2D TTE no significant difference emerged, including the SMR grade, except for the tricuspid annular plane systolic excursion (Figure 2). Biventricular 3D ejection fraction was significantly lower in EP+ vs. EP− (Figure 2). Residual intraoperative SMR grade after MC deployment was 1.9±0.6 in EP+ vs. 1.3±0.5 in EP− (p<0.001).

Conclusion

The proposed cut-off for EROA/LVEDV ratio may be suboptimal for predicting the MC utility in real-world populations. Rather, prognosis may be more influenced by the patient's pre-operative clinical status, right ventricular systolic function, 3D left ventricular ejection fraction, and by the success of the procedure.

Funding Acknowledgement

Type of funding sources: None.

Do valve type and post-ballooning affect transprosthetic gradients in patients undergoing transcatheter aortic valve-in-valve procedure?

Introduction

Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) is an appealing treatment option for patients with degenerated aortic bioprosthetic valves. However, high post-procedural transprosthetic gradients are very common after ViV-TAVI than after TAVI for native-valve aortic stenosis.

Aim

We sought to evaluate transprosthetic gradients (ΔP) and hemodynamic outcome in patients undergoing ViV-TAVI according to valve type and balloon post-dilation (balloon-expandable vs self-expandable with and without post-dilation).

Material and methods

We retrospectively analyzed 111 patients undergoing ViV-TAVI. A balloon-expandable valve was used in 35 patients (32%, Group 1), a self-expandable valve in 76 cases of which 39 (35%, Group 2) without balloon post-dilation and 37 (33%, Group 3) with balloon post-dilation. A comprehensive transthoracic echocardiography (TTE) was performed in all patients at baseline, at discharge and at 6-months follow-up.

Results

Successful ViV-TAVI was performed in 110 patients (99%). Baseline peak and mean ΔP, left ventricular volumes, ejection fraction, and pulmonary artery systolic pressure were similar among groups. A significant improvement in all echocardiographic parameters was observed in all groups over time (Table 1). In particular, a significant reduction in postprocedural gradients was observed at discharge and at 6-months follow-up compared to baseline in all groups. Immediately after ViV-TAVI procedure, the lowest value of mean ΔP was observed in Group 3 (12±7 mmHg) compared to both Group 1 (20±9 mmHg) and Group 2 (17±8 mmHg, p=0.001). This result was confirmed at 6-months follow-up (p=0.012). Rate of small valve size (≤23 mm) implanted was similar among groups (Group 1: 78%, Group 2: 60%, Group 3: 62%, p=0.123). Similar 1-year all-cause mortality was observed among groups (9%, 13%, 0%, respectively, p=0.135).

Conclusions

In patients with failed surgical aortic prosthesis, ViV-TAVI is an effective option and is associated with sustained improved hemodynamics in all patients. Anyway, the choice of prosthetic valve type and implantation technique are relevant on residual transprosthetic gradients and should be taken into account for a better long-term outcome.

Funding Acknowledgement

Type of funding sources: None.

Improving assessment of different flow state of aortic stenosis: implication for prognosis in patients undergoing transcatheter aortic valve replacement

Background

Low-flow low-gradient (LF-LG) aortic stenosis (AS) may occur with preserved or depressed left ventricular ejection fraction (EF), and both situations represent the most challenging subset of patients with AS to manage and generally have a poor prognosis with conservative therapy but a high operative mortality if treated surgically. Few and controversial data exist on the outcomes of these patients compared to normal-flow high-gradient (NF-HG) AS following transcatheter aortic valve replacement (TAVR).

Purpose

This study aims to better characterize patients with different transvalvular flow-gradient patterns undergoing TAVR and to examine the prognostic value of these flow state.

Methods

Overall, 1208 patients with severe symptomatic AS undergoing TAVR were categorized according to flow-gradient patterns as follow: 976 patients NF-HG (DPmean >40 mmHg), 107 paradoxical LF-LG (pLF-LG: DP mean <40 mmHg, EF >50%, and SVi <35 mL/m2), and 125 classical LF-LG (DP mean <40 mmHg, EF <50%, SVi <35 mL/m2).

Results

TAVR was feasible in all AS subtypes. When compared with NF-HG and pLF-LG, LF-LG had a worse symptomatic status (NYHA III–IV 86% vs 62% and 67%, respectively, p<0.001), a higher prevalence of eccentric hypertrophy (Figure 1, left), a higher level of LV global afterload reflected by a higher valvuloarterial impedance and a higher pulmonary pressure (Table). Valvular function after TAVR was excellent over time with respect to aortic pressure gradient (mean and peak) and aortic valve area regardless of flow state group. While intraoperative (p=0.935) and 30-day mortality (p=0.911) did not differ significantly among the 3 groups, LF-LG had a lower overall 5-year survival (LF-LG 50%, pLF-LG 65%, NF-HG 84%, p<0.001) (Figure 1, right). LF-LG AS was associated with a hazard ratio for 5-year mortality of 2.416 (95% CI: 1.658–3.520, p<0.001).

Conclusions

TAVR is an effective procedure in all patients with severe AS regardless of transvalvular flow-gradient patterns. However, special care should be given to characterized hemodynamic of AS, as patients with pLF-LG had similar survival rate than patients with NF-HG, whereas survival in LF-LG patients was 2-fold higher. Therefore, being able to identify patients less likely to improve after TAVR may help to guide treatment decision.

Funding Acknowledgement

Type of funding sources: None.

[Mitoxantrone Inhibits FMLP-Induced Degenerative Changes in Human Neutrophils]

Neutrophils fight with invading pathogens through various mechanisms including degranulation, phagocytosis, and the release of neutrophil extracellular traps (NETs). This study aimed to determine the impact of a synthetic formyl-peptide (FMLP) on human neutrophils in vitro, and to determine the role of mitoxantrone (MTX), a pharmacological blocker of mitochondrial Ca^(2+) Uniporter (MCU), on FMLP-induced alterations. Isolated neutrophils and a whole-blood preparation of neutrophils were pre-treated with MTX and then stimulated with FMLP. Field's-stained smears and brightfield microscopy were employed for morphological characterization and quantification of neutrophils. The release of cell-free DNA (cfDNA) was also measured for determining neutrophil damage. Our data demonstrated degenerative changes in neutrophils and a greater cfDNA release upon stimulation with FMLP which was negatively associated with the presence of resting platelets in whole blood preparation. Interestingly, MTX pre-treatment significantly reduced FMLP-triggered neutrophil damage and cfDNA release. Metformin, a known inhibitor of NETs formation, also decreased the FMLP-induced changes in neutrophils. In addition to confirming the degenerative potential of FMLP, this study reveals a novel contribution of MCU in regulating FMLP-induced morphological alterations in human neutrophils.

Prosthesis-patient mismatch after aortic valve in valve procedure: incidence, predictors and clinical outcomes

Funding Acknowledgements

Type of funding sources: None.

Background. Transcatheter aortic valve-in-valve (TAVI ViV) implantation is an appealing treatment option for patients with degenerated bioprostheses. However, elevated residual gradients after TAVI ViV procedure are very common. These are an unwanted effects of prosthesis-patient mismatch (PPM). Currently, the actual incidenceof PPM, its predictors and its clinical outcomes have not been completely investigated.

Purpose. The aims of this study was to investigate the incidence, predictors and clinical outcome of PPM and therefore of elevated gradients after TAVI ViV.

Methods. 75 patients (age 78 ± 9 years, 36 male), who underwent TAVI-ViV due to failed aortic biological valve (60 stented, 15 stentless), were enrolled. Mechanism of bioprosthetic valve failure was stenosis (34 cases, 45%), regurgitation (24 cases, 32%) or combination (17 cases, 23%). Elevated residual gradients were defined as a mean DP> 20 mmHg. PPM was identified by the indexed effective orifice area (EOAi) measured by echocardiography (moderate PPM if 0.65 < EOAi < 0.85 cm²/m²; severe PPM if EOAi < 0.6 cm²/m²).

Results. ViV TAVI was feasible in all patients, 33 patients (44%) were implanted with a balloon-expandable valve and 42 (56%) with a self-expandable valve. Post-procedural post-ballooning was performed in 16 out of 42 patients (38%) receiving a self-expandable valve. Post-operative mean DP> 20 mmHg was found in 35 patients (48%). Moderate PPM was found in 24 cases (33%) and severe PPM in 15 (20%). A logistic regression analyses identified small size of surgical prosthesis (size < 23 mm) [OR: 6.061(2.127-17.267), p = 0.001] and failed stented valve [OR: 20.727(2.522-170.364), p = 0.005] as independent predictors for the occurrence PPM. Interestingly PPM did not affect early and 1 years mortality (1 years mortality 1.3 %), while mortality was higher in pts with stentless prostheses (9%)

Conclusions. PPM is a frequent finding after ViV procedures. Despite elevated residual gradients, TAVI ViV resolved prosthetic dysfunction and PPM did not affect mortality.  Therefore, this procedure represents a promising new option for patients with failed biological prosthetic valves.

P1579 Detection of mechanical prosthetic valve dysfunction: an integrated multimodality imaging approach

Background

Although the long-term outcome of mechanical mitral and aortic prosthetic valve (M-PV, Ao-PV), PV dysfunction (PVD) remains a very serious complication associated with high morbidity and mortality. PVD, in terms of thrombosis/pannus or paravalvular leak, is not associated with a peculiar clinical presentation. However, a prompt PVD detection is essential for referring the patient to the optimal treatment (clinical follow-up, thrombolysis, surgery). An integrated multimodality imaging approach, comprising several parameters by transthoracic echocardiography (TTE) and fluoroscopy (F), is mandatory to address the patient to the best therapeutic option.

Purpose

This study aims to evaluate the incremental diagnostic value of combined TTE + F over each imaging modality alone in pts with Ao-PV or M-PV symptomatic for dyspnea, embolic events, fever or haemolysis and therefore at high suspicion for PVD.

Methods

We enrolled 388 consecutive pts (62 ± 11y, 213 Ao-PV, 175 M-PV) suspected for PVD. All patients were imaged by TTE and F within 2 days after the admission to the hospital. TTE was defined positive for PVD in presence of intra/para-prosthetic regurgitation or high transprosthetic gradient (DP > 20 mmHg in Ao-PV, DP >10 mmHg in M-PV) combined with other altered Doppler parameters (for Ao-PV: DVI < 0.25, AT > 95ms; for M-PV: Peak Mitral Velocity > 2.2m/sec, VTIPrMV/VTILVO > 2.5, PHT > 130ms). A positive F for PVD was defined by leaflet/s restriction. In all pts, PVD was confirmed by transoesophageal echocardiography (TOE), positive response of thrombolysis (T), or surgical inspection (S).

Results

PVD was found in 46% (99/213) of Ao-PV and in 56% (98/175) of M-PV at TOE/T/S. Sensitivity (SE), specificity (SP), negative predictive value (NPV), positive predictive value (PPV) and diagnostic accuracy (ACC) for TTE, F and combined TTE + F are reported in Table. The integration of TTE + F data significantly improved ACC both for Ao-PV and M-PV. At ROC analysis, the combined model of TTE + F showed the highest AUC for the detection of PVD compared with TTE and F alone (Figure).

Conclusions

In patients with clinical suspicion of PVD, the combined model of TTE + F had a significant incremental value over TTE or F alone to diagnose PVD. This multimodality imaging approach allows to overcome limitations of TTE or F alone and consequently provides a prompt PVD detection even though TOE remains the gold standard to diagnose paravalvular leak and non-obstructive thrombosis.

Table Ao-PV: TTE(n = 211) Ao-PV: F(n = 204) Ao-PV: TTE + F(n = 202) MV-PV: TTE(n = 175) MV-PV: F(n = 159) MV-PV: TTE + F(n = 159) Sensitivity/Specificity 86(79-93)/89(84-95) 59(49-68)/99(97-100) 94(89-99)/88(81-94) 83(75-90)/78(68-87) 45(35-55)/98(95-100) 87(81-94)/75(64-86) ACC 88(83-92) 79(74-85) 91(87-95) 81(75-90) 67(59-74) 82(76-88) Comparison of diagnostic accuracy between TTE, F, and TTE + F for detecting PVD

Abstract P1579 Figure. ROC curves

P1424 Long-term follow-up in patients undergoing early surgery (repair) for severe degenerative mitral regurgitation

In conclusions

a) early MV repair is associated with favourable LV remodelling and stable systolic function at FU; b) 2DTTE predicts in an early surgical strategy favourable LV remodelling c) pre-operative 3DTTE morphology (simple vs complex MVP) predicts repair procedure (simple vs complex) that in the large majority (91%) is associated with freedom from MR recurrence.

Table Pre-op 6-month FU 3-years FU Left ventricular end diastolic volume (ml) 140 ± 41 104 ± 30 * 103 ± 35 Left ventricular end systolic volume (ml) 49 ± 19 45 ± 19* 43 ± 22 Left ventricular ejection fraction (%) 65 ± 7 58 ± 8* 59 ± 7§ Mitral regurgitation (+) 3.9 ± 0.2 0.6±.6* 0.9±.9§ Left atrial volume (ml) 123 ± 48 91 ± 35* 87 ± 45 *= p < 0.01 6 ms vs pre-op; §=p < 0.01 3ys vs 6 ms

624 Is TAVI a useful procedure in paradoxical low flow-low gradient aortic stenosis? A long-term mortality study

Background

Clinical outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLF-LG) undergoing valve replacement are controversial. PLF-LG is a combination of a small aortic valve area (AVA < 1cm²), a preserved left ventricular (LV) ejection fraction (LVEF≥50%), and a ‘paradoxical’ low mean gradient due to the presence of low LV stroke volume (≤35 mL/m²). The low flow state is explained by the presence of a high afterload and pronounced LV concentric remodeling, with impaired LV filling. Surgical aortic valve replacement has been associated with very positive outcomes in normal-flow high-gradient (NF-HG) AS, whereas poorer outcomes has been reported in patients with PLF-LG AS.

Purpose

The aim of this study is to determine the clinical outcomes in patients with PLF-LG AS undergoing transcatheter aortic valve implantation (TAVI) compare to NF-HG patients.

Methods

A total of 624 patients (age 81 ± 7 years) with symptomatic severe AS and preserved LVEF who underwent TAVI, was enrolled and divided in 2 groups: group NF-HG included 554 patients (89%) and group PLF-LG including 70 patients (11%). At 1-year follow-up, death and clinical events were reported.

Results

TAVI was feasible in all patients. A significant reduction in mean aortic pressure gradient was observed after TAVI both in PLF-LG (baseline, 30 ± 6 mmHg; 1-year, 12 ± 4 mmHg; p < 0.001) and in NF-HG (baseline, 55 ± 12 mmHg; 1-year, 11 ± 4 mmHg; p < 0.001) together with an increase in AVA (PLF-LG: baseline, 0.73 ± 0.16 cm², 1-year: 1.82 ± 0.43 cm², p < 0.001; NF-HG: baseline, 0.66 ± 0.18 cm², 1-year: 1.84 ± 0.38cm², p < 0.001). Perioperative mortality at 30-days was similar in group NF-HG (17/554, 3%) and in group PLF-LG (2/70, 3%). Figure shows the survival curves up to 5 years follow-up according to the two groups. PLF-LG and HG-AS had similar survival rate throughout the long-term follow-up. Similarly, rehospitalization rate was not different in the two groups (PLF-LG: 12% vs NF-HG: 7%, p = 0.127).

Conclusions

Differently from surgical series, TAVI in PLF-LG AS is a useful procedure showing similar mortality and rehospitalization rates compared to NF-HG AS patients.

Abstract 624 Figure. Survival curve

P927Long-term mortality in patients with paradoxical low-flow low-gradient versus normal-flow high-gradient aortic stenosis undergoing transcatheter aortic valve implantation

Background

Controversial data exist on clinical outcomes of patients with paradoxical low-flow, low-gradient aortic stenosis (PLF-LG) undergoing valve replacement. This entity is a combination of a small aortic valve area (AVA<1cm2), a preserved left ventricular ejection fraction (LVEF≥50%), and a “paradoxical” low mean gradient due to the presence of low LV stroke volume (≤35 mL/m2). The low flow state is explained by the presence of a high afterload and pronounced LV concentric remodeling, with impaired LV filling. Currently, poorer outcomes have been reported after surgical aortic valve replacement in patients with PLF-LG AS compared with the normal-flow high-gradient (NF-HG) AS.

Purpose

The aim of this study was to determine the clinical outcomes in patients with PLF-LG AS undergoing transcatheter aortic valve implantation (TAVI) compare to NF-HG patients.

Methods

A total of 609 patients (age 81±6 years) with symptomatic severe AS and preserved LVEF who underwent TAVI, was enrolled and divided in two groups: group A included patients with NF-HG (542 patients) and group B including those with PLF-LG (66 patients). At 1-year follow-up, death and clinical events were reported.

Results

TAVI was feasible in all patients. A significant reduction in mean aortic pressure gradient was observed after TAVI both in PLF-LG (baseline, 30±5 mmHg; 1-year, 11±4 mmHg; p<0.001) and in NF-HG (baseline, 53±11 mmHg; 1-year, 12±4 mmHg; p<0.001) together with an increase in AVA (PLF-LG: baseline, 0.74±0.16 cm2, 1-year: 1.83±0.41 cm2, p<0.001; NF-HG: baseline, 0.65±0.16 cm2, 1-year: 1.84±0.35cm2, p<0.001). Perioperative mortality at 30-days was similar in group A (17/542, 3%) and in group B (2/66, 3%). Figure shows the survival curves up to 5 years follow-up according to the two groups. PLF-LG and HG-AS had similar survival rate throughout the long-term follow-up. Similarly, rehospitalization rate was not different in the two groups (PLF-LG: 12% vs NF-HG: 7%, p=0.121).

Kaplan-Meier analysis

Conclusions

Differently from surgical series, TAVI patients with PLF-LG AS had showed similar mortality and rehospitalization rates compared to NF-HG.

P1780Usefulness of multimodality imaging approach in the diagnosis of mechanical prosthetic valve dysfunction

Background

Although the long-term outcome of mechanical mitral and aortic prosthetic valve (M-PV, Ao-PV), PV dysfunction (PVD) remains a very serious complication associated with high morbidity and mortality. Thrombosis/pannus and paravalvular leak are the 2 main mechanisms of PVD. The diagnosis of PVD, based on clinical presentation may be challenging, but it is essential for referring the patient to the optimal treatment (clinical follow-up, thrombolysis, surgery). An integrated multimodality imaging approach, comprising several parameters by transthoracic echocardiography (TTE) and fluoroscopy (F), is mandatory to pursue the correct therapeutic pathway.

Purpose

This study aims to evaluate the incremental diagnostic value of combined TTE+F over each imaging modality alone in symptomatic pts with Ao-PV or M-PV and high suspicion of PVD.

Methods

387 consecutive pts (63±11y, 213 Ao-PV, 173 M-PV) suspected for PVD, symptomatic for dyspnea, embolic events, fever or haemolysis were enrolled. All patients were imaged by TTE and F within 2 days after the admission to the hospital. TTE was defined positive for PVD in presence of intra/para-prosthetic regurgitation or high transprosthetic gradient (>20mmHg in Ao-PV, >8mmHg in M-PV) together with altered Doppler parameters (for Ao-PV: DVI <0.25, AT>95ms; for M-PV: Peak Mitral Velocity>2m/sec, VTIPrMV/VTILVO>2.5, PHT>130ms). F was defined positive for PVD when leaflet/s restriction occurs. PVD was confirmed by transoesophageal echocardiography (TOE) or positive response of thrombolysis (T), or surgical inspection (S).

Results

PVD was found in 46% (99/213) of Ao-PV and in 53% (91/173) of M-PV at TOE/T/S. Sensitivity (SE), specificity (SP), negative predictive value (NPV), positive predictive value (PPV) and diagnostic accuracy (ACC) for TTE, F and combined TTE+F are reported in Table. The integration of TTE+F data significantly improved ACC both for Ao-PV and M-PV. At ROC analysis, the combined model of TTE+F showed the highest AUC for the detection of PVD compared with TTE and F alone (Figure).

Table 1. Comparison of diagnostic accuracy between TTE, F, and TTE+F TTE-Ao-PV (n=211) F-Ao_PV (n=204) TTE+F-Ao-PV (n=202) TTE-M-PV (n=172) F-M-PV (n=158) TTE+F-M-PV (n=157) SE / SP / NPV / PPV / ACC (%) 86 / 89 / 88 / 88 / 88 59 / 99 / 72 / 98 / 79 94 / 88 / 94 / 88 / 91 74 / 90 / 75 / 89 / 81 49 / 96 / 60 / 93 / 70 81 / 86 / 78 / 88 / 83

Figure 1. ROC curves

Conclusions

In patients with clinical suspicion of PVD, TTE and F are both valid tools to evaluate the PV performance. However, the combined model of TTE+F had a significant incremental value over TTE or F alone to diagnose the presence of PVD. This multimodality imaging approach allows to overcome several weaknesses of the TTE or F alone and consequently provides a prompt recognition of PVD even though TOE remains the gold standard to diagnose paravalvular Leak and non-obstructive thrombosis.

P3368Mitral annulus disjunction retrospective assessment by transthoracic and transoesophageal echocardiography in a large cohort of patients with mitral valve prolapse and significant mitral regurgitation

Background

The separation between the atrial wall-mitral valve junction and the left ventricular attachment (mitral annulus disjunction, MAD) is a recently discovered feature associated with Barlow's disease (BD). Correlations between MAD and morpho-functional alterations of the mitral valve (MV) apparatus have been described and different prevalence rates of MAD have been reported by several authors, analysing small sample size populations of patients with mixomatous MV prolapse (MVP).

Purpose

Aims of the study were 1) to estimate the prevalence and to assess MAD in a large cohort of patients with MVP (either BD or fibroelastic deficiency, FED) and significant mitral regurgitation with indication for surgical correction conforming to guidelines; 2) identification of any correlation between MAD and the MV anatomy, MVP aetiology and general characteristics of the study population.

Methods

A total of 979 patients presenting at our Centre from 2007 and 2018 with MVP and moderate-to-severe or severe mitral regurgitation were enrolled in the study. All patients underwent pre-operative transthoracic echocardiography (TTE) and 792 also intraoperative transoesophageal echocardiography (TOE). All recorded images and clips were saved in a central archive and were retrospectively analysed. MAD was defined as any distance observed between the atrial wall-MV junction and the left ventricular wall; it was evaluated in all available views and measured at end-systole.

Results

The overall population included 630 patients (64.4%) affected by BD and 349 (35.6%) with FED. Assessing off-line images from TTE and/or TOE, MAD was identified in 161 (16.4%) patients, respectively 21% and 8% in the BD and FED subgroups. Maximal MAD distance measured 6.6±2.2 mm at TTE and 6.7 mm ± 2.2 mm at TOE. Comparing MVP patients with and without MAD, it emerged that MAD was associated with younger age (60±14 vs 64±13 years, p<0.001) and slightly lower BMI (23.9±3.6 vs 24.5±3.6 kg/cm2, p=0.045). As concerns the MV apparatus, the presence of MAD showed a median larger MV annulus (medio-lateral diameter 41.0 [37.0–44.0] vs 39.0 [36.0–42.0] mm, p=0.001; antero-posterior diameter 38.0 [34.0–41.0] vs 36.0 [33.0–40.0] mm, p=0.001), greater incidence of bileaflet MVP (47.8% vs 25.9%, p<0.001) and mixomatous aetiology (82.0% vs 60.9%, p<0.001) and a lower prevalence of chordal rupture (61.5% vs 75.7%, p<0.001).

Conclusion

MAD significantly correlates with specific anatomical MV characteristics. Its prevalence results to be lower than reported in previous studies performed in different clinical contexts. In MVP population with surgical indication, MAD is clearly associated to BD, but it is also observed in a minority of patients with FED

Acknowledgement/Funding

None

P594Contrast transthoracic echocardiography as a gatekeeper for patent foramen ovale closure

Background.

The presence of patent foramen ovale (PFO) has been linked to many illness, including cryptogenic stroke, transient ischemic attack, migraine, platypnea-orthodeoxia syndrome and decompression sickness in scuba divers. Transesophageal echocardiography is the gold standard technique for the visualization of atrial septal anatomy, but it is a secondary level exam, not always available, with additional associated costs and not completely free from procedural risks. Standard transthoracic echocardiography (TTE) has a too low sensitivity for PFO screening.

Purpose.

The aim of the study was to assess the role of TTE associated with agitated saline contrast injection (contrast-TTE) as a gatekeeper for the identification of PFO in a large cohort of patients undergoing selection for percutaneous closure.

Methods.

A total of 200 patients undergoing a diagnostic work-up for the identification of PFO was imaged by contrast-TTE at rest and after provocative maneuvers (PM: Valsalva in all cases). Contrast TTE was graded from 0 to 4 on the bases of bubbles counting (0: no bubbles; 1: < 10 bubbles; 2: 10-30 bubbles; 3: >30 bubbles; 4: complete LV opacification). PFO closure was performed after a consensual clinical decision by the cardiologist and the neurologist taking into account comprehensive imaging, clinical evaluation and thrombophilia screening. PFO closure was always monitored by intracardiac echocardiography.

Results.

At baseline contrast TTE was positive (≥2) in 34 patients (17%) while contrast TTE with PM was positive in 94 cases (47%). 27 out of 200 patients (14%) had an interatrial septal aneurysms. PFO closure was performed in 34 cases (17%). All of these had severe right-to-left shunting (≥3) at contrast TTE and 9 cases had also an interatrial septal aneurysms. The procedure was aborted in only 1 patient due to a complex defect anatomy.

Conclusion.

Contrast TTE with PM may be not only considered an accurate tool for the detection of PFO but may be also inserted in the diagnostic work- up as a primary gatekeeper for percutaneous closure. Severe shunting at contrast TTE influences final decision making in a large cohort of cases undergoing screening for PFO closure.

Association of phenylthiocarbamide taste sensitivity with diabetes mellitus in Bangladesh

Screening for phenylthiocarbamide (PTC) taste insensitivity was performed and PTC taste threshold values using 13 solutions were obtained for 102 newly detected male diabetics and 103 male non-diabetics aged 21-40 years. The study revealed a significant difference in taste sensitivity to the bitterness of PTC crystals between the diabetics and non-diabetics, the former being less sensitive than the latter (16.7 vs. 6.8%).

Detection of pork and lard as adulterants in processed meat: liquid chromatographic analysis of derivatized triglycerides

A new method is described for detection of pork and lard as adulterants in processed beef and mutton mixtures. The unsaturated triglycerides in the fat are ozonized and then derivatized. The mixture of derivatized and saturated triglycerides is analyzed by liquid chromatography using a reverse-phase column and a UV detector. Pork fat has larger amounts of triglyceride containing saturated fatty acid at the C-2 position than does the fat of other meat. The ratio of triglyceride containing saturated fatty acid vs triglyceride containing unsaturated fatty acid at the same (C-2) position (SSU/SUS) in a sample is compared with those of pure meats. The presence of pork in the sample causes the ratio to increase compared with ratios for pure beef or mutton. The increase in the SSU/SUS ratio is significant for the addition of 1% pork in beef. In the case of mutton, the addition of 3% pork causes a noticeable change. The method is reliable and is also applicable to samples containing only fat. Processing (heating or cooking) does not affect the ratios.

Some hereditary blood factors of the Bengali Muslim of Bangladesh (red cell enzymes, haemoglobins, and serum proteins)

In a sample of Bengali Muslems from Dacca, haptoglobin, group-specific component, haemoglobin, adenosine deaminase, adenylate kinase, 6-phosphogluconate dehydrogenase, phosphoglucomutase, acid phosphatase and several other red cell enzyme types were studied. For most serum protein and red cell enzyme systems the gene frequencies are similar to those in other populations to the west of Bangladesh, but others suggest affinity with populations to the east.