P6486Flow state, gradients and anatomopathological valvular calcification: influence in aortic stenosis surgical outcomes

Introduction

Aortic stenosis (AS) patients are heterogeneous. The relationship between stenosis severity, transvalvular flow state and gradients is conflictive and non-linear.

Objective

To evaluate the relationship between transvalvular flow state and gradients with the anatomopathological aortic valve characteristics and perioperative morbimortality among patients (pt) submitted to aortic valve replacement (AVR).

Methods

We analyzed 516 pt with symptomatic severe AS (effective valve area <1 cm2) with preserved left ventricular ejection fraction (>50%) submitted to AVR. Perioperative mortality and a combined endpoint (death, low cardiac output syndrome and acute renal injury) were analyzed dividing the population by transvalvular flow (35 ml/m2) and mean gradient (40 mmHg), both measured by echocardiography. A morphologic evaluation of 383 operatively excised native cardiac valves was performed. Valvular thickening and calcification were categorized in mild, moderate and severe.

Results

Male subjects represented 52.9% (283 pt). Mean age were 69±11.5 years. Pt showed a mean ejection fraction of 61±4.8%, the peak gradient was 86.2±24 mmHg, and mean gradient was 53±18 mmHg.

Cardiac low output syndrome (normal flow (NF) – 14%, low flow (LF) – 23%; p<0,02), IABP (NF 1,8%, LF 6%, p<0,02) and perioperative mortality (NF 2,7%, LF 7%, p<0,02) were more frequent in low flow pt (185 – 35%).

Bicuspid valves represented 24.5% of the whole population. Bicuspid patients were younger 64±9 vs 73±12 years (p<0.05) and had more moderate–severe calcification (MSC) 93.4% vs 75.6% (p<0.05).

No difference was found in moderate -severe thickening (MSTh) and MSC when analyzing the population by flow (35 ml/m2). On the contrary, low gradient pt (<40mmHg) had lower MSC and MSTh. (Table)

Finally, 4 groups were considered: normal flow–high gradient NFHG (52.2%), normal flow–low gradient NFLG (12%), low flow–high gradient LFHG (25.5%) and low flow–low gradient LFLG (10.1%). A trend toward more perioperative events was seen in the LF-LG group despite less calcified and thickened valves. (Figure)

Table 1 Normal Flow Low Flow P value Normal gradient Low gradient P value M-S thickening 143 (58.1%) 80 (58.3%) NS 186 (62.4%) 37 (43.5%) 0.0018 M-S calcification 195 (79.2%) 119 (86.8%) NS 263 (88.2%) 51 (60%) <0.05 Bicuspid valve 62 (25%) 32 (23%) NS 62 (25.2%) 32 (23.3%) NS M-S: Moderate-Severe.

Figure 1

Conclusions

In our population of severe symptomatic AS with preserved ejection fraction submitted to AVR, low gradient pts had less calcified and thickened valves. LFLG pts presented a trend towards more perioperative events despite having less valvular calcification.

Factors related to inter-observer reproducibility of conventional Pap smear cytology: a multilevel analysis of smear and laboratory characteristics

OBJECTIVE

To identify factors that influence the inter-observer reproducibility of the routine, conventional Pap smear cytology (Pap smear test) in a network of certificated laboratories in a middle-income Latin American country.

METHODS

Twenty-six laboratories provided each an average of 26 negative for malignancy (NILM) and high-grade squamous intraepithelial lesion (HSIL) Pap smears. An external panel reviewed the slides. The kappa index and multilevel logistic regression were used to estimate the reproducibility and odds ratios (OR) of a false result with 95% confidence intervals (95% CI), respectively. Results are presented for laboratories that collect (collector laboratories) and do not collect (non-collector laboratories) samples.

RESULTS

The agreements ranged widely (median kappa 0.51, range 0.16-0.70). The overall false-positive (FP) and false-negative (FN) rates were 31% (95% CI 27-35) and 11% (95% CI 7-17). Among collector laboratories (N = 14), a bigger sample collection volume decreased the probability of a FP (OR-adjusted 0.05, 95% CI 0.02-0.1) whereas the number of quality defects (OR-adjusted 1.67, 95% CI 1.25-2.24), high workload (OR-adjusted 5.52, 95% CI 3.85-7.92) and collection by cytotechnologists (OR-adjusted 1.28, 95% CI 1.15-1.42) or health professionals (OR-adjusted 2.26, 95% CI 2.04-2.49) instead of nursing assistants increased it. Among non-collector laboratories (N = 9), the FP rate increased with the number of quality defects (OR-adjusted 1.86, 95% CI 1.06-3.26) but decreased if the samples were collected by health professionals instead of nursing assistants (OR-adjusted 0.37, 95%CI 0.17-0.80). No significant associations were observed for FN.

CONCLUSIONS

Staff in charge of cervical sampling significantly determined the reproducibility of the Pap smear test, but this depended on whether the laboratory collects samples or read samples collected elsewhere.

Continuous assessment of carotid intima-media thickness applied to estimate a volumetric compliance using B-mode ultrasound sequences

Recent reports have shown that the carotid artery wall had significant movements not only in the radial but also in the longitudinal direction during the cardiac cycle. Accordingly, the idea that longitudinal elongations could be systematically neglected for compliance estimations became controversial. Assuming a dynamic change in vessel length, the standard measurement of cross-sectional compliance can be revised. In this work, we propose to estimate a volumetric compliance based on continuous measurements of carotid diameter and intima-media thickness (IMT) from B-mode ultrasound sequences. Assuming the principle of conservation of the mass of wall volume (compressibility equals zero), a temporal longitudinal elongation can be calculated to estimate a volumetric compliance. Moreover, elongations can also be estimated allowing small compressibility factors to model some wall leakage. The cross-sectional and the volumetric compliance were estimated in 45 healthy volunteers and 19 asymptomatic patients. The standard measurement underestimated the volumetric compliance by 25% for young volunteers (p < 0.01) and 17% for patients (p < 0.05). When compressibility factors different from zero were allowed, volunteers and patients reached values of 9% and 4%, respectively. We conclude that a simultaneous assessment of carotid diameter and IMT can be employed to estimate a volumetric compliance incorporating a longitudinal elongation. The cross-sectional compliance, that neglects the change in vessel length, underestimates the volumetric compliance.

A global analysis of Y-chromosomal haplotype diversity for 23 STR loci

In a worldwide collaborative effort, 19,630 Y-chromosomes were sampled from 129 different populations in 51 countries. These chromosomes were typed for 23 short-tandem repeat (STR) loci (DYS19, DYS389I, DYS389II, DYS390, DYS391, DYS392, DYS393, DYS385ab, DYS437, DYS438, DYS439, DYS448, DYS456, DYS458, DYS635, GATAH4, DYS481, DYS533, DYS549, DYS570, DYS576, and DYS643) and using the PowerPlex Y23 System (PPY23, Promega Corporation, Madison, WI). Locus-specific allelic spectra of these markers were determined and a consistently high level of allelic diversity was observed. A considerable number of null, duplicate and off-ladder alleles were revealed. Standard single-locus and haplotype-based parameters were calculated and compared between subsets of Y-STR markers established for forensic casework. The PPY23 marker set provides substantially stronger discriminatory power than other available kits but at the same time reveals the same general patterns of population structure as other marker sets. A strong correlation was observed between the number of Y-STRs included in a marker set and some of the forensic parameters under study. Interestingly a weak but consistent trend toward smaller genetic distances resulting from larger numbers of markers became apparent.

Evolution of endogenous hormone concentration in embryogenic cultures of carrot during early expression of somatic embryogenesis

Embryogenic callus and suspension cultures of carrot (Daucus carota L., cv. Nantaise), growing on/in medium including 1 mg/l 2,4-dichlorophenoxy acetic acid (2,4-D), were transferred to medium with or without this plant growth regulator, to impair or induce, respectively, further development of somatic embryos. The endogenous hormone levels of the cultures were determined over 7 days by means of radio-immunoassay, to characterize their evolution in the initial stages of embryo development. In general, levels of indoleacetic acid (IAA) and abscisic acid (ABA) showed only short-lived differences among treatments during this time in both types of tissue analyzed (i.e., a peak of IAA in callus cultures in the absence of 2,4-D, 48 h after medium change, and higher ABA contents 144 h after subculture of suspension cultures in the presence of 2,4-D). Gibberellins (1, 3 and 20) were detected only in suspension cultures devoid of 2,4-D, starting 24 h after subculture. Concerning the evaluated cytokinins-zeatin/zeatin riboside and N6(Delta2-isopentenyl) adenine/N6(Delta2-isopentenyl) adenosine-the most remarkable observation is that high levels of the former generally coincided with low concentrations of the latter, indicating a shift from precursor to the active form, and vice versa.

Effectors of inflammation in actinic prurigo

BACKGROUND

Actinic prurigo is a specific familial photodermatosis of uncertain pathogenesis.

OBJECTIVE

Our purpose was to investigate the immunohistologic presentation of actinic prurigo to explore the involved pathomechanisms.

METHODS

The present immunohistochemical study was performed on biopsy specimens from 20 Mexican patients presenting with a severe and perennial form of the disease.

RESULTS

The dense inflammatory infiltrate was composed predominantly of helper T type 1 lymphocytes admixed with scattered B-cell lymphoid follicles and numerous dermal dendrocytes. Keratinocytes contained abundant tumor necrosis factor-alpha and calprotectin.

CONCLUSION

In subjects genetically predisposed to actinic prurigo, ultraviolet light may trigger excessive tumor necrosis factor-alpha production by keratinocytes whose sustained release in turn exerts its proinflammatory activity and deleterious epidermal effects. Such a cascade of events is in line with the therapeutic benefit already reported when thalidomide is used to treat actinic prurigo.

Endogenous hormone levels in habituated nucellar Citrus callus during the initial stages of regeneration

 Embryogenic nucellar callus cultures of different Citrus species and cultivars growing in hormone-free medium were transferred to medium containing either sucrose or glycerol as the only carbohydrate source. Glycerol has been reported to induce further development of Citrus somatic embryos, while in the presence of sucrose they continue to proliferate in an 'undifferentiated' manner. The endogenous hormone levels of the cultures were evaluated after 2 and 5  days to characterise the initial steps of embryo development. In most cases, differences among treatments were observed only after 5 days of culture. Higher cytokinin levels were found in most of the cultures transferred to the glycerol-containing medium. The effect of ageing sweet orange cultures on their endogenous hormone levels was determined by leaving them in the original culture medium without subculturing for 60 days. While no changes were observed in the free indoleacetic acid and gibberellin contents, lower levels of abscisic acid and cytokinins were found in the aged cultures than in those transferred at the normal interval, every 30 days. The endogenous hormone contents of Citrus callus of different genotypes were compared. Significant differences were observed in the levels of all hormones evaluated, even when the in vitro ontogeny of the different genotypes was very similar.

Percutaneous balloon mitral valvuloplasty: early and late results according to surgical risk and echocardiographic score

OBJECTIVE AND DESIGN

Early results, complications and follow-up of 70 patients undergoing percutaneous balloon mitral valvuloplasty (BMV) were retrospectively analyzed to establish whether an increased surgical risk or an unfavourable echocardiographic score influenced the results.

PATIENTS

The patients were divided into two groups according to the presence (group A, n = 31) or absence (group B, n = 38) of high surgical risk factors. The patients were also divided into two other groups according to the presence (group C, n = 46) or absence (group D, n = 20) of favourable mitral valve anatomy. Group A (high surgical risk) included patients fulfilling at least one of the following criteria: 65 years of age or older; previous surgical commissurotomy; depressed left ventricular function; respiratory or hepatic insufficiency; or previous aortic valve replacement. Mitral valve anatomy was classified as 4 to 16, according to the echocardiographic score established by Abascal et al. Group C patients had echocardiographic score below 8 and group D had echocardiographic scores of 8 or greater.

INTERVENTIONS

Mean mitral valve gradient (MVG) and area (MVA) were Doppler-estimated immediately before and 48 h after the BMV.

MAIN RESULTS

There were no differences in the early results and complications between groups A and B (MVA 1.8 +/- 0.5 versus 1.9 +/- 0.4 cm2). Final MVA was significantly greater in group C than in group D (MVA 1.9 +/- 0.4 versus 1.6 +/- 0.4 cm2; P = 0.03). There was no difference in the incidence of complications. Over a follow-up period averaging 19.1 months (range 1 to 55), 90.7% of the patients were in New York Heart Association functional class I or II. Four patients had a mitral valve replacement, one had a surgical commissurotomy and one had a second BMV. Two unrelated deaths occurred. There were no differences in the characteristics of the study population and the incidence of events in the follow-up period between groups.

CONCLUSIONS

The results and outcome of BMV were unrelated to the general surgical risk, suggesting that this procedure may be used with particular benefit in this group of patients. In contrast, mitral valve anatomy must be considered as an important determinant of the results.

Reversion by vagal reflex of a fetal paroxysmal atrial tachycardia detected by echocardiography

We report the reversion of fetal paroxysmal atrial tachycardia with 2:1 atrioventricular block obtained by vagal maneuvers during week 35 of gestation in a 31-year-old woman. All events were documented by fetal echocardiography.

Pleuritis by radiation: reports of two cases

Two cases of pleuritis by radiation, diagnosed by cytology studies of the pleural fluid, are reported. The clinical picture was that of a respiratory infection, with nonproductive cough and pleuritic chest pain. Chest x-ray studies showed a small pleural effusion that was confirmed by a thorax puncture. The aspirated fluid was hemorrhagic, and Papanicolaou studies were negative for tumor cells. However, multiple reactive mesothelial cells with vacuole formation within the cytoplasm and nuclei were seen. The differential diagnosis of pleuritis by radiation should include infectious pleuritis as well as pleural metastasis. A history of previous radiation and the typical findings in cytologic studies are important to confirm the diagnosis.