Left atrial emptying fraction: a powerful predictor of events in severe aortic stenosis

Background

Increasing evidence suggests that left atrial (LA) structural and functional changes have an important role in risk stratification and prediction of clinical outcomes. We know from multiple data that left atrial maximum volume (LAVI), measured at end-systole, is a powerful prognostic marker in multiple patient groups. However, recent studies have suggested that this marker may not be the best representative of diastolic function as it does not image the full spectrum of atrial mechanics. Another measure of LA function is the left atrial emptying fraction (LAEF), which has proved to be a significant prognostic marker in many patient groups. Less known is its role in event prediction in severe aortic stenosis patients, a disease with a very important burden in modern societies.

Purpose

The authors hypothesised that LAEF is a powerful predictor of clinical outcomes at 1 year in patients with severe aortic stenosis.

Methods

We retrospectively evaluated 151 patients referred to our echocardiography laboratory with the diagnosis of severe aortic stenosis. All patients underwent transthoracic echocardiography. LA maximum volume was indexed to body surface area. LAEF was calculated as LAVI-LA minimum volume divided by LAVI. Patients were followed for 1 year regarding clinical outcomes. Clinical outcome was defined as a composite of hospital admission for a cardiovascular (CV) cause, emergency department recurrence for a CV cause or CV death. Logistic binary regression was used to evaluate associations of LAEF with the outcome.

Results

A total of 51.7% of patients (n=78) were males. Mean patient age was 76.6±8.0 years. A total of 38.4% of patients were diabetics (n=56), 96% had dyslipidaemia (n=145) and 25% (n=37) had atrial fibrillation. Mean left ventricular ejection fraction (LVEF) was 60.6±7.3, and mean LAVI was 41.4±12.1. In a multivariable regression model including clinical and echocardiographic markers, higher LAVI and pulmonary artery systolic pressure (PASP) were associated with lower LAEF. Receiver operating characteristic curve analysis showed that the predictive value of LAEF for outcomes at 1 year was 0.693 (AUC=0.693, CI 95% 0.578–0.809, p=0.002), performing better than other echocardiographic markers such as LAVI (AUC=0.567, CI 95% 0.440–0.694, p=0.286), PASP (AUC=0.582, CI 95% 0.451–0.714, p=0.191) and LVEF (AUC=0.590, CI 95% 0.464–0.716, p=0.153). After adjustment of baseline characteristics, a LAEF less than 41.3% remained a good predictor of clinical outcomes at 1 year (OR 2.615, CI 95% 1.085–6.305, p=0.32).

Conclusions

In this cohort of severe aortic stenosis patients, a reduced LAEF was associated with greater incidence of cardiovascular events, being a stronger predictor than LAVI, PASP or LVEF. This study suggests that LA dysfunction over LA volumes correlates better with clinical outcomes.

Funding Acknowledgement

Type of funding source: None

Liver retransplantation in patients with acquired familial amyloid polyneuropathy: a Portuguese center experience

In 1995 Furtado et al performed the first domino transplantation using a donor liver with familial amyloid polyneuropathy (FAP), thereby increasing the pool of donors. Our experience showed that the onset of FAP symptoms occurs earlier in some patients. Patients with FAP acquired by transplantation are candidates for liver retransplantation to minimize the progression of symptoms. Liver retransplantation is considered to be a high-risk procedure and has lower survival compared with the first transplantation. We evaluated the risk of liver retransplantation in patients with acquired FAP. We did a retrospective analysis of these patients based on the records of perioperative data. From 1995 to 2004 we carried out 81 domino transplantations, of which 10 were submitted to liver retransplantation because of acquired FAP. The better outcomes in this group lead us to think that the liver retransplantation in patients with acquired FAP is not associated with the same risks of liver retransplantation in candidates with graft failure.

Evaluation of operative risk in de novo familial amyloid polyneuropathy retransplantation

Familial amyloid polyneuropathy (FAP) is the most common hereditary amyloidosis, characterized by progressive peripheral sensory and motor neuropathy. The livers of patients with FAP are used in domino liver transplantation in selected cases to increase the number of grafts available. In our department 10 patients underwent liver retransplantation (ReLTx) in the absence of liver dysfunction by de novo FAP after domino liver transplantation. Our aim was to compare the differences in the consumption of blood products and intraoperative hemodynamic support among patients with FAP undergoing liver transplantation (LTx) and patients with de novo FAP undergoing ReLTx in the same time frame. The anesthetic records of all patients who underwent LTx for FAP and ReLTx for de novo FAP were analyzed, from January 2009 to May 2014. Patients were divided into 2 groups: group 1 patients with FAP, and group 2 patients with de novo FAP. Statistical differences in the value of preoperative creatinine were found. Hemoglobin levels, preoperative international normalized ratio (INR), use of blood products, aminergic support, and surgical time showed no statistical difference. Major bleeding rates would be expected in patients undergoing ReLTx. Changes in renal function, chronic immunosuppressive therapy, and age may contribute to the increase in intraoperative complications. We did not find statistically significant differences, leading us to the conclusion that de novo FAP does not seem to be a predictor of perioperative risk.

Viral and bacterial contamination in recreational waters: a case study in the Lisbon bay area

AIMS

To assess the presence of viral pathogens in bathing water samples and to evaluate the interdependency of bacterial indicator counts and viral detection.

METHODS AND RESULTS

Bathing water samples of 16 beaches collected along a Portuguese Coastal area were screened for the hepatitis A virus (HAV) and norovirus genogroup I (NVGI) using RT-PCR technique. Bacteriological water quality was also assessed, according to European regulations. HAV and NVGI were detected in 95% and 27% of the water samples, respectively, whereas bacteriological quality was good in all but one sample, according to current water quality regulations.

CONCLUSIONS

All water samples would be considered of excellent quality according to the most recent European regulations. No relationship between viral detection and regulatory-based bacterial indicators was found.

SIGNIFICANCE AND IMPACT OF THE STUDY

The current results reinforce the importance of increased surveillance for pathogenic viruses in bathing waters.

Ocular coloboma and high myopia with Hirschsprung disease associated with a novel ZFHX1B missense mutation and trisomy 21

Syndromic Hirschsprung disease has been associated with mutations in ZFHX1B, a Smad-interacting transcriptional repressor protein. Tissue in situ hybridization has demonstrated strong expression of ZFHX1B in the developing eye, suggesting that some mutations in this gene may cause visual loss. However, none of the reported mutations have been associated with an ocular phenotype. We describe a patient with Down syndrome and Hirschsprung disease with high myopia and ocular coloboma affecting the iris and retina. In addition to trisomy 21, a novel, de novo heterozygous A to G transition in exon 8 of the ZFHX1B gene was identified, which results in a R953G amino acid substitution. This abnormality was not seen in a screen of 200 chromosomes from ethnically matched, normal controls. The arginine residue at position 953 is an extremely conserved amino acid throughout evolution. This is the first report associating Hirschsprung disease and severe eye defects with a specific genetic mutation and is the first report of a mutation in ZFHX1B causing a developmental ocular anomaly.

Bid acts on the permeability transition pore complex to induce apoptosis

Similar to most if not all pro-apoptotic members of the Bcl-2 family, Bid (and its truncated product t-Bid) triggers cell death via mitochondrial membrane permeabilization (MMP). This effect can be monitored in intact cells, upon microinjection of recombinant Bid protein into the cytoplasm, as well as in purified mitochondria, upon addition of Bid protein. Here we show that Bid-induced MMP can be inhibited, both in cells and in the cell-free system, by three pharmacological inhibitors of the permeability transition pore complex (PTPC), namely cyclosporin A, N-methyl-4-Val-cyclosporin A, and bongkrekic acid (a ligand of the adenine nucleotide translocase, ANT, one of the PTPC components). Bid effects on synthetic membranes were studied either in proteoliposomes or in synthetic bilayers subjected to electrophysiological measurements. Full length Bid preferentially permeabilizes membranes and induces the formation of large conductance channels at neutral pH, when added to liposomes or bilayers containing both purified ANT and Bax, yet has no or little effect combined with ANT or Bax alone. t-Bid acts on membranes containing ANT alone with the same efficiency as on those containing both ANT and Bax. These results suggest that the proapoptotic effects of Bid are mediated, at least in part, by its functional interaction with ANT, one of the major components of PTPC.

Immunophenotypic Aberrations, DNA Content, and Cell Cycle Analysis of Plasma Cells in Patients with Myeloma and Monoclonal Gammopathies

We describe the immunophenotypic and gross DNA defects in 55 patients with myeloma and 50 patients with monoclonal gammopathy and review the literature on this subject (MedLine, 1994-2000). Our data confirmed previous reports indicating that in myeloma nearly all marrow plasma cells are abnormal (98.7 +/- 8.1%). In monoclonal gammopathy the fraction of abnormal plasma cells was 35.0 +/- 32.8%. In both myeloma and monoclonal gammopathy, the most frequent aberrant phenotypic features consisted of absence of expression of CD19, strong expression of CD56, and decreased intensity of expression of CD38; aberrant expression of CD10, CD20, CD22, or CD28 was observed in less than one-third of myeloma cases. The vast majority of cases had two or more phenotypic aberrations. In the DNA studies, 7% of myeloma cases were biclonal and 93% of cases were monoclonal. In those studies with only one plasma cell mitotic cycle, 37% had normal DNA content and 63% were aneuploid (hyperploid, 61%; hypoploid, 2%). The mean percentages of plasma cells in S- and G2M phases were 4.9 +/- 8.5 and 4.4 +/- 6.9%, respectively. Thirty-eight percent of cases had more than 3% of plasma cells in S phase. In monoclonal gammopathy, the DNA index of abnormal plasma cells ranged from 0.89 to 1.30 and the percentage of diploid (31%) and aneuploid (69%) cases was not different from the results found in myeloma. The differences in percentage of abnormal plasma cells in S- (7.4 +/- 8.6%) and G2M-phases (2.4 +/- 1.7%) in patients with monoclonal gammopathy were not statistically significant.

Open mitral commissurotomy: the 'golden standard'

BACKGROUND AND AIM OF THE STUDY

Percutaneous balloon mitral commissurotomy (PBMC) has recently emerged as an alternative to surgical commissurotomy for the treatment of rheumatic mitral valve stenosis. However, this blind procedure may result in incomplete separation of the commissures, which could lead to accelerated restenosis. Hence, open mitral commissurotomy (OMC), which is a visually oriented procedure, remains our method of choice. This study was aimed at assessing the long-term outcome of the OMC procedure.

METHODS

A series of OMC performed between 1988 and 1991, involving 100 mitral valves, each with a preoperative echocardiographic score < or =10 was investigated clinically and by echocardiography.

RESULTS

Postoperatively, the mean valve area achieved was 2.89+/-0.49 cm2, compared with a mean preoperative value of 0.99+/-0.23 cm2. In a recent follow up, conducted after a mean of 8.5 years (range: 7-11 years), the mean valve area measured by echo-Doppler in this patient group was 2.37+/-0.42 cm2 (range: 1.6 - 3.6 cm2), and 81% of patients had a valve area >2.0 cm2. Reoperation was required in only two cases. The late mortality rate was 4% (0.5%/pt-yr), and was in no case valve-related. Two-thirds of the patients had no or only mild mitral insufficiency, and 93% were in NYHA functional class I or II. The nine-year actuarial survival rate was 96%, freedom from reoperation 98%, and freedom from all valve-related complications 92%. Complementary to this experience, during the past 10 years we have performed modified OMC in 919 (79%) of all 1,151 patients with mitral stenosis submitted for surgery, including 257 with mixed disease. The mean post-commissurotomy valve area (2.9 cm2) was identical to that of the study group. Moderate to severe valve calcification was not an absolute contraindication to valve conservation.

CONCLUSION

OMC remains the best alternative for the treatment of all cases of mitral stenosis, independently of the degree of pliability. In our experience, the medium- and long-term results are significantly better than those usually reported in PBMC series.

Haemodynamics during liver transplantation in familial amyloidotic polyneuropathy: study of the intraoperative cardiocirculatory data of 50 patients

BACKGROUND

Circulatory instability frequently complicates liver transplantation for familial amyloidotic polyneuropathy (FAP) and may be a source of surgical morbidity and mortality.

OBJECTIVE

To evaluate FAP intraoperative haemodynamic data and their relation to the duration of surgery, and need for anaesthetic drugs. RBC and sympathomimetic amines.

SETTING

Clinical study during a four year period. PATIENTS (mean +/- SD): Group I included 50 consecutive FAP ATTR Met 30 recipients of first transplantation. Age was 35.3 +/- 7.1 years, neurological score 34.3 +/- 13 in 100 and time elapsed from first symptom 5.0 +/- 2.7 years. Group II (control), not different concerning age and sex, included 51 patients transplanted during the same period with other pathologies.

METHOD

Anaesthetic protocol, monitoring and surgical techniques were similar in both groups. Data of the two groups were compared either by the Student's t-test or Fisher's exact test.

RESULTS

Low values of systemic vascular resistance index were observed in both groups, with no differences between them. Systemic arterial pressures were usually lower in group I, because cardiac index and heart rate were also significantly lower, although within normal values. However, in group I, isoflurane (a vasodilator anaesthetic) was used during less time (p < 0.05) and in lower concentrations (p < 0.01) and phenylephrine was necessary in 26% of patients vs 0 patients in group II (p < 0.001).

CONCLUSION

FAP patients presented a different intraoperative behaviour when compared to other patients submitted to liver transplantation. From a clinical point of view, the authors stress: 1--As a result of autonomic dysfunction, the administration of anaesthetic drugs to FAP patients always presents the risk of producing significant hypotension; even the use of ketamine does not prevent hypotension; 2--Safety is ensured by beat-to-beat surveillance of arterial pressures and the capacity to act immediately to support circulation; 3--These patients seem to be very sensitive to decreases in the pre-load; 4--Hypotension is also frequent with an adequate pre-load, usually as the result of low SVR; an infusion of a vasoconstrictor drug emerges as the most frequent treatment requested and our experience supports it as an effective one.

[Changes in the geometry of the heart cavities in patients with cardiac tamponade undergoing pericardial drainage]

OBJECTIVES

The objective of our study was to evaluate the changes in cardiac chamber dimension--longitudinal and transversal axis--in patients with cardiac tamponade after drainage of the pericardial effusion.

STUDY DESIGN

This is a five year retrospective study (from 1991 to 1995 inclusive) which evaluates patients with cardiac tamponade from a clinical and electrocardiographic, as well as echocardiographic, point of view.

MATERIALS AND METHODS

Thirty-nine consecutive patients with cardiac tamponade were evaluated clinically and by ECG and two-dimensional echocardiography, before and after drainage of the pericardial effusion. The drainage was done by pericardiocentesis alone in 28 cases (72%), pericardiocentesis followed by surgery in seven cases (18%) and surgery alone in four cases (10%).

MAIN RESULTS

After drainage we observed a reduction in the diameter of the pericardial effusion from 30.1 +/- 8 to 8.1 +/- 7 mm; the occurrence of jugular vein turgescence decreased from 87% to 5% (p < 0.001) and heart rate also decreased from 100 +/- 20 beats/minute to 79 +/- 17 beats/minute (p < 0.001). Systolic blood pressure increased from 107.8 +/- 20.4 mmHg to 134.6 +/- 20.3 mmHg (p < 0.001). All longitudinal and transversal diameters of the cardiac chambers increased after drainage. The greatest increase was observed in the transversal diameters of the right chambers.

CONCLUSIONS

Cardiac tamponade affects both right and left cardiac chambers which are affected in their transversal as well as longitudinal diameters; the effect of compression was more marked in the right chambers and in the transversal diameters.

Serum potassium concentrations after suxamethonium in patients with familial amyloid polyneuropathy type I

BACKGROUND

Suxamethonium produces an abnormal increase in serum potassium in some neurological diseases and some authors have suggested that it is safer not to use this drug in patients with familial amyloid polyneuropathy (FAP). However, there are no data previously reported to support this hypothesis. The aim of this study was to evaluate the magnitude of the potassium increase produced by suxamethonium in FAP type I.

METHOD

Twenty-one FAP Met 30 patients anaesthetised for liver transplantation were studied. Age was 34.9 +/- 6.9 years (mean +/- SD), time elapsed from first symptom 5.5 +/- 3.2 years and weight was 14 +/- 9% below ideal body weight. Anaesthesia was induced with thiopentone and low-dose fentanyl. Samples for blood gas and 5 min after 1 mg/kg of suxamethonium was given for tracheal intubation.

RESULTS

Before induction serum potassium levels were 3.8 +/- 0.4 mmol/L. One minute after suxamethonium, values were 3.8 +/- 0.4 mmol/L and 5 min after 4.3 +/- 0.5 mmol/L. The maximal increase observed was 1.6 mmol/L (from 3.4 mmol/L to 5.0 mmol/L).

CONCLUSION

The average increase in plasma potassium concentrations observed in FAP patients after suxamethonium was similar to the increase observed in a normal population by others. Our study can exclude the hypothesis that an anomalous increase in potassium would be a typical and frequent response to suxamethonium in FAP met 30 patients. However, we cannot exclude that a dangerous rise in serum potassium may exist in a certain percentage of FAP patients.