Quantitative angiographic assessment of aortic regurgitation post 11 different types of TAVI devices a multicentre pooled analysis of 2665 valves

Background

Regurgitation following TAVR impacts all-cause mortality. So far, no quantitative comparison of regurgitation by the same core lab has been performed among the various commercially available transcatheter heart valves (THV) We aimed to compare quantitative angiographic aortic regurgitation (AR) of 11 different types of THVs.

Method

This is a multicentre retrospective corelab pooled analysis of aortograms from 2704 consecutive patients treated with 11 different THV devices. Analysis was done by quantitative videodensitometric aortography (LVOT-AR), which is an objective, accurate, and reproducible tool for assessment of AR following TAVR. This method relies on time density changes in contrast medium after injection in the ascending aorta and its regurgitation (and subsequent density increase) in the LVOT. The ratio between the areas under the two-time density curves of these regions quantifies the AR in absolute percentage. The valves evaluated include ACURATE neo2 (n=120), Lotus (n=546), Myval (n=108), VitaFlow (n=105), Evolut PRO (n=95), SAPIEN 3 (n=397), Evolut R (n=295), SAPIEN XT (n=239), ACURATE neo (n=120), Venus-A (n=113) and CoreValve (n=532). Stratification of continuous variable regurgitation into categorical variables was performed according to the following pre-determined threshold criteria: 1) none/trace regurgitation (LVOT-AR<6%); 2) mild (6%≤ LVOT-AR ≤17%); and 3) moderate or severe (LVOT-AR >17%).

Results

The addition of anti PVR sealing features to the new generations ACURATE neo2 THV proved to be effective in reduction the incidence of significant PVR In comparison with the first generation ACURATE neo.

Myval, VitaFlow and Venus-A THVs are showing promising results.

Although the incidence of moderate/severe AR has regressed over time with new generations of THVs, the incidence of mild AR is still prominent with all THVs still exhibiting mild AR with an incidence ranging between 30% and 50% with the exception of the Lotus valve that had an 19% incidence of mild AR

Conclusion

ACURATE neo2 had the lowest severe/moderate percentage of AR showing significant improvements in comparison to ACURATE neo. Myval, VitaFlow and Venus-A are promising options in the THV armamentarium. These results should be confirmed in prospective randomized, head-to-head comparisons between THVs.

Funding Acknowledgement

Type of funding sources: None.

P931 Feasibility of comprehensive multi-plane right ventricular free wall longitudinal strain evaluation pre-LVAD implantation - preliminary results from a single centre experience

Conclusion

There is reasonable feasibility for assessing RV-FWLS using MPE in 3 out of the 4 free wall segments and mean values were considerably lower than normal reference values. A stronger negative correlation with increasing mPAP suggests that RV dysfunction may be detected better by strain than by TAPSE measurement in pre-LVAD recipients. Larger, multi-centre studies are required to further assess these preliminary findings.

Abstract P931 Figure. Multi-plane RV imaging with strain

Under-coracoid-around-clavicle (UCAC) loop in type II distal clavicle fractures

In Neer type II (Robinson type 3B) fractures of the distal clavicle the medial fragment is detached from the coracoclavicular ligaments and displaced upwards, whereas the lateral fragment, which is usually small, maintains its position. Several fixation techniques have been suggested to treat this fracture. The aim of this study was to assess the outcome of patients with type II distal clavicle fractures treated with coracoclavicular suture fixation using three loops of Ethibond. This prospective study included 14 patients with Neer type II fractures treated with open reduction and coracoclavicular fixation. Ethibond sutures were passed under the coracoid and around the clavicle (UCAC loop) without making any drill holes in the proximal or distal fragments. There were 11 men and three women with a mean age of 34.57 years (29 to 41). Patients were followed for a mean of 24.64 months (14 to 31) and evaluated radiologically and clinically using the Constant score. Fracture union was obtained in 13 patients at a mean of 18.23 weeks (13 to 23) and the mean Constant score was 96.07 (91 to 100). One patient developed an asymptomatic fibrous nonunion at one year. This study suggests that open reduction and internal fixation of unstable distal clavicle fractures using UCAC loops can provide rigid fixation and lead to bony union. This technique avoids using metal hardware, preserves the acromioclavicular joint and provides adequate stability with excellent results.

Cite this article: Bone Joint J 2013;95-B:983–7.

The role of hepatitis C in hepatocellular carcinoma: a case control study among Egyptian patients

BACKGROUND

Egypt has one of the highest prevalence rates of hepatitis C virus (HCV) infection in the world; however, the risk and attribution related to HCV in Egyptian patients with hepatocellular carcinoma (HCC) remains unknown.

GOALS

The current study was undertaken to estimate the risk of HCC in relation to HCV in Egypt.

STUDY

Thirty-three patients with HCC and 35 healthy controls who had a similar socioeconomic status were prospectively enrolled at the University of Cairo National Cancer Institute.

RESULTS

Anti-HCV antibodies were present in 75.8% of the patients and in 42.9% of the controls (p = 0.01); hepatitis B surface antigen (HBsAg) was present in 15.2% of the patients and in 2.9% of the controls (p = 0.03). In addition, the sex-and age-adjusted odds ratio (OR) for anti-HCV antibodies was 5.1 (95% CI = 1.5-17.4) and for HBsAg was 13.2 (95% CI = 1.2-148.2). Concurrent Schistosoma mansoni and anti-HCV was associated with an OR of 10.3 (95% CI = 1.3-79.8), which was higher than that for anti-HCV (6.5; 95% CI = 1.6-26.6) and S. mansoni infection (0.2; 95% CI = 0.1-6.2) alone. Finally, we estimated the attributable fraction of HCC to HCV to be 64% in this study population and 48% in the general Egyptian population.

CONCLUSIONS

Both HCV and hepatitis B virus infection increase the risk of HCC in Egyptian patients, whereas isolated Schistosoma infection does not. Because of the very high prevalence rate of HCV in the general Egyptian population, it accounts for most HCC cases in Egypt.

Postoperative radiotherapy of carcinoma in bilharzial bladder: improved disease free survival through improving local control

Two hundred thirty-six patients with T3 bladder cancer who survived radical surgery and proved to have P3a, P3b, or P4a tumors were randomized in two phases into three groups: (a) no further treatment (83 patients); (b) postoperative radiotherapy multiple daily fractionation (MDF), using 3 daily fractions of 1.25 Gy each, with 3 hr between fractions, up to a total dose of 37.5 Gy in 12 days (75 patients); and (c) postoperative radiotherapy conventional fractionation (CF), for a total dose of 50 Gy/5 weeks (78 patients). The tolerance of the patients to postoperative radiotherapy was quite acceptable, with equal acute reactions in MDF and CF groups. The 5-year disease-free survival (DFS) rates amounted to 49 and 44% in MDF and CF postoperative radiotherapy groups, respectively, compared to 25% in the cystectomy-alone group. The 5-year local control rates were 87% and 93% for those treated with multiple daily fractionation and conventional fractionation while it was 50% in the surgery-alone group. The therapeutic benefit of postoperative irradiation was consistent for all tumor types, histological grades, and pathological stages for both the disease-free survival and local control. Patients with nodal metastases demonstrated lower recurrence rates in the postoperative radiotherapy groups, but this was not associated with improved disease-free survival. Multivariate analysis using the Cox Model confirmed these results. The independent prognostic factors affecting both disease-free survival and local control were the addition of postoperative radiotherapy, the nodal status, the pathological stage, and the tumor grade. Late complications of radiotherapy in the skin, small intestine, rectum, and the anastomotic site of the urinary division were lower with MDF than with conventional fractionation.

Postoperative radiotherapy of carcinoma in bilharzial bladder using a three-fractions per day regimen

Patients with T3 bladder cancer who survived surgery and proved to have P3a, P3b or P4a tumors were randomized to either no further treatment (61 patients) or postoperative total pelvic irradiation (55 patients). A three-fraction per day regime was adopted with a dose per fraction of 125 cGy and an interval of 3 h between fractions. The total dose amounted to 3750 cGy divided into 30 fractions over 12 days. Patients of the postoperative radiotherapy group were re-randomized to radiotherapy alone or radiotherapy plus misonidazole (MISO) in a daily dose of 1 g/m2 given orally 2 h before the first daily fraction. The 2-year disease-free survival rate in the cystectomy alone group was 33 +/- 6% compared to 65 +/- 6% in the postoperative radiotherapy group. The therapeutic benefit applied to the two cell types, all histological grades and stages and to patients with or without nodal metastases. The benefit of postoperative irradiation was also verified by the Cox's multivariant analysis which adjusts for the relative representation of the important prognostic factors particularly pathological stage and nodal involvement. MISO did not seem to add to the therapeutic gain. No late complications were encountered in the wall of the rectum, small bowel or uretero-intestinal anastomotic sites. This is suggested to be due to the small dose per fraction used. However, early small bowel reactions were dose-limiting.

Misonidazole in the preoperative and radical radiotherapy of bladder cancer

Measurement of intercapillary distances suggests the presence of significant cell hypoxia in Bilharzial bladder cancer. This tumor seems to be capable of reoxygenation in view of the existence of a correlation between prognosis and immediate tumor shrinkage after irradiation. Two programs are presented: 1) Use of misonidazole with concentrated preoperative irradiation where the reoxygenation properties are not used fully. A prospective randomized study is presented whereby cystectomy alone is compared with cystectomy plus preoperative irradiation (6.5 Gy X 2F/1 week) with or without misonidazole. the drug is given either orally (in two doses 3 g/m2 each given 3.5 hours prior to each fraction; blood levels: 90-110 micrograms/ml) or intravesically. The intravesical administration is designed in the light of penetration studies and seems to have the advantage of the complete lack of systemic drug toxicity. Twenty-eight patients were included in this study and no drug toxicity was recorded. A second preoperative irradiation study is presented whereby cystectomy alone is compared with cystectomy plus preoperative irradiation (4.0 Gy X 5F) with or without misonidazole in individual doses of 2 g/m2. 2) Two radical radiotherapy regimes are presented. One protocol involves a split course (SC) protracted regime making full use of spontaneous reoxygenation. The drug is given in 0.5 g/m2 daily doses (total dose 14 g/m2 spread over 61 days, blood level: 15-20 micrograms/ml). A second protocol involves hyperfractionation stimulating continuous low-dose-rate irradiation. Higher blood levels are attained (60-80 micrograms/ml) after daily doses of 2 g/m2 (total dose: 14 g/m2 spread over 35 days). In a phase II study using SC technic, reversible grade 1 peripheral neuropathy was encountered in 5 of 22 patients. Complete tumor regression 3 months after irradiation was achieved in 18 of 22 patients with 3T tumors. No neuropathy was encountered in four patients subjected to the HF regimen who also showed complete tumor regression.

Amikacin in the treatment of genito-urinary tract infections in cancer patients

Amikacin was used in the treatment of severe urinary tract infections in twenty-five seriously ill patients. In twenty-four of the patients, cystitis or pyelonephritis complicated carcinoma of the bladder. Structural changes in the urinary tract, resulting from schistosomiasis, presented additional obstacles to treatment in many of the patients. The most commonly isolated pathogens were Escherichia coli and Pseudomonas. Most patients received 500 mg of amikacin every twelve hours. Three patients experienced adverse renal reactions which showed subsequent improvement. Amikacin effected twenty-one (84%) complete cures and four (16%) clinical cures in the twenty-five patients. This represents 100% clinical success in this study.