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.

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.

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.

Efficacy of HT 7 point acupressure stimulation in the treatment of insomnia in cancer patients and in patients suffering from disorders other than cancer

AIM

The induction of sleep would depend on interaction between gabaergic system and the pineal gland through its main hormone melatonin. Until few years ago benzodiazepines were the only drugs effective in the treatment of insomnia. Recently, however, both melatonin and acupressure have appear to be active in sleep disorders. The aim of study was to evaluate the efficacy of HT 7 point acupressure in insomnia.

METHODS

The study enrolled 25 patients affected by sleep disorders, 14 of whom had a neoplastic disease. They were treated by HT 7 stimulation for al least two consecutive weeks using a medical device named H7 Insomnia Control.

RESULTS

An improvement in the quality of sleep was achieved in 15/25 (60%) patients, with a more evident efficacy in cancer patients (11/14 [79%]).

CONCLUSION

This study confirms previous clinical data showing the efficacy of acupressure in the treatment of sleep disorders, particularly in cancer-related insomnia.

A progress study of 100 cancer patients treated by acupressure for chemotherapy-induced vomiting after failure with the pharmacological approach

AIM

The recent rediscovery of the natural traditional medical sciences has contributed to improve the treatment of the human diseases and, in particular, it has been shown that the pharmacological approach is not the only possible strategy in the treatment of nausea and vomiting, since bioenergetic approaches, such as acupressure and acupuncture, may also counteract the onset of vomiting due to different causes. Previous preliminary clinical studies had already suggested a possible efficacy of acupressure also in the treatment of chemotherapy-induced vomiting resistant to the classical antiemetic drugs. The aim of this study was to confirm these preliminary data.

METHODS

The study was performed in 100 consecutive metastatic solid tumour patients, who underwent chemotherapy for their advanced neoplastic disease, and who had no benefit from the standard antiemetic agents, including corticosteroids, antidopaminergics and 5-HT 3R-antagonists. Acupressure was made by a stimulation of PC6 acupoint.

RESULTS

The emetic symptomatology was reduced by acupressure in 68/100 (68%) patients, without significant differences in relation to tumour histotype. The lowest efficacy was observed in patients treated by anthracycline-containing regimens, without, however, statistically significant differences with respect to the other chemotherapeutic combinations.

CONCLUSION

This study confirms previous preliminary clinical results, which had already suggested the potential efficacy of acupressure in the treatment of vomiting due to cancer chemotherapy. Therefore, acupressure may be successfully included within the therapeutic strategies of cancer chemotherapy-induced vomiting.

A case-control study of Panicum Miliaceum in the treatment of cancer chemotherapy-induced alopecia

AIM

Alopecia still remains one of the most untreatable side-effects induced by cancer chemotherapy. According to the phytotherapeutic tradition, Panicum Miliaceum has been proven to be effective in the prevention of hair loss for different reasons. At present, however, there are no data about its possible efficacy in the treatment of cancer chemotherapy-induce alopecia. The aim of this study was to analyze the efficacy of Panicum Miliaceum in cancer patients treated with the most potent chemotherapeutic drugs in terms of hair loss, consisting of cisplatin (CDDP) and anthracyclines.

METHODS

This case-control study included 28 cancer patients concomitantly treated with Panicum Miliaceum and 56 patients receiving the same combinations of chemotherapy alone as a control group. Panicum Miliaceum was given orally at 300 mg (daily dose) 3 times per day, every day until the end of chemotherapy. The grade of hair loss was assessed by World Health Organization (WHO) criteria.

RESULTS

The percentage of alopecia of third grade observed in patients concomitantly treated with Panicum Miliaceum in association with CDDP-containing regimens was significantly lower than that found in those who received the chemotherapy only. The percentage was also lower under anthracycline-containing schedules, without, however, statistically significant differences. Panicum Miliaceum therapy was substantially well tolerated in all patients.

RESULTS

This preliminary study would suggest that the concomitant treatment with Panicum Miliaceum may be effective in preventing hair loss induced by CDDP-containing chemotherapies, whereas the benefit was lower in patients treated with anthracyclines. Future randomized studies will be necessary to confirm these preliminary

Effect of acupressure on nausea and vomiting induced by chemotherapy in cancer patients

AIM

Corticosteroids, antidopaminergig agents and 5-HT3 antagonists are the most commonly used drugs in the treatment of chemotherapy-induced vomiting. Acupuncture and acupressure have also appeared to exert antiemetic effects. The aim of this study was to evaluate the efficacy of acupressure in the treatment of chemotherapy-induced vomiting resistant to the standard antiemetic therapies.

METHODS

The study included 40 consecutive advanced cancer patients with untreatable chemotherapy-induced vomiting. Colorectal cancer, lung cancer and breast cancer were the neoplasm most frequent in our patients. According to tumour histotype, patients received chemotherapeutic regimens containing the main emetic cytotoxic agents, including cisplatin and athracyclines. Acupressure was made by PC6 point stimulation for at least 6 h/day at the onset of chemotherapy.

RESULTS

The therapeutic approach was well accepted by the overall patients. An evident improvement in the emetic symptomatology was achieved in 28/40 (70%) patients, without significant differences in relation to neither tumor histotype, nor type of chemotherapeutic agent.

CONCLUSIONS

This preliminary study seems to suggest that a bioenergetic approach by acupressure on PC6 point may be effective in the treatment of chemotherapy-induced vomiting resistant to the conventional pharmacological strategies, as previously demonstrated for vomiting occurring during pregnancy.

A psychoneuroendocrine study of brain dopaminergic sensitivity in locally limited or metastatic cancer patients

In addition to the occurrence of pain, the evidence of a diminished capacity to feel pleasure is one of the most common cancer-related symptoms. Recent advances in psychoneuroendocrinological knowledge has shown that the perception of pleasure is mainly mediated by the dopaminergic pathways in the brain. Moreover, it has also been demonstrated that the brain dopaminergic sensitivity may be clinically explored by evaluating the endocrine response to the administration of dopaminergic agents, such as apomorphine, which consists of a decline in PRL concentrations and an increase in GH and cortisol levels. The present study was performed to evaluate dopaminergic sensitivity by the administration of apomorphine in cancer patients in an attempt to document possible cancer-related neuroendocrine anomalies, which could explain the psychological status of the patients. The study included 24 cancer patients (breast cancer: 12; colorectal cancer: 7; non-small cell lung cancer: 5), 12 of whom showed distant organ metastases. Apomorphine was given orally at 0.01 mg/kg b.w., by collecting venous blood samples before and after 20 and 60 minutes. A normal decline in PRL levels was seen in both non-metastatic and metastatic cancer patients. No cortisol increase in response to apomorphine was achieved and the lack of cortisol response was particularly evident in metastatic patients. No GH rise occurred in either metastatic or non-metastatic cancer patients. Finally, no significant difference in the endocrine response to apomorphine was seen in relation to the histotype of tumor. The results of this study show that the neoplastic disease is characterized by neurochemical alterations involving pleasure-related dopaminergic pathways, which are more evident in the metastatic disease, without particular differences in relation to tumor histotype. Therefore, the psychological condition of cancer patients would not depend only on psychological factors, but it could be due at least in part to cancer-related neuroendocrine alterations involving the dopaminergic system.

Biotherapy with the pineal immunomodulating hormone melatonin versus melatonin plus aloe vera in untreatable advanced solid neoplasms

The possibility of natural cancer therapy has been recently suggested by advances in the knowledge of tumor immunobiology. Either cytokines such as IL-2, or neurohormones, such as the pineal indole melatonin (MLT), may activate anticancer immunity. In addition, immunomodulating substances have also been isolated from plants, particularly from Aloe vera. Preliminary clinical studies had already shown that MLT may induce some benefits in untreatable metastatic solid tumor patients, whereas, for the time being, no clinical trial has been performed with aloe products. We have carried out a clinical study to evaluate whether the concomitant administration of aloe may enhance the therapeutic results of MLT in patients with advanced solid tumors for whom no effective standard anticancer therapies are available. The study included 50 patients suffering from lung cancer, gastrointestinal tract tumors, breast cancer or brain glioblastoma, who were treated with MLT alone (20 mg/day orally in the dark period) or MLT plus A. vera tincture (1 ml twice/day). A partial response (PR) was achieved in 2/24 patients treated with MLT plus aloe and in none of the patients treated with MLT alone. Stable disease (SD) was achieved in 12/24 and in 7/26 patients treated with MLT plus aloe or MLT alone, respectively. Therefore, the percentage of nonprogressing patients (PR + SD) was significantly higher in the group treated with MLT plus aloe than in the MLT gorup (14/24 vs. 7/26, p < 0.05). The percent 1-year survival was significantly higher in patients treated with MLT plus aloe (9/24 vs. 4/26, p < 0.05). Both treatments were well tolerated. This preliminary study would suggest that natural cancer therapy with MLT plus A. vera extracts may produce some therapeutic benefits, at least in terms of stabilization of disease and survival, in patients with advanced solid tumors, for whom no other standard effective therapy is available.

[Current status of lumbar gangliectomy in the surgical treatment of chronic arteriopathies of the lower extremities]

Stress is laid on the important role that lumbar gangliectomy has acquired among treatments of chronic arteriopathies of the lower extremities. For patients at Leriche 2nd stage and suffering from obstructions confined to the superficial femoral, no other treatment would appear to boast such high success percentages over time. General surgeons are invited to make use of this comparatively simple and certainly effective intervention, in consideration of the fact, among others, that the few vascular surgery centres in existence are not in a position to meet the flow of requests from the arteriopathics who apply to them.

[The Martorell ischemic hypertensive leg ulcer]

The aetiopathogenesis and diagnosis of Martorell's supra-malleolar hypertensive ulcer are discussed in the light of 3 clinical cases. Stress is laid on the overriding need for proper general management designed to normalise the serious arterial hypertension. It is felt that raubasine vasokinetics (such as Circolene), and taurine tissue oxygenators (0-due) are useful supplementary aids, particularly when administered by slow infusion. Lumbar gangliectomy will be necessary in the case of persistently painful ulcers. Its success, however, is dependent on prior normalisation of pressure. Dermo-epidermal grafts would appear to be superfluous, while frequent topical application of trophodermic creams are apparently useless.