The effect of losartan therapy on ventricular function in Marfan patients with haploinsufficient or dominant negative FBN1 mutations.

BACKGROUND: Mild biventricular dysfunction is often present in patients with Marfan syndrome. Losartan has been shown to reduce aortic dilatation in patients with Marfan syndrome. This study assesses the effect of losartan on ventricular volume and function in genetically classified subgroups of asymptomatic Marfan patients without significant valvular regurgitation. METHODS: In this predefined substudy of the COMPARE study, Marfan patients were classified based on the effect of their FBN1 mutation on fibrillin-1 protein, categorised as haploinsufficient or dominant negative. Patients were randomised to a daily dose of losartan 100 mg or no additional treatment. Ventricular volumes and function were measured by magnetic resonance imaging at baseline and after 3 years of follow-up. RESULTS: Changes in biventricular dimensions were assessed in 163 Marfan patients (48 % female; mean age 38 ± 13 years). In patients with a haploinsufficient FBN1 mutation (n = 43), losartan therapy (n = 19) increased both biventricular end diastolic volume (EDV) and stroke volume (SV) when compared with no additional losartan (n = 24): left ventricular EDV: 9 ± 26 ml vs. -8 ± 24 ml, p = 0.035 and right ventricular EDV 12 ± 23 ml vs. -18 ± 24 ml; p < 0.001 and for left ventricle SV: 6 ± 16 ml vs. -8 ± 17 ml; p = 0.009 and right ventricle SV: 8 ± 16 ml vs. -7 ± 19 ml; p = 0.009, respectively. No effect was observed in patients with a dominant negative FBN1 mutation (n = 92), or without an FBN1 mutation (n = 28). CONCLUSION: Losartan therapy in haploinsufficient Marfan patients increases biventricular end diastolic volume and stroke volume, furthermore, losartan also appears to ameliorate biventricular filling properties.

Is cardiac CT a reproducible alternative for cardiac MR in adult patients with a systemic right ventricle?

OBJECTIVE: 20 % of patients with a systemic RV are pacemaker dependent, and unsuitable to undergo cardiac magnetic resonance (CMR). Multidetector row computed tomography (MDCT) could provide a reproducible alternative to CMR in these patients. The aim of this study was to compare variability of MDCT with CMR. METHODS: Thirty-five patients with systemic RV underwent either MDCT (n = 15) or CMR (n = 20). Systemic RV volumes and ejection fraction were obtained, and intra- and interobserver variability for both modalities were assessed and compared. RESULTS: We found the intra- and interobserver variability of volumes and function measurements of the systemic RV obtained with MDCT to be higher compared with those obtained with CMR. However, these differences in variability were not significant, the only exception being the interobserver variability of systemic RV stroke volume. CONCLUSIONS: MDCT provides a reproducible alternative to CMR for volumes and function assessment in patients with a systemic RV.

The value of 3.0Tesla diffusion-weighted MRI for pelvic nodal staging in patients with early stage cervical cancer.

OBJECTIVE: The purpose of this study is to investigate the diagnostic accuracy of 3.0Tesla (3T) diffusion-weighted magnetic resonance imaging (MRI) in addition to conventional MRI for the detection of lymphadenopathy in patients with early stage cervical cancer compared to histopathological evaluation of the systematically removed pelvic lymph nodes as reference standard. METHODS: 68 fédération internationale de gynécologie obstétrique (FIGO) stage Ia2 to IIb cervical cancer patients were included. Sensitivity and specificity rates for two experienced observers were computed for the detection of lymphatic metastasis. Reproducibility of conventional MRI was tested by kappa statistics. The variables included in the analysis were: size of the long axis, short axis, ratio short to long axis and apparent diffusion coefficient (ADC). RESULTS: Nine patients had 15 positive pelvic nodes at histopathological examination. The sensitivity and specificity of lymphatic metastasis detection by predefined conventional MRI characteristics was 33% (95% Confidence Interval (CI) 3-64) and 83% (95% CI 74-93) on patient level, and 33% (95% CI 7-60) and 97% (95% CI 95-99) on regional level respectively for observer 1. For observer 2 the sensitivity was 33% (95% CI 3-64) and the specificity 93% (95% CI 87-100) on patient level, and 25% (95% CI 1-50) and 98% (95% CI 97-100) on regional level, respectively. The kappa-value for reproducibility of metastasis detection on regional level was 0.50. The short axis diameter showed the highest diagnostic accuracy (area under the curve (AUC)=0.81 95% CI 0.70-0.91); ADC did not improve diagnostic accuracy (AUC=0.83 95% CI 0.73-0.93). CONCLUSIONS: Diffusion-weighted MRI did not result in additional diagnostic value compared to conventional MRI.

Effects of heart rate, filling and slice thickness on the accuracy of left ventricular volume measurements in a dynamic cardiac phantom using ECG-gated MDCT.

The objective of the study was to assess the effect of heart rate, filling condition and slice thickness on the accuracy of volumetric analysis based on multidetector-row computed tomography (MDCT) of a cardiac phantom. Retrospective electrocardiogram-gated MDCT of a pulsating phantom was performed under different conditions. End-diastolic volume (EDV) and end-systolic volume (ESV) for different heart rates (60-75 beats per minute), filling volumes and reconstructed slice thicknesses (2 mm and 5 mm) were obtained by three observers. Results were analysed by a linear mixed-effects model. Significant effects on the accuracy were found for heart rate (F-value, 7.3-39.2; p<0.004) and filling condition (F-value, 7.4-55.6; p<0.004), but not for slice thickness. Small relative differences in the assessment of EDV were found (range, -3% to 3%), but there was a trend for overestimation of the ESV (range, -1% to 18%). Underestimation of stroke volume and ejection fraction (range, -1% to -11%) became smaller under conditions of improved temporal resolution and larger EDV. Good interobserver agreement was found (SD <1.8 ml and <0.5%). In conclusion, MDCT allows sufficient and reliable measurements of ventricular volumes and calculation of left ventricle function for clinical applications. Heart rate and filling conditions significantly affect the accuracy of volumetrics, as demonstrated in this cardiac phantom. Thicker slices provide similar accuracy to thin slices.

[Hypertension in young adults: indication for possible aortic coarctation]. / Hypertensie bij jongvolwassenen: aanwijzing voor mogelijke coarctatio aortae.

Three adult patients, a woman aged 37 and two men aged 22 and 23 years respectively, were admitted due to an unexplained hypertension. After a significant delay, the diagnosis of aortic coarctation was established for these patients. In two of them the abnormality was operatively corrected and the blood pressure subsequently normalised; the third patient is on the waiting list for the operation. In all three patients an earlier diagnosis could have been established, had accurate blood-pressure measurements of both arms and at least one leg been performed. Late detection and treatment of aortic coarctation have a profound detrimental effect on survival. Therefore it is extremely important to accurately measure the blood pressure in the limbs of young patients with hypertension.

The predictive value of angiographic results for the outcome of percutaneous transluminal angioplasty in stenosed femoral bypass grafts.

PURPOSE: To assess the predictive value of immediate angiographic results after percutaneous transluminal angioplasty (PTA) for stenoses in femoral bypass grafts using duplex ultrasound (DUS) criteria. METHODS: A 1-year follow-up with DUS was performed in 38 patients with 50 stenoses in 41 grafts, treated with PTA for a graft stenosis. The indication for PTA according to DUS criteria was a severe stenosis in 43 lesions, and a moderate stenosis in 7 lesions. In the moderate stenosis group 3 patients showed claudication and 1 patient had a nonhealing ulcer. For the purposes of statistical evaluation, primary patency was considered present if the graft was not occluded. The graft was considered to have failed when it was found to be occluded on DUS, or when secondary interventions (surgery, repeat PTA) were performed. RESULTS: After 1 year the cumulative primary patency rate was 44% [95% confidence interval (CI) 27.8-59.8]. Stenoses with initially good angiographic results after PTA (< 30% residual stenosis) were 2.9 times more likely to be patent at 1 year than stenoses with initially poor or moderate angiographic results (hazard ratio 2.9, 95% CI 1.3-6.4, p = 0.007). CONCLUSION: A poor or moderate angiographic result immediately following PTA was prognostic for poor long-term results and may indicate a requirement for earlier surgical intervention.

Evaluation of femoropopliteal arteries with duplex ultrasound after angioplasty. Can we predict results at one year?

OBJECTIVES: To determine if Duplex ultrasound (DUS) 1 day after percutaneous transluminal angioplasty (PTA) is prognostic for haemodynamic and clinical results at 1 year. DESIGN: Prospective study. PATIENTS AND METHODS: Thirty-four femoropopliteal artery segments were treated with PTA. The peak systolic velocity ratio (PSV ratio = PSV in stenosis: PSV in normal segment) was determined with DUS before PTA, 1 day after PTA and 1 year after PTA. Clinical results were assessed with the SVS/ISCVS (Society for Vascular Surgery/International Society for CardioVascular Surgery) results classification. RESULTS: A 1 year, clinical benefit from PTA was seen in 16 of 25 patients (64%) and haemodynamic improvement in 20 of 34 treated segments (59%). With DUS three residual stenoses were found 1 day after PTA; all occluded within 1 year. Segments with good DUS results after PTA showed haemodynamic deterioration in 30%. Clinical improvement was seen in most patients with DUS improvement, whereas no change or deterioration was found in patients with both good and poor DUS results at 1 year. CONCLUSIONS: Residual stenosis on DUS 1 day after PTA is prognostic for failure within 1 year. However, good DUS results after PTA cannot predict haemodynamic success. Haemodynamic success at 1 year does not imply clinical success.

Iliac artery stenoses after percutaneous transluminal angioplasty: follow-up with duplex ultrasonography.

PURPOSE: To assess iliac artery stenosis before and up to 1 year after percutaneous transluminal angioplasty (PTA) with duplex ultrasound (DUS) to determine the incidence of residual and recurrent stenoses and correlate these findings to clinical outcome. PATIENTS AND METHODS: Sixty-one patients with 70 iliac artery segments treated with PTA were examined. The peak systolic velocity (PSV) ratio (PSV ratio = PSV in stenosis divided by PSV proximal or distal to stenosis) was determined by DUS before PTA and 1 day, 3 months and 1 year after PTA. Three categories of results were identified by using PSV ratios at the site of the treated stenosis 1 day and 1 year after PTA (good result, residual stenosis, and recurrent stenosis). The DUS-determined anatomic result was correlated with the clinical outcome at 1 year. Clinical outcome was classified according to Society for Vascular Surgery/International Society for Cardiovascular Surgery (SVS/ISCVS) criteria. RESULTS: Good results with DUS (PSV ratio 1 day and 1 year after PTA > or = to 2.5) were found in 45 of 70 segments (64.3%), residual stenoses (PSV ratio > or .5 1 day after PTA) in 15 of 70 segments (21.4%), and recurrent stenosis (PSV ratio 1 day after PTA < 2.5 and 1 year after PTA > or = 2.5) in 10 of 70 segments (14.3%). PSV ratios of residual stenoses decreased significantly between 1 day and 1 year after PTA because some residual stenoses improved hemodynamically in time. Clinical results were significantly better in patients with a good result compared with other patients. However, the clinical outcome of patients with residual stenoses was not significantly different from the patients with good DUS results. CONCLUSION: Some residual stenoses improved sonographically after PTA. Clinical results at 1 year are highly variable within different groups. Clinical outcome of patients with residual stenoses did not differ from patients with good DUS results, whereas clinical outcome in patients with recurrent stenoses was worse than in the other groups.

Residual stenosis determined by intravascular ultrasound and duplex ultrasound after balloon angioplasty of the superficial femoral artery.

Exact determination of the percentage luminal stenosis after balloon angioplasty is essential when deciding to redilate or not, especially since the percentage luminal stenosis may be a predictor for long-term outcome. Conflicting percentage residual stenosis is frequently observed when angiography is compared with duplex or intravascular ultrasound measurements. The aim of the present study was to compare the percentage luminal stenosis after balloon angioplasty determined by duplex and intravascular ultrasound. In 22 patients, balloon angioplasty was performed in the superficial femoral artery to treat disabling claudication. Intravascular ultrasound studies were performed immediately after balloon angioplasty; duplex studies were performed 24-36 h after intervention. Intravascular ultrasound percentage luminal stenosis was calculated with respect to a proximal reference lumen. Duplex percentage luminal stenosis was determined by two methods: first, by assuming that the increase in peak flow velocity is directly related to lumen area; and second, by considering a peak flow velocity ratio of 1.6 and 2.4 is representative for > 30% and > 50% diameter stenosis, respectively. The percentage luminal stenosis calculated from duplex measurements was higher compared with intravascular ultrasound measurements (y = 0.38x + 20.1, r = 0.57). Excluding cross-sections with vascular wall damage (dissection or plaque fracture) over more than 60 degrees of the circumference improved the slope and correlation coefficient of intravascular ultrasound measurements versus duplex measurements (y = 0.88x + 7.8, r = 0.70). Thus, after balloon angioplasty, conflicting percentage luminal stenosis is frequently observed using intravascular ultrasound and duplex measurements. These differences in percentage luminal stenosis may partly be explained by the extent of vascular wall damage visualized on the intravascular ultrasound image.

Peripheral angiography and angioplasty.

This paper reviews recent developments in diagnostic and therapeutic interventional procedures for the peripheral arteries reported from February 1991 to January 1992. Topics discussed include endovascular metallic stents, atherectomy catheters, and intravascular ultrasound.

Renal transplant artery stenosis in children: treatment with percutaneous transluminal angioplasty.

Hypertension due to transplant renal artery stenosis was treated with percutaneous transluminal angioplasty (PTA) in 6 children. 8 angioplasties were performed and the follow-up period varied between 3 and 66 months (average 23 months). The stenoses were located at the site of anastomosis in 4 children and distal to the anastomosis in 2. PTA resulted in improvement of hypertension in all patients, although the need for antihypertensive medication remained. No grafts were lost. Our findings show that PTA of transplant renal artery stenosis in children is a good first choice of treatment.

Antegrade puncture of the femoral artery: morphologic study.

To determine the optimal site for antegrade puncture of the femoral artery, the authors evaluated three cadaver specimens and computed tomographic (CT) scans of 50 patients. The relationships among the common femoral artery, the femoral artery bifurcation, the center of the femoral head, and the inguinal ligament were evaluated. CT showed that the center of the femoral head was always located caudal to the level of the inguinal ligament but cranial to the bifurcation of the common femoral artery. Therefore, the femoral head seems to provide a reliable landmark for entering the common femoral artery.