Three-dimensional Tricuspid Area. A New Criterion to Improve Patient Selection for Annuloplasty in Tricuspid Regurgitation.

INTRODUCTION AND OBJECTIVES: Late functional tricuspid regurgitation after rheumatic left-sided valve surgery is an important predictor of poor prognosis. This study investigated the usefulness and accuracy of 3-dimensional transthoracic echocardiography tricuspid area compared with conventional 2-dimensional diameter (2DD) for assessing significant tricuspid annulus dilatation, providing cutoff values that could be used in clinical practice to improve patient selection for surgery. METHODS: We prospectively included 109 patients with rheumatic heart disease in the absence of previous valve replacement. Tricuspid regurgitation was divided into 3 groups: mild, moderate, and severe. Optimal 3-dimensional area (3DA) and 2DD cutoff points for identification of significant tricuspid annulus dilatation were obtained and compared with current guideline thresholds. Predictive factors for 3DA dilatation were also assessed. RESULTS: Optimal cutoff points for both absolute and adjusted to body surface area (BSA) tricuspid annulus dilatation were identified (3DA: 10.4 cm2, 6.5 cm2/m2; 2DD: 35 mm, 21 mm/m2); 3DA/BSA had the best diagnostic performance (AUC=0.83). Three-dimensional transthoracic echocardiography tricuspid area helped to reclassify surgical indication in 14% of patients with mild tricuspid regurgitation (95%CI, 1%-15%; P=.03) and 37% with moderate tricuspid regurgitation (95%CI, 22%-37%; P<.0001), whereas 3DA/BSA changed surgery criteria in cases of mild tricuspid regurgitation (17%; 95%CI, 3%-17%; P=.01) compared with 2DD/BSA. On multivariable analysis, right and left atrial volumes and basal right ventricle diameter were independently correlated with 3DA. CONCLUSIONS: The current 40 mm threshold underestimates tricuspid annulus dilatation. Although 21 mm/m2 seems to be a reasonable criterion, the combination with 3DA assessment improves patient selection for surgery.

Impact of Calcium Score on Agreement Between Multidetector Computed Tomography and Invasive Coronary Angiography.

INTRODUCTION AND OBJECTIVES: Multidetector computed tomography (MDCT) has been demonstrated as a feasible alternative to invasive coronary angiography (ICA). However, contradictory results have been reported regarding the effect of coronary artery calcium score (CS) on the diagnostic accuracy of MDCT. Our aim was to assess the agreement of MDCT and ICA and to evaluate the influence of CS on this agreement. METHODS: We enrolled 266 consecutive patients who underwent evaluation with 64-slice MDCT and ICA. Standard CS software tools were used to calculate the Agatston score. Stenosis was qualitatively classified as mild, moderate, or severe by 1 blinded observer and the results were compared with those of ICA, which was used as the gold standard. RESULTS: The mean age of the patients was 65.4 ± 11.2 years, and 188 patients (70.3%) were men. A total of 484 segments with coronary stenosis ≥ mild were qualitatively evaluated and quantified with MDCT. Noninvasive measurements were concordant with ICA in 402 stenoses (83.05%; Kappa, 0.684), with no significant differences between vessels and with no statistically significant influence of CS on this agreement (OR, 0.93; 95%CI, 0.76-1.09; P = .21). Multidetector computed tomography had high sensitivity, specificity, positive predictive value, and negative predictive value on a per-segment, per-vessel, and per-patient basis. CONCLUSIONS: Non-ICA using MDCT showed good agreement with ICA in the qualitative quantification coronary stenosis and CS had no significant impact on this agreement.

Antibiotic-loaded Bone Cement as Prophylaxis in Total Joint Replacement.

One of its most serious complications associated with arthroplasty is the development of infections. Although its prevalence is only between 0.5% and 3%, in some cases it can lead to death. Therefore, an important challenge in joint surgery is the prevention of infections when an arthroplasty is performed. The use of antibiotic-loaded cements could be a suitable tool due to numerous advantages. The main advantage of the use of antibiotic loading into bone cement derives directly from antibiotic release in the effect site, allowing achievement of high concentrations at the site of action, and minimal or no systemic toxicity. This route of administration was first described by Buchholz and Engelbrecht. In the case of infection treatment, this is an established method and its good results have been confirmed. However, its role in infection prevention, and, therefore, the use of these systems in clinical practice, has proved controversial because of the uncertainty about the development of possible antibiotic resistance after prolonged exposure time, their effectiveness, the cost of the systems, toxicity and loosening of mechanical properties. This review discusses all these topics, focusing on effectiveness and safety, antibiotic decisions, cement type, mixing method, release kinetics and future perspectives. The final objective is to provide the orthopaedic surgeons the right information in their clinical practice based on current evidence.

Tricuspid annular plane systolic excursion inaccuracy to assess right ventricular function in patients with previous tricuspid annulopasty.

OBJETIVES: The clinical and prognostic usefulness of tricuspid annular plane systolic excursion (TAPSE) is well established. However, the ability of TAPSE to assess right ventricular (RV) function in patients with previous tricuspid valve annulopasty is controversial. This study examined the TAPSE suitability in patients with previous tricuspid valve annuloplasty using right ventricular fractional area change (RVFAC) as reference method. METHODS: We retrospectively analyzed 53 patients who underwent tricuspid valve annuloplasty at our hospital between 2013 and 2016. TAPSE and RVFAC were obtained in preoperative and postoperative periods using standard methodology. RESULTS: Mean age was 68±12years and 34 patients (64.1%) were women. TAPSE decreased significantly after surgery in comparison with pre-surgical values (17±4.2 Vs 12.9±4.1mm, p<0.001). On the contrary, RVFAC did not change significantly after surgery (37±9.2 Vs 36.2.9, p=0.25). The correlation between RVFAC and TAPSE was better in the preoperative (r=0.63, p<0.0001) than in the postoperative period (r=0.38, P=0.005). Good intra- and interobserver agreement for TAPSE and RVFAC was obtained, with intraclass correlation coefficients of 0.97 and 0.92 for TAPSE; and 0.90 and 0.85 for RVFAC, respectively. CONCLUSIONS: These findings suggest that TAPSE is not suitable after tricuspid valve annuloplasty and it leads to an underestimation of RV systolic function. It seems to be appropriate to rely on echocardiographic parameters of global RV function such as RVFAC in this context.

Should computed tomography coronary angiography be aborted when the calcium score exceeds a certain threshold in patients with chest pain?

BACKGROUND: There is ongoing debate about whether a computed tomography coronary angiography (CTCA) should be aborted when the calcium score (CS) exceeds a certain threshold in patients with chest pain. The aim of this study was to discover whether specific "cutpoints" regarding coronary artery CS could be determined to predict severe coronary stenoses assessed by CTCA, thus identifying patients amenable to an invasive diagnostic approach. METHODS: 294 consecutive patients with chest pain of uncertain cause who were referred for non-invasive diagnostic CTCA were included. Subjects underwent Agatston CS and CTCA using current 64-slice technology. RESULTS: Severe coronary stenoses were noted in 75 of 294 (25.1%) patients on CTCA. A very high prevalence of severe coronary stenoses was found in patients with CS ≥ 400 (87.0%). The CS had area under the ROC curve 0.86 to predict severe coronary stenoses on CTCA. The best discriminant cut-off point was CS ≥ 400 (sensitivity of 55.3%, specificity of 93.5, positive predictive value of 85.8%, negative predictive value of 84.0%). Multivariable logistic regression analysis controlling for traditional risk factors showed CS ≥ 400 remained an independent predictor of severe coronary stenoses on CTCA (OR 14.553, 95% confidence interval 4.043 to 52.384, p<0.001). CONCLUSIONS: CS can be used as a "gatekeeper" to CTCA in patients with chest pain. Due to the very high prevalence of severe coronary stenoses in patients with CS ≥ 400, further evaluation with CTCA is not warranted as these patients should be referred to invasive coronary angiography, avoiding the repeated exposure to ionizing radiation and iodinated contrast.

Chronic mitral regurgitation: a pilot study to assess preoperative left ventricular contractile function using speckle-tracking echocardiography.

BACKGROUND: The development of postoperative left ventricular (LV) dysfunction is a frequent complication in patients with chronic severe mitral regurgitation (MR) and implies a poor prognosis. The aim of this study was to evaluate the predictive value of preoperative regional LV contractile function assessment using two-dimensional echocardiography-based speckle-tracking analysis in patients with chronic severe MR. METHODS: Thirty-eight consecutive patients with chronic severe MR scheduled for mitral valve replacement were prospectively enrolled. Preoperative two-dimensional echocardiography-based speckle-tracking analysis at the level of the interventricular septum (IVS) was carried out, and strain and strain rate values were obtained. LV dP/dt and Doppler tissue imaging-derived strain and strain rate measurements were also obtained. LV volumes and LV ejection fraction (LVEF) were defined using three-dimensional echocardiography. RESULTS: Preoperative speckle tracking-derived longitudinal strain and strain rate values at the level of the IVS strongly predicted a postoperative LVEF decrease of >10%. Their predictive values were greater than those obtained for preoperative LV volumes and LVEF, LV dP/dt, and Doppler tissue imaging-derived strain and strain rate. The best discriminant parameter to detect a postoperative LVEF reduction of >10% with speckle tracking was a longitudinal strain rate at the level of the mid IVS < -0.80 s(-1) (area under the receiver operating characteristic curve, 0.88; sensitivity, 60%; specificity, 96.5%; positive predictive value, 90%; negative predictive value, 82.35%). CONCLUSIONS: IVS longitudinal speckle tracking-derived strain rate allows the accurate detection of early abnormalities in LV contractile function. It is a powerful predictor of early postoperative LVEF decreases in patients with chronic severe MR. Furthermore, speckle-tracking technology is more accurate than other methods. This new tool might assist clinicians in the optimal timing of surgery in patients with chronic severe MR.

Speckle-tracking-derived strain and strain-rate analysis: a technique for the evaluation of early alterations in right ventricle systolic function in patients with systemic sclerosis and normal pulmonary artery pressure.

BACKGROUND AND AIM: Systemic sclerosis is associated with pulmonary artery hypertension. Speckle-tracking-derived strain and strain rate may be a diagnostic tool to detect early changes in right ventricular function, before pulmonary artery hypertension development. Our aim was to assess whether speckle-tracking-derived strain and strain-rate parameters may detect right ventricular early alterations in patients with systemic sclerosis with normal pulmonary systolic artery pressure (PAP). METHODS: Seventeen asymptomatic patients with systemic sclerosis and 22 controls were enrolled. A complete two-dimensional echo with speckle-tracking-derived longitudinal strain and strain rate of the basal right ventricular free wall and interventricular septum was performed. RESULTS: Median age was 56 years (43.8-71.5) in the systemic sclerosis group and 48.5 years (32-56.5) in the control group. No differences in conventional left ventricular parameters, tissue Doppler indexes, or in tricuspid annular plane systolic excursion were found. Patients with systemic sclerosis had higher levels of peak tricuspid regurgitation velocity and less respiratory collapse in the inferior vena cava. There were no differences in the speckle-tracking-derived strain and strain-rate parameters measured at the level of the basal interventricular septum and in the strain values measured at the level of the basal lateral right ventricular free wall. Nevertheless, a significant increase of the longitudinal strain rate measured at the basal lateral free wall of the right ventricle was found in patients with systemic sclerosis when compared with controls [-5.5 (-6.4--2.6)/s vs. -1.8 (-3.9--1.4)/s; P = 0.014]. CONCLUSION: Speckle-tracking-derived longitudinal strain rate is useful to detect early right ventricular function changes in patients with systemic sclerosis with normal pulmonary systolic artery pressure levels. This alteration may preclude pulmonary artery hypertension development and reflect an adaptive response to higher levels of pulmonary systolic artery pressure.

MR pharmacokinetic modeling of the patellar cartilage differentiates normal from pathological conditions.

PURPOSE: To study the pharmacokinetic parameters derived from dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) of the patellar cartilage under normal and pathological conditions. MATERIALS AND METHODS: DCE-MRI was obtained in 22 cases. There were 17 patients with degenerative patellar conditions (eight with chondromalacia and nine with osteoarthritis) and five normal subjects. The cartilage pharmacokinetic parameters of K(trans) (vascular permeability), k(ep) (extraction ratio), upsilon(e) (extravascular extracellular space [EES] volume fraction), and upsilon(p) (intravascular space volume fraction) were extracted. RESULTS: Statistically significant differences were observed between the different groups (normal cartilage, chondromalacia and osteoarthritis) for K(trans) and upsilon(e). K(trans) values were (mean +/- SD) 1.06 +/- 0.62, 11.97 +/- 8.91, and 21.21 +/- 16.03 mL x minute(-1) x 100 mL(-1) (P < 0.02), respectively; and upsilon(e) values were 0.71 +/- 0.69, 3.59 +/- 2.21, and 10.51 +/- 8.20% (P < 0.002). Reproducibility of the pharmacokinetic calculations was assessed with a second set of analyses of 10 random cases one week after the first analysis, showing a test-retest root mean square (RMS) coefficient of variation of 9.78% for K(trans) and 14.72% for upsilon(e). CONCLUSION: The vascular permeability and EES fraction of cartilage increases with the severity of the degeneration. Pharmacokinetic models allow to study the vascular properties of the cartilage and may have applications as a surrogate index in longitudinal studies to quantify the evolution of drug trials.

Factores asociados a aumento de la sensibilidad del ecocardiograma transtorácico en el diagnóstico de la endocarditis infecciosa / Associated factors to increased sensitivity in the transthoracic echocardiogram for the diagnosis of infective endocarditis

INTRODUCTION AND OBJECTIVES: Echocardiography is considered a basic tool in the diagnosis and management of infective endocarditis. Transesophageal echocardiography is more sensitive than transthoracic echocardiography. Our aim was to describe which factors are related to the ability of transthoracic echocardiography to establish the diagnosis of infective endocarditis. The presence of this factors in a patient with a normal transthoracic echocardiography would make unnecessary to perform a transesophageal echocardiography and would suggest to seek for other diagnostic possibilities. METHODS: 127 consecutive patients admitted to our hospital with the diagnosis of infective endocarditis and a complete transthoracic echocardiography and transesophageal echocardiography comprised our study group. Predisposing factors and clinical, echocardiographic and microbiological variables were studied. RESULTS: The presence of a cardiac murmur, the presence of an optimal acoustic window, degenerative valvular disease as the predisposing factor for infective endocarditis and positive blood cultures were related to the ability of transthoracic echocardiography to diagnose the existence of signs of infective endocarditis on its own. Nevertheless, only the presence of a cardiac murmur (RR 2.724; 95% CI 1.071-6.926; p 0,035) and the presence of an optimal acoustic window (RR 5.538; 95% IC 2.75-11.15; p < 0.001) were found as independent factors to detect those patients in which transthoracic echocardiography is able to diagnose signs of infective endocarditis on its own. CONCLUSIONS: The diagnostic accuracy of transthoracic echocardiography to detect echocardiographic signs of infective endocarditis is high in those patients with cardiac murmur and optimal acoustic window. In those patients with these characteristics, without prosthetic heart valves and a negative transthoracic echocardiography for infective endocarditis other diagnostic possibilities should be ruled out before performing of a transesophageal echocardiography.

Infective endocarditis: mid-term prognosis in patients with good in-hospital outcome.

BACKGROUND AND AIM OF THE STUDY: The study aim was to analyze the mid-term prognosis of infective endocarditis (IE) in patients managed with medical therapy during the in-hospital phase and who had a good initial outcome. Comparison was made with the prognosis of patients treated surgically during this period. METHODS: A total of 151 patients diagnosed with IE was studied, and in-hospital outcome, clinical characteristics and mid-term follow up data were analyzed. The main end-point was a composite of death and need for surgical repair. RESULTS: Among 151 patients, 84 (56%) underwent surgery or died during the in-hospital phase, while 67 patients (44%) received medical treatment and were discharged clinically stable with a final diagnosis of healed infective endocarditis. A better baseline profile was seen in the medically treated group, but outcome in this group showed extensive mid-term morbidity/mortality. In total, 52.2% of patients underwent surgery to correct complications and 60% died as a consequence of the disease. The event-free survival rate was 20% at five years. CONCLUSION: Despite a favorable in-hospital clinical course and successful medical treatment, patients with IE are at risk of late complications that result in a need for surgical repair, or in death. A close follow up should be made in order to treat late complications.

Usefulness of real-time 3-dimensional echocardiography in the assessment of infective endocarditis: initial experience.

OBJECTIVE: Our aim was to provide an initial description of the usefulness of real-time 3-dimensional (3D) echocardiography when evaluating patients with infective endocarditis. METHODS: For this purpose, we describe 3 cases in which the usefulness of real-time 3D echocardiography is shown. RESULTS: Better definition of the morphologic characteristics of the vegetation and valvular apparatus was achieved with real-time 3D echocardiography. Furthermore, the information provided by the real-time 3D echocardiogram to the surgical team was accurate and direct because it was not based on detailed verbal information for performing a 3D mental reconstruction but was a simple image similar to what would be found in the operating room. In all cases, the information provided by the real-time 3D echocardiography was confirmed during surgery. CONCLUSIONS: Real-time 3D echocardiography is an important tool for aiding diagnosis or for fine tuning a suspected diagnosis when traditional echocardiography is not completely clear for both medical and surgical decision making.

Impact of echocardiography in the short- and long-term prognosis of patients with infective endocarditis and negative blood cultures.

BACKGROUND AND AIM OF THE STUDY: Higher morbidity and mortality have been attributed to patients suffering endocarditis but with negative blood cultures. The study aim was to determine whether, in the present era of routine echocardiography, patients with negative-culture endocarditis had a worse short- and long-term outcome, and whether outcomes in patients with true negative and aborted positive blood cultures were different. METHODS: When endocarditis was clinically suspected, an early (<24 h) echocardiographic examination was performed in all patients, regardless of blood culture results. In total, 151 patients diagnosed with infective endocarditis (IE) comprised the study group. Among these patients, 40 (26%) had negative blood cultures, and 28 of this subgroup (70%) had received previous antibiotic therapy. Short- and long-term features and prognosis were compared between both groups. The combined main end-point was death or need for surgical repair. RESULTS: Similar anatomic and clinical characteristics were present among those patients with positive and negative cultures. In addition, mortality and need for surgery with regard to short- and long-term follow up of both groups was similar. There were no significant differences between patients with true- or aborted-negative cultures in terms of short- and long-term prognosis. CONCLUSION: No differences in short- and long-term prognosis were seen among patients with IE and positive versus negative blood cultures. The prognosis was also similar between those with true negative culture versus aborted negative cultures. Early echocardiography in patients with clinically suspected IE may have changed the outcome in patients with negative cultures.

Negative predictive value of dipyridamole vs. dobutamine stress echocardiography in the long-term follow-up of patients undergoing major vascular surgery.

INTRODUCTION: Perioperative cardiovascular complications are a significant cause of post-surgical morbidity and mortality in patients undergoing major vascular surgery (MVS). Dobutamine stress echocardiography is the most important method of detecting coronary artery disease in these patients. Although dipyridamole stress echocardiography (SE-DIP) and dobutamine stress echo (SE-DOB) have demonstrated similar negative predictive value (NPV) in the early postoperative period in patients undergoing MVS, there are few data concerning the negative predictive value of SE-DIP in the long-term follow-up of this subgroup of patients. OBJECTIVE: Our aim was to compare the long-term NPV of these two types of stress echocardiography and to compare it with perioperative NPV, based on the working assumption that they are similar. PATIENTS AND METHODS: A retrospective study was made of 157 patients based on preoperative evaluations for vascular surgery between February 1997 and February 2000. Clinical history and the results of consecutive stress exams were analyzed. We excluded patients with a positive stress echo and those that performed dobutamine stress echo which was considered inconclusive since they did not reach 85% of the maximum heart rate for their age. Therefore, 110 patients were included, 29 (26.4%) with dobutamine and 81 (73.6%) dipyridamole-atropine. The patients were followed after surgery for a period of 2.2 +/- 1 years. Cardiac events were defined as cardiac death, nonfatal acute myocardial infarction and hospitalization for unstable angina. The cumulative probability of event-free survival was compared. RESULTS: The patients' mean age was 65 +/- 10 years, and 108 (98.1%) were men. After 2.2 +/- 1 years of follow-up, 7 cardiac events occurred in the group with negative SE-DIP (8.6%) and 3 in patients with negative SE-DOB (10.3%). There were no statistically significant differences between the two groups concerning event-free survival (3.7 +/- 0.2 vs. 3.5 +/- 0.2 years for SE-DIP and SE-DOB respectively; p = 0.91). Negative predictive values for SE for perioperative and long-term cardiac events were 97.3% and 90.9% respectively. CONCLUSIONS: SE-DIP is a good alternative to SE-DOB in the preoperative evaluation of patients undergoing MVS, with the NPV of SE-DIP being similar to SE-DOB in the perioperative period and in long-term follow-up.