Cardiac computed tomography-based assessment of mitral annular calcification in patients undergoing mitral transcatheter edge-to-edge repair.

BACKGROUND: The role of assessment of mitral annular calcification (MAC) using cardiac computed tomography (CCT) in mitral transcatheter edge-to-edge repair (TEER) remains unclear. The aim of this study was to investigate the association of MAC assessed by CCT with procedural and clinical outcomes in patients undergoing TEER. METHODS: We retrospectively analyzed 275 patients who underwent pre-procedural CCT prior TEER. Mitral calcium volume (MCV) and MAC score were measured by CCT. Functional procedural success was defined as residual mitral regurgitation of ≤2+ with mean transmitral gradient of <5 â€‹mmHg at discharge. All-cause mortality within two years after TEER was collected. RESULTS: MAC was present in 115 of 275 patients (41.8 %). The median MCV was 198 â€‹mm3 (interquartile range [IQR]: 84 to 863 â€‹mm3), and the median MAC score was 3 (IQR: 2 to 4). Higher MCV and MAC score were inversely related to the rate of functional procedural success, independently of anatomical features of mitral valve. Patients with moderate/severe MAC, defined as MAC score of ≥4, had a lower rate of functional procedural success than those without MAC (56.1 â€‹% vs. 81.3 â€‹%; p â€‹= â€‹0.002). Moreover, higher MCV and MAC score were associated with a higher risk of all-cause mortality within two years, irrespective of baseline characteristics and functional procedural success. CONCLUSIONS: The presence and burden of MAC assessed by CCT were associated with procedural and clinical outcomes in patients undergoing TEER. The CCT-based assessment of MAC may improve patient selection for TEER.

Diagnostic performance of tomosynthesis, digital mammography and a dedicated digital specimen radiography system versus pathological assessment of excised breast lesions.

BACKGROUND: The aim of the study was to compare the performance of full-field digital mammography (FFDM), digital breast tomosynthesis and a dedicated digital specimen radiography system (SRS) in consecutive patients, and to compare the margin status of resected lesions versus pathological assessment. PATIENTS AND METHODS: Resected tissue specimens from consecutive patients who underwent intraoperative breast specimen assessment following wide local excision or oncoplastic breast conservative surgery were examined by FFDM, tomosynthesis and SRS. Two independent observers retrospectively evaluated the visibility of lesions, size, margins, spiculations, calcifications and diagnostic certainty, and chose the best performing method in a blinded manner. RESULTS: We evaluated 216 specimens from 204 patients. All target malignant lesions were removed with no tumouron-ink. One papilloma had positive microscopic margins and one patient underwent reoperation owing to extensive in situ components. There were no significant differences in measured lesion size among the three methods. However, tomosynthesis was the most accurate modality when compared with the final pathological report. Both observers reported that tomosynthesis had significantly better lesion visibility than SRS and FFDM, which translated into a significantly greater diagnostic certainty. Tomosynthesis was superior to the other two methods in identifying spiculations and calcifications. Both observers reported that tomosynthesis was the best performing method in 76.9% of cases. The interobserver reproducibilities of lesion visibility and diagnostic certainty were high for all three methods. CONCLUSIONS: Tomosynthesis was superior to SRS and FFDM for detecting and evaluating the target lesions, spiculations and calcifications, and was therefore more reliable for assessing complete excision of breast lesions.

Radiopaque tissue transfer and X-ray system versus standard specimen radiography for intraoperative margin assessment in breast-conserving surgery: randomized clinical trial.

BACKGROUND: Reduction of positive margin rate (PMR) in breast-conserving surgery (BCS) of non-palpable breast cancer remains a challenge. The efficacy of intraoperative specimen radiography (SR) is unclear. This randomized trial evaluated whether the PMR was reduced by the use of devices that allow precise localization of the affected margins. METHODS: Patients with microcalcification-associated breast cancer undergoing planned BCS were enrolled. Study participants were randomized to receive either SR with radiopaque tissue transfer and X-ray system (KliniTrayTM) or the institutional standard procedure (ISO). In all patients with a radiological margin less than 5 mm, an immediate re-excision was conducted. The primary outcome was the PMR. Risk factors for positive margins and the effect of immediate re-excision on final surgery were secondary analyses. RESULTS: Among 122 randomized patients, 5 patients were excluded due to the extent of primary surgery and 117 were available for analysis. Final histopathology revealed a PMR of 31.7 per cent for the KliniTrayTM group and 26.3 per cent for the ISO group (P = 0.127). Independent factors for positive margins were histological tumour size more than 30 mm (adjusted OR (aOR) 10.73; 95 per cent c.i. 3.14 to 36.75; P < 0.001) and specimen size more than 50 mm (aOR 6.65; 95 per cent c.i. 2.00 to 22.08; P = 0.002). Immediate re-excision due to positive SR led to an absolute risk reduction in positive margins of 13.6 per cent (from 42.7 to 29.1 per cent). CONCLUSION: Specimen orientation with a radiopaque tissue transfer and X-ray system did not decrease the PMR in patients with microcalcification-associated breast cancer; however, SR and immediate re-excision proved to be helpful in the reduction of PMR. REGISTRATION NUMBER: DRKS00011527 (https://www.drks.de).

Ureteral Stent Encrustation: Epidemiology, Pathophysiology, Management and Current Technology.

PURPOSE: Encrustation is a common phenomenon that can occur following placement of a ureteral stent into the urinary tract, and it can lead to serious complications. The following review addresses the mechanism of encrustation, the management of these stents and the newest technology developed to mitigate this issue. MATERIALS AND METHODS: We performed a comprehensive literature search on stent encrustation including peer-reviewed publications, public product listings, and material on current and future stent technology. RESULTS: The mechanism of encrustation is complex and multifaceted, including dwell time, patient specific risk factors, conditioning film formation, biofilm formation and mineral deposition. Several technological developments in stent materials and coatings may have a role in reducing the risk of stent encrustation. It is important to identify the extent of stent encrustation and plan treatment strategies accordingly. We propose a novel treatment algorithm for the management encrusted ureteral stents. CONCLUSIONS: The ubiquity of ureteral stents in urology practice mandates updated knowledge about the prevention of stent encrustation, identification of high risk patients and preparedness for removal using multimodal techniques.

Global, Regional, and National Burden of Calcific Aortic Valve and Degenerative Mitral Valve Diseases, 1990-2017.

BACKGROUND: Nonrheumatic valvular diseases are common; however, no studies have estimated their global or national burden. As part of the Global Burden of Disease Study 2017, mortality, prevalence, and disability-adjusted life-years (DALYs) for calcific aortic valve disease (CAVD), degenerative mitral valve disease, and other nonrheumatic valvular diseases were estimated for 195 countries and territories from 1990 to 2017. METHODS: Vital registration data, epidemiologic survey data, and administrative hospital data were used to estimate disease burden using the Global Burden of Disease Study modeling framework, which ensures comparability across locations. Geospatial statistical methods were used to estimate disease for all countries, because data on nonrheumatic valvular diseases are extremely limited for some regions of the world, such as Sub-Saharan Africa and South Asia. Results accounted for estimated level of disease severity as well as the estimated availability of valve repair or replacement procedures. DALYs and other measures of health-related burden were generated for both sexes and each 5-year age group, location, and year from 1990 to 2017. RESULTS: Globally, CAVD and degenerative mitral valve disease caused 102 700 (95% uncertainty interval [UI], 82 700-107 900) and 35 700 (95% UI, 30 500-42 500) deaths, and 12.6 million (95% UI, 11.4 million-13.8 million) and 18.1 million (95% UI, 17.6 million-18.6 million) prevalent cases existed in 2017, respectively. A total of 2.5 million (95% UI, 2.3 million-2.8 million) DALYs were estimated as caused by nonrheumatic valvular diseases globally, representing 0.10% (95% UI, 0.09%-0.11%) of total lost health from all diseases in 2017. The number of DALYs increased for CAVD and degenerative mitral valve disease between 1990 and 2017 by 101% (95% UI, 79%-117%) and 35% (95% UI, 23%-47%), respectively. There is significant geographic variation in the prevalence, mortality rate, and overall burden of these diseases, with highest age-standardized DALY rates of CAVD estimated for high-income countries. CONCLUSIONS: These global and national estimates demonstrate that CAVD and degenerative mitral valve disease are important causes of disease burden among older adults. Efforts to clarify modifiable risk factors and improve access to valve interventions are necessary if progress is to be made toward reducing, and eventually eliminating, the burden of these highly treatable diseases.

Third generation dual source CT with ultra-high pitch protocol for TAVI planning and coronary tree assessment: feasibility, image quality and diagnostic performance.

PURPOSE: To evaluate the feasibility, image quality (IQ) and diagnostic performance of third generation 192 × 2 dual source computer tomography (DSCT) with ultra-high pitch acquisition for trans-catheter aortic valve implantation (TAVI) planning and coronary tree assessment. METHOD: In this prospective study, 223 patients underwent to DSCT for TAVI. Coronary calcium scoring (CCS) was calculated. Attenuation values were measured at aortic levels, femoral and coronary arteries. IQ was evaluate with a 4-point scale. The CT performance, in the assessment of coronary stenosis ≥50 % and ≥70 %, was compared with invasive coronary angiography (ICA), served as reference standard. Aortic annulus (AoA) CT derived area and implanted prosthesis size were correlate with Spearman's test. RESULTS: Attenuation values >400HU were obtain in all segments. IQ median value was ≥ 3. In the assessment of stenosis ≥50 %, on a segment-based analysis, CT sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were 97.6 %, 87.6 %, 64.2 %, 99.0 % and 89.6 %, on patient-based analysis were 97.8 %, 88.8 %, 68.8 %, 99.4 % and 90.6 %, respectively. In the assessment of stenosis ≥70 %, on segment-based analysis, were 88.5 %, 83.8 %, 54.7 %, 96.8 % and 84.8 %, and on patient-based analysis were 92.5 %, 85.8 %, 58.7 %, 98.1 % and 87.0 %, respectively. The CT performed better in the group with lower CCS. A direct correlation was found between AoA CT derived area and prosthesis size. CONCLUSION: DSCT, using a single prospective ECG-triggered ultra-high pitch acquisition, is feasible for TAVI planning and in the assessment of coronary stenosis. CT performed worse in patients with severe coronary calcifications.

Comparison of the value of superficial mark guided localization and hook-wire guided localization techniques for non-palpable breast microcalcifications: A retrospective clinical research.

AIM: The present study compares the effect and accuracy of the superficial mark guided localization (SGL) and hook-wire guided localization (WGL) techniques for non-palpable breast microcalcifications. METHODS: This retrospective study was conducted to compare SGL and WGL techniques. These techniques were performed on 51 patients with non-palpable breast microcalcifications from January 2015 to May 2016. RESULTS: Among these 51 patients, 25 (49.01%) patients were subjected to WGL and 26 patients (50.99%) were subjected to SGL. The SGL technique had a higher rate of malignant cancer detection (WGL = 12.0% and SGL = 23.0%). Furthermore, no significant differences were found with regard to average age, the rate of a second excision and the diameter of the excised tissue. Moreover, no complications were observed in the SGL group, while four (16.0%) patients in the WGL group experienced problems. CONCLUSION: The SGL technique is as accurate as the WGL technique. Furthermore, the procedure has advantages of being less expensive and causing less complications.

Risk factors for atrioventricular block after transcatheter aortic valve implantation: a single-centre analysis including assessment of aortic calcifications and follow-up.

AIMS: To assess the contribution of aortic valve calcification to the occurrence of transient or permanent atrioventricular block (AVB) and the need for permanent pacemaker implantation (PPI) after transcatheter aortic valve implantation (TAVI) in a large single-centre cohort. METHODS AND RESULTS: We retrospectively analysed pre-operative contrast-enhanced multidetector computed tomography scans of patients who underwent TAVI in our centre between 2012 and 2016. Calcium volume was calculated for each aortic cusp above (aortic valve), and below [left ventricular outflow tract (LVOT)] the basal plane. Clinical and procedural data as well as pre-operative electrocardiograms were evaluated. Multivariate analysis was performed to evaluate risk factors for transient and permanent AVB. A total of 342 patients receiving a balloon-expandable prosthesis were included in the study. Overall incidence of transient and permanent AVB was 4% (n = 14) and 7.6% (n = 26), respectively. On logistic regression analysis, baseline right bundle branch block [odds ratio (OR) 7.36, 95% confidence interval (CI) 2.6-20.6; P < 0.01], degree of oversizing (OR 1.04, 95% CI 1.01-1.07 P = 0.02), prior percutaneous coronary intervention (OR 2.8, 95% CI 1.1-7.3), and LVOT calcification beneath the non-coronary cusp (OR for an increase of 10 mm3 = 1.06, 95% CI 1-1.1; P = 0.03) were found to be independently associated with permanent AVB and PPI, whereas calcification of LVOT beneath the right coronary cusp (OR for an increase of 10 mm3 = 1.16, 95% CI 1.02-1.3; P = 0.02) and balloon post-dilation (OR 3.8, 95% CI 1.2-11.8; P = 0.02) were associated with reversible AVB. CONCLUSION: Left ventricular outflow tract calcifications are associated with transient and non-reversible AVB after TAVI, and its evaluation could help in predicting onset and reversibility of AVB.

Impact of a Claims-Based Frailty Indicator on the Prediction of Long-Term Mortality After Transcatheter Aortic Valve Replacement in Medicare Beneficiaries.

Background Prospectively collected frailty markers are associated with an incremental 1-year mortality risk after transcatheter aortic valve replacement (TAVR) compared with comorbidities alone. Whether information on frailty markers captured retrospectively in administrative billing data is similarly predictive of long-term mortality after TAVR is unknown. We sought to characterize the prognostic importance of frailty factors as identified in healthcare billing records in comparison to validated measures of frailty for the prediction of long-term mortality after TAVR. Methods and Results Adult patients undergoing TAVR between August 25, 2011, and September 29, 2015, were identified among Medicare fee-for-service beneficiaries. The Johns Hopkins Claims-based Frailty Indicator was used to identify frail patients. We used nested Cox regression models to identify claims-based predictors of mortality up to 4 years post-procedure. Four groups of variables, including cardiac risk factors, noncardiac risk factors, patient procedural risk factors, and nontraditional markers of frailty, were introduced sequentially, and their integrated discrimination improvement was assessed. A total of 52 338 TAVR patients from 558 clinical sites were identified, with a mean follow-up time period of 16 months. In total, 14 174 (27.1%) patients died within the study period. The mortality rate was 53.9% at 4 years post-TAVR. A total of 34 863 (66.6%) patients were defined as frail. The discrimination of each of the 4 models was 0.60 (95% CI, 0.59-60), 0.65 (95% CI, 0.64-0.65), 0.68 (95% CI, 0.67-0.68), and 0.70 (95% CI, 0.69-0.70), respectively. The addition of nontraditional frailty markers as identified in claims improved mortality prediction above and beyond traditional risk factors (integrated discrimination improvement: 0.019; P<0.001). Conclusions Risk prediction models that include frailty as identified in claims data can be used to predict long-term mortality risk after TAVR. Linkage to claims data may allow enhanced mortality risk prediction for studies that do not collect information on frailty.

Our Surgical Experience: Open Versus Endoscopic Carpal Tunnel Surgery.

Carpal tunnel release is one of the most common hand operations in the United States and every year approximately 500,000 patients undergo surgical release. In this article, we examine the argument for endoscopic carpal tunnel release versus open carpal tunnel release, as well as some of the literature on anatomical variants in the median nerve at the wrist. We further describe the experience of several surgeons in a large academic practice. The goals of this article are to describe key anatomic findings and to present several cases that have persuaded us to favor offering patients open carpal tunnel release.

Noninvasive Assessment of Carotid Plaques Calcification by 18F-Sodium Fluoride Accumulation: Correlation with Pathology.

BACKGROUD: Vascular calcification is currently recognized as an important pathobiological process in atherosclerosis, but the mechanism remains elusive. Given the similarities in vascular calcification and bone formation, 18F-sodium fluoride (18F-NaF) is now considered a novel marker of vascular calcification. This study aimed to correlate 18F-NaF accumulation with the histological characterization of vascular calcification in carotid plaques. METHODS: A total of 8 patients who were undergoing carotid endarterectomy (CEA) for carotid artery stenosis were recruited. Before CEA, 18F-NaF positron emission tomography and computed tomography (PET-CT) studies were conducted. 18F-NaF uptake was measured by the maximum standardized uptake value and the target-to-background ratio. The Hounsfield unit (HU) value was also measured. Postoperative carotid plaques were investigated by hematoxylin and eosin staining, alizarin red staining, and immunohistochemistry (alpha-smooth muscle actin and CD68). RESULTS: 18F-NaF uptake was observed in the bilateral carotid bifurcation of all patients. Compared with the pathology results, there was a significant correlation between tracer activity in the carotid plaques and the calcification in the corresponding histological sections (integrated optical density [IOD]: r = .781, P = .022; positive area: r = .765, P = .027). A negative correlation was observed between 18F-NaF uptake and smooth muscle cell staining (IOD: r = -.710, P = .049). 18F-NaF uptake did not correlate with carotid artery stenosis, HU value, or inflammation. CONCLUSIONS: 18F-NaF PET-CT is a noninvasive imaging method for the assessment of calcification in human carotid atherosclerotic plaques and a promising approach to studying calcification in atherosclerotic lesions.

Assessment of aortic valve calcium load by multidetector computed tomography. Anatomical validation, impact of scanner settings and incremental diagnostic value.

OBJECTIVES: To validate aortic valve calcium (AVC) load measurements by multidetector row computed tomography (MDCT), to evaluate the impact of tube potential and slice thickness on AVC scores, to examine the accuracy of AVC load in distinguishing severe from nonsevere aortic stenosis (AS) and to investigate its effectiveness as an alternative diagnosis method when echocardiography remains inconclusive. METHODS: We prospectively studied 266 consecutive patients with moderate to severe AS who underwent MDCT to measure AVC load and a comprehensive echocardiographic examination to assess AS severity. AVC load was validated against valve weight in 57 patients undergoing aortic valve replacement. The dependence of AVC scores on tube potential and slice thickness was also tested, as well as the relationship between AVC load and echocardiographic criteria of AS severity. RESULTS: MDCT Agatston score correlated well with valve weight (r = 0.82, p < 0.001) and hemodynamic indices of AS severity (all p < 0.001). Ex-vivo Agatston scores decreased significantly with increasing tube potential and slice thickness (repeated measures ANOVA p < 0.001). Multivariate analysis identified mean gradient, the indexed effective orifice area, male gender and left ventricular outflow tract cross-sectional area as independent correlates of the in-vivo AVC load. CONCLUSIONS: MDCT-derived AVC load correlated well with valve weight and hemodynamic indices of AS severity. It also depends on tube potential and slice thickness, thus suggesting that these parameters should be standardized to optimize reproducibility and accuracy.

Validation of American Thyroid Association Ultrasound Risk Assessment of Thyroid Nodules Selected for Ultrasound Fine-Needle Aspiration.

OBJECTIVE: The aim of this study was to validate the American Thyroid Association (ATA) sonographic risk assessment of thyroid nodules. METHODS: The ATA sonographic risk assessment was prospectively applied to 206 thyroid nodules selected for ultrasound-guided fine-needle aspiration (US-FNA), and analyzed with The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC), as well as surgical pathology for the subset undergoing surgical excision. RESULTS: The analysis included 206 thyroid nodules averaging 2.4 cm (range 1-7 cm; standard error of the mean 0.07). Using the ATA US pattern risk assessment, nodules were classified as high (4%), intermediate (31%), low (38%), and very low (26%) risk of malignancy. Nodule size was inversely correlated with sonographic risk assessment, as lower risk nodules were larger on average (p < 0.0001). Malignancy rates determined by cytology/surgical pathology were high 100%, intermediate 11%, low 8%, and very low 2%, which were closely aligned with ATA malignancy risk estimates (high 70-90%, intermediate 10-20%, low 5-10%, and very low 3%). ATA US pattern risk assessment also appropriately predicted the proportion of nodules classified as malignant or suspicious for malignancy through TBSRTC classification-high (77%), intermediate (6%), low (1%), and very low 0%-as well as benign TBSRTC classification-high (0%), intermediate (47%), low (61%), and very low (70%) (p < 0.0001). Malignancy rates of surgically excised, cytologically indeterminate nodules followed ATA sonographic risk stratification (high 100%, intermediate 21%, low 17%, and very low 12%; p = 0.003). CONCLUSION: This prospective study supports the new ATA sonographic pattern risk assessment for selection of thyroid nodules for US-FNA based upon TBSRTC and surgical pathology results. In the setting of indeterminate cytopathology, nodules categorized as atypia of undetermined significance/follicular lesion of undetermined significance with ATA high-risk sonographic patterns have a high likelihood of being malignant.

Echocardiographic Assessment of Degenerative Mitral Stenosis: A Diagnostic Challenge of an Emerging Cardiac Disease.

Degenerative mitral stenosis (DMS) is characterized by decreased mitral valve (MV) orifice area and increased transmitral pressure gradient due to chronic noninflammatory degeneration and subsequent calcification of the fibrous mitral annulus and the MV leaflets. The "true" prevalence of DMS in the general population is unknown. DMS predominantly affects elderly individuals, many of whom have multiple other comorbidities. Transcatheter MV replacement techniques, although their long-term outcomes are yet to be tested, have been gaining popularity and may emerge as more effective and relatively safer treatment option for patients with DMS. Echocardiography is the primary imaging modality for evaluation of DMS and related hemodynamic abnormalities such as increased transmitral pressure gradient and pulmonary arterial pressure. Classic echocardiographic techniques used for evaluation of mitral stenosis (pressure half time, proximal isovelocity surface area, continuity equation, and MV area planimetry) lack validation for DMS. Direct planimetry with 3-dimensional echocardiography and color flow Doppler is a reasonable technique for determining MV area in DMS. Cardiac computed tomography is an essential tool for planning potential interventions or surgeries for DMS. This article reviews the current concepts on mitral annular calcification and its role in DMS. We then discuss the epidemiology, natural history, differential diagnosis, mechanisms, and echocardiographic assessment of DMS.

Rates of presurgical underestimation of breast cancer after standardized assessment of breast calcifications.

PURPOSE: To determine the frequency of histopathological underestimation of breast cancer after vacuum-assisted biopsy (VAB) in standardized assessment of breast calcifications compared to postsurgical diagnosis. MATERIALS AND METHODS: The retrospective study included acquired data of 506 consecutively examined women, who underwent VAB for the assessment of pure calcifications after standardized digital mammographic and sonographic imaging. 119/506 (24.5 %) women underwent further surgical procedures: 37 women had a surgical diagnostic excision biopsy, 82 women a surgical procedure based on a therapeutic concept. Presurgical results of VAB were compared with the postsurgical histopathological reports. RESULTS: In 91/119 women (76.5 %) the final histology was malignant. The rate of ductal carcinoma in situ (DCIS) was 79.1 % (72/91) and the rate of invasive carcinoma was 20.9 % (19/91). In 9/37 women with diagnostic excision biopsy, the presurgical status of benign or uncertain changed to a postsurgical diagnosis of malignant (24.3 %). In eight cases underestimation included DCIS (21.6 %) and in one case invasive cancer (2.7 %). Seven of the nine underestimated cases (77.8 %) resulted from excision biopsy of atypical epithelial proliferation of ductal type (AEPDT, positive predictive value 30.4 % (7/23)). After surgery due to DCIS in 7/71 women invasive breast cancer was diagnosed (9.9 %). In 11/82 women with oncological surgery, invasive cancer was already diagnosed by VAB. CONCLUSION: Underestimation of invasive cancer in terms of presurgical DCIS diagnosis can be minimized by the standardized assessment protocol to about 10 %. Underestimation of DCIS is mainly related to presurgical diagnosis of AEPDT. KEY POINTS: • The standardized use of digital mammographic and sonographic imaging prior to vacuum-assisted biopsy is suitable for minimizing underestimation of invasive breast cancer. AEPDT represents a high risk diagnosis for underestimation of DCIS.

Challenges in the echocardiographic assessment of aortic stenosis.

Calcific aortic valve stenosis is common in the elderly. While history and examination can establish the diagnosis, determination of its severity typically requires echocardiography to define valve anatomy, measure stenosis severity and assess left ventricular response. The purpose of this review is to describe some of the commonly encountered challenges in the echocardiographic assessment of aortic stenosis. These include errors in the calculation of aortic valve area, assessment of aortic stenosis during atrial fibrillation, determining the presence of aortic stenosis in the setting of low transvalvular pressure gradients and discriminating other forms of obstruction to left ventricular ejection from aortic stenosis. Lastly, a review of how echocardiography is utilized to select patients for transcatheter aortic valve replacement is presented.

Significance of aortic valve calcification in patients with low-gradient low-flow aortic stenosis.

BACKGROUND: Assessment of patients with aortic stenosis (AS) and impaired left ventricular function remains challenging. Aortic valve calcium (AVC) scoring with computed tomography (CT) and fluoroscopy has been proposed as means of diagnosing and predicting outcomes in patients with severe AS. HYPOTHESIS: Severity of aortic valve calcification correlates with the diagnosis of true severe AS and outcomes in patients with low-gradient low-flow AS. METHODS: Echocardiography and CT database records from January 1, 2000 to September 26, 2009 were reviewed. Patients with aortic valve area (AVA)<1.0 cm2 who had ejection fraction (EF)≤25% and mean valvular gradient≤25 mmHg with concurrent noncontrast CT scans were included. AVC was evaluated using CT and fluoroscopy. Mortality and aortic valve replacement (AVR) were established using the Social Security Death Index and medical records. The role of surgery in outcomes was evaluated. RESULTS: Fifty-one patients who met the above criteria were included. Mean age was 75.1±9.6 years, and 15 patients were female. Mean EF was 21%±4.6% with AVA of 0.7±0.1 cm2. The peak and mean gradients were 35.5±10.6 and 19.0±5.1 mmHg, respectively. Median aortic valve calcium score was 2027 Agatston units. Mean follow-up was 908 days. Patients with calcium scores above the median value were found to have increased mortality (P=0.02). The benefit of surgery on survival was more pronounced in patients with higher valvular scores (P=0.001). Fluoroscopy scoring led to similar findings, where increased AVC predicted worse outcomes (P=0.04). CONCLUSIONS: In patients with low-gradient low-flow AS, higher valvular calcium score predicts worse long-term mortality. AVR is associated with improved survival in patients with higher valve scores.

Gender differences in mitral valve surgery.

BACKGROUND: Knowledge regarding gender-specific mitral valve (MV) pathology and postoperative outcome is rare. We herein describe a single-center experience focusing on gender differences in MV surgery. MATERIALS AND METHODS: A total of 3,761 patients underwent minimal invasive MV surgery at our institution between 1999 and 2011. Demographic data, pre-, intra-, and postoperative characteristics have been collected, including details on MV pathology and surgical technique. Patient data have been analyzed with consideration of gender-specific differences. RESULTS: The cohort consisted of 2,124 male (56.5%; 58.8 ± 12.5 years) and 1,637 female (43.5%; 64.5 ± 13 years) patients. Mitral regurgitation was observed equally in women (91.3%) and men (92.4%). Additional MV stenosis has been diagnosed in 2.7% of men but in 13.9% of women (p < 0.001). Calcification of the posterior MV leaflet showed a similar trend: 20.1% in women compared with 6.5% in men. Prolapse of the posterior leaflet was present predominantly in men with 63.1 versus 35.7% in women (p < 0.001). Distinct MV repair differences were retrospectively detected between genders: posterior mitral leaflet resection was performed in 17.9% of men versus 10.1% of women; posterior mitral leaflet chordae replacement was performed in 39.3% of men compared with 20.4% of women. Prosthetic MV replacement was necessary in 26.8% of women compared with only 10.7% of men. Concomitant tricuspid valve surgery was mostly performed in women (14.4 versus 8.2%). Male patients showed a significant better postoperative long-term survival than females, with 96, 89, and 72% compared with 92, 82, and 58% after 1, 5, and 10 years, respectively (p < 0.0001). CONCLUSION: Substantial gender-specific differences regarding MV pathology, operative strategy, and long-term outcome are present that need to be addressed in clinical practice.