Predictors of mortality in patients undergoing percutaneous aortic valve implantation.

AIM: Transcatheter aortic valve implantation (TAVI) became an attractive alternative to surgery for patients with severe aortic stenosis and high operative risk. The first multicenter randomized trial, conducted in such high risk cohort, showed 20% reduction in mortality in the group treated with TAVI compared to those treated with medical therapy (30.7% vs. 50.7% P=0.001) and a non-inferiority of TAVI compared to traditional valve surgical replacement for all-cause mortality at 1 year with, similar improvement of symptoms and physical performance. However, mortality rate of TAVI remains high (20-30% at one year). The purpose of this prospective single center study was to identify predictors of mortality and adverse events in patients undergoing TAVI in order to be able to select the ones who benefit most from the procedure. METHODS: Between June 2009 and June of 2011, 118 patients with severe aortic stenosis treated with TAVI at IRCCS Humanitas Clinical Institute were included in a prospective registry. Pre procedural clinical and ecocardiographic evaluations, surgical risk estimation, and procedural complications, defined by VASC criteria, were recorded. Clinical and echocardiographic evaluations were performed at 1, 6 and 12 months after the implants. To investigate the predictors of mortality, clinical and anatomical characteristics of alive patients were compared with those of death ones at one month and one year follow-up. RESULTS: The procedural success occurred in 92.4% of procedures; vascular complications (33%), bleeding complications (22%), postimplant paravalvolar grade ≥2 AR (20.4%) a new permanent pacemaker implant (19.7%), were the most common complications. Survival for the whole cohort at 30 days was 6.8%, survival at one year was 82.2%. In the logistic regression test, one month mortality was significantly adversely affected by the renal functional status (odd ratio 0.9356), by a previous history of coronary artery bypass grafting (odd ratio 39) and by the mean aortic annular diameter (odd ratio 0.512) (P=0.0005). One year mortality was influenced by high EuroSCORE (odd ratio 1.0399) and the presence of hemodynamically significant prosthetic regurgitation (odd ratio 3.8438). CONCLUSION: TAVI procedure, in high risk patients with critical aortic stenosis, can be accomplished with low procedural mortality. The worst outcome affects particularly patients with renal insufficiency and previous coronary bypass. However, the long-term mortality remains high due to the poor baseline conditions, mainly related to co-morbidity and to the presence of residual post-procedural aortic insufficiency.

Anatomical patterns of patent foramen ovale (PFO): do they matter for percutaneous closure?

AIM: The aim of this study was to describe and classify the various anatomical pattern of patent foramen ovale (PFO) with transesophageal echocardiography (TEE) and to relate such classification to the selection of PFO closure devices. METHODS: This study enrolled 216 PFO patients (118 females) mostly with previous cryptogenic stroke or transitory ischemic attack (TIA) who underwent percutaneous closure of PFO with deep sedation under TEE control. Anatomical patterns were classified as follows: simple: PFO characterised by central/superior eccentric shunt or with a valve mechanism (45%); reduse: widely redundant septum primum (22%); ASA: atrial septal aneurysm (11%); EASA: entire atrial septal aneurysm (1.4%); CRIB: cribriform septum primum (9%); tunnel: tunnel between septum primum and secundum >10 mm (11%). Degree of right-to-left shunt, either at basal condition or at Valsalva manoeuvre, was classified as: 1=mild (45%); 2=moderate (42%); 3=severe (13%). Additional right-atrium anatomical features are also described. RESULTS: Procedure was successful in 100% of the cases. At follow-up recurrent TIA occurred in two patients. Residual shunts were present in 4.9% of the patients after Valsalva manoeuvre. Palpitations were reported in 4%. CONCLUSIONS: Closing the PFO choosing the device following strict anatomical criteria based on TEE assessment allowed excellent immediate and late results minimizing residual shunts.

Admission glycemia and markers of inflammation are independent outcome predictors in primary PCI in non-diabetic patients.

AIM: To assess the prognostic value of admission plasma glucose (APG) respect to clinical variables and inflammatory markers in a selected population of non-diabetic patients with ST elevation myocardial infarction (STEMI) treated with primary angioplasty (primary coronary intervention, PCI). METHODS: A total of 188 consecutive non-diabetic STEMI patients undergoing primary PCI were divided into four quartiles based on APG (<117, 117-140, 141-170, >170 mg/dL). Combined end-point of major adverse cardiac events (MACE) was defined as death, acute heart failure, re-infarction, unstable angina or inducible ischemia. RESULTS: Event-free survival from MACE was significantly (P<0.001) correlated with APG quartiles and decrease from the lowest to the highest: 6 months event-free survival was 89.3%, 77.4%, 59.1%, 42.5%. Patients with higher APG were characterized by a significantly higher Killip class (P<0.001), higher serum creatinine (P<0.05) on admission, and a lower rate of thrombolysis in myocardial infarction (TIMI) 3 flow after PCI (P<0.05). Multivariate analysis showed APG>170 mg/dL (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.24 to 4.65, P<0.01), admission high-sensitivity C-reactive protein level (HR 1.19, 95% CI 1.07 to 1.31, P<0.001), white blood cells count (HR 1.07, 95% CI 1.00 to 1.14, P<0.04) and heart rate (HR 1.02, 95% CI 1.00 to 1.04, P<0.02) to be independent predictors of MACE. CONCLUSION: Admission glycemia and inflammatory markers are independent predictors of MACE in the mid-term follow-up in non-diabetic STEMI treated with primary PCI. Further investigations are needed to study the pathogenesis of stress hyperglycaemia, interactions with mechanisms of inflammation and whether early and aggressive treatment with insulin may influence outcome of primary PCI.

Treatment of vaginal agenesis with a new vulvovaginoplasty.

The correction of vaginal agenesis requires the creation of a canal that is in the correct axis and ideally of adequate size, texture, and secretion. A simple surgical technique is described which has a good anatomic and functional result with minimal morbidity. It combines the traditional dissection of the rectovesical space described by McIndoe with a significantly modified vulvovaginoplasty based on the Williams method. The technique has been performed with good results and no complications in three patients. Closely monitored vaginal dilatation is essential in the postoperative period. At this stage, only one patient has engaged in intercourse.

Uterine lavage in the diagnosis of endometrial malignancy and its precursors.

A negative-pressure uterine lavage technique and simple cytologic processing were employed in the detection of endometrial disease in 1,606 patients, 366 of whom were postmenopausal and asymptomatic. Asymptomatic endometrial cancer and its precursors were detected by lavage in patients with negative cervical smear findings, while some symptomatic patients with negative cervical smears and curettage had persistent lavage cytologic abnormalities that preceded histologic confirmation. This technique detected 90.9% of the adenocarcinomas and 59.1% of the atypical/adenocarcinomatous hyperplasias, as compared with 52.3% and 27.3%, respectively, using cervical scraping. Detection rates for endometrial hyperplasia were improved by reporting as abnormal the presence of many clusters of otherwise-normal endometrial cells. In postmenopausal patients, representative endometrial material was obtained in 82.0%, and the procedure was abandoned in 4.1% due to cervical stenosis. Since intrauterine manipulation is unnecessary, the technique was well accepted by elderly asymptomatic women and appears suitable for routine cancer screening.

A case of platypnea-orthodeoxia syndrome caused by the interaction between the presence of corrected transposition of the great arteries and patent foramen ovale.

A 42-year-old was admitted to our institution for recurrent episodic dyspnea on exertion. The patient had also a history of recurrent transient ischemic attacks. Careful history taking revealed that she developed dyspnea in an upright position, whereas the symptoms were relieved in a supine position (platypnea). The patient was given the diagnosis of platypnea-orthodeoxia syndrome. Transthoracic echocardiography showed cardiac situs solitus levocardia with great artery transposition with intact interventricular septum, patent foramen ovale (PFO) and moderate right atrial dilatation. Agitated saline contrast injection demonstrated the presence of spontaneous right-to-left shunt. The patient underwent transcatheter closure of PFO. After percutaneous closure of PFO patient became asymptomatic and hypoxemia induced by orthostatic conditions did not appear again. A transthoracic echocardiography performed after two months, showed the complete closure of PFO, without residual shunt.

Non-immune hydrops fetalis: rapidity of onset and usefulness of prenatal ultrasonography.

Non-immune hydrops fetalis (NIHF) has become more common than immune hydrops fetalis as a cause of fetal hydrops and its contribution to the total perinatal mortality rate has increased from 0.1% to 3.0% for the 10 years to 1979. A case is reported where an antenatal ultrasonograph performed within 24 hours of delivery showed hydrops was not present, however, at birth the infant was grossly hydropic and died despite intensive management. This case shows the rapidity of onset of NIHF and the devastating effect of this disorder. A review of two large series of NIHF revealed that in only 11.4% and 16.3% respectively, a significant uncorrectible associated major malformation may have been missed by antenatal ultrasonography. Hence, if prenatal ultrasonography fails to reveal a major malformation a viable fetus with NIHF should be regarded as salvageable. Pulmonary hypoplasia occurred in over 90% and is probably due to compression from serous cavity effusions. Thus to improve survival the ultrasonographer needs to watch for the development of serous cavity effusions so that a pregnancy complicated by NIHF can be terminated before the fetus develops pulmonary hypoplasia.