Heyde syndrome revisited: anaemia and aortic stenosis.

BACKGROUND: The association of anaemia with aortic stenosis (AS) has been recognised for over 50 years; however, although there have been several sporadic reports, there are few data on the prevalence of this syndrome. AIMS: We sought to compare the prevalence of anaemia in adults with AS with that of controls who had undergone coronary artery bypass grafting (CABG). METHODS: We conducted a retrospective cohort study comparing pre-procedural levels of haemoglobin in 1537 adults who underwent aortic valve replacement (AVR) for AS with 8025 contemporaneous patients who had CABG. We hypothesised that the prevalence of anaemia in patients with AS would be significantly higher than in the control group. RESULTS: A total of 30.1% in the AVR group was anaemic compared to 16.2% in the CABG group. The mean haemoglobin concentration measured across the whole population was significantly lower (132 g/L) in AVR patients than in those who underwent CABG (138 g/L). In a multivariable model, haemoglobin levels varied significantly by treatment group, gender and age. The adjusted marginal mean haemoglobin value was 135.6 g/L in AVR patients compared to 137.3 g/L in CABG patients. CONCLUSIONS: The prevalence of anaemia was significantly greater in patients with AS than in a contemporaneous cohort that underwent CABG. This may indicate that Heyde syndrome is more common than has been generally appreciated and should be considered in the evaluation of anaemia in patients with AS.

Factors Contributing to Acute Kidney Injury and the Impact on Mortality in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) patients are at a high risk of acute kidney injury (AKI). This study aimed to investigate AKI and the relationship with iodinated contrast media (ICM), whether there are significant pre- or peri- procedural variables predicting AKI, and whether AKI impacts on hospital length of stay and mortality. METHODS: Serum creatinine (SC) levels pre- and post- (peak) TAVR were recorded in 209 consecutive TAVR patients. AKI was defined by the Valve Academic Research Consortium 2 (VARC2) criteria. Baseline characteristics, procedural variables, hospital length of stay (LOS) and mortality at 72hours, 30 days and one year were analysed. RESULTS: Eighty-two of 209 (39%) patients suffered AKI. Mean ICM volume was 228cc, with no difference between patients with AKI and those with no AKI (227cc (213-240(95%CI)) vs 231cc (212-250) p=0.700)). Univariate and multivariate analysis demonstrated that chronic kidney disease, respiratory failure, previous stroke, the need for blood transfusion and valve repositioning were all predictors of AKI. Acute kidney injury increased LOS (5.6 days (3.8 - 7.5) vs 3.2 days (2.6 - 3.9) no AKI (P=0.004)) but was not linked to increased mortality. Mortality rates did increase with AKI severity. CONCLUSION: Acute kidney injury is a common complication of TAVR. The severity of AKI is important in determining mortality. Acute kidney injury appears to be independent of ICM use but pre-existing renal impairment and respiratory failure were predictors for AKI. Transcatheter aortic valve replacement device repositioning or retrieval was identified as a new risk factor impacting on AKI.

Medical management of chronic stable angina.

Stable angina pectoris is characterised by typical exertional chest pain that is relieved by rest or nitrates. Risk stratification of patients is important to define prognosis, to guide medical management and to select patients suitable for revascularisation. Medical treatment aims to relieve angina and prevent cardiovascular events. Beta blockers and calcium channel antagonists are first-line options for treatment. Short-acting nitrates can be used for symptom relief. Low-dose aspirin and statins are prescribed to prevent cardiovascular events.

Transcatheter valve-in-valve replacement of degenerated bioprosthetic aortic valves: a single Australian Centre experience.

BACKGROUND: Patients with degenerated surgical bioprosthetic valves may be at high risk for further surgery because of age, comorbidities and the difficulties of repeat procedures. Percutaneous valve-in-valve implantation offers what may be a simpler and safer procedure. METHODS: From May 2009 to March 2014 at the Prince Charles Hospital 1625 patients underwent surgical aortic valve replacement while 262 underwent transcatheter aortic valve implantation. Twelve patients had valve-in-valve implants for degenerated bioprosthetic aortic valves. RESULTS: These implants were deployed successfully without major valvular or paravalvular regurgitation. There were no periprocedural deaths, myocardial infarcts, neurological events or major vascular complications. Two patients died after 1624 and 1319days. Median survival for the remainder is 581days; they are stable with New York Heart Association class I/II functional status although 4 have a degree of patient-prosthesis mismatch, one has moderate aortic regurgitation and one required surgery for a late aortic dissection. CONCLUSION: Transcatheter valve-in-valve implantation is safe and effective treatment for patients with failed bioprosthetic aortic valves for whom reoperation is considered to be hazardous.

Anterior ECG changes following iatrogenic dissection of the right coronary artery into the aortic root: exclusion of left coronary obstruction with transoesophageal echocardiography.

One of the most troublesome complications of percutaneous coronary intervention (PCI) or angiography is retrograde dissection of the artery into the aortic root. We report a case involving the right coronary artery (RCA) which was treated with prompt deployment of stents. Recurrent chest pain and ST segment elevation in V(2-4) mimicked the ECG appearance of acute anterior infarction and prompted concern that the dissection had extended to impair flow in the left coronary artery (LCA). Transoesophageal echocardiography (TOE) demonstrated that the aortic root dissection had been contained and that the LCA was not compromised.

Conservative treatment of spontaneous dissection of multiple coronary arteries.

A young woman who presented with chest pain was shown with CT and selective coronary angiography to have spontaneous dissections of her left anterior descending and distal right coronary arteries. She was managed with enoxaparin, aspirin, clopidogrel and metoprolol: she was well with a normal stress echocardiogram fourteen months later. Surgical intervention or angioplasty and stent deployment may be avoided in such patients if they are clinically stable.

Fistula from aneurysmal saphenous vein graft to right atrium treated with covered stents.

Rarely aneurysmal dilatation of saphenous vein grafts following coronary artery bypass surgery may be complicated by fistulae which communicate with cardiac chambers. We describe our attempt to close a fistula which entered the right atrium by deploying covered stents within the graft.

Diagnostic accuracy of nodal enhancement pattern of rectal cancer at MRI enhanced with ultrasmall superparamagnetic iron oxide: findings in pathologically matched mesorectal lymph nodes.

OBJECTIVE: The purpose of this study was to evaluate the diagnostic accuracy of the pattern of nodal enhancement at MRI enhanced with ultrasmall superparamagnetic iron oxide (USPIO) in the nodal classification of rectal cancer in pathologically matched mesorectal lymph nodes. SUBJECTS AND METHODS: Twenty-five patients with adenocarcinoma of the rectum underwent prospective evaluation with 3-mm axial T2-weighted and USPIO-enhanced T2*-weighted MRI before surgery. Mesorectal nodes visible at in vivo MRI were independently scored by two radiologists as malignant or nonmalignant according to morphologic criteria (irregular nodal contour, heterogeneous signal intensity) on T2-weighted MR images and according to USPIO enhancement pattern on T2*-weighted MR images. The sensitivity, specificity, and positive and negative predictive values of morphologic and USPIO criteria in identification of malignancy in the pathologically matched mesorectal nodes were compared by use of the McNemar test. Interobserver agreement was compared by use of kappa statistics. RESULTS: After surgery, radiologic-pathologic comparison of 126 mesorectal nodes (116 benign, 10 malignant) was possible. Use of morphologic criteria resulted in an average sensitivity of 65% (95% CI, 35-88%); specificity, 75% (67-83%); positive predictive value, 19% (8-34%); and negative predictive value, 96% (91-99%). Use of USPIO criteria resulted in an average sensitivity of 65% (95% CI, 35-88%); specificity, 93% (87-96%); positive predictive value, 43% (21-67%); and negative predictive value, 97% (92-99%). Use of USPIO MRI improved diagnostic specificity for both observers (p < 0.01). Interobserver agreement was fair for morphologic criteria (kappa = 0.39) but good for USPIO criteria (kappa = 0.68). CONCLUSION: Use of the pattern of USPIO enhancement had higher diagnostic specificity than but the same sensitivity as morphologic findings in pathologically matched mesorectal lymph nodes.

The value of dual-source 64-slice CT coronary angiography in the assessment of patients presenting to an acute chest pain service.

BACKGROUND: The absence of radiological evidence of plaque on computed tomographic coronary angiography (CTCA) reliably excludes obstructive coronary artery disease. METHODS: We studied patients who presented to our emergency department with chest pain and were admitted to our chest pain assessment service. If they were free of pain and without high-risk features of myocardial ischaemia including elevation of serum biomarkers they underwent CTCA and performed a standard treadmill exercise test. RESULTS: Eighty-nine patients aged 56.3+/-8.6 years were admitted. Eleven of them had selective angiography; CTCA identified all who had obstructive disease. More than half of the 85 patients who had normal values of cardiac troponin and of the 75 with a negative exercise test had radiological evidence of disease. During follow-up for 355+/-72 days none died, suffered myocardial infarction or required coronary artery surgery: two with obstructive disease underwent percutaneous coronary intervention 1 and 7 days after the index study. CONCLUSIONS: The CTCA findings were significantly correlated with those of selective angiography and with troponin status and increased the ascertainment of coronary artery disease in a cohort of patients at low risk for clinically significant ischaemic heart disease.

A comparison of anticoagulation with bivalirudin and provisional GPIIb/IIIa inhibition with unfractionated heparin and mandatory GPIIb/IIIa inhibition during percutaneous coronary intervention in relation to platelet activation and the inhibition of coagulation.

AIMS: Our study sought to evaluate mechanisms of the current strategies for optimal anticoagulation during percutaneous coronary intervention (PCI). METHODS AND RESULTS: Thirty-two high risk acute coronary syndrome patients were randomised to bivalirudin and provisional GPIIb/IIIa inhibition (GPIIb/IIIa) or unfractionated heparin (UFH) and mandatory GPIIb/IIIa. Flow cytometric measurements immediately after anticoagulation showed that, unlike UFH, bivalirudin did not activate platelets as indicated by P-selectin expression and fibrinogen binding while decreasing platelet-monocyte aggregates and monocyte expression of tissue factor. UFH released tissue factor pathway inhibitor (TFPI) during and immediately after PCI while bivalirudin (irrespective of GP IIb/IIIa) did not. Lower levels of TFPI with bivalirudin were seen during and immediately after PCI (P<0.01). Thrombin generation as indicated by prothrombin fragment F 1+2 levels was reduced during PCI in the UFH group (P<0.01) but not with bivalirudin. Soluble CD40 ligand is associated with thrombosis and levels were higher in the bivalirudin group irrespective of GPIIb/IIIa at the same stages (P<0.05). CONCLUSIONS: Bivalirudin has some early advantages on platelet activation when compared to UFH. However, there are significant limitations in its mechanism of action, particularly a lack of release of tissue factor pathway inhibitor.

Point-of-care testing shows clinically relevant variation in the degree of inhibition of platelets by standard-dose abciximab therapy during percutaneous coronary intervention.

Administration of GP IIb/IIIa inhibitors during percutaneous coronary intervention (PCI) has proven clinical benefit, but is administered at a dose allowing for the patients' weight but not other variables. This study of 75 patients evaluated platelet inhibition achieved by standard-dose abciximab therapy during PCI as measured by two point-of-care (POC) instruments, Plateletworks (PW) and whole blood aggregation (WB). Results were related to the decrease of platelet activation produced as well as patients' return of angina within 30 days. Flow cytometric measurement showed abciximab suppressed platelet-monocyte aggregates (P < 0.001) and activated glycoprotein IIb/IIIa (P < 0.001) but not P-selectin. Greater POC-measured inhibition corresponded to less postabciximab expression of platelet-monocyte aggregates (P < 0.01). Patients above the lowest quartile of POC inhibition with PW demonstrated a relative risk of experiencing return of angina within 30 days of 0.48 (0.23-0.99). In conclusion, POC measurements reflect platelet activation suppression, higher PW measurements being associated with a decreased risk of return of angina.

Rectal cancer: mesorectal lymph nodes at MR imaging with USPIO versus histopathologic findings--initial observations.

PURPOSE: To compare histopathologic findings with appearances of mesorectal lymph nodes at magnetic resonance (MR) imaging with ultrasmall particles of iron oxide (USPIO) in rectal cancer. MATERIALS AND METHODS: Mesorectal lymph nodes in 12 patients with adenocarcinoma of the rectum were evaluated with USPIO and high-spatial-resolution MR imaging. Appearance and signal intensity of lymph nodes at T2- and T2*-weighted imaging were recorded before and after USPIO administration. Two radiologists visually assessed pattern of enhancement; interobserver agreement was tested with the kappa statistic. After total mesorectal excision, MR imaging of surgical specimens was performed, and it enabled node-by-node correlation with histopathologic findings. RESULTS: Appearances of 74 nodes at in vivo MR imaging were compared with histopathologic findings. Sixty-eight nodes were nonmalignant (34 were normal, 34 showed reactive changes); six nodes were malignant. Four patterns of USPIO uptake were demonstrated at T2*-weighted imaging: uniform low signal intensity, central low signal intensity, eccentric high signal intensity, and uniform high signal intensity. Two radiologists showed good interobserver agreement (kappa = 0.88, P <.01) in classification of nodes into these four categories. Sixty-five (96%) of 68 nonmalignant nodes showed uniform or central low-signal-intensity patterns; 16 (47%) of 34 reactive nodes showed central low-signal-intensity patterns. Compared with uniform low-signal-intensity pattern, central low-signal-intensity pattern was more commonly observed in reactive nodes (P <.01, chi(2) test; positive predictive value, 67%; 95% CI: 47%, 87%). Eccentric and uniform high-signal-intensity patterns were observed in lymph nodes that contained metastases larger than 1 mm in diameter. CONCLUSION: Mesorectal lymph nodes can be characterized by using USPIO and T2*-weighted MR imaging. Uniform and central low-signal-intensity patterns are features of nonmalignant nodes. Reactive nodes frequently show central low signal intensity at T2*-weighted imaging.