Background: Endoscopic application of hemoclips (HC) was prospectively compared with heat probe (HP) treatment in patients with bleeding ulcers. Methods: One hundred thirteen patients with major ...stigmata of ulcer hemorrhage were randomly assigned to receive HP (n = 57) or HC (n = 56). Clinical and endoscopic features were comparable in both groups. Recurrent bleeding was retreated with the modality previously used. Patients in whom treatment or retreatment was unsuccessful underwent emergency surgery. Results: Hemostasis, adequate treatment of visible vessel, 30-day mortality, and emergency surgery rates were similar for both groups. Recurrent bleeding was 21% for HP and 1.8% for HC (p < 0.05). Length of hospital stay and transfusion requirements were significantly lower in the HC group. There was no evidence of clip-induced tissue injury or impaired ulcer healing. Clips dislodged spontaneously in most patients within 8 weeks of treatment. No further hemorrhage occurred on a median follow-up of 11 months (range 1-23). Conclusions: The hemoclip is safe and effective in the treatment of severe ulcer bleeding and is superior to HP in preventing early recurrent bleeding. (Gastrointest Endosc 2001;53:147-51.)
Abstract
Aims
To perform a comparative analysis of right ventricle (RV) myocardial mechanics, assessed by 2D speckle-tracking echocardiography (2D-STE), between patients with Fabry disease and ...patients with sarcomeric disease.
Methods and results
Patients with Fabry cardiomyopathy (FC) (n = 28) were compared with patients with sarcomeric hypertrophic cardiomyopathy (HCM), matched for degree of left ventricle hypertrophy (LVH) and demographic characteristics (n = 112). In addition, patients with Fabry disease and no LVH phenotype-negative carriers of pathogenic α-galactosidase gene mutations (GLA LVH-) (n = 28) were compared with age and sex-matched carriers of sarcomeric gene mutations without LVH Phenotype-negative carriers of pathogenic sarcomeric gene mutations (Sarc LVH-) (n = 56). Standard echocardiography and 2D-STE were performed in all participants. Despite a subtle impairment of RV global longitudinal strain (RV-GLS) was common in both groups, patients with FC showed a more prominent reduction of RV free wall longitudinal strain (RV-FWS) and lower values of difference between RV-FWS and RV-GLS (ΔRV strain), in comparison to individuals with HCM (P < 0.001 and P = 0.002, respectively). RV-FWS and ΔRV strain demonstrated an independent and additive value in discriminating FC from HCM, over the presence of symmetric LVH, systolic anterior motion of the mitral valve and RV hypertrophy. Similar results were found in GLA LVH- patients: they had worse RV-FWS and lower values of ΔRV strain as compared to Sarc LVH- patients (both P < 0.001).
Conclusion
Patients with FC show a specific pattern of RV myocardial mechanics, characterized by a larger impairment of RV-FWS and lower ΔRV strain in comparison to patients with HCM, which may be helpful in the differential diagnosis between these two diseases.
Graphical Abstract
Graphical Abstract
(1) Background: Left ventricular global longitudinal (LVGLS) and right ventricular free wall strain (RVFWS) demonstrated separate prognostic values in patients with severe aortic stenosis (AS). ...However, studies evaluating the combined assessment of LVGLS and RVFWS have shown contradictory results. This study explored the prognostic value of combining LVGLS and RVFWS in a large group of severe AS patients referred for transcatheter aortic valve implantation. (2) Methods: Patients were classified into three groups: preserved (LVGLS ≥ 15% AND RVFWS > 20%), single-ventricle impaired (LVGLS < 15% OR RVFWS ≤ 20%), or biventricular-impaired strain group (LVGLS < 15% AND RVFWS ≤ 20%). The cut-off values were based on previously published data and spline analyses. The endpoint was all-cause mortality. (3) Results: Of the 712 patients included (age 80 ± 7 years, 53% men), 248 (35%) died. The single-ventricle impaired and biventricular-impaired (vs. preserved) strain groups showed significantly lower 5-year survival rates (68% and 55% vs. 77%, respectively,
< 0.001). Through multivariable analysis, single-ventricle impaired (HR 1.762; 95% CI: 1.114-2.788;
= 0.015) and biventricular-impaired strain groups (HR 1.920; 95% CI: 1.134-3.250;
= 0.015) were independently associated with all-cause mortality. These findings were confirmed with a sensitivity analysis in patients with preserved LV ejection fraction. (4) Conclusions: In patients with severe AS, biventricular strain allows better risk stratification, even if LV ejection fraction is preserved.
There is limited evidence regarding the association between right ventricular-to-pulmonary artery (RV-PA) coupling and outcomes after transcatheter aortic valve replacement (TAVR).
This study aimed ...to explore the evolution of RV-PA coupling in patients with severe aortic stenosis undergoing TAVR and its prognostic impact.
A total of 900 patients who underwent TAVR in 2 tertiary centers and with echocardiographic analysis performed within 3 months before and after the procedure were included. RV-PA coupling was measured as the ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PASP). RV-PA uncoupling was defined by TAPSE/PASP <0.55, whereas a TAPSE/PASP <0.32 identified a severe uncoupling. The primary endpoint was all-cause mortality.
A total of 520 patients (58%) showed RV-PA uncoupling before TAVR, whereas post-TAVR RV-PA uncoupling was observed in 407 patients (45%). During a median follow-up of 40 months, 250 deaths (28%) occurred. Post-TAVR RV-PA uncoupling was independently associated with an increased risk of mortality (adjusted HR: 1.474; 95% CI: 1.115-1.948; P = 0.006), whereas pre-TAVR uncoupling did not. Among patients with post-TAVR RV-PA uncoupling, the presence of severe uncoupling identified a subgroup with the worst survival (P = 0.008). Patients with RV-PA coupling recovery after TAVR showed similar outcomes as compared with patients with normal coupling. Conversely, the presence of either persistent or new-onset RV-PA uncoupling following TAVR was associated with an increased mortality risk.
Post-TAVR RV-PA uncoupling is an independent predictor of long-term mortality, irrespective of coupling before intervention. Assessment of TAPSE/PASP response after TAVR may be helpful to improve risk stratification.
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Abstract
OBJECTIVES
This study evaluated the prognostic value of staging right heart failure in patients with significant tricuspid regurgitation (TR) undergoing tricuspid valve (TV) surgery.
METHODS
...Patients with significant TR who underwent TV surgery were divided into 4 right heart failure stages according to the presence of right ventricular (RV) dysfunction and clinical signs of right heart failure: stage 1 was defined as no RV dysfunction and no signs of right heart failure; stage 2 indicated RV dysfunction without signs of right heart failure; stage 3 included RV dysfunction and signs of right heart failure; and stage 4 was defined as RV dysfunction and refractory signs of right heart failure at rest.
RESULTS
A total of 278 patients mean age 64 (12), 49% males were included, of whom 34 (12%) patients were classified as stages 1 and 2, 141 (51%) as stage 3 and 103 (37%) as stage 4 right heart failure. The majority of patients (91%) had TV surgery concomitant to left-sided valve surgery or coronary artery bypass grafting and 95% underwent TV annuloplasty. Cumulative survival rates were 89%, 78% and 61% at 1 month, 1 year and 5 years, respectively. Stages 1 and 2 and stage 3 were independently associated with better survival compared to stage 4 (hazard ratio: 0.391 95% confidence interval: 0.186–0.823 and 0.548 95% confidence interval: 0.369–0.813, respectively).
CONCLUSIONS
Patients with significant TR undergoing TV surgery and diagnosed without advanced right heart failure have better survival as compared to patients with right heart failure.
The prognostic implications of severe tricuspid regurgitation (TR) have been reported in several patient cohorts and left untreated, severe TR is associated with poor survival 1, 2.
The present study aimed to investigate (1) the association between left ventricular diastolic dysfunction (LVDD), graded according to the algorithm proposed by the Cirrhotic Cardiomyopathy ...Consortium, and long‐term survival in patients with cirrhosis undergoing transjugular intrahepatic portosystemic shunt (TIPS) and (2) the additive prognostic value of left atrial (LA) function, as assessed by LA reservoir strain, using two‐dimensional speckle‐tracking echocardiography (2D‐STE). A total of 129 TIPS candidates (mean ± SD, 61 ± 12 years; 61% men) underwent a comprehensive preprocedural echocardiography. LA dysfunction was defined by LA reservoir strain ≤35%, based on a previously suggested cut‐off value. The outcome was all‐cause mortality after TIPS. In the current cohort, 65 (50%) patients had normal diastolic function, 26 (20%) patients had grade 1 LVDD, 21 (16%) patients had grade 2 LVDD, and 17 (13%) patients had indeterminate diastolic function. Additionally, LA dysfunction (based on LA reservoir strain ≤35%) was noted in 67 (52%) patients. After a median follow‐up of 36 months (range, 12–80), 65 (50%) patients died. All‐cause mortality rates increased along worse grades of LVDD (log‐rank p = 0.007) and with LA dysfunction (log‐rank p = 0.001). On multivariable Cox regression analysis, Model for End‐Stage Liver Disease score (hazard ratio HR,1.06; p = 0.003), hemoglobin (HR, 0.74; p = 0.022), and LA strain, expressed as a continuous variable (HR, 0.96; p = 0.005) were independently associated with all‐cause mortality. Notably, the addition of LA strain to the model provided incremental prognostic value over the established prognostic variables (delta χ2 = 8.27, p = 0.004). Conclusion: LA dysfunction assessed with 2D‐STE is independently associated with all‐cause mortality in patients with cirrhosis treated by TIPS.
Left ventricular diastolic dysfunction (LVDD), graded according to the algorithm proposed by the Cirrhotic Cardiomyopathy Consortium, and left atrial (LA) reservoir strain are independently associated with long‐term survival in patients with cirrhosis treated by TIPS. The assessment of LA reservoir strain provides incremental prognostic value over the severity of liver disease, assessed by the MELD score, and grading of LVDD using conventional parameters.
Abstract Aims To evaluate the prognostic implications of the left atrial reservoir strain–defined diastolic dysfunction (LARS-DD) grade in patients undergoing transcatheter aortic valve implantation ...(TAVI) for severe aortic stenosis (AS) and to determine whether post-TAVI LARS was more closely associated with new-onset atrial fibrillation than pre-TAVI LARS. Methods and results Pre-TAVI LARS-DD was evaluated by speckle-tracking echocardiography and was assigned as Grade 0 to 1 (LARS ≥24%), Grade 2 (LARS 19–24%), and Grade 3 (LARS <19%). Patients were followed up for the primary endpoint of all-cause mortality from the date of TAVI. For the secondary endpoint, patients with pre- and post-TAVI LARS measurements and no history of atrial fibrillation were evaluated for the occurrence of new-onset atrial fibrillation. A total of 601 patients median age 81 (76–85) years, 53% males were included. Overall, 169 patients (28%) were LARS-DD Grade 0/1, 96 patients (16%) were LARS-DD Grade 2, and 336 (56%) were LARS-DD Grade 3. Over a median follow-up of 40 (interquartile range 26–58) months, a total of 258 (43%) patients died. In a comprehensive multivariable Cox regression model, the LARS-DD grade was independently associated with all-cause mortality adjusted hazard ratio (HR) 1.28 per one-grade increase, 95% confidence interval (CI) 1.07–1.53, P = 0.007. For the secondary endpoint of new-onset atrial fibrillation, a total of 285 patients were evaluated. Post-TAVI LARS (subdistributional HR 1.14 per 1% <20%, 95% CI 1.05–1.23, P = 0.0009), but not pre-TAVI LARS (P = 0.93), was independently associated with new-onset atrial fibrillation. Conclusion An increased LARS-DD grade was independently associated with long-term post-TAVI survival in patients with severe AS. Post-TAVI LARS was closely related to the occurrence of new-onset atrial fibrillation.
Purposes
Predicting hemodynamic changes of stenotic mitral valve (MV) lesions with mitral annular calcification (MAC) following transcatheter aortic valve implantation (TAVI) may inform clinical ...decision-making. This study aimed to investigate the association between the MAC severity quantified by computed tomography (CT) and changes in mean transmitral gradient (mTMG), mitral valve area (MVA) and stroke volume index (SVi) following TAVI.
Methods and results
A total of 708 patients (median age 81, 52% male) with severe aortic stenosis (AS) underwent pre-procedural CT and pre- and post-TAVI transthoracic echocardiography. According to the classification of MAC severity determined by CT, 299 (42.2%) patients had no MAC, 229 (32.3%) mild MAC, 102 (14.4%) moderate MAC, and 78 (11.0%) severe MAC. After adjusting for age and sex, there was no significant change in mTMG following TAVI (Δ mTMG = 0.07 mmHg, 95% CI -0.10 to 0.23, P = 0.92) for patients with no MAC. In contrast, patients with mild MAC (Δ mTMG = 0.21 mmHg, 95% CI 0.01 to 0.40, P = 0.018), moderate MAC (Δ mTMG = 0.31 mmHg, 95% CI 0.02 to 0.60, P = 0.019) and severe MAC (Δ mTMG = 0.43 mmHg, 95% CI 0.10 to 0.76, P = 0.0012) had significant increases in mTMG following TAVI, with greater changes associated with increasing MAC severity. In contrast, there was no significant change in MVA or SVi following TAVI.
Conclusion
In patients with severe AS undergoing TAVI, MAC severity was associated with greater increases in post-procedural mTMG whereas MVA or SVi remained unchanged. MAC severity should be considered for potential subsequent MV interventions if TAVI does not improve symptoms.
Risk stratification of patients with ischemic heart disease (IHD) still depends mainly on the left ventricular ejection fraction (LVEF). LV inward displacement (InD) is a novel parameter of LV ...systolic function, derived from feature tracking cardiac magnetic resonance (CMR) imaging. We aimed to investigate the prognostic impact of InD in patients with IHD and prior myocardial infarction. A total of 111 patients (mean age 57 ± 10, 86% male) with a history of myocardial infarction who underwent CMR were included. LV InD was quantified by measuring the displacement of endocardially tracked points towards the centreline of the LV during systole with feature tracking CMR. The endpoint was a composite of all-cause mortality, heart failure hospitalization and arrhythmic events. During a median follow-up of 142 (IQR 107–159) months, 31 (27.9%) combined events occurred. Kaplan-Meier analysis demonstrated that patients with LV InD below the study population median value (23.0%) had a significantly lower event-free survival (P < 0.001). LV InD remained independently associated with outcomes (HR 0.90, 95% CI 0.84–0.98, P = 0.010) on multivariate Cox regression analysis. InD also provided incremental prognostic value to LVEF, LV global radial strain and CMR scar burden. LV InD, measured with feature tracking CMR, was independently associated with outcomes in patients with IHD and prior myocardial infarction. LV InD also provided incremental prognostic value, in addition to LVEF and LV global radial strain. LV InD holds promise as a pragmatic imaging biomarker for post-infarct risk stratification.
Context. The radio galaxy IC 310 has recently been identified as a γ-ray emitter based on observations at GeV energies with Fermi-LAT and at very high energies (VHE, E > 100 GeV) with the MAGIC ...telescopes. Originally classified as a head-tail radio galaxy, the nature of this object is subject of controversy since its nucleus shows blazar-like behavior. Aims. To understand the nature of IC 310 and the origin of the VHE emission, we studied the spectral and flux variability of IC 310 from the X-ray band to the VHE γ-ray regime. Methods. The light curve of IC 310 above 300 GeV has been measured with the MAGIC telescopes from 2009 October to 2010 February. Contemporaneous Fermi-LAT data (2008−2011) in the 10−500 GeV energy range were also analyzed. In the X-ray regime, archival observations from 2003 to 2007 with XMM-Newton, Chandra, and Swift-XRT in the 0.5−10 keV band were studied. Results. The VHE light curve reveals several high-amplitude and short-duration flares. Day-to-day flux variability is clearly present (>5σ). The photon index between 120 GeV and 8 TeV remains at the value Γ ~ 2.0 during both low and high flux states. The VHE spectral shape does not show significant variability, whereas the flux at 1 TeV changes by a factor of ~7. Fermi-LAT detected only eight γ-ray events in the energy range 10 GeV–500 GeV in three years of observation. The measured photon index of Γ = 1.3 ± 0.5 in the Fermi-LAT range is very hard. The X-ray measurements show strong variability in both flux and photon index. The latter varied from 1.76 ± 0.07 to 2.55 ± 0.07. Conclusions. The rapid variability measured in γ-rays and X-rays confirms the blazar-like behavior of IC 310. The multi-TeV γ-ray emission seems to originate from scales of less than 80 Schwarzschild radii (for a black hole mass of 2 × 108 M⊙) within the compact core of its FR I radio jet with orientation angle 10°−38°. The spectral energy distribution resembles that of an extreme blazar, albeit the luminosity is more than two orders of magnitude lower.
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