Background
Bioprosthetic valve thrombosis is a complication of transcatheter aortic valve replacement (TAVR). It is believed to be platelet independent, mainly driven by contact phase activation, and ...more likely to be targeted by oral anticoagulant (OAC).
Case summary
We report case of an 86-year-old man with history of TAVR, who presented an early TAVR aortic valve thrombosis occurring in the context of heparin-induced thrombocytopenia (HIT) and pulmonary embolism. The patient rapidly recovered and was discharged 17 days after readmission. OAC by Coumadin was administered for 3 months. Chest tomography after 3 months showed the disappearance of the hypoattenuated leaflet thickening.
Discussion
Although HIT has been fully described and is known for being a prothrombotic disorder, this is the first case report of aortic valve thrombosis after TAVR due to HIT. HIT is rare but possibly lethal. Diagnosis is based on pre-test probability evaluation with the 4T clinical score and confirmation with laboratory evidence of anti-PF4/heparin complexes and positivity of a functional test. Management of HIT is based on heparin discontinuation, and treatment of thrombotic complication with direct anti-IIa inhibitor or anti-Xa inhibitor. According to our knowledge, this case represents the first report of bioprosthetic valve thrombosis after TAVR due to HIT.
Objectives
To retrospectively investigate the incidence of acute adrenal infarction (AAI) in patients who underwent chest CT for severe SARS-CoV-2 infection and to correlate findings with prognosis.
...Methods
The local ethics committee approved this retrospective study and waived the need of informed consent. From March 9 to April 10, 2020, all patients referred to our institution for a clinical suspicion of COVID-19 with moderate to severe symptoms underwent a chest CT for triage. Patients with a/parenchymal lesion characteristics of COVID-19 involving at least 50% of lung parenchyma and b/positive RT-PCR for SARS-CoV-2 were retrospectively included. Adrenal glands were reviewed by two independent readers to look for AAI. Additional demographics and potential biological markers of adrenal insufficiency were obtained. Correlations with ICU stay and mortality were sought.
Results
Out of the 219 patients with critical (
n
= 52) and severe lung (
n
= 167) parenchyma lesions, 51 (23%) had CT scan signs of AAI, which was bilateral in 45 patients (88%). Four patients had an acute biological adrenal gland insufficiency (8%). Univariate analysis in AAI+ patients demonstrated a higher rate of ICU stay (67% vs. 45%,
p
< 0.05) and a longer stay (more than 15 days for 31% for AAI+ vs. 19%,
p
< 0.05) compared with AAI− patients. Mortality rate was similar (27%,
p
= 0.92).
Conclusions
Acute adrenal infarction on initial chest evaluation of severe COVID-19 is frequent (51/219, 23%) and might be a sign of poorer prognosis.
Key Points
• Acute adrenal infarction on initial chest CT evaluation of severe COVID-19 is frequent (51/219).
• AAI might be a factor of poorer prognosis, with increased rate of ICU hospitalization and length of stay.
With the steady increase of endovascular procedures involving the aortic arch (AA), an actual depiction of its anatomy has become mandatory. It has also become necessary to evaluate the natural ...evolution of the AA morphology as part of the evaluation of endovascular devices durability. The objective of this study was to perform a morphological and anatomical study of the AA and of the supra aortic trunks (SAT) in healthy patients, with an evaluation of their evolution with time, with a specific orientation applied to endovascular therapies of the AA.
Sixty-one patients (31 men, mean age 50.8 18-82) with a normal anatomy were included in the study. Measurements included the diameters of the AA and SAT in 17 locations, their distance and angulation based on computed tomography angiography data. Statistical analysis focused on descriptive statistics, differences between genders, as well as correlations with age.
Aortic diameters (mean ± SD) were 29.5 ± 3.9 mm at the ascending aorta, 28.6 ± 3.9 mm at the innominate artery (IA), 27.1 ± 3.2 mm at the left common carotid artery (LCCA), 25.3 ± 3.0 mm at the left subclavian artery (LSCA), 23.9 ± 3.3 mm at the descending aorta. Mean angulation of the AA was 82° (95% confidence interval CI: 78.95-85.19°), mean angulation between LSCA/LCCA was -5.7° (95% CI: -0.9 to 18.7°) and -1.8° (95% CI: 5.4-26.4°) between LCCA/IA. Mean distance between the LSCA and the LCCA was 14.3 mm (95% CI: 13-15.6 mm) and 21.8 mm (95% CI: 20.3-23.4 mm) between LCCA and IA. All diameters of the AA increased with age (P < 0.05). Men had diameters statistically (P < 0.05) greater than women except at the LCCA ostium level. A statistically significant increase of the distances between the LSCA and the LCCA, between the LSCA and the IA and between the IA and the LCCA was found with age, P = 0.027, <0.01 and 0.012 respectively.
This study allows obtaining accurate information of the AA and the SAT anatomy. It enabled to obtain a better understanding of the three-dimensional aspects of the AA, confirmed the variability and heterogeneity of the SAT disposition, and discussed the principles of vascular aging.
Neurologic Features in Severe SARS-CoV-2 Infection Helms, Julie; Kremer, Stéphane; Merdji, Hamid ...
New England journal of medicine/The New England journal of medicine,
06/2020, Letnik:
382, Številka:
23
Journal Article
Abstract
Background
Patients with atrial fibrillation (AF) are likely to have a poor prognosis including bleedings following transcatheter aortic valve replacement (TAVR). Closure time of adenosine ...diphosphate (CT-ADP) is a primary hemostasis point-of-care test and is a predictor of bleeding events following TAVR. We aimed to evaluate the impact of ongoing primary hemostatic disorders on bleeding events in TAVR patients with AF.
Methods
We enrolled 878 patients from our prospective registry. The primary endpoint was VARC-2 major/life-threatening bleeding complications (MLBCs) at 1 year after TAVR and secondary endpoint was major adverse cardiac and cerebrovascular events (MACCEs) at 1 year, defined as a composite of all-cause death, myocardial infarction, stroke, and heart failure hospitalization. Ongoing primary hemostatic disorder was defined by a postprocedural CT-ADP >180 seconds.
Results
Patients with AF had a higher incidence of MLBCs (20 vs. 12%,
p
= 0.002), MACCE (29 vs. 20%,
p
= 0.002), and all-cause mortality (15 vs. 8%,
p
= 0.002) within 1 year compared to non-AF patients. When the cohort was split into four subgroups according to AF and CT-ADP >180 seconds, patients with AF and CT-ADP >180 seconds had the highest risk of MLBCs and MACCE. Multivariate Cox regression analysis confirmed that the patients with AF and CT-ADP >180 seconds had 3.9-fold higher risk of MLBCs, whereas those patients were no longer associated with MACCE after the adjustment.
Conclusion
In TAVR patients, AF with postprocedural CT-ADP >180 seconds was strongly associated with MLBCs following TAVR. Our study suggests that persistent primary hemostatic disorders contribute to a higher risk of bleeding events particularly in AF patients.
Objective
Frequency of normal chest CT in symptomatic COVID-19 patients as well as the outcome of these patients remains unknown. The objectives of this work were to assess the incidence of initially ...normal chest CT in a cohort of consecutive confirmed COVID-19 patients with respiratory symptoms and to compare their clinical characteristics and their outcome to matched patients with typical COVID-19 lesions at initial CT.
Methods
From March 6
th
to April 22
nd
, all consecutive adult patients referred to the COVID-19 clinic of our Emergency Department were retrospectively analyzed. Each patient with a positive SARS-CoV-2 RT-PCR and a normal initial chest CT after second reading was 1:1 matched based on sex, age and date of CT acquisition to a patient with positive RT-PCR and initial chest CT with typical COVID-19 lesions. Clinical data, laboratory results and outcomes (major being mechanical ventilation and/or death) were compared between both groups, using Wilcoxon signed-rank test, McNemar’s chi-squared test and/or exact McNemar’s test where appropriate.
Results
Fifty-seven chest CT out of 1091 (5.2%, 95% CI 4.0–6.7) in symptomatic patients with positive RT-PCR were normal, with a median onset of symptoms of 4.5 days (IQR 1.25–10.25). After a median follow-up of 43 days, death and/or mechanical ventilation occurred in 3 patients (5.3%) in the study group, versus 11 (19.3%) in the control group (
p
= 0.011).
Conclusions
Normal initial chest CT occurred in 5.2% of symptomatic confirmed COVID-19 cases in our cohort. While better than those with abnormal chest CT, outcome was not entirely benign with 5.3% death and/or mechanical ventilation.
Key Points
• In a cohort of 1091 symptomatic COVID-19 patients, initial chest CT was normal in 5.2% of cases.
• Normal chest CT in confirmed COVID-19 is frequent even when onset of symptoms is greater than 3 days.
• The outcome of COVID-19 patients with initial normal chest CT, while better than those with abnormal CT, was not entirely benign with 5.3% death and/or mechanical ventilation.
Objectives
To investigate the radiation dose exposure, image quality, and diagnostic performance of enhanced 100-kVp abdominopelvic single-energy CT protocol with tin filter (TF).
Methods
...Ninety-three consecutive patients referred for a single-phase enhanced abdominopelvic CT were prospectively included after informed consent. They underwent in addition to a standard protocol (SP) an acquisition with TF. Both examinations were performed on a third-generation dual-source CT system (DSCT), in single energy, using automatic tube current modulation, identical pitch, and identical level of iterative reconstruction. Radiation metrics were compared. Size-specific dose estimates (SSDE), contrast to noise ratio (CNR), and figure of merit (FOM) were calculated. Diagnostic confidence for the assessment of a predetermined list of abdominal lesions was rated by two independent readers.
Results
The mean dose of the TF protocol was significantly lower (CDTI 1.56 ± 0.43 mGy vs. 8.13 ± 3.32,
p
< 0.001; SSDE 9.94 ± 3.08 vs. 1.93 ± 0.39,
p
< 0.001), with an effective dose close to 1 mSv (1.14 mSv ± 0.34;
p
< 0.001). TF group exhibited non-significant lower liver CNR (2.76 vs. 3.03,
p
= 0.56) and was more dose efficient (FOM 10.6 vs. 2.49/mSv,
p
< 0.001) in comparison to SP. The mean diagnostic confidence for visceral, bone, and peritoneal tumors was equivalent between both groups.
Conclusions
Enhanced 100-kVp abdominopelvic CT acquired after spectral shaping with tin filtration can achieve similar diagnostic performance and CNR compared to a standard CT protocol, while reducing the radiation dose by 81%.
Key Points
• 100-kVp spectral filtration enables enhanced abdominal CT with high-dose efficiency.
• The radiation dose reaches the 1-mSv range.
• Predetermined abdominopelvic lesions can be assessed without impairing on diagnostic confidence.
Objectives
Diagnostic performance and potential radiation dose reduction of wide-area detector CT sequential acquisition (“wide-volume” acquisition (WV)) in unenhanced chest examination are unknown. ...This study aims to assess the image quality, the diagnostic performance, and the radiation dose reduction of WV mode compared with the classical helical acquisition for lung parenchyma analysis in an ultra-low-dose (ULD) protocol.
Methods
After Institutional Review Board Approval and written informed consent, 64 patients (72% men; 67.6 ± 9.7 years old; BMI 26.1 ± 5.3 kg/m
2
) referred for a clinically indicated unenhanced chest CT were prospectively included. All patients underwent, in addition to a standard helical acquisition (120 kV, automatic tube current modulation), two ULD acquisitions (135 kV, fixed tube current at 10 mA): one in helical mode and one in WV mode. Image noise, subjective image quality (5-level Likert scale), and diagnostic performance for the detection of 9 predetermined parenchymal abnormalities were assessed by two radiologists and compared using the chi-square or Fisher non-parametric tests.
Results
Subjective image quality (4.2 ± 0.7 versus 4.2 ± 0.8,
p
= 0.56), image noise (41.7 ± 8 versus 40.9 ± 8.7,
p
= 0.3), and diagnostic performance were equivalent between ULD WV and ULD helical. Radiation dose was significantly lower for the ULD WV acquisition (mean dose-length product 14.1 ± 1.3 mGy cm versus 15.8 ± 1.3,
p
< 0.0001).
Conclusion
An additional 11% dose reduction is achieved with the WV mode in ULD chest CT with fixed tube current, with equivalent image quality and diagnostic performance when compared with the helical acquisition.
Key Points
• Image quality and diagnostic performance of ultra-low-dose unenhanced chest CT are identical between wide-volume mode and the reference helical acquisition.
• Wide-volume mode allows an additional radiation dose reduction of 11% (mean dose-length product 14.1 ± 1.3 mGy cm versus 15.8 ± 1.3, p < 0.0001).
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