Severe isolated mitral stenosis: are we facing different phenotypes?

Funding Acknowledgements

Type of funding sources: None.

Introduction

Rheumatic mitral valve stenosis (MS) causes progressive left atrial (LA) fibrosis and functional impairment, pulmonary artery systolic hypertension and right ventricular (RV) dysfunction.

Purpose

The aim of the study was the evaluate the different characteristics between high gradients (HG) and low gradient (LG) MS and, within the LG group those with high (LG-HF) or low flow (LG-LF). Moreover, we wanted to evaluate if there was any difference in overall complications and atrial fibrillation (AF) incidence.

Methods

A total of 147 patients with isolated severe MS were retrospectively enrolled from the institutional echo database.  Echocardiograms were read offline and clinical information were obtained from patients` records. Patients were divided into a group with HG (31 patients, mean MS gradient > 10 mmHg) and LG (116 patients, mean MS gradient ≤ 10 mmHg). The group of LG was then divided in low flow (Stroke volume index (SVi) ≤ 35 ml/m2, LF-LG: 68 patients) and in high flow (SVi > 35 ml/m2, HF-LG: 48 patients).

Results

The HG group was younger, although the difference did not reach statistical significance, higher percent of males (45% M vs 22% F, p = 0.02), higher heart rate (HR), left atrial volume, higher tricuspid regurgitation velocity (TVR) and derived pulmonary artery systolic pressure (PASP), RV fractional area changes (RV FAC) but similar RV longitudinal contraction. Moreover, the HG group had more severe MS calculated according to PHT.  The group of LG was divided according to SVi:  LF-LG group compare to HG-MS had higher percent of females (45% F vs 13% M, p < 0.001), similar AF (43% vs 32%, p = ns) and pre surgical complications (19% vs 16%, p = ns). LF-LG group had smaller LA systolic volume (117 ± 51 51 ml vs 148.6 ± 38 ml, p < 0.0001), lower LV-S` (5.3 ± 1.4 vs 6 ± 1.6 cm/s, p = 0.004), lower TRV (2.47 ± 0.5 vs 3.24 ± 0.7 m/s, p < 0.0001), higher TAPSE/PASP (0.64 ± 0.3  vs 0.45 ± 0.29, p < 0.001), lower RV S` (9.79 ± 2.01m/s vs 11.25 ± 3.1 m/s, p = 0.01), higher RVFAC (38.5 ± 9.6% vs 30.9 ± 9.2%, p = 0.0005). The group of LG-LF had also less severe MS (1.3 ± 0.6 cm2 vs 1.15 ± 0.3 cm2, p < 0.01).

Conclusion

Patients with HG MS were those with worst left ventricular involvement, higher PASP and lower RV function. The LF-LG MS were older, and more females were included and even though they had smaller LA, lower values of PASP they had significantly higher percent of AF and similar pre surgical complications.  It could be speculated that LF-LG severe MS patients could be a different phenotype of the disease.

Stuck mechanical valve complication in non-COVID-19 patients during COVID-19 pandemic: single center experience

Funding Acknowledgements

Type of funding sources: None.

Background

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication.

Purpose

We wanted to explore how did the COVID-19 pandemic restrictions impacted mechanical valve replacement patients on chronic anticoagulation and the long-term consequences of limiting their access to health service.

Methods

We present a series of 10 patients on warfarin anticoagulation therapy who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute.

Results

Eight patients were female, two of whom were pregnant at the first trimester and eventually went on to receive an abortion; six patients received urgent valve replacement cardiac surgery; four patients were managed medically e.g. with heparin; none had thrombolytic therapy. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization including intensive care admission, with high in-hospital mortality rates and high costs were necessary. Mean hospital admission time was 27.5 ± 18.5 days.  The cost of treatment, as average estimated reimbursement, was 11,000 USD for medical admission only, and 43,200 USD when surgery was required, up to 64,000 USD when ECMO was part of patient management.

Conclusion

Despite governments’ efforts to implement telemedicine and virtual clinics, COVID-19 restrictions and health-messaging affected the routine follow-up of non-COVID-19 patients. We report dramatic consequences to this drastic change in healthcare: clinical complications, lost lives and inflated healthcare costs in patients with a prosthetic valve. We believe that non-COVID-19 patients have paid, and will continue to pay in the future, a price that is much greater than those patients who have suffered from COVID-19. Active engagement of patients should be implemented in a time of emergencies, and further studies should address the efficacy and cost-effectiveness of public policies aimed to decrease the burden of avoidable complications and missed diagnoses. Abstract Figure. Fluoroscopy in a 70 years old patient

Rates and causes of readmissions following index admissions for Takotsubo syndrome-a meta-analysis of 118,941 index hospitalizations

Background

Rising trends in takotsubo syndrome (TTS)-related complications warrant data to identify the rate, causes and predictors of readmission on a large scale. We conducted the first-ever meta-analysis to evaluate the pooled rate of short-term and long-term readmissions after index TTS admissions.

Methods

PubMed/Medline, EMBASE and SCOPUS databases were systematically reviewed to find studies through October 2019 reporting rates and causes of readmission following index TTS admissions. Random effects models were used to estimate pooled rates and causes of readmissions and I2 statistics were used to report inter-study heterogeneity.

Results

A total of 16 cohorts with 118,941 TTS index admissions (mean age 65–75 yrs; female >85%, median follow-up 272.5 days) revealed a 16.6% [95% CI-13.2%-20.3%, I2=99%] pooled rate of readmission. Short-term and long-term pooled readmission rates are displayed in Fig.1. The readmission rate was higher in cohorts with young patients (<70 vs. >70 yrs), smaller sample size (n<100 vs. n>100) and single-centres vs. multicentres. Studies published from the USA (16.4% vs. 14.9%) had a higher readmission rate as compared to Italy. The most frequent causes were cardiac (40.6%), respiratory (15.7%) and renal (7.0%). Among readmissions with cardiac diagnoses, heart failure was most common (40.1%).

Conclusions

This global meta-analysis revealed that the pooled rate of readmission following index TTS admissions was ∼17% and causes were mainly cardiac or respiratory.

Funding Acknowledgement

Type of funding source: None

Single-nucleus RNA-seq identifies Huntington disease astrocyte states

Huntington Disease (HD) is an inherited movement disorder caused by expanded CAG repeats in the Huntingtin gene. We have used single nucleus RNASeq (snRNASeq) to uncover cellular phenotypes that change in the disease, investigating single cell gene expression in cingulate cortex of patients with HD and comparing the gene expression to that of patients with no neurological disease. In this study, we focused on astrocytes, although we found significant gene expression differences in neurons, oligodendrocytes, and microglia as well. In particular, the gene expression profiles of astrocytes in HD showed multiple signatures, varying in phenotype from cells that had markedly upregulated metallothionein and heat shock genes, but had not completely lost the expression of genes associated with normal protoplasmic astrocytes, to astrocytes that had substantially upregulated glial fibrillary acidic protein (GFAP) and had lost expression of many normal protoplasmic astrocyte genes as well as metallothionein genes. When compared to astrocytes in control samples, astrocyte signatures in HD also showed downregulated expression of a number of genes, including several associated with protoplasmic astrocyte function and lipid synthesis. Thus, HD astrocytes appeared in variable transcriptional phenotypes, and could be divided into several different “states”, defined by patterns of gene expression. Ultimately, this study begins to fill the knowledge gap of single cell gene expression in HD and provide a more detailed understanding of the variation in changes in gene expression during astrocyte “reactions” to the disease.

Corkscrewing of retinal arterioles leading to diagnosis of coarctation of aorta

Coarctation of aorta (CoA) usually leads to elevation of blood pressure above the site of obstruction and this elevated blood pressure probably gets transferred and is reflected in the retinal arterioles producing certain signs of hypertensive retinopathy. Fundus examination helps in differentiating hypertension due to CoA from other causes of juvenile hypertension, as corkscrewing of retinal arterioles is seen only in CoA but not in other conditions. A 16 year hypertensive male who was on antihypertensive treatment presented for routine checkup. On examination his visual acuity was 6/6 in both eyes. Funduscopy of both eyes revealed a normal optic disc with generalised narrowing of arterioles and broadened light reflex. The arterioles showed corkscrew tortuosity (U shaped arterioles). Based on the fundus findings, CoA was suspected and the patient was referred for cardiac evaluation. Echocardiogram revealed post ductal CoA. In juvenile hypertension, careful examination of the fundus can provide a clue to the systemic diagnosis and this case highlights the importance of ophthalmoscopic examination in diagnosing a potentially fatal systemic disease.

Effects of the Razor Clam Tagelus plebeius on the Fate of Petroleum Hydrocarbons: A Mesocosm Experiment

The relationship between organisms and contaminants may be a two-way interaction: contaminants affecting the biota and the biota affecting the environmental fate and distribution of the contaminants. This may be especially so for sediment-dwelling organisms, because their burrowing and feeding can drastically influence sediment characteristics. The present study looked at the influence of the suspension-feeding stout razor clam Tagelus plebeius on the distribution of crude oil and pyrene in greenhouse mesocosm experiments. Water column turbidity and sediment redox also were monitored during the 15- to 30-day exposures to provide information on the influence of hydrocarbons and the razor clams on environmental conditions. For the experiment with crude oil, sediment was taken from the mesocosms at the end of the experiment, and the hydrocarbon-degradation potential was assessed in incubations with ¹⁴C-naphthalene. The experiments used four treatments: hydrocarbons present/absent and razor clams present/absent. Hydrocarbon dosing levels were relatively low (1 mL of oil or 30 mg of pyrene per mesocosm with 22 L of natural sediment and 11 L of seawater). The presence of the razor clams resulted in hydrocarbon concentrations at the sediment surface being 25% lower than in mesocosms without clams. No consistent effects were noted for polycyclic aromatic hydrocarbon (PAH) concentrations in the water column or in subsurface sediment. The naphthalene-degradation potential was elevated for sediment from mesocosms dosed with oil, but the presence of the clams did not affect this potential. The presence of the razor clams resulted in a lowering of water column turbidity, but no effect on sediment redox. The hydrocarbon addition had no effect on turbidity, but sediment redox was lowered. While results show that the presence of the razor clams resulted in a loss of hydrocarbons from the surface sediment, the other results do not provide a clear picture of the underlying mechanisms and the fate of the PAHs lost from the sediment surface. We hypothesize that the loss of surface sediment PAHs was due to burial of surface sediment and possibly bioaccumulation by the clams. While additional research is needed for further insights into underlying mechanisms, the present work demonstrates that the presence of sediment-burrowing suspension feeders decreases hydrocarbon levels in surface sediment. This means that assessments of the impact of an oil spill should pay attention to effects on these organisms and to their influence on the fate and distribution of the spilled oil.

Serum iron status in Orang Asli children living in endemic areas of soil-transmitted helminths

We conducted a cross sectional study to examine the association of intestinal parasitic infections and protein energy malnutrition (PEM) with iron-status indicators and anaemia among Orang Asli children in Selangor, Malaysia. A total of 281 children aged 2 - 15 years were studied. The data were collected using structured questionnaires, anthropometric measurements and laboratory analysis for blood and faecal samples. All children were infected either by A. lumbricoides, T. trichiura or hookworm and almost 19%, 26% and 3% of the children had severe infection of ascariasis, trichuriasis and hookworm infection respectively. The prevalence of giardiasis among them was 24.9%. Overall, 41.5% of the children were anaemic (haemoglobin < 11.0 g/dL). Of these 61.0% of the children had iron deficiency and 36.5% had iron deficiency anaemia (IDA), which accounted for 88.0% of anaemia in this population. Severe trichuriasis had the most significant correlation with anaemia and iron deficiency in this population. It contributed to low concentrations of haemoglobin, serum iron and serum ferritin and high total iron binding capacity (TIBC). Significant underweight and stunting were associated with low concentrations of haemoglobin and serum iron while significant wasting was significantly associated with low concentration of serum ferritin. Logistic regression analysis confirmed that severe trichuriasis was a strong predictor of IDA. It also confirmed that children who were significantly underweight and whose mother was working were independent predictors of IDA in this population.

Giardiasis as a predictor of childhood malnutrition in Orang Asli children in Malaysia

A cross-sectional study to examine the association of giardiasis with protein-energy malnutrition, vitamin A deficiency and iron deficiency anaemia was conducted among Orang Asli children in Selangor, Malaysia. A total of 281 children aged 2-15 years were studied. The data were collected using structured questionnaires, anthropometric measurements and laboratory analysis of blood and faecal samples. The results showed that 24.9% of the children were infected with Giardia duodenalis, while 56.5, 61.3 and 15.1% had significant underweight, stunting and wasting, respectively. Giardiasis was statistically identified as a strong predictor of significant wasting in this study population.

Protein-energy malnutrition and soil-transmitted helminthiases among Orang Asli children in Selangor, Malaysia

This study aims to determine the prevalence of protein-energy malnutrition and its association with soil-transmitted helminthiases in Orang Asli (Aborigine) children in Selangor, Malaysia. The results obtained from 368 children aged 2-15 years showed that the overall prevalence of mild and significant underweight was 32.1% and 56.5% respectively. The prevalence of mild stunting was 25.6% while another 61.3% had significant stunting. The overall prevalence of mild and significant wasting was 39.0% and 19.5% respectively. The overall prevalence of ascariasis, trichuriasis and hookworm infection were 61.9%, 98.2% and 37.0% respectively and of these 18.9%, 23.5% and 2.5% of the children had severe infection of the respective helminthes. The overall prevalence of giardiasis was 24.9%. The present study vividly shows that stunting and underweight are highly prevalent among Orang Asli children and therefore of concern in this community. In this population intestinal parasitic infections, especially severe trichuriasis and giardiasis, were identified as the main predictors of stunting and wasting respectively, in addition to age between 2 to 6 years.