Frequency, characteristics and risk assessment of pulmonary arterial hypertension with a left heart disease phenotype

AIM

To obtain real-world evidence about the features and risk stratification of pulmonary arterial hypertension (PAH) with a left heart disease (LHD) phenotype (PAH-LHD).

METHODS AND RESULTS

By reviewing the records of consecutive incident PAH patients at 7 tertiary centers from 2001 to 2021, we selected 286 subjects with all parameters needed to determine risk of death at baseline and at first follow-up with COMPERA and COMPERA 2.0 scores. Fifty seven (20%) had PAH-LHD according to the AMBITION definition. Compared with no-LHD ones, they were older, had higher BMI, more cardiovascular comorbidities, higher E/e' ratio and left atrial area, but lower BNP concentrations and better right ventricular function and pulmonary hemodynamics. Survival was comparable between PAH-LHD and no-LHD patients, although the former were less commonly treated with dual PAH therapy. Both COMPERA and COMPERA 2.0 discriminated all-cause mortality risk of PAH-LHD at follow-up, but not at baseline. Risk profile significantly improved during follow-up only when assessed by COMPERA 2.0. At multivariable analysis with low-risk status as reference, intermediate-high and high-risk, but not LHD phenotype, were associated with higher hazard of all-cause mortality. Results were comparable in secondary analyses including patients in the last 10 years and atrial fibrillation and echocardiographic abnormalities as additional criteria for PAH-LHD.

CONCLUSIONS

In real life, PAH-LHD patients are frequent, have less severe disease and are less likely treated with PAH drug combinations than no-LHD. The COMPERA 2.0 model may be more appropriate to evaluate their mortality risk during follow-up and how it is modulated by therapy.

Value of the HFA-PEFF and H2FPEF scores in patients with heart failure and preserved ejection fraction caused by cardiac amyloidosis

Aims

The HFA-PEFF and H2FPEF scores have been developed to diagnose heart failure with preserved ejection fraction (HFpEF), and hold prognostic value. Their use in patients with HFpEF caused by cardiac amyloidosis (CA) has never been investigated.

Methods and results

We evaluated the diagnostic and prognostic value of the HFA-PEFF and H2FPEF scores in 304 patients from 3 cohorts with HFpEF caused by transthyretin (ATTR)-CA (n=160, 53%) or immunoglobulin light-chain (AL)-CA (n=144, 47%). A diagnosis of HFpEF was more likely using the HFA-PEFF score with 2 (1%), 71 (23%), and 231 (76%) patients ranked as having a low (0–1), intermediate (2–4) or high (5–6) probability of HFpEF, respectively. Conversely, 36 (12%), 179 (59%) and 89 (29%) of patients ranked as having a low (0–1), intermediate (2–5) or high (6–9) probability of HFpEF using the H2FPEF score. During a median follow-up of 19 months (interquartile range 8–40), 132 (43%) patients died. The HFA-PEFF score, but not the H2FPEF, predicted a high risk of all-cause death which remained significant after adjustment for age, AL-CA diagnosis, high-sensitivity troponin T, N-terminal pro-B-type natriuretic peptide, and echocardiographic parameters, including left ventricular (LV) global longitudinal strain, LV diastolic function and right ventricular function (hazard ratio 1.51, 95% confidence interval 1.16–1.95, p=0.002 for every 1-point increase in HFA-PEFF).

Conclusions

The HFA-PEFF score has a high sensitivity to diagnose HFpEF caused by CA and holds independent prognostic value for all-cause mortality, while the H2FPEF score does not.

Funding Acknowledgement

Type of funding sources: None.

COVID-19 in Heart Transplant Recipients: A Multicenter Analysis of the Northern Italian Outbreak

OBJECTIVES

The aim of this study was to assess the clinical course and outcomes of all heart transplant recipients affected by coronavirus disease-2019 (COVID-19) who were followed at the leading heart transplant centers of Northern Italy.

BACKGROUND

The worldwide severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pandemic has created unprecedented challenges for public health, demanding exceptional efforts for the successful management and treatment of affected patients. Heart transplant patients represent a unique cohort of chronically immunosuppressed subjects in which SARS-CoV-2 may stimulate an unpredictable clinical course of infection.

METHODS

Since February 2020, we enrolled all 47 cases (79% male) in a first cohort of patients, with a mean age of 61.8 ± 14.5 years, who tested positive for SARS-CoV-2, out of 2,676 heart transplant recipients alive before the onset of the COVID-19 pandemic at 7 heart transplant centers in Northern Italy.

RESULTS

To date, 38 patients required hospitalization while 9 remained self-home quarantined and 14 died. Compared to the general population, prevalence (18 vs. 7 cases per 1,000) and related case fatality rate (29.7% vs. 15.4%) in heart transplant recipients were doubled. Univariable analysis showed older age (p = 0.002), diabetes mellitus (p = 0.040), extracardiac arteriopathy (p = 0.040), previous PCI (p = 0.040), CAV score (p = 0.039), lower GFR (p = 0.004), and higher NYHA functional classes (p = 0.023) were all significantly associated with in-hospital mortality. During the follow-up two patients died and a third patient has prolonged viral-shedding alternating positive and negative swabs. Since July 1st, 2020, we had 6 new patients who tested positive for SARS-CoV-2, 5 patients asymptomatic were self-quarantined, while 1 is still hospitalized for pneumonia. A standard therapy was maintained for all, except for the hospitalized patient.

CONCLUSIONS

The prevalence and mortality of SARS-CoV-2 should spur clinicians to immediately refer heart transplant recipients suspected as having SARS-CoV2 infection to centers specializing in the care of this vulnerable population.

Coronavirus disease 2019 (COVID-19) in the heart transplant population: a single-centre experience

OBJECTIVES

Few anecdotal cases have been reported in the literature regarding heart transplant recipients and infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We report our experience with 6 patients hospitalized in Northern Italy during the outbreak.

METHODS

Of the 396 living heart transplant recipients from 1985 to 2020 included in the study, 6 patients developed the novel 2019 coronavirus disease. Risk factors, last follow-up characteristics, onset presentation, in-hospital course of disease and blood examinations data were collected for these patients.

RESULTS

All patients were symptomatic and had positive results from a nasopharyngeal swab test for SARS-CoV-2. Of the 6 patients, 5 were hospitalized and 1 remained self-quarantined at home. Two patients died and 3 were discharged home. Two patients were admittted to the intensive care unit . Immunosuppressive therapy was modified with a median reduction comprising doses that were 50% cyclosporine and 50% mycophenolate. All patients received a medium-dose of corticosteroids as a bolus medication in addition to their therapy. All hospitalized patients received hydroxychloroquine; 2 patients received ritonavir/lopinavir. Broad-spectrum antibiotics for prophylaxis were administered to all. One patient had an ischaemic stroke and died of sepsis.

CONCLUSIONS

In the absence of any strong evidence regarding the treatment of heart transplant recipients infected with SARS-CoV-2, we faced a new challenge in managing viral infection in an immunosuppressed population. Because immunomodulation interaction with the infection seems to be crucial for developing severe forms of the disease, we managed to reduce immunosuppressive therapy by adding medium doses of corticosteroids. Despite the limited number of affected patients, this report suggests that special considerations should be given to treating coronavirus disease in the heart transplant recipient population.

Clinical utility of postmortem microcomputed tomography of the fetal heart: diagnostic imaging vs macroscopic dissection

OBJECTIVES

Congenital cardiac malformations are commonly identified at perinatal autopsy, which can be challenging in fetuses of early gestation and in macerated fetuses. Our objective was to examine fetal complex congenital heart disease by microcomputed tomography (micro-CT), using standard autopsy as the gold standard.

METHODS

In this ethically approved study, ex-vivo isolated fetal heart and fetal heart-lung blocks underwent iodine preparation prior to micro-CT, and were fixed in formalin after the micro-CT examination. Images were acquired using a microfocus-CT scanner with individual specimen image optimization. Twenty-one indices assessed normally at autopsy were evaluated for each dataset. Cardiac dissection was performed using a dissecting microscope within 24 h of the micro-CT examination.

RESULTS

We examined six fetal hearts, comprising five with complex congenital cardiac malformations at a gestational age of 17-23 weeks and an anatomically normal heart of 23 weeks' gestation for reference. All specimens demonstrated excellent internal contrast at micro-CT examination, and the correct overall diagnosis was made in all cases. There was agreement for 114/126 indices assessed on micro-CT and at autopsy dissection (overall concordance of 95.8% (95% CI, 90.5-98.2%)). Micro-CT was particularly useful in the assessment of ventricular morphology in macerated fetuses.

CONCLUSIONS

Micro-CT of small ex-vivo fetal specimens can provide highly accurate three-dimensional rendering of complex congenital fetal heart disease. This approach represents a significant advance in postmortem imaging and confirms the potential of this technology for non-invasive examination of small fetuses and organs.

Postmortem microcomputed tomography (micro-CT) of small fetuses and hearts

OBJECTIVE

To assess the feasibility and utility of contrast-enhanced microcomputed tomography (micro-CT) for identifying structural anomalies in ex-vivo first- and second-trimester human fetuses and isolated fetal hearts.

METHODS

Radiopaque iodine staining and micro-CT scanning protocols were first developed in rodent studies and then used to examine routinely fixed whole human fetuses (n = 7, weight 0.1-90 g, gestational age, 7-17 weeks) and isolated fetal hearts (n = 14, weight 0.1-5.2 g, gestational age, 11-22 weeks). Samples were scanned using an isotropic resolution of 18 (and, if necessary, 9 or 35) µm and findings were interpreted jointly by four fetal pathologists, a fetal cardiologist and a radiologist. Samples with gestational ages ≥ 13 weeks also underwent conventional autopsy or dissection.

RESULTS

Micro-CT identified all anatomical structures and abnormalities documented by the macroscopic examination. In all seven cases involving fetuses ≤ 13 weeks (four fetuses, three isolated hearts), micro-CT excluded the presence of structural anomalies. In the remaining 14 cases, it provided all the information obtained with invasive autopsy or dissection and in seven of the 14 (two fetuses, five isolated hearts) it furnished additional diagnostic details.

CONCLUSIONS

This pilot study confirms the feasibility of postmortem contrast-enhanced micro-CT assessment of structural anomalies in whole small fetuses and fetal hearts. Further study is needed to confirm our findings, particularly in whole fetuses, and to define the extent to which this virtual examination might be used instead of conventional invasive autopsy.

Fetal echocardiography at 11-13 weeks by transabdominal high-frequency ultrasound

OBJECTIVES

To assess the accuracy of fetal echocardiography at 11-13 weeks performed by well-trained obstetricians using a high-frequency linear ultrasound transducer.

METHODS

Fetal echocardiography was performed by obstetricians immediately before chorionic villus sampling for fetal karyotyping at 11-13 weeks. Digital videoclips of the examination stored by the obstetrician were reviewed offline by a specialist fetal cardiologist.

RESULTS

The obstetrician suspected 95 (95%) of the 100 cardiac defects identified by the fetal cardiologist and made the correct diagnosis in 84 (84%) of these cases. In 54 fetuses, the defect was classified as major and in 46 it was minor. In 767 (86.6%) cases, the heart was normal and in 19 (2.1%) the views were inadequate for assessment of normality or abnormality. A subsequent second-trimester scan in the normal group identified major cardiac defects in four cases. Therefore, the first-trimester scan by the obstetricians and cardiologists identified 54 (93.1%) of the 58 major cardiac defects.

CONCLUSIONS

A well-trained obstetrician using high-resolution ultrasound equipment can assess the fetal heart at 11-13 weeks with a high degree of accuracy.

Reliability of the first-trimester cardiac scan by ultrasound-trained obstetricians with high-frequency transabdominal probes in fetuses with increased nuchal translucency

OBJECTIVE

To examine prospectively the reliability of ultrasound-trained obstetricians performing a first-trimester fetal cardiac scan with high-frequency transabdominal probes, by confirming normal or abnormal heart anatomy, in pregnancies referred for increased nuchal translucency thickness (NT).

METHODS

Trained obstetric operators assessed the fetal heart in 133 fetuses with increased NT (> 95th centile) at 11-14 weeks of gestation. A high-frequency transabdominal probe was used to confirm or refute normal cardiac anatomy rather than to establish a specific diagnosis. Following this preliminary screening by the ultrasound-trained obstetrician, specialized fetal echocardiographers rescanned the fetal heart in order to confirm the accuracy of the obstetric operators' findings and to establish a diagnosis in abnormal cases. Fetal cardiologists repeated the examinations at 20 and 32 weeks of pregnancy. Postnatal follow-up lasted 2 years. Twelve fetuses with normal karyotype and normal anatomy were lost to follow-up.

RESULTS

A total of 121 fetuses with increased NT between 11 and 14 weeks' gestation were studied. Congenital heart disease (CHD) was detected in 20/121 (16.5%) fetuses. In addition, there were three with mild ventricular disproportion, the right ventricle being larger than the left, considered as a minor non-specific cardiac abnormality. CHD was associated with chromosomal anomalies in 12/20 (60%) cases. Among the 121 fetuses, there was agreement between ultrasound-trained obstetricians and fetal cardiologists in 116 (95.9%) of the cases, and the ultrasound-trained obstetricians correctly identified 18 cases with major cardiac defects. However, there was disagreement in five cases: two with small ventricular septal defects and three with ventricular disproportion.

CONCLUSIONS

Our results provide evidence that obstetricians, trained to study the heart in the second trimester, can also differentiate reliably between normal and abnormal heart findings in the first trimester, when using a high-frequency transabdominal ultrasound probe.

Fetal echocardiography at the time of the nuchal translucency scan

OBJECTIVE

The fetal heart is not studied routinely in the first trimester because of technical and time limitations. Our aim was to assess the feasibility of performing a fetal cardiac study in pregnancies referred for nuchal translucency (NT) screening, using high-frequency linear transabdominal transducers with a specific ultrasound preset.

METHODS

A single trained operator assessed the fetal heart in pregnancies with a fetal crown-rump length (CRL) of 60-84 mm that had been referred for NT screening. A 15- or 6-MHz transabdominal linear transducer with a specific preset suitable mainly for color-flow mapping was used to confirm or refute normal cardiac anatomy rather than to establish a specific diagnosis. Fetuses having an increased risk for congenital heart disease were referred to a tertiary center for a further examination within 1 week. This group consisted of all fetuses with NT > 95(th) centile and those in which a family history or the initial heart scan increased the risk.

RESULTS

A total of 608 fetuses with a median CRL of 65 mm was examined between 2003 and 2005. A cardiac scan was performed successfully in 456 (75%) using a 15-MHz linear transducer alone, and the additional use of a 6-MHz transducer allowed diagnostic images to be obtained in a further 152. Normal cardiac anatomy was assessed confidently within 10 min in 517/608 (85%) pregnancies; in 85 (14%) a longer time was needed and six patients were rescheduled within 2 weeks because of non-diagnostic images at the initial scan. In 571/608 (94%) the risk for congenital heart disease (CHD) was not increased and the heart was considered normal at initial echocardiography; this was confirmed by later scans and at postnatal follow-up. In 37/608 (6%) fetuses the risk for CHD was increased (35 for NT > 95(th) centile and two for family history). In this group normal heart anatomy was described in 34 fetuses and confirmed by subsequent specialist echocardiography. Cardiac defects were suspected in three fetuses (all with increased NT) and confirmed by a fetal cardiologist in each case.

CONCLUSIONS

A trained operator can perform a fetal heart study during the NT screening test using transabdominal high-resolution transducers in an acceptable length of time.

First metatarsophalangeal arthrodesis for treatment of hallux rigidus: a retrospective study

This was a retrospective study of 17 patients (21 operated feet) treated with first metatarsophalangeal arthrodesis for hallux rigidus of varying severity levels. Patients were evaluated according to a modified American Orthopedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal rating scale containing 60 subjective and 30 objective points. At an average follow-up time of 28.1 months, patients demonstrated a mean subjective improvement from 21.2 to 47.8/60, with mean total scores improving from 39.1 to 75.6/90. A comparison of pre- and postoperative radiographic angular measurements demonstrated a significant improvement (p = .001) in intermetatarsal, first metatarsal declination, and lateral talo-first metatarsal angles. Significant positive correlations were found between subjective results and patient age (p = .05) and the preoperative lateral talo-first metatarsal angles (p = .001).

Treatment of congenital convex pes valgus with navicular excision and subtalar arthroereisis: a case study

This article presents a case study of a 4-year-old female with a delayed diagnosis of congenital convex pes valgus. The severe soft-tissue contractures and osseous abnormalities in this case necessitated excision of the navicular and subtalar arthroereisis in addition to standard soft-tissue releases in order to achieve and maintain adequate reduction. A review of the literature and a discussion of these adjunctive techniques is provided to examine the concepts relevant to treatment of this condition.

External constant tension expansion of soft tissue for the treatment of ulceration of the foot and ankle

A clinical series of the management of 74 lesions in the foot and ankle region in 67 patients using a constant tension-approximating device is presented. The technical aspects of this methodology are detailed as they have been developed over the past 4 years. The indications, contraindications, and the requirements to obtain a successful result are discussed. The differences, as well as the possible advantages over other mechanical devices used in wound management, are discussed. The incidence and degree of complications are considered to be minimal when compared to both flap procedures and internal expansion technologies.

Necrotizing fasciitis in the lower extremity: a review and case presentation

Necrotizing fasciitis is a rare but potentially fatal disease which is often confused with cellulitis. By examining the pathogenesis, clinical presentation, treatment, and a representative case study, this article proposes to lend a broader perspective to this infection. Emphasis is placed on the necessity of surgical debridement in combination with antibiotic therapy to minimize the possible morbidity associated with this condition.

Isolated fusions of the hindfoot

Increasingly, isolated arthrodeses are being used to successfully manage disorders of the hindfoot. Their relative simplicity makes these procedures an attractive alternative to the triple arthrodesis. Each joint fusion is not without certain pitfalls, and issues such as the location of the pain, origin, planal dominance, and multiple joint involvement must be taken into consideration when choosing a specific procedure. With proper patient selection and careful technique, the surgeon will find these procedures provide a valuable addition to his/her armamentarium.

Modified arthroscopic excision of the symptomatic os trigonum and release of the flexor hallucis longus tendon: operative technique and case study

This article presents an operative technique for modified arthroscopic excision of the symptomatic os trigonum and release of the flexor hallucis longus tendon sheath. The procedure uses two stacked posterolateral subtalar joint portals, rather than the customary anterolateral and posterolateral portal combination. By visualizing the os trigonum with an arthroscope positioned in a distal portal and introducing instrumentation through a proximal portal, the ossicle may be quickly exposed and excised with minimal dissection. A case study with a 22-month follow-up and a discussion of os trigonum syndrome are included to illustrate this procedure as an alternative to open excision or traditional arthroscopic excision.

Talonavicular joint arthrodesis and Evans calcaneal osteotomy for treatment of posterior tibial tendon dysfunction

The purpose of this study was to evaluate the combination of talonavicular fusion and Evans calcaneal osteotomy for the treatment of posterior tibial tendon dysfunction. This was a retrospective study of 10 patients, mean age 48.7 years, who had continued pain despite 6 months of conservative treatment and a minimum Johnson and Strom stage II deformity. Patients completed a detailed questionnaire, were physically examined, and their postoperative improvement was graded according to the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Rating Scale. At a mean of 35 months (range 8-72 months) after surgery, patients demonstrated a significant improvement (p<.001) both in their subjective discomfort and in the structural alignment and function of their feet. The authors feel that this combination of procedures allows greater correction and stability than either procedure performed alone, and provides a viable alternative to triple arthrodesis.

Three select subungual pathologies: subungual exostosis, subungual osteochondroma, and subungual hematoma

Special attention has been given to the differences between subungual exostosis and subungual osteochondroma. Once a diagnosis has been made and symptoms persist, complete excision of the lesion with curettage of the base is the treatment of choice for both conditions. Subungual hematoma is an exquisitely painful condition that usually results from trauma, but may also be caused by systemic pathology, medication and drug reactions, and aging. Prompt decompression will significantly reduce pain and further damage to the nail bed and matrix. Radiographs must be taken because of the high incidence of associated distal phalangeal fracture. Patients must be warned that onycholysis, transient and permanent nail deformity, and infection are possible complications, even with the best treatment.

Stress fracture of the tarsal navicular: two unusual case reports

Stress fractures of the tarsal navicular are an uncommon entity in podiatric and orthopedic literature, being reported only 40 times. These cases were usually in the younger, active patient population. The cases reported in this paper were older individuals that were inactive. Both cases were originally misdiagnosed, but later shown to be stress fractures, one being the only hypertrophic nonunion recorded to date. The authors believe the stress-fractured navicular is often misdiagnosed, and probably more common than recently reported.