Prognosis of low-flow low-gradient aortic valve stenosis with atrial fibrillation

Background

Patients with Low-flow low-gradient (LFLG) aortic valve stenosis (AS) have possibly poor prognosis. Recently, it was reported that the LFLG AS patients have similar outcomes compared to high-gradient (HG) patients but worse outcomes compared to the normal-flow low-gradient [NFLG: SVi≥35 ml/m2, mPG <40mmHg] subgroup. The main determinant of LF state in severe AS patients with preserved LVEF are male gender, heart rate, LV volume and atrial fibrillation (AF). However, the relationship between the comorbidity with AF in LFLG AS and the risk of heart failure (HF) remains unclear.

Purpose

We elucidated about the prognosis of LFLG AS with AF.

Methods

We included 225 consecutive patients with severe AS (SAS, iAVA<0.6 cm2/m2) from 2013 to 2020. Among these patients, high-gradient SAS [HG-SAS; mean pressure gradient (mPG) ≥40 mmHg, n=88] and LFLG AS [stroke volume index (SVi) ≤35 ml/m2, mPG <40 mmHg, n=82] patients was extracted and the baseline characteristics including the presence or absence of AF were evaluated. The primary endpoint was worsening HF that required unplanned hospitalization or readjustment of HF drug therapy.

Results

Among patients with HG SAS and LFLG AS, worsening HF was observed in 65 patients. LFLG AS patients exhibited a higher oral rate of renin-angiotensin-system inhibitors (p=0.02). In addition, SVi and E/e' was lower in LFLG AS patients compared with HG SAS [SVi; 29.4 (24.4–34.0) versus 37.7 (28.2–45.3), p<0.0001, E/E'; 16.0 (13.1–21.5) vs 20.9 (16.0–27.4), p=0.002]. There is no differences between 2 groups in AF prevalence. Furthermore, 2 groups were subdivided as follow; HG SAS with AF (n=25), HG SAS without AF (n=63), LFLG AS with AF (n=24), LFLG AS without AF (n=58). The Kaplan Meier curves demonstrated LFLG SAS with AF experienced higher rate of worsening HF compared with HG SAS without AF and equivalent rate of worsening HF compared with HG SAS with AF (log rank, p<0.001). In the Cox hazard analysis among the LFLG AS patients, LFLG AS with paroxysmal AF (pAF, n=12) instead of chronic AF (cAF, n=12) showed a higher risk for worsening HF compared with those without AF (HR 5.0; 95% CI, 1.8–14; p=0.0028, HR 1.9; 95% CI, 0.62–5.8; p=0.26, respectively).

Conclusion

LFLG AS with AF exhibited a poor prognosis for HF compared with HG SAS without AF and equivalent rate of worsening HF compared with HG SAS with AF. Furthermore, the presence of pAf was associated with an increased risk of HF in patients with LFLF AS. Thus, intervention including drugs and catheter ablation for pAF in LFLG AS patients could lead to prevent worsening clinical outcomes.

Funding Acknowledgement

Type of funding sources: None.

Applying patient characteristics, stent-graft selection, and pre-operative computed tomographic angiography data to a machine learning algorithm: Is endoleak prediction possible?

INTRODUCTION

This study aims to predict endoleak after endovascular aneurysm repair (EVAR) using machine learning (ML) integration of patient characteristics, stent-graft configuration, and a selection of vessel lengths, diameters and angles measured using pre-operative computed tomography angiography (CTA).

METHODS

We evaluated 1-year follow-up CT scans (arterial and delayed phases) in patients who underwent EVAR for the presence or absence of an endoleak. We also obtained data on the patient characteristics, stent-graft selection, and preoperative CT vessel morphology (diameter, length, and angle). The extreme gradient boosting (XGBoost) for the ML system was trained on 30 patients with endoleaks and 81 patients without. We evaluated 5217 items in 111 patients with abdominal aortic aneurysms, including the patient characteristics, stent-graft configuration and vascular morphology acquired using pre-EVAR abdominal CTA. We calculated the area under the curve (AUC) of our receiver operating characteristic analysis using the ML method.

RESULTS

The AUC, accuracy, 95% confidence interval (CI), sensitivity, and specificity were 0.88, 0.88, 0.79-0.97, 0.85, and 0.91 for ML applying XGBoost, respectively.

CONCLUSIONS

The diagnostic performance of the ML method was useful when factors such as the patient characteristics, stent-graft configuration and vessel length, diameter and angle of the vessels were considered from pre-EVAR CTA.

IMPLICATIONS FOR PRACTICE

Based on our findings, we suggest that this is a potential application of ML for the interpretation of abdominal CTA scans in patients with abdominal aortic aneurysms scheduled for EVAR.

Radiation dose reduction method combining the ECG-Edit function and high helical pitch in retrospectively-gated CT angiography

INTRODUCTION

The purpose of this study was to demonstrate that dose reduction does not compromise image quality when combining high helical pitch (HP) and the ECG-Edit function during low HP retrospectively gated computed tomography angiography (CTA).

METHODS

This study made use of a pulsating cardiac phantom (ALPHA 1 VTPC). The heart rate (HR) of the cardiac phantom was changed in five intervals, every 5 beats per minute (bpm), from 40 to 60 bpm. Evaluation of a range of HR was important because data loss might occur when combining a low HR and high HP. We performed retrospectively gated CTA scans five times using a low HP (0.16) and high HP (0.24), for each of the five HR intervals, using a 64-detector row CT scanner. The CT volume dose index (CTDI_vol) was recorded from the CT console of each scan. For the images with data loss, data were repaired using the ECG-Edit function. We compared the CTDI_vol, estimated cardiac phantom volume, and the visualization of the coronary ladder phantom between HP 0.16, with or without repaired HP 0.24, using the ECG-Edit function.

RESULTS

Data loss occurred with a HR of 40 bpm and 45 bpm when using HP 0.24. The CTDI_vol was reduced by approximately 33% with HP 0.24 when compared with HP 0.16. There were no significant differences in the mean cardiac motion phantom volume and visualization scores between HP 0.16 and with and without repaired HP 0.24 using the ECG-Edit function (p < 0.05).

CONCLUSION

The ECG-Edit function is potential useful for repairing the lost data in patients with a low HR, and when combined with a high HP, it is possible to reduce the radiation dose by approximately 33%.

IMPLICATIONS FOR PRACTICE

The ECG-Edit function and high HP may be a viable option in pediatric CTA studies.

Effect of injection duration on contrast enhancement during cardiac computed tomography angiography in newborns and infants

INTRODUCTION

To investigate how changing the injection duration at cardiac computed tomography angiography (CCTA) affects contrast enhancement in newborns and infants.

METHODS

Included were 142 newborns and infants with confirmed congenital heart disease who underwent CCTA between January 2015 and December 2018. In group 1 (n = 71 patients), the injection duration was 8 s; in group 2 (n = 71) it was 16 s. Our findings were assessed by one-to-one matching analysis to estimate the propensity score of each patient. We compare the CT number for the pulmonary artery (PA), ascending aorta (AAO), left superior vena cava (SVC), AAO and PA enhancement ratio, and the scores for visualization between the two groups.

RESULTS

In group 1, median CT number and ranges was 345 (211-591) HU in the AAO, 324 (213-567) HU in the PA, and 62 (1-70) HU in the SVC. These values were 465 (308-669) HU, 467 (295-638) HU, and 234 (67-443) HU, respectively, in group 2 (p < 0.05). The median score for volume-rendering visualization on 3D images of the CCTA was 2 in group 1 and 3 in group 2; the score for visualization of the left SVC of the maximum intensity projection images was 2 in group 1 and 3 in group 2 (p < 0.05). The CT number for the AAO and PA enhancement ratio was 15.2 in group 1 and 9.2 in group 2 (p < 0.05).

CONCLUSION

The 16-sec injection protocol yielded significantly higher CT numbers for the AAO, PA, and the SVC than the 8-sec injection protocol; the visualization scores were also significantly higher in group 2.

IMPLICATIONS FOR PRACTICE

In newborns and infants, the longer injection time for CCTA yields stable and higher contrast enhancement at identical CM concentrations.

Enhancement rate of venous phase to portal venous phase computed tomography and its correlation with ultrasound elastography determination of liver fibrosis

INTRODUCTION

This study aimed to compare the correlation between the computed tomography (CT) enhancement rate of the venous to portal venous phase (VP-ER) and the extracellular volume (ECV) fraction with shear-wave ultrasound elastography (USE) findings in patients with liver fibrosis.

METHODS

We included 450 patients with clinically suspected liver cirrhosis who underwent triphasic dynamic CT studies and USE. We compared the USE results with the unenhanced CT phase, with enhancement in the hepatic artery phase (HAP), portal venous phase (PVP), and venous phase (VP), and with the ECV fraction and the VP-ER. We also compared the area under the curve (AUC) of the receiver operating characteristic (ROC) curve of the ECV fraction and VP-ER with that of the values obtained with USE.

RESULTS

The VP-ER was the most highly correlated with the liver stiffness value determined with USE (Pearson's correlation coefficient: r = 0.37), followed by enhancement in the PVP (r = -0.25), CT number on unenhanced CT scans (r = -0.22), the ECV fraction (r = 0.19), enhancement in the VP (r = 0.059), and enhancement in the HAP (r = -0.023) (all p < 0.01). The VP-ER showed a significantly higher AUC than the ECV fraction (0.75 vs 0.62) when the liver stiffness was >15 kPa in USE studies (p = 0.04).

CONCLUSION

Compared to the ECV fraction, the VP-ER is more useful for predicting all degrees of liver fibrosis on routine triphasic dynamic CT images.

IMPLICATIONS FOR PRACTICE

Although improvement is needed, the VP-ER has a higher diagnostic ability for liver fibrosis than the ECV fraction in clinical practice.

Efficacy of the spiral flow generating extended tube during paediatric CCTA

INTRODUCTION

To compare the computed tomography (CT) number for paediatric cardiac computed tomography angiography (CCTA) and visualisation score of the three-dimensional (3D) images using the conventional T-shaped extended tube (T-tube) and spiral flow-generating extended tube (spiral-tube) connected between the contrast injector and cannula.

METHODS

In total, 108 patients suspected to have congenital heart disease (CHD) were considered for inclusion. We utilised the T-tube for intravenous contrast and spiral-tube in 54 patients each. Observers individually inspected randomized volume rendering images of the internal thoracic artery, each acquired from the with or without spiral-tube groups, using a four-point scale. We compared the mean CT number of the ascending aorta (AAO) and pulmonary artery (PA), contrast noise ratio (CNR), CT number for the AAO and PA enhancement ratio, and the visualisation scores between the groups.

RESULTS

There were no significant differences in patient characteristics between the with or without spiral-tube groups (p > 0.05). The mean CT number ±standard deviation for the AAO and PA, and the CNR without or with spiral-tube groups were 441.2 ± 89.2 and 489.8 ± 86.1 HU for the AAO, 436.3 ± 100.6 and 475.3 ± 85.2 HU for the PA, and 9.5 ± 2.2 and 10.8 ± 2.4 for the CNR, respectively (p < 0.05). In the spiral-tube group, the CT number, CNR, and visualisations score of the 3D images were significantly higher for the AAO and PA than those in the T-tube group (p < 0.05).

CONCLUSION

The spiral-tube proved to be beneficial in improving the CT number for the AAO and PA, CNR, and visualisation score compared with the conventional T-tube during paediatric CCTA.

IMPLICATIONS FOR PRACTICE

The spiral-tube may allow the visualisation of smaller blood vessels than those visualised by the conventional T-tube for paediatric patients in CCTA.

Constituents of Crinoidea, 4. Isolation and structure of ceramides and glucocerebrosides from the feather star Comanthus japonica

Five ceramides, JC-1-JC-5, and four glucocerebrosides, JCer-1-JCer-4, have been isolated from their parent ceramide and glucocerebroside molecular species JC and JCer obtained from the less polar lipid fraction of the chloroform/methanol extract of the feather star Comanthus japonica. The structures of these sphingolipids have been determined on the basis of chemical and spectroscopic evidence. Reversed-phase HPLC was effective at isolating these sphingolipids, revealing very close resemblance in their structures. JC-1, JC-3, JC-4, JC-5 and JCer-2, JCer-4 are newly found ceramides and glucocerebrosides, respectively.

Constituents of Crinoidea. 3. Isolation and Structure of a Glycosyl Inositolphosphoceramide-Type Ganglioside with Neuritogenic Activity from the Feather Star Comanthus japonica

A glycosyl inositolphosphoceramide-type ganglioside, CJP4, was obtained from the polar lipid fraction of the chloroform/methanol extract of the feather star Comanthus japonica. The structure of this ganglioside has been determined on the basis of chemical and spectroscopic evidence to be 9-O-methyl-(N-glycolyl-alpha-D-neuraminosyl)-(2-->11)-9-O-methyl-(N-glycolyl-alpha-D-neuraminosyl)-(2-->11)-9-O-methyl-(N-glycolyl-alpha-D-neuraminosyl)-(2-->3)-inositolphosphoceramide, which contains C(16)-sphingosine and C(22:0)-, C(24:0)-fatty acid. This is the first report on the isolation and structural elucidation of a trisialo-glycosyl inositolphosphoceramide-type ganglioside. Moreover, CJP4 exhibited neuritogenic activity toward the rat pheochromocytoma PC12 cells in the presence of nerve growth factor.

[Relationship between prothrombin time international normalized ratio and thrombo test (%)]

OBJECTIVES

The optimal therapeutic range for laboratory evaluation of oral anticoagulant therapy is now defined by the prothrombin time international normalized ratio (PT-INR). However, the thrombo test (TT), an alternative method to measure intensity of anticoagulation, is also currently used throughout Japan. The relationship between PT-INR and TT (%) has yet to be clarified. This study investigated the relationship between PT-INR and TT (%).

METHODS

The PT-INR and TT (%) were simultaneously measured of 505 consecutive samples from patients treated with warfarin in our hospital. Fourteen functions were used for regression analyses: a fractional function (Y = a/X + b), a square root function (Y = aX0.5 + b), a natural logarithmic function (Y = a.lnX + b), a power series function (Y = aXb), a quotient function (Y = abX), and polynomial functions [Y = anXn + an - 1Xn - 1 +......+ a1X1 + b, (1 < or = n < or = 9)]. The results were confirmed by the same methods in 383 samples and 296 samples from another two laboratories.

RESULTS

The power series function showed the most significant (p < 0.0001) and highest adjusted R2 (0.858) correlation, with a regression formula of TT (%) = e4.48 (PT-INR)-2.09 in our laboratory. Using the same analyses, the power series function also showed the most significant and highest adjusted R2 in samples from the other two laboratories.

CONCLUSIONS

This study showed that a power series function is the most appropriate for expressing the relationship between PT-INR and TT (%) among the 14 functions. The function between PT-INR and TT (%) is mainly derived from the relationship between TT (%) and TT (sec). Both internal validity and external validity confirmed the relationship between PT-INR and TT (%).

Constituents of crinoidea. 2. Isolation and structure of the novel type gangliosides from the feather star Comanthus japonica

Two novel type gangliosides CJP2 and CJP3 have been obtained from the feather star Comanthus japonica. On the basis of methylation linkage analysis combined with ammonolysis and other chemical and spectroscopic evidence, the chemical structures of CJP2 and CJP3 were determined to be alpha-9-O-Me-NeuGc-(2-->3)-inositolphosphoceramide and alpha-9-O-Me-NeuGc-(2-->11)-alpha-9-O-Me-NeuGc-(2-->3)-inositolphosphoceramide, respectively. These gangliosides are unique in that they are inositolphosphoceramide derivatives possessing sialic acid; such gangliosides have not previously been identified. The presence of 9-O-methyl-N-glycolyl-neuraminosyl residues is also unique in naturally occurring gangliosides.

Purification, characterization and differentiation-dependent expression of a perchloric acid soluble protein from rat kidney

We have recently reported the presence of a novel perchloric acid soluble protein in rat liver (PSP1) that inhibits cell-free protein synthesis in a rabbit reticulocyte system. While studying the perchloric acid soluble proteins from different tissues of rats, we found that the kidney protein cross-reacted with antibody against the PSP1. In this investigation, we have purified a perchloric acid soluble protein from the rat kidney and studied its characterization and expression. The protein extracted from the postmitochondrial supernatant fraction with 5% perchloric acid was purified by ammonium sulfate fractionation and CM-Sephadex chromatography. By immunoscreening with the rabbit antisera against the PSP1, we detected a cDNA that contained an open reading frame of 411 bp, encoding a 137 amino-acid protein with a molecular mass of 14,149 daltons. The deduced amino acid sequence was completely identical with that of PSP1 from rat liver. The perchloric acid soluble protein from rat kidney (K-PSP1) also inhibited cell-free protein synthesis in the rabbit reticulocyte lysate system in a different manner than RNase A. Immunohistochemistry showed that the expression of K-PSP1 increased from fetal 17th day to postnatal 4th week, and it remained almost the same until the 7th week of postnatal age. Furthermore, the expression of K-PSP1 in the kidney of the nephrotic rat model was shown to be differentiation dependent. On the other hand, the expression of K-PSP1 in renal tumor cells was downregulated as compared with intact tissue. These results suggest that the expression of K-PSP1 is regulated in a differentiation-dependent manner in the kidney.

Santonin-related compound 2 inhibits the expression of ICAM-1 in response to IL-1 stimulation by blocking the signaling pathway upstream of I kappa B degradation

Santonin-related compounds (SRCs) were synthesized from the starting material L-alpha-santonin and tested for the biological activity on the expression of intercellular adhesion molecule-1 (ICAM-1) in response to IL-1 stimulation on human adenocarcinoma cells. One of the bromoketone derivatives termed SRC2 [11S-2 alpha-bromo-3-oxoeudesmanno-13,6 alpha-lactone] strongly inhibited the ICAM-1 expression at an IC(50) value of 5.9 microM, whereas L-alpha-santonin itself was totally inactive up to 100 microM. The blockage of ICAM-1 expression by SRC2 was not due to the direct inhibition of de novo RNA and protein synthesis. The nuclear translocation of NF-kappaB subunit p65 was markedly prevented by SRC2. Moreover, I kappa B alpha degradation upon IL-1 stimulation was strongly inhibited by SRC2. These observations suggest that SRC2 blocks the IL-1 signaling pathway upstream of I kappa B degradation.

Congenital balloon digits in two neonates caused by constriction rings

Balloon digits were found in two neonates with congenital constriction ring syndrome. The affected digits were the right long finger and right great toe. They were surgically treated at the age of 10 and 9 days, respectively. Morphologic improvement was dramatic after surgery. In cases with extensive enlargement, severe cyanosis, redness, and no subsidence of edema within several days after birth, early operative treatment may be necessary to maintain digit viability and prevent autoamputation due to circulatory embarrassment. It can also be helpful to prevent fibrosis of the subcutaneous tissue. Pathologic examination revealed marked proliferation of fibrous tissue and lymphatic vessels.

Antley-Bixler syndrome: a disorder characterized by congenital synostosis of the elbow joint and the cranial suture

The Antley-Bixler syndrome is a rare disorder characterized by craniosynostosis, midface hypoplasia, radiohumeral synostosis, joint contractures, arachnodactyly, and femoral bowing and fractures. We report four cases with this disorder, all of which had craniosynostosis, midface hypoplasia with characteristic facial appearance, and contractures of bilateral elbow joints. However, femoral bowing, fractures, and arachnodactyly were not seen in our patients. In addition, proximal phalanges of the thumb and the great toe showed deformity of the delta phalanx in two cases. Characteristic features in these cases were the synostotic deformity of the elbow joint; three had radioulnahumeral synostosis, and one had radioulnar synostosis. Therefore, our cases indicated that various synostotic patterns of the elbow joints may exist in this syndrome. It is reasonable to propose that characteristic craniofacial appearance associated with the synostosis of the elbow joints of various forms should be considered minimal diagnostic criteria of the Antley-Bixler syndrome.

Costunolide and dehydrocostus lactone as inhibitors of killing function of cytotoxic T lymphocytes

Costunolide and dehydrocostus lactone were isolated from an extract of mokko (Saussurea lappa Clarke) as inhibitors of killing activity of cytotoxic T lymphocytes (CTL). Mokko lactone was also isolated as an inactive compound from the extract. The structure-activity relationship indicated that alpha-methylene-gamma-butyrolactone is required for the inhibitory effect. Costunolide markedly inhibited the granule exocytosis and the production of inositol phosphates in response to anti-CD3 monoclonal antibody (mAb) stimulation at a concentration that did not affect the binding of anti-CD3 mAb. Tyrosine phosphorylation induced by crosslinking of CD3 molecules was significantly inhibited by costunolide in a dose-dependent manner. These results suggest that costunolide inhibits the killing activity of CTL through preventing the increase in tyrosine phosphorylation in response to the crosslinking of T-cell receptors.

Paraparesis after rib penetration of the spinal canal in neurofibromatous scoliosis

Paraplegia or paraparesis is uncommon in patients with neurofibromatous scoliosis. The main causes of spinal cord compression in neurofibromatosis are vertebral angulation, vertebral subluxation, and tumorous lesions around the spinal cord. We report a rare case of paraparesis due to spinal cord compression by a rib penetrating the spinal canal in a patient with neurofibromatous scoliosis. There was complete recovery after laminectomy and proximal resection of the compressing rib along with combined anterior and posterior spinal fusion.

Bone dysplasia in a child born to parents with osteogenesis imperfecta and pseudoachondroplasia

We report on a boy born to a mother with pseudoachondroplasia and a father with osteogenesis imperfecta (Sillence type III). At birth, the boy was found to have osteogenesis imperfecta type III. Although clinical findings of pseudoachondroplasia were not manifested at the age of 8 months, roentgenographic findings showed characteristics of pseudoachondroplasia in addition to those of osteogenesis imperfecta. He died of respiratory distress at age 15 months.