A novel echocardiographic risk score predicts prognosis in AL-amyloidosis

Background

Prognosis in light chain (AL) amyloidosis is largely determined by the severity of cardiac involvement. Conventional (Mayo) staging includes 1) hs troponin 2) N-terminal pro-beta natriuretic peptide (NT-pro BNP) and 3)free light chain difference.

Methods

In a retrospective study of 75 AL amyloidosis patients referred to a quaternary amyloid clinic, all patients underwent comprehensive echocardiographic assessment. Echocardiographic parameters included left ventricular (LV) ejection fraction, LV mass, diastolic function, global longitudinal strain (GLS) and indexed left atrial volume (LAVI). Mortality was assessed through review of clinical records.

Results

Over a median follow up of 51 months, 29/75 (39%) of patients died. LAVI, E/e', e', LVGLS, were univariate predictors of mortality (p<0.1). LAVI was the only independent echocardiographic predictor in a multivariable model. Kaplan Meir analysis evaluated LAVI, LVGLS and E/e' using clinical cutoffs as a predictor of survival; only LAVI and LVGLS were significant. A novel “Echo score” comprising of LAVI (>42 ml/m2) and LVGLS (<−12%) was a predictor of mortality with similar prognostic performance as Mayo stage. (Echo score AUC 0.745, 95% CI 0.64–0.85 vs Mayo score AUC 0.752 95% CI 0.66–0.86, p=0.9).

Conclusion

LAVI, a simple, echocardiographic parameter was as an independent predictor of mortality in AL amyloidosis. A composite echocardiographic score combining LAVI and LVGLS stratified AL-amyloidosis patients into 3 distinct groups with similar prognostic power as Mayo stage for all-cause mortality.

Funding Acknowledgement

Type of funding sources: None.

Comparison of 4 Different 4-Strand Core Suturing Techniques for Flexor Tendon Laceration: An Ex Vivo Biomechanical Study

BACKGROUND

Forces applied to the repaired flexor tendon should not exceed its yield force during early postoperative rehabilitation to prevent gapping and rupture. We aimed to biomechanically compare the tensile strengths and the 2-mm gapping of 4 different 4-strand core suturing techniques for flexor tendon repair.

METHODS

Fifty-six goat deep digital flexor tendons were repaired with the 4-strand double-modified Kessler, the 4-strand augmented Becker, the 4-strand Savage, and the 4-strand modified Tang techniques. All tendons were repaired with 4-0 polyester for core suture and 5-0 polyester for continuous epitendinous running suture. The specimens were subjected to static linear tensile testing by applying a single linear load-to-failure pull. After the linear load testing, the yield load, the ultimate strength of the repaired tendons, and the force exerted to yield a 2-mm gap were measured.

RESULTS

All peripheral sutures ruptured near the yield point. All core suture techniques were similar regarding the yield force. The augmented Becker 4-strand technique had the greatest ultimate strength (98.7 [82-125.3] N). The modified double Kessler technique was the weakest in resisting a 2-mm gap formation. The 4-strand modified Tang repair had the shortest (11.3 [7-15] minutes), while the 4-strand augmented Becker had the longest operative time (29 [23-33] minutes).

CONCLUSIONS

All 4 techniques demonstrated similar yield force, with differences in operative time, ultimate strength, and resistance to gapping. Future clinical studies can further elucidate their appropriateness for early active motion protocols.

Clinical and echocardiographic characteristics of cardioembolic stroke

BACKGROUND AND PURPOSE

Ischaemic stroke frequently has a cardioembolic (CE) source. Clinical and echocardiographic parameters associated with CE stroke were evaluated.

METHODS

In all, 93 consecutive ischaemic stroke patients who underwent a transthoracic echocardiogram were retrospectively analysed; strokes were classified by TOAST (Trial of Org 10172 in Acute Stroke Treatment) criteria. Echocardiographic parameters related to CE stroke, including left atrial volumes and function, were compared to 73 healthy controls.

RESULTS

Of 93 patients (mean age 66.1 years, 56% male), nine (10%) had large artery atherosclerosis, 38 (41%) CE stroke, two (2%) small vessel disease, two (2%) other and 42 (45%) undetermined aetiology. Left atrial (LA) maximum volumes (LAVI_max ) and minimum volumes (LAVI_min ) were larger in the CE group than the non-CE group (45 vs. 32 ml/m² , 32 vs. 13 ml/m² , respectively, P < 0.001), whilst LA function indices including LA emptying fraction and LA function index (LAFI) were lower in the CE group (34% vs. 55%, and 0.12 vs. 0.35, respectively, P < 0.001). Adjusting for clinical characteristics, LAFI ≤0.3 was an independent predictor of CE stroke (adjusted odds ratio 5.3, P = 0.001). Additionally, LAVI_max and LAVI_min were larger (61 vs. 44 and 32 vs. 24 ml/m² respectively, P < 0.01) and LAFI significantly lower (0.34 vs. 0.52, P < 0.001) in the undetermined aetiology group versus healthy controls.

CONCLUSIONS

Left atrial enlargement with reduced LA function was associated with CE stroke and LAFI was the best independent predictor. LA parameters were also altered in the undetermined aetiology group, suggesting an underlying LA myopathy in this subset.

Two to nineteen years follow-up of arthroscopic meniscal repair using the outside-in technique: a retrospective study

PURPOSE

To perform a long-term follow-up evaluation of the outside-in technique of arthroscopic meniscal repair.

TYPE OF STUDY

Retrospective study.

METHODS

Between the years 1986 and 2002, 93 cases of arthroscopic meniscal repair using the outside-in technique have been operated by the senior author (F.L.). Forty-one patients were available for the follow-up evaluation with a mean follow-up of 11.71 years. The International Knee Documentation Committee (IKDC), the modified Lysholm score, the SF-36 (short form 36) health survey score, a visual analogue scale (VAS) for assessment of patients' satisfaction and another VAS for assessment of patients' pain were used retrospectively to evaluate the patients. We also used the Kellgren and Lawrence (K/L) classification of osteoarthritis to evaluate the preoperative X-rays and the X-rays done at the time of the follow-up evaluation. Failure was defined as having a meniscectomy procedure post-operatively.

RESULTS

From the 93 patients, 52 could not be retrieved for the follow-up evaluation, while 41 were available for it; 36 patients were clinically successful and 5 were considered as failure. Thirty-six patients were classified as grade "A" in the objective IKDC score, mean modified Lysholm score was 87.29 (SD 16.43), while mean SF-36 score was 85.73 (SD 14.17). The results of the VAS for operation satisfaction ranging from -10 to +10 revealed that the mean of the answers was 8.05 (SD 2.99). The results of the VAS for pain ranging from 0 to 10 revealed that the mean of the patients' pain at the time of the follow-up evaluation was 1.8 (SD 2.42). Twenty out of 24 (only 24 preoperative X-rays were available) were classified as having no osteoarthritis pre-operatively, whereas only 12 out of the 41 patients were classified as having no osteoarthritis (normal) at the time of the follow-up evaluation according to the K/L classification which indicates progression of osteoarthritis. No complications related to the outside-in arthroscopic meniscal repair procedure were reported.

CONCLUSION

We conclude that arthroscopic meniscal repair using the outside-in technique is a safe surgical procedure with a good clinical outcome.