Many hands make light work. Echocardiography and computed tomography results from the Tricuspid Regurgitation IMAging (TRIMA) study

Background

Anatomic knowledge of the tricuspid valve (TV) is the first step in the diagnostic algorithm of patients with tricuspid regurgitation (TR), who are candidates for transcatheter tricuspid valve intervention (TTVI). Currently, echocardiography and computed tomography (CT) are available instruments to study the TV anatomy, guide the decision-making process and support the development of novel transcatheter therapies.

Purpose

The Tricuspid Regurgitation IMAging (TRIMA) study aimed to correlate CT parameters to commonly used echocardiographic variables.

Methods

This prospective, single-center study enrolled 22 consecutive patients with TR equal to or greater than severe (≥3+). All patients underwent transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE) and cardiac CT study, in order to obtain anatomical dimensions of the tricuspid annulus and quantification of right-chambers remodeling and function. Novel CT scan measurements were analyzed. Correlation between measurements on echocardiography and CT imaging was assessed.

Results

Severe TR (3+) was present in 27.4% patients, massive (4+) in 4.8% and torrential (5+) in 3.2%. The mean right ventricle (RV) length, RV mid diameter, and right atrium area were 60.81±9.11 mm, 41.27±7.67 mm and 31.72±9.66 cm2, respectively. Tricuspid annular plane excursion, fractional area change, longitudinal myocardial velocity (S') were 16.09±3.25 mm, 33.36±9.47% and 9.18±1.94 cm/sec, respectively. The annular dimensions obtained by CT scan were generally observed to reduce from diastole to systole, except for eccentricity, angles and distance between the postero-septal and antero-posterior commissure and distance between centroid and antero-posterior commissure. A Kruskal-Wallis test showed a stepwise increase in the tricuspid anatomical regurgitant orifice area (AROA) values by CT across the expanded TR grades by TEE, χ2(2)=6,466, p=0.039. Using the Pearson correlation coefficient, we found a relationship between the AROA and TR grade (r=0.593; p<0.004), as well as ARO-perimeter and TR grade (r=0.470; p<0.027). Additionally, a significant correlation was found between septal lateral annulus diameter obtained by TEE and CT (r=0.637; p=0.001). Anyway, no correlations were found between novel CT variables and TR grade or RV function assessed by echocardiogram, as well as between CT systo-diastolic annulus variability and RV function.

Conclusions

Standard echocardiographic study provide invaluable information about the anatomy and function of the right-chambers, as well as an accurate grade of TR. Conventional and novel variables derived by CT scan may step up the anatomical assessment of the complex morphology of the TV apparatus, thanks to the high spatial resolution of the technique. Therefore, an integrated multimodality assessment is the key point of the screening process of TR candidates for TTVI.

Funding Acknowledgement

Type of funding sources: None.

Dual kidney transplant techniques: A systematic review

BACKGROUND

Dual kidney transplantation (DKT) was developed to improve outcomes from transplantation of extended criteria donors (ECD). This study examined which surgical techniques have been reported for DKT and whether any technique had superior patient and graft survival.

METHOD

Electronic databases were searched for published studies mapping to MESH terms: "kidney or renal" AND "transplan*" AND "dual or double." Single case reports, studies of patients less than 18 years old, studies which did not describe the surgical technique, and studies that did not report patient or graft survival were excluded.

RESULTS

Fifteen reports of 434 DKT recipients were identified. Three techniques were described: bilateral placement; unilateral placement with separate anastomoses; and unilateral placement with patch anastomoses. Patient survival across all three techniques was over 95% at 1 year, and graft survival was also similar at over 90%. Rates of delayed graft function were between 20% and 30% across all techniques.

CONCLUSION

The three techniques have equivalent delayed graft function as well as patient and graft survival rates. This is an encouraging result as it means that the surgeon can choose to use the technique which is most appropriate for their own skills and for the patient.

Evaluation of hand circulation with CardioWaves photoplethysmograph device during Allen test in healthy volunteers

OBJECTIVE

Radial artery occlusion is a potential complication of transradial procedures and its occurrence ranges from 0.8 to 30%. It is virtually always asymptomatic but the functional and sensorial consequences of a long acting hand hypoperfusion could go underestimated. CardioWaves is a novel photoplethysmograh device that allows us to detect the pulse wave amplitude of the blood flowing to the hand. Our objective was to assess in normal subjects the hand blood flow supplied by radial arteries and ulnopalmar arches, respectively, by using CardioWaves device during modified Allen's test (MAT).

PATIENTS AND METHODS

MAT was performed on both hands of 60 normal subjects, age ranging 21 to 66 years, without any cardiovascular factor risk.

RESULTS

Photoplethysmograh and MAT showed a high positive linear correlation (r=0.93). Despite that, MAT tends to give a higher reading by between 1.05 and 1.6 sec. 11 of 120 readings (9%) by CardioWaves showed values of radial/ulnar pulse amplitude ratio more than mean + 1 SD, suggesting a significant decrease in ulnopalmar arterial circulation when radial blood flow supply would ceased.

CONCLUSIONS

The CardioWaves device allows us an accurate reading of the flow because of its independency from respiratory changes. Furthemore, the evaluation of radial and ulnar pulse wave amplitude and the ratio between them would reveal an insufficient blood flow supply by the ulnar artery irrespective of the MAT results. We suggest that their assessment before performing coronary angiography and interventions may reduce potential complication of transradial access.

Systematic review of actual 10-year survival following resection for hepatocellular carcinoma

BACKGROUND

Hepatic resection is a potentially curative therapy for hepatocellular carcinoma (HCC), but recurrence of disease is very common. Few studies have reported 10-year actual survival rates following hepatic resection; instead, most have used actuarial measures based on the Kaplan-Meier method. This systematic review aims to document 10-year actual survival rates and to identify factors significant in determining prognosis.

METHODS

A comprehensive search was undertaken of MEDLINE and EMBASE. Only studies reporting the absolute number of patients alive at 10 years after first resection for HCC were included; these figures were used to calculate the actual 10-year survival rate. A qualitative review and analysis of the prognostic factors identified in the included studies were performed.

RESULTS

Fourteen studies, all of which were retrospective case series, including data on 4197 patients with HCC were analysed. Ten years following resection, 303 of these patients were alive. The 10-year actual survival rate was 7.2%, whereas the actuarial survival quoted from the same studies was 26.8%. Positive prognostic factors included better hepatic function, a wider surgical margin and the absence of satellite lesions.

CONCLUSIONS

The actual long-term survival rate after resection of HCC is significantly inferior to reported actuarial survival rates. The Kaplan-Meier method of actuarial survival analysis tends to overestimate survival outcomes as a result of censorship of data and subgroup analysis.

An auditory variant of eye movement desensitization in a case of childhood post-traumatic stress disorder

The present paper reports a case study documenting the success of a child-appropriate variant of eye movement desensitization (EMD) in the treatment of post-traumatic stress disorder (PTSD). Although there have been numerous case studies and some preliminary controlled trials of this method in adult cases of PTSD, there does not appear to be any information on its use in children. The available literature suggests that it is a more rapid and less traumatic treatment than traditional exposure based therapies. The present paper describes a child-appropriate auditory variant of eye-movement desensitization applied to a case of childhood PTSD.