Tissue-Tracking Mitral Annular Displacement in Neonates: A Novel Index of Left Ventricular Systolic Function

OBJECTIVES

To assess the feasibility, accuracy, and reproducibility of tissue-tracking mitral annular displacement (TMAD) compared with other measures of left ventricular systolic function in healthy preterm and term neonates in the transitional period.

METHODS

This was a prospective observational study. Two echocardiograms were performed at 24 and 48 hours of life. TMAD, shortening fraction (SF), ejection fraction (EF), s', and global longitudinal strain (GLS) were measured offline. Accuracy to detect impaired GLS was tested by ROC curve analysis. DeLong test was used to compare AUCs. Intra and interobserver reproducibility of the off-line analysis was calculated.

RESULTS

Mean ± SD gestational age and weight were 34.2 ± 3.8 weeks and 2162 ± 833 g, respectively. TMAD was feasible in 168/180 scans (93%). At 24 hours the AUC (95% CI) of SF, EF, s', and TMAD (%) was 0.51 (0.36-0.67), 0.68 (0.54-0.82), 0.63 (0.49-0.77), and 0.89 (0.79-0.99) respectively. At 48 hours the AUC (95% CI) of SF, EF, s', and TMAD (%) was 0.64 (0.51-0.77), 0.59 (0.37-0.80), 0.70 (0.54-0.86), and 0.96 (0.91-1.00), respectively. The AUC of TMAD was superior to the AUC of SF, EF, s', at both timepoints (P < .02). Intraclass correlation coefficients (95% CI) of intra and interobserver reproducibility of TMAD were 0.97 (0.95-0.99) and 0.94 (0.88-0.97), respectively.

CONCLUSION

TMAD showed improved accuracy and optimal reproducibility in neonates in the first 48 hours of life.

Impact of Aortic Diameter Measurements at Three Anatomical Landmarks on Left Ventricular Output Calculation in Neonates

OBJECTIVES

To assess reproducibility and accuracy of left ventricular output (LVO) quantifications in neonates, when left ventricular outflow tract diameter (LVOTD) was measured at the hinges of the aortic valve (AV), at the aortic sinus (AS), and at the sinotubular junction (STJ).

METHODS

This was an observational study. In the first cohort of very preterm neonates, we assessed intraobserver and interobserver repeatability of LVOTD measured at the AV, AS, and STJ and of the corresponding LVO. In the second cohort of older neonates, we compared paired LVO measurements by echo and magnetic resonance imaging (MRI).

RESULTS

In the first cohort of 48 neonates, mean (standard deviation) weight and age at scan were 1046 (302) g and 28.1 (2.7) weeks. Interobserver bias (95% limits of agreement [LOA]) for LVOTD at the AV, AS, and STJ was 0 (-0.3 to 0.3) mm, 0 (-0.7 to 0.7) mm, and 0 (-0.8 to 0.7) mm, respectively. Interobserver bias (95% LOA) for the corresponding LVO was -1.3 (-31 to 33) ml/kg/min, -0.5 (-88 to 87) ml/kg/min, and -7.2 (-83 to 69) ml/kg/min, respectively. In the second cohort of 10 neonates, median (range) weight and age at scan were 1942 (970-3640) g and 37.2 (31.7-39.8) weeks. LVO measured at the AV showed stronger agreement with MRI: bias (LOA) -10.6 (-74 to 52) ml/kg/min, compared to LVO measured at AS and STJ: 194 (-0.5 to 388) ml/kg/min and 43 (-72 to 159) ml/kg/min respectively.

CONCLUSIONS

Reproducibility and accuracy of LVO quantification by echo were better when aortic diameter was measured at AV.

A case report of aorto-pulmonary window in an infant born to a diabetic mother

Several studies have described the association between pre-gestational maternal diabetes and cardiac disease in the newborn. Infants of diabetic mothers have an increased incidence of congenital heart disease, reported between 3% and 6% compared to 0.8% of the general population. A particularly high prevalence of conotruncal defects has been recently described among congenital heart diseases. This group of malformations affects ventricular outflows, aorta, and pulmonary artery and shares a common embryogenic origin. They include persistence of the truncus arteriosus, transposition of great arteries, tetralogy of Fallot, interruption of the aortic arch, and double outlet right ventricle. Aorto-pulmonary window, a rare congenital heart disease belonging to conotruncal malformations, has never been previously described in association with maternal diabetes. We describe the case of a male infant born to a mother suffering from a poorly controlled type 1 diabetes during pregnancy. In the early postnatal life the infant showed respiratory distress, tachycardia, and failure to thrive. He was found to be affected by aorto-pulmonary window that required corrective surgical intervention. <Learning objective: This case report warns us to consider this congenital abnormality as a possible finding in infants born to a diabetic mother. Furthermore, it shows how difficult the echocardiographic diagnosis of aorto-pulmonary windows can be.>.

Association between Hemodynamically Significant Patent Ductus Arteriosus and Bronchopulmonary Dysplasia

OBJECTIVE

To assess whether the duration and magnitude of the shunt with patent ductus arteriosus (PDA) are related to a higher incidence of bronchopulmonary dysplasia (BPD) or death.

STUDY DESIGN

A total of 242 infants ≤ 28 weeks gestational age were evaluated retrospectively between 2007 and 2012; 105 (43.3%) developed BPD or died (group 1) and 137 (56.6%) did not (group 2). A review of all echocardiographic evaluations performed from birth up to 36 weeks of postconceptional age or final ductal closure was carried out, to detect the presence of PDA, and estimate the severity of ductal shunt through the "PDA staging system" proposed by McNamara and Sehgal.

RESULTS

Group 1 presented with a hemodynamically significant ductus arteriosus (DA) (E3 and/or E4-PDA) for a longer period of time vs group 2: 4.8 vs 2.3 days, respectively (P < .001). Persistence of a nonsignificant DA (E2) was not associated with development of BPD (P = .16). Each week of a hemodynamically significant DA represented an added risk for BPD (OR 1.7), and the duration of a small, nonsignificant DA (E2) did not. Surgical ligation of PDA itself was not found to be an independent risk factor for BPD. In the subgroup of patients who received ligation, a later ligation (33 vs 23 days) and a prolonged PDA were the only factors associated to BPD or death.

CONCLUSIONS

A shared scoring system of the severity of ductal shunt is helpful to correctly evaluate the association between PDA morbidities, to compare scientific studies, and to guide treatment.

Admission glycemia and markers of inflammation are independent outcome predictors in primary PCI in non-diabetic patients

AIM

To assess the prognostic value of admission plasma glucose (APG) respect to clinical variables and inflammatory markers in a selected population of non-diabetic patients with ST elevation myocardial infarction (STEMI) treated with primary angioplasty (primary coronary intervention, PCI).

METHODS

A total of 188 consecutive non-diabetic STEMI patients undergoing primary PCI were divided into four quartiles based on APG (<117, 117-140, 141-170, >170 mg/dL). Combined end-point of major adverse cardiac events (MACE) was defined as death, acute heart failure, re-infarction, unstable angina or inducible ischemia.

RESULTS

Event-free survival from MACE was significantly (P<0.001) correlated with APG quartiles and decrease from the lowest to the highest: 6 months event-free survival was 89.3%, 77.4%, 59.1%, 42.5%. Patients with higher APG were characterized by a significantly higher Killip class (P<0.001), higher serum creatinine (P<0.05) on admission, and a lower rate of thrombolysis in myocardial infarction (TIMI) 3 flow after PCI (P<0.05). Multivariate analysis showed APG>170 mg/dL (hazard ratio [HR] 2.39, 95% confidence interval [CI] 1.24 to 4.65, P<0.01), admission high-sensitivity C-reactive protein level (HR 1.19, 95% CI 1.07 to 1.31, P<0.001), white blood cells count (HR 1.07, 95% CI 1.00 to 1.14, P<0.04) and heart rate (HR 1.02, 95% CI 1.00 to 1.04, P<0.02) to be independent predictors of MACE.

CONCLUSION

Admission glycemia and inflammatory markers are independent predictors of MACE in the mid-term follow-up in non-diabetic STEMI treated with primary PCI. Further investigations are needed to study the pathogenesis of stress hyperglycaemia, interactions with mechanisms of inflammation and whether early and aggressive treatment with insulin may influence outcome of primary PCI.

Impaired efficacy of selective LDL-apheresis in primary biliary cirrhosis

Low-density lipoprotein apheresis (LDL-apheresis) was done with either cascade filtration (DF) or dextran sulfate cellulose adsorption (DSC) in a patient with primary biliary cirrhosis who developed severe dyslipidemia associated with cholestasis and accumulation of lipoprotein-X (LP-X). The extracorporeal treatment was initially performed weekly, and resulted in a sharp drop in total cholesterol from 1038 to 430 mg/dl. During the next four months the patient was treated every 10-15 days, and pre-apheresis cholesterol levels were maintained between 438 and 505 mg/dl, until an orthotopic liver transplantation was successfully performed. With semi-selective DF a mean 47.1% of total cholesterol was removed per procedure compared to 30.0% with DSC, although the volume of treated plasma was 38.0 vs 49.9 ml/kg body weight. The changes in plasma cholesterol levels during DSC and DF showed that the kinetics of cholesterol removal were similar with both techniques, but the efficacy differed; DF removed both LDL and LP-X from plasma, whereas DSC selectively lowered the LDL content. Cascade filtration may therefore be considered as a first-choice treatment for patients with LP-X accumulation due to cholestasis.

Polymorphonuclear cell phagocytosis and surface receptor modulation after extracorporeal circulation

Polymorphonuclear cells (PMN) from patients treated with hemodialysis (HD) or plasma exchange (PE) were analyzed by flow cytometry to determine modulation in phagocytic capacity and Fc-gamma and C3bi receptor expression following extracorporeal circulation (EC). Fluorescent microbeads (phi 2.02 m) were used in the evaluation of phagocytosis, and phycoerythrin conjugated Leu11c and Leu15 monoclonals identified Fc-gamma and C3bi receptors respectively. The percentage of positive cells and mean receptor density on PMN surfaces were calculated for each antibody before and after the procedures. Fc-gamma receptor expression was reduced overall in HD and PE cases, but unaffected after EC even with specific paraprotein removal. C3bi receptor was normally expressed on PMNs before and after EC, but receptor density on the cell surface increased, and phagocytosis was qualitatively and quantitatively depressed after EC. The resulting effect of EC on PMNs was therefore a temporary increase in C3bi receptor density after the procedure, which was independent of HD or PE technique, of the primary disease, and of the quality of the PE reinfusion solutions, suggesting a procedure-related effect, and a down-regulation of PMN phagocytic activity. Both effects may be related to membrane biocompatibility.

Different cascade filtration operating modalities in clinical use

Cascade filtration (CF) can be performed in either the single-pass or dead-end configuration. The distinction, as predicted by experimental models, is that solute removal is lower but constant in the former, and higher but variable with the quantity of filtrate in the latter. Moreover, unpredictable plugging reduces permeability during operation. It is therefore unclear which configuration is preferable in clinical use. In four cryo- and three macroglobulinemic patients, the data of 10 dead-end CF (QP) and 11 modified single-pass CF with high flow rate recycling plasma (QD) were compared. Both groups had similar starting values. Centrifugal primary plasma separation was performed. No exogenous reinfusions were used. Either 0.8 and 1.2 sq.m. surface secondary filters were employed. The ratio of plasma processed to patients' plasma volume was 1.1 +/- 0.3 in QP, and 0.94 +/- 0.09 in QD. The mean percentage removals of albumin, IgG and IgM respectively were 25.8 +/- 9, 32 +/- 17 and 47.5 +/- 26% in QP, 30.5 +/- 12, 40.5 +/- 19 and 48 +/- 17.5% in QD: albumin vs IgM p less than 0.025 in QP and p less than 0.02 in QD. A/G ratio increased from 1.6 +/- 0.5 to 2.06 +/- 0.6 in QP, and from 1.5 +/- 0.3 to 1.7 +/- 0.3 in QD. Plugging occurred in both groups, requiring 2.3 +/- 1.8 washouts/run in QP vs 1.5 +/- 1.2 in QD. IgM removal was comparable. Removal of albumin and IgG was slightly higher in QD. Similar performances can be obtained with either technique in clinical use, provided an adequate fractionation surface is available.

Selective and semiselective low-density lipoprotein apheresis in familial hypercholesterolemia

Seven patients with familial hypercholesterolemia were treated fortnightly for 3 months by selective low-density lipoprotein apheresis with dextran-sulfate cellulose column (DSC). Subsequently, 4 of them were treated with semiselective double filtration. No cholesterol-lowering drugs were given. Plasma processed ranged from 39 to 58 ml/kg body weight/procedure. Fractional removals from plasma filtrate at the secondary treatment (adsorption or fractionation) for total cholesterol, high-density lipoprotein cholesterol, and albumin, respectively, were 0.84, 0.06, and 0.03 with DSC and 0.74, 0.47 and 0.35 with double filtration. Postapheresis reductions of total cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol were 57, 15, and 59% with DSC and 47,35, and 48% with double filtration. Both methods are suitable for clinical use, but with a 15-day treatment schedule, lowering circulating lipid fraction levels are maintained with DSC.