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Grubb KJ, Gada H, Mittal S, Nazif T, Rodés-Cabau J, Fraser DGW, Lin L, Rovin JD, Khalil R, Sultan I, Gardner B, Lorenz D, Chetcuti SJ, Patel NC, Harvey JE, Mahoney P, Schwartz B, Jafar Z, Wang J, Potluri S, Vora AN, Sanchez C, Corrigan A, Li S, Yakubov SJ. Clinical Impact of Standardized TAVR Technique and Care Pathway: Insights From the Optimize PRO Study. JACC Cardiovasc Interv 2023; 16:558-570. [PMID: 36922042 DOI: 10.1016/j.jcin.2023.01.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Procedural success and clinical outcomes after transcatheter aortic valve replacement (TAVR) have improved, but residual aortic regurgitation (AR) and new permanent pacemaker implantation (PPI) rates remain variable because of a lack of uniform periprocedural management and implantation. OBJECTIVES The Optimize PRO study evaluates valve performance and procedural outcomes using an "optimized" TAVR care pathway and the cusp overlap technique (COT) in patients receiving the Evolut PRO/PRO+ (Medtronic) self-expanding valves. METHODS Optimize PRO, a nonrandomized, prospective, postmarket study conducted in the United States, Canada, Europe, Middle East, and Australia, is enrolling patients with severe symptomatic aortic stenosis and no pre-existing pacemaker. Sites follow a standardized TAVR care pathway, including early discharge and a conduction disturbance management algorithm, and transfemoral deployment using the COT. RESULTS A total of 400 attempted implants from the United States and Canada comprised the main cohort of this second interim analysis. The mean age was 78.7 ± 6.6 years, and the mean Society of Thoracic Surgeons predictive risk of mortality was 3.0 ± 2.4. The median length of stay was 1 day. There were no instances of moderate or severe AR at discharge. At 30 days, all-cause mortality or stroke was 3.8%, all-cause mortality was 0.8%, disabling stroke was 0.7%, hospital readmission was 10.1%, and cardiovascular rehospitalization was 6.1%. The new PPI rate was 9.8%, 5.8% with 4-step COT compliance. In the multivariable model, right bundle branch block and the depth of the implant increased the risk of PPI, whereas using the 4-step COT lowered 30-day PPI. CONCLUSIONS The use of the TAVR care pathway and COT resulted in favorable clinical outcomes with no moderate or severe AR and low PPI rates at 30 days while facilitating early discharge and reproducible outcomes across various sites and operators. (Optimize PRO; NCT04091048).
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Affiliation(s)
- Kendra J Grubb
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia, USA.
| | - Hemal Gada
- Department of Interventional Cardiology, University of Pittsburgh Medical Center Pinnacle, Wormleysburg, Pennsylvania, USA; Center for Heart Valve Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Suneet Mittal
- Division of Cardiology and the Snyder Center for Comprehensive Atrial Fibrillation at Valley Health System, Ridgewood, New Jersey, USA
| | - Tamim Nazif
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York, USA
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Hospital Clínic de Barcelona, Barcelona, Spain
| | - Douglas G W Fraser
- Cardiology Department, Manchester Heart Centre, Central Manchester University Hospitals, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Lang Lin
- Department of Interventional Cardiology, Morton Plant Hospital, Clearwater, Florida, USA; Department of Cardiovascular Surgery, Morton Plant Hospital, Clearwater, Florida, USA
| | - Joshua D Rovin
- Department of Interventional Cardiology, Morton Plant Hospital, Clearwater, Florida, USA; Department of Cardiovascular Surgery, Morton Plant Hospital, Clearwater, Florida, USA
| | - Ramzi Khalil
- Department of Cardiology, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Department of Interventional Cardiology, University of Pittsburgh Medical Center Pinnacle, Wormleysburg, Pennsylvania, USA; Center for Heart Valve Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Blake Gardner
- Saint George Regional Hospital, St. George, Utah, USA
| | - David Lorenz
- Saint Vincent's Medical Center, Bridgeport, Connecticut, USA
| | - Stanley J Chetcuti
- Department of Interventional Cardiology, University of Michigan Hospitals, Ann Arbor, Michigan, USA; Department of Cardiovascular Surgery, University of Michigan Hospitals, Ann Arbor, Michigan, USA
| | - Nainesh C Patel
- Division of Cardiology, Lehigh Valley Health Network/University of South Florida College of Medicine, Allentown, Pennsylvania, USA
| | - James E Harvey
- Department of Cardiovascular Diseases, York Hospital-Wellspan Health System, York, Pennsylvania, USA
| | - Paul Mahoney
- Structural Heart Center, Sentara Heart Hospital, Norfolk, Virginia, USA
| | - Brian Schwartz
- Department of Cardiology, Kettering Medical Center, Dayton, Ohio, USA
| | - Zubair Jafar
- Department of Cardiology, Vassar Brothers Medical Center, Poughkeepsie, New York, USA
| | - John Wang
- Section of Interventional Cardiology, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Srinivasa Potluri
- Department of Interventional Cardiology, Baylor Scott and White The Heart Hospital, Plano, Texas, USA
| | - Amit N Vora
- Department of Interventional Cardiology, University of Pittsburgh Medical Center Pinnacle, Wormleysburg, Pennsylvania, USA; Center for Heart Valve Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carlos Sanchez
- Department of Interventional Cardiology, Riverside Methodist-OhioHealth, Columbus, Ohio, USA
| | - Amy Corrigan
- Department of Clinical Research, Medtronic, Minneapolis, Minnesota, USA
| | - Shuzhen Li
- Department of Structural Heart and Aortic Clinical Research and Medical Science, Medtronic, Minneapolis, Minnesota, USA
| | - Steven J Yakubov
- Department of Interventional Cardiology, Riverside Methodist-OhioHealth, Columbus, Ohio, USA
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Toff WD, Hildick-Smith D, Kovac J, Mullen MJ, Wendler O, Mansouri A, Rombach I, Abrams KR, Conroy SP, Flather MD, Gray AM, MacCarthy P, Monaghan MJ, Prendergast B, Ray S, Young CP, Crossman DC, Cleland JGF, de Belder MA, Ludman PF, Jones S, Densem CG, Tsui S, Kuduvalli M, Mills JD, Banning AP, Sayeed R, Hasan R, Fraser DGW, Trivedi U, Davies SW, Duncan A, Curzen N, Ohri SK, Malkin CJ, Kaul P, Muir DF, Owens WA, Uren NG, Pessotto R, Kennon S, Awad WI, Khogali SS, Matuszewski M, Edwards RJ, Ramesh BC, Dalby M, Raja SG, Mariscalco G, Lloyd C, Cox ID, Redwood SR, Gunning MG, Ridley PD. Effect of Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement on All-Cause Mortality in Patients With Aortic Stenosis: A Randomized Clinical Trial. JAMA 2022; 327:1875-1887. [PMID: 35579641 PMCID: PMC9115619 DOI: 10.1001/jama.2022.5776] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement and is the treatment of choice for patients at high operative risk. The role of TAVI in patients at lower risk is unclear. OBJECTIVE To determine whether TAVI is noninferior to surgery in patients at moderately increased operative risk. DESIGN, SETTING, AND PARTICIPANTS In this randomized clinical trial conducted at 34 UK centers, 913 patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk due to age or comorbidity were enrolled between April 2014 and April 2018 and followed up through April 2019. INTERVENTIONS TAVI using any valve with a CE mark (indicating conformity of the valve with all legal and safety requirements for sale throughout the European Economic Area) and any access route (n = 458) or surgical aortic valve replacement (surgery; n = 455). MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 1 year. The primary hypothesis was that TAVI was noninferior to surgery, with a noninferiority margin of 5% for the upper limit of the 1-sided 97.5% CI for the absolute between-group difference in mortality. There were 36 secondary outcomes (30 reported herein), including duration of hospital stay, major bleeding events, vascular complications, conduction disturbance requiring pacemaker implantation, and aortic regurgitation. RESULTS Among 913 patients randomized (median age, 81 years [IQR, 78 to 84 years]; 424 [46%] were female; median Society of Thoracic Surgeons mortality risk score, 2.6% [IQR, 2.0% to 3.4%]), 912 (99.9%) completed follow-up and were included in the noninferiority analysis. At 1 year, there were 21 deaths (4.6%) in the TAVI group and 30 deaths (6.6%) in the surgery group, with an adjusted absolute risk difference of -2.0% (1-sided 97.5% CI, -∞ to 1.2%; P < .001 for noninferiority). Of 30 prespecified secondary outcomes reported herein, 24 showed no significant difference at 1 year. TAVI was associated with significantly shorter postprocedural hospitalization (median of 3 days [IQR, 2 to 5 days] vs 8 days [IQR, 6 to 13 days] in the surgery group). At 1 year, there were significantly fewer major bleeding events after TAVI compared with surgery (7.2% vs 20.2%, respectively; adjusted hazard ratio [HR], 0.33 [95% CI, 0.24 to 0.45]) but significantly more vascular complications (10.3% vs 2.4%; adjusted HR, 4.42 [95% CI, 2.54 to 7.71]), conduction disturbances requiring pacemaker implantation (14.2% vs 7.3%; adjusted HR, 2.05 [95% CI, 1.43 to 2.94]), and mild (38.3% vs 11.7%) or moderate (2.3% vs 0.6%) aortic regurgitation (adjusted odds ratio for mild, moderate, or severe [no instance of severe reported] aortic regurgitation combined vs none, 4.89 [95% CI, 3.08 to 7.75]). CONCLUSIONS AND RELEVANCE Among patients aged 70 years or older with severe, symptomatic aortic stenosis and moderately increased operative risk, TAVI was noninferior to surgery with respect to all-cause mortality at 1 year. TRIAL REGISTRATION isrctn.com Identifier: ISRCTN57819173.
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Affiliation(s)
| | - William D Toff
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, England
| | - Jan Kovac
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - Michael J Mullen
- Institute of Cardiovascular Science, University College London, London, England
| | - Olaf Wendler
- Department of Cardiothoracic Surgery, King's College Hospital NHS Foundation Trust, London, England
| | - Anita Mansouri
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Ines Rombach
- Oxford Clinical Trials Research Unit, Nuffield Department of Orthopedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, England
| | - Keith R Abrams
- Centre for Health Economics, University of York, York, England
- Department of Statistics, University of Warwick, Coventry, England
- Department of Health Sciences, University of Leicester, Leicester, England
| | - Simon P Conroy
- Department of Health Sciences, University of Leicester, Leicester, England
| | - Marcus D Flather
- Norwich Medical School, University of East Anglia, Norwich, England
| | - Alastair M Gray
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England
| | - Philip MacCarthy
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, England
| | - Mark J Monaghan
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, England
| | | | - Simon Ray
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, England
| | | | | | - John G F Cleland
- Robertson Centre for Biostatistics and Glasgow Clinical Trials Unit, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland
| | - Mark A de Belder
- National Institute for Cardiovascular Outcomes Research, Barts Health NHS Trust, London, England
| | - Peter F Ludman
- Institute of Cardiovascular Sciences, Birmingham University, Birmingham, England
| | - Stephen Jones
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, England
| | - Cameron G Densem
- Department of Cardiology, Royal Papworth Hospital, Cambridge, England
| | - Steven Tsui
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, England
| | - Manoj Kuduvalli
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, England
| | - Joseph D Mills
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, England
| | - Adrian P Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Rana Sayeed
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Ragheb Hasan
- Department of Cardiothoracic Surgery, Manchester University NHS Foundation Trust, Manchester, England
| | - Douglas G W Fraser
- Department of Cardiovascular Medicine, University of Manchester, Manchester, England
| | - Uday Trivedi
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals NHS Trust, Brighton, England
| | - Simon W Davies
- Cardiac Department, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Alison Duncan
- Cardiac Department, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Nick Curzen
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, England
| | - Sunil K Ohri
- Wessex Cardiothoracic Centre, University Hospital Southampton, Southampton, England
| | | | - Pankaj Kaul
- Department of Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, England
| | - Douglas F Muir
- Department of Cardiology, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, England
| | - W Andrew Owens
- Department of Cardiothoracic Surgery, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, England
| | - Neal G Uren
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Renzo Pessotto
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, Scotland
| | - Simon Kennon
- Barts Heart Centre, Barts Health NHS Trust, London, England
| | - Wael I Awad
- Barts Heart Centre, Barts Health NHS Trust, London, England
| | - Saib S Khogali
- Heart and Lung Centre, New Cross Hospital, Wolverhampton, England
| | | | - Richard J Edwards
- Cardiothoracic Department, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, England
| | | | - Miles Dalby
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, England
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, University of Leicester, Leicester, England
- National Institute for Health Research Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, England
| | - Clinton Lloyd
- Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth, England
| | - Ian D Cox
- Department of Cardiology, Derriford Hospital, Plymouth, England
| | - Simon R Redwood
- Cardiovascular Division, King's College London, British Heart Foundation Centre of Research Excellence, Rayne Institute, St Thomas' Hospital, London, England
| | - Mark G Gunning
- Cardiology Department, Royal Stoke University Hospital, Stoke-on-Trent, England
| | - Paul D Ridley
- Department of Cardiothoracic Surgery, Royal Stoke University Hospital, Stoke-on-Trent, England
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3
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Pisaniello AD, Fraser DGW, Colville H, Hasan R. Transcatheter Aortic Valve Replacement via the Right Subclavian Artery Approach: A Case Series. Innovations (Phila) 2021; 16:188-191. [PMID: 33480304 DOI: 10.1177/1556984520984436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The right subclavian artery (RSA) approach is an infrequently used alternative-access method for transcatheter aortic valve replacement (TAVR), which may be considered when transfemoral and left subclavian artery (LSA) access routes are contraindicated. The double arterial bend encountered along the course of the RSA to the aortic root makes advancement of the TAVR delivery system more challenging, but can be overcome using a steerable delivery system over an ultra-stiff guidewire. We report 5 cases from our institution of TAVRs performed via the RSA approach in patients with severe aortic stenosis that were unsuitable for transfemoral or LSA access. The procedures were performed under general anesthesia, using a 5-cm infraclavicular incision. In each case, an Edwards Commander Delivery System was advanced through an eSheath over an Innowi guidewire, and an Edwards SAPIEN 3 valve was successfully deployed. The mean fluoroscopy time was 19.5 ± 3.8 minutes. No aortic regurgitation (AR) was present postprocedure for 4 out of 5 cases, and 1 had mild to moderate AR. The length of hospital stay was 2 to 3 days for 4 patients. All patients had an excellent outcome at 12 months post-procedure. The RSA approach is a safe and feasible access method for TAVR, and we recommend that it be considered as the next best access method if transfemoral and LSA approaches are unsuitable.
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Affiliation(s)
| | - Douglas G W Fraser
- 105551 Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
| | - Helen Colville
- 105551 Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
| | - Ragheb Hasan
- 105551 Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK
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4
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Pisaniello AD, Makki HBE, Jahangeer S, Daniels MJ, Hasan R, Fraser DGW. Low Rates of Permanent Pacing Are Observed Following Self-Expanding Transcatheter Aortic Valve Replacement Using an Annular Plane Projection for Deployment. Circ Cardiovasc Interv 2021; 14:e009258. [PMID: 33430606 PMCID: PMC7813438 DOI: 10.1161/circinterventions.120.009258] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anthony D Pisaniello
- Discipline of Medicine, The University of Adelaide, Australia (A.D.P.).,School of Medicine, Johns Hopkins University, Baltimore, MD (A.D.P.).,Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Trust, United Kingdom (A.D.P., H.B.E.M., S.J., M.J.D., R.H., D.G.W.F.)
| | - Haytham B E Makki
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Trust, United Kingdom (A.D.P., H.B.E.M., S.J., M.J.D., R.H., D.G.W.F.)
| | - Saleem Jahangeer
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Trust, United Kingdom (A.D.P., H.B.E.M., S.J., M.J.D., R.H., D.G.W.F.)
| | - Matthew J Daniels
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Trust, United Kingdom (A.D.P., H.B.E.M., S.J., M.J.D., R.H., D.G.W.F.).,Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre (M.J.D.), University of Manchester, United Kingdom.,Division of Cell Matrix Biology and Regenerative Medicine (M.J.D.), University of Manchester, United Kingdom
| | - Ragheb Hasan
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Trust, United Kingdom (A.D.P., H.B.E.M., S.J., M.J.D., R.H., D.G.W.F.)
| | - Douglas G W Fraser
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Trust, United Kingdom (A.D.P., H.B.E.M., S.J., M.J.D., R.H., D.G.W.F.)
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Ullah A, Fraser DGW, Fath-Ordoubadi F, Holt CM, Malik N. Decrease in cardiac catheterization and MI during COVID pandemic. ACTA ACUST UNITED AC 2020; 1:100001. [PMID: 34173587 PMCID: PMC7520383 DOI: 10.1016/j.ahjo.2020.100001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 09/01/2020] [Indexed: 10/30/2022]
Abstract
The consequences of severe acute viral respiratory syndrome (COVID 19) pandemic include collateral effects, one of which has been the significant reduction in routine hospital work. With widespread reports indicating reduction of cardiac procedures including MI presentation to hospitals, we aimed to analyze the local data over a 10-week period during lockdown in a tertiary cardiac centre Catheter Laboratory in England. Methods We conducted a retrospective review of the coronary catheterisation procedures and admissions with MI over the peak COVID-19 pandemic 10-week period (23rd March-30th May) in 2020, compared with the same 10-week period (25th March-2nd June) in 2019. Results In 2019, 539 patients were admitted to the Cath lab for coronary catheterisation (M = 385:F = 154; mean age 65 years; STEMI = 186, NSTEMI = 192, elective = 161). In 2020, during peak period of COVID19 pandemic in England, a total of 278 patients were admitted for coronary catheterisation over the 10-week period (M = 201:F = 77; mean age 60.5 years; STEMI = 132, NSTEMI = 118, elective = 28). During peak COVID19 pandemic, this represents a 48.4% drop in all coronary catheterisations. The reduction in STEMI was 29% (54 less), in NSTEMI was 38.9% (74 less) and elective procedures dropped by 83% (133 less). Conclusion During peak COVID hospital admission period in England, we report a 48.5% reduction in coronary catheterisation in our tertiary hospital. These results are consistent with reports from other countries, and highlight the worrying potential consequences for these patients arising from delays in presentation with MI, and the challenges for restoring services post-pandemic.
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Affiliation(s)
- A Ullah
- Manchester Heart Centre, Purple Zone 1st Floor, Manchester Foundation Trust, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - D G W Fraser
- Manchester Heart Centre, Purple Zone 1st Floor, Manchester Foundation Trust, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Core Technology Facility, 46 Grafton Street, Manchester M13 9NT, UK
| | - F Fath-Ordoubadi
- Manchester Heart Centre, Purple Zone 1st Floor, Manchester Foundation Trust, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - C M Holt
- Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Core Technology Facility, 46 Grafton Street, Manchester M13 9NT, UK
| | - N Malik
- Manchester Heart Centre, Purple Zone 1st Floor, Manchester Foundation Trust, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Core Technology Facility, 46 Grafton Street, Manchester M13 9NT, UK
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6
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Dowling C, Firoozi S, Panoulas V, Dalby M, Kashyap MN, Kabir T, Kalogeras K, Buch MH, Levy R, Chowdhary S, Saraf S, Roberts D, More R, Wiper A, Abdelaziz HK, Neylon A, Mylotte D, Pisaniello AD, Fraser DGW, Anderson R, Cunnington MS, Malkin CJ, Blackman DJ, Brennan PF, Owens CG, Manoharan G, Spence MS, Brecker SJ. Initial experience of a self-expanding transcatheter aortic valve with an outer pericardial wrap: The United Kingdom and Ireland Implanters' registry. Catheter Cardiovasc Interv 2019; 95:1340-1346. [PMID: 31713325 DOI: 10.1002/ccd.28512] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/12/2019] [Accepted: 09/16/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES The United Kingdom and Ireland Implanters' registry is a multicenter registry which reports on real-world experience with new transcatheter heart valves. BACKGROUND The Evolut PRO (Medtronic, Minneapolis, MN) transcatheter aortic valve is a self-expanding transcatheter aortic valve with an outer pericardial wrap, designed to minimize paravalvular regurgitation. METHODS Between July 2017 and December 2018, clinical, procedural, and 30-day outcome data were prospectively collected from all patients receiving the Evolut PRO valve across nine participating centers in the United Kingdom and Ireland. The primary efficacy outcome was the Valve Academic Research Consortium-2 (VARC-2)-defined endpoint of device success. The primary safety outcome was the VARC-2-defined composite endpoint of early safety at 30 days. RESULTS A total of 317 patients underwent implantation. Mean age was 81.8 ± 6.4 years and Society of Thoracic Surgeons Predicted Risk of Mortality Score 5.5 ± 1.8%. Iliofemoral access was used in 99.1% of patients. Device success was 91.2%. Mean gradient was 7.6 ± 4.7 mmHg and effective orifice area 1.9 ± 0.7 cm2 . The incidence of moderate paravalvular regurgitation was 1.7% and there was no severe paravalvular regurgitation. A new permanent pacemaker was implanted in 17.8% of patients without a pacemaker at baseline. Early safety was demonstrated in 92.7%. At 30 days, all-cause mortality was 0.6%, stroke 3.8%, and major vascular complication 2.8%. CONCLUSIONS Real-world experience of the Evolut PRO transcatheter aortic valve demonstrated favorable procedural success, safety, valve function, and incidence of new permanent pacemaker implantation.
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Affiliation(s)
- Cameron Dowling
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's Hospital, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Sami Firoozi
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's Hospital, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Vasileios Panoulas
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Miles Dalby
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Mavin N Kashyap
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Tito Kabir
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Konstantinos Kalogeras
- Department of Cardiology, Harefield Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Mamta H Buch
- North West Cardiac Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Richard Levy
- North West Cardiac Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Saqib Chowdhary
- North West Cardiac Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Smriti Saraf
- North West Cardiac Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK.,Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Roberts
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Ranjit More
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Andrew Wiper
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Hesham K Abdelaziz
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK.,Cardiovascular Department, Ain Shams University, Cairo, Egypt
| | - Antoinette Neylon
- Department of Cardiology, University Hospital Galway, Galway University Hospitals, Galway, Ireland
| | - Darren Mylotte
- Department of Cardiology, University Hospital Galway, Galway University Hospitals, Galway, Ireland
| | - Anthony D Pisaniello
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Douglas G W Fraser
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Richard Anderson
- Department of Cardiology, University Hospital of Wales, Cardiff and Vale University Health Board, Cardiff, UK
| | - Michael S Cunnington
- Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher J Malkin
- Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Daniel J Blackman
- Department of Cardiology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul F Brennan
- Belfast Heart Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Colum G Owens
- Belfast Heart Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Ganesh Manoharan
- Belfast Heart Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Mark S Spence
- Belfast Heart Centre, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Stephen J Brecker
- Cardiology Clinical Academic Group, St. George's, University of London and St. George's Hospital, St. George's University Hospitals NHS Foundation Trust, London, UK
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Choudhury TR, Al-Saigh S, Burley S, Li L, Shakhshir N, Mirhosseini N, Wang T, Arnous S, Khan MA, Mamas MA, Fraser DGW. Longitudinal deformation bench testing using a coronary artery model: a new standard? Open Heart 2017; 4:e000537. [PMID: 29226914 PMCID: PMC5708317 DOI: 10.1136/openhrt-2016-000537] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/15/2017] [Accepted: 06/13/2017] [Indexed: 11/03/2022] Open
Abstract
Objectives To compare susceptibility of five different stent platforms with longitudinal stent deformation (LSD) using a clinically relevant bench testing model simulating both short and long malapposed lengths. Background Recent data suggest that design modifications to the Promus Element stent which led to the Promus Premier stent has reduced susceptibility to LSD. However, susceptibility to LSD at long malapposed lengths has not been tested. Furthermore, the mechanisms behind susceptibility to LSD are as yet unclear. Methods The Omega, Integrity, Multilink 8, Biomatrixand Promus Premier stent platforms were tested. The Omega, Integrity and Multilink 8 platforms were used in place of their drug-eluting equivalents. 3.5 mm stents were deployed in a stepped tube with the distal portion fixed and the proximal test section exposed. The force required to compress stents by a fixed distance at different exposed lengths was compared. Symmetrical and point loading were used. Results The Promus Premier was longitudinally as strong as Multilink and Integrity at a short exposed length (4 mm) but weaker, in between Omega and the other platforms, at longer exposed lengths (12 mm). As previously noted, the Omega (Promus Element) platform was significantly weaker than the other stents and Biomatrix was the strongest stent. Conclusion Susceptibility to LSD varies depending on length of malapposed segment when tested using a clinically relevant model as in this study. The mechanisms behind the susceptibility are likely multifactorial, including connector number, strut thickness, connector alignment and ring orientation but remain to be elucidated.
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Affiliation(s)
| | - Salwan Al-Saigh
- School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, UK.,College of Engineering, University of Mosul, Mosul, Iraq
| | - Steve Burley
- School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, UK
| | - Lin Li
- School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, UK
| | - Nizar Shakhshir
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester, UK
| | - Nazanin Mirhosseini
- Faculty of Medical and Human sciences, University of Manchester, Manchester, UK
| | - Tao Wang
- Institute of Human Development, University of Manchester, Manchester, UK
| | - Samer Arnous
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester, UK
| | - Muhammad A Khan
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester, UK
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, UK
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Luckie MJ, Khattar RS, Fraser DGW. The authors' reply:. Heart 2009. [DOI: 10.1136/hrt.2009.176289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Fraser DGW, Moody AR, Morgan PS, Martel A. Iliac compression syndrome and recanalization of femoropopliteal and iliac venous thrombosis: a prospective study with magnetic resonance venography. J Vasc Surg 2004; 40:612-9. [PMID: 15472585 DOI: 10.1016/j.jvs.2004.05.029] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Poor iliac vein recanalization has been associated with compression of the left common iliac vein by the right common iliac artery (RCIA/LCIV compression); however, this finding has been difficult to confirm. In a baseline study, RCIA/LCIV compression was detected with magnetic resonance imaging in patients with deep venous thrombosis. We compared recanalization of left femoropopliteal and iliac thrombosis with and without RCIA/LCIV compression. METHODS This was a prospective blinded study carried out in a 1355-bed university hospital. Thirty-one patients were recruited from consecutive cohorts of patients with iliofemoral and femoropopliteal DVT who underwent direct thrombus magnetic resonance imaging, venous enhanced peak arterial magnetic resonance venography, and magnetic resonance arteriography as part of the baseline study relating RCIA/LCIV compression to extent of thrombosis. Magnetic resonance venography was performed 6 weeks, 6 months, and 1 year after diagnosis of deep venous thrombosis. Femoropopliteal and iliac venous segments that were occluded at diagnosis were classified as occluded, partially occluded, or patent on follow-up scans. RESULTS At 6-week follow-up, recanalization of all segments was incomplete. At both 6-month and 1-year follow-up, recanalization of left iliac segments associated with RCIA/LCIV compression was poorer compared with recanalization of left iliac segments not associated with compression (6 of 6 occluded vs 1 of 6 occluded and 1 of 6 partially occluded at 6 months, P =.015; 6 of 6 occluded vs 5 of 5 patent at 1 year, P = .002). This was due to complete failure of recanalization of left common iliac veins associated with RCIA/LCIV compression in 6 of 6 cases. All other iliac and femoropopliteal segments including left external iliac veins associated with RCIA/LCIV compression had high rates of recanalization at both 6 months and 1 year. CONCLUSION RCIA/LCIV compression is associated with persistent occlusion of the left common iliac vein. The recanalization rate for all other femoropopliteal and iliac segments was high.
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Fraser DGW, Moody AR, Martel A, Morgan PS. Re-evaluation of iliac compression syndrome using magnetic resonance imaging in patients with acute deep venous thromboses. J Vasc Surg 2004; 40:604-11. [PMID: 15472584 DOI: 10.1016/j.jvs.2004.07.039] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The majority of proximal deep venous thromboses (DVTs) are thought to have propagated as a contiguous column from the calf veins. However, several authors have proposed that ileofemoral DVT commonly originates in the left common iliac vein (LCIV) at a site of compression by the overlying right common iliac artery (RCIA/LCIV compression). This mechanism could explain both the left-sided predominance of ileofemoral DVT and the finding that ileofemoral DVT frequently occurs either in the absence of calf vein thrombosis (isolated ileofemoral DVT) or is not contiguous with calf vein thrombosis (noncontiguous ileofemoral DVT). This mechanism remains unconfirmed. OBJECTIVES The purpose of this study was to detect RCIA/LCIV compression using multimodal magnetic resonance imaging in thrombosed and patent iliac veins, to determine whether RCIA/LCIV compression occurs more frequently in cases of left ileofemoral DVT than other types of DVT, and to determine if RCIA/LCIV compression is specifically associated with left isolated and noncontiguous ileofemoral DVT. PATIENTS AND METHODS This prospective study conducted at the 1355-bed University Hospital included 18 patients with ileofemoral DVT, 23 with femoropopliteal DVT, 15 with isolated calf DVT recruited consecutively, and 28 control patients in whom DVT had been excluded. Interventions included magnetic resonance direct thrombus imaging (MRDTI), venous enhanced peak arterial magnetic resonance venography (VESPA) and magnetic resonance arteriography (MRA) within 48 hours of routine conventional venography (CV). RCIA/LCIV compression of patent LCIVs was assessed using VESPA and MRA; RCIA/LCIV compression of thrombosed LCIVs was assessed using MRDTI and MRA. The extent of calf and popliteal thrombosis was detected using CV; the extent of femoral and iliac thrombosis was detected using VESPA and MRDTI. RESULTS RCIA/LCIV compression was more commonly detected in cases of left ileofemoral DVT (9/16 cases) than in cases of left femoropopliteal DVT (1/11 cases; P = .018), right femoropopliteal DVT (2/12 cases; P = .054), left isolated calf DVT (1/9 cases; P = .037), right isolated calf DVT (0/6 cases; P = .046) and control patients (4/28 cases; P = .006). RCIA/LCIV compression was more commonly detected in cases of left isolated ileofemoral DVT (6/6 cases; P = .005), and cases of left noncontiguous ileofemoral DVT (2/2 cases; P = .067) than in cases in which thrombosis was contiguous from the calf to the iliac veins (1/8 cases). CONCLUSION RCIA/LCIV compression was strongly associated with left ileofemoral DVT and was specifically associated with cases that involve independent ileofemoral thrombosis.
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Fraser DGW, Moody AR, Davidson IR, Martel AL, Morgan PS. Deep venous thrombosis: diagnosis by using venous enhanced subtracted peak arterial MR venography versus conventional venography. Radiology 2003; 226:812-20. [PMID: 12601180 DOI: 10.1148/radiol.2263012205] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess diagnostic accuracy and interobserver variability at venous enhanced subtracted peak arterial (VESPA) magnetic resonance (MR) venography compared with those at conventional venography for the diagnosis of femoral and iliac deep venous thrombosis (DVT). MATERIALS AND METHODS A single anteroposterior maximum intensity projection (MIP) venogram of the femoral and iliac veins was constructed by using VESPA MR venography in 55 symptomatic patients suspected of having lower limb DVT. All patients also underwent conventional venography, results of which were used as the standard of reference. VESPA MR venograms were interpreted by two independent reviewers (reviewers A and B) who were unaware of other results. Sensitivity and specificity of VESPA MR venography for the diagnosis of thrombus in the femoral and iliac veins were calculated. Interobserver variability was calculated for these observations by using weighted kappa with equally spaced weights for positive, nondiagnostic, and negative studies. Nondiagnostic studies were reinterpreted separately by reviewer A on the basis of source data. RESULTS Sensitivity of VESPA MR venography for the femoral veins (20 of 20) and iliac veins (seven of seven) was 100% for both reviewers. Specificity was 100% (39 of 39 for reviewer A, 40 of 40 for reviewer B) for the iliac veins and 97% (31 of 32) for the femoral veins for both reviewers. Segments in which the VESPA MR venograms were nondiagnostic were excluded from this analysis. Interobserver variability as calculated by using weighted kappa for positive, negative, and nondiagnostic studies was 0.85 for femoral veins and 0.97 for iliac veins. Interpretation of the source data led to correct diagnosis in six of six cases in which the VESPA MR venograms were nondiagnostic. CONCLUSION VESPA MR venography yielded MIP venograms that were highly accurate for the diagnosis of DVT in femoral and iliac veins. Interpretation of the studies was also highly reproducible.
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Affiliation(s)
- Douglas G W Fraser
- Department of Academic Radiology, Queen's Medical Centre, Nottingham, England
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Fraser DGW, Moody AR, Morgan PS, Martel AL, Davidson I. Diagnosis of lower-limb deep venous thrombosis: a prospective blinded study of magnetic resonance direct thrombus imaging. Ann Intern Med 2002; 136:89-98. [PMID: 11790060 DOI: 10.7326/0003-4819-136-2-200201150-00006] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Current magnetic resonance techniques generate high signal from venous blood and show thrombi as filling defects. Magnetic resonance direct thrombus imaging (MRDTI) directly visualizes acute thrombus. OBJECTIVE To determine the accuracy of MRDTI for diagnosis of acute symptomatic deep venous thrombosis (DVT) below and above the knee. DESIGN Prospective, blinded study. SETTING A 1355-bed university hospital. PATIENTS 101 patients with suspected DVT who had had routine venography. Participants were recruited from a cohort of patients with suspected DVT. All patients with a positive venogram and one quarter of patients with a negative venogram were selected by using a random sequence. INTERVENTION MRDTI was performed within 48 hours of venography and was interpreted by two reviewers. MEASUREMENTS Diagnosis of DVT overall; isolated calf, femoropopliteal, and ileofemoral DVT; and thrombus in the calf, femoropopliteal, and iliac segments. RESULTS The reports from two readers had sensitivities of 96% and 94% and specificities of 90% and 92% for diagnosis of DVT. Sensitivities were 92% and 83% for isolated calf DVT, 97% and 97% for femoropopliteal DVT, and 100% and 100% for ileofemoral DVT. Specificities were 94% and 96% for isolated calf DVT and 100% and 100% for both femoropopliteal and ileofemoral DVT. Similarly, sensitivity and specificity within each of the venous segments ranged from 91% to 100%. Interobserver variability measured by using a weighted kappa statistic ranged from 0.89 to 0.98 for these measures. CONCLUSION Magnetic resonance direct thrombus imaging is an accurate noninvasive test for diagnosis of DVT, and its accuracy is maintained below the knee. Comparison of individual venous segments showed that results of MRDTI agreed strongly with findings on venography. Scanning was well tolerated, and interpretation was highly reproducible.
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Affiliation(s)
- Douglas G W Fraser
- Department of Academic Radiology, University Hospital, Derby Road, Nottingham NG7 2UH, United Kingdom
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