Preoperative evaluation of pulmonary hypertension in lung transplant candidates: echocardiography versus right heart catheterization

Background

Right heart catheterization (RHC) and echocardiography are both routinely used for pulmonary hypertension (PH) assessment in LT candidates, although this is not mandatory according to guidelines. We aim to describe the correlation between the pulmonary artery systolic pressure (PASP) measured by echocardiography to that measured by RHC in this population.

Methods

From a retrospective registry of 461 LT candidates, undergoing RHC between 2015–2019, 393 consecutive patients were assessed for the presence of pulmonary hypertension according to two methods – echocardiography and RHC. The primary outcome was the correlation between the estimated PASP measured by echocardiography to that measured by RHC. Secondary outcome was the accuracy of the echocardiographic assessment of PH.

Results

Patients were predominantly males (63.6%) with a mean age of 61.46±8.33y. The two most common etiologies for lung failure were interstitial lung disease or pulmonary fibrosis (52.2%) and chronic obstructive pulmonary disease (30.5%). Estimated PASP as measured by echocardiography was available in 89.31% of the patients, with a mean value of 49.5±20.02 mmHg. Mean PASP measured by RHC was 42.47±17.96 mmHg. The correlation between the two measurements was moderate (Pearson's correlation: r=0.609, p<0.01). The accuracy of the echocardiographic estimation of PASP was poor with >10 mmHg differences between the two values in 79.9% of the patients.

Conclusions

In the pre-surgical evaluation of LT candidates, echocardiographic estimation of PASP has moderate correlation with the PASP measured by RHC and relatively poor accuracy.

Funding Acknowledgement

Type of funding sources: None.

Serum Cardiac Troponin I in the Evaluation of Nonaccidental Trauma

OBJECTIVE

To determine if troponin I is more often elevated in children with suspected nonaccidental trauma (NAT) compared with uninjured children of similar age, and describe associations between troponin I elevation and NAT injuries.

STUDY DESIGN

Prospective 2-group study of children less than 2 years of age presenting to the emergency department with nonaccidental abdominal, thoracic, or intracranial injuries, and similarly aged uninjured children. Primary outcome was serum troponin I (≥ 0.04 ng/mL) using frozen blood samples from the 2 groups. Secondary outcomes included descriptive analyses of age, injury characteristics, and clinical appearance.

RESULTS

There were 129 subjects; 60 injured patients and 69 uninjured patients. Groups had similar age and sex. Troponin I was elevated in 38% of injured children compared with 17% of uninjured children (P = .008). No uninjured patient over 3 months of age had elevated troponin I. Abdominal trauma, acute rib fractures, or the child's ill-appearance in the emergency department were associated with having elevated troponin I.

CONCLUSIONS

Troponin I is more often elevated in children with suspected NAT than uninjured children. Elevation of troponin I in children greater than 3 months of age with suspected NAT is concerning for trauma. Occult cardiac injury is more likely to occur in children with inflicted abdominal trauma, acute rib fractures, or ill appearance.

Sudden cardiac death caused by native aortic valve thrombosis in an adult patient with a complex congenital cyanotic heart disease

Cyanotic congenital heart disease is associated with an increased risk of thromboembolism. We describe the case of sudden cardiac death caused by native aortic valve thrombosis in adult cyanotic patient. Such embolic complication was not previously described in cyanotic patient. It is also the first report of sudden cardiac death as an initial presentation of the native aortic valve thrombosis. Cyanotic congenital heart disease (CCHD) is associated with an increased risk of thromboembolism due to different haemathologic abnormalities associated with hypoxemia and secondary polycythemia [H. Kajimoto, M. Nakazawa, K. Murasaki, et al. Increased thrombogenesity in patients with cyanotic congenital heart disease. Circ J Jun 2007;71(6):948-953]. Cerebrovascular events, venous and arterial thrombosis have been described in patients with CCHD [N. Ammash, C.A. Warnes. Cerebrovascular events in adult patients with cyanotic congenital heart disease. J Am Coll Cardiol Sep 1996;28(3):768-772]. We present a case of the native aortic valve thrombosis in an adult patient with a complex cyanotic congenital heart lesion which led to sudden death.

Revisiting animal models of aortic stenosis in the early gestation fetus

BACKGROUND

Mechanisms leading to left ventricular hypoplasia and endocardial fibroelastosis in the fetus remain unknown. Prevailing theory is that obstruction to blood flow through the left ventricle leads to elevated end-diastolic pressures, compromised myocardial perfusion, and endocardial ischemia. Fetal interventions are now being performed, based on the presumption that they would prevent such pathogenic mechanisms.

METHODS

Forty first-trimester fetal sheep (mean gestational age, 53 days) were studied. Severe fetal left ventricular outflow obstruction was created by banding the ascending aorta in 25 fetuses; 15 control fetuses underwent "sham" surgery with thoracotomy. Serial fetal echocardiography was used to assess left ventricular growth and fetal hemodynamics. Findings were correlated to morphologic and histopathologic changes, and intracardiac pressure measurements obtained from fetal cardiac catheterization.

RESULTS

Surviving banded fetuses (n = 13) had one of two phenotypes: compensatory left ventricular hypertrophy (n = 7) or noncompensatory left ventricular dilatation (n = 6) with hydrops and severe left ventricular dysfunction. All fetuses had elevated left ventricular end-diastolic pressures (mean, 21 mm Hg; range, 14 to 28 mm Hg), which correlated to the gradient across the ascending aorta (mean, 41 mm Hg; range, 28 to 73 mm Hg). In vivo echocardiography findings were incongruous with those at autopsy, and demonstrated preservation of left ventricular growth indices in all fetuses. Endocardial fibroelastosis and myocardial fibrosis were not observed in any banded fetus.

CONCLUSIONS

While early gestational obstruction to flow can compromise left ventricular function in the fetus, it does not retard normal growth. Similarly, an elevated left ventricular end-diastolic pressure is not sufficient to cause myocardial fibrosis or endocardial fibroelastosis in the fetus.

The risk for congenital heart defects in offspring of individuals with congenital heart defects

BACKGROUND

Congenital heart defects (CHDs) occur in approximately 1% of all live births. Although most CHDs are of unknown etiology, a family history of CHDs is a known risk factor, and offspring of individuals with CHDs are at a higher risk of having CHDs. The aim of this study was to investigate the relative risk for CHDs to offspring of individuals with CHDs.

METHODS

The prevalence rates of CHDs in offspring of 203 individuals with CHDs and 282 individuals without CHDs were investigated. The study participants completed a questionnaire that included information on medical and reproductive history, lifestyle indicators, and family history of CHDs and other congenital malformations. The prevalence rates of CHDs in offspring were calculated.

RESULTS

The prevalence of CHDs was 3.1% (18/575) in offspring of individuals with CHDs and 1.3% (8/589) in offspring of individuals without CHDs. The adjusted odds ratio for CHDs to offspring of parents with CHDs was 1.73 (95% confidence interval [95% CI] 0.89-2.44, p=0.02). The estimated relative risk for offspring to females with CHD was higher than for males [2.3 (95% CI 1.1-4.7, p=0.03) versus 1.31 (95% CI 0.48-4.30, p=0.66), respectively]. There was no suggestion of association between CHDs and maternal smoking, alcohol consumption, and use of medication during pregnancy.

CONCLUSIONS

Offspring of parents with CHDs are at a higher risk for CHDs compared with the general population. Couples where one member is affected with CHD should receive pre-conceptional or pre-natal genetic counseling and should be informed about the magnitude of the potential risk of CHDs to the offspring.

Continuous rt-PA infusion as a salvage strategy to maintain patency of the infarct artery; safety of high cumulative dose and subsequent emergency coronary artery angioplasty and bypass surgery

Acute re-occlusion of an infarct artery reperfusion attained by thrombolytic therapy may be treated by emergency coronary angioplasty or bypass surgery. Repeated infusion of a thrombolytic agent is an additional treatment strategy. Three patients with reinfarctions that occurred very early after successful reperfusion were treated with continuous infusion of recombinant tissue-type plasminogen activator (rt-PA). These patients received a rt-PA dose of 300-360 mg while they awaited emergency mechanical revascularization procedures. Two patients had coronary angioplasty immediately after receiving repeated infusions of rt-PA and one underwent coronary bypass surgery while receiving a third rt-PA infusion. There were no bleeding complications in the 2 patients who underwent coronary angioplasty, and no excessive bleeding in the patient who received coronary bypass surgery. Thus, repeated continuous rt-PA infusions can be used to maintain the patency of recurrently occluding infarct arteries until definitive mechanical revascularization can be performed.

Differential effects of fornix and caudate nucleus lesions on two radial maze tasks: evidence for multiple memory systems

The present experiments were designed to examine the hypothesis that the mammalian brain contains anatomically distinct memory systems. Rats with bilateral lesions of caudate nucleus or fimbria-fornix and a control group were tested postoperatively on 1 of 2 versions of the radial maze task. In a standard win-shift version, each of the 8 arms of the maze was baited once, and the number of errors (revisits) in the first 8 choices of each trial was recorded. Fimbria-fornix rats were impaired in choice accuracy, while caudate animals were unimpaired relative to controls. Different groups of rats with similar lesions were tested on a newly developed win-stay version of the radial maze, in which the location of 4 randomly selected baited arms was signaled by a light at the entrance to each arm, and which required rats to revisit arms in which reinforcement had been previously acquired within a trial. Rats with fimbria-fornix lesions were superior to controls in choice accuracy on the win-stay radial maze task, while caudate animals were impaired relative to controls. The results demonstrate a double dissociation of the mnemonic functions of the hippocampus and caudate nucleus. Some implications of the presence of 2 memory systems in the mammalian brain are discussed.

Lissauer form of paretic neurosyphilis with a cerebral mass lesion

A 40-year-old male patient with progressive dementia presented adversive seizures, and CT scan showed an enlarging focal mass lesion in the right cerebral hemisphere. Cerebrospinal fluid examination and brain biopsy confirmed the diagnosis of neurosyphilis. After a course of penicillin therapy there was disappearance of the cerebral mass lesion and the CT scan showed focal atrophy in the right cerebral hemisphere. This case suggests that Lissauer form of paretic neurosyphilis may present as a focal mass lesion.

The effect of the spacing of background elements upon optomotor memory responses in the crab: the influence of adding or deleting features during darkness

1. Study was made of the effect of separation between stripes in the visual field upon responses which indicate memory of those stripes. 2. The amount of separation between white stripes had very little effect, whereas response strength and the amount of separation between black stripes were directly proportional. 3. The presence of extra, non-displaced black stripes prior to or following displacement reduced the size of the memory responses. 4. The effects of the amount of separation in the two cases were comparable. In both situations the separation affected only the responses to displacement of the stripe borders nearest to the extra stripe. 5. The effect of extra stripes present prior to displacement was in turn affected by the duration of the dark period, whilst the effect of those present during the post-displacement period was not. This accounts for the larger effect of extra stripes present during the psot-displacement period. 6. By expanding stripe width during darkness it was possible to distinguish between the effects of distance between stripes and the amount of white space separating them. Reducing white space while distance remains constant causes reductions in response strength, whereas reducing the distance between a memory zone and the white space between it and the neighboring stripe increased the size of the memory response.

On the organization of memeory in the optomotor system of the crab Pachygrapsus crassipes

Memory responses of the optomotor system to rotations of various stripe patterns were studied. The separate elements of the visual background are individually remembered in terms of the parts of the eye on which their images fell. A visual illusion resulting from this property is described. All parts of the retina have an equal capacity to contribute to memory. The memory response results from the summation of contributions from individual elements rather than the maintenance of a fixation upon any particular feature of the situation. Both the separation between background elements for angles from 6 degrees up to 60 degrees and the number of elements present affect the size of the memory evoked response.

Form discrimination performance of linguistically retarded children

Intra- and intermodal form-discrimination performance was studied in 9 linguistically retarded children. Stimuli were the blocks which comprise the Seguin Form Board. The main findings were that haptic intramodal discriminations were the most difficult of the various conditions and that visual-haptic intermodal discriminations were not significantly more difficult than visual intramodal ones. The first finding may be in part an artifact of simultaneous versus successive stimulation. The second finding was discussed in relation to dissimilar findings from previous studies of various other retarded groups. Methodological problems inherent in previous designs were described, and reasons for the disparity in experimental results were suggested.