50岁以上瓣膜性心脏病冠脉造影分析

目的探讨老年瓣膜性心脏病合并冠心病的情况。方法96例50岁以上瓣膜性心脏病住院患者,其中男性38例,女性58例,常规予Judkins法经股动脉或桡动脉行冠脉造影。并结合冠心病的危险因素、瓣膜病的病因、病变部位进行多因素分析。结果96例瓣膜性心脏病患者合并冠心病11例,总发生率11.5%。其中风湿性瓣膜性心脏病82例,合并冠心病7例,发生率8.5%,非风湿性瓣膜性心脏病14例,合并冠心病4例,发生率28.5%,两组相比P<0.05。多危险因素组46例,合并冠心病9例,发生率19.6%,少危险因素组50例,合并冠心病2例,发生率4%,两组相比P<0.05。主动脉瓣病变者合并冠心病2例,二尖瓣病变者合并冠心病3例,联合瓣膜病变者合并冠心病5例,各组相比P>0.05。结论瓣膜性心脏病合并冠心病发生率不高且合并冠心病者多为非风湿性病因,其中危险因素组冠心病发生率较高,不同瓣膜病变在合并冠心病发病率上无显著性差异。     

Coronary Access Following Redo TAVR: Impact of THV Design,Implant Technique,and Cell Misalignment

BackgroundThe implications and potential challenges of coronary access after redo transcatheter aortic valve replacement (TAVR) are unknown.ObjectivesThe authors sought to evaluate the impact of different transcatheter heart valve (THV) designs, neoskirt height, implant technique, and cell misalignment on coronary access after redo TAVR.MethodsDifferent THV designs (Sapien 3 [Edwards Lifesciences LLC], Evolut Pro [Medtronic], ACURATE neo [Boston Scientific Corporation], and Portico [Abbott Structural Heart]) and sizes were implanted inside Sapien XT (Edwards Lifesciences LLC) and Evolut R (Medtronic) THVs, which were modeled as the “failed” THVs, at different implant depths. Valve combinations underwent micro–computed tomography to determine the neoskirt height and dimensions of the lowest accessible cell for potential coronary access. This was compared with dimensions of 6-F/7-F/8-F coronary guiding catheters.ResultsRedo TAVR combinations resulted in a wide range of neoskirt heights (15.4-31.6 mm) and a variable diameter of the lowest accessible cell (1.9-21.8 mm). An ACURATE neo implanted in a Sapien XT resulted in the largest accessible cells, whereas a Portico implanted in a Sapien XT resulted in the lowest neoskirt heights. The smallest accessible cell was observed in the Evolut Pro–in–Evolut R configuration with higher neoskirt heights. Redo TAVR in a tall frame valve with supra-annular leaflets caused a taller neoskirt height. In Evolut-in-Evolut combinations, misalignment of the cells of the 2 THVs reduced the cell area by 30% to 50% compared with an aligned configuration.ConclusionsThis study demonstrates that different redo TAVR combinations are not equivalent in terms of future coronary access. Redo TAVR using a tall frame valve in a failed tall frame valve and misaligned cells may lead to potentially challenging coronary access.     

A seven-year study on an integrated hospital-community diabetes management program in Chinese patients with diabetes

Aims

To assess whether an integrated hospital-community diabetes management program could improve major cardiovascular risk factor control among patients with diabetes in real-world clinical settings.

Predictors and Clinical Impact of Prosthesis-Patient Mismatch After Self-Expandable TAVR in Small Annuli

ObjectivesThe aim of this study was to define predictors of prosthesis-patient mismatch (PPM) and its impact on mortality after transcatheter aortic valve replacement (TAVR) with self-expandable valves (SEVs) in patients with small annuli.BackgroundTAVR seems to reduce the risk for PPM compared with surgical aortic valve replacement, especially in patients with small aortic annuli. Nevertheless, predictors and impact of PPM in this population have not been clarified yet.MethodsPredictors of PPM and all-cause mortality were investigated using multivariable logistic regression analysis from the cohort of the TAVI-SMALL (International Multicenter Registry to Evaluate the Performance of Self-Expandable Valves in Small Aortic Annuli) registry, which included patients with severe aortic stenosis and small annuli (annular perimeter <72 mm or area <400 mm² on computed tomography) treated with transcatheter SEVs: 445 patients with (n = 129) and without (n = 316) PPM were enrolled.ResultsIntra-annular valves conferred increased risk for PPM (odds ratio [OR]: 2.36; 95% confidence interval [CI]: 1.16 to 4.81), while post-dilation (OR: 0.46; 95% CI: 0.25–0.84) and valve oversizing (OR: 0.53; 95% CI: 0.28–1.00) seemed to protect against PPM occurrence. At a median follow-up of 354 days, patients with severe PPM, but not those with moderate PPM, had a higher all-cause mortality rate compared with those without PPM (log-rank p = 0.008). Multivariable Cox regression confirmed severe PPM as an independent predictor of all-cause mortality (hazard ratio: 4.27; 95% CI: 1.34 to 13.6).ConclusionsAmong patients with aortic stenosis and small aortic annuli undergoing transcatheter SEV implantation, use of intra-annular valves yielded higher risk for PPM; conversely, post-dilation and valve oversizing protected against PPM occurrence. Severe PPM was independently associated with all-cause mortality.     

Transcatheter Aortic Valve Replacement in Patients With Multivalvular Heart Disease

As transcatheter aortic valve replacement becomes a more dominant treatment option across all risk profiles, the frequency of encountering patients with multivalvular disease will increase. Furthermore, percutaneous interventions to treat other valvular lesions are also evolving. Understanding the clinical implications and treatment options for a second valvular lesion is becoming increasingly important to guide heart team decisions, and this paper aims to review the evidence around these situations. Diagnosis of multivalvular disease can be challenging because of changes in physiology. There are little randomized data to guide therapy in multivalvular disease. Multidisciplinary heart team decisions can be invaluable in integrating the plethora of clinical, hemodynamic, and imaging data on which an optimal management strategy can be planned. Prospective studies to assess the role of structural valve interventions in the transcatheter aortic valve replacement era would greatly help improve outcomes for structural heart patients.     

强直性脊柱炎髋关节异常的CT检查

目的：总结分析强直性脊柱炎(AS)髋关节异常在CT上的表现特点。方法：对21例有髋部症状的As病人进行了髋关节CT轴位3mm层厚连续扫描。结果:全部病例都出现髋关节间隙变窄，按放射学指数(BASR)-hip分级，69％(29／42)的关节有3、4级的较严重改变；其他改变有关节软骨下囊性变(90.5％)，股骨颈特征性的“衣领样”骨质增生改变、骨质疏松、关节囊肿胀等。结论:AS的髋关节异常在CT上有一定的特征性表现，结合同时有骶髂关节改变，可取得正确诊断。     

Cardiac Involvement in Fabry Disease: JACC Review Topic of the Week

Fabry disease (FD) is a rare X-linked inherited lysosomal storage disorder caused by deficient α-galactosidase A activity that leads to an accumulation of globotriasylceramide (Gb3) in affected tissues, including the heart. Cardiovascular involvement usually manifests as left ventricular hypertrophy, myocardial fibrosis, heart failure, and arrhythmias, which limit quality of life and represent the most common causes of death. Following the introduction of enzyme replacement therapy, early diagnosis and treatment have become essential to slow disease progression and prevent major cardiac complications. Recent advances in the understanding of FD pathophysiology suggest that in addition to Gb3 accumulation, other mechanisms contribute to the development of Fabry cardiomyopathy. Progress in imaging techniques have improved diagnosis and staging of FD-related cardiac disease, suggesting a central role for myocardial inflammation and setting the stage for further research. In addition, with the recent approval of oral chaperone therapy and new treatment developments, the FD-specific treatment landscape is rapidly evolving.     

Multiphase Assessment of Mitral Annular Dynamics in Consecutive Patients With Significant Mitral Valve Disease

ObjectivesThe aim of this study was to clarify the dynamics of the mitral annulus throughout the cardiac cycle and its relevance to transcatheter mitral valve replacement (TMVR) sizing and case selection.BackgroundLimited data are available regarding the relevance of mitral annular (MA) and neo–left ventricular outflow tract (LVOT) dynamics in the overall population presenting with significant mitral valve disease.MethodsPatients attending a combined surgical-transcatheter heart valve clinic for severe symptomatic mitral valve disease were assessed using multiphase computed tomography. The relative influence of MA and neo-LVOT dynamics to TMVR case selection was studied.ResultsA total of 476 patients with significant mitral valve disease were evaluated. In 99 consecutive patients with severe mitral regurgitation, a 10-phase assessment showed that the mitral annulus was on average largest in late systole. On comparing maximal MA dimension with late systolic dimension, TMVR size assignment changed in 24.2% of patients. If the average MA perimeter was used to determine sizing, 48.5% were excluded because of MA dimension being too large; in a multiphase assessment of the neo-LVOT, an additional 16.2% were excluded on the basis of neo-LVOT dimension. In an expanded series of 312 consecutive patients, selection protocol influenced anatomical exclusion: a manufacturer-proposed early systolic approach excluded 69.2% of patients, whereas a late systolic approach excluded 82.7% of patients, the vast majority because of large mitral annuli.ConclusionsContemporary TMVR can treat only a minority of patients with severe mitral regurgitation, principally because of limitations of large MA dimension.     

Prevalence and predictors of anxiety and depression in a sample of chronic heart failure patients with left ventricular systolic dysfunction

OBJECTIVE: To determine the prevalence and predictors of anxiety and depression in patients with heart failure due to Left Ventricular Systolic Dysfunction (LVSD). BACKGROUND: Psychological adjustment to Chronic Heart Failure (CHF) can be poor, with the prevalence of depression in out-patients ranging from 13% to 48%. The prevalence of anxiety disorders in this population is unknown and the factors that predict anxiety and depression are not well understood. METHODS: 100 out-patients from a community heart failure programme completed a clinical diagnostic interview--the Structured Clinical Interview (SCID-I), to evaluate anxiety and depression. Mean age was 67+/-11 years, 17% were women and 91% were NYHA Class II or III. Other standardised measures were of cognition, biomedical status, social support and previous physical and mental health history. RESULTS: The prevalence rates of anxiety and depression (all subtypes) were 18.4% and 28.6%, respectively. Predictors of depression included a reported history of mental ill-health and NYHA class. Predictors of anxiety included a reported history of mental ill-health, co-morbid physical illness (diabetes and angina) and NYHA class. Severity of LVSD did not predict either anxiety or depression. CONCLUSIONS: Both anxiety and depression are common in CHF patients. The data on the predictors of poor psychological adjustment might assist in targeting bio-psychosocial intervention for patients who are at most at risk of anxiety and depression, within community CHF disease management programmes.     

How safe is primary knee replacement surgery? Perioperative complication rates in Northern Illinois, 1993–1999

Objective

To describe inpatient complications for primary total knee replacement (TKR) in a period of rapidly growing orthopedic surgery capacity, declining length of stay, and more frequent discharge to rehabilitation facilities.

Methods

Complication incidence according to published coding algorithms was estimated for 35,531 primary TKR admissions of northern Illinois residents to 65 Illinois hospitals. Complication odds were estimated as a function of patients' clinical and sociodemographic status, hospital volume, residency training, TKR length of stay, International Classification of Diseases, Ninth Revision (ICD‐9) coding intensity, and discharges to skilled nursing or rehabilitation facilities.

Results

Primary TKR admissions increased 36% between 1993 and 1999, length of stay declined 43%, average ICD‐9 code use increased 31%, and rehabilitation discharges increased 68%. Major complication rates declined 44% (12.4% to 6.9%; P < 0.0001) over this period, reflecting a 50% reduction in the adjusted odds of complication between 1993 and 1999. There was no association of procedure volume and outcome.

Conclusion

It is likely that the reduction in complications reflects true safety improvements as well as reduced length of stay.