Nutritional status in tricuspid regurgitation: implications of transcatheter repair

Aims To characterize the prevalence and clinical relevance of malnutrition in patients undergoing transcatheter tricuspid valve edge-to-edge repair (TTVR). Methods and results Overall, 86 consecutive patients (mean age 78 ± 7 years) with moderate-to-severe tricuspid regurgitation (TR) at prohibitive surgical risk were analysed. Mini Nutritional Assessment (MNA), quality of life assessment, 6-min walk test distance and laboratory analyses were performed before and 1 month after TTVR. A total of 43 patients (50%) underwent concomitant transcatheter mitral valve repair. According to MNA, 81 patients (94%) were malnourished or at risk of malnutrition before TTVR. Following TTVR, MNA improved in 64 patients (74%). As compared to patients without MNA improvement, patients with increased MNA score had greater reductions in TR [regurgitation volume −17.0 (interquartile range, IQR −25.0; −7.0) mL vs. −26.4 (IQR −40.3; −14.5) mL, P < 0.001] and inferior vena cava diameter. Only patients with increased MNA score displayed a decrease in N-terminal pro-brain natriuretic peptide levels [−320 (IQR −1294; 105) pg/mL vs. +708 (IQR −342; 2708) pg/mL, P = 0.009], improvements in cholinesterase levels (0.0 ± 11.9 μmoL/L vs. +10.9 ± 16.7 μmoL/L, P < 0.001) and renal function during follow-up. Beneficial effects on quality of life scores and 6-min walk test distance following TTVR were observed exclusively in patients with improvement in MNA. During a median follow-up of 6 months, patients with worsened MNA had an increased risk of death and rehospitalization for heart failure. Conclusion Nutritional impairment is common and of prognostic importance in patients undergoing TTVR. Hepatorenal function modestly improves after successful TTVR. Further study of extracardiac implications of TR-associated right heart failure is warranted to improve care in this vulnerable patient population

Influence of filter age on Fe, Mn and NH4+ removal in dual media rapid sand filters used for drinking water production

Rapid sand filtration is a common method for removal of iron (Fe), manganese (Mn) and ammonium (NH4+) from anoxic groundwaters used for drinking water production. In this study, we combine geochemical and microbiological data to assess how filter age influences Fe, Mn and NH4+ removal in dual media filters, consisting of anthracite overlying quartz sand, that have been in operation for between ∼2 months and ∼11 years. We show that the depth where dissolved Fe and Mn removal occurs is reflected in the filter medium coatings, with ferrihydrite forming in the anthracite in the top of the filters ( 1 m). Removal of NH4+ occurs through nitrification in both the anthracite and sand and is the key driver of oxygen loss. Removal of Fe is independent of filter age and is always efficient (> 97% removal). In contrast, for Mn, the removal efficiency varies with filter age, ranging from 9 to 28% at ∼2–3 months after filter replacement to 100% after 8 months. After 11 years, removal reduces to 60–80%. The lack of Mn removal in the youngest filters (at 2–3 months) is likely the result of a relatively low abundance of mineral coatings that adsorb Mn2+ and provide surfaces for the establishment of a microbial community. 16S rRNA gene amplicon sequencing shows that Gallionella, which are known Fe2+ oxidizers, are present after 2 months, yet Fe2+ removal is mostly chemical. Efficient NH4+ removal (> 90%) establishes within 3 months of operation but leakage occurs upon high NH4+loading (> 160 µM). Two-step nitrification by Nitrosomonas and Candidatus Nitrotoga is likely the most important NH4+ removal mechanism in younger filters during ripening (2 months), after which complete ammonia oxidation by Nitrospira and canonical two-step nitrification occur simultaneously in older filters. Our results highlight the strong effect of filter age on especially Mn2+but also NH4+ removal. We show that ageing of filter medium leads to the development of thick coatings, which we hypothesize leads to preferential flow, and breakthrough of Mn2+. Use of age-specific flow rates may increase the contact time with the filter medium in older filters and improve Mn2+ and NH4+ removal

Miljöövervakning i Kalmar län : En kort beskrivning av tillståndet i länet

Broschyren sammanfattar övervakning och resultat inom ett urval av delprogram inom den regionala miljöövervakningen i Kalmar län

Cardioscopically-guided beating heart surgery: paravalvular leak repair

Purpose: There remains a paucity of direct visualization techniques for beating-heart intracardiac procedures. To address this need, we evaluated a novel cardioscope in the context of aortic paravalvular leaks (PVLs) localization and closure.Description: A porcine aortic PVL model was created using a custom-made bioprosthetic valve, and PVL presence was verified by epicardial echocardiography. Transapical delivery of occlusion devices guided solely by cardioscopy was attempted 13 times in a total of three pigs. Device retrieval after release was attempted six times. Echocardiography, morphologic evaluation, and delivery time were used to assess results.Evaluation: Cardioscopic imaging enabled localization of PVLs via visualization of regurgitant jet flow in a paravalvular channel at the base of the prosthetic aortic valve. Occluders were successfully placed in 11 of 13 attempts (84.6%), taking on average 3:03 ± 1:34 min. Devices were cardioscopically removed successfully in three of six attempts (50%), taking 3:41 ± 1:46 min. No damage to the ventricle or annulus was observed at necropsy.Conclusions: Cardioscopy can facilitate intracardiac interventions by providing direct visualization of anatomic structures inside the blood-filled, beating-heart model

Nutritional status in tricuspid regurgitation: implications of transcatheter repair

Aims To characterize the prevalence and clinical relevance of malnutrition in patients undergoing transcatheter tricuspid valve edge-to-edge repair (TTVR). Methods and results Overall, 86 consecutive patients (mean age 78 ± 7 years) with moderate-to-severe tricuspid regurgitation (TR) at prohibitive surgical risk were analysed. Mini Nutritional Assessment (MNA), quality of life assessment, 6-min walk test distance and laboratory analyses were performed before and 1 month after TTVR. A total of 43 patients (50%) underwent concomitant transcatheter mitral valve repair. According to MNA, 81 patients (94%) were malnourished or at risk of malnutrition before TTVR. Following TTVR, MNA improved in 64 patients (74%). As compared to patients without MNA improvement, patients with increased MNA score had greater reductions in TR [regurgitation volume −17.0 (interquartile range, IQR −25.0; −7.0) mL vs. −26.4 (IQR −40.3; −14.5) mL, P < 0.001] and inferior vena cava diameter. Only patients with increased MNA score displayed a decrease in N-terminal pro-brain natriuretic peptide levels [−320 (IQR −1294; 105) pg/mL vs. +708 (IQR −342; 2708) pg/mL, P = 0.009], improvements in cholinesterase levels (0.0 ± 11.9 μmoL/L vs. +10.9 ± 16.7 μmoL/L, P < 0.001) and renal function during follow-up. Beneficial effects on quality of life scores and 6-min walk test distance following TTVR were observed exclusively in patients with improvement in MNA. During a median follow-up of 6 months, patients with worsened MNA had an increased risk of death and rehospitalization for heart failure. Conclusion Nutritional impairment is common and of prognostic importance in patients undergoing TTVR. Hepatorenal function modestly improves after successful TTVR. Further study of extracardiac implications of TR-associated right heart failure is warranted to improve care in this vulnerable patient population

Nutritional status in tricuspid regurgitation: implications of transcatheter repair

Aims To characterize the prevalence and clinical relevance of malnutrition in patients undergoing transcatheter tricuspid valve edge-to-edge repair (TTVR). Methods and results Overall, 86 consecutive patients (mean age 78 ± 7 years) with moderate-to-severe tricuspid regurgitation (TR) at prohibitive surgical risk were analysed. Mini Nutritional Assessment (MNA), quality of life assessment, 6-min walk test distance and laboratory analyses were performed before and 1 month after TTVR. A total of 43 patients (50%) underwent concomitant transcatheter mitral valve repair. According to MNA, 81 patients (94%) were malnourished or at risk of malnutrition before TTVR. Following TTVR, MNA improved in 64 patients (74%). As compared to patients without MNA improvement, patients with increased MNA score had greater reductions in TR [regurgitation volume −17.0 (interquartile range, IQR −25.0; −7.0) mL vs. −26.4 (IQR −40.3; −14.5) mL, P < 0.001] and inferior vena cava diameter. Only patients with increased MNA score displayed a decrease in N-terminal pro-brain natriuretic peptide levels [−320 (IQR −1294; 105) pg/mL vs. +708 (IQR −342; 2708) pg/mL, P = 0.009], improvements in cholinesterase levels (0.0 ± 11.9 μmoL/L vs. +10.9 ± 16.7 μmoL/L, P < 0.001) and renal function during follow-up. Beneficial effects on quality of life scores and 6-min walk test distance following TTVR were observed exclusively in patients with improvement in MNA. During a median follow-up of 6 months, patients with worsened MNA had an increased risk of death and rehospitalization for heart failure. Conclusion Nutritional impairment is common and of prognostic importance in patients undergoing TTVR. Hepatorenal function modestly improves after successful TTVR. Further study of extracardiac implications of TR-associated right heart failure is warranted to improve care in this vulnerable patient population

Short‐Term Effects of Different Transcatheter Edge‐to‐Edge Devices on Mitral Valve Geometry

Background Short‐term effects on mitral valve (MV) anatomy after transcatheter edge‐to‐edge repair using the PASCAL system remain unknown. Precise quantification might allow for an advanced analysis of predictors for mean transmitral gradients. Methods and Results Consecutive patients undergoing transcatheter edge‐to‐edge repair for secondary mitral regurgitation using PASCAL or MitraClip systems were included. Quantification of short‐term MV changes throughout the cardiac cycle was performed using peri‐interventional 3‐dimensional MV images. Predictors for mean transmitral gradients were identified in univariable and multivariable regression analysis. Long‐term results were described during 1‐year follow‐up. A total of 100 patients undergoing transcatheter edge‐to‐edge repair using PASCAL (n=50) or MitraClip systems (n=50) were included. Significant reductions of anterior‐posterior diameter, annular circumference, and area throughout the cardiac cycle were found in both cohorts (P<0.05 for all). Anatomic MV orifice area remained larger in the PASCAL cohort in mid (2.8±1.0 versus 2.4±0.9 cm2; P=0.049) and late diastole (2.7±1.1 versus 2.2±0.8 cm2; P=0.036) compared with the MitraClip cohort. Besides a device‐specific profile of independent predictor of mean transmitral gradients, reduction of middiastolic anatomic MV orifice area was identified as an independent predictor in both the PASCAL (β=−0.410; P=0.001) and MitraClip cohorts (β=−0.318; P=0.028). At follow‐up, reduction of mitral regurgitation grade to mild or less was more durable in the PASCAL cohort (90% versus 72%; P=0.035). Conclusions PASCAL and MitraClip showed comparable short‐term effects on MV geometry. However, PASCAL might better preserve MV function and demonstrated more durable mitral regurgitation reduction during follow‐up. Identification of independent predictors for mean transmitral gradients might potentially help to guide device selection in the future