Assessment of paravalvular regurgitation following TAVR : a proposal of unifying grading scheme.

Paravalvular regurgitation (PVR) is a frequent complication of transcatheter aortic valve replacement that has been shown to be associated with increased mortality. The objective of this article is to review the most up-to-date information about the assessment and management of PVR and to propose a new more comprehensive and unifying scheme for grading PVR severity. A multimodality, multiparametric, integrative approach including Doppler echocardiography, cineangiography, hemodynamic assessment, and/or cardiac magnetic resonance is essential to accurately assess the severity of PVR and the underlying etiology. Corrective procedures such as balloon post-dilation, valve-in-valve, or leak closure may be considered, depending on the severity, location, and etiology of PVR

Determination of aortic valve area in valvular aortic stenosis by direct measurement using intracardiac echocardiography: A comparison with the gorlin and continuity equations

AbstractObjectives. This study sought to 1) show that intracardiac echocardiography can allow direct measurement of the aortic valve area, and 2) compare the directly measured aortic valve area from intracardiac echocardiography with the calculated aortic valve area from the Gorlin and continuity equations.Background. Intracardiac echocardiography has been used in the descriptive evaluation of the aortic valve; however, direct measurement of the aortic valve area using this technique in a clinical setting has not been documented. Despite their theoretical and practical limitations, the Gorlin and continuity equations remain the current standard methods for determining the aortic valve orifice area.Methods. Seventeen patients underwent intracardiac echocardiography for direct measurement of the aortic valve area, including four patients studied both before and after valvuloplasty, for a total of 21 studies. Immediately after intracardiac echocardiography, hemodynamic data were obtained from transthoracic echocardiography and cardiac catheterization.Results. Adequate intracardiac echocardiographic images were obtained in 17 (81%) of 21 studies. The average aortic valve area (mean ± SD) determined by intracardiac echocardiography for the 13 studies in the Gorlin analysis group was 0.59 ± 0.18 cm2(range 0.37 to 1.01), and the average aortic valve area determined by the Gorlin equation was 0.62 ± 0.18 cm2(range 0.31 to 0.88). The average aortic valve area determined by intracardiac echocardiography for the 17 studies in the continuity analysis group was 0.66 ± 0.23 cm2(range 0.37 to 1.01), and that for the continuity equation was 0.62 ± 0.22 cm2(range 0.34 to 1.06). There was a significant correlation between the aortic valve area determined by intracardiac echocardiography and the aortic valve area calculated by the Gorlin (r = 0.78, p = 0.002) and continuity equations (r = 0.82, p < 0.0001).Conclusions. In the clinical setting, intracardiac echocardiography can directly measure the aortic valve area with an accuracy similar to the invasive and noninvasive methods currently used. This study demonstrates a new, quantitative use for intracardiac echocardiographic imaging with many potential clinical applications

901-110 Three-Dimensional Ultrasound Can Accurately Reconstruct Intravascular Thrombi: In Vitro Validation

High-frequency ultrasound can potentially display gross morphologic changes during thrombus formation and lysis. Current intravascular ultrasound (IVUS) devices, however, provide only 2-dimensional cross-sectional images with limited overall appreciation of thrombus size and 3-dimensional (3D) configuration. The purpose of this study was to explore the ability of 3D reconstruction of serial ultrasound images to provide a quantitative assessment of intravascular thrombi. We therefore imaged 11 arterial thrombi of varying shape and volume (10 to 116mm3). To avoid thrombus disruption, we used an epivascular approach (also suitable for transvenous imaging) with a 20MHz IVUS catheter withdrawn at 1mm/sec. A 3D voxel image intensity data set was reconstructed, and thrombus volume was semiautomatically extracted based on its intensity. Calculated volume was compared with directly measured values by volume displacement in a miniature cylinder.Results3D reconstruction provided previously unobtainable longitudinal and 3D views that improved spatial appreciation of thrombus size, shape and channel formation. Calculated thrombus volumes agreed well with actual volumes: y=0.92x+2.4, r=0.98, SEE=5mm3, mean error = 1±5mm3(ns vs 0).Conclusion3D reconstruction can improve spatial appreciation of the shape of thrombi and accurately measure their volumes. This approach, suitable for epivascular or transvenous imaging, could potentially be used to study thrombus formation and lysis in research and clinical studies

Catheter-based autologous bone marrow myocardial injection in no-option patients with advanced coronary artery disease A feasibility study

AbstractObjectivesWe conducted a pilot study to evaluate the feasibility of transendocardial delivery of autologous bone marrow (ABM) strategy in patients with severe symptomatic chronic myocardial ischemia not amenable to conventional revascularization.BackgroundTransendocardial injection of ABM cells appears to enhance perfusion of ischemic porcine myocardium.MethodsTen patients underwent transendocardial injection of freshly aspirated and filtered unfractionated ABM using left ventricular electromechanical guidance. Twelve injections of 0.2 ml each were successfully delivered into ischemic noninfarcted myocardium pre-identified by single-photon emission computed tomography perfusion imaging.ResultsAutologous bone marrow injection was successful in all patients and was associated with no serious adverse effects; in particular, there was no arrhythmia, evidence of infection, myocardial inflammation, or increased scar formation. Two patients were readmitted for recurrent chest pain. At three months, Canadian Cardiovascular Society angina score significantly improved (3.1 ± 0.3 vs. 2.0 ± 0.94, p = 0.001), as well as stress-induced ischemia occurring within the injected territories (2.1 ± 0.8 vs. 1.6 ± 0.8, p < 0.001). Treadmill exercise duration, available in nine patients, increased, but the change was not significant (391 ± 155 vs. 485 ± 198, p = 0.11).ConclusionsThis study provides preliminary clinical data indicating feasibility of catheter-based transendocardial delivery of ABM to ischemic myocardium

Neural origins of human sickness in interoceptive responses to inflammation

BACKGROUND: Inflammation is associated with psychological, emotional, and behavioral disturbance, known as sickness behavior. Inflammatory cytokines are implicated in coordinating this central motivational reorientation accompanying peripheral immunologic responses to pathogens. Studies in rodents suggest an afferent interoceptive neural mechanism, although comparable data in humans are lacking. METHODS: In a double-blind, randomized crossover study, 16 healthy male volunteers received typhoid vaccination or saline (placebo) injection in two experimental sessions. Profile of Mood State questionnaires were completed at baseline and at 2 and 3 hours. Two hours after injection, participants performed a high-demand color word Stroop task during functional magnetic resonance imaging. Blood samples were performed at baseline and immediately after scanning. RESULTS: Typhoid but not placebo injection produced a robust inflammatory response indexed by increased circulating interleukin-6 accompanied by a significant increase in fatigue, confusion, and impaired concentration at 3 hours. Performance of the Stroop task under inflammation activated brain regions encoding representations of internal bodily state. Spatial and temporal characteristics of this response are consistent with interoceptive information flow via afferent autonomic fibers. During performance of this task, activity within interoceptive brain regions also predicted individual differences in inflammation-associated but not placebo-associated fatigue and confusion. Maintenance of cognitive performance, despite inflammation-associated fatigue, led to recruitment of additional prefrontal cortical regions. CONCLUSIONS: These findings suggest that peripheral infection selectively influences central nervous system function to generate core symptoms of sickness and reorient basic motivational states. PMID:19409533[PubMed - indexed for MEDLINE] PMCID: PMC2885492Free PMC Articl