HUBUNGAN MITRAL VALVE AREA (MVA) DENGAN HIPERTENSI PULMONAL PADA STENOSIS MITRAL

Latar belakang: Penyebab stenosis mitral paling sering adalah demam rematik. Bertambahnya angka kejadian penyakit demam rematik juga meningkatkan angka kejadian penyakit hipertensi pulmonal yang merupakan komplikasi dari stenosis mitral. Tujuan: Untuk mengetahui bagaimana hubungan antara mitral valve area dengan hipertensi pulmonal pada pasien stenosis mitral di RSUP Dr Kariadi Semarang. Metode: Penelitian ini merupakan penelitian analitik observasional menggunakan data sekunder hasil ekokardiografi dan rekam medik. Sampel sebanyak 21 pasien stenosis mitral yang memenuhi kriteria tertentu. Dari hasil ekokardiografi didapatkan nilai mitral valve area dan right ventricle systolic pressure. Uji statistik menggunakan uji korelasi pearson. Hasil: Pemeriksaan ekokardiografi pada pasien stenosis mitral didapatkan sebanyak 4,76% menderita stenosis mitral ringan, 23,81% menderita stenosis mitral sedang dan 71,43% menderita stenosis mitral berat. Rata-rata luas mitral valve area 0,81 ± 0,36 cm. Hasil pemeriksaan ekokardiografi pada pasien stenosis mitral juga didapatkan sebanyak 42,86% menderita hipertensi pulomonal sedang dan 57,14% menderita hipertensi pulmonal berat. Rata-rata nilai right ventricle systolic pressure 60,16 ± 21,51 mmHg. Pada uji Pearson didapatkan hasil terdapat korelasi negatif derajat kuat antara mitral valve area dan right ventricle systolic pressure (r = -0,618, p = 0,001). Kesimpulan: Mitral valve area memiliki korelasi negatif yang kuat dengan hipertensi pulmonal pada stenosis mitral Kata kunci: Stenosis mitral, mitral valve area, hipertensi pulmonal

Length of carotid stenosis predicts peri-procedural stroke or death and restenosis in patients randomized to endovascular treatment or endarterectomy.

BACKGROUND: The anatomy of carotid stenosis may influence the outcome of endovascular treatment or carotid endarterectomy. Whether anatomy favors one treatment over the other in terms of safety or efficacy has not been investigated in randomized trials. METHODS: In 414 patients with mostly symptomatic carotid stenosis randomized to endovascular treatment (angioplasty or stenting; n = 213) or carotid endarterectomy (n = 211) in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), the degree and length of stenosis and plaque surface irregularity were assessed on baseline intraarterial angiography. Outcome measures were stroke or death occurring between randomization and 30 days after treatment, and ipsilateral stroke and restenosis ≥50% during follow-up. RESULTS: Carotid stenosis longer than 0.65 times the common carotid artery diameter was associated with increased risk of peri-procedural stroke or death after both endovascular treatment [odds ratio 2.79 (1.17-6.65), P = 0.02] and carotid endarterectomy [2.43 (1.03-5.73), P = 0.04], and with increased long-term risk of restenosis in endovascular treatment [hazard ratio 1.68 (1.12-2.53), P = 0.01]. The excess in restenosis after endovascular treatment compared with carotid endarterectomy was significantly greater in patients with long stenosis than with short stenosis at baseline (interaction P = 0.003). Results remained significant after multivariate adjustment. No associations were found for degree of stenosis and plaque surface. CONCLUSIONS: Increasing stenosis length is an independent risk factor for peri-procedural stroke or death in endovascular treatment and carotid endarterectomy, without favoring one treatment over the other. However, the excess restenosis rate after endovascular treatment compared with carotid endarterectomy increases with longer stenosis at baseline. Stenosis length merits further investigation in carotid revascularisation trials

Computed poststenotic flow instabilities correlate phenotypically with vibrations measured using laser Doppler vibrometry : perspectives for a promising in vivo device for early detection of moderate and severe carotid stenosis

Early detection of asymptomatic carotid stenosis is crucial for treatment planning in the prevention of ischemic stroke. Auscultation, the current first-line screening methodology, comes with severe limitations that create urge for novel and robust techniques. Laser Doppler vibrometer (LDV) is a promising tool for inferring carotid stenosis by measuring stenosis-induced vibrations. The goal of the current study was to evaluate the feasibility of LDV for carotid stenosis detection. LDV measurements on a carotid phantom were used to validate our previously verified high-resolution computational fluid dynamics methodology, which was used to evaluate the impact of flowrate, flow split, and stenosis severity on the poststenotic intensity of flow instabilities (IFI). We evaluated sensitivity, specificity, and accuracy of using IFI for stenoses detection. Linear regression analyses showed that computationally derived pressure fluctuations correlated (R2 = 0.98) with LDV measurements of stenosis-induced vibrations. The flowrate of stenosed vessels correlated (R2 = 0.90) with the presence of poststenotic instabilities. Receiver operating characteristic analyses of power spectra revealed that the most relevant frequency bands for the detection of moderate (56–76%) and severe (86–96%) stenoses were 80–200 Hz and 0–40 Hz, respectively. Moderate stenosis was identified with sensitivity and specificity of 90%; values decreased to 70% for severe stenosis. The use of LDV as screening tool for asymptomatic stenosis can potentially provide improved accuracy of current screening methodologies for early detection. The applicability of this promising device for mass screening is currently being evaluated clinically

High-sensitivity troponin I concentrations are a marker of an advanced hypertrophic response and adverse outcomes in patients with aortic stenosis

Aims: High-sensitivity cardiac troponin I (cTnI) assays hold promise in detecting the transition from hypertrophy to heart failure in aortic stenosis. We sought to investigate the mechanism for troponin release in patients with aortic stenosis and whether plasma cTnI concentrations are associated with long-term outcome. Methods and results: Plasma cTnI concentrations were measured in two patient cohorts using a high-sensitivity assay. First, in the Mechanism Cohort, 122 patients with aortic stenosis (median age 71, 67% male, aortic valve area 1.0 ± 0.4 cm2) underwent cardiovascular magnetic resonance and echocardiography to assess left ventricular (LV) myocardial mass, function, and fibrosis. The indexed LV mass and measures of replacement fibrosis (late gadolinium enhancement) were associated with cTnI concentrations independent of age, sex, coronary artery disease, aortic stenosis severity, and diastolic function. In the separate Outcome Cohort, 131 patients originally recruited into the Scottish Aortic Stenosis and Lipid Lowering Trial, Impact of REgression (SALTIRE) study, had long-term follow-up for the occurrence of aortic valve replacement (AVR) and cardiovascular deaths. Over a median follow-up of 10.6 years (1178 patient-years), 24 patients died from a cardiovascular cause and 60 patients had an AVR. Plasma cTnI concentrations were associated with AVR or cardiovascular death HR 1.77 (95% CI, 1.22 to 2.55) independent of age, sex, systolic ejection fraction, and aortic stenosis severity. Conclusions: In patients with aortic stenosis, plasma cTnI concentration is associated with advanced hypertrophy and replacement myocardial fibrosis as well as AVR or cardiovascular death

Cerebral perfusion MR imaging using FAIR-HASTE in chronic carotid occlusive disease: comparison with dynamic susceptibility contrast-perfusion MR imaging.

To determine the efficacy of flow-sensitive alternating inversion recovery using half-Fourier single-shot turbo spin-echo (FAIR-HASTE) in detecting cerebral hypoperfusion in chronic carotid occlusive disease, we subjected 12 patients with various degrees of cervical internal carotid artery stenoses and/or occlusion (Stenosis group) and 24 volunteers (Normal group) to FAIR-HASTE. In addition, 10 out of 12 patients in the Stenosis group underwent dynamic susceptibility contrast-perfusion magnetic resonance imaging (DSC-pMRI) before and after revascularization in the dominantly affected side. The absolute asymmetry indexes (AIs) of both cerebral hemispheres in the Normal and Stenosis groups were compared in FAIR-HASTE. In addition, the AIs were compared with those in the Stenosis group before and after revascularization in both FAIR-HASTE and regional cerebral blood flow (rCBF), calculated with DSC-pMRI. A statistically significant difference was recognized between the AIs in the Normal and Stenosis groups (AI = 2.25 +- 1.92, 8.09 +- 4.60, respectively ; p < 0.0001). Furthermore, in the Stenosis group the AIs on both FAIR-HASTE (8.88 +- 4.93, 2.22 +- 1.79, respectively ; p = 0.0003) and rCBF (7.13 +- 3.57, 1.25 +- 1.33, respectively ; p = 0.0003) significantly decreased after revascularization. In the Stenosis group, before revascularization, signal intensity on both FAIR-HASTE and rCBF had a tendency to be lower in the dominantly affected side. FAIR-HASTE imaging was useful in the detection and evaluation of cerebral hypoperfusion in chronic occlusive carotid disease

Investigation of physiological pulsatile flow in a model arterial stenosis using large-eddy and direct numerical simulations

Physiologicalpulsatileflow in a 3D model of arterialstenosis is investigated by using largeeddysimulation (LES) technique. The computational domain chosen is a simple channel with a biological type stenosis formed eccentrically on the top wall. The physiological pulsation is generated at the inlet using the first harmonic of the Fourier series of pressure pulse. In LES, the large scale flows are resolved fully while the unresolved subgrid scale (SGS) motions are modelled using a localized dynamic model. Due to the narrowing of artery the pulsatileflow becomes transition-to-turbulent in the downstream region of the stenosis, where a high level of turbulent fluctuations is achieved, and some detailed information about the nature of these fluctuations are revealed through the investigation of the turbulent energy spectra. Transition-to-turbulent of the pulsatileflow in the post stenosis is examined through the various numerical results such as velocity, streamlines, velocity vectors, vortices, wall pressure and shear stresses, turbulent kinetic energy, and pressure gradient. A comparison of the LES results with the coarse DNS are given for the Reynolds number of 2000 in terms of the mean pressure, wall shear stress as well as the turbulent characteristics. The results show that the shear stress at the upper wall is low just prior to the centre of the stenosis, while it is maximum in the throat of the stenosis. But, at the immediate post stenotic region, the wall shear stress takes the oscillating form which is quite harmful to the blood cells and vessels. In addition, the pressure drops at the throat of the stenosis where the re-circulated flow region is created due to the adverse pressure gradient. The maximum turbulent kinetic energy is located at the post stenosis with the presence of the inertial sub-range region of slope −5/3

Can Emergency Physicians Perform Carotid Artery Point-of-Care Ultrasound to Detect Stenosis in Patients with TIA and Stroke? A Pilot Study

Introduction: Patients with severe, symptomatic carotid stenosis can have their subsequent stroke risk reduced by surgical intervention if performed soon after a transient ischemic attack (TIA) or stroke. Patients presenting to an emergency department (ED) without computed tomography angiography (CTA) with TIA/stroke, may require transfer to another hospital for imaging to rule out carotid artery stenosis. The objective of this study was to determine the test characteristics of carotid artery point-of-care ultrasound (POCUS) in detecting greater than 50% stenosis in patients presenting with TIA/stroke.Methods: We conducted a prospective cohort study on a convenience sample of adult patients presenting to a comprehensive stroke centre with TIA or stroke between June–October 2017. Carotid POCUS was performed. Primary outcome measure, stenosis ≥ 50%, was determined by the final radiology report of CTA. A blinded POCUS expert separately reviewed the archived carotid POCUS scans. We calculated sensitivity and specificity for stenosis ≥ 50%.Results: We conducted POCUS on 75 patients, of which 70 were included in our analyses. Of those 70, 14.3% were diagnosed with greater than 50% stenosis. Carotid POCUS performed as follows: sensitivity 70.0% (95% confidence interval [CI], 34.8%-93.3%); specificity 86.7% (95% CI, 75.4%-94.1%); positive likelihood ratio (LR +) 5.3 (95% CI, 1.2-9.3); negative likelihood ratio (LR -) 0.4 (95% CI, 0.0-0.7). The inter-rater reliability between POCUS performer interpretation and expert interpretation had moderate agreement (k = 0.68). Scans took a mean 6.2 ± 2.2 minutes to complete.Conclusion: Carotid POCUS has low to moderate association with CTA for detection of carotid artery stenosis ≥ 50%. Further research and investigation is needed prior to widespread use of carotid POCUS in patients with acute cerebral ischemia. Additionally, external validity is likely affected by availability of training, maintenance of competency, and experience in more rural centres

Classical supravalvar aortic stenosis and peripheral pulmonary stenosis

Supravalvar aortic stenosis as well as peripheral pulmonary stenosis are rare forms of congenital heart disease, which occur, however, relatively frequently in association. This article reports and discusses the classical findings of SVAS and PPS upon clinical examination and imaging in a sixyear-old girl that presented with repeated respiratory tract infections and failure to thrive.peer-reviewe

A model based on clinical parameters to identify myocardial late gadolinium enhancement by magnetic resonance in patients with aortic stenosis: An observational study

Objective With increasing age, the prevalence of aortic stenosis grows exponentially, increasing left heart pressures and potentially leading to myocardial hypertrophy, myocardial fibrosis and adverse outcomes. To identify patients who are at greatest risk, an outpatient model for risk stratification would be of value to better direct patient imaging, frequency of monitoring and expeditious management of aortic stenosis with possible earlier surgical intervention. In this study, a relatively simple model is proposed to identify myocardial fibrosis in patients with a diagnosis of moderate or severe aortic stenosis. Design Patients with moderate to severe aortic stenosis were enrolled into the study; patient characteristics, blood work, medications as well as transthoracic echocardiography and cardiovascular magnetic resonance were used to determine potential identifiers of myocardial fibrosis. Setting The Royal Brompton Hospital, London, UK Participants One hundred and thirteen patients in derivation cohort and 26 patients in validation cohort. Main outcome measures Identification of myocardial fibrosis. Results Three blood biomarkers (serum platelets, serum urea, N-terminal pro-B-type natriuretic peptide) and left ventricular ejection fraction were shown to be capable of identifying myocardial fibrosis. The model was validated in a separate cohort of 26 patients. Conclusions Although further external validation of the model is necessary prior to its use in clinical practice, the proposed clinical model may direct patient care with respect to earlier magnetic resonance imagining, frequency of monitoring and may help in risk stratification for surgical intervention for myocardial fibrosis in patients with aortic stenosis

Assessment of carotid atherosclerotic disease using three-dimensional cardiovascular magnetic resonance vessel wall imaging: comparison with digital subtraction angiography.

BACKGROUND:A three-dimensional (3D) cardiovascular magnetic resonance (CMR) vessel wall imaging (VWI) technique based on 3D T1 weighted (T1w) Sampling Perfection with Application-optimized Contrast using different flip angle Evolutions (SPACE) has recently been used as a promising CMR imaging modality for evaluating extra-cranial and intra-cranial vessel walls. However, this technique is yet to be validated against the current diagnostic imaging standard. We therefore aimed to evaluate the diagnostic performance of 3D CMR VWI in characterizing carotid disease using intra-arterial digital subtraction angiography (DSA) as a reference. METHODS:Consecutive patients with at least unilateral > 50% carotid stenosis on ultrasound were scheduled to undergo interventional therapy were invited to participate. The following metrics were measured using 3D CMR VWI and DSA: lumen diameter of the common carotid artery (CCA) and segments C1-C7, stenosis diameter, reference diameter, lesion length, stenosis degree, and ulceration. We assessed the diagnostic sensitivity, specificity, accuracy, and receiver operating characteristic (ROC) curve of 3D CMR VWI, and used Cohen's kappa, the intraclass correlation coefficient (ICC), and Bland-Altman analyses to assess the diagnostic agreement between 3D CMR VWI and DSA. RESULTS:The ICC (all ICCs ≥0.96) and Bland-Altman plots indicated excellent inter-reader agreement in all individual morphologic measurements by 3D CMR VWI. Excellent agreement in all individual morphologic measurements were also found between 3D CMR VWI and DSA. In addition, 3D CMR VWI had high sensitivity (98.4, 97.4, 80.0, 100.0%), specificity (100.0, 94.5, 99.1, 98.0%), and Cohen's kappa (0.99, 0.89, 0.84, 0.96) for detecting stenosis > 50%, stenosis > 70%, ulceration, and total occlusion, respectively, using DSA as the standard. The AUC of 3D CMR VWI for predicting stenosis > 50 and > 70% were 0.998 and 0.999, respectively. CONCLUSIONS:The 3D CMR VWI technique enables accurate diagnosis and luminal feature assessment of carotid artery atherosclerosis, suggesting that this imaging modality may be useful for routine imaging workups and provide comprehensive information for both the vessel wall and lumen