Jiaqiong Xu

Three-Dimensional Color Doppler Echocardiography for Direct Measurement of Vena Contracta Area in Mitral Regurgitation: In Vitro Validation and Clinical Experience

OBJECTIVES Our goal was to prospectively compare the accuracy of real-time three-dimensional (3D) color Doppler vena contracta (VC) area and two-dimensional (2D) VC diameter in an in vitro model and in the clinical assessment of mitral regurgitation (MR) severity. BACKGROUND Real-time 3D color Doppler allows direct measurement of VC area and may be more accurate for assessment of MR than the conventional VC diameter measurement by 2D color Doppler. METHODS Using a circulatory loop with an incorporated imaging chamber, various pulsatile flow rates of MR were driven through 4 differently sized orifices. In a clinical study of patients with at least mild MR, regurgitation severity was assessed quantitatively using Doppler-derived effective regurgitant orifice area (EROA), and semiquantitatively as recommended by the American Society of Echocardiography. We describe a step-by-step process to accurately identify the 3D-VC area and compare that measure against known orifice areas (in vitro study) and EROA (clinical study). RESULTS In vitro, 3D-VC area demonstrated the strongest correlation with known orifice area (r = 0.92, p < 0.001), whereas 2D-VC diameter had a weak correlation with orifice area (r = 0.56, p = 0.01). In a clinical study of 61 patients, 3D-VC area correlated with Doppler-derived EROA (r = 0.85, p < 0.001); the relation was stronger than for 2D-VC diameter (r = 0.67, p < 0.001). The advantage of 3D-VC area over 2D-VC diameter was more pronounced in eccentric jets (r = 0.87, p < 0.001 vs. r = 0.6, p < 0.001, respectively) and in moderate-to-severe or severe MR (r = 0.80, p < 0.001 vs. r = 0.18, p = 0.4, respectively). CONCLUSIONS Measurement of VC area is feasible with real-time 3D color Doppler and provides a simple parameter that accurately reflects MR severity, particularly in eccentric and clinically significant MR where geometric assumptions may be challenging.

Flow Acceleration Time and Ratio of Acceleration Time to Ejection Time for Prosthetic Aortic Valve Function

OBJECTIVES We sought to evaluate whether ejection dynamics, particularly acceleration time (AT) and the ratio of AT to ejection time (ET), can differentiate prosthetic aortic valve (PAV) stenosis from controls and prosthesis-patient mismatch (PPM). BACKGROUND Diagnosing PAV stenosis, especially in mechanical valves, may be challenging and has significant clinical implications. METHODS Doppler echocardiography was quantitated in 88 patients with PAV (44 mechanical and 44 bioprosthetic; age 63 ± 16 years; valve size range 18 to 25 mm) of whom 22 patients had documented PAV stenosis, 22 had PPM, and 44 served as controls. Quantitative Doppler parameters included ejection dynamics (AT, ET, and AT/ET) and conventional PAV parameters. RESULTS Patients with PAV stenosis had significantly lower effective orifice area (EOA) values and higher gradients compared with controls and PPM. Flow ejection parameters (AT and AT/ET) were significantly longer in the stenotic valves compared with PPM and controls (respective values for AT: 120 ± 24 ms, 89 ± 16 ms, and 71 ± 15 ms; for AT/ET: 0.4, 0.32, and 0.3, p ≤ 0.001). Patients with PPM had gradients and ejection dynamics that were intermediate between normal and stenotic valves. Receiver-operator characteristic (ROC) curve analysis showed that AT and AT/ET discriminated PAV stenosis from PPM and controls (area under ROC curve = 0.92 and 0.88, respectively). Combining AT with the conventional Doppler velocity index gave the highest area under the curve of 0.98 but was not statistically different from that of AT alone (p = 0.12). A cutoff of AT = 100 ms had a sensitivity and specificity of 86% for identifying PAV stenosis; for an AT/ET = 0.37, the sensitivity and specificity were 96% and 82%, respectively. Analysis by valve type (mechanical and biological) revealed similar results; however, biological valves had slightly higher areas under the curve for all systolic time intervals. CONCLUSIONS Ejection dynamics through PAV, particularly AT and AT/ET, are reliable angle-independent parameters that can help evaluate valve function and identify PAV stenosis.

Mitral Annulus Dynamics Early after Valve Repair: Preliminary Observations of the Effect of Resectional Versus Non-Resectional Approaches

BACKGROUND Mitral repair is recommended for patients with significant organic mitral regurgitation (MR). The nonresectional dynamic mitral valve repair (NVR) method involves a complete flexible ring and artificial chordal insertion but without leaflet resection or annular plication. The aim of this study was to compare changes in mitral annular structure and function after the NVR technique with those after a resectional mitral valve repair (RVR) method, which involves leaflet resection and annuloplasty with a partial flexible ring. METHODS Patients with organic severe MR undergoing mitral valve repair with either technique underwent three-dimensional transesophageal echocardiography before and after surgery. The mitral annulus was tracked offline and measured throughout the cardiac cycle. Mitral leaflet mobility was also measured. RESULTS Fifteen patients underwent repair with NVR, and 13 underwent repair with RVR (age, 56 vs 61 years, respectively). Both operations reduced mitral annular area significantly (maximum area reduction, from 18.5 ± 4.6 to 6.6 ± 1.7 cm(2) and from 20.1 ± 4.8 to 6 ± 1.5 cm(2) with the NVR and RVR techniques, respectively; P < .001). In contrast to RVR, patients who underwent NVR maintained dynamic changes in mitral annular area, circumference, and anterior-posterior diameter during the cardiac cycle. Mitral leaflet mobility was reduced with both techniques, but posterior leaflet mobility was restricted with RVR. CONCLUSIONS The size of the mitral annulus is reduced after repair with either surgical approach. Compared with resectional valve repair, more dynamic changes in the structure of the mitral annulus are maintained during the cardiac cycle with the NVR technique early postoperatively, along with more preserved motion of the posterior leaflet.

Renal Function and Risk Stratification of Diabetic and Nondiabetic Patients Undergoing Evaluation for Coronary Artery Disease

OBJECTIVES The aim of this study was to evaluate the impact of renal function by estimated glomerular filtration rate (eGFR) on risk stratification of diabetic and nondiabetic patients undergoing myocardial perfusion imaging (MPI) by single-photon emission computed tomography for suspected ischemia. BACKGROUND Coronary artery disease is the leading cause of death among diabetic persons; however, diabetic persons are a very heterogeneous group in terms of cardiovascular risk, necessitating further risk stratification. METHODS Patients (n = 1,747, age 65 +/- 10 years, 37% diabetic) undergoing MPI were followed for cardiac death (CD) for a mean of 2.15 +/- 0.8 years. Chronic kidney disease (CKD) was defined by an eGFR <60 ml/min. RESULTS In the presence of a normal scan, annual CD rate was 0.9% for those with no diabetes mellitus (DM) and no CKD, 0.5% in the DM alone group, 2.35% in CKD alone, and 2.9% in those with both DM and CKD (p < 0.001). Patients with DM+CKD had a 2.7-fold risk of CD compared with no DM no CKD (p = 0.001) after controlling for age, ejection fraction, history of coronary artery disease, and other risk factors. The risk of CD increased as a function of the presence and severity of perfusion defects, regardless of CKD or DM status. Presence of CKD conferred a several-fold higher risk of CD for the various strata of perfusion defects. Log-rank test for difference in probability of CD was nonsignificant for comparison between patients with no DM no CKD and those with DM alone (p = 0.73) but was significant for comparison between patients with no DM no CKD and patients with CKD alone (p < 0.001) or DM+CKD (p < 0.001). CONCLUSIONS MPI and eGFR provide valuable risk stratification for diabetic and nondiabetic patients. Diabetic patients without CKD seem to have similar short-term cardiac outcomes compared with nondiabetic patients. Underlying CKD seems to identify a high-risk subgroup of diabetic patients.

Direct assessment of normal mechanical mitral valve orifice area by real-time 3D echocardiography.

A reliable method for the assessment of the mitral valve (MV) area is essential for the management of patients with a prosthetic MV. In this study, we assess the feasibility of 3-dimensional (3D) echocardiography to directly measure the mechanical MV orifice area in both an in vitro study of

Multiple Human Papilloma Virus Infections and Their Impact on the Development of High-Risk Cervical Lesions

Objective: Individuals are often infected with multiple genotypes of human papillomavirus (HPV) simultaneously, but the role these infections play in the development of cervical disease is not well established. This study aimed to determine the association of multiple HPV infections with high-risk cervical lesions (hrCLs). Study Design: HPV genotyping was performed on 798 SurePath specimens collected between December 1, 2009, and April 30, 2011. The cases were classified as hrCL (n = 90) or non-hrCL (n = 708) based on cytology diagnoses. The association between hrCL and HPV infection patterns was analyzed. Results: Multiple HPV infections were frequently encountered (38.2%) in the cohort. Increased frequency of hrCLs was associated with a single high-risk HPV (hrHPV) infection. An additive or synergistic effect was not observed for hrCL in multiple HPV infections. The hrCL rates appeared to decrease in various patterns of multiple HPV infections, but the reduction was not statistically significant. Conclusions: Multiple HPV infections are common with no additive or synergistic effect on the development of hrCL. Conversely, reduced hrCL rates were observed in various patterns of multiple HPV infections compared to their single-genotype infection counterparts, suggestive of possible intergenotypic competition or more effective immune response triggered by multiple infections. Further studies in larger cohorts are needed.

Cardiac MRI is safe in patients with pacemakers and defibrillators

Background MRI has generally been contraindicated in patients (pts) with pacemakers (PM) or defibrillators (ICD) due to concern of a variety of potential complications. Several recent series have suggested potential safety of MRI in pts with cardiac devices, but most excluded cardiac or thoracic imaging. Additionally there is very limited data on safety of CMR in pts with devices, especially in pts with ICD.

Reply: Validation of Predicted Cardiovascular Disease Risk to Guide Intensity of Blood Pressure Treatment

Dr. Messerli and colleagues, Dr. Saeed and colleagues, and Dr. Vieira and colleagues provide valuable perspectives on our recent investigation of risk-based outcomes in SPRINT (Systolic Blood Pressure Intervention Trial) [(1)][1]. We agree with Dr. Messerli and colleagues that, as shown in their

Aptima Human Papillomavirus E6/E7 mRNA Test Results Strongly Associated with Risk for High-Grade Cervical Lesions in Follow-Up Biopsies

Objective Human papillomavirus (HPV) tests and genotyping (GT) have been used in clinical risk assessment. The purpose of this study was to analyze the performance of 2 common HPV testing platforms in risk evaluation for high-grade cervical lesions. Materials and Methods Between January 1, 2015, and December 31, 2016, a total of 4,562 Pap tests with follow-up biopsies in our laboratory database were analyzed along with HPV tests performed on Cobas (CHPV, n = 3,959) or Aptima (AHPV, n = 603) platforms. Results The sensitivity for biopsy-confirmed HSIL or worse lesions was 97% for both CHPV and AHPV (p = .75). AHPV showed significantly lower positive rates than CHPV in benign (56% vs 86%) or LSIL (66% vs 90%) biopsies, resulting in significantly higher specificity for HSIL or worse than CHPV (38% vs 12%, p < .001). AHPV demonstrated significantly higher positive predictive value for HSIL or worse (24% vs 16%, p < .001) and overall accuracy (48% vs 24%, p < .001) than CHPV. AHPV GT also had significantly higher specificity for biopsy-confirmed HSIL or worse than CHPV (88% vs 72%, p < .001) with comparable sensitivity (50% vs 51%, p = .75). Women with HPV 16 on AHPV were significantly more likely to have HSIL or worse on biopsies than those with HPV 16 on CHPV (likelihood ratio = 4.3 vs 2.0, p = .004). Conclusions Although both AHPV and CHPV were highly sensitive for biopsy-confirmed HSIL or worse lesions, AHPV and GT demonstrated significantly higher specificity and positive predictive value than CHPV. The difference is probably related to E6/E7 overexpression after viral DNA integration in high-grade lesions. The significantly higher specificity and overall accuracy of AHPV and GT for HSIL or worse lesions may be useful in clinical risk management.

Optimal positioning of self-expanding valves before deployment decreases paravalvular regurgitation following transcatheter aortic valve replacement

To evaluate the association between measurements performed during Medtronic CoreValve (MCV) deployment and paravalvular leak (PVL).