Ralf Trauzeddel

Blood flow characteristics in the ascending aorta after aortic valve replacement-a pilot study using 4D-flow MRI

BACKGROUND Aortic remodeling after aortic valve replacement (AVR) might be influenced by the postoperative blood flow pattern in the ascending aorta. This pilot study used flow-sensitive four-dimensional magnetic resonance imaging (4D-flow) to describe ascending aortic flow characteristics after various types of AVR. METHODS 4D-flow was acquired in 38 AVR patients (n=9 mechanical, n=8 stentless bioprosthesis, n=14 stented bioprosthesis, n=7 autograft) and 9 healthy controls. Analysis included grading of vortex and helix flow (0-3 point scale), assessment of systolic flow eccentricity (1-3 point scale), and quantification of the segmental distribution of peak systolic wall shear stress (WSS(peak)) in the ascending aorta. RESULTS Compared to controls, mechanical prostheses showed the most distinct vorticity (2.7±0.5 vs. 0.7±0.7; p<0.001), while stented bioprostheses exhibited most distinct helicity (2.6±0.7 vs. 1.6±0.5; p=0.002). Instead of a physiologic central flow, all stented, stentless and mechanical prostheses showed eccentric flow jets mainly directed towards the right-anterior aortic wall. Stented and stentless prostheses showed an asymmetric distribution of WSS(peak) along the aortic circumference, with significantly increased local WSS(peak) where the flow jet impinged on the aortic wall. Local WSS(peak) was higher in stented (1.4±0.7 N/m(2)) and stentless (1.3±0.7 N/m(2)) compared to autografts (0.6±0.2 N/m(2); p=0.005 and p=0.008) and controls (0.7±0.1 N/m(2); p=0.017 and p=0.027). Autografts exhibited lower absolute WSS(peak) than controls (0.4±0.1 N/m(2) vs. 0.7±0.2 N/m(2); p=0.003). CONCLUSIONS Flow characteristics in the ascending aorta after AVR are different from native aortic valves and differ between various types of AVR.

Efficacy and safety of etanercept in patients with the enthesitis-related arthritis category of juvenile idiopathic arthritis: results from a phase III randomized, double-blind study.

To evaluate the efficacy and safety of etanercept in patients with enthesitis‐related arthritis (ERA) in juvenile idiopathic arthritis (JIA).

Comparison of native high-resolution 3D and contrast-enhanced MR angiography for assessing the thoracic aorta

AIMS To omit risks of contrast agent administration, native magnetic resonance angiography (MRA) is desired for assessing the thoracic aorta. The aim was to evaluate a native steady-state free precession (SSFP) three-dimensional (3D) MRA in comparison with contrast-enhanced MRA as the gold standard. METHODS AND RESULTS Seventy-six prospective patients with known or suspicion of thoracic aortic disease underwent MRA at 1.5 T using (i) native 3D SSFP MRA with ECG and navigator gating and high isotropic spatial resolution (1.3 × 1.3 × 1.3 mm(3)) and (ii) conventional contrast-enhanced ECG-gated gradient-echo 3D MRA (1.3 × 0.8 × 1.8 mm(3)). Datasets were compared at nine aortic levels regarding image quality (score 0-3: 0 = poor, 3 = excellent) and aortic diameters, as well as observer dependency and final diagnosis. Statistical tests included paired t-test, correlation analysis, and Bland-Altman analysis. Native 3D MRA was acquired successfully in 70 of 76 subjects (mean acquisition time 8.6 ± 2.7 min), while irregular breathing excluded 6 of 76 subjects. Aortic diameters agreed close between both methods at all aortic levels (r = 0.99; bias ± SD -0.12 ± 1.2 mm) with low intra- and inter-observer dependency (intraclass correlation coefficient 0.99). Native MRA studies resulted in the same final diagnosis as the contrast-enhanced MRA. The mean image quality score was superior with native compared with contrast-enhanced MRA (2.4 ± 0.6 vs. 1.6 ± 0.5; P < 0.001). CONCLUSION Accuracy of aortic size measurements, certainty in defining the diagnosis and benefits in image quality at the aortic root, underscore the use of the tested high-resolution native 3D SSFP MRA as an appropriate alternative to contrast-enhanced MRA to assess the thoracic aorta.

Evaluation of Aortic Blood Flow and Wall Shear Stress in Aortic Stenosis and Its Association With Left Ventricular Remodeling.

Background—Aortic stenosis (AS) leads to variable stress for the left ventricle (LV) and consequently a broad range of LV remodeling. The aim of this study was to describe blood flow patterns in the ascending aorta of patients with AS and determine their association with remodeling. Methods and Results—Thirty-seven patients with AS (14 mild, 8 moderate, 15 severe; age, 63±13 years) and 37 healthy controls (age, 60±10 years) underwent 4-dimensional-flow magnetic resonance imaging. Helical and vortical flow formations and flow eccentricity were assessed in the ascending aorta. Normalized flow displacement from the vessel center and peak systolic wall shear stress in the ascending aorta were quantified. LV remodeling was assessed based on LV mass index and the ratio of LV mass:end-diastolic volume (relative wall mass). Marked helical and vortical flow formation and eccentricity were more prevalent in patients with AS than in healthy subjects, and patients with AS exhibited an asymmetrical and elevated distribution of peak systolic wall shear stress. In AS, aortic orifice area was strongly negatively associated with vortical flow formation (P=0.0274), eccentricity (P=0.0070), and flow displacement (P=0.0021). Bicuspid aortic valve was associated with more intense helical (P=0.0098) and vortical flow formation (P=0.0536), higher flow displacement (P=0.11), and higher peak systolic wall shear stress (P=0.0926). LV mass index and relative wall mass were significantly associated with aortic orifice area (P=0.0611, P=0.0058) and flow displacement (P=0.0058, P=0.0283). Conclusions—In this pilot study, AS leads to abnormal blood flow pattern and peak systolic wall shear stress in the ascending aorta. In addition to aortic orifice area, normalized flow displacement was significantly associated with LV remodeling.

Two-year Efficacy and Safety of Etanercept in Pediatric Patients with Extended Oligoarthritis, Enthesitis-related Arthritis, or Psoriatic Arthritis

Objective. The main objective was to determine the 2-year clinical benefit and safety of etanercept (ETN) in children with the juvenile idiopathic arthritis (JIA) categories of extended oligoarthritis (eoJIA), enthesitis-related arthritis (ERA), or psoriatic arthritis (PsA). Methods. CLIPPER was a 96-week, phase IIIb, open-label, multicenter study. Patients with eoJIA, ERA, or PsA received ETN 0.8 mg/kg once weekly (50 mg max) for up to 96 weeks. The proportions of patients reaching the JIA American College of Rheumatology (ACR) 30/50/70/90/100 and inactive disease responses at Week 96 were calculated. Adverse events (AE) were collected throughout the study (intention-to-treat sample). Results. There were 127 patients (eoJIA n = 60, ERA n = 38, PsA n = 29) who received ≥ 1 dose of ETN. The mean disease duration was 31.6 (eoJIA), 23.0 (ERA), and 21.8 (PsA) months. At Week 96, JIA ACR 30/50/70/90/100/inactive disease responses (95% CI) were achieved by 84.3% (76.7, 90.1), 83.5% (75.8, 89.5), 78.7% (70.6, 85.5), 55.1% (46.0, 63.9), 45.7% (36.8, 54.7), and 27.6% (20.0, 36.2) of patients, respectively. The most common AE (no. events, events per 100 patient-yrs) overall were headache (23, 10.7), pyrexia (12, 5.6), and diarrhea (10, 4.6). The most common infections were upper respiratory tract infection (83, 38.6), pharyngitis (50, 23.2), gastroenteritis (22, 10.2), bronchitis (19, 8.8), and rhinitis (17, 7.9). No cases of malignancy, active tuberculosis, demyelinating disorders, or death were reported. Conclusion. Over 96 weeks of therapy, ETN demonstrated sustained efficacy at treating the clinical symptoms of all 3 JIA categories, with no major safety issues.

Cardiovascular magnetic resonance in adults with previous cardiovascular surgery

Cardiovascular magnetic resonance (CMR) is a versatile non-invasive imaging modality that serves a broad spectrum of indications in clinical cardiology and has proven evidence. Most of the numerous applications are appropriate in patients with previous cardiovascular surgery in the same manner as in non-surgical subjects. However, some specifics have to be considered. This review article is intended to provide information about the application of CMR in adults with previous cardiovascular surgery. In particular, the two main scenarios, i.e. following coronary artery bypass surgery and following heart valve surgery, are highlighted. Furthermore, several pictorial descriptions of other potential indications for CMR after cardiovascular surgery are given.

Blood flow pattern in the ascending aorta after TAVI and conventional aortic valve replacement: Analysis using 4D-Flow MRI

Background Transarterial aortic valve implantation (TAVI) is a valid alternative to treat aortic stenosis in patients with high surgical risk. The impact of TAVI on changes in blood flow dynamics in the ascending aorta has not been systematically analyzed. Using temporally resolved, three-dimensional, phase contrast MRI (4D-flow), we studied 3D hemodynamics in the ascending aorta (AAo) after TAVI and compared the results to patients with conventional aortic valve replacement (AVR) as well as healthy controls.

Arthrosonographic Reference Values of the Shoulder Joint in Healthy Children and Adolescents: A Cross-Sectional Multicentre Ultrasound Study

Background Defining of gray scale ultrasound standard reference values of the shoulder joint in childhood and adolescence during maturation. PATIENTS We examined 445 healthy girls and boys between 1 year and 18 years of age. Method A cross-sectional multicentre grey-scale ultrasound study was performed to examine the shoulder joint on both sides. The children were divided according to their gender and were further classified into six age groups, which constituted three-year age ranges, to record anatomical development changes. We measured the capsule-bone distance (BCD) as a representation of the intracapsular cavity, as well as the thickness of the joint capsule and joint cartilage. Values were expressed in mean±standard deviation (SD) and minimum-maximum (min-max). The shape of the joint capsule and capsule-bone junction zone was qualitatively analysed. Results The joint cartilage thickness decreased with increasing age in all joints independently from sex and body side. However, the BCD and the capsule thickness increased with age. There was no intraarticular fluid visible. The joint capsule had a predominantly concave form, whereas the capsule-bone junction was mostly sharp. Discussion This study is the first describing age-related normal values of the intracapsular cavity, joint capsule and cartilage thickness as well as their respective shape in a large cohort of healthy children. Conclusion The findings could be helpful to differentiate between physiological and pathological joint conditions and thereby distinguishing age-related variations from alterations caused by inflammation.

Fluorescence optical imaging in pediatric patients with inflammatory and non-inflammatory joint diseases: a comparative study with ultrasonography

BackgroundValid detection of arthritis is essential in differential diagnosis of joint pain. Indocyanin green (ICG)-enhanced fluorescence optical imaging (FOI) is a new imaging method that visualizes inflammation in wrist and finger joints. Objectives of this study were to compare FOI with ultrasonography (US, by gray-scale (GS) and power Doppler (PD)) and clinical examination (CE) and to estimate the predictive power of FOI for discrimination between inflammatory and non-inflammatory juvenile joint diseases.MethodsFOI and GSUS/PDUS were performed in both hands of 76 patients with joint pain (53 with juvenile idiopathic arthritis (JIA), 23 with non-inflammatory joint diseases). Inflammation was graded by a semiquantitative score (grades 0–3) for each imaging method. Joints were defined clinically active if swollen or tender with limited range of motion. Sensitivity and specificity of FOI in three phases dependent on ICG enhancement (P1–P3) were analyzed with CE and GSUS/PDUS as reference.ResultsFor JIA patients, FOI had an overall sensitivity of 67.3%/72.0% and a specificity of 65.0%/58.8% with GSUS/PDUS as reference; specificity was highest in P3 (GSUS 94.3%/PDUS 91.7%). FOI was more sensitive for detecting clinically active joints than GSUS/PDUS (75.2% vs 57.3%/32.5%). In patients with non-inflammatory joint diseases both FOI and US showed positive (i.e., pathological) findings (25% and 14% of joints). The predictive value for discrimination between inflammatory and non-inflammatory joint diseases was 0.79 for FOI and 0.80/0.85 for GSUS/PDUS.ConclusionsDependent on the phase evaluated, FOI had moderate to good agreement with CE and US. Both imaging methods revealed limitations and should be interpreted cautiously. FOI may provide an additional diagnostic method in pediatric rheumatology.Trial registrationDeutsches Register Klinischer Studien DRKS00012572. Registered 31 July 2017.

Pharmacovigilance in juvenile idiopathic arthritis patients (Pharmachild) treated with biologic agents and/or methotrexate. Consolidated baseline characteristics from Pharmachild and other national registries

The availability of methotrexate (MTX) and biological agents has provided a major change in the treatment of children with juvenile idiopathic arthritis (JIA). An international registry named Pharmachild (European Union grant 260353) has been set up by the Pediatric Rheumatology International Trials Organisation (PRINTO)/Pediatric Rheumatology European Society (PRES). In parallel several national registries with the same purpose have been set up in different European Countries for the follow-up of these patients.