Association between Right Ventricular Function and Exercise Capacity in Patients with Chronic Heart Failure.

BACKGROUND: The association between right ventricular function and exercise capacity in patients with chronic heart failure remains uncertain. Several studies very recently mentioned the association between right ventricular reserve and exercise capacity, whereas the implication of tricuspid annular plane systolic excursion (TAPSE) remains uninvestigated. We aimed to assess the impact of TAPSE on exercise capacity in cardiac rehabilitation candidates. METHODS: Data from patients with chronic heart failure who received cardiopulmonary exercise tests and transthoracic echocardiography prior to cardiac rehabilitation were retrospectively collected, and their association was investigated. RESULTS: A total of 169 patients with chronic heart failure (70.3 ± 11.7 years old, 74.6% men) were included. Tertiled tricuspid annular plane systolic excursion significantly stratified anaerobic threshold (10.2 ± 2.2, 11.4 ± 2.2, and 12.2 ± 2.8 mm; p < 0.01) and peak oxygen consumption (15.9 ± 4.5, 18.3 ± 5.3, and 19.8 ± 5.6 mm; p < 0.01). In the multivariate logistic regression analyses, TAPSE was an independent factor associated with anaerobic threshold and peak oxygen consumption (p < 0.05 for both). CONCLUSIONS: Right ventricular impairment was associated with reduced exercise capacity in patients with chronic heart failure. Such knowledge would be useful to estimate patients' exercise capacity and prescribe cardiac rehabilitation. Its longitudinal association and clinical implication need further studies.

A novel surgical approach to the lumbar spine involving hemilateral split-off of the spinous process to preserve the multifidus muscle: technical note.

In the conventional posterior approach to the lumbar spine, the lamina is exposed by stripping the paravertebral muscles from the spinous process, and the resulting paravertebral muscle damage can produce muscle atrophy and decreased muscle strength. The author developed a novel surgical approach to the lumbar spine in which the attachment of the paravertebral muscles to the spinous process is preserved. In the novel approach, the spinous process is split on the midline without stripping the attached muscles, and a hemilateral half of the spinous process is then resected at the base, exposing only the ipsilateral lamina. Before closing, the resected half is sutured and reattached to the remaining half of the spinous process. Thirty-eight patients with lumbar spinal canal stenosis (LSCS) undergoing unilateral partial laminectomy and bilateral decompression using this novel approach were analyzed. Postoperative changes in the multifidus muscle were evaluated by T2 signal intensity on MR images. MRI performed 1 year after the operation revealed no significant difference in the T2 signal intensity of the multifidus muscle between the approach and nonapproach sides. This result indicated that postoperative changes of the multifidus muscle on the approach side were slight. The clinical outcomes of unilateral partial laminectomy and bilateral decompression using this approach for LSCS were satisfactory. The novel approach can be a useful alternative to the conventional posterior lumbar approach.

Acute kidney injury after transcatheter aortic valve implantation: Impact of contrast agents, predictive factors, and prognostic importance in 203 patients with long-term follow-up.

BACKGROUND: Acute kidney injury (AKI) frequently occurs following transcatheter aortic valve implantation (TAVI) and has been related to a worse outcome. We investigated the importance of contrast medium composition, either iso-osmolar (IOCM) or low-osmolar (LOCM) and assessed predictors for AKI after TAVI. METHODS AND RESULTS: We assessed AKI in 203 TAVI patients treated mainly with trans-femoral implantation and analgosedation. A total of 100 patients received IOCM and 103 LOCM. AKI was defined according to the Valve Academic Research Consortium. Following TAVI, 39 patients (19.2%) developed AKI; 17.0% of the IOCM and 21.4% of the LOCM group (p=0.43). The only independent predictor for AKI was baseline serum creatinine [odds ratio (OR) 0.26, 95% confidence interval (CI) 0.01-0.64, p=0.002]. Patients with advanced AKI (stages 2 and 3) post-TAVI had significantly higher mortality at 2 years (log rank p<0.001), whereas patients with AKI stage 1 had a similar long-term outcome to non-AKI patients. CONCLUSIONS: Following TAVI, we observed no difference in the occurrence of AKI between IOCM and LOCM. Baseline creatinine was the only independent predictor of AKI, and patients who developed advanced AKI had significantly higher mortality at 2 years.

Aortic regurgitation after transcatheter aortic valve implantation with balloon- and self-expandable prostheses: a pooled analysis from a 2-center experience.

OBJECTIVES: This study sought to assess aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) with the self-expandable Medtronic CoreValve (MCV) (Medtronic Inc., Minneapolis, Minnesota) versus balloon-expandable Edwards Sapien XT valve (ESV) (Edwards Lifesciences, Irvine, California). BACKGROUND: AR after TAVI has been associated with poor survival, but limited data exist comparing MCV with ESV. METHODS: We pooled the prospective TAVI databases of 2 German centers. The primary endpoint was more-than-mild post-TAVI AR assessed by echocardiography. We also assessed device success and survival within 1 year. Endpoints were adjudicated according to the Valve Academic Research Consortium criteria and analyzed by unadjusted and propensity-score-adjusted models. RESULTS: A total of 394 patients were included, 276 treated with MCV and 118 with ESV. More-than-mild AR was significantly higher with MCV than with ESV (12.7% vs. 2.6%, p = 0.002). This difference remained significant after propensity adjustment (adjusted odds ratio [OR]: 4.59, 95% confidence interval [CI]: 1.03 to 20.44). The occurrence of any degree of AR was also higher with MCV (71.6% vs. 56.9%, p = 0.004). Device success was mainly influenced by the occurrence of AR and was consequently higher with ESV (95.8% vs. 86.6%, p = 0.007), but this was not significant after propensity adjustment (adjusted OR: 0.34, 95% CI: 0.11 to 1.03, p = 0.06). At 1 year, survival was comparable between both valve types (83.8% MCV vs. 88.2% ESV, p = 0.42), but was significantly worse in patients with more-than-mild AR (69.8% vs. 87.4%, p = 0.004) and in those with device failure (65.6% vs. 87.4%, p < 0.001). CONCLUSIONS: More-than-mild AR after TAVI was more frequent with MCV than with ESV. This finding deserves consideration, as more-than-mild AR was associated with higher mortality at 1 year.

Predictive factors of re-restenosis after repeated sirolimus-eluting stent implantation for SES restenosis and clinical outcomes after percutaneous coronary intervention for SES restenosis.

Sirolimus-eluting stent (SES) is established to be effective in reducing restenosis. Repeat revascularization, however, is still required in up to 5-8% of patients. In this study, we analyzed clinical and angiographic variables that might be related with SES re-restenosis and variables related with re-restenosis after repeat SES implantation for SES restenosis. We also assessed clinical outcomes at 2-year follow-up after percutaneous coronary intervention (PCI) for SES restenosis. Repeat revascularization for SES restenosis was performed in 113 patients with 140 lesions. Of the 140 lesions, follow-up coronary angiography (CAG) was performed on 117 lesions (101 patients) and revealed 46 SES re-restenotic and 71 non-re-restenotic lesions. In multivariate analysis, SES-in-SES-strategy and reference diameter before the second PCI were independent predictors of re-restenosis after PCI for SES restenosis. However, the reference diameter was the only independent predictor of re-restenosis after SES-in-SES. Major adverse cardiac events (MACE) at 2 years were found in 44 patients (43.5%), and target lesion revascularization (TLR) was performed in 33.7% of patients after SES restenosis. In conclusion, the incidence of MACE and TLR was relatively high in patients with SES restenosis, but the placement of another SES on larger-diameter vessels may be an effective strategy for the second PCI.

Arthroscopic treatment for septic arthritis of the shoulder in an infant.

We report a case of septic arthritis in the shoulder of an infant treated with a combination of arthroscopic irrigation, debridement, and synovectomy. The results were encouraging. The patient was a boy who was 2 years 6 months of age. His first symptoms were a body temperature of 40 degrees C and right upper arm pain. Five days after the onset, he was brought to our institution. His shoulder was swollen and erythematous. Yellowish fluid (7 ml) was aspirated from his shoulder joint; the causative organism was group A Streptococcus. On admission, arthroscopic surgery was performed. His temperature gradually decreased, and inflammatory markers including the white blood cell count and C-reactive protein level improved. At his 1-year follow-up there was no sign of infection, and a full range of motion in the shoulder was maintained. The interval between the onset and the start of treatment is an important factor affecting the prognosis. The patient was brought to our institution 5 days after onset and underwent arthroscopic surgery on the same day. This early treatment was one of the factors that contributed to a successful result. Arthroscopic surgery, including irrigation and debridement, may be one of the options for treating septic arthritis of an infant's shoulder.