Differential prognostic accuracy of right ventricular dysfunction, the Seattle heart failure model and the MAGGIC score in patients with severe mitral regurgitation undergoing the MitraClip® procedure.

BACKGROUND: MitraClip ® (MC) is an established procedure for severe mitral regurgitation (MR) in patients deemed unsuitable for surgery.Right ventricular dysfunction (RVD) is associated with a higher mortality risk. The prognostic accuracy of heart failure risk scores like the Seattle heart failure model (SHFM) and Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in pts undergoing MC with or without RVD has not been investigated so far. METHODS: SHFM and MAGGIC score were calculated retrospectively. RVD was determined as tricuspid annular plane systolic excursion (TAPSE) ≤15 mm. Area under receiver operating curves (AUROC) of SHFM and MAGGIC were performed for one-year all-cause mortality after MC. RESULTS: N = 103 pts with MR III° (73 ± 11 years, LVEF 37 ± 17%) underwent MC with a reduction of at least I° MR. One-year mortality was 28.2%.In Kaplan-Meier analysis, one- year mortality was significantly higher in RVD-pts (34.8% vs 2.8%, p = 0.009).Area under the Receiver Operating Characteristic (AUROC) for SHFM and MAGGIC were comparable for both scores (SHFM: 0.704, MAGGIC: 0.692). In pts without RVD, SHFM displayed a higher AUROC and therefore better diagnostic accuracy (SHFM: 0.776; MAGGIC: 0.551, p < 0.05). In pts with RVD, MAGGIC and SHFM displayed comparable AUROCs. CONCLUSION: RVD is an important prognostic marker in pts undergoing MC. SHFM and MAGGIC displayed adequate over-all prognostic power in these pts. Accuracy differed in pts with and without RVD, indicating higher predictive power of the SHFM score in pts without RVD.

[Implantable loop recorders in the diagnosis of syncope]. / Implantierbare Loop-Rekorder in der Synkopendiagnostik.

In syncope patients, it is essential to make the right diagnosis with respect to underlying etiology. Cardiac (arrhythmic and structural) syncopal episodes carry untoward prognostic implication compared with reflex syncope. While rhythm-symptom correlation of a spontaneous syncopal episode is key to making the correct diagnosis, in case of unclear syncope the early implantation of a loop recorder leads to faster, more efficacious, and more cost-effective diagnosis. This review article summarizes the current data regarding diagnostic accuracy and clinical role of implantable loop recorders. It outlines the superiority of loop recorders in the management of unclear syncope according to present knowledge.

Catheter Ablation for "Lone" Atrial Fibrillation: Efficacy and Predictors of Recurrence.

BACKGROUND: Atrial fibrillation in otherwise healthy young patients has been termed "lone" atrial fibrillation (AF). The best treatment choice is still under discussion. The aim of this study was to report on efficacy and safety of catheter ablation. METHODS: Among 855 patients referred to our center between 2011 and 2013, 76 (9%) met the diagnostic criteria for lone AF (mean age 45 ± 8 years; mean LA diameter 37 ± 4 mm; paroxysmal AF 82%; persistent AF 18%). The primary endpoint was freedom from any atrial tachycardia after the first ablation; the secondary endpoint was freedom from any atrial tachycardia after the last ablation procedure without antiarrhythmic drugs. RESULTS: The primary endpoint occurred in 56 patients (74%) after a mean follow-up time of 444 ± 344 days. The secondary endpoint occurred in 73 patients (96%) after a mean of 1.3 ablations/patient during a follow-up time of 459 ± 366 days. The risk of AF recurrence was not influenced by AF duration or by the type of AF (paroxysmal versus persistent). In a multivariate regression analysis smoking (P = 0.001), first degree atrioventricular block (P = 0.001), and early (< 3 months) AF recurrence (P = 0.001) were independently associated with a higher risk of AF recurrence. Major peri-procedural adverse events did not occur. CONCLUSIONS: Catheter ablation in young healthy patients is highly effective and safe. The outcomes are maintained during long-term follow-up irrespective of preoperative AF duration. Patients with AF recurrence were more likely to smoke, have first degree AV block and early AF recurrence.

[Genetic analyses as basis for a personalized medicine in patients with coronary artery disease]. / Genetische Analysen als Basis einer individualisierten Medizin bei koronarer Herzkrankheit.

Knowledge about the etiology of coronary artery disease (CAD) entered new dimensions using genome-wide association studies. The current situation is that 46 chromosomal loci have been identified to be associated with CAD with genome-wide significance, i.e. p<5×10(-8), in Western Europeans. As the individual DNA sequence remains unchanged after fertilization, the risk variants cannot occur due to confounders, such as secondary disease processes. Thus, it can be proposed that these variants are directly affecting a primary and thereby causal pathophysiological process in CAD. Interestingly, only 20% of the effects mediated by the identified loci can be explained by the influence of traditional risk factors. This implies that yet unknown mechanisms and, as a consequence, new therapeutic targets play an important role in the pathophysiology of CAD. However, the high allele frequency of risk loci was also surprising. In the diploid chromosome set Western European individuals carry on average 30-50 risk variants at the 46 loci. Considering this, every individual in the population carries a larger or smaller genetic predisposition for CAD. On the other hand it is remarkable that many risk allele carriers seem to be able to compensate the genetic risk: even in old age not everyone suffers from CAD. This indicates yet unknown gene-gene and gene-environment interactions and limits the current possibilities in individual risk prediction.

The ratio of visceral to subcutaneous fat, a metric of body fat distribution, is a unique correlate of cardiometabolic risk.

AIMS/HYPOTHESIS: The anatomic location of excess body fat has an impact on associated cardiometabolic morbidity, and visceral adipose tissue (VAT) is more pathogenic than subcutaneous adipose tissue (SAT). However, VAT or SAT alone provides little information regarding the relative distribution of body fat. We hypothesised that the propensity to store energy in VAT relative to SAT depots may be a correlate of cardiometabolic risk, and tested this hypothesis using the VAT/SAT ratio as a metric of fat distribution. METHODS: We investigated associations of the VAT/SAT ratio with cardiometabolic traits in 3,223 participants (48% women) from the Framingham Heart Study. Fat depots were quantified by multidetector computed tomography (CT) scanning. RESULTS: In women and men, higher VAT/SAT ratio was associated (p < 0.05) with most assessed cardiovascular risk factors reflecting blood pressure, dyslipidaemia and insulin resistance. Additional adjustment for BMI did not materially change the findings in women, and generally strengthened associations in men. Further adjustment for VAT attenuated some associations in women, but those with lower HDL-cholesterol, higher triacylglycerol (both p < 0.0001) and higher prevalence of hypertension (p = 0.02), diabetes (p = 0.01) and the metabolic syndrome (p = 0.005) remained significant. Similarly, in men, associations with higher systolic (p = 0.006) and diastolic blood pressure (p = 0.03), higher fasting glucose (p = 0.0005), lower HDL-cholesterol and higher triacylglycerol (both p < 0.0001) and higher prevalence of diabetes (p = 0.006) remained significant. CONCLUSIONS/INTERPRETATION: VAT/SAT ratio is a correlate of cardiometabolic risk, above and beyond BMI and VAT. The propensity to store fat viscerally versus subcutaneously may be a unique risk factor independent of absolute fat volumes.

Association between anthropometric obesity measures and coronary artery disease: a cross-sectional survey of 16,657 subjects from 444 Polish cities.

BACKGROUND: Excessive body weight is known to cluster with cardiovascular (CV) risk factors, but it is not clear which anthropometric obesity measure provides best independent predictive value of coronary artery disease (CAD). METHODS AND RESULTS: We explored associations between CAD and four different obesity measures (body mass index (BMI), waist circumference, waist/height and waist/height(2)) in a cohort of 16 657 subjects (40.4% men; 20.8% CAD patients), recruited by 700 primary care physicians in 444 Polish cities. 42.8% of subjects were classified as overweight, 31.7% as obese and 39.8% had abdominal obesity. In univariate analyses all obesity measures correlated with CAD (p>0.001), but waist/height(2) was the strongest discriminator between CAD patients and controls. Age-adjusted and sex-adjusted analyses confirmed a graded increase in CAD risk across distributions of all four obesity measures-1 standard deviation (SD) increase in BMI, waist, waist/height and waist/height(2) increased the odds of CAD by 1.23, 1.24, 1.26 and 1.27, respectively (all p<0.001). In models fully adjusted for CV risk factors, waist/height(2) remained the strongest obesity correlate of CAD, being the only independent associate of CAD in men. In a fully adjusted BMI-waist circumference stratified model, sarcopenic obesity (waist > median, BMI < median) and simple obesity (waist and BMI > median) were the strongest independent associates of CAD in men (p = 0.008) and women (p>0.001), respectively. CONCLUSION: This cross-sectional study showed that waist/height(2) may potentially offer a slightly higher predictive value of CAD than BMI or waist circumference and revealed an apparent sexual dimorphism in correlations between obesity measures and CAD.

Odontological identification of the victims of flight AI. IT 5148 air disaster Lyon-Strasbourg 20.01.1992.

The authors report on the contribution of odontological identification of the flight AI. IT 5148 air disaster victims, which occurred on 20th January 1992. The identification procedure was difficult due to large numbers of bodies and mutilations and required the involvement of multidisciplinary teams composed of odontologists, forensic pathologists, radiologists and biologists. The authors set up a simple, discriminant classification which was easy to handle by a multidisciplinary team. Four groups were defined according to the matching characteristics between ante and post mortem data. Perfect matching characteristics between ante and post mortem data were achieved in only 44 cases (Group A). Partial matching characteristics between ante and post mortem data were achieved in 12 cases (Group B). In 29 cases, the insufficiency or absence of odontological data (Group C and D) did not enable the victim to be identified. The results of the investigations showed that the dental examination alone enabled 17 victims to be identified and by including a morphological examination the figure reached 33. By the end of the investigations, 85 of the 87 victims were positively identified. Odontological identification is an essential, accurate and rapid method with allows a body to be identified from its dental characteristics. This anthropometrical method of identification is included with the descriptive and the biological methods. The authors present their experience in performing a formal identification of 44 victims in less than 15 days.

[The use of the teeth in genetic fingerprinting]. / L'utilisation de la dent dans le domaine des empreintes génétiques.

Blood, hairs and sperm are tissues currently used in forensic science to carry out DNA fingerprints in the field of individual identification. Our study aims at showing that dental pulp can also be an exploitable DNA source. A quantitative and qualitative DNA investigation on a yield gel with sizing extracted from this tissue shows that the molecule appears to be in a great quantity and of a high molecular weight. The last characteristic allows the use of the restriction fragments length polymorphic technique to make DNA fingerprints, based on the individual variations of the restriction sites disposition, within the DNA molecule, for a given enzyme. Thus, for an enzyme, the length of the restriction fragments obtained and revealed by a probe, is visualized by autoradiograph. According to this technique, we compared the DNA fingerprints obtained on 8 persons with the probe MS43A, from both pulpal and nucleated blood cells. During the extraction of the third molar of each sample, a small quantity of blood was taken in the tooth socket. In the same time DNA was recovered. For a same person, the autoradiograph showed the same pattern for both blood and tooth sample. The DNA profile similitude confirms the possibility of using the tooth for genetic analysis. The interest in using dental tissues as a DNA source of individual identification falls within the particular character of resistance of this organ towards physical or chemical exterior aggressions. The tooth which until now was used in Anthropology and Forensic Science for its morphological aspects could be used this way for genetic study.

Medico-legal investigations of the Airbus, A320 crash upon Mount Ste-Odile, France.

The authors present the medico-legal investigations and identification after the aircrash of the Airbus A320 upon the Mount Sainte-Odile (France). The identification team comprising investigators from the gendarmerie, forensic pathologists, odontologists, and scientists of the Institute from Legal Medecine rapidly retrieved and identified 85 of the 87 victims, with 17 being identified through DNA typing, three through fingerprints and the remaining through dental records and specific physical or X-ray findings. Full autopsies were performed on all fatalities to determine patterns of injury and cause of death. Results lead us to point out the importance of a multidisciplinary team of forensic practitioners especially trained for managing medico-legal investigation in mass disaster and the ability of DNA technology to solve complex identification problems.

Atherosclerosis of the carotid arteries in young patients with familial hypercholesterolemia.

Patients with heterozygous and homozygous Familial Hypercholesterolemia exhibit a high incidence of premature coronary heart disease, presumably due to atheromatous plaque-formation in the coronary arteries. Clinical symptoms develop when the disease has progressed to more severe stages of atherosclerosis. Aim of our study was to visualize and document early atheromatous lesions in the carotid arteries of asymptomatic patients with familial hypercholesterolemia under 30 years of age by Duplex-scan. Of 44 patients, 70% had detectable carotid plaques, while only 12% of the controls were affected. All patients with severe carotid disease had serum cholesterol levels above 350 mg/dl. In the age group 2-20 years, 66% of the patients exhibited plaques. Only 6% of the FH patients 21-30 years had normal carotid arteries. We conclude that the process of atheromatous plaque formation in patients with FH starts early in life, severity of atherosclerosis being a function of both extent and duration of hypercholesterolemia. Duplex-scan examination of the carotid arteries is efficient and precise non-invasive method suitable to visualize this process and, by measuring regression, monitor the efficacy of therapeutic measures.