Subject(s)
Aortic Valve Insufficiency/diagnosis , Aortic Valve/surgery , Heart Valve Prosthesis , Hemodynamic Monitoring , Hemodynamics , Transcatheter Aortic Valve Replacement/adverse effects , Transcatheter Aortic Valve Replacement/instrumentation , Aged , Aged, 80 and over , Aortic Valve/physiopathology , Aortic Valve Insufficiency/etiology , Aortic Valve Insufficiency/physiopathology , Female , Humans , Male , Pilot Projects , Predictive Value of Tests , Prosthesis Design , Risk Assessment , Risk Factors , Transcatheter Aortic Valve Replacement/mortality , Treatment OutcomeABSTRACT
Oncologic emergencies have a high rate of morbidity and mortality. This review covers several scenarios of gastrointestinal malignancies presenting emergently as various acute abdominal pathologies. Radiologists should be familiar with the typical imaging findings, clinical presentations, and laboratory values which may suggest a background neoplasm, particularly when encountered in the context of an acute inflammatory state. Imaging plays a vital role in the workup of these patients; delays in appropriate diagnosis negatively affect outcomes, oftentimes resulting in the need for additional intervention. It is important for radiologists to understand which patients may have a higher likelihood of an underlying malignancy. Correctly identifying these malignancies when seen in an emergency room is particularly vital, as radiologists may be among the first providers to suggest a diagnosis of cancer in this setting.
Subject(s)
Emergencies , Gastrointestinal Neoplasms/diagnostic imaging , Acute Disease , Diagnosis, Differential , Emergency Service, Hospital , Humans , InflammationABSTRACT
OBJECTIVES: We investigated the hemodynamic durability of the transcatheter aortic valves (TAVs) using the updated Valve Academic Research Consortium-2 (VARC-2) criteria. BACKGROUND: The updated VARC-2 consensus criteria combine flow-dependent and flow-independent echocardiographic parameters for hemodynamic assessment of TAVR. Data on the hemodynamic durability of TAV and clinical risk factors associated with valve hemodynamic deterioration (VHD) are lacking. METHODS: All patients (n = 276) who received TAV between 2006 and 2012 and had ≥2 follow-up echocardiograms were studied. RESULTS: During a median follow up period of 3.3 (1.8-4.4) years, 8 patients (3%) developed moderate to severe valve stenosis per the VARC-2 criteria, while 20 had mild stenosis. In a Cox proportional hazards model analysis, moderate to severe stenosis by VARC-2 criteria was associated with younger age (P = 0.03, HR 0.94), absence of dual antiplatelet therapy (DAPT) (P = 0.026, HR 0.18), and lower baseline left ventricular ejection fraction (LVEF) (P = 0.006, HR 0.94). Longitudinal analysis using a mixed effect model showed that presence of stenosis by VARC-2 criteria was associated with an increase in aortic valve mean gradient (P < 0.001, +2.34 mmHg per year). In a subset of 93 patients with analyzable fluoroscopic images, deeper valve implantation was associated with increase in mean gradient (P = 0.004, +0.2 mmHg per year per 1 mm increase in implantation depth). CONCLUSION: Despite good hemodynamic durability of TAV, patients with younger age, lower LVEF and those not on DAPT after undergoing a TAV replacement, are at a higher risk for development of VHD.
Subject(s)
Aortic Valve Stenosis/surgery , Aortic Valve/surgery , Bioprosthesis , Heart Valve Prosthesis , Hemodynamics , Transcatheter Aortic Valve Replacement/instrumentation , Age Factors , Aged , Aged, 80 and over , Aortic Valve/diagnostic imaging , Aortic Valve/physiopathology , Aortic Valve Stenosis/diagnostic imaging , Aortic Valve Stenosis/physiopathology , Female , Humans , Male , Platelet Aggregation Inhibitors/therapeutic use , Prosthesis Design , Prosthesis Failure , Recurrence , Retrospective Studies , Risk Assessment , Risk Factors , Severity of Illness Index , Stress, Mechanical , Time Factors , Transcatheter Aortic Valve Replacement/adverse effects , Treatment Outcome , Ventricular Function, LeftABSTRACT
BACKGROUND: The Society of Thoracic Surgeons (STS) scores are used to screen patients for transcatheter aortic valve replacement (TAVR). The STS scores were also used to risk stratify patients in major TAVR trials. This study evaluates the reclassification of predicted risk of mortality by the currently available online STS score calculator compared with the 2008 STS risk model in patients undergoing TAVR. METHODS AND RESULTS: All patients who underwent TAVR from 2006 to 2016 were included in the study. The STS scores for all included patients were calculated by applying the 2008 STS risk model and again using the current STS online calculator. Among 1209 patients who underwent TAVR, 30-day mortality was 27 (2.2%). The overall predicted risk of mortality estimated by using the current online STS risk calculator was significantly lower than the 2008 STS risk model (6.3±4.4 vs 7.3±4.9; P<0.001). A total of 235 (19%) patients were reclassified into a lower risk category per the current STS risk model. In a multivariable logistic regression analysis, patients with persistent atrial fibrillation (odds ratio, 1.4; 95% CI, 1.0-1.9; P=0.03), chronic heart failure (odds ratio, 6.0; 95% CI, 3.8-10.1; P<0.001), and New York Heart Association class IV heart failure (odds ratio, 2.4; 95% CI, 1.3-4.4; P=0.007) were more likely to be reclassified into a lower risk category per the current STS risk model. CONCLUSIONS: The current STS calculation method produces significantly lower predicted risk of mortality than the 2008 calculator, more pronounced in patients with certain comorbid conditions. These results should be considered while evaluating data from prior studies of TAVR.
