Cardiovascular magnetic resonance validation of fractional changes in annulo-apical angles and tricuspid annular plane systolic excursion for rapid assessment of right ventricular systolic function.

PURPOSE: To evaluate the use of right ventricular (RV) annulo-apical angle (AA) changes acquired by magnetic resonance imaging (MRI), alongside tricuspid annular plane systolic excursion (TAPSE), for its association with RV systolic function. MATERIALS AND METHODS: Thirty patients with varying RV dysfunction and 10 normal controls were enrolled and scanned after obtaining written consent. Systolic change in AAs, alpha (α), beta (ß), and theta (θ), subtended by a triangle connecting the septal and lateral extent of the tricuspid valve annulus and RV apex, and TAPSE were measured. Spearman rank correlations of parameters with RV ejection fraction (RVEF) were performed. Receiver operating characteristic (ROC) analysis was used to determine accuracy of these surrogate markers for detecting abnormal RVEF. RESULTS: Correlations with RVEF included: TAPSE (r = 0.74 P < 0.001), fractional systolic changes in α angle (0.64, P < 0.001), ß angle (-0.39, P < 0.05), and θ angle (-0.77, P < 0.001). The best markers for RVEF <50% were fractional θ angle change ≥ -25.5% (eg, -24%) (sensitivity of 97% and specificity of 91%), and TAPSE ≤1.87 cm (sensitivity of 100% and specificity of 82%). Intra- and inter-observer agreement was excellent, with intraclass correlation coefficients for fractional θ angle change (intra = 0.96, inter = 0.94) and TAPSE (intra = 0.98, inter = 0.87). CONCLUSION: Fractional θ angle change is a useful semiquantitative parameter associated with the presence and severity of RV systolic dysfunction, with high observer agreement.

A pilot project of familial screening in patients with bicuspid aortic valve disease.

BACKGROUND AND AIM OF THE STUDY: Bicuspid aortic valve (BAV) is a common congenital cardiac abnormality, is often familial, and is associated with dilatation of the aortic root. The risk of dissection is significantly higher than that in the general population, occurring at a younger age than in patients with idiopathic aortic aneurysms. Current ACC/AHA guidelines recommend familial echocardiographic screening which, to the present authors' knowledge, is not performed routinely and uniformly. The aim of this pilot project was to explore the practicalities of running such a program. METHODS: An initial cohort of 47 patients who had undergone surgery for BAV disease and/or associated aneurysmal aortic dilatation were offered counseling and familial screening. Referred first-degree relatives (FDR) underwent aortic valve and root assessment by standard two-dimensional echocardiography. RESULTS: Twenty-four index patients (51%) referred a total of 75 FDR (approximately three per patient) who wished to undergo echocardiography, of whom 52 (70%) attended for review. The pick-up rate of newly detected BAV was 8% (four of 52 relatives). One of these asymptomatic individuals had a significant ascending aortic aneurysm, which required prompt surgery. In the families of the 24 index patients, there was a total of eight cases (14% prevalence) of aortic valve disease, either known or newly detected via screening. CONCLUSION: This pilot study confirmed the relatively high prevalence of BAV among FDR of patients who have undergone surgery for BAV-associated pathology. Patients should be made aware of the condition's pattern of inheritance, and familial screening should be actively pursued to reduce the potential morbidity and mortality associated with BAV and its related aortopathy. A number of important and practical considerations for setting-up a familial screening program are discussed.

Lipid-lowering therapy in chronic kidney disease: is there a role for ezetimibe?

The use of lipid-lowering therapy (LLT) in chronic kidney disease (CKD) results in a reduction in atherosclerotic cardiovascular events but not mortality. The risk reduction for patients on dialysis appears to be less than in pre-dialysis CKD. These findings may be due to the higher rate of non-atherosclerotic cardiovascular disease found in end-stage disease. Because of this, the role of LLT is less clear in CKD than in the general population. This review outlines the results of recent trials of LLT, particularly Ezetimibe, and implications for patients with CKD. The evidence in favour of lipid lowering in CKD comes largely from the SHARP study. This study used combined simvastatin and Ezetimibe to reduce cholesterol. Though the benefits of statins are well proven, there is no evidence that Ezetimibe independently reduces cardiovascular events in any population. Data which support the use of Ezetimibe show only that it effectively reduces cholesterol. Surrogate end-point data are contentious. Some studies suggest benefit whilst others suggest off-target effects that question the validity of Ezetimibe in the absence of quality cardiovascular outcome data.

Is high body mass index associated with increased risk of groin complications using manual compression after diagnostic coronary angiography?

There is a common perception that high body mass index (BMI) is associated with an increased risk of bleeding complications at the site of femoral puncture when manual compression is used for achieving hemostasis. Because of lack of evidence to support or refute this, we conducted a study to assess whether raised BMI is associated with increased risk of groin complications. 15 cases of groin complications after manual compression over 2 years and 40 controls were each divided into 3 groups according to BMI. Baseline characteristics of cases and controls were similar. High BMI was not found to be associated with increased risk of groin complications, suggesting that manual compression is safe and effective in patients with raised BMI.