Prognostic Impact of Tricuspid Regurgitation in Patients Undergoing Aortic Valve Surgery for Aortic Stenosis

Background

The prognostic significance of tricuspid regurgitation (TR) and right ventricular (RV) function in patients undergoing aortic valve replacement (AVR) for severe aortic stenosis (AS) is unknown. The aim of the present study was to evaluate the impact of TR and RV systolic dysfunction on early and late mortality in this setting.

Methods

This was a prospective single-center observational study. 465 consecutive patients who were referred to AVR for severe AS were investigated. Significant TR was defined as TR≥moderate by transthoracic echocardiography.

Results

At baseline, significant TR was present in 26 (5.6%) patients. Patients with TR presented with a higher EuroSCORE I (p = 0.001), a higher incidence of previous cardiac surgery (p<0.001), pulmonary hypertension (p = 0.003), more dilated RVs (p = 0.001), and more frequent RV dysfunction (p = 0.001). Patients were followed for an average of 5.2 (±2.8 SD) years. By multivariable Cox regression analysis TR (p = 0.014), RV dysfunction (p = 0.046), age (p = 0.001) and concomitant coronary artery bypass graft surgery (CABG, p = 0.003) were independently associated with overall mortality. By Kaplan-Meier analysis, survival rates were significantly worse in patients with significant than with non-significant TR (log rank p = 0.001).

Conclusions

TR, RV dysfunction, age, and concomitant CABG are associated with outcome in patients undergoing AVR for severe AS. This finding underlines the importance of a thorough echocardiographic evaluation with particular consideration of the right heart in these patients.     

超声心动图对缺血性二尖瓣反流血流动力学的研究

目的:应用超声心动图研究缺血性二尖瓣反流(IMR)所致左室、二尖瓣环动力学变化。方法:超声心动图检测86例缺血性二尖瓣反流患者(前壁心肌梗死49例,下壁心肌梗死37例)和30例正常人的心脏,测量左室参数及二尖瓣环形态参数。结果:IMR组左室EDV、ESV增加,LVEF减低,但与对照组无显著差异;二尖瓣环面积及位移与对照组有显著差异;不同部位心肌梗死均发生明显左室重构;下壁梗死组PPM-AMP明显延长。结论:超声心动图作为心肌梗死患者的常规检查,可以针对不同患者进行不同的参数检查,这也为临床医生选择个性化治疗方案和疗效评价提供了依据。     

Detection of the third and fourth heart sounds using Hilbert-Huang transform

Background

Magnetic nanoparticles are gaining great roles in biomedical applications as targeted drug delivery agents or targeted imaging contrast agents. In the magnetic nanoparticle applications, quantification of the nanoparticle density deposited in a specified region is of great importance for evaluating the delivery of the drugs or the contrast agents to the targeted tissues. We introduce a method for estimating the nanoparticle density from the displacement of tissues caused by the external magnetic field.

Methods

We can exert magnetic force to the magnetic nanoparticles residing in a living subject by applying magnetic gradient field to them. The nanoparticles under the external magnetic field then exert force to the nearby tissues causing displacement of the tissues. The displacement field induced by the nanoparticles under the external magnetic field is governed by the Navier's equation. We use an approximation method to get the inverse solution of the Navier's equation which represents the magnetic nanoparticle density map when the magnetic nanoparticles are mechanically coupled with the surrounding tissues. To produce the external magnetic field inside a living subject, we propose a coil configuration, the Helmholtz and Maxwell coil pair, that is capable of generating uniform magnetic gradient field. We have estimated the coil currents that can induce measurable displacement in soft tissues through finite element method (FEM) analysis.

Results

From the displacement data obtained from FEM analysis of a soft-tissue-mimicking phantom, we have calculated nanoparticle density maps. We obtained the magnetic nanoparticle density maps by approximating the Navier's equation to the Laplacian of the displacement field. The calculated density maps match well to the original density maps, but with some halo artifacts around the high density area. To induce measurable displacement in the living tissues with the proposed coil configuration, we need to apply the coil currents as big as 10⁴A.

Conclusions

We can obtain magnetic nanoparticle maps from the magnetically induced displacement data by approximating the Navier's equation under the assumption of uniform-gradient of the external magnetic field. However, developing a coil driving system with the capacity of up to 10⁴A should be a great technical challenge.     

Surgery Issue: Solving the Puzzle of Chronic Ischemic Mitral Regurgitation

Chronic ischemic mitral regurgitation is a prevalent problem among patients following a myocardial infarction. Until recently, the pathophysiology was poorly understood, resulting in surgical strategies with suboptimal results and limited durability. The surgical approach has evolved from revascularization alone to an additional mitral valve procedure, replacement, or repair. When the valve was repaired, isolated annuloplasty was performed. The dilemma that surgeons had when repairing a mitral valve was which type of ring to use and what size. In all series with annuloplasty alone, the results were poor with very high recurrence rates. The primary feature of ischemic mitral regurgitation is a prolapse of the anterior leaflet at A3 ± A2. This prolapse can be caused by fibrotic elongation of the papillary muscle supporting A3 ± A2 or tethering of P3 by a ballooning posterior left ventricular wall. Using a technique that corrects this prolapse with Gore-Tex neochords, we have achieved excellent results with effective and durable correction of the ischemic mitral regurgitation.     

A Pig Model of Ischemic Mitral Regurgitation Induced by Mitral Chordae Tendinae Rupture and Implantation of an Ameroid Constrictor

A miniature pig model of ischemic mitral regurgitation (IMR) was developed by posterior mitral chordae tendinae rupture and implantation of an ameroid constrictor. A 2.5-mm ameroid constrictor was placed around the left circumflex coronary artery (LCX) of male Tibetan miniature pigs to induce ischemia, while the posterior mitral chordae tendinae was also ruptured. X-ray coronary angiography, ECG analysis, echocardiography, and magnetic resonance imaging (MRI) were used to evaluate heart structure and function in pigs at baseline and one, two, four and eight weeks after the operation. Blood velocity of the mitral regurgitation was found to be between medium and high levels. Angiographic analyses revealed that the LCX closure was 10–20% at one week, 30–40% at two weeks and 90–100% at four weeks subsequent ameroid constrictor implantation. ECG analysis highlighted an increase in the diameter of the left atria (LA) at two weeks post-operation as well as ischemic changes in the left ventricle (LV) and LA wall at four weeks post-operation. Echocardiography and MRI further detected a gradual increase in LA and LV volumes from two weeks post-operation. LV end diastolic and systolic volumes as well as LA end diastolic and systolic volume were also significantly higher in pig hearts post-operation when compared to baseline. Pathological changes were observed in the heart, which included scar tissue in the ischemic central area of the LV. Transmission electron microscopy highlighted the presence of contraction bands and edema surrounding the ischemia area, including inflammatory cell infiltration within the ischemic area. We have developed a pig model of IMR using the posterior mitral chordae tendineae rupture technique and implantation of an ameroid constrictor. The pathological features of this pig IMR model were found to mimic the natural history and progression of IMR in patients.     

A method for identifying sounds used in the classification of alarm calls

In this study, we present a methodology that identifies acoustic units in Gunnison's prairie dog alarm calls and then uses those units to classify the alarm calls and bouts according to the species of predator that was present when the calls were vocalized. While traditional methods measure specific acoustic parameters in order to describe a vocalization, our method uses the variation in the internal structure of a vocalization to define possible information structures. Using a simple representation similar to that used in human speech to identify vowel sounds, a software system was developed that uses this representation to recognize acoustic units in prairie dog alarm calls. These acoustic units are then used to classify alarm calls and their associated bouts according to the species of predator that was present when the alarm calls were vocalized. Identification of bouts with up to 100% accuracy was obtained. This work represents a first step toward revealing the details of how information is encoded in a complex nonhuman communication system. Furthermore, the techniques discussed in this paper are not restricted to a database of prairie dog alarm calls. They could be applied to any animal whose vocalizations include multiple simultaneous frequencies.     

The Role of Rubella in the Etiology of Supravalvular Aortic Stenosis

The possibility of an etiological relationship between rubella embryopathy and sporadic forms of supravalvular aortic stenosis is considered. A case is presented of a patient with rubella embryopathy and supravalvular aortic stenosis associated with pulmonary valvular and peripheral pulmonary artery stenosis, bicuspid aortic valve, aortic valve stenosis and subendothelial myocardial fibrosis. A review of the literature revealed many clinical and pathological features common to both syndromes. The hypothesis that rubella virus produced germ-cell mutation and subsequent persistence of rubella in the zygote produced further fetal damage is presented to explain these observations.     

A method for computerized modification of certain natural animal sounds for communication study purposes

A new method for computerized modification of sound signals is presented. With digital signal processing in the time domain it is possible to alter the amplitude, the frequency and the time scale of natural sounds independently. The method can be applied to natural sounds with reasonably pure tonal quality.     

Solving inverse problems for biological models using the collage method for differential equations

In the first part of this paper we show how inverse problems for differential equations can be solved using the so-called collage method. Inverse problems can be solved by minimizing the collage distance in an appropriate metric space. We then provide several numerical examples in mathematical biology. We consider applications of this approach to the following areas: population dynamics, mRNA and protein concentration, bacteria and amoeba cells interaction, tumor growth.     

A generating model of realistic synthetic heart sounds for performance assessment of phonocardiogram processing algorithms

A new model which is capable of generating realistic synthetic phonocardiogram (PCG) signals is introduced based on three coupled ordinary differential equations. The new PCG model takes into account the respiratory frequency, the heart rate variability and the time splitting of first and second heart sounds. This time splitting occurs with each cardiac cycle and varies with inhalation and exhalation. Clinical PCG statistics and the close temporal relationship between events in ECG and PCG are used to deduce values of PCG model parameters.In comparison with published PCG models, the proposed model allows a larger number of known PCG features to be taken into consideration. Moreover it is able to generate both normal and abnormal realistic synthetic heart sounds. Results show that these synthetic PCG signals have the closest features to those of a conventional heart sound in both time and frequency domains. Additionally, a sound quality test carried out by eight cardiologists demonstrates that the proposed model outperforms the existing models.This new PCG model is promising and useful in assessing signal processing techniques which are developed to help clinical diagnosis based on PCG.