I read with great interest the report by Macheret et al., (1) who
conducted an 11-year prospective study in 3190 older adults, aged 65 years
or older, without cardiovascular disease for monitoring incident atrial
fibrillation (AF). The authors measured plasma total adiponectin, high
molecular weight (HMW) adiponectin and amino-terminal pro-brain
natriuretic peptide 1-76 (NT-proBNP1-76). There were 886 incident AF
events,...
I read with great interest the report by Macheret et al., (1) who
conducted an 11-year prospective study in 3190 older adults, aged 65 years
or older, without cardiovascular disease for monitoring incident atrial
fibrillation (AF). The authors measured plasma total adiponectin, high
molecular weight (HMW) adiponectin and amino-terminal pro-brain
natriuretic peptide 1-76 (NT-proBNP1-76). There were 886 incident AF
events, and they demonstrated a positive, not U-shaped, association
between incident AF and total or HMW adiponectin with causality by
adjusting NT-proBNP1-76, adiposity and other confounders. I have some
concerns on their study.
First, the authors speculated some possible mechanism on the risk of
increased plasma total and HMW adiponectin for incident AF in older
adults. I fundamentally agree with their comments, but sex difference on
total and HMW adiponectin should be handled with caution. The authors
presented the decreasing trend in the percentage of men, stratified by
quartiles of total and HMW adiponectin in their Tables 1 and S1. As there
is a sex difference on AF (2), stratified analysis by sex in addition to
the adjustment with sex would present useful information.
Second, the authors selected the Cox proportional hazard model for
the risk assessment of AF by plasma total and HMW adiponectin. The authors
presented that correlation coefficient between total and HMW adiponectin
was 0.94, and I agree with their statistical procedure of precluding
simultaneous inclusion into independent variables. Is there no superiority
between total and HMW adiponectin for the prediction of AF in older
adults?
Barnett and Piccini (3) also recommended further research to confirm
the possible mechanism on the association, which would lead to the
prevention of AF in older adults. Anyway, studies presenting the positive
or no association between adiponectin and incident AF would be summarized
by meta-analysis in the future(4,5).
References
1. Macheret F, Bartz TM, Djousse L, et al. Higher circulating
adiponectin levels are associated with increased risk of atrial
fibrillation in older adults. Heart 2015;101:1368-74.
2. Rienstra M, Van Veldhuisen DJ, Hagens VE, et al. Gender-related
differences in rhythm control treatment in persistent atrial fibrillation:
data of the Rate Control Versus Electrical Cardioversion (RACE) study. J
Am Coll Cardiol 2005;46:1298-306.
3. Barnett AS, Piccini JP Sr. Adiponectin: an accurate biomarker for
patients at risk for atrial fibrillation? Heart 2015;101:1351-2.
4. Knuiman M, Briffa T, Divitini M, et al. A cohort study examination
of established and emerging risk factors for atrial fibrillation: the
Busselton Health Study. Eur J Epidemiol 2014;29:181-90.
5. Rienstra M, Sun JX, Lubitz SA, et al. Plasma resistin,
adiponectin, and risk of incident atrial fibrillation: the Framingham
Offspring Study. Am Heart J 2012;163:119-124.e1.
We thank Dr. Kawada for his comments regarding our study. Consistent
with the sexual dimorphism in circulating adiponectin levels documented in
both rodents and humans, plasma concentrations of total and high-molecular
-weight (HMW) adiponectin were higher in female than male participants in
the Cardiovascular Health Study.[1] Despite such differences, we have not
found evidence of effect modification by sex for total or H...
We thank Dr. Kawada for his comments regarding our study. Consistent
with the sexual dimorphism in circulating adiponectin levels documented in
both rodents and humans, plasma concentrations of total and high-molecular
-weight (HMW) adiponectin were higher in female than male participants in
the Cardiovascular Health Study.[1] Despite such differences, we have not
found evidence of effect modification by sex for total or HMW adiponectin
for a variety of outcomes in this cohort, including diabetes,[2]
mortality,[1] cardiovascular disease,[3] heart failure[4] and now atrial
fibrillation (AF).[5] In our view, this lack of support for sex
interaction obviates the need for stratified analyses. As relates to Dr.
Kawada's query regarding the possible superiority of HMW adiponectin for
prediction of AF, we note that although the risk estimates are somewhat
higher numerically for the HMW fraction as compared with total
adiponectin, the broadly overlapping 95% confidence intervals do not
support the presence of a real difference between the two. Last, as
detailed in our manuscript and the accompanying editorial, our findings
lay out the need for further study into the adiponectin-AF relationship,
and we agree with Dr. Kawada that such efforts should include meta-
analytic approaches.
References
1. Kizer JR, Benkeser D, Arnold AM, Mukamal KJ, Ix JH, Zieman SJ,
Siscovick DS, Tracy RP, Mantzoros CS, Defilippi CR, Newman AB, Djousse L.
Associations of total and high-molecular-weight adiponectin with all-cause
and cardiovascular mortality in older persons: The cardiovascular health
study. Circulation. 2012;126:2951-2961
2. Kizer JR, Arnold AM, Benkeser D, Ix JH, Djousse L, Zieman SJ,
Barzilay JI, Tracy RP, Mantzoros CS, Siscovick DS, Mukamal KJ. Total and
high-molecular-weight adiponectin and risk of incident diabetes in older
people. Diabetes Care. 2012;35:415-423
3. Kizer JR, Benkeser D, Arnold AM, Djousse L, Zieman SJ, Mukamal KJ,
Tracy RP, Mantzoros CS, Siscovick DS, Gottdiener JS, Ix JH. Total and high
-molecular-weight adiponectin and risk of coronary heart disease and
ischemic stroke in older adults. J Clin Endocrinol Metab. 2013;98:255-263
4. Karas MG, Benkeser D, Arnold AM, Bartz TM, Djousse L, Mukamal KJ,
Ix JH, Zieman SJ, Siscovick DS, Tracy RP, Mantzoros CS, Gottdiener JS,
deFilippi CR, Kizer JR. Relations of plasma total and high-molecular-
weight adiponectin to new-onset heart failure in adults >/=65 years of
age (from the cardiovascular health study). Am J Cardiol. 2014;113:328-334
5. Macheret F, Bartz TM, Djousse L, Ix JH, Mukamal KJ, Zieman SJ,
Siscovick DS, Tracy RP, Heckbert SR, Psaty BM, Kizer JR. Higher
circulating adiponectin levels are associated with increased risk of
atrial fibrillation in older adults. Heart. 2015;101:1368-1374
Revascularization of chronic total coronary occlusions
Christophe Bauters a, b, c, MD; Gilles Lemesle a, c, MD.
a Centre Hospitalier R?gional et Universitaire de Lille, Lille,
France
b Inserm U1167, Institut Pasteur de Lille, Universit? de Lille 2, Lille,
France
c Facult? de M?decine de Lille, Lille, France
To the Editor,
We read with great interest the article by Ladwiniec et al. (1...
Revascularization of chronic total coronary occlusions
Christophe Bauters a, b, c, MD; Gilles Lemesle a, c, MD.
a Centre Hospitalier R?gional et Universitaire de Lille, Lille,
France
b Inserm U1167, Institut Pasteur de Lille, Universit? de Lille 2, Lille,
France
c Facult? de M?decine de Lille, Lille, France
To the Editor,
We read with great interest the article by Ladwiniec et al. (1) on
the prognostic impact of percutaneous interventions (PCI) for chronic
total coronary occlusions (CTO). Indeed, there are obvious limitations in
the previously published literature that essentially demonstrated a better
prognosis after successful CTO PCI than after failed CTO PCI. A propensity
-matched approach comparing CTO PCI versus medically treated CTO as
performed in the present report, does not have the strength of a
randomized trial, but nevertheless has the potential to provide meaningful
information for physicians.
In the modern era of secondary prevention, the prognosis of patients with
stable coronary artery disease (CAD) has been shown to be favorable (2).
Although this may make difficult to demonstrate a survival benefit by a
new intervention, this is however a global figure and subgroups of
patients, such as those with CTO, may do worse than others; therefore,
focusing studies on these high-risk stable CAD patients certainly makes
sense.
The study by Ladwiniec et al. (1) reports interesting trends suggesting
that revascularization of a CTO might be beneficial. However, one
important point that would need to be clarified is the level of secondary
prevention in this study, and whether this level was the same in all
groups of patients. There are consistent data in the literature showing
that patients with a recent revascularization have higher prescription of
secondary prevention drugs (statins, antiplatelets, angiotensin-converting
enzyme inhibitors, ?-blockers) than patients without revascularization
(3). In addition, information on the use of dual antiplatelet therapy
(DAPT) would also be important. Due to the frequent use of drug-eluting
stents (DES), and long stented segments, it is conceivable that an
extended duration of DAPT was used in a significant proportion of the
patients with CTO PCI. Extended DAPT has recently been shown to reduce
thrombotic events after DES implantation (4); this impact is not only
related to a decrease in very late stent thrombosis but also to a
reduction in non-stent-thrombosis-related myocardial infarction. An
imbalance toward more intense secondary prevention in the CTO PCI group
could potentially explain the trends for the improved outcome. If the
information is available, providing data on the combination of secondary
prevention drugs at discharge and also during the course of the study
would therefore be very useful.
References
[1] Ladwiniec A, Allgar V, Thackray S, Alamgir F, Hoye A. Medical
therapy, percutaneous coronary intervention and prognosis in patients with
chronic total occlusions. Heart 2015;101:1907-14.
[2] Bauters C, Deneve M, Tricot O, Meurice T, Lamblin N. Prognosis of
patients with stable coronary artery disease (from the CORONOR study). Am
J Cardiol 2014;113:1142-5.
[3] Meurice T, Tricot O, Lemesle G et al. Prevalence and correlates of non
-optimal secondary medical prevention in patients with stable coronary
artery disease. Arch Cardiovasc Dis 2015;108:340-6.
[4] Mauri L, Kereiakes DJ, Yeh RW et al. Twelve or 30 months of dual
antiplatelet therapy after drug-eluting stents. N Engl J Med 2014;371:2155
-66.
"Time to act"1 - a message which resonates with the
team on our metropolitan Delivery Suite, who this week managed an acute
myocardial infarction in a postnatal lady. Our patient has two of the risk
factors mentioned in the editorial, her being 36 years old and a smoker.
In addition she had an important risk factor which can be missed, as
demonstrated by our recent experience. Since most women with acu...
"Time to act"1 - a message which resonates with the
team on our metropolitan Delivery Suite, who this week managed an acute
myocardial infarction in a postnatal lady. Our patient has two of the risk
factors mentioned in the editorial, her being 36 years old and a smoker.
In addition she had an important risk factor which can be missed, as
demonstrated by our recent experience. Since most women with acute
coronary syndrome (ACS) in pregnancy and the puerperium have no symptoms
before pregnancy2, risk factor stratification is important.
Our patient, who has a history of heroin addiction and was on
methadone, arrived by ambulance in preterm labour (35+ weeks gestation)
and bleeding per vaginam. She had an uncomplicated vaginal delivery of a
growth restricted baby soon after arrival. The total intrapartum blood
loss was 540 millilitres.
One hour after delivery the patient was noted to be profoundly
hypotensive with bradycardia. There was no evidence of vaginal bleeding.
Physical examination was unremarkable and the hypotension responded to
fluid resuscitation. An electrocardiogram (ECG) showed ST elevation on the
inferior leads. A diagnosis of acute myocardial infarction was made. She
was stabilised with morphine, aspirin and nitrates and was transferred for
Primary Percutaneous Coronary Intervention. Angiography revealed gross
spasm of the Right Coronary Artery and a 50-60% occlusion thereof. After
stenting, the ECG changes normalised. She made a good recovery within 24
hours.
Urine toxicology subsequently revealed recent abuse with cocaine and
other illicit substances.
Substance misuse amongst women of childbearing age is increasing3.
The United States National Survey on Drug Use and Health 2005 estimates a
4% prevalence of illicit drug use in pregnant women4. Research into the
effects of the various drugs of abuse on the physiology of pregnancy and
on the myocardium is ongoing. Coronary spasm is a recognised adverse
effect of cocaine. Accelerated atherosclerosis can be attributed in part
to the smoking of tobacco and drugs.
We feel that there should be a high index of suspicion for ACS in
patients with a history of substance misuse, even if they are on a
supervised treatment programme. Women with a history of substance misuse
are a high-risk group, and the antenatal period offers a precious
opportunity to screen for cardiovascular disease and current drug use,
when these women might be more likely to engage. Patients on methadone are
managed as part of a multidisciplinary team, providing scope for
cardiovascular risk assessment and preconception counseling as part of
this process.
References
1. Nelson-Piercy C, Adamson D, Knight M. Acute coronary Syndrome in
pregnancy: time to act. Heart 2012 ;98:760-761
2. Royal College of Obstetricians and Gynaecologists (RCOG). Cardiac
Disease in Pregnancy (Good Practice No. 13) (2011)
http://www.rcog.org.uk/files/rcog-
corp/GoodPractice13CardiacDiseaseandPregnancy.pdf (accessed 29 May 2012)
3. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers' Lives:
Reviewing maternal deaths to make motherhood safer: 2006-2008. The eighth
report of Confidential Enquiries into Maternal Deaths in the United
Kingdom. BJOG 2011;118(suppl 1):1-203
4. US Dept Health Human Services, Substance Abuse and Mental Health
Services Administration, Office of Applied Studies. Results from the 2005
National Survey on Drug Use and Health: National Findings. Rock-ville, Md:
US Dept Health Human Services;
2006.http://www.oas.samhsa.gov/nsduh/2k5nsduh/2k5Results.pdf (accessed 31
May 2012)
Thank you for your correspondence with respect to our study (1). We
have read your paper (2) with interest and congratulate you on an
important paper providing further empirical evidence to support more
appropriate methods of generating body size independent cardiac indices.
We are delighted your data demonstrated the importance of fat free mass
something we and others have proposed...
Thank you for your correspondence with respect to our study (1). We
have read your paper (2) with interest and congratulate you on an
important paper providing further empirical evidence to support more
appropriate methods of generating body size independent cardiac indices.
We are delighted your data demonstrated the importance of fat free mass
something we and others have proposed empirically before and represented
in previous review articles (3, 4). Your recent study is a very insightful
contribution to this field and we hope others in the clinical field read
this work and follow suit. We feel our additional comments in the meta-
analysis support a revisionist approach to the use of cardiac indices.
We would go further though and not stop at structural data and charge
all interested groups to look at how key functional data are indexed. We
have some empirical data published in respect of longitudinal tissue
velocities (5) and we feel this work should be extended.
References
1. Utomi V, Oxborough D, Whyte GP, Somauroo J, Sharma S, Shave R, et al.
Systematic review and meta-analysis of training mode, imaging modality and
body size influences on the morphology and function of the male athlete's
heart. Heart 2013;99:1727-1733.
2. Pressler A, Haller B, Scherr J, Heitkamp D, Esefeld K, Boscheri A, et
al. Association of body composition and left ventricular dimensions in
elite athletes. European Journal of Preventive Cardiology. 2012;19(5):1194
-204.
3. Batterham A, George K, Whyte G, Sharma S, McKenna W. Scaling cardiac
structural data by body dimensions: a review of theory, practice, and
problems. Int J Sports Med. 1999;20(8):495-502.
4. Dewey F, Rosenthal D, Murphy DJ, Froelicher V, Ashley E. Does size
matter? Clinical applications of scaling cardiac size and function for
body size. Circulation. 2008;117(17):2279-87.
5. Oxborough D, Batterham AM, Shave R, Artis N, Birch KM, Whyte G, et al.
Interpretation of two-dimensional and tissue Doppler-derived strain (?)
and strain rate data: is there a need to normalize for individual
variability in left ventricular morphology? Eur J Echocardiogr.
2009;10(5):677-82.
We read with great interest the article titled "Contemporary clot
busting in ST-elevation myocardial infarction: beware of the embolus"(1).
Since the publication of the TAPAS trial(2) in 2008 thrombus aspiration
has become a useful part of the paradigm for treatment of ST elevation
myocardial infarction. As demonstrated in the report by Rawlins et al
great care needs to be taken during the use of any a...
We read with great interest the article titled "Contemporary clot
busting in ST-elevation myocardial infarction: beware of the embolus"(1).
Since the publication of the TAPAS trial(2) in 2008 thrombus aspiration
has become a useful part of the paradigm for treatment of ST elevation
myocardial infarction. As demonstrated in the report by Rawlins et al
great care needs to be taken during the use of any aspiration catheter.
By its very nature this device is removing thrombus from a vascular bed
and exposing the rest of the circulation to the risk of embolization.
Aspiration devices themselves have a relatively small internal lumen
diameter and the risk of occlusive thrombus from large occluded coronary
arteries is potentially understated.
The journal has demonstrated occlusion of the aspiration catheter
preventing flow back into the aspiration syringe. We have also seen an
occurrence of occlusion of the guide catheter itself during thrombus
aspiration from a right coronary artery. As stated by Rawlins et al lack
of flow into the aspiration syringe should raise suspicion of an occluded
aspiration catheter, but of equal importance is the monitoring of the
guiding catheter pressure trace. If the guide catheter becomes damped
during aspiration then the possibility of thrombus in the catheter should
be considered. It is vitally important to maintain suction on the
aspiration catheter while it is withdrawn, and should the guide catheter
become damped, this too should be withdrawn from the circulation whilst
applying negative pressure.
Large thrombotic burdens potentially may be better treated by the use
of the angiojet device(3) with the potential to break up the thrombus in
situ.
References
1. Rawlins J, Shah N, O'Kane P. Contemporary clot busting in ST-elevation myocardial infarction: beware of the embolus. Heart 2012;98(16):1259-60.
2. Svilaas T, Vlaar PJ, van der Horst IC, et al.
Thrombus aspiration during primary percutaneous coronary intervention. N Engl J Med 2008;358(6):557-67.
3. Migliorini A, Stabile A, Rodriguez AE, et al.
Comparison of AngioJet rheolytic thrombectomy before direct infarct artery stenting with direct stenting alone in patients with acute myocardial infarction. The JETSTENT trial. J Am Coll Cardiol 2010;56(16):1298-306.
We read with great interest the recent article by Bhattacharyya et.
al.1 They state that a high proportion (71/250) of stress echocardiograms
(SE) were performed on low risk patients and were inappropriate,
concluding that implementation of diagnostic appropriateness criteria2
would reduce this.
Appropriateness criteria2 published in 2011 reviewed clinical
scenarios warranting SE and graded these on a scale of...
We read with great interest the recent article by Bhattacharyya et.
al.1 They state that a high proportion (71/250) of stress echocardiograms
(SE) were performed on low risk patients and were inappropriate,
concluding that implementation of diagnostic appropriateness criteria2
would reduce this.
Appropriateness criteria2 published in 2011 reviewed clinical
scenarios warranting SE and graded these on a scale of 1 to 9. Classifying
patients into 3 categories, appropriate (grade 7-9), uncertain (grade 4-6)
and inappropriate (grade 1-3). The 2013 ECS guidelines3 for investigation
of stable coronary artery disease (CAD) recommends functional testing for
patients with intermediate (15-85%) pre-test probability (PTP). However,
Bhattacharyya et. al. do not elaborate on the PTP of patients in each
classification. Thus, in accordance with new ESC guideline SE may have
been appropriate in some of the patients classified as uncertain or
inappropriate.
Furthermore, a proportion of patients classified as inappropriate
included previously revascularised patients with stable symptoms.
Cardiologists may feel obliged to perform investigations on symptomatic
previously revascularised patients, often with invasive coronary
angiography, even if they are stable with a negative SE within the
previous two years. To reduce the burden on SE, cardiac CT is a viable
alternative that demonstrates grafts and proximal stent patency.
Finally, NICE, ESC and ACC/AHA guidelines all differ in diagnostic
guidelines, enabling cardiologists to use their experience and local
expertise to select the most appropriate investigation for individual
patients.
I was intrigued to read the editorial of Calum MacRae,1 where he
leads with the provocative statement that "The sinoatrial node,
atrioventricular (AV) node and proximal His-Purkinje system can each be
seen with the naked eye in humans". I am sure that cardiac surgeons
worldwide will be delighted at this news. It is, therefore, unfortunate
that MacRae does not share with us the means of achieving the
v...
I was intrigued to read the editorial of Calum MacRae,1 where he
leads with the provocative statement that "The sinoatrial node,
atrioventricular (AV) node and proximal His-Purkinje system can each be
seen with the naked eye in humans". I am sure that cardiac surgeons
worldwide will be delighted at this news. It is, therefore, unfortunate
that MacRae does not share with us the means of achieving the
visualisation of these crucial structures. I have spent most of my career
seeking to establish landmarks to help in determining their location, but
never have I been fortunate enough, with certainty, to see them with "the
naked eye". It is the case that, with the eye of faith, it is possible to
discern the likely site of the sinus node, but the atrioventricular node
is buried within the floor of the triangle of Koch, while the proximal His
-Purkinje system is insulated within the central fibrous body. Would it
not be appropriate if MacRae shared with all your readers the technique he
used in observing these entities with his "naked eye"?
References
1. MacRae CA. Pattern recognition: combining informatics and genetics to
re-evaluate conduction disease. Heart 2012;98:1263-1264
We really appreciate the clarifications offered by Alexandros
Briasoulis concerning his article, but in our opinion our claim about the
importance of including in the meta-analysis information only (or mostly)
from elderly patients remains well founded. In this regard, the Cochrane
Hypertension Group encourages to accept only studies if 70% or more of the
participants meet the definition, or individual patient data are
a...
We really appreciate the clarifications offered by Alexandros
Briasoulis concerning his article, but in our opinion our claim about the
importance of including in the meta-analysis information only (or mostly)
from elderly patients remains well founded. In this regard, the Cochrane
Hypertension Group encourages to accept only studies if 70% or more of the
participants meet the definition, or individual patient data are
available, or data of relevant patients are provided separately allowing
specific inclusion of the population as defined (1). Moreover, the
inclusion of INVEST trial (2) in the ACCF/AHA 2011 (3) cannot be claimed
as a relevant argument to support proceeding in the same manner in the
meta-analysis, because of the inherent low level of evidence showed by
consensus. On the other hand, the INVEST trial has a very high risk of
bias. It is an open trial and no information on the sequence generation
nor the allocation concealment is provided.
We agree with the author in the conclusion showed by the secondary
analysis (4). But in fact this provides to us compelling evidence of the
importance of separating the information between young and older people.
Furthermore, it is not clear to us why these findings are said to be "in
accordance" with the results of the sensitivity analysis performed by the
author. According to the Discussion (1), the subgroup analysis of studies
with patients over 70 years showed that "the beneficial effects of
antihypertensive treatment remained significant in the first group of
studies (treatment versus placebo group)" but the meta-analysis did not
take into account blood pressure levels, thereby both papers seem to be
focused on very different issues. Also, we have not been able to read in
the last article cited (5) the assertion made on the J-curve association
in patients above or below age of 65. In fact, this study did not compare
different age subgroups any time but different blood pressure strata, and
the mean age values in each 10-mm Hg blood pressure stratum were very
similar (66-67 years).
In short, if elderly age begins at 65, we need to found our practices
on studies including real elderly people. Evidence based on the results of
studies with patients of a mean age close to 65 is not trustworthy.
(1) Gorricho J, Garjon J, Celaya MC, Muruzabal L, Montoya R, Lopez A,
Malon MDM, Saiz LC. Blood pressure targets for the treatment of patients
with hypertension and cardiovascular disease. Cochrane Database of
Systematic Reviews 2013, Issue 1. Art. No.: CD010315. DOI:
10.1002/14651858.CD010315.
(2) Pepine CJ, Handberg EM, Cooper-DeHoff RM, et al. A calcium antagonist
vs a non-calcium antagonist hypertension treatment strategy for patients
with coronary artery disease. The International Verapamil- Trandolapril
Study (INVEST): a randomized controlled trial. JAMA. 2003;290(21):2805-16.
(3) Aronow WS, Fleg JL, Pepine CJ, et al. ACCF/AHA 2011 expert consensus
document on hypertension in the elderly: a report of the American College
of Cardiology Foundation Task Force on Clinical Expert Consensus
Documents. Circulation. 2011;123:2434-2506.
(4) Denardo SJ, Gong Y, Nichols WW, et al. Blood pressure and outcomes in
very old hypertensive coronary artery disease patients: an international
verapamil ST-Trandolapril (INVEST) substudy. Am J Med. 18 2010;123:719-26.
(5) Messerli FH, Mancia G, Conti CR, et al. Dogma disputed: can
aggressively lowering blood pressure in hypertensive patients with
coronary artery disease be dangerous? Ann Intern Med. 2006;144:884-93.
Luis Carlos Saiz, Pharm D
Pharmacotherapy Research Coordinator
Navarre Health Service, Spain
Juan Erviti, Pharm D, PhD
Head of Unit, Drug Information
Navarre Health Service, Spain
I read with interest the recent paper by Kim and co-authors on "Mild-
to-moderate functional tricuspid regurgitation (TR) in patients undergoing
valve replacement for rheumatic mitral valve (MV) disease".1 The authors,
reporting on 236 patients divided into two groups, concluded that compared
with MV replacement alone, concomitant TV repair was associated with
better postoperative TV function that ma...
I read with interest the recent paper by Kim and co-authors on "Mild-
to-moderate functional tricuspid regurgitation (TR) in patients undergoing
valve replacement for rheumatic mitral valve (MV) disease".1 The authors,
reporting on 236 patients divided into two groups, concluded that compared
with MV replacement alone, concomitant TV repair was associated with
better postoperative TV function that may help to improve long-term
clinical outcomes. The authors should be congratulated on their work,
which added more insight into the treatment of this pathology.
However, a point should be underlined: In patients with rheumatic MV
disease, TV regurgitation is not always only functional. It is true that
in patients with rheumatic MV disease, tricuspid involvement is usually
secondary to pulmonary hypertension and right ventricular volume overload,
however, TV may be directly involved in the rheumatic inflammatory process
in up to 8% of cases.2,3 Nonetheless, a recent imaging study aiming to
analyze the prevalence of TV involvement in rheumatic heart disease
reported 18.3% with organic TV disease.4 Three-dimensional
echocardiography has been proposed to better study the TV morphology,
since with this methodology all three leaflets are simultaneously
visualized and seen from both atrial and ventricular aspects.3 However, I
did not find in Kim's study population any patient with definite organic
TV disease from rheumatic endocarditis. Cardiovascular practice in western
countries has changed over the years, reflecting the decreased incidence
of acute rheumatic fever (RF). However, in countries that still have a
high incidence of RF, it is not unusual to see during surgery Aschoff's
nodules on the TV. Rheumatic TV inflammation causes scarring and fibrosis
with retraction of valve leaflets and/or fusion of its commissures. An
organic rheumatic TV involvement would result in organic valve
regurgitation and/or stenosis. Nevertheless, annular TV dilatation may
also coexist with organic disease. Functional TV regurgitation due to
annular dilatation from right ventricular volume overload is usually
treated by annular reduction or valve bicuspidalization. Instead,
rheumatic leaflet involvement may require more challenging surgical
reparative procedures whose uncertain results are probably underreported
in the literature. TV organic involvement at the time of surgery would
influence short and long term results. In 2008, Bernal et al, reporting on
328 consecutive patients that underwent TV valve surgery for rheumatic
disease, concluded that "organic tricuspid valve disease associated with
rheumatic mitral or aortic lesions increases hospital and late
mortality."5 In addition, in a recent work Naqshband et al analyzed their
follow-up results of TV repair and reported that deterioration in
regurgitation grade occurred only in those patients having some organic
involvement of TV.6 In conclusion, preoperative imaging studies aiming to
carefully visualize TV leaflets, together with intraoperative data on TV
leaflet morphology from institutions dealing with a high volume of
rheumatic heart valve disease would in the future help to provide more
insight into the treatment of this condition.
References
1. Kim JB, Yoo DG, Kim GS, et al. Mild-to-moderate functional
tricuspid regurgitation in patients undergoing valve replacement for
rheumatic mitral disease: the influence of tricuspid valve repair on
clinical and echocardiographic outcomes. Heart. 2012;98(1):24-30
2. Hauck AJ, Freeman DP, Ackermann DM, et al. Surgical pathology of
the tricuspid valve: a study of 363 cases spanning 25 years. Mayo Clin
Proc. 1988;63(9):851-63.
3. Anwar AM, Geleijnse ML, Soliman OI, et al. Evaluation of rheumatic
tricuspid valve stenosis by real-time three-dimensional echocardiography.
Heart. 2007;93(3):363-4
4. Arora R, Sattur A, Ambar S, et al. Prevalence of tricuspid valve
disease in rheumatic heart disease. J Am Coll Cardiol. 2012;59(13s1):E1263
-E1263. doi:10.1016/S0735-1097(12)61264-9
5. Bernal JM, Pont?n A, Diaz B, et al. Surgery for rheumatic
tricuspid valve disease: a 30-year experience. J Thorac Cardiovasc Surg.
2008;136(2):476-81
6. Naqshband MS, Abid AR, Akhtar RP, et al. Functional tricuspid
regurgitation in rheumatic heart disease: surgical options. Ann Thorac
Cardiovasc Surg. 2010;16(6):417-25
I read with great interest the report by Macheret et al., (1) who conducted an 11-year prospective study in 3190 older adults, aged 65 years or older, without cardiovascular disease for monitoring incident atrial fibrillation (AF). The authors measured plasma total adiponectin, high molecular weight (HMW) adiponectin and amino-terminal pro-brain natriuretic peptide 1-76 (NT-proBNP1-76). There were 886 incident AF events,...
We thank Dr. Kawada for his comments regarding our study. Consistent with the sexual dimorphism in circulating adiponectin levels documented in both rodents and humans, plasma concentrations of total and high-molecular -weight (HMW) adiponectin were higher in female than male participants in the Cardiovascular Health Study.[1] Despite such differences, we have not found evidence of effect modification by sex for total or H...
Revascularization of chronic total coronary occlusions
Christophe Bauters a, b, c, MD; Gilles Lemesle a, c, MD.
a Centre Hospitalier R?gional et Universitaire de Lille, Lille, France b Inserm U1167, Institut Pasteur de Lille, Universit? de Lille 2, Lille, France c Facult? de M?decine de Lille, Lille, France
To the Editor,
We read with great interest the article by Ladwiniec et al. (1...
Dear Editor
"Time to act"1 - a message which resonates with the team on our metropolitan Delivery Suite, who this week managed an acute myocardial infarction in a postnatal lady. Our patient has two of the risk factors mentioned in the editorial, her being 36 years old and a smoker. In addition she had an important risk factor which can be missed, as demonstrated by our recent experience. Since most women with acu...
Dear Professor Pressier,
Thank you for your correspondence with respect to our study (1). We have read your paper (2) with interest and congratulate you on an important paper providing further empirical evidence to support more appropriate methods of generating body size independent cardiac indices. We are delighted your data demonstrated the importance of fat free mass something we and others have proposed...
Dear Editor,
We read with great interest the article titled "Contemporary clot busting in ST-elevation myocardial infarction: beware of the embolus"(1). Since the publication of the TAPAS trial(2) in 2008 thrombus aspiration has become a useful part of the paradigm for treatment of ST elevation myocardial infarction. As demonstrated in the report by Rawlins et al great care needs to be taken during the use of any a...
We read with great interest the recent article by Bhattacharyya et. al.1 They state that a high proportion (71/250) of stress echocardiograms (SE) were performed on low risk patients and were inappropriate, concluding that implementation of diagnostic appropriateness criteria2 would reduce this.
Appropriateness criteria2 published in 2011 reviewed clinical scenarios warranting SE and graded these on a scale of...
Dear Editor,
I was intrigued to read the editorial of Calum MacRae,1 where he leads with the provocative statement that "The sinoatrial node, atrioventricular (AV) node and proximal His-Purkinje system can each be seen with the naked eye in humans". I am sure that cardiac surgeons worldwide will be delighted at this news. It is, therefore, unfortunate that MacRae does not share with us the means of achieving the v...
We really appreciate the clarifications offered by Alexandros Briasoulis concerning his article, but in our opinion our claim about the importance of including in the meta-analysis information only (or mostly) from elderly patients remains well founded. In this regard, the Cochrane Hypertension Group encourages to accept only studies if 70% or more of the participants meet the definition, or individual patient data are a...
Dear Editor,
I read with interest the recent paper by Kim and co-authors on "Mild- to-moderate functional tricuspid regurgitation (TR) in patients undergoing valve replacement for rheumatic mitral valve (MV) disease".1 The authors, reporting on 236 patients divided into two groups, concluded that compared with MV replacement alone, concomitant TV repair was associated with better postoperative TV function that ma...
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