Research Spotlight

Posted July 17th 2020

Reoperation After Transcatheter Aortic Valve Replacement: An Analysis of the Society of Thoracic Surgeons Database.

Michael J. Mack M.D.

Michael J. Mack M.D.

Jawitz, O. K., B. C. Gulack, M. V. Grau-Sepulveda, R. A. Matsouaka, M. J. Mack, D. R. Holmes, Jr., J. D. Carroll, V. H. Thourani and J. M. Brennan (2020). “Reoperation After Transcatheter Aortic Valve Replacement: An Analysis of the Society of Thoracic Surgeons Database.” JACC Cardiovasc Interv Jun 6;S1936-8798(20)30978-X. [Epub ahead of print.].

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OBJECTIVES: The study sought to report the largest series of patients receiving a surgical reoperation after transcatheter aortic valve replacement (TAVR) using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. BACKGROUND: TAVR has become an effective means of treating aortic stenosis. As TAVR is used in progressively lower-risk cohorts, management of device failure will become increasingly important. METHODS: The STS Adult Cardiac Surgery Database was queried for patients with a history of prior TAVR undergoing surgical aortic valve replacement from 2011 to 2015. Observed-to-expected (O/E) mortality ratios were determined to facilitate comparison across reoperative indications and timing from index TAVR procedure. RESULTS: A total of 123 patients met inclusion criteria (median age 77 years) with an STS Predicted Risk of Mortality of 4%, 4% to 8%, and >8% in 17%, 24%, and 59%, respectively. Median time to reoperation was 2.5 (interquartile range: 0.7 to 13.0) months, and the operative mortality rate was 17.1%. Common indications for reoperation included early TAVR device failures such as paravalvular leak (15%), structural prosthetic deterioration (11%), failed repair (11%), sizing or position issues (11%), and prosthetic valve endocarditis (10%). All pre-operative risk categories were associated with an increased O/E mortality ratio (Predicted Risk of Mortality <4%: O/E 5.5; 4% to 8%: O/E 1.7; >8%: O/E 1.2). CONCLUSIONS: SAVR following early failure of TAVR, while rare, is associated with worse-than-expected outcomes as compared with similar patients initially undergoing SAVR. Continued experience with this developing technology is needed to reduce the incidence of early TAVR failure and further define optimal treatment of failed TAVR prostheses.


Posted July 17th 2020

Assessing Femoral Trochlear Morphologic Features on Cross-Sectional Imaging Before Trochleoplasty: Dejour Classification Versus Quantitative Measurement.

Barrett N. Luce, M.D.

Barrett N. Luce, M.D.

Nacey, N. C., M. G. Fox, B. N. Luce, D. M. Boatman and D. R. Diduch (2020). “Assessing Femoral Trochlear Morphologic Features on Cross-Sectional Imaging Before Trochleoplasty: Dejour Classification Versus Quantitative Measurement.” AJR Am J Roentgenol Jun 6;1-7. [Epub ahead of print.]. 1-7.

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OBJECTIVE. The purpose of this study is to assess the use of cross-sectional imaging to qualitatively and quantitatively categorize trochlear dysplasia as low grade (type A) or high grade (types B-D) according to the Dejour classification. MATERIALS AND METHODS. A retrospective review of CT and MRI knee examinations performed before patients underwent deepening trochleoplasty was independently conducted by two musculoskeletal radiologists. Each case of trochlear dysplasia was qualitatively assigned a Dejour type. Subsequently, quantitative measurements of the sulcus angle, distance from the tibial tubercle to the trochlear groove, trochlear depth, lateral trochlear inclination, trochlear facet asymmetry, and degree of patellar lateralization were performed. RESULTS. A total of 35 patients (29 female patients and six male patients; mean age, 21.1 years) with 39 affected knees (17 right knees and 22 left knees) were included. Readers had exact qualitative agreement using Dejour classification for 30 of 39 knees (77% [κ = 0.77; 95% CI, 0.62-0.91]) and agreement on classification of low-grade versus high-grade dysplasia for 36 of 39 knees (92%). For these 36 knees, the mean differences in measurements of low- versus high-grade dysplasia, respectively, were as follows: for sulcus angle, 153° versus 168° (p < 0.001); for trochlear depth, 4 versus 1 mm (p < 0.001); for lateral trochlear inclination, 12 versus 7 mm (p < 0.02); and for decreased trochlear facet asymmetry, 13% versus 92% (p < 0.001). Trochlear depth, lateral trochlear inclination, and trochlear facet asymmetry were also different in comparisons of knees with Dejour type B and C trochlear dysplasia versus those with Dejour types B and D (all p < 0.05). No quantitative measurement differentiated between trochlear dysplasia of Dejour types C and D. The distance from the tibial tubercle to the trochlear groove and the degree of patellar lateralization were not statistically different between low- and high-grade dysplasia. CONCLUSION. Qualitative use of the Dejour classification accurately categorizes trochlear dysplasia as low grade or high grade in 92% of cases, with exact agreement reached in 77% of cases. Furthermore, the trochlear depth, lateral trochlear inclination, trochlear facet asymmetry, and sulcus angle can differentiate between low-grade and high-grade dysplasia, with trochlear depth, lateral trochlear inclination, and trochlear facet asymmetry useful for differentiating between Dejour types B and C and Dejour types B and D.


Posted July 17th 2020

Multicenter study on the diagnostic performance of multiframe volumetric laser endomicroscopy targets for Barrett’s esophagus neoplasia with histopathology correlation.

Vani J.A. Konda M.D.

Vani J.A. Konda M.D.

Struyvenberg, M. R., A. J. de Groof, A. Kahn, B. Weusten, D. E. Fleischer, E. K. Ganguly, V. J. A. Konda, C. J. Lightdale, D. K. Pleskow, A. Sethi, M. S. Smith, A. J. Trindade, M. B. Wallace, H. C. Wolfsen, G. J. Tearney, S. L. Meijer, C. L. Leggett, J. Bergman and W. L. Curvers (2020). “Multicenter study on the diagnostic performance of multiframe volumetric laser endomicroscopy targets for Barrett’s esophagus neoplasia with histopathology correlation.” Dis Esophagus Jul 1;doaa062. [Epub ahead of print.].

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Volumetric laser endomicroscopy (VLE) has been shown to improve detection of early neoplasia in Barrett’s esophagus (BE). However, diagnostic performance using histopathology-correlated VLE regions of interest (ROIs) has not been adequately studied. We evaluated the diagnostic accuracy of VLE assessors for identification of early BE neoplasia in histopathology-correlated VLE ROIs. In total, 191 ROIs (120 nondysplastic and 71 neoplastic) from 50 BE patients were evaluated in a random order using a web-based module. All ROIs contained histopathology correlations enabled by VLE laser marking. Assessors were blinded to endoscopic BE images and histology. ROIs were first scored as nondysplastic or neoplastic. Level of confidence was assigned to the predicted diagnosis. Outcome measures were: (i) diagnostic performance of VLE assessors for identification of BE neoplasia in all VLE ROIs, defined as accuracy, sensitivity, and specificity; (ii) diagnostic performance of VLE assessors for only high level of confidence predictions; and (iii) interobserver agreement. Accuracy, sensitivity, and specificity for BE neoplasia identification were 79% (confidence interval [CI], 75-83), 75% (CI, 71-79), and 81% (CI, 76-86), respectively. When neoplasia was identified with a high level of confidence, accuracy, sensitivity, and specificity were 88%, 83%, and 90%, respectively. The overall strength of interobserver agreement was fair (k = 0.29). VLE assessors can identify BE neoplasia with reasonable diagnostic accuracy in histopathology-correlated VLE ROIs, and accuracy is enhanced when BE neoplasia is identified with high level of confidence. Future work should focus on renewed VLE image reviewing criteria and real-time automatic assessment of VLE scans.


Posted July 17th 2020

The Uniform Dataset 3.0 Neuropsychological Battery: Factor Structure, Invariance Testing, and Demographically Adjusted Factor Score Calculation.

Andrew M. Kiselica, Ph.D.

Andrew M. Kiselica, Ph.D.

Kiselica, A. M., T. A. Webber and J. F. Benge (2020). “The Uniform Dataset 3.0 Neuropsychological Battery: Factor Structure, Invariance Testing, and Demographically Adjusted Factor Score Calculation.” J Int Neuropsychol Soc 26(6): 576-586.

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OBJECTIVE: The goals of this study were to (1) specify the factor structure of the Uniform Dataset 3.0 neuropsychological battery (UDS3NB) in cognitively unimpaired older adults, (2) establish measurement invariance for this model, and (3) create a normative calculator for factor scores. METHODS: Data from 2520 cognitively intact older adults were submitted to confirmatory factor analyses and invariance testing across sex, age, and education. Additionally, a subsample of this dataset was used to examine invariance over time using 1-year follow-up data (n = 1061). With the establishment of metric invariance of the UDS3NB measures, factor scores could be extracted uniformly for the entire normative sample. Finally, a calculator was created for deriving demographically adjusted factor scores. RESULTS: A higher order model of cognition yielded the best fit to the data χ2(47) = 385.18, p < .001, comparative fit index = .962, Tucker-Lewis Index = .947, root mean square error of approximation = .054, and standardized root mean residual = .036. This model included a higher order general cognitive abilities factor, as well as lower order processing speed/executive, visual, attention, language, and memory factors. Age, sex, and education were significantly associated with factor score performance, evidencing a need for demographic correction when interpreting factor scores. A user-friendly Excel calculator was created to accomplish this goal and is available in the online supplementary materials. CONCLUSIONS: The UDS3NB is best characterized by a higher order factor structure. Factor scores demonstrate at least metric invariance across time and demographic groups. Methods for calculating these factors scores are provided.


Posted July 17th 2020

Commentary on “Live Birth Following Uterine Transplantation from a Nulliparous Deceased Donor.

Liza Johannesson, M.D.

Liza Johannesson, M.D.

Testa, G. and L. Johannesson (2020). “Commentary on “Live Birth Following Uterine Transplantation from a Nulliparous Deceased Donor”.” Transplantation Jun 9. [Epub ahead of print.].

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Uterus transplantation (UTx), with less than 100 transplants performed worldwide, is a fertility treatment that has the potential to help thousands of women affected by absolute uterinefactor infertility experience gestation and childbirth.The article by Fronek et al in Transplantation reports a live birth from a mother who had received a uterus from a nulliparous deceased donor. The report provides valuable information that may change the previous praxis of not using uterine grafts from nulliparous donors in UTx and thereby may increase organ availability. Among the 20 reported live births after UTx, only 3, including the one reported in this issue, have occurred from deceased donors, and in the 2 preceding cases the deceased donor had at least 1 proven pregnancy and delivery. [No abstract available; excerpt from article.].