Research Spotlight

Murdoch, D. J., J. Sathananthan, M. Hensey, M. C. Alu, Y. Liu, A. Crowley, D. Wood, A. Cheung, J. Ye, T. Feldman, R. T. Hahn, W. A. Jaber, M. J. Mack, S. C. Malaisrie, M. B. Leon and J. G. Webb (2020). “Mitral regurgitation in patients undergoing transcatheter aortic valve implantation for degenerated surgical aortic bioprosthesis: Insights from PARTNER 2 Valve-in-Valve Registry.” Catheter Cardiovasc Interv Mar 2. [Epub ahead of print].

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BACKGROUND: Valve-in-valve (VIV) treatment with transcatheter aortic valve replacement (TAVR) is a viable option for patients with failing aortic bioprosthetic valves. Optimal management of those with concomitant mitral regurgitation (MR) remains undetermined. Therefore, we sought to assess the implications of concomitant MR in patients undergoing VIV-TAVR. METHODS AND RESULTS: The PARTNER 2 VIV registry enrolled patients with degenerated surgical aortic bioprosthesis at high risk for reoperation. Patients with core-laboratory echocardiographic assessment of MR were analyzed; severe MR was excluded. We compared patients with less-than-or-equal-to mild MR versus moderate MR and assessed changes in MR severity and clinical outcomes. A total of 339 patients (89 initial registry, 250 continued access) underwent VIV procedures; mean age 79.0 +/- 10.2 years, mean Society of Thoracic Surgeon score 8.9 +/- 4.5%. At baseline, 228/339 (67.3%) had less-than-or-equal-to mild MR and 111/339 (32.7%) had moderate MR. In paired analysis, there was significant improvement in greater-than-or-equal-to moderate MR from baseline to 30 days (32.6% vs. 14.5%, p < .0001 [n = 304]), and no significant change between 30 days and 1 year (13.4% vs. 12.1%, p = .56 [n = 224]) or 1 year and 2 years (11.0% vs. 10.4%, p = .81 [n = 182]). There was no difference in death or stroke between less-than-or-equal-to mild MR and moderate MR at 30 days (4.0% vs. 7.2%, p = .20), 1 year (15.5% vs. 15.3%, p = .98) or 2 years (26.5% vs. 23.5%, p = .67). CONCLUSION: Moderate concomitant MR tends to improve with VIV-TAVR, and was not a predictor of long-term adverse outcomes in this cohort. In selected patients undergoing VIV-TAVR, it may be appropriate to conservatively manage concomitant MR. ClinicalTrials.gov NCT# 03225001.

McMinn, K. R., E. V. Thomas, K. R. Martin, J. N. Khetan, E. E. McShan, M. M. Bennett, J. Solis, A. L. Jones, M. B. Powers and A. M. Warren (2020). “Psychological morbidity and functional impairment following traumatic pelvic injury.” Injury Feb 11. [Epub ahead of print].

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Pelvic injuries often result from high-energy trauma and lead to significant functional impairment. While the physical outcomes of these injuries have been widely studied, the psychological consequences remain largely unexplored. The purpose of this study was to examine psychosocial and functional outcomes of patients with pelvic trauma in the year after injury. The sample (N=32) consisted of adult patients with traumatic pelvic injures, as defined by ICD-9 codes, who were admitted to a Level I Trauma Center for at least 24 h. Participants were primarily female (53%) with a mean age of 48.7 years (SD=17.9). Demographic, injury-related, and psychosocial data (e.g., posttraumatic stress disorder (PTSD), depression, alcohol use, quality of life, pain, return to work) were gathered at the time of hospitalization as well as at 3-, 6-, and 12 month follow-ups. Mixed regression models were used to examine the outcome variables over time. There were significant decreases in pain and alcohol use at each follow-up compared to baseline. However, despite the decrease, the levels of pain and alcohol use remained high. Physical and mental health also decreased significantly, indicating worsened functioning and lowered quality of life. Neither PTSD nor depression changed significantly over time, indicating that participants’ symptoms were not likely to improve. These data suggest that sustaining a traumatic pelvic injury increases the risk of diminished quality of life, both mentally and physically. Even one-year post-injury, participants experienced moderate physical pain and higher levels of PTSD, depression, and problematic alcohol use than would be expected in the general population. These findings highlight the need for an interdisciplinary approach to treating patients with pelvic injuries, including psychological screening and intervention in acute care and throughout recovery.

Madill-Thomsen, K., M. Abouljoud, C. Bhatti, M. Ciszek, M. Durlik, S. Feng, B. Foroncewicz, I. Francis, M. Grat, K. Jurczyk, G. Klintmalm, M. Krasnodebski, G. McCaughan, R. Miquel, A. Montano-Loza, D. Moonka, K. Mucha, M. Myslak, L. Paczek, A. Perkowska-Ptasinska, G. Piecha, T. Reichman, A. Sanchez-Fueyo, O. Tronina, M. Wawrzynowicz-Syczewska, A. Wiecek, K. Zieniewicz and P. F. Halloran (2020). “The molecular diagnosis of rejection in liver transplant biopsies: First results of the INTERLIVER study.” Am J Transplant Feb 23. [Epub ahead of print].

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Molecular diagnosis of rejection is emerging in kidney, heart, and lung transplant biopsies and could offer insights for liver transplant biopsies. We measured gene expression by microarrays in 235 liver transplant biopsies from 10 centers. Unsupervised archetypal analysis based on expression of previously annotated rejection-related transcripts identified four groups: normal ‘R1normal ‘ (N=129), T cell-mediated rejection (TCMR) ‘R2TCMR ‘ (N=37), early injury ‘R3injury ‘ (N=61), and fibrosis ‘R4late ‘ (N=8). Groups differed in median time post-transplant e.g. R3injury 99 days vs. R4late 3117 days. R2TCMR biopsies expressed typical TCMR-related transcripts e.g. intense IFNG-induced effects. R3injury displayed increased expression of parenchymal injury transcripts (e.g. hypoxia-inducible factor EGLN1). R4late biopsies showed immunoglobulin transcripts and injury-related transcripts. R2TCMR correlated with histologic rejection although with many discrepancies, and R4late with fibrosis. R2TCMR , R3injury , and R4late correlated with liver function abnormalities. Supervised classifiers trained on histologic rejection showed less agreement with histology than unsupervised R2TCMR scores. No confirmed cases of clinical ABMR were present in the population, and strategies that previously revealed antibody-mediated rejection (ABMR) in kidney and heart transplants failed to reveal a liver ABMR phenotype. In conclusion, molecular analysis of liver transplant biopsies detects rejection, has the potential to resolve ambiguities, and could assist with immunosuppressive management.

Mack, M. J. and L. Svensson (2020). “Why Does More SAVR Make Better TAVR?” JACC Cardiovasc Interv 13(3): 344-345.

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It has been well documented that there is a direct correlation between institutional procedural volume of transcatheter aortic valve replacement (TAVR) and the outcomes of patients undergoing TAVR. It has also been clearly demonstrated that a center’s surgical aortic valve replacement (SAVR) volume is directly related to better SAVR outcomes. However, does the same volume-outcome relationship exist between an institution’s SAVR volume and the outcomes of TAVR and if so, why does it matter. In this issue of JACC: Cardiovascular Interventions, Hirji et al. address this first question by comparing SAVR volume with corresponding TAVR outcomes. (Excerpt from text, n.p.; no abstract available.)

Kwon, J. K., N. Trexler, J. Reisch, C. M. Pfeifer, J. Ginos, J. A. Powell, J. Veltkamp, A. Anene, N. Fernandes and L. E. Chen (2020). “Correlating Abdominal Wall Thickness and Body Mass Index to Predict Usefulness of Right Lower Quadrant Ultrasound for Evaluation of Pediatric Appendicitis.” Pediatr Emerg Care 36(3): e156-e159.

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OBJECTIVES: To inform selective and efficient use of appendix ultrasound (US) beyond adult parameters of body mass index (BMI) of less than 25 kg/m, we correlate abdominal wall thickness (AWT) with age and BMI to generate parameters for male and female children. Information presented in chart format can aid in the decision to utilize US for the evaluation of appendicitis. METHODS: In this observational study, 1600 pediatric computed tomography scans of the abdomen and pelvis were analyzed to obtain measurements of AWT in the right lower quadrant. Measurements were correlated by patient age, BMI, and sex. Results and consensus-based recommendations were presented in chart format with color-coded groupings to allow for convenient referencing in the clinical setting. RESULTS: One thousand four hundred eighty-eight computed tomography scans and AWT measurements were included. All age groups with BMI of less than 25 kg/m and all male and female groups younger than 6 years regardless of BMI had median AWT of less than 4 cm resulting in strong recommendation for US. Males older than 6 years and all female age groups with BMI of greater than 30 kg/m and female older than 15 years and BMI of greater than 25 kg/m had AWT of more than 5 cm resulting in low recommendation for US. CONCLUSIONS: While the BMI cutoff standard of less than 25 kg/m for usefulness of appendix US holds in the adult population, our data expand the acceptable range in children younger than 9 years regardless of BMI and male children with BMI up to 30 kg/m. Female children younger than 15 years with a BMI up to 30 kg/m may also be amenable to right lower quadrant US based on AWT. These parameters inform selective and efficient use of US for appendix evaluation.