181 Impact of leaflet-tethering angle correction on the assessment of tricuspid regurgitation severity using the PISA method

Aims Severe tricuspid regurgitation (TR) is associated with excess mortality and morbidity. Therefore, accurate assessment of TR severity is pivotal. In clinical routine, the calculation of the effective regurgitant orifice area (EROA) and the regurgitant volume (RVol) using flow convergence method (PISA) by echocardiography are among the recommended parameters to define TR severity. However, the distortion of the proximal convergence zone related to the extent of valve leaflet tethering may result in smaller PISA radius and in underestimation of TR severity. Correcting for the angle of the leaflet tethering could reduce errors due to geometric assumption of a flat valvular plane and improve the accuracy of the calculations. The aims of our study were: (1) to evaluate whether taking into account the extent of leaflet tethering by applying the angle correction (AC) in the PISA formula improves the accuracy of the quantitative assessment of TR severity; (2) to assess the potential clinical impact of AC. Methods and results Forty-one patients with functional TR (73.5 ± 11.8 years, 51% men, 36% sinus rhythm, 17% severe), underwent 2D and 3D echocardiography. We compared the RVol obtained by volumetric method (as reference) with the RVol by PISA with and without AC. TR RVol by volumetric method was calculated as: total RV stroke volume (RV SV)–left ventricular forward SV (LV SV), where RV SV was obtained by subtracting the end-systolic from end-diastolic RV volume measured by 3D echocardiography and LV SV was calculated by multiplying LV outflow area by velocity time integral (VTI). TR RVol by PISA was calculated as EROA × VTI TR. Uncorrected EROA was calculated using the formula: 6.28 r2 × Va/PeakV TR (r—PISA radius, Va, aliasing velocity, PeakV TR—TR peak velocity). The corrected EROA accounting for the PISA geometric distortion by leaflet tethering angle (α) was calculated as: 6.28 r2 × Va (α/180)/PeakV TR (PISAAC), where α was measured using a protractor generated by dedicated software. PISA radius and angle were 5.5 ± 1.97 mm and 211.2° ± 13.6°, respectively. Application of AC to PISA method resulted in larger EROA and RVol (0.34 ± 0.38 cm2 vs. 0.24 ± 0.24 cm2 and, 25.2 ± 19.3 ml vs. 18.6 ± 13.1 ml, respectively). The percentage change in EROAAC was over 40%. When compared to the volumetric method, RVol by corrected PISA method was significantly closer and correlated (bias −3.95 ml, LOA ± 6.41 ml, r = 0.987; P < 0.001) than the conventional PISA without AC (bias −10.5 ml, LOA ± 15 ml, r = 0.975). Angle correction resulted in a change of TR severity in 32% of cases and in a greater concordance of TR severity grade with the volumetric method (75%, 31/41 with AC vs. 52%, 22/41 without AC). Conclusions Angle-corrected PISA method that accounts for the extent of the leaflet tethering in TR provided significantly larger TR RVol that were closely correlated with the volumetric RVol by 3D echocardiography. A simple geometric angle correction of the proximal flow with PISA method reclassified up to one-third of patients with functional TR.

Comparison of Outcomes between Minimally Invasive Lateral Approach Vertebral Reconstruction Using a Rectangular Footplate Cage and Conventional Procedure Using a Cylindrical Footplate Cage for Osteoporotic Vertebral Fracture

The aim of the current study was to compare outcomes between lateral access vertebral reconstruction (LAVR) using a rectangular footplate cage and the conventional procedure using a cylindrical footplate cage in patients with osteoporotic vertebral fracture (OVF). We included 46 patients who underwent anterior–posterior combined surgery for OVF: 24 patients underwent LAVR (Group L) and 22 underwent the conventional procedure (Group C). Preoperative, postoperative, and 1- and 2-year follow-up X-ray images were used to measure local lordotic angle, correction loss, and cage subsidence (>2 mm in vertebral endplate depression). In anterior surgery, the operation time was significantly shorter (183 vs. 248 min, p < 0.001) and the blood loss was significantly less (148 vs. 406 mL, p = 0.01) in Group L than in Group C. In Group C, two patients had anterior instrumentation failure. Correction loss was significantly smaller in Group L than in Group C (1.9° vs. 4.9° at 1 year, p = 0.02; 2.5° vs. 6.5° at 2 years, p = 0.04, respectively). Cage subsidence was significantly less in Group L than in Group C (29% vs. 80%, p < 0.001). LAVR using a rectangular footplate cage is an effective treatment for OVF to minimize surgical invasiveness and postoperative correction loss.

Basics for performing a high-quality color Doppler sonography of the vascular access

In the last years, the systematic use of ultrasound mapping of the upper limb vascular network before the arteriovenous fistula (AVF) implantation, access maturation, and clinical management of late complications is widespread and expanding. Therefore, a good knowledge of theoretical outlines, instrumentation, and operative settings is undoubtedly required for a thorough examination. In this review, the essential Doppler parameters, B-Mode setting, and Doppler applications are considered. Basic concepts on the Doppler shift equation, angle correction, settings on pulse repetition frequency, operative Doppler frequency, gain are reported to ensure adequate and correct sampling of blood flow velocity. A brief analysis of the Doppler inherent artefacts (as random noise, blooming, aliasing, and motion artefacts) and the adjustment setting to minimize or eliminate the confounding artefacts are also considered. Doppler aliasing occurs when the pulse repetition frequency is set too low. This artefact is particularly frequent in vascular access sampling due to the high velocities range registered in the fistula’s different segments. Aliasing should be recognized because its correction is crucial to analyse the Doppler signals correctly. Recent advances in instrumentation are also considered about a potential purchase of a portable ultrasound machine or a top-of-line, high-end, or mid-range ultrasound system. Last, the pulse wave Doppler setting for vascular access B-Mode and Doppler assessment is summarized.

Alternate In-Brace and Out-of-Brace Radiographs Are Recommended to Assess Brace Fitting and Curve Progression With Adolescent Idiopathic Scoliosis Follow-Up

Study Design: Retrospective cohort study. Objective: To determine the prevalence of missed curve progression in patients with adolescent idiopathic scoliosis (AIS) undergoing brace treatment with only in-brace follow-up radiographs, and to provide recommendations on when in-brace and out-of-brace should be obtained during follow-up. Methods: 133 patients who had documented clinically significant curve progression during brace treatment or only when an out-of-brace radiograph were studied. Of these, 95 patients (71.4%) had curve progression noted on in-brace radiographs while 38 patients (28.6%) showed curve progression only after brace removal. We analyzed differences in age, sex, curve types, Risser stage, months after menarche, standing out-of-brace Cobb angle, correction rate, and flexibility rate between the groups. Multivariate logistic regression was performed to determine factors contributing to curve progression missed during brace treatment. Results: There were no differences in initial Cobb angle between out-of-brace and in-brace deterioration groups. However, the correction rate was higher (32.7% vs 25.0%; P = .004) in the in-brace deterioration group as compared to the out-of-brace deterioration group. A lower correction rate was more likely to result in out-of-brace deterioration (OR 0.970; P = .019). For thoracic curves, higher flexibility in the curves was more likely to result in out-of-brace deterioration (OR 1.055; P = .045). For double/triple curves, patients with in-brace deterioration had higher correction rate (OR 0.944; P = .034). Conclusions: Patients may develop curve progression despite good correction on in-brace radiographs. Those with higher flexibility and suboptimal brace fitting are at-risk. In-brace and out-of-brace radiographs should be taken alternately for brace treatment follow-up.

Radial Club Hand Treated by Paley Ulnarization Generation 3: Is this the New Centralization?

(1) Background: Patients treated with the two previous generations of ulnarization developed a bump related to the ulnar head becoming prominent on the radial side of the hand. To finally remedy this problem, a third generation of ulnarization was developed to keep the ulnar head contained. While still ulnar to the wrist center, the center of the wrist remains ulnar to the ulnar head, with the ulnar head articulating directly with the trapezoid and when present the trapezium. (2) Methods: Between 2019 and 2021, 22 radial club hands in 17 patients were surgically corrected with this modified version of ulnarization. (3) Results: In all 17 patients, the mean HFA (hand–forearm-angle) correction was 68.5° (range 12.2°–88.7°). The mean ulna growth was 1.3 cm per year (range 0.2–2 cm). There were no recurrent radial deviation deformities more than 15° of the HFA. (4) Conclusions: This new version of ulnarization may solve the problem of the ulna growing past the carpus creating a prominent ulnar bump. The results presented are preliminary but promising. Longer-term follow-up is needed to fully evaluate this procedure.

Boston vs. Providence brace in treatment of Adolescent Idiopathic Scoliosis

Adolescent idiopathic scoliosis (AIS) is a complex condition characterized by a lateral curvature and axial rotational deformity of the spine. Though bracing is effective, a need remains to identify the effect brace type has on spine curvature. To examine differences in patient demographics between the Boston and Providence brace, determine the corrective change in Cobb angle and RVAD and investigate the effect of brace type on curvature over time. A retrospective chart review was conducted of 105 patients diagnosed with AIS from 2013–2016 at CHW. Five spinal parameters were measured: Cobb angle, Risser, RVAD, kyphosis and lordosis. Data was collected before bracing, in-brace and at 24 months. A final treatment outcome of either Cobb angle correction (reduction >5°), stabilization (change ±5°) or progression (deterioration >5°) was then evaluated. Providence brace provided significantly greater in-brace thoracolumbar Cobb angle and RVAD reduction in comparison to the Boston brace (Cobb angle -21.9° vs. -12.5°; RVAD: -1.8° vs. 1.62°). Similarly, Providence users had a significantly smaller increase in Cobb angle and RVAD over time (Cobb angle: thoracic 14.2° vs. 15.0°; thoracolumbar 23.6° vs. 26.0°; RVAD: 5.2° vs. 8.5°). Ultimately, no significant difference in final treatment outcome was established between brace groups. Although the Providence brace provides less of an increase in thoracic and thoracolumbar curvatures over time, both braces are an effective treatment and achieve comparable outcomes. Selection of braces may vary with primary curve angle, curve location, patient compliance and quality of life.

Methodology for the Correction of the Spatial Orientation Angles of the Unmanned Aerial Vehicle Using Real Time GNSS, a Shoreline Image and an Electronic Navigational Chart

Undoubtedly, Low-Altitude Unmanned Aerial Vehicles (UAVs) are becoming more common in marine applications. Equipped with a Global Navigation Satellite System (GNSS) Real-Time Kinematic (RTK) receiver for highly accurate positioning, they perform camera and Light Detection and Ranging (LiDAR) measurements. Unfortunately, these measurements may still be subject to large errors-mainly due to the inaccuracy of measurement of the optical axis of the camera or LiDAR sensor. Usually, UAVs use a small and light Inertial Navigation System (INS) with an angle measurement error of up to 0.5∘ (RMSE). The methodology for spatial orientation angle correction presented in the article allows the reduction of this error even to the level of 0.01∘ (RMSE). It can be successfully used in coastal and port waters. To determine the corrections, only the Electronic Navigational Chart (ENC) and an image of the coastline are needed.