608 The VCX Index: a novel haemodynamic quantification of mitral regurgitation

Percutaneous edge-to-edge mitral valve (MV) repair is extensively used in different pathological MV conditions. Randomized controlled trials have evaluated the role of this technique in both primary (organic) and secondary (functional) mitral regurgitation (MR). Furthermore, recent analyses of these studies have shown the relevance of echocardiographic patient selection in the functional setting of MR, differentiating proportionate MR from disproportionate MR according to the degree of the effective regurgitant orifice area (EROA) related to the left ventricular volume. The haemodynamic impact of MR cannot be univocally measured by echocardiography alone and the aim of our study was to determine how invasive LAP monitoring during percutaneous edge-to-edge MV repair can predict long-term procedural success on top of the echocardiographic assessment by introducing the VCX INDEX and identifying haemodynamic variables with direct influence on filling pressures. The VCX INDEX, reflecting the impact of MR, is calculated by dividing the difference between v wave (ventricular systole in the left atrial pressure, LAP, or in the pulmonary capillary wedge pressure, PCWP, waveform) and the mean minimum LAP or mean minimum PCWP (mean between minimum LAP or minimum PCWP, x wave, and a/c wave) by systolic arterial pressure (SAP): (v wave – mean minimum LAP or mean minimum PCWP)/SAP. 85 patients at our centres underwent invasive intracardiac pressure monitoring either measuring LAP during percutaneous edge-to-edge MV repair or PCWP during right heart catheterization. Median VCX INDEX was 0.1 (Q1 0.05, Q3 0.16). The study population was further analysed according to the echocardiographic aetiology of MR: in the organic MR subgroup median VCX INDEX was 0.08 (Q1 0.05, Q3 0.14), in the functional proportionate MR subgroup median VCX INDEX was 0.07 (Q1 0.03, Q3 0.13) and in the functional disproportionate MR subgroup median VCX INDEX was 0.11 (Q1 0.06, Q3 0.19). 20 patients were deemed inoperable by the Heart Team and no further intervention was performed, while 65 patients underwent percutaneous edge-to-edge MV repair with MitraClip device and VCX INDEX was recalculated after the procedure. Median post-MitraClip VCX INDEX was 0.04 (Q1 0.02, Q3 0.07) and a subanalysis based on the echocardiographic MR aetiology was repeated: median post-MitraClip VCX INDEX was 0.02 in the organic MR subgroup (Q1 0.01, Q3 0.05), 0.03 in the functional proportionate MR subgroup (Q1 0.02, Q3 0.07) and 0.05 in the functional disproportionate MR subgroup (Q1 0.03, Q3 0.07). Median VCX INDEX in patients who did not undergo MitraClip implantation was 0.07 (Q1 0.04, Q3 0.12). The variation of VCX INDEX when comparing pre- and post-procedural invasive pressure assessment gives an insight of MitraClip’s favourable haemodynamic effect in terms of VCX INDEX reduction in the treated subgroup of the study and how the intervention has a comparable haemodynamic impact between different echocardiographic MR aetiologies. Further studies are needed to explore the incremental diagnostic role in the decision-making process as well as the prognostic value of the VCX INDEX in patients undergoing percutaneous edge-to-edge MV repair.

Reduction in Right Atrial Pressures Is Associated With Hemodynamic Improvements After Transcatheter Edge-to-Edge Repair of the Tricuspid Valve

Background: Investigational transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR) has shown promise as an alternative to surgery, but factors influencing outcomes, optimal patient selection, and procedural timing remain incompletely defined. Given the limitations of determining TR severity by conventional echocardiography, our objectives were to determine whether invasive right atrial (RA) pressures performed during the procedure are related to patient outcomes. Methods: This study was a retrospective review of patients who underwent off-label tricuspid TEER using MitraClip (Abbott Vascular, Menlo Park, CA) for significant TR at a single institution. Intraprocedural mean RA pressure, RA peak V-wave, RA pressure nadir, and systolic increase in RA pressure (XV height) were recorded. Results: Thirty-eight patients underwent tricuspid TEER; 33 underwent concomitant mitral TEER for mitral regurgitation. The study cohort was 39% female with a mean age of 78.6±14.3 years. Median follow-up was 339 days (interquartile range, 100–601). Any reduction in mean RA pressure, RA peak V-wave, RA nadir, and XV height occurred in 74%, 82%, 45%, and 87% of patients, respectively. At 1 year, event-free survival was 47%. Postprocedure XV height correlated with TR severity as determined by echocardiography ( P <0.0001). The highest quartile of postprocedure XV height (>8 mm Hg) had worse event-free survival compared with those who had concluding XV height ≤8 mm Hg ( P =0.02). Attainment of a concluding XV height less than or equal to median value was associated with a lower creatinine the next day (1.27±0.47 versus 1.64±0.47 mg/dL, P= 0.04). Conclusions: Intraprocedural XV height correlates with TR severity after tricuspid TEER, and lower concluding pressures are associated with improved outcomes. Analysis of RA pressures may serve as a complementary tool for the evaluation of disease severity and procedural guidance.

Exercise Hemodynamic Profiling Is Associated With Outcome in Patients Undergoing Percutaneous Mitral Valve Repair

Background: Percutaneous mitral valve repair (PMVR) in high-risk patients is currently controversial, especially in those with secondary mitral regurgitation (MR). Exercise pulmonary hemodynamics may help to unmask cardiac dysfunction as well as the dynamic impact of MR. The present study sought to explore the clinical impact of preprocedural exercise right heart catheterization (RHC) for the selection of patients who could most benefit from PMVR. Methods: Sixty-eight patients with symptomatic primary and secondary MR and exercise RHC before PMVR were included in this retrospective analysis of the association of exercise RHC parameters with survival and improvement in New York Heart Association class within 12 months. Results: Median patient age was 77 years (±8.5), 37% were female, and 81% presented with New York Heart Association class III. A total of 65% of the patients had left ventricular ejection fraction <55%. MR was severe in 49% and moderate-to-severe in 51%. Twenty-two patients (32%) died within the follow-up period of 19 months (interquartile range, 9–32); they had a lower rise (Δ) in the V-wave on pulmonary artery wedge pressure tracings. Patients with ΔV-wave ≥17 mm Hg had a reduced risk of death after PMVR (hazard ratio, 0.11 [95% CI, 0.04–0.33], P <0.001), independent of age, frailty index, and workload during RHC. A higher ΔV-wave was also associated with New York Heart Association improvement (odds ratio, 1.14 [95% CI, 1.07–1.24]; P <0.001), and 79% of patients with ∆V-wave ≥15 mm Hg were in New York Heart Association class I or II at follow-up (<15 mm Hg: 28%). These results were for the most part confirmed in the subgroup of patients with secondary MR (65%). Conclusions: In our cohort of patients with indication for PMVR, preprocedural exercise RHC was able to identify patients with an unfavorable outcome. Further studies with larger patient numbers are warranted before this approach can be implemented in a structured diagnostic workup of patients under evaluation for PMVR.

Elevated Left and Right Atrial Pressures Long‐Term After Atrial Septal Defect Correction: An Invasive Exercise Hemodynamic Study

Background Despite correction of the atrial septal defect (ASD), patients experience atrial fibrillation frequently and have increased morbidity and mortality. We examined physical capacity, cardiac performance, and invasive hemodynamics in patients with corrected ASD. Methods and Results Thirty‐eight corrected patients with isolated secundum ASD and 19 age‐matched healthy controls underwent right heart catheterization at rest and during exercise with simultaneous expired gas assessment and echocardiography. Maximum oxygen uptake was comparable between groups (ASD 32.7±7.7 mL O 2 /kg per minute, controls 35.2±7.5 mL O 2 /kg per minute, P =0.3), as was cardiac index at both rest and peak exercise. In contrast, pulmonary artery wedge v wave pressures were increased at rest and peak exercise (rest: ASD 14±4 mm Hg, controls 10±5 mm Hg, P =0.01; peak: ASD 25±9 mm Hg, controls 14±9 mm Hg, P =0.0001). The right atrial v wave pressures were increased at rest but not at peak exercise. The transmural filling pressure gradient (TMFP) was higher at peak exercise among patients with ASD (10±6 mm Hg, controls 7±3 mm Hg, P =0.03). One third of patients with ASD demonstrated an abnormal hemodynamic exercise response defined as mean pulmonary artery wedge pressure ≥25 mm Hg and/or mean pulmonary artery pressure ≥35 mm Hg at peak exercise. These patients had significantly elevated peak right and left atrial a wave pressures, right atrial v wave pressures, pulmonary artery wedge v wave pressures, and transmural filling pressure compared with both controls and patients with ASD with a normal exercise response. Conclusions Patients with corrected ASD present with elevated right and in particular left atrial pressures at rest and during exercise despite preserved peak exercise capacity. Abnormal atrial compliance and systolic atrial function could predispose to the increased long‐term risk of atrial fibrillation. Registration Information clinicaltrials.gov. Identifier: NCT03565471.

Contralateral Masking in the Measurement of Auditory Brainstem Responses with Air-Conducted Tone Burst Stimuli in Individuals with Unilateral Hearing Loss

Background Contralateral noise masking is an important aspect of auditory brainstem response (ABR) measurements. Purpose The primary aim of this study is to determine how contralateral white noise (WN) masking influences the amplitude and the latency of V wave generated during ABR measurements, using tone burst (TB), in adult ears with normal hearing (NH). The secondary aim of this study is to ascertain the need of contralateral masking in ABR measurements with the TB stimuli using a 3A insertion earphone, and to propose the applicability of WN masking in unilateral sensorineural hearing loss (USNHL). Research Design It is a cross-sectional observational and descriptive study. Study Sample Experiment 1: Thirty individuals, without any otologic, psychological, or neurological dysfunction, were selected. Experiment 2: Fifteen individuals with previous audiological diagnoses of severe and profound USNHL were considered. Intervention The study involves ABR TB at specific frequencies of 0.5, 1, 2, and 4 kHz. Data Collection and Analysis Experiment 1: The evaluation was performed at the fixed intensity of 80 dB nHL (decibel normalized hearing level) on the tested ear, followed by the application of simultaneous masking to the nontested ear, intensity ranged from 0 to 80 dB. Experiment 2: ABR threshold measurements were first performed on the ear with hearing loss (HL) at the frequencies of 1, 2, and 4 kHz. The results were subsequently confirmed using contralateral masking. Results Experiment 1: At any given frequency, there were no statistically significant differences in the amplitude and latency of V wave with increase in the intensities of WN masking. Experiment 2: Cross-hearing was observed at least once in all frequencies analyzed through the occurrence of V wave. Conclusion In conclusion, the contralateral WN masking at the maximum intensity of 80 dB does not affect the amplitude and latency of V wave of the ABR TB at 1, 2, and 4 kHz. Contralateral masking for the ABR TB presented using 3A insertion earphones is necessary at 1, 2, and 4 kHz in individuals with severe or profound degrees of USNHL and at intensities of 15, 20, and 10 dB above the ABR threshold of the nontested ear.

New perspective on qualitative and quantitative indicators of juvenile crime in Russia

The goal of this research consists in determination and analysis of the current trends of juvenile crime in Russia. The subject of this article is the basic patterns of juvenile crime identified by keeping track of its dynamics, modification and activity in Russia from 1991 to 2019, and classified by the authors into separate periods &ndash; &ldquo;waves&rdquo; in accordance with the &ldquo;bursts&rdquo; of such type of crime. It is underlined that the timely identification of factors and conditions that lead to the spate of criminal activity among juveniles in a specific time period allows preventing similar situations in future, as well as contributes to the development of an effective toolset for preventing deviant behavior of teenagers. The empirical basis of this research is comprised of the statistical reports on the state of juvenile crime in Russia that are posted annually on the official websites of the Ministry of Internal Affairs of Russia and the Prosecutor General's Office of the Russian Federation. The authors also lean on the fundamental Russian and foreign research dedicated to the problematic questions of preventing juvenile crime. In the course of studying statistical data that reflect qualitative and quantitative indicators of juvenile crime in Russia from 1991 to 2019, the authors determined five so-called &ldquo;waves&rdquo; of juvenile crime: I wave 1991-1997, II wave 1998-2002, III wave 2003-2012, IV wave 2012-2014, and V wave 2014-2019. Examination of media source, publicistic and scientific literature allowed revealing the most probable causes of the sharp increase in criminogenic situation in the juvenile environment. The article also reveals certain negative trends, such as the increase in the rate of grave and especially grave crimes committed by minors.

Insights into the combination of neuromuscular electrical stimulation and motor imagery in a training-based approach

Introduction Training stimuli that partially activate the neuromuscular system, such as motor imagery (MI) or neuromuscular electrical stimulation (NMES), have been previously shown as efficient tools to induce strength gains. Here the efficacy of MI, NMES or NMES + MI trainings has been compared. Methods Thirty-seven participants were enrolled in a training program of ten sessions in 2 weeks targeting plantar flexor muscles, distributed in four groups: MI, NMES, NMES + MI and control. Each group underwent forty contractions in each session, NMES + MI group doing 20 contractions of each modality. Before and after, the neuromuscular function was tested through the recording of maximal voluntary contraction (MVC), but also electrophysiological and mechanical responses associated with electrical nerve stimulation. Muscle architecture was assessed by ultrasonography. Results MVC increased by 11.3 ± 3.5% in NMES group, by 13.8 ± 5.6% in MI, while unchanged for NMES + MI and control. During MVC, a significant increase in V-wave without associated changes in superimposed H-reflex has been observed for NMES and MI, suggesting that neural adaptations occurred at supraspinal level. Rest spinal excitability was increased in the MI group while decreased in the NMES group. No change in muscle architecture (pennation angle, fascicle length) has been found in any group but muscular peak twitch and soleus maximal M-wave increased in the NMES group only. Conclusion Finally, MI and NMES seem to be efficient stimuli to improve strength, although both exhibited different and specific neural plasticity. On its side, NMES + MI combination did not provide the expected gains, suggesting that their effects are not simply cumulative, or even are competitive.