Objectives: Mitral valve disease is increasingly prevalent. Timely diagnosis and the choice of the right intervention are very important in the early stages, as valvular dysfunction often leads to cardiac failure and even sudden death. The focus of this paper is on the various pathologies of the mitral valve, their etiology, and clinical management. Methods: Mitral regurgitation (MR) can be managed surgically, percutaneously or medically. Treatment methods for primary MR include percutaneous mitral valve (MV) repair, MV replacement, minimally invasive mitral valve surgery (MIMVS), and more recently, robotics. Additionally, conventional sternotomy has been used for both MR and mitral stenosis. Nonetheless, ongoing clinical trials are a clear indicator that the management of valve diseases is continuously evolving. Results: Multiple studies favour MV repair via MIMVS, over conventional sternotomy or percutaneous approach. However, more data is needed to optimize patient selection. Robot assisted repair is a new alternative, but attention should be given to the steep learning curve and medical training of professionals wishing to perform this intervention. Cost effectiveness and possible side effects should be explored by clinical trials as well. While guidelines are fairly straightforward for primary MR, there is insufficient evidence to suggest that surgical treatment is advantageous for secondary MR. Management is usually pharmaceutical and aims to treat symptoms rather than cause. Conclusion: Mitral valve disease remains a medical challenge, but numerous research and clinical trials have been embarked upon to refine old methods and discover new ones to improve treatment success and procedural safety.
Objective To review the evidence behind the role and relevance of redo coronary artery bypass grafting (CABG) in the current practice of percutaneous coronary intervention (PCI). Methods A comprehensive electronic literature search was performed to identify articles that discuss the practice of PCI and redo CABG in patients that require coronary revascularization. All relevant studies are summarized in narrative manner to reflect current indications and preference. Results The advancement in utilization of PCI has reduced the rate of redo CABG in patients with previous CABG that requires revascularization of an already treated coronary disease or a new onset of coronary artery stenosis. Redo CABG is associated with satisfactory perioperative outcomes but higher mortality at immediate postoperative period when compared to PCI. Conclusion Redo CABG patients are less likely to develop comorbidities associated with revascularisation, but the operative mortality is higher and long-term survival rates are similar in comparison to PCI. There is a need for further research into the role of redo CABG in the current advanced practice of PCI.
RATIONALE Dynamic Chest radiography (DCR) involves taking sequential x-ray images throughout the patients breathing cycle. This allows for quantifiable measurements of diaphragmatic movement, cardiac motion, pulmonary ventilation and circulation. Recent studies have begun to correlate DCR obtained values with conventional measures of pulmonary physiology, such as spirometry. This technique therefore has the potential to become a rapid means of assessing both pulmonary anatomy and physiology. Two key DCR measurements, 'maximal distance from lung apex to the diaphragm' and 'total lung area' can used to calculate the change in area occurring between inspiration and expiration, or 'DCR equivalent Forced Vital Capacity' (DCR FVC). The aim of this study is to investigate the use of DCR FVC and assess the level of agreement between the two key measurements. METHODS The DCR images for 50 individual patients were obtained. The values for 'maximal distance from lung apex to the diaphragm' and 'total lung area' were calculated for both lungs during maximal inspiration and expiration. The difference between inspiration and expiration was used to generate DCR FVC and data was collated in a spreadsheet. Summary statistics were calculated, and Pearson's correlation coefficients were used to compare 'maximal distance from lung apex to the diaphragm' and 'total lung area' values. RESULTS Values were obtained for all 50 patients. The
RATIONALE Dynamic chest radiography (DCR) is a new imaging technique that involves taking sequential chest radiographs throughout the respiratory cycle. This allows the real time observation of the changes in lung and diaphragmatic movement occurring during respiration. Recent studies have correlated DCR acquired measures with those of pulmonary function testing, indicating that it can be an alternative measure of pulmonary physiology. Currently DCR values are manually recorded introducing an element of subjectivity. If this technique is to be widely adopted the nature of the inter-operator variability will need to be characterised. This study evaluates the inter-operator variability between two observers recording two key DCR obtained values. METHODS Two independent reviewers separately recorded measurements from the DCR image sequences of 50 patients. Their values for 'maximal distance from lung apex to diaphragm' and 'total lung area' at the point of maximal inspiration and expiration for both the right and left lungs were collated in a database. The inter-operator variability (IOV) for their inspiratory and expiratory values was assessed using Bland-Altman plots and Deming regression analysis was used to investigate statistical error in the observations. RESULTS The Bland-Altman pIot demonstrates the majority of the reviewer's observations for 'maximum distance' in the inspiratory images were within the 95% limits of agreement, with only a few outliers (right lung maximum distance; slope= 1.01 (SE 0.02, 95% CI 0.97-1.05) left lung max distance; slope= 0.98 (SE 0.04 95% CI 0.90-1.05). This was a similar picture for lung area (right lung area; slope= 1.0 (SE 0.01 95% CI 0.98-1.03), left lung area; slope= 1.02 (SE 0.01 95% CI 0.97-1.05)). Deming regression analysis showed good agreement. The two reviewers also had good agreement for expiratory images (right lung maximum distance; slope= 1.01 (SE 0.06, 95% CI 0.98-1.04) left lung max distance; slope= 0.99 (SE 0.05 95% CI 0.89-1.09). Again 'lung area' measurements were similar (right lung area; slope= 0.16 (SE 0.86 95% CI -1.58-1.88), left lung area; slope= 1.03 (SE 0.01 95% CI 1.0-1.06)). Deming regression showed poor fit however this was influenced by an outlying measurement. CONCLUSIONS In general there was good agreement between the two reviewers when interpreting the various images. However, as this imaging technique becomes more widespread the image analysis would benefit from being uniformly interpreted.
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