Mitral Stenosis Patients Research Articles

Mitral Leaflet Separation Index (MLSI): A step ahead to assess severity of mitral stenosis in patients with Atrial Fibrillation

Mitral Leaflet Separation Index (MLSI): A step ahead to assess severity of mitral stenosis in patients with Atrial Fibrillation

The assessment of left/right ventricular strain and deformation in patients with severe rheumatic mitral stenosis before and after balloon mitral valvuloplasty using speckle tracking echocardiography

Background: Rheumatic mitral stenosis (MS) poses substantial burden in developing countries and is an important cause of cardiovascular morbidity. Speckle tracking echocardiography is a novel technique which assesses the left and right ventricular mechanics and deformation by grey scale imaging. Aims and Objectives: We aimed to assess the left and right ventricular strain and deformation in patients with severe rheumatic mitral stenosis to analyse the subclinical ventricular dysfunction in these patients as compared to healthy controls and to see the effect of balloon mitral valvotomy (BMV) on these parameters. Material and Methods: 50 patients of severe rheumatic mitral stenosis were recruited into study and divided into two groups: cases ( severe MS patients underging BMV, n = 30 ) case controls(severe MS patients on medical management not opting for BMV, n = 20). 10 -healthy normal controls were taken. Baseline LV strain and deformation was assessed in these patients and effect of balloon mitral valvotomy was seen on these parameters in cases at early (24-48 hrs) and short term (1-month) period as compared to changes in case controls and normal controls. Results: Baseline LV global longitudinal (GL) (-13.1 ± 3.67) and circumferential strain (GC) (-19.18 ± 7.58) was significantly reduced in cases as compared to healthy controls (-22.17 ± 2.30) and (-30.21 ± 4.17) respectively (p

Left Atrial Appendage Mechanical Changes in Patient with Mitral Stenosis Speckle Tracking Imaging Study

Background: LAA is the major site of thrombus formation in mitral stenosis; active LAA blood flow and contractile function may be disturbed in MS. TEE is the modality of choice for evaluating LAA and Speckle-tracking echocardiography (STE) is a recently developed technique for the characterization and quantification of myocardial deformation. It permits measurement of LA and LAA strain and strain rate which can be used to assess the mechanical function of LAA. Objective: To assess the mechanical function of left atrial appendage (LAA) in mitral stenosis (MS) patients with sinus rhythm by 2D speckle tracking strain and strain rate through transesophageal echocardiography (TEE). Patients & Method: Thirty-three patients with moderate tosevere MS and sinus rhythm, 38.33 ± 5.66 years as a case group and twenty-two age and sex matched healthy volunteers as a control group. All participants underwent compete conventional transthoracic echocardiography; TEE for assessment of LAA morphology and Doppler flow and speckle tracking strain & strain rate were measured from LAA walls. Results: LAA Doppler flow peak velocities, LAA strain, reservoir strain rate (RSr), conduit strain rate (CSr) and atrial contractile strain rate (ASr) all were significantly lower in patient group. Global Strain of LAA had a negative correlation with LA diameter, pulmonary artery systolic pressure & degree of spontaneous echo contrast and a positive correlation with MS area and LAA Doppler flow.Conclusion: 2D speckle tracking strain and strain rate of LAA is a feasible technique and is significantly reduced in patients with mitral stenosis even with sinus rhythm.

Role of Two Dimension Strain and Strain Rate Echocardiography in Assessment of Rheumatic Mitral Valve Stenosis

Introduction: Current echocardiographic parameters have a limitation in assessing mitral valve (MV)apparatus in rheumatic mitral stenosis (MS) patient. In the current study, we use 2 dimensional (2D)longitudinal strain (S) and strain rate (Sr) imaging in evaluating the papillary muscle longitudinal strain (LS) as an objective and quantitative echocardiographic parameter with high reproducibility in the assessment of MV apparatus in patients with mild to moderate rheumatic MS with preserved ejection fraction (EF%). Patients and Method: The study included 40 patients with established diagnosis of MS subdivided in to 31 patients with moderate MS (mean age: 32 ± 5) and 9 patients with mild MS (mean age: 31 ± 6). 20 healthy individuals (mean age 31 ± 6) as a control for cases. The mitral valve area (MVA) was estimated using planimetry and pressure half time (PHT) methods. 2D longitudinal systolic S and Sr imaging was carried out for all participants from the apical long axis (LAX), 4 chamber (4C), 2 chamber (2C) views. Global longitudinal systolic S and Sr were estimated by averaging the 3 apical views. Longitudinal myocardial strain of papillary muscle PMs was assessed by the use of the free strain method from apical 4 chamber view for the antrolateral papillary muscle (APM) and apical long axis view for postromedial papillary muscle (PPM). Results: Patients with MS had significantly decreased longitudinal LV systolic S and Sr in comparison with control group (p Conclusion: Patients with MS and preserved EF% had decreased APM-LS & PPM-LS in comparison with control group, and had decreased longitudinal LV systolic S and Sr when compared with control group. 2D strain as well as Sr imaging might be a useful method for assessment of mitral valve apparatus in patients with MS & preserved EF%.

Association between late gadolinium enhancement and global longitudinal strain in patients with rheumatic mitral stenosis.

The correlation between the extent of myocardial fibrosis and subclinical left ventricle (LV) systolic dysfunction in rheumatic mitral stenosis (MS) has not been widely studied. We sought to evaluate the correlation between the extent of LV myocardial fibrosis quantified by late gadolinium enhancement (LGE) using cardiac magnetic resonance (CMR) and global longitudinal strain (GLS) by speckle tracking echocardiography (STE) in patients with rheumatic MS. We prospectively evaluated 36 consecutive rheumatic MS patients who were planning to undergo mitral valve surgery. Then we evaluate the correlation between the extent of LV myocardial fibrosis quantified by LGE CMR and the systolic LV function by GLS using STE. Thirty-six patients with mean age of 45.7 ± 9.9years old, showed mean LGE was 4.9 ± 2.7%. The mean LV ejection fraction (EF) measured by CMR was 50 ± 10.8%, and the mean LV GLS was 13.5 ± 3.9%. There was a moderate correlation between GLS and LGE (r - 0.432, p = 0.009). There were no correlations between GLS with mitral valve area (MVA) with r 0.149, p = 0.385, mean mitral valve gradient (MVG) with r -0.078, p = 0.653, and LVEF (r 0.299, p = 0.076). There was a moderate correlation between LGE and GLS in patients with rheumatic MS.

Assessement of left atrial appendage functions with TEE in patients of severe rheumatic mitral stenosis before, immediately after and 3 months after PTMC

Assessement of left atrial appendage functions with TEE in patients of severe rheumatic mitral stenosis before, immediately after and 3 months after PTMC

Comparison of immediate and 6-month follow-up results of percutaneous transseptal mitral commissurotomy in patients of rheumatic mitral stenosis in sinus rhythm and atrial fibrillation – An echocardiographic and haemodynamic study

Comparison of immediate and 6-month follow-up results of percutaneous transseptal mitral commissurotomy in patients of rheumatic mitral stenosis in sinus rhythm and atrial fibrillation – An echocardiographic and haemodynamic study

Right ventricle function assessment by various Echocardiographic parameters including strain in severe mitral stenosis patients and effect of PTMC on these parameters

Right ventricle function assessment by various Echocardiographic parameters including strain in severe mitral stenosis patients and effect of PTMC on these parameters

Correlation between Mitral Valve Area and Right Ventricle Function based on TAPSE (Tricuspid Annular Plane Systolic Excursion) Parameter in Mitral Stenosis Patient

Background: Mitral stenosis is the most common mitral valve disease found in Indonesia. Mechanical obstruction of blood flow from left atrium to left ventricle is compensated by pressure elevation in the left atrium and pulmonary circulation. It leads to right ventricle dysfunction which can be scored using TAPSE (Tricuspid Annular Plane Systolic Excursion) Parameter.Aim: The goal of this study is to assess the relationship between mitral valve area and right ventricle function based on TAPSE parameter in mitral stenosis patient.Methods: This study was conducted in Dr. Sardjito Hospital from May until July 2017. This was a part of mitral stenosis registry study. The parameter used was planimetry mitral valve area and TAPSE from echocardiography. The relationship between mitral valve area and TAPSE score we reanalyzed using Spearman correlation test in SPSS software.Results: The total sample included in this study was 132 people, consisted of thirty-eight (28.79%) males and ninety-four (71.21%) females. The range of the subjects’age was 18 68 year oldand the mean was 43.31±11.13 year old. The body mass index median was 21.24 (14.24–35.38) kg/m2. The subjects were dominated by severe degree mitral stenosis patients, those were ninety-three (70.45%) people, followed by moderate degree patients, those were thirty-two (24.24%) people, and mild degree patients, those were seven (5.30%) people. Twenty-eight (21.21%) people had isolated mitral stenosis. The mitral valve area median was 0.8 (0.27–1.90) cm2. The TAPSE score range was 6–30 mm and the mean was 17.48±4.58 mm. The result from Spearman correlation test showed that the relationship strength between mitral valve area and TAPSE score were very weak (r=0.167) with significant p-value (p=0.028).Conclusion: There is a statistically significant positive relationship with very weak strength between mitral valve area and TAPSE score as a right ventricle function parameter in mitral stenosis patients (r = 0.167, p = 0.028).

NON-VITAMIN K ANTAGONIST ORAL ANTICOAGULANT (NOAC) USE AND DOSING IN CANADIAN PRACTICE: INSIGHTS FROM THE OPTIMIZING PHARMACOTHERAPY IN THE MANAGEMENT APPROACH TO LOWERING RISK IN ATRIAL FIBRILLATION (OPTIMAL-AF) PROGRAM

When non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) are prescribed by Canadian primary care physicians (PCPs) and specialists for non-valvular atrial fibrillation (NVAF), data has suggested that lower doses are commonly used. We aimed to: (1) identify the proportion on CCS AF Guideline-recommended OAC; (2) estimate the rate of NOAC dosing that is lower- and higher-than-recommended; and, (3) understand the reasons why patients receive reduced NOAC doses. The OPTIMAL AF Program is an ethically approved, national, observational, knowledge translation, quality enhancement initiative where PCPs and specialists are undertaking a chart audit of their anticoagulated NVAF (i.e., excluding mechanical heart valve, rheumatic mitral stenosis) patients (≥18 years age, without severe renal dysfunction) through either an electronic medical record (EMR) system (Telus Health Platforms/Practice Solutions/Med Access) or standardized, paper-based data collection forms. As of April 5, 2018, 1512 patients (EMR n=965, paper-based n=547) from 95 physician practices (84 PCPs, 11 specialists) in eight provinces are included. The median age is 77 (25th, 75th percentiles: 70, 83) years; 89% are ≥65 years; 38% are female; 11% have a body weight ≤60 kg; the median CHADS2 score is 2 (1, 3) and CHA2DS2-VASc is score 4 (3, 5); and (as most recently reported by local laboratory) the median eGFR was 61 (50, 74) ml/min/1.73 m2. By inclusion criterion, all patients are receiving OAC: 16% of patients receive warfarin, 52% of whom have their most recent INR in the 2-3 range. 84% are on NOAC: apixaban 49%, rivaroxaban 34%, dabigatran 17%, edoxaban <1%. Standard dose NOAC is used in 77% (see Figure). When comparing NOAC dose with Health Canada prescribing recommendations, we observed apparent lower-than-recommended dosing in 41% of patients on reduced dose (i.e., 9% of the overall NOAC cohort) and higher-than-recommended dosing in 5% on standard dose (i.e., 4% overall). Among patients on reduced dose NOAC that was discordant with prescribing recommendations, physicians provided reason(s) (see Table). More than eight in 10 NVAF Canadian patients in our study are receiving NOAC for stroke prevention as per CCS AF Guideline recommendations. However, among warfarin-treated patients there is suboptimal INR control in ∼50%. Despite relatively infrequent apparent lower-than-recommended dosing (∼one in 11 patients) and higher-than-recommended dosing (∼one in 26 patients) of NOAC, opportunities remain to further minimize the discordance between product monograph-based prescribing recommendations and NOAC dosing used in routine clinical practice.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Mitral Leaflet Separation Index (MLSI): A Step Ahead to Assess Severity of Mitral Stenosis in Patients with Atrial Fibrillation

Mitral Leaflet Separation Index (MLSI): A Step Ahead to Assess Severity of Mitral Stenosis in Patients with Atrial Fibrillation

Immediate impact of percutaneous transvenous mitral commisurotomy on right ventricle longitudinal strain in patients of mitral stenosis.

Right ventricular (RV) function has prognostic value in terms of survival and symptoms in patients with mitral stenosis (MS). The aim of the study was to assess RV function by strain analysis in the patients of mitral stenosis and the effect of percutaneous transvenous mitral commisurotomy (PTMC) on it. Eighty patients of severe mitral stenosis without overt right heart failure and normal sinus rhythm undergoing PTMC were included. Conventional echocardiography and RV function by TDI-derived longitudinal strain and strain rate were assessed prior and 24hours post PTMC and compared with 40 healthy age-matched controls. Eighty subjects (mean age 31+10years, 70% females) were included. Patients with MS had significantly lower RV strain of basal and mid-free wall, tricuspid annular plane systolic excursion (TAPSE), and RV fractional area change (FAC) as compared to controls. There was a significant increase in pre- and post-PTMC in TAPSE (19.5±2.7mm vs 21.4±3.3mm; P<0.001), RV basal free wall longitudinal strain (-24.4+6.1% vs -27.7+5.8%; P<0.001), and right ventricle mid-free wall longitudinal strain (-25.6+5.5% vs -28.6+5.1%; P<0.001), respectively. There was no significant change in RV Tei index (0.43+0.06 vs 0.41+0.03; P=0.06). There was a significant negative correlation between RV longitudinal strain and right ventricle systolic pressure, left atrium diameter, RV Tei index, and pulmonary capillary wedge pressure, and positive correlation between RV FAC and RV TAPSE. Patients with severe MS with normal RV systolic function had decreased RV strain, which was significantly increased after a successful PTMC with reduction in afterload.

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement.

The concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR). Using weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in-hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility. A total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (P < 0.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in-hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392-0.964, P = 0.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group. In patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR.

Abstract 671: Looking with the Poiseuille’s Glasses - a Proposal of a Novel Hypothetical Method to Increase the Dimensions of the Coronary Arteries when Required

Background: The purpose was to develop a novel hypothetical method to increase the dimensions of coronary arteries. Methods: In the long-term observation, the coronary sizes were dilated in three unexpected scenarios. The coronary artery sizes were observed in patients with mitral stenosis patients (n=12) by angiogram. The coronaries of patients with patent ductus arteriosus who underwent surgical/coil closure in the past (n=7) were examined by echocardiogram. These patients also had normal aortic and left ventricular dimensions, and all had surgeries/coil closure more than four years prior to this observation. Patients with renal failure on long-term dialysis through peripheral arterio-venous fistula without left ventricular hypertrophy (n=13) were studied by echocardiography for coronary dimensions. Normal age and sex-matched coronary sizes served as controls in the study. All these observations were made over a period of 10 years. Results: The sizes of coronaries in patients with mitral stenosis were greater than 22% (± 4) of the normal. The coronary sizes were 32% (±4) higher than normal in patients with patent ductus arteriosus without left ventricular or aortic dilatation. Patients with renal failure on hemodialysis without left ventricular hypertrophy had coronary sizes 28% (±5) higher than similarly sized ventricles. Reducing the diastolic blood pressures, the increase in coronary angulation by sine (θ) function, and increase in the coronary length and diameters can be achieved by observing the differential equations of Poiseuille’s. A hypothetical model to increase the coronary sizes could be developed based on the analysis of the differential equations. The proposed method is creating a peripheral arterio-venous fistula, which can be closed later by a percutaneous method/surgery. The closure time needs to be determined by experimental studies. The other methods could be a continuous exercise program or usage of beta-blockers. Conclusion: A novel hypothetical method of peripheral arterialvenous fistula formation could potentially increase the size of the coronaries. Further experiments need to be performed to observe the results.

Prevalence and Outcomes of Mitral Stenosis in Patients Undergoing Transcatheter Aortic Valve Replacement: Findings From the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry

ObjectivesThis study sought to examine the prevalence of mitral stenosis (MS) and its impact on in-hospital and 1-year clinical outcomes among patients undergoing transcatheter aortic valve replacement (TAVR). BackgroundPatients with coexisting severe aortic stenosis and MS are increasingly being considered for TAVR. MethodsThe study cohort included 44,755 patients (age ≥18 years) who underwent TAVR during November 1, 2011, to September 30, 2015, and were registered in Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies (TVT) Registry. One-year outcomes were assessed by linking TVT registry data of this cohort to patient-specific Centers for Medicare & Medicaid Services administrative claims data (n = 31,453). The primary outcome was the composite of death, stroke, heart failure–related hospitalization, and mitral valve intervention at 1 year. ResultsMS was present in 11.6% of cohort (mean age, 82 years; 52% males), being severe in 2.7%. Severe MS was associated with higher in-hospital mortality rates (5.6% vs. 3.9% for nonsevere MS and 4.1% for no MS; p = 0.02). In contrast to those without MS, severe MS group had significantly higher risk for the primary outcome, mortality (1 year), and heart failure–related hospitalization (1 year) (adjusted hazard ratio: 1.2 [95% confidence interval (CI): 1.1 to 1.4], 1.2 [95% CI: 1.0 to 1.4], and 1.3 [95% CI: 1.1 to 1.5], respectively; p < 0.05 for all). ConclusionsApproximately one-tenth of patients undergoing TAVR have concomitant MS. Severe MS is an independent predictor of 1-year adverse clinical outcomes following TAVR. The higher risk for long-term adverse events must be considered when evaluating patients with combined aortic stenosis and MS for TAVR.

TCTAP A-113 Impact of Mitral Annular Calcification on Immediate Hemodynamic and Echocardiographic Results of Percutaneous Transvenous Mitral Commissurotomy in Patients of Symptomatic Mitral Stenosis

Mitral annular calcification (MAC) is degenerative, fibrous calcification of the mitral valve annulus. It is more common in people over 70 years old. It is a marker of increased cardiovascular risk which occurs in a graded fashion by MAC severity. the Wilkins scoring system does not examine mitral

Comprehensive microRNA profiling reveals potential augmentation of the IL1 pathway in rheumatic heart valve disease

BackgroundValvular heart disease is a leading cause of cardiovascular mortality, especially in China. More than a half of valvular heart diseases are caused by acute rheumatic fever. microRNA is involved in many physiological and pathological processes. However, the miRNA profile of the rheumatic valvular heart disease is unknown. This research is to discuss microRNAs and their target gene pathways involved in rheumatic heart valve disease.MethodsSerum miRNA from one healthy individual and four rheumatic heart disease patients were sequenced. Specific differentially expressed miRNAs were quantified by Q-PCR in 40 patients, with 20 low-to-moderate rheumatic mitral valve stenosis patients and 20 severe mitral valve stenosis patients. The target relationship between certain miRNA and predicted target genes were analysis by Luciferase reporter assay. The IL-1β and IL1R1 expression levels were analyzed by immunohistochemistry and western blot in the mitral valve from surgery of mitral valve replacement.ResultsThe results showed that 13 and 91 miRNAs were commonly upregulated or downregulated in all four patients. Nine miRNAs, 1 upregulated and 8 downregulated, that had a similar fold change in all 4 patients were selected for quantitative PCR verification. The results showed similar results from miRNA sequencing. Within these 9 tested miRNAs, hsa-miR-205-3p and hsa-miR-3909 showed a low degree of dispersion between the members of each group. Hsa miR-205-3p and hsa-miR-3909 were predicted to target the 3’UTR of IL-1β and IL1R1 respectively. This was verified by luciferase reporter assays. Immunohistochemistry and Western blot results showed that the mitral valve from rheumatic valve heart disease showed higher levels of IL- 1β and IL1R1 expression compared with congenital heart valve disease. This suggested a difference between rheumatic heart valve disease and other types of heart valve diseases, with more inflammatory responses in the former.ConclusionIn the present study, by next generation sequencing of miRNAs, it was revealed that interleukin 1β and interleukin 1 receptor 1 was involved in rheumatic heart diseases. And this is useful for diagnosis and understanding of mechanism of rheumatic heart disease.

PERSISTENT PULMONARY HYPERTENSION AFTER BALLOON MITRAL VALVULOPLASTY

Persistence of Pulmonary artery Hypertension (PPAH) in cases of Rheumatic Mitral stenosis following Percutaneous balloon Mitral valvuloplasty (BMV) is not uncommon. It has been found that in Patients of Mitral stenosis, with mild PAH the Pulmonary artery pressure and Pulmonary vascular resistance

CRT-700.53 Immediate Hemodynamic & Echocardiograpgic Results of Percutaneous Transvenous Mitral Commissurotomy in Patients of Symptomatic Mitral Stenosis with Mitral Annular Calcification

To see the immediate hemodynamic and echocardiographic results of Percutaneous Transvenous Mitral Commissurotomy (PTMC) in patients with mitral stenosis with mitral annular calcification. Rheumatic mitral stenosis is a very common problem in our population having an incidence of 54 percent among

A new simple score to predict late outcome of balloon mitral commissurotomy

Balloon mitral commissurotomy (BMC) has become widely accepted as the treatment of choice for mitral stenosis in patients with favorable anatomy, but few tools are available to predict its long-term outcome. We sought to determine a simple score to predict late outcome of BMC in patients with mitral stenosis. Late results of BMC were assessed in 1035 consecutive patients at our institution. A good immediate result was defined as valve area ≥ 1.5 cm 2 without mitral regurgitation > 2/4. BMC procedure was performed using the double balloon or the Inoue balloon techniques. Ore to predict late outcome of BMC in patients with mitral stenosis. Mean age of our population was 35.6 ± 12 years. A successful procedure was observed in 92.4% of cases. At a mean follow-up of 20 years, the rate of survival with freedom from mitral surgery, or repeat percutaneous mitral commissurotomy and with New York Heart Association class I or II was of 47.6 ± 2.4%. By multivariate analysis using Cox regression model, three predictors of poor late functional results were identified: prior commissurotomy ( P = 0.014), Wilkins score > 8 ( P < 0.0001) and final mitral valve area < 1.8 cm 2 ( P < 0.0001). From the results of this analysis, we sought to develop a scoring system using the items indicated in the table below. Patients were considered at low risk if the score was of 0 to 5 (17.6% of patients). They were considered at middle risk if the score was of 6 to 8 (37.8% of patients) and were considered at high risk if the score was of 9 to 14 (51% of patients) ( Table 1 ). Twenty-year outcome of balloon mitral commissurotomy in a relatively young population is very encouraging and can be predicted by a simple score.