Systolic Velocity Measurements Research Articles

Orbital doppler ultrasound as an ancillary test for diagnosing brain death: A prospective, single blind comparative study

ObjectiveTranscranial Doppler ultrasound (TDUS), computed tomography angiography (CTA), and transcranial Doppler ultrasound to detect cerebral blood flow are among the adjunctive tests in diagnosing brain death. This study aimed to investigate the effectiveness of orbital doppler ultrasound (ODUS). MethodsThis prospective, single-blind study included 66 patients for whom brain death was to be diagnosed. Primary outcome measures were ODUS measurements, Ophthalmic artery peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive indices (RI) measurements recorded during the brain death determination process. Secondary outcome measures were computed tomography angio (CTA), transcranial Doppler ultrasound (TDUS), and demographic data. ResultsThis study investigating the effectiveness of ODUS in diagnosing brain death provided diagnostic success with 100% sensitivity and 93% specificity compared to CT angiography. It was noted that anatomical variations may limit its use. ConclusionODUS was found to have high sensitivity and specificity in the diagnosis of clinical brain death. It may assist in early prognostic assessment and shorten patient follow-up and diagnostic processes.

Retinal nerve fiber layer and ophthalmic artery blood flow parameters in pseudoexfoliation syndrome and pseudoexfoliative glaucoma

To investigate the relationship between ophthalmic artery (OA) blood flow parameters and retinal nerve fiber layer (RNFL) thickness in eyes with pseudoexfoliation (PEX). We compared PEX eyes without glaucoma (group A, n=53) and those with glaucoma (group B, n=18) with control eyes (group C, n=44). Subsequently, eyes in groups A and B were compared. Finally, OA color Doppler imaging measurements were recorded, and peripapillary RNFL analysis was performed. The total RNFL measurements differed significantly among the groups (P=0.012), being thicker in group C than in group A (P=0.010) and significantly different between group B and groups A and C (both P=0.001). The peak systolic velocity (PSV) and end diastolic velocity (EDV) measurements of groups A and B were lower than those of group C (PSV: P=0.001 and P=0.001, respectively; EDV: P=0.001 and P=0.001, respectively). No significant difference was noted in resistive index (RI) measurements (P=0.370). In group B, significant negative correlations were noted between total RNFL and PSV (r=-0.743; P=0.001) and between total RNFL and EDV (r=-0.691; P=0.001), but not between total RNFL and RI measurements (P=0.548). Pseudoexfoliation syndrome (PXS) with or without glaucoma was associated with a decrease in the PSV and EDV values of the OA. An extensive study may be needed to further explore the role of PXS in OA blood flow parameters. Total RNFL thickness values were lower in eyes with PEX than in those without.

1179: NOVEL ECHOCARDIOGRAPHIC PHENOTYPES FOR ASSESSMENT OF SYSTOLIC FUNCTION IN PATIENTS WITH SEPSIS

Introduction: LVEF in often influenced by loading conditions compared to mitral annular peak systolic velocity (MASV). Therefore, the clinical utility of LVEF under varying physiologic states especially in septic shock patients is unclear. We plan to identify distinct echocardiographic phenotypes using systolic wave (s’) obtained with Tissue Doppler Imaging (TDI) to assess left ventricle (LV) systolic function. Methods: We conducted a retrospective study between 2011 – 2020 of all adult patients admitted to the medical intensive care unit (MICU) with sepsis and septic shock that underwent a transthoracic echocardiogram (TTE) within 72 hours of admission. We excluded any patient without LVEF or mitral annular peak systolic velocity (MASV) measurements. Patients were divided into 4 novel phenotypes based on their LVEF and average MASV (α, β, γ, and δ). α = LVEF ≥ 55% & MASV average ≥ 8.5 cm/sec, β = LVEF ≥ 55% & MASV average < 8.5 cm/sec, γ = LVEF < 55% & MASV average ≥ 8. 5 cm/sec and finally δ = LVEF < 55 & MASV average < 8.5 cm/sec. The primary outcome was to identify the derived phenotype (α, β, γ, and δ) frequency and its association with in-hospital mortality. Results: Total of 3120 patients were admitted with sepsis or septic shock during the study period, of which 2481 met the inclusion criteria. Of the 4 derived phenotypes, the α phenotype was the most common (n =1,063; 43%) and included patients with lowest median age 43 (34 - 51) and had more liver dysfunction (n= 231, 22%); β phenotype (n = 599; 24%) had older patients 51 (42 - 60) and more chronic illness (Diabetes and chronic obstructive pulmonary disease); in the γ phenotype (n = 266; 11%), patients had the highest acute physiology score 73 (53 - 95); and in the δ phenotype (n = 593; 24%), patients had highest Mitral E/e′ ratio (12.6) and lowest TAPSE measurement (1.6). The ICU mortality was 28% for the α phenotype; 36% for the β phenotype; 29% for the γ phenotype; and 35% for the δ phenotype. Conclusions: In this analysis of systolic function among patients with sepsis, β (LVEF ≥ 55% & MASV < 8.5 cm/sec) and δ (LVEF < 55 & MASV < 8.5 cm/sec) phenotypes were associated with higher mortality. Further research is needed to establish the utility of these distinct LV systolic function phenotypes in outcomes of patient with sepsis and septic shock.

Surgical shortening of lengthened iliac arteries in endurance athletes: Short-term and long-term satisfaction

ObjectiveEndurance athletes are prone to develop flow limitations in iliac arteries (FLIA). Especially in cyclists and ice speed skaters, excessive hemodynamic loading coupled with hip hyperflexion may cause kinking in lengthened iliac arteries necessitating surgical correction. This study investigated the short-term (≤1.5 years) and long-term (≥5 years) satisfaction of operative shortening of the iliac artery in endurance athletes. MethodsAll patients who were diagnosed and operated for FLIA owing to lengthened and kinked iliac arteries between 1997 and 2015 in one center were analyzed. Short-term follow-up consisted of an incremental maximal cycling test, ankle-brachial index with flexed hips, echo-Doppler examination with peak systolic velocity measurements and contrast-enhanced magnetic resonance angiography before and 6 to 18 months after surgery. Both short- and long-term satisfaction were assessed using questionnaires. ResultsA total of 83 patients (90 operated legs; 96.7% males; median age of 34 years at the time of surgery; interquartile range [IQR], 29-47) were analyzed. In the short-term, 87.5% reported symptom reduction with an 86.4% overall satisfaction rate. Symptom-free cycling improved from 272 ± 84 W to 384 ± 101 W (P < .001), whereas the maximal workload increased from 419 ± 72 W to 428 ± 67 W (P = .01). The ankle-brachial index with flexed hips increased from 0.55 (IQR, 0.45-0.65) to 0.62 (IQR, 0.52-0.74; P = .008), and the peak systolic velocity measured with hips flexed decreased from 2.50 m/s (IQR, 1.77-3.13 m/s) to 1.57 m/s (IQR, 1.20-2.04 m/s; P < .001). After a median of 12 years (IQR, 9.0-15.4 years), symptoms were still decreased in 84.1% of patients with an 81.2% overall satisfaction rate (79.5% response rate). Three patients needed a reintervention (recurrent FLIA, n = 2; failure, n = 1). ConclusionsOperative shortening of a lengthened and kinked iliac artery causing FLIA is successful both in the short- and long-term.

CORRELATION BETWEEN PEAK MITRAL ANNULAR SYSTOLIC VELOCITY AND LEFT VENTRICULAR EJECTION FRACTION IN SEPSIS AND SEPTIC SHOCK

CORRELATION BETWEEN PEAK MITRAL ANNULAR SYSTOLIC VELOCITY AND LEFT VENTRICULAR EJECTION FRACTION IN SEPSIS AND SEPTIC SHOCK

Hepatic artery and portal vein Doppler ultrasound reference values in children aged 0-17 years old.

Doppler ultrasound of the portal vein peak systolic velocity and hepatic artery peak systolic velocity and resistive index in children is often performed during abdominal ultrasound for the assessment of liver and other abdominal pathology. However, evidence-based reference values are not available. We aimed to determine these reference values and to investigate whether they are age-dependent. Children who underwent abdominal ultrasound between 2020 and 2021 were retrospectively identified. Patients without hepatic or cardiac abnormalities at the time of ultrasound or during at least 3 months follow-up were eligible for the study. Ultrasound without hepatic hilum portal vein peak systolic velocity and/or hepatic artery peak systolic velocity and resistive index measurements were excluded. Age-dependent changes were analyzed using linear regression. Normal range reference values were described using percentiles for all ages, and for age subgroups. One-hundred ultrasound examinations performed in 100 healthy children aged 0-17.9 years (median 7.8 years, interquartile range 1.1-14.1 years) were included. Ninety-nine portal vein peak systolic velocity and 80 hepatic artery peak systolic velocity and resistive index measurements were obtained. There was no significant association between portal vein peak systolic velocity and age (β = -0.056, p = 0.68). There were significant associations between age and hepatic artery peak systolic velocity, and between age and hepatic artery resistive index (β = -0.873, p = 0.04 and β = -0.004, p < 0.001, respectively). Detailed reference values were provided for all ages, and for age subgroups. Reference values for the hepatic hilum portal vein peak systolic velocity, hepatic artery peak systolic velocity, and hepatic artery resistive index in children were established. Portal vein peak systolic velocity is not age-dependent, whereas hepatic artery peak systolic velocity and hepatic artery resistive index decrease when children get older.

Clitoral blood flow using color Doppler ultrasonography in women with and without provoked vestibulodynia.

To compare blood flow of the dorsal clitoral artery in women diagnosed with provoked vestibulodynia (PVD) and in healthy controls using color Doppler ultrasonography. We hypothesized that women with PVD would have a restricted blood flow compared to controls. This cross-sectional study evaluated the function of the dorsal clitoral artery through the spectral wave analysis of color Doppler ultrasonography (US) in 20 women diagnosed with PVD according to Friedrich's criteria and 21 healthy controls. Participants were evaluated during their follicular phase and were asked to abstain from sexual activities 24 ho prior the examination. Assessment was performed by an assessor blinded to participant diagnosis, in the morning after a 10-min rest period in a supine lying position in a room with temperature set at 22 °C. Measurements of the peak systolic velocity (PSV), time-averaged maximum velocity (TAMX), end-diastolic velocity (EDV), pulsatility (PI) and resistance index (RI) were performed at rest considering the mean value of three consecutive waveforms. Women with PVD and healthy controls did not present any statistically different baseline characteristics. Participants with PVD presented higher values of Doppler-US PSV, TAMX, EDV and RI compared to controls (p ≤ 0.05), which are suggestive of a decrease in blood flow. However, non-significant difference was found regarding PI values between the two groups (p > 0.05). Our findings revealed decreased peripheral tissue perfusion in women with PVD compared to healthy controls using color Doppler US, based on the alteration of four of the five assessed data of US parameters.

Vascular Calcification in Chronic Kidney Disease PatientsA Cross-sectional Study

Introduction: Vascular Calcification (VC) is considered as a cardiovascular risk marker in Chronic Kidney Disease (CKD) patients. VC is a process characterised by thickening and loss of elasticity of muscular arteries walls. The three pathological forms of cardiovascular disease in CKD are cardiac geometry, atherosclerosis and arteriosclerosis of the large vessels (carotid artery or aorta). Aim: To evaluate VC as a cardiovascular risk marker in CKD patients. Materials and Methods: This cross-sectional study was conducted in the Nephrology Department at Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India, from November 2019 to December 2020. The study included 27 CKD patients who were on maintenance haemodialysis. The participants were 20 to 70 years of age, and of both genders. The Intima Media Thickness (IMT) was assessed by ultrasonography. Peak Systolic Velocity (PSV) measurement was done using doppler ultrasonography. Both the measurements were done on common Carotid Artery (CCA), and Internal Carotid Artery (ICA) on both sides of the neck. Student’s t-test and Chi-square test was used in this study. Data were expressed as mean±SD. The p-value &lt;0.05 was considered as statistically significant. Results: Out of 27 study participants, 20 (74%) were male and females were 7 (26%), with mean age of 48 years. There was significant increase in IMT of the ICA on the right side of the neck compared to left side (p-value=0.01). Also, there was significant increase in PSV of ICA on the right side compared to left side of the neck (p-value=0.04). There were no statistically significant differences in IMT and PSV when CCA on the right side was compared to that of the left side of the neck. Conclusion: The IMT was increased in ICA and CCA. But there was statistically significant difference only in ICA, where it was more prominent on the right side compared to left side. CKD patients on haemodialysis management could have the risk factors in the form of increased IMT predisposing them to early mortality from cardiovascular complications.

Middle Cerebral Artery Dopplers and Abnormal Neonatal Outcomes among Pregnant Women with Zika Virus Infection.

The aim of this study was to investigate the role of middle cerebral artery (MCA) Doppler measurements for the prediction of abnormal neonatal outcomes in pregnancies affected by Zika virus (ZIKV). Secondary analysis of a prospective cohort of pregnant women diagnosed with ZIKV infection from September 2015 to December 2016 at a single regional referral center. Ultrasonography with measurements of MCA peak systolic velocity (PSV), PSV multiples of the median (MoM) for gestational age, and pulsatility index (PI) were collected. The primary outcome was a composite abnormal neonatal outcome. MCA Doppler values of normal and abnormal neonatal outcomes were compared with Wilcoxon rank sum test. The predictive value of MCA Dopplers for development of abnormal neonatal outcome was calculated by logistic regression. One-hundred twenty-seven ZIKV-positive pregnancies with MCA Doppler measurements and known neonatal outcomes were included. Of the 132 neonates, 66 (50%) had an abnormal neonatal outcome. Lower MCA PSV (p = 0.027) and PSV MoM (p = 0.008) were associated with abnormal neonatal outcomes. There was no significant difference in MCA PI. Abnormal neonatal outcomes had lower MCA PSV by 5.36 cm/s (95% confidence interval [CI]: 0.95-9.77, p = 0.018) and lower MCA PSV MoM by 0.13 (95% CI: 0.05-0.22, p = 0.002). MCA PSV of 30 cm/s had a 65% predicted probability of an abnormal neonatal outcome (95% CI: 51-79%). In ZIKV-infected pregnancies, lower MCA PSV and PSV MoM measurements were seen with abnormal neonatal outcomes. This may represent a physiologic response to fetal ZIKV infection. Evaluation of MCA Dopplers may be of clinical utility in the surveillance of ZIKV-affected pregnancies. · Significantly lower MCA PSV is associated with abnormal neonatal outcomes in ZIKV pregnancies.. · Lower MCA PSV may reflect the underlying neuropathology of ZIKV exposure on the fetus.. · There is potential utility for MCA Doppler evaluation in antepartum surveillance of ZIKV pregnancies..

Incidence, Predictive Factors, and Prognostic Impact of Right Ventricular Dysfunction Before Transcatheter Aortic Valve Implantation

Right ventricular dysfunction (RVD) is considered to be a late marker of aortic stenosis. However, there is a lack of consensus regarding the incidence, prognostic impact, and evolution of RVD in patients treated with transcatheter aortic valve implantation (TAVI). All patients treated with TAVI for severe aortic stenosis were included in a prospective single-center database. Patients who had a quantitative assessment of right ventricular (RV) function including tricuspid annular plane systolic excursion (TAPSE) and/or Doppler tissue imaging-derived tricuspid lateral annular systolic velocity (S' wave) measurements were eligible for this study. RVD was defined as TAPSE <17 mm or S' <9.5 cm/s if TAPSE was not available. Between 2014 and 2019, 503 patients with RV function assessment were included. The incidence of RVD before TAVI was 18.7%. Predictors of RVD were diabetes (p=0.03), atrial fibrillation (p=0.001), impaired left ventricular ejection fraction (p <0.0001), left ventricular dilatation (p=0.007), and previous cardiac surgery (p=0.002). Long-term survival was worse in patients with RVD before TAVI compared with those without RVD (hazard ratio 1.97, 95% confidence interval 1.1 to 3.4, p=0.01). One year after TAVI, 58.7% of patients with baseline RVD had normal RV function and had similar outcomes as compared with those without RVD at baseline. In contrast, patients with persistent RVD had the worst prognosis. In conclusion, RVD is not rare and has a deleterious prognostic impact in patients treated with TAVI. Recovery of normal RV function is frequent after TAVI, whereas persistence of RVD is associated with poor outcomes.

Right ventricular dysfunction before transcatheter aortic valve implantation: incidence, predictive factors and prognostic impact

Abstract Background Right ventricular dysfunction (RVD) is considered to be a late marker of advanced aortic stenosis (AS) and is associated with poor prognosis. Currently. there are conflicting data on the impact of RVD on clinical outcomes in patients with severe AS treated with TAVI. Moreover, few studies have studied the evolution (recovery or persistence) of RVD and its prognostic impact. Objectives To assess the incidence and predictive factors of RVD before TAVI, its prognostic impact and its evolution after TAVI. Methods All patients treated with TAVI for severe AS were included in a prospective single center database. Only patients who had a quantitative assessment of RV including Tricuspid Annular Plane Systolic Excursion (TAPSE) and/or doppler tissue imaging-derived tricuspid lateral annular systolic velocity (S') measurements, were eligible to this study. RVD was defined by a TAPSE &amp;lt;17 mm or S' &amp;lt;9.5 cm/s if TAPSE was not available. Results Between May 2014 and April 2019, 503 patients with RV function evaluation were included. Incidence of RVD before TAVI was 18.7%. Predictors of RVD were diabetes (P=0.03), atrial fibrillation (P=0.001), altered left ventricular ejection fraction (P&amp;lt;0.0001), left ventricular dilatation (P=0.007), and previous cardiac surgery (P=0.002). Long-term survival was altered in patients with RVD before TAVI as compared to those without RVD (HR 1.97, 95% CI: 1.1–3.4, P=0.01). One year after TAVI, 58.7% of patients with baseline RVD had a normal RV function and had similar outcome as compared to those without RVD at baseline. In contrast, patients with persistent RVD had the worst prognosis. Conclusions RVD is not rare and has a deleterious prognostic impact in patients treated by TAVI. Recovery of normal RV function is frequent after TAVI whereas persistence of RVD is associated with poor outcomes. Funding Acknowledgement Type of funding sources: None.

Multi-plane echocardiographic assessment of right ventricular function in adults with repaired Tetralogy of Fallot

In patients with repaired Tetralogy of Fallot (ToF), detailed assessment of right ventricular (RV) function is important for management and timing of possible pulmonary valve re-intervention. The aim of this study was to evaluate RV function using two-dimensional multi-plane echocardiography (2D MPE), a novel four-wall imaging method obtained from one apical acoustic window utilising electronic plane rotation. In sixty-two ToF patients (aged - 28 [22, 39] years, 65% male), systolic function of four different RV walls (lateral, anterior, inferior and inferior coronal) were evaluated using MPE. Tricuspid annular plane systolic excursion (TAPSE), tricuspid annular peak systolic velocity (RV-S′) and RV wall longitudinal strain (RV-LS) measurements were compared with those of matched healthy individuals. 2D MPE measurements were highly feasible across the four RV walls (93.5–100% for TAPSE/S′; 66.1–95.1% for RVLS) and could be performed more reliably than 3D RV ejection fraction (RVEF − 56.5%). All functional values were significantly reduced when compared to the control group (p < 0.001). Higher RV-LS values were seen in the lateral (− 17.8 ± 4.5%) and inferior (− 17.8 ± 4.2%) walls compared to the anterior (− 15.9 ± 3.8%) and inferior coronal (− 15.1 ± 3.9%) walls. 3D RVEF correlated strongest with RV-LS values from the lateral (r − 0.50; p = 0.002) and anterior walls (r − 0.74; p < 0.001) and furthermore the four-wall average (r − 0.57; p = 0.001). 2D MPE evaluation of the RV is highly feasible in ToF patients. This novel method provides new insights into regional RV wall function, enabling a more comprehensive and quantitative approach to RV assessment in daily clinical practice.

Parvovirus B19 in Pregnancy: A Case Review.

Parvovirus B19 has been identified as the cause of erythema infectiosum, a common childhood illness. Also known as fifth disease, this virus is highly contagious among school-age children, especially during the winter months when outbreaks within classrooms are widespread. The majority of adults have had the infection in childhood and are immune to recurrence. Approximately 40% of childbearing-age individuals, however, remain nonimmune and susceptible to infection. If acquired during pregnancy, parvovirus B19 infection can have devastating fetal consequences, especially if contracted in the second trimester. Vertical transmission of parvovirus B19 occurs more readily during this gestational period, and fetal loss rates of 8% to 17% have been reported as a result of severe fetal anemia and hydrops fetalis. Unfortunately, adults with parvovirus B19 infection are often asymptomatic and do not exhibit the classic slapped-cheek rash seen in childhood. More commonly, adults will exhibit atypical symptoms such as joint arthralgias. Maternal history of direct exposure to a confirmed case within the family or the presence of atypical symptoms warrants serum antibody screening. Although the presence of immunoglobulin G confirms immunity, any immunoglobulin M positivity will require ongoing fetal surveillance for evidence of fetal anemia and hydrops fetalis. Serial ultrasound imaging for 8 to 12 weeks with Doppler measurements of the peak systolic velocity in the middle cerebral artery are the mainstays of fetal monitoring. Referral to a maternal-fetal medicine specialist with experience in fetal blood sampling and intrauterine transfusion is recommended for any cases of hydrops fetalis or if a concern for severe fetal anemia exists.

In vitro evaluation of cerebrospinal fluid velocity measurement in type I Chiari malformation: repeatability, reproducibility, and agreement using 2D phase contrast and 4D flow MRI

BackgroundPhase contrast magnetic resonance imaging, PC MRI, is a valuable tool allowing for non-invasive quantification of CSF dynamics, but has lacked adoption in clinical practice for Chiari malformation diagnostics. To improve these diagnostic practices, a better understanding of PC MRI based measurement agreement, repeatability, and reproducibility of CSF dynamics is needed.MethodsAn anatomically realistic in vitro subject specific model of a Chiari malformation patient was scanned three times at five different scanning centers using 2D PC MRI and 4D Flow techniques to quantify intra-scanner repeatability, inter-scanner reproducibility, and agreement between imaging modalities. Peak systolic CSF velocities were measured at nine axial planes using 2D PC MRI, which were then compared to 4D Flow peak systolic velocity measurements extracted at those exact axial positions along the model.ResultsComparison of measurement results showed good overall agreement of CSF velocity detection between 2D PC MRI and 4D Flow (p = 0.86), fair intra-scanner repeatability (confidence intervals ± 1.5 cm/s), and poor inter-scanner reproducibility. On average, 4D Flow measurements had a larger variability than 2D PC MRI measurements (standard deviations 1.83 and 1.04 cm/s, respectively).ConclusionAgreement, repeatability, and reproducibility of 2D PC MRI and 4D Flow detection of peak CSF velocities was quantified using a patient-specific in vitro model of Chiari malformation. In combination, the greatest factor leading to measurement inconsistency was determined to be a lack of reproducibility between different MRI centers. Overall, these findings may help lead to better understanding for application of 2D PC MRI and 4D Flow techniques as diagnostic tools for CSF dynamics quantification in Chiari malformation and related diseases.

858 Secondary sonographic markers for diagnosis of twin anemia polycythemia sequence (TAPS)

TAPS is a complication of monochorionic-diamniotic (MCDA) twins diagnosed by middle cerebral artery peak systolic velocity (MCA-PSV) measurements using either absolute (MCA-PSV > 1.5 and MCA-PSV < 1.0 MoMs) or relative (difference in MCA-PSV > 0.5 MoMs) criteria. “Starry sky” liver in the plethoric twin, placental echogenicity discordance, and cardiomegaly in the anemic twin are proposed secondary markers for TAPS. We sought to determine the diagnostic performance of these markers’ in the absolute vs. relative criteria. This is a case-control study of MCDA pregnancies followed between 2011 to 2020. Patients diagnosed with TAPS with or without twin to twin transfusion syndrome (TTTS) were identified from ultrasound reports. Controls were matched to cases by gestational age of TAPS diagnosis randomly in a 1:2 ratio. Controls were selected from a cohort with no complications of MCDA twinning (including TAPS) throughout their pregnancies. Ultrasound images were systematically reviewed for the presence of each of the three secondary markers. Cardiothoracic ratio (CTCR) was assessed for cardiomegaly. TAPS was diagnosed in 69 cases by relative criteria; 18 of these cases also met absolute criteria. We matched 140 control patients. Characteristics were similar between patients diagnosed by each criterion (Table 1). Starry sky liver occurred in 77.8%, 57.4%, and 3.6% of the absolute TAPS, relative TAPS, and control groups, respectively (p<0.01). Placental discordance occurred in 44.4%, 40.3%, and 4.3% of patients in these groups, respectively (p<0.01). There was no difference in the CTCRs among the three groups (0.53 ± 0.05, 0.51 ± 0.05, and 0.51 ± 0.03, NS). Placental discordance was more common with greater differences in MCA-PSV between twins and Stage II or higher TAPS (Figure). Placental discordance is associated with greater differences in the MCA-PSV between twins and more severe TAPS (Stage II+). Absolute criteria for TAPS coupled with the presence of secondary markers may help improve diagnostic accuracy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Changes in Internal Carotid Artery Doppler Velocity Measurements With Different Angles of Insonation: A Pilot Study.

Doppler velocity measurements are fundamental diagnostic criteria for vascular ultrasound examinations. Insonation angles are kept to 60° or less to minimize error. The purpose of this study was to assess variance of Doppler-detected peak systolic velocity (PSV) measurements in the internal carotid arteries at different angles (45°, 50°, 55°, and 60°) with different beam steering. The PSV was recorded from the right and left internal carotid arteries in 22 asymptomatic volunteers with straight vessels (total of 44 vessels). A standardized approach was used for recording velocities with the Doppler cursor center steered and steered 15° from right to left. An analysis of variance was performed. The PSV varied significantly with the 4 different angles of insonation (P < .01). The maximum variation between 45° and 60° angles within a single vessel was 29 cm/s. The average variation over the 4 angles was 14 ± 6 cm/s. Relative to the calculated mean velocity for all patients, the standard deviation for the PSV at 60° was nearly twice that recorded at 50° (7.9 versus 3.9). The best correlation of the calculated mean velocity for all patients existed between the angles of 45° and 50° [r(36) = 0.92; P < .001 for center-steered data; and r(40) = 0.96; P < .001 for right-steered data]. These results indicate a statistically significant difference in the PSV measurements taken at varying Doppler angles. The greatest mean, variance, and lowest correlations all result when using 60°. The findings support the need for consistent ultrasound techniques and suggest that further study is warranted regarding the optimal Doppler angle for velocity measurements.

Performance of Antenatal Diagnostic Criteria of Twin-Anemia-Polycythemia Sequence.

This study aims to elicit the validation performance of different diagnostic criteria and to evaluate the disease course and perinatal outcomes of pregnancies complicated by twin anemia polycythemia sequence (TAPS). Monochorionic diamniotic (MCDA) twin pregnancies who received serial middle cerebral artery (MCA) peak systolic velocity (PSV) measurements without non-TAPS-related demise or major anomalies were included. Course of disease, antenatal intervention, additional ultrasound features, and perinatal outcomes were compared between each criteria and onset. Forty-nine cases of TAPS and 203 non-TAPS controls were identified. The incidence of TAPS was 19.2%, 15.7%, 7.8%, and 6.3% for ΔPSV MoM > 0.373, ΔPSV MoM > 0.5, traditional, and Delphi consensus criteria, respectively (p < 0.001). The incidence of antenatal intervention was 55.1, 62.5, 75.0, and 87.5%, respectively. Furthermore, cases detected according to the Delphi consensus criteria had a higher rate of progression or intervention compared to cases detected with ΔPSV MoM > 0.373 (87.0 vs. 59.0%, p = 0.037). TAPS had a significantly higher birth weight discordance than uncomplicated MCDA twins (25.3 vs. 7.3%, p < 0.001). Application of four different diagnostic criteria for TAPS leads to significant differences in the incidence, severity, and antenatal intervention. The Delphi criteria identified more severe cases likely to require intervention, and the delta PSV > 0.373 criteria identified milder cases, without a significant impact on neonatal outcomes.

Middle Cerebral Artery Doppler Velocimetry for the Diagnosis of Twin Anemia Polycythemia Sequence: A Systematic Review.

Twin anemia polycythemia sequence (TAPS) is a rare complication of monochorionic diamniotic (MCDA) twins. Middle cerebral artery peak systolic velocity (MCA-PSV) measurements are used to screen for TAPS while fetal or neonatal hemoglobin levels are required for definitive diagnosis. We sought to perform a systematic review of the efficacy of MCA-PSV in diagnosing TAPS. Search criteria were developed using relevant terms to query the Pubmed, Embase, and SCOPUS electronic databases. Publications reporting diagnostic characteristics of MCA-PSV measurements (i.e., sensitivity, specificity or receiver operator curves) were included. Each article was assessed for bias using the Quality Assessment of Diagnostic Accuracy Studies II (QUADAS II) tool. Results were assessed for uniformity to determine whether meta-analysis was feasible. Data were presented in tabular form. Among publications, five met the inclusion criteria. QUADAS II analysis revealed that four of the publications were highly likely to have bias in multiple areas. Meta-analysis was precluded by non-uniformity between definitions of TAPS by MCA-PSV and neonatal or fetal hemoglobin levels. High-quality prospective studies with consistent definitions and ultrasound surveillance protocols are still required to determine the efficacy of MCA-PSV in diagnosing TAPS. Other ultrasound findings (e.g., placenta echogenicity discordance) may augment Doppler studies.

Defining critical antibody titre in column agglutination method to guide fetal surveillance

IntroductionA critical anti D antibody titre, defined for the conventional tube method of Indirect Coomb’s test (ICT), when employed in the more sensitive column method could result in unnecessary referrals and frequent obstetric doppler scans. This study aimed to compare anti D titres by tube and column method in antenatal mothers, to assess their correlation with fetal anemia and to determine a critical titre for the column method. MethodsForty six antenatal mothers with anti D antibody were included in the study. Antibody titration was performed by serial twofold dilution of serum by both column and tube method and were correlated with middle cerebral artery peak systolic velocity (MCA PSV) measurement by Doppler ultrasonography. Receiver operating curve (ROC) was used to determine the cut-offs for critical titre by tube and column method in predicting fetal anemia. ResultsColumn method had a median titre 3 fold higher than tube method. There was a significant association between fetal anemia by USG with median critical titres determined for both column (p = 0.031) and tube method (p = 0.016). ROC analysis showed the cut off for critical titres in column method as 64 with 90 % sensitivity, 72.7 % specificity and 75.38 % accuracy. ConclusionsThe use of critical titre for anti D antibody, defined for the tube method, when applied to the column agglutination method would lead to increased referrals to specialized fetal medicine centres. Rather, an Anti D titre of 64 by column method can predict the likelihood of fetal anemia and should be considered as the critical titre to guide patient referrals.

The Effect of Spinal and General Anesthesia on Metastatic Lymph Node Flow in Bladder Cancer Surgery: A Pilot Study.

The sympathetic regulation of contractile function of lymphatic vessels has received much attention in terms of metastasis mechanism nowadays in animal studies. The aim of the study to evaluate the effect of spinal or general anesthesia on flow in malignant lymph nodes in patients undergoing bladder tumor surgery with doppler ultrasound. This prospective, observational, pilot study was performed on the patients (ASA II and III, aged 45-85) who scheduled for elective bladder tumor surgery under spinal or general anesthesia from July 2018 to August 2019. Patients were divided into two groups, spinal anesthesia and general anesthesia. Resistivity index, pulsatility index, peak systolic velocity and end diastolic velocity measurements were recorded preoperatively and postoperatively n the inguinal lymph nodes by doppler ultrasound. In the malignant lymph nodes, the pulsatility index value decreased with the spinal anesthesia (n=12) compared to the preoperative period (p = 0.002) but increased in the general anesthesia group (n=11) (p = 0.003). There was a significant difference in postoperative pulsatility index between the two groups (p = 0.0001) (cut off => 5.49, sensitivity 81.82%, specificity 91.67%). Postoperative peak systolic velocity values were significantly higher than preoperative values only in general anesthesia group (p = 0.021). Lymphatic flow in metastatic lymph nodes decreased by spinal anesthesia compared to general anesthesia evaluated by using doppler ultrasound in our study. Although this new mechanism is new in the reduction of lymphatic metastasis during cancer surgery, prospective randomized studies evaluating long-term recurrence and survival are warranted.