Myocardial work in patients with heart failure and ischemic cardiomyopathy according to the mode of coronary revascularization

BACKGROUND

The association of percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) on myocardial function, as reflected in myocardial work (MyW) parameters, in patients with ischemic cardiomyopathy and heart failure (HF) is unknown.

METHODS

We analyzed data from 68 patients who were hospitalized with chronic HF due to ischemic cardiomyopathy and stratified them according to the mode of revascularization. All patients underwent a 2D speckle tracking echocardiography exam performed by the same expert sonographer and had complete MyW data including global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE).

RESULTS

The mean age of patients was 70 ± 10 years and 86.8% were men. The mean left ventricular ejection fraction (LVEF) in overall cohort was 31.6 ± 9.5%. Both subgroups did not significantly differ in terms of baseline LVEF, comorbidities, and pharmacotherapy. Compared with those who received PCI, patients revascularized with CABG had significantly greater GWI (821 vs. 555 mmHg%, p = 0.002), GCW (1101 vs. 794 mmHg%, p = 0.001), GWE (78 vs. 72.6%, p = 0.025), and global longitudinal strain (-8.7 vs. -6.7%, p = 0.004). Both patient subgroups did not significantly differ with respect to GWW (273 vs. 245 mmHg%, p = 0.410 for CABG and PCI, respectively) and survival during the median follow-up of 18 months (log-rank p = 0.813).

CONCLUSION

Patients with HF and ischemic cardiomyopathy revascularized with CABG had greater myocardial work performance when compared with those revascularized with PCI. This might suggest a higher degree of functional myocardial revascularization associated with the CABG procedure.

Emerging Therapies for the Treatment of Atherosclerotic Cardiovascular Disease: From Bench to Bedside

Primarily a consequence of sedentary lifestyle, atherosclerosis has already reached pandemic proportions, and with every year the burden of it is only increasing. As low-density lipoprotein cholesterol (LDL-C) represents a crucial factor in atherosclerosis formation and progression, stringent lipid-lowering therapy could conceivably be the key to preventing the unfavorable outcomes that arise as a consequence of atherosclerosis. The use of statins in lipid-lowering is often burdened by adverse events or is insufficient to prevent cardiovascular events as a monotherapy. Therefore, in the present review, the authors aimed to discuss the underlying mechanisms of dyslipidemia and associated atherosclerotic cardiovascular disease (ASCVD) and preclinical and clinical trials of novel therapeutic approaches to its treatment, some of which are still in the early stages of development. Apart from novel therapies, a novel change in perspective is needed. Specifically, the critical objective in the future management of ASCVD is to embrace emerging evidence in the field of atherosclerosis, because clinicians are often burden by common practice and personal experience, both of which have so far been shown to be futile in the setting of atherosclerosis.

Conservative Management of Spontaneous Left Main Coronary Artery Dissection (SCAD) Triggered by Emotional Stress in the Late Postpartum Period: Case Report and Pathophysiology

A spontaneous coronary artery dissection (SCAD) during the postpartum period is a serious medical emergency and the most important non-atherosclerotic cause of coronary artery disease (CAD) in this population. While conservative management is recommended in most SCAD scenarios, cases complicated by hemodynamic instability or cardiogenic shock are particularly challenging and might be amenable only with invasive percutaneous or cardiothoracic surgical management. Herein, we present a case of a 35-year-old otherwise healthy woman that suffered an intense emotional stress event and was subsequently admitted with crushing chest pain to the emergency department. The initial electrocardiogram showed dynamic changes suggesting anterolateral ST-elevation myocardial infarction. She gave birth to a healthy child 3 months before the current presentation. Diagnostic angiography found no occlusive CAD but instead an extensive intramural hematoma originating from the left main artery dissection and extending to the whole left coronary circulation was observed. Hemodynamic instability and hypotension soon followed, and the patient went into cardiogenic shock. The heart team opted for conservative and supportive intensive care management without surgical or percutaneous intervention. This decision ultimately led to the successful extubation of the patient and the achievement of hemodynamic stability. The patient was eventually safely discharged home without any permanent disability.

Clinical use of ivabradine in the acute coronary syndrome: A systematic review and narrative synthesis of current evidence

Heart rate (HR) lowering during acute coronary syndrome (ACS) is beneficial as it reduces myocardial oxygen consumption. However, the role of ivabradine as an HR-lowering agent in the setting of ACS is not clear. We aimed to systematically review and synthesize the current evidence on the role of ivabradine use in the ACS. A systematic review was conducted for eligible randomized clinical trials and quasi-experimental studies, between 2009 and 2020, that investigated the use of ivabradine in ACS. Various clinical endpoints were evaluated such as major adverse cardiovascular events, efficacy in HR control, impact on left ventricular (LV) dimensions and function, and overall safety. Eleven publications were included encompassing a total of 1833 patients. The mean age of the examined cohort was 57 ± 11 years and 80 % were men. Seven studies were in the setting of ST-segment elevation myocardial infarction (MI) while the remaining studies also included patients with unstable angina and non-ST-segment elevation MI. Ivabradine was administered as a peroral drug with dosing from 2.5 to 7.5 mg b.i.d. Overall, the addition of ivabradine was superior to the control arm concerning HR control with a good safety profile. Beneficial effects on LV function and potential impact on infarct size reduction were observed as well. The use of ivabradine appeared to not affect short-term mortality. In conclusion, the use of ivabradine for HR control is safe, feasible, and efficacious for HR control in the ACS. Further studies are required to elucidate other potentially beneficial effects of ivabradine.

Right ventricular free wall strain in acutely decompensated heart failure patients with ischemic and non-ischemic cardiomyopathy

AIMS

Right ventricular (RV) dysfunction is a predictor of adverse outcomes among patients with HF with reduced ejection fraction (HFrEF); however, differences in RV parameters in HFrEF patients with ischemic (ICM) and non-ischemic cardiomyopathies (NICM) are not well understood. We investigated echocardiographic characteristics, including RV strain, in patients with acute decompensated heart failure (ADHF) and compared patients with ICM and NICM etiology.

METHODS

Consecutive patients who presented with ADHF and NYHA class III-IV were prospectively enrolled if they had LVEF < 40% and history of ICM or NICM. All patients underwent clinical exam, laboratory evaluation and 2-D echocardiographic assessment of the left ventricular (LV) and RV function, LV and RV global longitudinal strain (LVGLS, RVGLS), and RV free wall strain (RVfwLS).

RESULTS

Of 84 patients, 44 had ICM and 40 NICM. The groups had similar blood pressure, NT-proBNP, and echocardiographic parameters of LV function including LVGLS. Absolute RVGLS values were lower than RVfwLS values in both groups. Patients with NICM had significantly lower RVfwLS, but not RVGLS, compared to patients with ICM (-13% to -17%, p = 0.006). Similar differences in RVfwLS were seen in patients in NYHA class III (NICM vs ICM: -13% and -17%, respectively, 95% CI: -8.5 to -.5) and NYHA class IV (NICM vs ICM: -13.8% and -17%, respectively, 95% CI: -6.4 to -.59).

CONCLUSION

Among patients hospitalized with ADHF, patients with nonischemic etiology compared with the patients with ICM, have more severe RV dysfunction measured by RVfwLS, despite similar extent of LV impairment and the same functional limitation class.

The use of Smith-modified Sgarbossa criteria to diagnose an extensive anterior acute myocardial infarction in a patient presenting with a left bundle branch block

Patients with LBBB of unknown onset presenting with chest pain can pose a diagnostic challenge in the ED while Smith-Modified-Sgarbossa (SMS) ECG criteria might facilitate AMI diagnosis. We demonstrate a case of a 79-year-old man that presented to the ED with chest pain. Original Sgarbossa criteria were negative for AMI while SMS criteria were applied showing proportionally excessive discordance between ST-segment and preceding S-wave thus fulfilling diagnostic criterion for AMI. The coronary angiogram showed the total occlusion of the culprit left anterior descending artery. In this case, awareness of SMS criteria aided in the early prehospital diagnosis of AMI in the setting of LBBB and impacted the course of treatment.

Xanthine oxidase activity in patients with age-related cataract associated with hypertension

Reactive oxygen species and lipid peroxidation are important factors that contribute to the development of age-related cataract. The study included 130 patients with age-related cataract, 69 of whom were diagnosed with hypertension (HT), 20 with hypertension and type 2 diabetes mellitus (DM), and 41 had no accompanying condition. The following parameters were measured in the serum of the examinees: products of lipid peroxidation malondialdehyde (MDA) and lipofuscin-like fluorophores (LLF), activity of prooxidative enzymes xanthine oxidase (XO) and myeloperoxidase (MPO), antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GPx), the concentration of thiol groups, and the ferric reducing activity of plasma. The activity of prooxidative enzymes XO and MPO was higher in the plasma of patients with HT (XO=9.0±1.2 U/L; MPO=77.3±8.4 U/L) and with HT and DM (XO=11.9±0.9 U/L; MPO=89.5±5.0 U/L) compared to patients with age-related cataract (XO=6.2±0.9 U/L; MPO=52.4±6.3 U/L; P<0.01). Our research has shown that patients with age-related cataract and hypertension were exposed to increased oxidative damage of biomolecules, based on the increased plasma LLF and MDA content and decreased levels of thiol groups. Oxidative changes of biomolecules in these patients were associated with increased activity of the XO, MPO, and GPx enzymes and a lower extracellular SOD activity and total ferric reductive ability of plasma.

Pseudoexfoliation syndrome and its antioxidative protection deficiency as risk factors for age-related cataract

PURPOSE

Pseudoexfoliation syndrome (PES) seems to be a systemic condition. However, to an ophthalmologist it represents a continual challenge, due to unclear etiology and patho-genesis, and because of a potential for development of an aggressive glaucoma, and cataract surgery complications. According to some findings, PES could be a factor of hastened aging, which means that it could be considered as a secondary aging factor.

METHODS

Frequencies of secondary aging diseases (non-insulin dependent diabetes mellitus, atherosclerotic myocardiopathy, chronic obstructive lung diseases, arterial hypertension, and PES) were investigated in 162 patients with age-related cataract and 55 age- and sex-matched control subjects, and analyzed by a logistic regression. The authors also determined elements of antioxidative protection in a group of sera from patients with cataract and PES, and compared them to those obtained from patients with cataract without PES (activity of catalase and peroxidase, glutathione, vitamins C and E), and total antioxidative protection (%iMDA). Antioxidant defense of aqueous humors, expressed as a rate of induced malondialdehyde (%iMDA), and total thiol groups in the lens corticonuclear blocks (TSH) were estimated in samples of 17 patients with PES and cataract and 55 patients with cataract only.

RESULTS

Logistic regression showed the highest odds ratio for PES (OR=4.516; p<0.05). Catalytic activity of serum catalase had significantly lower values in patients with PES (p<0.05). Anti oxidative defense of aqueous humor and lens had lower values in patients with PES.

CONCLUSIONS

The results indicate that PES might be a significant factor for cataractogenesis. At least a part of pathogenesis alterations in an eye with PES could be the result of higher intensity of oxidative stress.

[Computer tomography in the diagnosis and therapy of acetabular fractures]

INTRODUCTION

Acetabular fractures and fracture dislocations of the hip joint are frequently complex, and the precise pathological anatomy is not easily demonstrated by routine radiographs. Conventional radiographs are often supplemented by oblique views [1]. The most commonly used classification of acetabular fractures has been based on conventional radiographs which are, in majority of cases, sufficient to determine the type of acetabular injuries [1-3]. It has been shown that computed tomography is useful method in precise evaluation of the fracture type the soft-tissue damage and integrity of joint space [4-6].

AIM

The aim of the study was to evaluate advantages of computed tomography in diagnosis of complex acetabular fractures.

METHODS

We studied 737 patients with acetabular injuries over the period from 1989 to 1998. Five hundred and seventy five (78%) were males and 162 (22%) females. Eighty patients with acetabular fractures, with and with out hip dislocation, underwent pelvic CT following AP and 45 degrees oblique pelvic radiographs. Each patient was studied while supine, using 5 mm slice thickness at the acetabulum level and 10 mm at other parts of pelvis. Sections were obtained from the iliac crest to the greater trochanter [7].

RESULTS

The causes of acetabular fractures were: 621 (84.3%) patients participated in traffic accidents, 103 (14%) fell from a height, 7 (0.9%) covered in a mine and 6 (0.8%) were wounded. Femur was the most frequently associated injuries of all bones--155 (66.5%) (Graph 1). Permanent growth of acetabular fractures was noted from 1989 to 1993 regarding gender and years (Table 1), but that growth declined in 1993. It can be explained by a lower number of traffic accidents. Traffic, as an aetiological factor is nearly related with economic and energy crisis in our country (Graph 2). There were 176 (23.8%) fractures of the posterior wall, 23 (3.1%) fractures of the posterior column, 14 (1.9%) fractures of the anterior wall, 29 (3.9%) fractures of the anterior column. Transverse fractures were present in 61 patients (8.3%), "T" fractures in 51 (6.9%) patients and 383 (52.1%) were combined fractures. Of 80 patients loose bodies within the hip joint were noted on the CT scan in 77 (96%) patients, and only in 19 (24%) on radiographs. There was a statistically strong difference between methods (chi 2 = 12.376; p < 0.01). There was no significant difference between two methods in fracture of the femoral head detecting (chi 2 = 1.905; p > 0.05), but it has to bee noted that only two patients had fracture of the anterior aspect of the femoral head, both noted on CT but not on radiographs. In 78 (98%) versus 53 (66%) patients chondral defect of acetabulum was detected on radiografs. Difference was significant (chi 2 = 4.372; p < 0.05). Also, stability of the hip joint regarding size and location of the posterior wall fragment was better seen on CT than on radiographs (chi 2 = 5.555; p < 0.05).

DISCUSSION

Our series demonstrates that in many cases details of acetabular fractures are not well visible on conventional radiographs. Because of the complexity of acetabular fractures, precise pathological anatomy is not easily demonstrated by routine radiographs. In a series of Pearson and Shirkhoda et al. [12,13], one third of acetabular fracture was not apparent on the initial radiographs; however, additional views taken three months later demonstrated a fracture. Mossed fractures should decrease with using the CT, which can also reveal the loose bodies in the joint space, occult femoral haed and chondral acetabular impaction. The size of the posterior wall fracture, and thus the stability of the hip, could be better determined by the CT scan than by a conventional radiograph. In conclusion, the information obtained from CT can help the surgeon to decide whether the surgery is necessary, and, if so, the proper approach. We believe that CT is a very helpful supplement to routine AP and 45 degrees oblique views when surgery of acetabular fractures is in question.

[Pseudoarthrosis of the scaphoid bone associated with carpal collapse: factors in choice of surgical approach]

INTRODUCTION

The most common fracture involving the wrist is a fracture of the scaphoid bone [1], and only 5% to 10% of these fractures proceed to nonunion. Although not symptomatic initially, most (if not all) nonunions later produce a painful wrist with impaired function, clinically significant loss of motion, increased weakness and degenerative arthritis. Nonunion of the scaphoid bone should be treated by open reduction and internal fixation. Many surgical procedures have been advocated to achieve union. Most widely used technique for the treatment of scaphoid nonunion was described by Russe [2], but this method may overcome the flexion deformity of the scaphoid and carpal deformities. The ununited scaphoid usually undergoes resorption of the fractures surfaces, principally over the anterolateral aspect of the fracture, so that the scaphoid becomes misshapen. The restoration of the exact length and form is enabled by insertion of a tight-fitting trapezoidal corticocancellous graft, a technique described by Fernandez [11].

AIM

We analysed the results of treatment of scaphoid nonunion utilized by two bone-grafting techniques and pointed out the need of choice of the best operative method.

METHODS

From 1977 to 1993, at the Institute of Orthopaedic Surgery and Traumatology in Belgrade, 40 patients were surgically treated for symptomatic nonunion of the scaphoid bone. The mean duration of follow-up was 10.2 years (range, from 6 to 22 years). Eighteen (45%) patients were operated by Fernandez technique and 22 (55%) patients were operated using Russe's technique. Volar approach and Kirschner's wire fixation were performed in both operative methods. We used two rating scales proposed by Cooney [13] to evaluate the results. Objective scale (Table 1a) included the radiographic appearance of the wrist, the range of motion and grip strength. Subjective scale (Table 1b) comprised function, pain perception of a decrease in performance because of limited motion or strength, and satisfaction. These scales were used to compare the objective and subjective results in patients who had postoperatively carpal collapse with the results in patients who had not such deformity.

RESULTS

The union rate was 92.5% in both methods. Russe's technique resulted in union in 20 (91%) of 22 cases with two ununited. Fernandez technique achieved union in 17 (94%) of 18 cases. Fracture union was determined by both clinical and roentgenographic examinations. Correction of the lateral interscaphoid angle was obtained in 14 (82%) patients operated by Fernandez technique and 9 (45%) patients operated by Russe's technique. Correction of dorsal tilt of the lunate were achieved in 6 (30%) patients operated by Russe's technique, and 13 (76.6%) patients operated by Fernandez technique. There was a highly significant correlation (p < 0.01) between increased deformity of the scaphoid and extent of carpal collapse (Graph 1). Also, there was significant difference between two operative techniques regarding correction of lateral interscaphoid angle (p < 0.05). Arthrosis of the wrist was present in all patients. We could not demonstrate a significant difference (p > 0.05) between intensity of degenerative changes and increase of lateral interscaphoid angle, but obviously, the large flexion deformity of the scaphoid the worse intensity of degenerative changes (Graph 2). The grip strength significantly increased after Fernandez technique (p > 0.05) (Graph 3), but wrist motion changed a little. The average objective score was 71 points for the patients in whom the lateral interscaphoid angle was 45 degrees or less, and 63 points for those in whom the angle was more than 45 degrees. This difference was significant (p < 0.05), but we could not demonstrate a significant difference between the two groups in terms of the average subjective score.

DISCUSSION

In our series, both procedures provided a high union rate [2]. In cases with severe scaphoid shortening and flexion deformity, Russe's procedure has proved to be insufficient to restore anatomic length and correction of carpal alignment [6, 11, 17]. Previous authors have reported that the progression in degenerative changes was slower in patients who had a lateral interscaphoid angle less than 45 degrees [13]. Also, grip strength and range of motion increased in patients in whom flexion deformity of the scaphoid had been corrected [2, 4, 6, 16, 17]. Our study supports these findings, except results regarding the movement. We believe that this was due to postoperative scarring. Discrepancy between the subjective and objective results may have been due to postoperative relief of pain obtained by increased carpal stability or decreased range of motion of the carpal joints due to postoperative scarring. If pain is relieved, patients readily adapt to the functional deficit of decreased range of motion. We concluded that angulatory collapse of the scaphoid resulted in nonunion as well as malunion with secondary functional loss. Recognition and avoidance in acute fractures were important. When recognised late, volar wedge grafting appeared to be a satisfactory method of treatment.

Liver angiosarcoma and hemangiopericytoma after occupational exposure to vinyl chloride monomer

Various malignant tumors of the liver, especially liver angiosarcoma, have been described after occupational exposure to vinyl chloride monomer. We present the case records and pathologic findings of two plastic industry workers who had been exposed to high concentrations of vinyl chloride. These workers developed hepatic neoplasms, angiosarcoma, or hemangiopericytoma. We discuss the histogenesis of these tumors; the common vascular origin and the mutual transformation of these two tumors suggest that the hemangiopericytoma may also have developed during occupational exposure to high concentrations of vinyl chloride monomer.

Korotkoff sound: the cavitation hypothesis

Blood pressure is universally measured by the auscultatory method, but the origin of the Korotkoff sounds remains controversial. A reproducible, brief and high amplitude signal, simultaneous to the Korotkoff sound, and instantly followed by the systolic wave, was recorded amongst ten healthy subjects by a pulsed Doppler examination during the deflation of the sphygmomanometer. A device simulating the brachial artery was also built in order to reproduce the high amplitude signal. It is explained by the cavitation phenomenon which takes place when the blood changes to vapor due to the release of the cuff pressure. With the incoming flow, the cavitation bubbles collapse and the energy is released as noise.

[The sirocco wind increases the onset of paroxysmal atrial fibrillation in patients in the central Dalmatian coastal region]

The influence of weather on the onset of paroxysmal atrial fibrillation (PAF) was studied in 1099 patients who were admitted to the Outpatient Clinic of the Department of Internal Medicine Split during the period 1981-1987. The cumulative frequencies of PAF during bora, sirocco and calm weather were determined. There were 870 bora or sirocco days when the wind lasted at least 8 hours at the velocity exceeding 20 km/h. Thirty two windy days that were neither bora nor sirocco were not studied. The rest of 1654 days were considered as calm weather. The incidence of PAF during 1654 calm days (0.41/day) was significantly different from PAF incidence during 440 days with sirocco (0.50/day, p < .05), but not from the incidence of PAF during 430 days with bora (0.46/day, p < .05). Logistic regression analysis, and control of the patients ages, revealed a significant correlation between type of the wind of various intensities and onset of PAF (chi 2 = 12.73, d.f. = 6, p < .05). The greatest contribution to this correlation was exerted by sirocco in patients over 50 years of age.