Prognostic value of right ventricular diastolic dysfunction in patients with inferior ST elevated myocardial infarction

Background

Right ventricle infarction (RVI) is predominantly a complication of inferior wall myocardial infarction; it occurs in approximately one third of these patients. Right ventricle dysfunction in patients with inferior STEMI and RV infarction was under assessed. Nevertheless, studies which targeted RV assessment by echocardiography, did not evaluate RV diastolic dysfunction.

Purpose

In this study, we aimed to evaluate RV diastolic dysfunction and its prognostic value in patients with inferior STEMI and RVI.

Methods

Sixty patients with inferior STEMI and RV infarction, who underwent primary PCI were enrolled in the study. Presence of a pre-existing clinical conditions that might affect RV function, were excluded. Echocardiography was performed within twenty-four hours following the PCI, to assess the RV systolic and diastolic functions with special focus on tricuspid inflow velocities (E velocity, A velocity and E/A ratio) by pulsed wave (PW) doppler and tricuspid annular velocities by tissue doppler index (TDI) (e', a' and E/e' ratio). Clinical features and MACE, including cardiogenic shock, arrhythmia, stroke, reinfarction and death were analyzed in all our patients within 3 months follow up period.

Results

The average age of the study population was 51.58±10.11 years, 10% were females. Five patients developed MACE (death, cardiogenic shock and pulmonary oedema, anterior STEMI and cardiogenic shock, recurrent inferior STEMI, and arrhythmia and stroke), of whom four occurred in hospital within the first 48 hours. Patients who developed MACE had high filling pressures, as all of them had E/e' >6. E' velocity ≤6 cm/s was associated with increased MACE as 25% of patients with e' velocity ≤6 cm/s had MACE compared with 2.3% of patients with e' velocity >6 cm/s with a P value of 0.015.

Conclusions

Because tricuspid inflow velocities by PW doppler varies with respiration, volume status and other conditions, tricuspid annular velocities by TDI are essential when evaluating RV diastolic dysfunction. E/e' and e' has a prognostic value in patients with Inferior STEMI and RV infarction.

Funding Acknowledgement

Type of funding sources: None.

The effect of pre-infarction angina on no-reflow phenomenon and in-hospital MACE in primary PCI patients

Funding Acknowledgements

Type of funding sources: None.

Background

No reflow has detrimental outcomes in STEMI patients undergoing primary PCI (PPCI). It leads to poor post PCI LV function and higher mortality. The protective effect of ischemic pre-conditioning ( clinically manifested as pre-infarction angina) was controversial in the literature.

Purpose

Our aim was to study the effect of pre-infarction angina on the occurrence of no-reflow phenomenon and in-hospital major adverse cardiac events (MACE) in PPCI patients.

Methods

After obtaining ethical approvals and informed consents, we prospectively studied 120 STEMI patients admitted for PPCI in a consecutive manner. Patients with history of CABG or previous PCI and in-stent restenosis were excluded. The definition of in-hospital MACE included cardiac death, myocardial reinfarction, stent thrombosis, or target vessel revascularization. The data were analysed by professional statisticians using SPSS software.

Results

15 patients ( 12.5%) had no-reflow, 5 patients ( 4.2%) had cardiac death and one patient had both(0.8 %). The admission characteristics of the studied groups are presented in table 1. Pre-infarction angina was present in 43 patients in the normal flow group and 6 patients in the no-reflow/MACE group. The odds ratio for no-reflow/MACE in those who had pre-infarction angina was 0.52 (95% CI 0.19-1.45, P = 0.21).

Conclusion

In our studied group, pre-infarction angina has not shown to be protective against no-reflow and in-hospital MACE in PPCI patients. The loss of the protective effect of ischemic pre-conditioning might be secondary to higher admission random plasma glucose levels in our patients compared to those included in similar studies. Similar effect was previously shown in studies on mice. Further in-human studies are needed to confirm the negative effect of hyperglycemia on ischemic pre-conditioning.

Characteristics of studied groups Normal flow (n = 99) No-reflow/MACE(n = 21) P value Age (mean ± SD) 56.3 ± 10.3 62.3 ± 7.9 0.014 Male sex (n) 75 13 0.19 Diabetes (n) 37 12 0.094 Hypertension (n) 48 7 0.21 Smokers (n) 52 9 0.42 Dyslipidemia (n) 54 15 0.16 Family history of IHD (n) 17 2 0.52 Pre-infarction angina 43 6 0.21 Admission random plasma glucose in mg/dl(mean ± SD) 186.4 ± 84.7 275.3 ± 104.1 0.001

Association of the polymorphism of the Toll-like receptor (TLR)-3 and TLR-9 genes with hepatitis C virus-specific cell-mediated immunity outcomes among Egyptian health-care workers

Variations in the immune response could explain resistance to hepatitis C virus (HCV) infection. Toll-like receptor gene (TLR)-3 is an innate detector of dsRNA viruses, and the TLR-9 gene recognizes bacterial and viral unmethylated cytosine-phosphate-guanosine (CpG) motifs. We previously reported that the TLR-3.rs3775290 CC genotype was associated with HCV chronicity and that the TLR-9 gene played no major role in this infection. This study identified the role of TLR-3.rs3775290 (c.1377C/T), TLR-9.rs5743836 (-1237T→C) and TLR-9.rs352140 (G2848A) gene polymorphisms in predicting the outcome of HCV-specific cell-mediated immunity (CMI) among Egyptian health-care workers (HCWs). We enrolled 265 HCWs in this study and divided them into four groups. Group 1: 140 seronegative-aviraemic HCWs; group 2: 20 seronegative-viraemic HCWs; group 3: 35 subjects with spontaneously resolved HCV infection; and group 4: 70 chronic HCV HCWs (patients). All subjects were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis for the TLR-3.rs3775290, TLR-9.rs5743836 and TLR-9.rs352140 single nucleotide polymorphisms (SNPs). We also quantified HCV-specific CMI in the four groups using an interferon (IFN)-γ enzyme-linked immunospot (ELISPOT) assay in response to nine HCV genotype 4a, overlapping 15mer peptide pools covering the whole viral genome. No statistically significant difference was found between CMI-responding subjects with different HCV states and TLR-3.rs3775290 or TLR-9.rs352140 genotypes. However, there was a significant relationship between the outcome of the HCV-specific CMI and the TLR-9.rs5743836 genotype among the responding subjects (P = 0·005) and the chronic HCV patients (P = 0·044). In conclusion, TLR-9.rs5743836 SNP, but not TLR-3.rs3775290 or TLR-9.rs352140 genotypes, could predict the outcome of HCV-specific CMI responses among Egyptians infected with genotype-4.

Prevalence of anti-HEV IgM among blood donors in Egypt

Hepatitis E virus (HEV) is a common cause of acute viral hepatitis (AVH) in developing countries. In Egypt; where up to 80% of the inhabitants of rural villages have anti-HEV antibodies denoting past infection, most of these infections are asymptomatic with little evidence that the infection causes AVH. There are accumulating reports which suggest potential risk of HEV transmission by blood transfusion. However, detection of serological markers for HEV infection or HEV RNA in Egyptian blood banks is not routinely performed. 760 blood samples from apparently healthy donors at the National blood bank were tested for markers of acute HEV infection to estimate the seroprevalence of acute HEV infection, and potential risk of infection by blood transfusion. They included 124 females (16.82%) and 636 males (83.68%), with a mean age of 23.8 +/- 5.3 years and mean ALT value of 23.3 +/- 13.2 IU/ml. Samples were tested as pools of 10 subjects. Pools with highest reactivity were retested individually to determine the frequency of positive subjects. Out of the 760 samples, three (0.45%) samples were positive for anti-HEV IgM and two of them had HEV RNA as determined by RT-PCR. In conclusion, this study suggests that the tested blood donors have low prevalence of ongoing subclinical infection with HEV and that the potential risk of transfusion may be low.

Monocytes/macrophages and natural killer cells characterize the tumor microenvironment of inflammatory breast cancer in Egyptian patients

Abstract #1054

Background: Inflammatory breast cancer (IBC) is the most aggressive form of breast cancer. IBC incidence appears to be higher in Egypt as compared to USA. Although the role of leukocytes in regulating breast cancer dissemination has been studied extensively, their role in IBC progression is not well understood. Previously, we showed that human monocytes augment the invasiveness and proteolytic activity of IBC cell lines. Aim: To compare the immunophenotype of IBC and non-IBC and to identify IBC tumor-infiltrated immune cell that may be associated with poor prognosis of IBC.
 Methods: We enrolled two groups of patients: IBC (n=13) and non-IBC (n=27) being treated at Ain Shams University hospitals. All patients underwent modified radical mastectomy. IBC patients had 7 or more metastatic axillary lymph nodes whereas non-IBC patients had 3 or less metastatic axillary lymph nodes. During surgery, blood draining from the breast tumor microenvironment, through branches of axillary vein, and peripheral blood was collected. Total mononuclear cells were isolated from collected blood and their phenotype was examined using flow cytometry. Monoclonal antibodies specific for cell surface markers for particular cells types were used: namely T-helper cells (CD3+CD4+), T-cytotoxic cells (CD3+CD4-), natural killer (NK) cells (CD56+) and monocytes/macrophages (CD14+). Results: Within each group we compared the leukocytic composition of blood collected from the tumor drainage to that of peripheral blood in IBC and non-IBC patients. 1) In IBC, we detected a significant increase in the mean percentage of NK cells and monocytes collected from the tumor site, but no significant difference in CD8+ and CD4+ cells. 2) In non-IBC, the percentage of CD4+ T cells collected from the tumor site was significantly higher than from peripheral blood. No significant differences were detected in CD8+, CD56+ and CD14+ cells.
 We compared the leukocyte composition of blood collected from both IBC and non-IBC patients. 1) In peripheral blood of IBC patients, we detected a significant increase in CD4+ T cells, but no significant differences in CD8+, CD56+ and CD14+ cells when compared to non-IBC patients. 2) When we compared the leukocyte content of blood collected from the tumor site in IBC and non-IBC, we found a significant increase in CD56+, and CD14+ cells and a significant decrease in CD4+ T cells in IBC, but no significant difference in CD8+ T cells. Conclusion: Differences in the immunophenotype of IBC versus non-IBC suggests a role for these immune cells in the metastatic dissemination and progression of IBC.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1054.

Characterization of hepatitis E-specific cell-mediated immune response using IFN-gamma ELISPOT assay

In developing countries, hepatitis E (HEV) and hepatitis A (HAV) are the major causes of acute viral hepatitis with similar feco-oral modes of transmission. In contrast to the high seroprevalence of hepatitis A infection, a low seroprevalence of HEV among children in endemic areas has been reported. These data suggest the possibility that silent HEV infection is undiagnosed by the current available methods. Many of the serological tests used for HEV diagnosis have poor specificity and are unable to differentiate among different genotypes of HEV. Moreover, the RT-PCR used for HEV isolation is only valid for a brief period during the acute stage of infection. Cell-mediated immune (CMI) responses are highly sensitive, and long lasting after sub-clinical infections as shown in HCV and HIV. Our objective was to develop a quantitative assay for cell-mediated immune (CMI) responses in HEV infection as a surrogate marker for HEV exposure in silent infection. Quantitative assessment of the CMI responses in HEV will also help us to evaluate the role of CMI in HEV morbidity. In this study, an HEV-specific interferon-gamma (IFN-gamma) ELISPOT assay was optimized to analyze HEV-specific CMI responses. We used peripheral blood mononuclear cells (PBMC) and sera from experimentally infected chimpanzees and from seroconverted and control human subjects to validate the assay. The HEV-specific IFN-gamma ELISPOT responses correlated strongly and significantly with anti-HEV ELISA positive/negative results (rho=0.73, p=0.02). Moreover, fine specificities of HEV-specific T cell responses could be identified using overlapping HEV ORF2 peptides.

Angioplasty of distal venous bypasses: is it worth the cost?

Saphenous vein is the best graft for long term patency infragenicular bypass. During follow-up, stenoses can appear on the graft. Is angioplasty a good solution for the treatment of these lesions? During the follow-up of 612 saphenous bypass with below-knee distal anastomosis, 90 stenoses (over 70%) were discovered. Among them 36 were treated with transluminal angioplasty (34 bypasses). Stenoses were detected at a mean follow-up of 7 months after bypass realization. They were located 17 times on the graft itself and 19 times near the anastomoses and they were never longer than 5 cm. Percutaneous approach was preferred for 11 cases and surgical for the others. Immediate success was obtained in 33 cases (91%). Among the 3 failed cases 2 needed a new bypass. Mean follow-up was 33 months after the initial bypass and 24 months after angioplasty. Graft patency was ensured by a single angioplasty in 18 cases. Assisted primary patency, cumulative patency, limb salvage rate were respectively 65%, 91%, 100% at one year and 53%, 72%, 96% at 2 years. Transluminal angioplasty can be advised for the treatment of short stenosis of infrainguinal vein graft: this technique has a weak risk, little surgical aggressiveness, short hospitalisation. Results are acceptable and not very different with the location of the stenosis.