Neutrophil-activating Peptide 2 as a Novel Modulator of Fibrin Clot Properties in Patients with Atrial Fibrillation

Neutrophil-activating peptide 2 (NAP-2, CXCL7), a platelet-derived neutrophil chemoattractant, is involved in inflammation. We investigated associations between NAP-2 levels, neutrophil extracellular traps (NETs) formation, and fibrin clot properties in atrial fibrillation (AF). We recruited 237 consecutive patients with AF (mean age, 68 ± 11 years; median CHA₂DS₂VASc score of 3 [2-4]) and 30 apparently healthy controls. Plasma NAP-2 concentrations were measured, along with plasma fibrin clot permeability (K_s) and clot lysis time (CLT), thrombin generation, citrullinated histone H3 (citH3), as a marker of NETs formation, and 3-nitrotyrosine reflecting oxidative stress. NAP-2 levels were 89% higher in AF patients than in controls (626 [448-796] vs. 331 [226-430] ng/ml; p < 0.0001). NAP-2 levels were not associated with demographics, CHA₂DS₂-VASc score, or the AF manifestation. Patients with NAP-2 in the top quartile (> 796 ng/ml) were characterized by higher neutrophil count (+ 31.7%), fibrinogen (+ 20.8%), citH3 (+ 86%), and 3-nitrotyrosine (+ 111%) levels, along with 20.2% reduced K_s and 8.4% prolonged CLT as compared to the remaining subjects (all p < 0.05). NAP-2 levels were positively associated with fibrinogen in AF patients (r = 0.41, p = 0.0006) and controls (r = 0.65, p < 0.01), along with citH3 (r = 0.36, p < 0.0001) and 3-nitrotyrosine (r = 0.51, p < 0.0001) in the former group. After adjustment for fibrinogen, higher citH3 (per 1 ng/ml β = -0.046, 95% CI -0.029; -0.064) and NAP-2 (per 100 ng/ml β = -0.21, 95% CI -0.14; -0.28) levels were independently associated with reduced K_s. Elevated NAP-2, associated with increased oxidative stress, has been identified as a novel modulator of prothrombotic plasma fibrin clot properties in patients with AF.

Management of valvular heart disease in patients with cancer: Multidisciplinary team, cancer-therapy related cardiotoxicity, diagnosis, transcatheter intervention, and cardiac surgery. Expert opinion of the Association on Valvular Heart Disease, Association of Cardiovascular Interventions, and Working Group on Cardiac Surgery of the Polish Cardiac Society

The Association on Valvular Heart Disease, Association of Cardiovascular Interventions, and the Working Group on CardiacSurgery of the Polish Cardiac Society have released a position statement on risk factors, diagnosis, and management of patients with cancer and valvular heart disease (VHD). VHD can occur in patients with cancer in several ways, for example, it can exist or be diagnosed before cancer treatment, after cancer treatment, be an incidental finding during imaging tests, endocarditis related to immunosuppression, prolonged intravenous catheter use, or combination treatment, and nonbacterial thrombotic endocarditis. It is recommended to employ close cardiac surveillance for patients at high risk of complications during and after cancer treatment and for cancer treatments that may be cardiotoxic to be discussed by a multidisciplinary team. Patients with cancer and pre-existing severe VHD should be managed according to the 2021 European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) guidelines for VHD management, taking into consideration cancer prognosis and patient preferences.

Flow Cytometric Assessment of Endothelial and Platelet Microparticles in Patients With Atrial Fibrillation Treated With Dabigatran

The prothrombotic state in patients with atrial fibrillation (AF) is related to endothelial injury, the activation of platelets and the coagulation cascade. We evaluated the levels of platelet- (CD42b) and endothelial-derived (CD144) microparticles in the plasma patients with non-valvular AF treated with dabigatran at the time of expected minimum and maximum drug plasma concentrations. Following that, we determined the peak dabigatran plasma concentration (c_peak ). CD42b increased after taking dabigatran (median [IQR] 36.7 [29.4-53.3] vs. 45.6 [32.3-59.5] cells/µL; p = 0.025). The concentration of dabigatran correlated negatively with the post-dabigatran change in CD42b (ΔCD42b, r = -0.47, p = 0.021). In the multivariate model, the independent predictors of ΔCD42b were: c_peak (HR -0.55; with a 95% confidence interval, CI [-0.93, -0.16]; p = 0.007), coronary artery disease (CAD) (HR -0.41; 95% CI [-0.79, -0.02]; p = 0.037) and peripheral artery disease (PAD) (HR 0.42; 95% CI [0.07, 0.74]; p = 0.019). CD144 did not increase after dabigatran administration. These data suggest that low concentrations of dabigatran may be associated with platelet activation. PAD and CAD have distinct effects on CD42b levels during dabigatran treatment.

Increased Levels of Platelets and Endothelial-Derived Microparticles in Patients With Non-Valvular Atrial Fibrillation During Rivaroxaban Therapy

It is known that atrial fibrillation (AF) is associated with the procoagulant state. Several studies have reported an increase of circulating microparticles in AF, which may be linked to a hypercoagulable state, atrial thrombosis and thromboembolism. We evaluated in our study alterations in both platelet (PMP, CD42b) and endothelial-derived (EMP, CD144) microparticle levels on anticoagulant therapy with rivaroxaban in nonvalvular AF. After administration of rivaroxaban, PMP levels were increased (median, [IQR] 35.7 [28.8-47.3] vs. 48.4 [30.9-82.8] cells/µL; P = 0.012), along with an increase in EMP levels (14.6 [10.0-18.6] vs. 18.3 [12.9-37.1] cells/µL, P < 0.001). In the multivariable regression analysis, the independent predictor of post-dose change in PMPs was statin therapy (HR −0.43; 95% CI −0.75,−0.10, P = 0.011). The post-dose change in EMPs was also predicted by statin therapy (HR −0.34; 95% CI −0.69, −0.01, P = 0.046). This study showed an increase in both EMPs and PMPs at the peak plasma concentration of rivaroxaban. Statins have promising potential in the prevention of rivaroxaban-related PMP and EMP release. The pro-thrombotic role of PMPs and EMPs during rivaroxaban therapy requires further study.

Evolution of left ventricular function after Wharton's jelly mesenchymal stem cells transcoronary administration: 5-year follow up in a pilot cohort of CIRCULATE-AMI Randomized Trial

Introduction

CIRCULATE-Acute Myocardial Infarction is a double-blind controlled trial randomizing (RCT) in 105 consecutive patients with their first, large AMI (cMRI-LVEF ≤45% and/or cMRI-infarct size ≥10% of LV) with successful infarct-related artery (IRA) primary percutaneous coronary intervention (pPCI) to transcoronary administration of Wharton's Jelly Mesenchymal Stem Cells (WJMSCs) vs. placebo (2:1). The pilot study cohort (PSC) preceded the RCT.

Aim

To evaluate WJMSCs long-term safety, and evolution of left-ventricular (LV) function in CIRCULATE-AMI PSC.

Material and methods

30 000 000 WJMSCs (50% labelled with 99mTc-exametazime) were administered via IRA in a ten-patient PCS (age 32–65 years, peak hs-Troponin T 17.3±9.1ng/mL and peak CK-MB 533±89U/L, cMRI-LVEF 40.3±2.7% and infarct size 20.1±2.8%) at ≈5–7 days after AMI using a cell delivery-dedicated, coronary-non-occlusive method. Other treatments were per guidelines.

WJMSCs showed an unprecedented high myocardial uptake (30.2±5.3%; 95% CI 26.9–33.5%), corresponding to ≈9×10 000 000 cells retention in the infarct zone – in absence of epicardial flow or myocardial perfusion impairment (TIMI-3 in all; cTFC 45±8 vs. 44±9, p=0.51) or any hs-Troponin T elevation. Five-year follow up included cardiac Magnetic Resonance Imaging (cMRI) (at baseline, 1 year and 3 years) and detailed echocardiography (echo) at baseline, 1 year, 3 years and 5 years.

Results

By 5 years, one patient died from a new, non-index territory AMI. There were no other cardiovascular events and MACCE that might be related to WJMSCs transplantation.

On echo (Fig), there was an increase in left ventricular ejection fraction (LVEF) between WJMSCs administration point and 1 year (37.7±2.9% vs. 48.3±2.5%, p=0.002) that was sustained at 3 years (47.2±2.6%, p=0.005 vs. baseline) and at 5 years: (44.7±3.2%, p=0.039 vs. baseline). LVEF reached a peak at 1 year after the AMI and WJMSCs transfer (Fig). cMRI data (obtained up to 3 years; 1 year 41.9±2.6% vs. 51.0±3.3%, p&lt;0.01; 3 years 52.2±4.0%, p&lt;0.01 vs. baseline) were consistent with the echo LVEF assessment.

Conclusions

5-year follow up in CIRCULATE-AMI PSC indicates that WJMSC transcoronary application is safe and may be associated with an LVEF improvement. The magnitude of LV increase appears to peak at 1 year, suggesting a potential role for repeated WJMSCs administration(s). Currently running double-blind RCT will provide placebo-controlled insights into the WJMSCs effect(s) on changes in LV function, remodelling, scar reduction and clinical outcomes.

Echo-LVEF evolution

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): STRATEGMED 265761 “CIRCULATE” National Centre for Research and Development/Poland/ZDS/00564 Jagiellonian University Medical College

The benefit of atrial septal defect closure in the elderly patients

Objective

Closure of the atrial septal defect in the elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in elderly patients.

Methods

From a total of 650 pts with ASD who underwent transcatheter closure 120 pts over 60 years (70 F, 50 M) with a mean age of 66.7±18.1 (60–78) were analyzed. All patients had an isolated secundum ASD with a mean Qp:Qs: 2.79±1.8 (1.5–3.9). A symptom-limited treadmill exercise tests with respiratory gas exchange analysis and transthoracic color Doppler echocardiographic study as well as Quality of life (QoL) measured using the SF36 questionnaire (SF36q) were repeated in all pts before procedure and after 12 months of follow-up.

Results

The device was successfully implanted in all pts (procedure time 30.1±9.9 (10–59) minutes, fluoroscopy time 10.1±7.2 (6–40) minutes). There were no major complications. The defect echo diameter was 19.5±15.4 (12 - 34) mm. The mean balloon stretched diameter of ASD was 22.0±7.8 (14 - 36) mm. The diameter of the implanted devices ranged 16 - 38 mm. After 12 months of ASD closure, all the pts showed a significant improvement of exercise capacity parameters. Seven QoL parameters (except mental health) improved at 12 months follow up compared to their baseline data. The mean SF36q scale increased significantly in 96 (80.2%) pts of mean 41.6±26.1 (4–71). The right ventricular dimension decreased in 101 pts (84.2%) (Table 1).

Conclusions

Closure of ASD in elderly patients caused a significant clinical and hemodynamic improvement after percutaneous treatment, which is maintained to long-term follow-up what justified this procedure in old age.

Funding Acknowledgement

Type of funding source: None

Interventional closure of patent foramen ovale in prevention of thromboembolic events. Consensus document of the Association of Cardiovascular Interventions and the Section of Grown‑up Congenital Heart Disease of the Polish Cardiac Society

The presence of patent foramen ovale (PFO) was found to be associated with a number of medical conditions, including embolic stroke and recurrent transient neurological defects. The closure of PFO remains controversial; however, in recently published guidelines from the European Association of Percutaneous Cardiovascular Interventions in collaboration with 7 other European societies, which extensively refer to the latest randomized clinical trials, it is explicitly recommended to perform percutaneous PFO closure in the prevention of recurrent thromboembolic events. In connection with the above facts and expected increasing number of PFO closure procedures, the joint expert group of the Association of Cardiovascular Interventions and the Grown‑Up Congenital Heart Disease Section of the Polish Cardiac Society developed the following consensus opinion in order to standardize the principles of diagnosis, indications, methods of performing procedures, and postoperative care in relation to Polish conditions and experiences.

P4604Insights into left ventricular remodelling and clinical outcomes after Wharton's jelly multipotent stem cells transcoronary administration in a pilot cohort of CIRCULATE-AMI Trial (NCT03404063)

Introduction

CIRCULATE-Acute Myocardial Infarction Trial (NCT03404063) is a double-blind controlled trial (RCT) that is randomizing consecutive patients with their first, large AMI (LVEF ≤45% and/or cMRI -infarct size ≥10% of LV) successfully treated by infarct-related artery (IRA) primary percutaneous coronary intervention reperfusion (TIMI ≥2) to transcoronary administration of Wharton Jelly Multipotent Stem Cells (WJMSCs) vs. placebo (2:1), preceded by evaluation of safety, WJMSCs myocardial uptake, and echocardiographic, cMRI and SPECT left ventricular remodelling and hemodynamic changes in pilot study cohort (PSC).

Purpose

To evaluate LV remodelling and hemodynamic features following WJMSCs transplantation in CIRCULATE-AMI PSC.

Methods

Ten consecutive patients (age 32–65 years) were administered 30 000 000 WJMSCs via the infarct-related artery at ≈5–7 days after AMI using transradial approach and a coronary-non-occlusive catheter dedicated to cell delivery. Within 3 years of follow up SPECT was performed at baseline and 1 year, echo and cMRI were performed at baseline, 1 year and 3 years.

Results

3-year observation (cMRI) shows a significant decrease of median left ventricular mass (LVM) between WJMSCs administration and 1 year 140 g (IQR 128–150) vs. 97 g (95–128), that is sustained at 3 years 93 g (80–119), p<0,001. There were no significant changes of left ventriular end-diastolic volume (LVEDV) in all diagnostic methods: SPECT baseline vs. 1 year (157.1±27.1 ml vs. 174±24 ml); cMRI baseline vs. 1 year vs. 3 years (171.6±17.7 ml vs. 198.2±23.4 ml vs. 181.9±17.6 ml) and Echo (137±13.3 ml vs. 135±2.9 ml vs. 148±21.8 ml), p value >0,05 for all. Furthermore, there was a significant increase in stroke volume measured by SPECT baseline vs. 1 year (53.3±7.6 ml vs. 68.2±5.2ml); cMRI baseline vs. 1 year vs. 3 years (72.7±5.2 ml vs. 96.9±8.1 ml vs. 93.2±7.8 ml) and Echo (64.3±2.9 ml vs. 68.8±4.1 ml vs. 81.9±7.1 ml), p<0,05 for all. By 3 years there was one non-index territory AMI. There were no other adverse events in the study cohort.

cMRI Left Ventricular Mass evolution

Conclusions

Long-term follow up in CIRCULATE-AMI PSC suggests that transcoronary administration of WJMSCs in a recent large AMI in humans might be associated with an inhibition of LV adverse remodelling and a significant hemodynamic improvement. Our currently running randomized double-blind controlled trial will verify LV remodelling evolution in WJMSCs-treated patients.

Acknowledgement/Funding

K/ZDS/00564 Jagiellonian University Medical College; STRATEGMED 265761 “CIRCULATE” National Centre for Research and Development/Poland

P1800The benefit of atrial septal defect closure in patients with borderline shunt

Objective

Closure of atrial septal defect in patients with borderline shunt is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) in the patients with the borderline shunt.

Methods

215 pts (126 F,89 M) with a mean age of 31.9±18.2 (16–58) years with a small ASD who underwent transcatheter closure were analyzed. All patients had an isolated secundum ASD with pulmonary to systemic blood flow Qp:Qs ratio≤1.5, mean 1.2±0.6 (1.1–1.5).

A symptom-limited treadmill exercise test with respiratory gas exchange analysis, transthoracic color Doppler echocardiographic study and Quality of life (QoL) (using the SF36 questionnaire (SF36q)) were repeated in all pts before and 36 months after the procedure.

Results

The device was successfully implanted in all pts (procedure time 19.1±5.2 (8–38) minutes, fluoroscopy time 8.1±4.4 (6–13) minutes). There were no major complications. The defect echo diameter was 7.7±3.9 (5 - 15) mm. The diameter of the implanted devices ranged from 6 to 18 mm.

After 36 months of ASD closure, all the pts showed a significant improvement of exercise capacity. 7 QoL parameters (except mental health) improved at 36 months of follow-up compared with baseline. The mean SF36q scale increased in 168 (78.1%) pts of mean 40.2±20.1 (9–72). The right ventricular dimension decreased in 173 pts (80.4%) (Table 1).

Table 1 Parameter Before ASD closure 36 months after ASD closure p value Time of exercise (min) 12.1±5.2 18.6±4.3 <0.001 VO2 peak (ml/kg/min) 10.2±4.7 14.8±4.2 <0.001 SF36q scale 0–100 37.3±22.3 79±29.5 <0.001 Right atrial area (cm2) 20.1±1.7 14.7±1.5 <0.001 Right ventricular area (cm2) 18.1±1.4 12.2±1.5 <0.001

Conclusions

ASD closure in patients with borderline shunt resulted in a significant and long-term clinical and hemodynamic improvement after percutaneous treatment.

Transcatheter closure of atrial septal communication: Impact on quality of life in mid-term follow-up

BACKGROUND

Atrial septal defect (ASD) and patent foramen ovale (PFO) are specific types of atrial septal communications (ASC).

OBJECTIVES

We aimed to assess quality of life (QoL) in patients before and after percutaneous closure of ASC and determine the factors influencing QoL in this group of patients.

MATERIAL AND METHODS

We performed a clinical assessment and conducted an SF-36 questionnaire, electrocardiography and echocardiography studies in patients before and 6 months after percutaneous ASC closure.

RESULTS

Patients with ASD (n = 56) had a lower SF-36 total score than those with PFO (n = 73), before and after percutaneous ASC occlusion (both p < 0.001). After the procedure, the improvement of SF-36 total score in patients with ASD or atrial fibrillation was greater (p < 0.001 and p = 0.005, respectively). We observed correlations between improvement of QoL and baseline supraventricular extrasystolic beats (rs = 0.28; p = 0.002), but not ventricular extrasystolic beats (rs = 0.03; p = 0.76). Quality of life improvement was predicted in patients with ASD by higher baseline tricuspid annular plane systolic excursion (TAPSE) and right ventricular longitudinal dimension R2 = 0.38; p < 0.001. However, in patients with PFO, this was predicted by TAPSE, lack of arterial hypertension and usage of angiotensin-converting enzyme inhibitors, R2 = 0.30; p < 0.001.

CONCLUSIONS

Patients with ASD have lower QoL than those with PFO before and after percutaneous ASC occlusion. Six months after the procedure, the improvement of QoL in patients with ASD was higher than in those with PFO. The change in QoL self-assessed by patients after the procedure was associated with episodes of arrhythmia and was predicted with echocardiographic and clinical parameters.

[Przezskórne zamknięcie ubytku w przegrodzie międzyprzedsionkowej: wpływ na prawy przedsionek, dyspersję załamka P i zaburzenia rytmu serca w obserwacji średnioterminowej]

The size of the right atrium (RA) reduces after transcatheter closure of the atrial septal defect (ASD). Inverse structural and electrical remodeling is observed.

AIM

The aim of study was to analyze the parameters predisposing to the lack of normalization of enlarged RA after transcatheter closure of ASD during 6-month follow-up.

MATERIALS AND METHODS

A prospective study included 56 consecutive adult patients (12 men) aged from 23 to 76 years (49.8±13.3 years) with ASD, in whom transcatheter ASD closure was performed. Each patient was assessed before and 6 months after the treatment using standard 12-lead resting electrocardiogram (ECG), 24-hour Holter monitoring and echocardiography.

RESULTS

Before the procedure in 37 patients with ASD enlarged RA was observed, while after transcatheter ASD closure in 24 patients normalization of enlarged RA was noted. Patients in whom 6 months after the procedure there was no normalization of the enlarged RA were older, characterized by higher right ventricular systolic pressure (RVSP), pulmonary to systemic blood flow ratio (Qp/Qs), larger size of the occluder, interatrial septal defect, longer fluoroscopy time and lower left ventricular ejection fraction. P-wave dispersion (Pdysp) was found to be a destimulant i.e. increased Pdysp (>67 ms, P<0.000) decreased the chance of RA normalization after procedure. On the other hand, minimum P-wave duration (Pmin) was a stimulant, therefore, increased Pmin (>72ms, P<0.000) increased the chance of RA normalization. A significant association was found between the reduction of supraventricular extrasystolic beats and RA area normalization (P<0.001), and there was no association between the incidence of atrial fibrillation episodes and RA area normalization.

CONCLUSIONS

Evaluation of the duration of the P-wave and its dispersion may help to assess the prognosis of the right atrium size normalization in the mid-term follow-up after transcatheter closure of ASD. There is a significant relationship between normalization of the right atrium size and reduction of supraventricular extrasystolic beats.

Noninvasive assessment of liver status in adult patients after the Fontan procedure

INTRODUCTION A hemodynamic derangement in Fontan circulation causes liver pathology known as Fontan‑‑associated liver disease. Although liver biopsy is a standard for diagnosis of liver fibrosis, noninvasive methods are being developed, including shear wave elastography (SWE). OBJECTIVES We aimed to evaluate the degree of liver stiffness (LS) using SWE in patients with Fontan circulation in a long‑‑term follow‑‑up and to investigate a relationship between patient characteristics and LS. PATIENTS AND METHODS The study included 59 patients after the Fontan procedure. Clinical examinations and laboratory tests were performed. According to the stage of LS, patients were divided into 2 subgroups: group 1 (METAVIR stages F1 and F2) and group 2 (METAVIR stages F3 and F4). The ratio of aspartate transaminase to alanine transaminase, aspartate transaminase‑‑to‑‑platelet ratio index (APRI), fibrosis‑‑4 (FIB‑‑4) score, and Forns index were assessed. RESULTS The median LS was 9.1 kPa (interquartile range, 3.9-18.5 kPa). Five patients (9%) demonstrated LS in stage F1; 14 (26%), F2; 28 (52%), F3; and 7 (13%), F4. Group 2 had significantly higher aspartate transaminase and γ‑‑glutamyltranspeptidase levels, APRI, FIB‑‑4, and Forns index, and lower platelet count than group 1. A canonical correlation analysis indicated that LS and thrombocytopenia were related to time from the Fontan procedure, age at procedure, and single ventricular ejection fraction. CONCLUSIONS We showed that adult patients after the Fontan procedure develop liver dysfunction. Time from surgery, age at procedure, and single ventricular ejection fraction are related to the degree of LS assessed by SWE. Finally, SWE, APRI, Forns index, and FIB‑4 score may help assess the degree of liver fibrosis.

Association between carotid-femoral pulse wave velocity and overall cardiovascular risk score assessed by the SCORE system in urban Polish population

BACKGROUND

The Systemic COronary Risk Estimation (SCORE) system is recommended for the assessment of cardiovascular disease (CVD) death risk in individuals free of CVD.

AIM

We sought to determine the association between carotid-femoral pulse wave velocity (CFPWV) and SCORE.

METHODS

The study involved 1008 Krakow residents, and a random subsample of 3424 men and 3205 women who participated in Wave 2 of the Polish part of the Health, Alcohol, and Psychosocial factors in Eastern Europe (HAPIEE) study. At baseline we performed a medical interview, physical examination, evaluation of present comorbidities, medications using standardised methods. A follow-up of 4.9 years included measurement of CFPWV using an automatic, computerised Complior® system.

RESULTS

Final analysis included 720 patients (378 women), aged 58.5 ± 6.5 years at baseline. In 488 individuals without his- tory of CVD and/or diabetes, SCORE was calculated. Median CFPWV was higher (p = 0.002) in men (12.5 m/s; interquartile range [IQR] 10.3-15.7) than in women (11.7 m/s; IQR 10.1-13.7). High CFPWV (> 10 m/s) was observed in 270 men (78.9%) and in 285 women (75.4%). We observed a strong association between high CVD risk (SCORE ≥ 5%) and high CFPWV (odds ratio 2.29; 95% confidence interval 1.17-4.46). The CFPWV cut-off value to differentiate between patients with low and high CVD risk was 11.7 m/s (with 58.6% sensitivity and 71.3% specificity, AUC = 0.68).

CONCLUSIONS

Our study is the first to describe the distribution of CFPWV in the adult Polish population. SCORE ≥ 5% pre- dicted high CFPWV in 4.9 years of follow-up, which was independent of other risk factors. CFPWV > 11.7 m/s was most valid in relation to high CVD risk.

Long-term follow-up in adults after tetralogy of Fallot repair

Background

Tetralogy of Fallot (ToF) is the most common cyanotic congenital heart disease and the population of ToF repair survivors is growing rapidly. Adults with repaired ToF develop late complications. The aim of this study was to describe and analyze long-term follow-up of patients with repaired ToF.

Methods

This is a retrospective cohort study. Consecutive 83 patients with repaired ToF who did not undergo pulmonary valve replacement were included. Mean age of all patients was 30.5 ± 10.7. There were 49 (59%) male. Patients were divided into two groups according to the time since the repair (< 25 years and ≥ 25 years). The electrocardiographic (ECG), cardiopulmonary exercise testing (CPET), echocardiographic and cardiac magnetic resonance (CMR) data were reviewed retrospectively.

Results

In CPET values were not significantly different in the two groups. In CMR volumes of left and right ventricles were not significantly different in the two groups. There were no differences between the groups in ventricular ejection fraction, mass of ventricles, or pulmonary regurgitation fraction. Among all the patients, ejection fraction and left and right ventricle mass, indexed pulmonary regurgitation volume measured by CMR did not correlate with the time since repair. In ECG among all the patients, ejection fraction of the RV, measured in CMR, negatively correlated with QRS duration (r = − 0.43; p < 0.001). There was a positive correlation between QRS duration and end diastolic volume of the RV (r = 0.30; p < 0.02), indexed end diastolic volume of the RV (r = 0.29; p = 0.04), RV mass (r = 0.36; p < 0.001) and left ventricle mass (r = 0.26; p = 0.04).

Conclusion

Long-term survival and clinical condition after surgical correction of ToF in infancy is generally good and the late functional status in ToF – operated patients could be excellent up to 25 years after the repair. QRS duration could be an utility and easy factor to assessment of right ventricular function.

Trial registration

The study protocol was approved by the local Ethics Committee. Each participant provided informed consent to participate in the study (license number 122.6120.88.2016 from 28.04.2016).

Long-Term Effects of Percutaneous Fenestration Following the Fontan Procedure in Adult Patients with Congenital Univentricular Heart

Background

The Fontan procedure, performed for univentricular heart, may also include the technique of percutaneous fenestration to create a small atrial septal defect (ASD) and a right-to-left shunt. The aim of this study was to evaluate the long-term effects of fenestration in adult patients who had a Fontan procedure for univentricular heart.

Material/Methods

Fontan surgery was performed in 39 patients, including 19 (49%) patients with fenestration (Group I), and 20 (51%) patients without the fenestration procedure (Group II). Laboratory tests in both groups included echocardiography, plethysmography, cardiopulmonary exercise testing, and 24-hour Holter monitoring.

Results

Compared with patients in Group I, patients in Group II had a significantly increased level of N-terminal pro-brain natriuretic peptide (NT-proBNP) (p=0.04), alkaline phosphatase (ALP) (p=0.01) and a significant increase in frequency of atrial fibrillation (p=0.04). Patients in Group I had a significantly increased systemic ventricular ejection fraction (SVEF) (p=0.05) and increased heart rate (HR) (p=0.006), heart rate reserve (HRR) (p=0.02), ventilatory equivalent (VE) (p=0.01), and VO₂ peak (p=0.05) on cardiopulmonary exercise testing (CPET). Renal, hematologic, and ventilatory parameters, and incidence of thromboembolism showed no significant differences between the groups.

Conclusions

Long-term follow-up of patients who underwent Fontan procedures with percutaneous fenestration had improved single ventricular function, lower NT-proBNP levels, improved exercise capacity, and reduced ALP levels. These findings indicate that percutaneous fenestration closure should be considered for adult patients who have undergone Fontan procedure for univentricular heart.

[Type and frequency of cardiac symptoms in patients with pulmonary sarcoidosis]

AIM

The aim of the study was to assess the type and frequency of prevalence of cardiac symptoms in patients with pulmonary sarcoidosis.

MATERIALS AND METHODS

The study group consisted of 54 patients (21 female, 33 male), with biopsy-proven pulmonary sarcoidosis. Mean age was 45.85 +/-11.77 years. According to time passed from diagnosis of sarcoidosis patients were divided into 2 subgroups. Additionally, age, sex, left ventricular ejection fraction, cigarette smoking and comorbidities were analyzed. Course and stage of sarcoidosis were also included in the analysis.

RESULTS

The frequency of cardiovascular symptoms in the study group was 87.04%. 59.26% of patients reported chest pain, the same subjects reported dyspnoea. 48.15% of respondents reported heart palpitations, 33.33% pre-syncope states, 12.96% syncope, and 37.04% edema of lower limbs. There were no statistically significant differences in the incidence of analyzed symptoms, depending on the duration of lung sarcoidosis.

CONCLUSIONS

Patients with pulmonary sarcoidosis who report cardiovascular symptoms require further diagnostics.

[Evaluation of the clinical suitability of automated left ventricle's fraction and volume measurements in 3-dimensional echocardiography compared to values obtained in magnetic resonance imaging (pilot study)]

Recently a lot of authors have been trying to determine the usefulness of 3-dimensional echocardiography (TTE 3D) in evaluation of ejection fraction and left ventricular volume, but few attempt to compare it to the current gold standard of cardiac magnetic resonance (CMR). 3D imaging technics allows to avoid errors caused by geometry of the heart chambers and foreshortened views. American Echocardiographic Guidelines recommend the use of 3-dimensional echocardiography in daily clinical practice.

AIM

The aim of the study was to establish clinical usefulness of automated 3D TTE software to calculate left ventricle ejection fraction (LVEF), left ventricle end diastolic volume (LVEDV) and left ventricle end systolic volume (LVESV), and to compare those measurements calculated in CMR and in 3D TTE.

MATERIALS AND METHODS

The aim of the study was to establish clinical usefulness of automated 3D TTE software to calculate left ventricle ejection fraction (LVEF), left ventricle end diastolic volume (LVEDV) and left ventricle end systolic volume (LVESV), and to compare those measurements calculated in CMR and in 3D TTE.

RESULTS

The mean LVEF in 3D TTE was 65% +/- 12%; LVEDV 123 ml +/- 67 ml, LVESV 42 ml +/- 29 ml. The CMR LVEF in the study group was 61% +/- 9%, LVEDV 134 ml +/- 51ml, LVESV 54 ml +/- 33 ml. Wilcoxon rank test showed no difference between medians of the measurements, the correlation coefficient between LVEF in 3D TTE and CMR was R = 0.84 (p = 0.036). LVEF calculated in 3D TTE shows good correlation with LVEF computed in CMR. However good visualization of the endocardium, especially in the apex, is essential. The volume of left ventricle is underestimated in 3D TTE. In previous studies underestimation of LVEDV and LVESV was explained by exclusion of endocardial trabeculae from the left ventricle cavity in automated measurement.

CONCLUSIONS

The automated 3D TTE software allows simple, fast and precise evaluation of parameters of the left ventricle - especially LVEF. Automated 3D TTE software gives hope for the inclusion of 3D TTE in routine clinical practice due to its repeatability and easy use of the Heart Model software.

[Multiorgan malfunction after Fontan operation in adult patients]

Although 85% of patients with univentricular heart after Fontan procedure survive twenty years after operation, the procedure alone seems to be an inadequate treatment as a permanent clinical solution. Patients with a "Fontan physiology" additionally have to face a various extra-cardiac complications, including thyroid, liver and kidney dysfunction, which are not only potentially life-threatening, but also can potentiate the circulatory insufficiency.

AIM

The aim of the study was to assess a multiorgan dysfunction in adult patients after Fontan operation in long term follow-up and compare to healthy controls.

MATERIALS AND METHODS

54 patients after Fontan procedure (age=25.1±7 years, time after operation =19.8±6.3 years, age at the time of the procedure =5.3±4.3 years) and 30 controls (26.2±5.8 years) were included to the study. Clinical and laboratory examinations were performed including: hematologic, hepatic, renal and thyroid function tests. The following laboratory tests were performed: red blood cell counts (RBC), hematocrit (Ht), hemoglobin (Hb), platelets count, red blood cell distribution width (RDW), iron level; Btype natriuretic peptide (NT-proBNP), proteinogram blood test, alanine aminotransferase (ALT), aspartate aminotransferase (AST), gammaglutamyl transpeptidase (GGTP), alkaline phosphatase (ALP), total bilirubin, alpha fetoprotein (AFP) level. Furthermore creatinine level; cystatin C, urine albumin to creatynine ratio (ACR) and urinalysis were assessed. To assess a thyroid function free triiodothyronine (fT3), free thyroxine (fT4) and thyroid stimulating hormone (TSH) were measured. Furthermore an abdomen ultrasonography was performed.

RESULTS

In terms of the hematological disorders Fontan patients had a statistically significant higher level of RBC (5.6±0,8 vs 4.8±0.4 109/μl; p<0,001), Hb (16.5±2.8 vs 14.2±1.2 g/dl; p<0,001), HCT (48.7±8.1 vs 42.1±3 %; p<0,001), RDW (14±2.6 vs 12.8±0.5 %; p=0.001), as compared to control group, while PLT level was statistically lower in Fontan group (156.2±61.4 vs 224.2±48 103/μl; p<0,0001). Hepatic parameters in Fontan patients were statistically significant higher, as depicted by the level of: ALT (28.5±10.5 vs 21.5±6 U/l, p<0,001), GGTP (85.6±48.8 vs 19.3±9 U/ l, p<0,001), total bilirubin (26.6±24.8 vs 8.9±4.7 μmol/l; p<0,001), ALP (82.4±31.5 vs 51.2±16 U/l; p<0,001) and INR (1.21±0.3 vs 0.98±0.2; p<0,001). Other parameters such as: AFP, total protein and albumin level did not statistically significantly differ. Additionally five patients (9%) according to clinical symptoms and serum albumin level were diagnosed protein-losing enteropathy (PLE). There was no difference in serum creatinine level between Fontan patients and control group (79.6±23.6 vs 75.9±18.9 μmol/l; p=0.8) as well as in uric acid level (342.7±102 vs 303±105 μmol/l; p=0.2). Cystatin C level was significantly higher in Fontan group in comparison to controls (1.1±0.6 vs 0.8±0.1 ng/ml; p=0,05). Furthermore four Fontan patients (7%) had abnormal microalbumin/creatynine ratio. Urine testing preformed in 30 Fontan patients pointed to 7 cases (23%) where hematuria was observed, while proteinuria was detected in 4 cases (13%) and urobilinogen in 2 (7%). Dysfunction of the thyroid gland was found in 30% of patients after Fontan operation (7% in the control group, p=0,034). Among disorders of the thyroid gland: 13% of patients were diagnosed with hyperthyroidism, 54% diagnosed with subclinical hypothyroidism, and the remaining 33% with hypothyroidism.

CONCLUSIONS

Our study show that adult patients after Fontan procedure in long-term follow are exposed to multiorgan complications including hematological, liver, kidney and thyroid dysfunction.

[Exercise capacity in patients with pulmonary sarcoidosis]

Exertional dyspnea is a common manifestation of sarcoidosis. Cardiopulmonary exercise testing (CPET) is a useful tool to evaluate exercise tolerance of sarcoid patients.

AIM

The aim of the study was to evaluate of exercise capacity in patients with pulmonary sarcoidosis with regard to duration of the disease. Analysis of differences in physical tolerance between patients with cardiac sarcoidosis and without cardiac sarcoidosis.

MATERIALS AND METHODS

39 patients diagnosed with pulmonary sarcoidosis were enrolled to our study. Cardiopulmonary exercise test was used to assess exercise capacity. According to time passed from diagnosis of sarcoidosis patients were grouped into 2 groups. Cardiac sarcoidosis was diagnosed in 9 subjects (23.07%). The control group consisted of 33 healthy volunteers.

RESULTS

The results of the ergospirometry test in patients with lung sarcoidosis showed statistically significant differences in comparison to the control group. The age of patients with pulmonary sarcoidosis correlated negatively with maximal heart rate, oxygen consumption at peak exercise and at anaerobic threshold, breathing frequency at peak exercise, minute ventilation at peak exercise and metabolic equivalent. There was a negative, statistically significant correlation between the oxygen pulse at the peak of exercise and the treatment of steroids in the past.

CONCLUSIONS

Exercise limitation in patients with pulmonary sarcoidosis is a consequence of both ventilatory and cardiocirculatory impairment. Patients with longer disease history of sarcoidosis achieved worse results at cardiopulmonary exercise test than patients with shorter disease history. Trend towards worse exercise tolerance in patients with cardiac sarcoidosis compared to patients without cardiac sarcoidosis was observed.

Effect of ventricular function and volumes on exercise capacity in adults with repaired Tetralogy of Fallot

Objectives

Investigate the effects of left and right ventricular function and severity of pulmonary valve regurgitation, quantified by cardiac magnetic resonance (CMR), on exercise tolerance in adult patients who underwent ToF repair at a young age.

Methods

This is a retrospective cohort study of 52 patients after ToF surgery and 33 age- and sex-matched healthy volunteers. CMR and cardiopulmonary exercise testing (CPET) were performed on all patients; CPET was performed on control subjects.

Results

The main finding of CPET was a severe decrease in oxygen uptake at peak exercise VO_2peak in TOF patients. The patients were characterized also by lower pulse O_2peak and heart rate at peak exercise. Ejection fraction of the right and left ventricles was correlated (r = 0,32; p = 0,03). Left ventricle ejection fraction was negatively correlated with right ventricular volumes (r = −0,34; p = 0,01) and right ventricular mass (r = −046; p < 0,00). Right ventricular mass was positively correlated with left ventricular variables (left ventricle end diastolic volume, r = 0,43; p = 0,002; left ventricle end systolic volume, r = 0,54; p < 0,00) as was VO_2peak: LVEDV (r = 0,38; p = 0,01); LVESV (r = 0,33; p = 0,03) and LV mass (r = 0,42; p = 0,006).

Conclusion

Exercise intolerance in adults with repaired ToF is markedly depressed. The decreased exercise capacity is correlated with impaired RV function and may be associated also with LV dysfunction, which suggests right-to-left ventricular interaction.

Noninvasive techniques for the diagnosis of anomalous origin of the left coronary artery from the pulmonary artery in adult patients

Background Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac anomaly which requires surgical treatment, which improves left ventricular function and clinical outcomes. The definitive diagnosis of ALCAPA is based on coronary angiography, however, noninvasive visualization of the origin of the coronary artery is often helpful in the diagnosis of ALCAPA. Objectives The purpose of this study was to evaluate noninvasive techniques for the diagnosis of ALCAPA, and present the clinical outcomes in adults after surgical correction of ALCAPA. Methods Medical charts of five patients with ALCAPA treated at the John Paul II Hospital in Cracow between 2004 and 2012 were analyzed retrospectively. Noninvasive imaging techniques were used to visualize coronary vessels preoperatively. Patients were followed one year after the operation with echocardiograms and assessment of the New York Heart Association functional class. Results Computed tomography showed ALCAPA in four patients. Magnetic resonance imaging showed abnormal left ventricle remodeling suggestive of ischemia of the anterior cardiac wall. Myocardial perfusion imaging revealed ischemia of the middle and periapical segments of the anterior and anterolateral wall of the left ventricle in two patients. Postoperatively, patients had symptomatic improvement, but there was no statistically significant difference in mean ejection fraction. Conclusions Noninvasive techniques can be used to visualize the origin of the coronary arteries and characterize their morphology. Long-term follow-up of adult patients after surgical correction of ALCAPA is not well documented in the literature, but surgical treatment revealed beneficial short-term effects and symptoms relief.

[Cardiac sarcoidosis - clinical manifestation and diagnosis]

Sarcoidosis is a multisystem inflammatory disease defined histologically by the formation of noncaseating granulomas. The etiology of sarcoidosis remains unknown. Heart involvement in the course of sarcoidosis concerns about 5% of patients. The most common manifestation of cardiac sarcoidosis are conduction abnormalities, arrhythmias and heart failure. The diagnostic algorithm includes performing a clinical history, a 12-lead electrocardiogram (ECG) and an echocardiogram. If any of the initial screening investigations yields an abnormality, diagnostics should be continue using advanced imaging techniques: cardiovascular magnetic resonance (CMR) or fluorodeoxyglucose positron emission tomography (FDG-PET). Nowadays endomyocardial biopsy is not performed routinely.The clinical picture of cardiac sarcoidosis is highly variable. Screening for cardiac sarcoidosis should be performed in all patients diagnosed with extracardiac sarcoidosis. Cardiac sarcoidosis should also be suspected in young patients without a diagnosis of sarcoidosis who present with conduction abnormalities of unknown etiology, because cardiac sarcoidosis may be the first or the only manifestation of the disease.

Antiphospholipid and Antinuclear Antibodies in Young Patients after Myocardial Revascularization Procedures

BACKGROUND

The role of autoimmune factors in the etiology of coronary artery disease (CAD) was suggested in numerous studies but has not been definitively determined.

OBJECTIVES

To assess the possible influence of antiphospholipid and antinuclear antibodies on atherosclerosis development in young patients after myocardial revascularization procedures.

METHODS

The study group included 39 patients younger than 45 years with CAD who underwent myocardial revascularization. Serum levels of antiphospholipid (aPL), antinuclear (ANA) and antineutrophil cytoplasmatic (ANCA) antibodies were tested within 1 month after the procedure.

RESULTS

All three types of aPL were significantly higher in CAD patients when compared to healthy controls: anti-β2-glycoprotein I (aβ2GPI), both immunoglobulin (Ig)G and IgM classes (median 4.10 SGU, range 3.45-21.63 vs. 0.76, 0.12-6.01, P < 0.001, and 2.82 SGU, 1.44-11.70 vs. 1.08, 0.44-3.64, P < 0.001, respectively); anticardiolipin antibodies (aCL) both IgG and IgM classes (3.13 GPL, 1.32-14.03 vs. 2.42, 0.96-18.45, P = 0.0037, and 6.94 MPL, 1.90-26.40 vs. 4.32, 1.9-28.73, P < 0.008, respectively); and lupus anticoagulant (LA) (27.7% vs. 0%, P = 0.005). ANA were elevated in one patient and ANCA in 23 (60%). The levels of aPL did not correlate with the presence of a clot in a coronary vessel detected during angiography or with exacerbation of coronary artery atherosclerosis.

CONCLUSIONS

In young patients with CAD who underwent myocardial revascularization the levels of aPL were significantly higher than in young healthy subjects. Thus, besides the classic risk factors for CAD, autoimmunity may play an important role in atherosclerotic plaque formation and progression.

[Lyme carditis]

Lyme disease is a multisystem infectious disease caused by the spirochete Borrelia burgdorferi. A steady increase in the number of cases is noticed both in Poland and Europe. Cardiac involvement in the course of borreliosis is relatively rare. It is estimated that it concerns about 0.5-10% of patients with Lyme disease. Cardiac involvement generally occurs in the early phase of illness. The most common manifestation of Lyme carditis are transient conduction abnormality, arrhythmias, myocarditis and pericarditis. The basic method of treatment Lyme carditis are antibiotics. The clinical course is usually benign. In most cases a complete recovery is observed. However, in a small proportion of patients dilated cardiomyopathy may occur. Furthermore, death from Lyme carditis has been reported. Lyme carditis remains a real diagnostic and therapeutic challenge for clinicians. Factors that can make the diagnosis difficult are: atypical clinical picture, negation of tick bite, the absence of erythema migrans, onset of symptoms outside the period of tick activity and negative serological results in the initial stage of the disease.

Conduction abnormality and arrhythmia after transcatheter closure of atrial septal defect

BACKGROUND

The aim of this study was to prospectively perform ambulatory 24-h ECG monitoring to assess the effects of transcatheter closure of atrial septal defect (ASD).

METHODS AND RESULTS

A total of 235 consecutive subjects (female, n=163; male, n=72; age, 44.6±14.4 years) were enrolled in the study, who were due undergo ASD closure. Holter monitoring was performed before procedure and at 1, 6 and 12 months of follow-up. During the procedure transient supraventricular arrhythmia occurred in 8 patients (3.4%), and bradycardia in 3 (1.3%). In 3 patients (1.3%) an episode of atrial fibrillation occurred in the first hour after the procedure. In 8 patients (3.4%) transient first-degree atrioventricular block was noted. A significant increase in number of supraventricular extrasystoles (SVES)/24 h was noted 1 month after the procedure (P<0.001). On multiple forward stepwise regression analysis, device size and fluoroscopy time had an influence on increase in number of SVES seen 1 month after the procedure (P<0.001).

CONCLUSIONS

Transcatheter closure of ASD is associated with a transient increase in supraventricular premature beats and a small risk of conduction abnormalities and paroxysmal atrial fibrillation in early follow-up. Transcatheter closure of ASD does not reduce arrhythmia that appears prior to ASD closure. Larger device size and longer procedure time are associated with increased risk of supraventricular arrhythmia on early follow-up.

Conduction Abnormality and Arrhythmia After Transcatheter Closure of Atrial Septal Defect

Background:The aim of this study was to prospectively perform ambulatory 24-h ECG monitoring to assess the effects of transcatheter closure of atrial septal defect (ASD).Methods and Results:A total of 235 consecutive subjects (female, n=163; male, n=72; age, 44.6±14.4 years) were enrolled in the study, who were due undergo ASD closure. Holter monitoring was performed before procedure and at 1, 6 and 12 months of follow-up. During the procedure transient supraventricular arrhythmia occurred in 8 patients (3.4%), and bradycardia in 3 (1.3%). In 3 patients (1.3%) an episode of atrial fibrillation occurred in the first hour after the procedure. In 8 patients (3.4%) transient first-degree atrioventricular block was noted. A significant increase in number of supraventricular extrasystoles (SVES)/24 h was noted 1 month after the procedure (P<0.001). On multiple forward stepwise regression analysis, device size and fluoroscopy time had an influence on increase in number of SVES seen 1 month after the procedure (P<0.001).Conclusions:Transcatheter closure of ASD is associated with a transient increase in supraventricular premature beats and a small risk of conduction abnormalities and paroxysmal atrial fibrillation in early follow-up. Transcatheter closure of ASD does not reduce arrhythmia that appears prior to ASD closure. Larger device size and longer procedure time are associated with increased risk of supraventricular arrhythmia on early follow-up.

The benefit of atrial septal defect closure in elderly patients

Objective

Closure of an atrial septal defect in elderly patients is controversial. The aim of the study was to evaluate the outcomes of transcatheter closure of secundum atrial septal defects (ASDs) in elderly patients.

Patients and methods

From a total of 488 patients with ASDs who underwent transcatheter closure, 75 patients aged over 60 years (45 female, 30 male) with a mean age of 65.3±15.7 (60–75) years were analyzed. All patients had an isolated secundum ASD with a mean pulmonary blood flow:systemic blood flow of 2.84±1.9 (1.5–3.9). Symptom-limited treadmill exercise tests with respiratory gas-exchange analysis and transthoracic color Doppler echocardiographic study, as well as quality of life measured using the Short Form (36) Health Survey (SF-36) were repeated in all patients before the procedure and after 12 months of follow-up.

Results

The atrial septal device was successfully implanted in all patients (procedure time 37.7±4.5 [13–59] minutes, fluoroscopy time 11.2±9.9 [6–40] minutes). There were no major complications. The defect echo diameter was 17.7±15.8 (12–30) mm. The mean balloon-stretched diameter of ASDs was 22.4±7.9 (14–34) mm. The diameter of the implanted devices ranged from 16 to 34 mm. Significant improvement of exercise capacity was noted at 6 and 12 months after the procedure. Exercise time within 6 months of ASD closure was longer (P<0.001) compared to baseline values, and also oxygen consumption increased (P<0.001). Seven quality-of-life parameters (except mental health) improved at 12-month follow-up compared to baseline data. The mean SF-36 scale increased significantly in 66 (88%) patients, with a mean of 46.2±19.1 (5–69). As early as 1 month after the procedure, a significant decrease of the right ventricular dimension and the right atrium dimension was observed (P<0.001). The right ventricular dimension decreased in 67 patients (89.3%).

Conclusion

Closure of ASDs in elderly patients caused significant clinical and hemodynamic improvement after percutaneous treatment, which was maintained during long-term follow-up, justifying this procedure in old age.

Transcranial Doppler ultrasonography should it be the first choice for persistent foramen ovale screening?

Background

Persistent foramen ovale (PFO) is considered a cause of cryptogenic stroke and a risk factor for neurological events in young patients. The reference standard for identifying a PFO is contrast-enhanced transesophageal echocardiography (TEE).

The goal of this study was to evaluate the feasibility of transcranial color Doppler (TCD) and its diagnostic sensitivity compared with TEE.

Methods

We investigated 420 patients admitted to our department with cryptogenic stroke, transient ischemic attacks or other neurological symptoms. All patients underwent TCD and TEE evaluation. TCD and TEE examinations were performed according to a standardized procedure: air-mixed saline was injected into the right antecubital vein three times, while the Doppler signal was recorded during the Valsalva maneuver. During TCD the passage of contrast into the right-middle cerebral artery was recorded 25 seconds following the Valsalva maneuver.

Results

We detected a right-to-left shunt in 220 patients (52.3%) and no-shunts in 159 patients (37.9%) with both TCD and TEE. In 20 (4.8%) patients TEE did not reveal contrast passage which was then detected by TCD. In 21 (5.0%) patients only TEE revealed a PFO. The feasibility of both methods was 100%. TCD had a sensitivity of 95% and a specificity of 92% in the diagnosis of PFO.

Conclusions

TCD has a relatively good sensitivity and specificity. TCD and TEE are complementary diagnostic tests for PFO, but TCD should be recommended as the first choice for screening because of its simplicity, non-invasive character, low cost and high feasibility.

Arterial stiffness in adult patients after Fontan procedure

Objectives

Increased arterial stiffness is a risk factor of atherosclerosis and cardio-vascular complications. The aim of the study was to determine whether peripheral vascular function might be an early marker of impaired health status in patients with a single ventricle after Fontan procedure.

Methods and results

Twenty five consecutive adults (11 women and 14 men) aged 24.7 ± 6.2 years after the Fontan procedure and 25 sex, age and BMI match healthy volunteers underwent physical examination, blood analysis, transthoracic echocardiography and noninvasive assessment of aortic stiffness. Augmented pressure and Augmentation Index (AIx) were both significantly elevated in Fontan when compared to the controls (6,08 ± 0,7 vs. 2,0 ± 3,7; p = 0.002 and 17,01 ± 3,3 vs. 6,05 ± 11; p < 0.001, respectively). There were no differences in pulse wave velocity (PWV), mean blood pressure (BP), brachial pulse pressure (PP), central: systolic BP, diastolic BP and PP. In Fontan group we find negative correlation between PWV and SatO2 (r = −0.68; p = 0.04) and positive correlation with WBC (0.72; p = 0.72; p = 0.013), INR (0.81; p = 0.008), TNFα (r = 0.45; p = 0.04), and postoperative time (r = 0.77; p = 0.02). AIx correlates positively only with age at surgery (r = 0.45; p = 0.04). Bilirubin level correlates positively with brachial PP (r = 0.71; p = 0.02) and central PP (r = 0.68; p = 0.03).

The multivariate model showed that SatO2 (β = −0.44, p = 0.04) was the only independent predictor of PWV (R² = 0.32, p = 0.03).

Conclusion

Adult Fontan patients have an increased arterial stiffness assessed by a noninvasive technique. Low arterial oxygen saturation postoperative time, age at surgery, white blood cells, TNFα and bilirubin level are associated with arterial stiffening in these patients. The combination of blood parameters of the hepatic function and noninvasive measurements of arterial stiffness could be helpful in comprehensive care of patients with Fontan circulation.

Secondary prevention in patients after hospitalisation due to coronary artery disease: what has changed since 2006?

BACKGROUND

The evidence concerning the quality of secondary prevention of coronary artery disease (CAD) in Poland in recent years is scarce.

AIM

To compare the implementation of secondary prevention guidelines into everyday clinical practice between 2006-2007 and 2011-2012 in patients after hospitalisation due to CAD.

METHODS

Five hospitals with departments of cardiology serving a city and its surrounding districts in the southern part of Poland participated in the study. Consecutive patients aged ≤ 80 years, hospitalised from April 1, 2005 to July 31, 2006 (first survey) and from April 1, 2010 to June 30, 2011 (second survey) due to acute coronary syndrome or for a myocardial revascularisation procedure were recruited and interviewed 6-18 months after hospitalisation.

RESULTS

Medical records of 640 patients were reviewed and included in the first survey and 466 in the second survey. The proportion of medical records with available information on smoking did not differ between the surveys, whereas the proportion of medical records with available information on blood pressure and total cholesterol was lower in patients hospitalised in 2010-2011. The prescription rate of β-blockers at discharge decreased from 90% to 84% (p < 0.05), whereas the prescription rates at discharge of other drug classes did not change significantly. The proportion of patients with high blood pressure (≥ 140/90 mm Hg) one year after hospitalisation decreased in 2011-2012 compared to 2006-2007 (from 48% to 35%, p < 0.05), whereas the proportion of subjects with high LDL cholesterol, high fasting glucose, and obesity did not change significantly. We did not note a significant difference in the smoking rate. The proportions of patients taking an antiplatelet agent (90% vs. 91%), a β-blocker (87% vs. 79%), an ACE inhibitor or a sartan (79% vs. 76%), a calcium antagonist (22% vs. 25%), a diuretic (35%vs. 45%), and a lipid-lowering drug (86% vs. 87%) one year after discharge did not change significantly (all p > 0.05).

CONCLUSIONS

We noted a modest improvement in the implementation of CAD secondary prevention guidelines in everyday clinical practice: blood pressure was better controlled, although the control of all other main risk factors did not change significantly. Our data provides evidence that there is a considerable potential for further reduction of cardiovascular risk in CAD patients.

[The influence of knowledge of cardiovascular risk factors for 1st and 6th year medical students' lifestyle]

BACKGROUND

The most important way to reduce the incidence of the atherosclerotic cardiovascular disease (CVD) is prevention, which should include modification of risk factors.

AIM

To define knowledge of primary CVD prevention, and to rate compliance with prevention rules among students'.

MATERIAL AND METHODS

The study included 275 first year (ly) students and 161 sixth year (6y) students of the Faculty of Medicine (303 Females and 133 Males; aged 18-29 years). Anonymous questionnaire on acquaintance with the primary prevention, compliance with it and correct values and units of blood pressure, blood glucose and cholesterol level was conducted among survey participants.

RESULTS

6y students indicated risk factors of CVD significantly more correctly than ly students. The proper value of male and female waist circumference was indicated correctly more often by 6y students than ly students. When compared to ly students, 6y students more often marked properly the heart attack symptoms, tests which are necessary to diagnose ACS, and markers of the myocardial necrosis. Respectively, among the ly and 6y students the mean BMI was: 20.82 kg/m2 vs. 21, 74 kg/m2, mean waist circumference: 70.00 cm vs.74.81 cm. 6y students more often than ly students eat regular meals, eat fruits and vegetables more than 4 times a week, exercise more than 30 minutes a day.

CONCLUSIONS

Sixth year medical students' knowledge about the prevention of CVD is greater than the first year students' but still is unsatisfactory. Sixth year students slightly often follow the rules of primary prevention than first year students.

Assessment of left ventricle function in aortic stenosis: mitral annular plane systolic excursion is not inferior to speckle tracking echocardiography derived global longitudinal peak strain

BACKGROUND

Early detection of left ventricle (LV) systolic dysfunction is essential for management of patients with aortic stenosis (AS). Two- dimensional speckle tracking derived global longitudinal peak strain (GLPS) is more sensitive than ejection fraction (EF) but requires good image quality and is not easily accessible. The aim of the study was to compare GLPS with traditional echocardiographic parameter- mitral annular plane systolic excursion (MAPSE) in AS.

MATERIAL AND METHODS

In consecutive patients with moderate to severe AS and LV ejection fraction ≥ 50% standard echocardiography and two-dimensional speckle tracking echocardiography were performed. Mitral annular plane systolic excursion and global longitudinal peak strain were obtained from apical echocardiographic views.

RESULTS

A total of 82 patients were examined, median age was 68 (60-78), 56% of them were men. There was a positive correlation between aortic valve area index (AVAI) and: MAPSE (r = 0.334, p = 0.002), MAPSE indexed for body surface area- MAPSEI (r = 0.349, p = 0.001) and GLPS (r = 0.342, p = 0.002) but not EF (r = 0.031, p = 0.782). A positive correlation was found between GLPS and MAPSE (r = 0.558, p < 0.001) and between GLPS and MAPSEI (r = 0.543, p < 0.001). All above parameters were significantly lower in symptomatic patients compared to asymptomatic subjects (GLPS: -13.82 ± 3.56 vs. -16.39 ± 3.16%, p = 0.002, MAPSE: 10.49 ± 1.91 vs. 11.95 ± 1.82 mm, p = 0.001 and MAPSEI: 5.66 (4.83-6.6) vs. 6.46 ± 0.97 mm/m2, p = 0.005).

CONCLUSION

Despite the development of the modern echocardiographic techniques, mitral annular plane systolic excursion can still be used as a sensitive tool to detect early longitudinal LV systolic dysfunction.

Nonstenotic bicuspid aortic valve is associated with elevated plasma asymmetric dimethylarginine

BACKGROUND

Recently, it has been reported that nonstenotic bicuspid aortic valve (BAV) with dilated proximal aorta is linked with increased matrix metalloproteinase-2 (MMP-2) and endothelial dysfunction.

OBJECTIVE

We wondered whether asymmetric dimethylarginine (ADMA), a nitric oxide synthase inhibitor, might be altered and associated with MMP-2 in BAV patients. We assessed the relation between ADMA levels and aortic diameters and hypothesized that elevated ADMA might be an independent predictor of progressive aortic dilatation in BAV patients.

METHODS

We studied 20 patients with nonstenotic BAV (17 men and 3 women, median age 27, range 24-33 years). Twenty age-matched patients with tricuspid aortic valves served as controls. Plasma levels of ADMA, symmetric dimethylarginine (SDMA), L-arginine, serum MMP-2, MMP-9, and plasma total homocysteine (tHcy), together with parameters of aortic elasticity, were measured.

RESULTS

ADMA and MMP-2 levels were higher in the BAV group compared with controls (medians, 0.55 vs. 0.43 μmol/l, P < 0.001 and 1.25 vs. 1.00 μmol/l, P < 0.001, respectively). The BAV patients also had higher SDMA and tHcy levels than controls (0.39 vs. 0.35 μmol/l, P < 0.001 and 11.5 vs. 9.7 μmol/l, P = 0.006). ADMA levels in BAV patients correlated with aortic annulus (r = 0.4, P = 0.043), peak aortic velocity (r = 0.6, P = 0.001), aortic distensibility (r = 0.6, P = 0.004), aortic stiffness index (r = 0.7, P < 0.001), and aortic strain (r = 0.7, P < 0.001) as well as with MMP-2 (r = 0.6, P = 0.002) and tHcy (r = 0.4, P = 0.042).

CONCLUSIONS

This study is the first to show that circulating ADMA together with MMP-2 is a marker of proximal ascending aortic dilatation and impaired aortic elastic properties in nonstenotic BAV patients. It might be speculated that plasma ADMA could be helpful in identifying BAV patients at a higher risk of aortic aneurysm.

Assessment of left ventricle function in patients with symptomatic and asymptomatic aortic stenosis by 2-dimensional speckle-tracking imaging

Background

Global longitudinal peak strain (GLPS) quantifies left ventricle (LV) long-axis contractility. Early detection of LV systolic dysfunction is pivotal in diagnosis and treatment of patients with aortic stenosis (AS). This study was performed to assess LV longitudinal systolic function by GLPS derived from 2-dimensional speckle tracking imaging (2D-STI) in AS patients in comparison to standard echocardiographic parameters.

Material/Methods

Laboratory tests, standard echocardiography, tissue Doppler imaging (TDI) and 2D-STI examinations with GLPS calculation were performed in 49 consecutive patients with moderate to severe AS with LV ejection fraction ≥50% and 18 controls.

Results

While LVEF do not differentiate AS patients from controls, GLPS was significantly decreased in the AS group (−15.30±3.25% vs. −19.60±2.46% in controls, p<0.001). GLPS was significantly reduced in symptomatic AS patients as compared to the asymptomatic AS group [−15.5 (11.8–16.8) vs. −17.5 (14.7–18.9)%, p=0.02].

Conclusions

In aortic stenosis patients, despite normal left ventricle ejection fraction, long-axis left ventricular function is impaired, which manifests in global longitudinal peak strain reduction. GLPS reveals that LV function impairment is more pronounced in symptomatic as compared to asymptomatic AS patients. Further studies are needed to determine the prognostic significance of early LV function impairment in aortic stenosis patients showed by GLPS.