Low incidence of severe acute and chronic graft-versus-host disease in a long-term retrospective study with ATG Grafalon routine use

Since 2006, combined graft-versus-host disease (GVHD) prophylaxis with ATG Grafalon has been our department's base of peri-transplant supportive care. This recent retrospective study included 398 patients who underwent their first allogeneic hematopoietic stem cell transplantation after receiving a defined dose of ATG Grafalon. Our observations recorded reduced incidence of severe acute and chronic GVHD without negative impact on overall survival in a nonselected group with standard and uniform GVHD prophylaxis.

Early ganglion stellate blockade as part of two-step treatment algorithm suppresses electrical storm and need for intubation

BACKGROUND

For the treatment of patients with electrical storm (ES), we established a two-step algorithm comprising standard anti-arrhythmic measures and early ultrasound-guided stellate ganglion blockade (SGB). In this single-center study, we evaluated the short-term efficacy of the algorithm and tested the hypothesis that early SGB might prevent the need for intubations.

METHODS

Overall, we analyzed data for 70 ES events in 59 patients requiring SGB (mean age 67.7 ± 12.4 years, 80% males, left ventricular ejection fraction 30.0% ± 9.1%), all with implantable cardioverter-defibrillators (ICDs).

RESULTS

The mean time from ES onset to SGB was 13.2 ± 12.3 hours. Percentage and mean absolute reduction in shocks at 48 hours after SGB reached 86.8% (-6.3 shocks), and anti-tachycardiac pacing (ATP) declined by 65.9% (-51.1 ATPs; all P < 0.001). Patients with the highest sustained ventricular arrhythmia (VA) burden (shocks ≥10/48 h; ATPs 10-99/48 h and ≥100/48 h) experienced the highest percentage decrease in ICD therapy (shocks -99.1%; ATPs -92.1% and -100.0%, respectively). For clinical response by defined criteria and two outcome periods (1/no sustained VA ≤48 hours post SGB, and 2/no ICD shock or <3 ATPs/day from day 3 to discharge/catheter ablation/day 8), 75.7% and 76.1% experienced complete response, respectively. Catecholamine support, no/low-dose β-blocker therapy, polymorphic/mixed-type VA, and baseline sinus rhythm versus atrial fibrillation were more frequent in patients with early arrhythmia recurrence. Temporary Horner's syndrome occurred in 67.1%, and no other adverse events were recorded. Intubation and general anesthesia during and after SGB were not needed.

CONCLUSION

The presented two-step algorithm for treating ES proved efficacious and safe. The results support implementation of early SGB in routine ES management.

Orally Administered Probiotics in the Prevention of Chemotherapy (± Radiotherapy)-Induced Gastrointestinal Toxicity: A Systematic Review With Meta-Analysis of Randomized Trials

BACKGROUND

Chemoradiotherapy-induced gastrointestinal toxicity may lead to a significant impairment of the oncological patient's quality of life, as well as to reduced adherence to the treatment, which may have a negative impact on survival and mortality rates.

OBJECTIVE

The aim of this review was to investigate whether oral probiotic administration prevents chemotherapy (± radiotherapy)-induced gastrointestinal toxicity, particularly diarrhea.

METHODS

We searched the MEDLINE, Web of Science, and SCOPUS databases for randomized controlled trials in English published between 1990 and 2020. We conducted statistical data analyses expressing the treatment effect size as a risk ratio (RR) together with a 95% confidence interval (CI). Implications are based on trials rated as having a low risk of bias (RoB).

RESULTS

We included 8 trials (n = 697 participants), from which 3 studies rated as low RoB contained primary endpoint data; the risk of developing grade 3/4 diarrhea in patients receiving probiotics was reduced by 78% compared to the control group (RR = 0.22 [95% CI 0.05-1.08]; P = .06; n = 114 participants). Probiotics showed preventive effects in patients treated with chemotherapy alone (RR = 0.34 [0.12-0.94]; P = .04, n = 121 participants) and in patients with colorectal cancer (RR = 0.56 [0.34-0.92]; P = .02; n = 208 participants). The reduction in the incidence of overall diarrhea was not significant.

CONCLUSIONS

Probiotics failed to prove a preventive effect of statistical significance against the development of severe and overall diarrhea in cancer patients treated with chemotherapy (± radiotherapy). However, we cannot rule out that the effects of probiotics are clinically relevant, especially in certain subgroups of patients. This needs to be clarified in further well-performed studies.

Cardiac sequelae after COVID-19: Results of a 1-year follow-up study with echocardiography and biomarkers

Objective

To evaluate the need for cardiac monitoring in unselected patients recovered from COVID-19 and to estimate the risk of heart complications after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Materials and methods

During March 2020 and January 2021, 106 patients who had recovered from SARS-CoV-2 (alpha and beta variants) were enrolled in prospective observational cohort study CoSuBr (Covid Survivals in Brno). The diagnosis was based on a reverse transcription-polymerase chain reaction swab test of the upper respiratory tract. Demographic parameters, patient history, clinical evaluation, cardiac biomarkers, ECG and echocardiography were recorded during three visits (Visit 1 at least 6 weeks after infection, Visit 2 three months later, and Visit 3 one year after Visit 1).

Results

58.5% of the study group (n = 106) were female, while the mean age was 46 years (range 18-77 years). The mean time interval between the onset of infection and the follow-up visit was 107 days. One quarter (24.5%) of the patients required hospitalization during the acute phase of the disease; the rest recovered at home. 74% suffered a mild form of the disease, with 4.8, 18.1, and 2.9% suffering moderate, severe, and critical forms, respectively. At the time of enrolment, 64.2% of the patients reported persistent symptoms, while more than half of the whole group (50.9%) mentioned at least one symptom of possible cardiac origin (breathing problems, palpitations, exercise intolerance, fatigue). In the 1-year follow-up after COVID-19 infection, left ventricle ejection fraction showed no significant decrease [median (IQR) change was -1.0 (-6.0; 4.0)%, p = 0.150], and there were no changes of troponin (mean change -0.1 ± 1.72 ng/L; p = 0.380) or NT-proBNP [median (IQR) change 2.0 (-20.0; 29.0) pg/mL; p = 0.315]. There was a mild decrease in right ventricle end diastolic diameter (-mean change 2.3 ± 5.61 mm, p < 0.001), while no right ventricle dysfunction was detected. There was very mild progress in left ventricle diastolic diameter [median (IQR) change 1.0 (-1.0; 4.0) mm; p = 0.001] between V1 and V3, mild enlargement of the left atrium (mean change 1.2 ± 4.17 mm; p = 0.021) and a non-significant trend to impairment of left ventricle diastolic dysfunction. There was a mild change in pulmonary artery systolic pressure [median (IQR) change 3.0 (-2.0; 8.0) mmHg; p = 0.038].

Conclusion

Despite a lot of information regarding cardiac impairment due to SARS-CoV2, our study does not suggest an increased risk for developing clinically significant heart changes during the 1-year follow-up. Based on our results, routine echocardiography and biomarkers collection is currently not recommended after COVID-19 recovery.

No cardiac sequelae after COVID-19: results of the one year follow-up with echocardiography and biomarkers

Objective

To evaluate the need for cardiac monitoring of unselected patients recovered from COVID-19 and to estimate the risk of heart failure development after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

Methods

During March 2020 and January 2021, 106 patients recovered from SARS-CoV-2 (alfa and beta variants) were enrolled in the prospective observational cohort study, CoSuBr (Covid Survivals in Brno). The diagnosis was established by reverse transcription polymerase chain reaction on swab test of the upper respiratory tract.

Demographic parameters, patient history, clinical evaluation, cardiac biomarkers, ECG and echocardiography were recorded within three visits (V1 at least six weeks after infection, V2 three months later and V3 one year after V1).

Results

The study group (n=106) included 58% women, mean age was 46 years (range 18–77 years). Mean time interval between the onset of the infection and the follow-up visit was 107 days. One quarter (24.5%) of the patients required hospitalisation during the acute phase of the disease, the rest recovered at home. 74% suffered from mild form, 3.8% moderate, 18.3% severe and 2.9% of critical form of the disease. At the time of enrolment 63.5% of the patients were referring the ongoing symptoms, while more than half of the whole group (50.9%) mentioned at least one symptom of possible cardiac origin (breathing problems, palpitations, exercise intolerance, fatigue).

During one year follow up after COVID-19 infection there was no decrease of left ventricle ejection fraction (V1: 62.1±5.26% to V3: 60.8±6.24%, p=0,150), no changes of troponin (4.8±3.41 to 4.7±3.31ng/L; p=0.417) and NT-proBNP (74.3±75.15 to 95.3±137.28pg/mL; p=0,315). There was a mild decrease of right ventricle end diastolic diameter (28.9±5.59 to 26.8±3.83mm, p<0.001), while no right ventricle dysfunction was detected. There was a very mild progress in a left ventricle diastolic diameter (47.9±6.34 to 49.3±4.21mm; p<0.001) between V1 a V3, a mild enlargement of left atrium (37.1±5.85 to 38.2±5.65mm; p=0,021) and non-significant trend to impairment of left ventricle diastolic dysfunction. There was a mild change of pulmonary artery systolic pressure (24.7±7.92 to 27.5±6.97mmHg; p=0,038).

Conclusion

Despite many information regarding cardiac impairment of SARS-CoV-2 our study does not suggest increased risk of development of heart failure during the one year follow-up. Based on our results the routine echocardiography and biomarkers collection is currently not recommended after COVID-19 recovery.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): MH CZ - DRO; MEYS - RI CZECRIN

Ganglion stellate blockade in the treatment algorithm of the malignant electric storm: one center, five years and 72 procedures in 59 patients

Funding Acknowledgements

Type of funding sources: None.

Introduction

Malignant electric storm (ES) is a life-threatening condition with a high mortality rate. With years of increasing numbers of implanted ICDs, we witness increasing numbers of patients treated for ES. The role of local suppression of sympathetic nerve activity using ultrasound-guided anesthetic ganglion stellate blockade (GSB) is still under investigation with the first favorable published data from prospective cohorts.

Objective

To present data from a cohort of consecutive patients treated for ES at our cardiac center using a two-stage algorithm including GSB.

Method and Cohort

Between 2017 and 2021, 59 patients were treated using the two-stage algorithm ( when the first stage of standard procedures failed - ions, antiarrhythmic drugs, ischemia correction, heart rate modification, sedation, and GSB was performed as the second stage of the algorithm when ventricular arrhythmia recurred) in 72 GSB procedures.

57 GSB in men (79.2%)/15 GSB (20.8%) in women. Mean age 68.1 +/- 12.1 years. Mean LV EF 29.6 +/- 8.9%. 22 GSB in diabetic patients (30.6%). Ischemic etiology of ES in 41 cases (56.9%). Monomorphic ventricular tachycardia dominated among arrhythmias with 53 cases ( 73.6%). Betablocker and amiodarone were administered in 67 and 56 cases, respectively ( 93.1 and 77.8%).

A statistically significant decrease of 87.7% in ventricular arrhythmias treated with shock ICD or ATP was seen ( decrease from 57.2 to 1.43 episodes 48 hours before vs. 48 hours after GSB, p&lt;.0001) (Table 1).

Hemodynamically unstable patients on continuous catecholamines responded significantly less to the two-step algorithm, including GSB. Horner’s syndrome and other demographic and medication parameters did not appear to predict a better response to GSB (Table 2 ). No serious adverse events were observed. In one case, intermittent ( couple hours) vocal chord paresis after bilateral GSB has been observed.

Conclusion

The two-stage algorithm for the treatment of ES, including ganglion stellate blockade, has shown stable high efficacy over the years with exceptional safety. However, the actual efficacy must be proven in a double-blinded study to allow the widespread method to the clinical practice.

Prediction of Vagal Nerve Stimulation Efficacy in Drug-Resistant Epilepsy (PRECISE): Prospective Study for Pre-implantation Prediction/Study Design

Background

Vagal nerve stimulation (VNS) can be indicated in patients with drug-resistant epilepsy, who are not eligible for resective epilepsy surgery. In VNS therapy, the responder rate (i.e., percentage of subjects experiencing ≥50% seizure reduction) is ~50%. At the moment, there is no widely-accepted possibility to predict VNS efficacy in a particular patient based on pre-implantation data, which can lead to unnecessary surgery and improper allocation of financial resources. The principal aim of PRediction of vagal nerve stimulation EfficaCy In drug-reSistant Epilepsy (PRECISE) study is to verify the predictability of VNS efficacy by analysis of pre-implantation routine electroencephalogram (EEG).

Methods

PRECISE is designed as a prospective multicentric study in which patients indicated to VNS therapy will be recruited. Patients will be classified as predicted responders vs. predicted non-responders using pre-implantation EEG analyses. After the first and second year of the study, the real-life outcome (responder vs. non-responder) will be determined. The real-life outcome and predicted outcome will be compared in terms of accuracy, specificity, and sensitivity. In the meantime, the patients will be managed according to the best clinical practice to obtain the best therapeutic response. The primary endpoint will be the accuracy of the statistical model for prediction of response to VNS therapy in terms of responders and non-responders. The secondary endpoint will be the quantification of differences in EEG power spectra (Relative Mean Power, %) between real-life responders and real-life non-responders to VNS therapy in drug-resistant epilepsy and the sensitivity and specificity of the model.

Discussion

PRECISE relies on the results of our previous work, through which we developed a statistical classifier for VNS response (responders vs. non-responders) based on differences in EEG power spectra dynamics (Pre-X-Stim).

Trial Registration

www.ClinicalTrials.gov, identifier: NCT04935567.

N-of-1 Trials in Pediatric Oncology: From a Population-Based Approach to Personalized Medicine-A Review

Pediatric oncology is a critical area where the more efficient development of new treatments is urgently needed. The speed of approval of new drugs is still limited by regulatory requirements and a lack of innovative designs appropriate for trials in children. Childhood cancers meet the criteria of rare diseases. Personalized medicine brings it even closer to the horizon of individual cases. Thus, not all the traditional research tools, such as large-scale RCTs, are always suitable or even applicable, mainly due to limited sample sizes. Small samples and traditional versus subject-specific evidence are both distinctive issues in personalized pediatric oncology. Modern analytical approaches and adaptations of the paradigms of evidence are warranted. We have reviewed innovative trial designs and analytical methods developed for small populations, together with individualized approaches, given their applicability to pediatric oncology. We discuss traditional population-based and individualized perspectives of inferences and evidence, and explain the possibilities of using various methods in pediatric personalized oncology. We find that specific derivatives of the original N-of-1 trial design adapted for pediatric personalized oncology may represent an optimal analytical tool for this area of medicine. We conclude that no particular N-of-1 strategy can provide a solution. Rather, a whole range of approaches is needed to satisfy the new inferential and analytical paradigms of modern medicine. We reveal a new view of cancer as continuum model and discuss the "evidence puzzle".

The effect of MitraClip mitral valve repair on a number of ventricular tachycardia episodes

Background

Mitral valve repair with MitraClip is an established method in the treatment of severe mitral regurgitation. Effect on mitral regurgitation severity, NYHA class and left ventricular function is known, as well as on mortality and number of hospitalizations. Otherwise, there is a lack of evidence, if a successful repair can affect the number of episodes of malignant arrhythmias.

Purpose

To compare the number of ventricular arrhythmias and ICD therapies before and after successful mitral valve repair with MitraClip in retrospective analysis.

Methods

We analysed patients after a MitraClip mitral valve repair in whom an ICD was implanted at least 1 month before the procedure. Out of 217 patients, there were 47 with ICD, traceable history and successful repair (MR grade ≤2.5 after the procedure). We searched all recorded ICD controls for evidence of ventricular arrhythmias and ICD therapies (ATP or shock). Statistical analysis was performed comparing the number of ventricular arrhythmias and ICD therapies “per month-per patient” before and after the procedure.

Results

We didn't found any statistical difference in number of malignant arrhytmia events before and after the procedure (mean 0.024±0.069 vs 0.029±0.079, p=0.46), neither in ATP therapies (mean 0.038±0.146 vs 0.542±3.249, p=0.39) nor in shocks (mean 0.063±0.225 vs 0.148±0.499, p=0.33). After dividing patients into two groups – with or without previous myocardial infarction, there was also no statistical difference in both groups. In “MI” group: a number of ventricular arrhythmia (mean 0.016±0.036 vs 0.016±0.047, p=0.95), ATP therapies (mean 0.029±0.109 vs 0.073±0.285, p=1.0), shocks (mean 0.049±0.184 vs 0.048±0.172, p=0.77). In “no MI” group: a number of ventricular arrhythmia (mean 0.035±0.098 vs 0.047±0.108, p=0.22), ATP therapies (mean 0.05±0.19 vs 1.203±5.024, p=0.16), shocks (mean 0.083±0.277 vs 0.289±0.733, p=0.17).

Conclusion

Our results don't reflect any influence of MitraClip mitral valve repair on ventricular arrhythmias, ATP therapies or shocks before and after the procedure. Another and deeper analysis should be performed to understand these results.

Funding Acknowledgement

Type of funding sources: None.

The effect of patient weight and amiodarone use on the energy of a successful shock in cardioversion of atrial arrhythmias – single-center experience study

Background

Electrical cardioversion (DCCV) is an effective method of sinus rhythm restitution. Recently published data suggest higher efficiencies of higher discharge energies. The influence of individual parameters on the success of cardioversion is still studying.

Purpose

To evaluate the influence of individual patient parameters on the energy of a successful external defibrillator shock during cardioversion of atrial arrhythmias

Methods

The retrospective analysis cohort of all patients treated by DCCV due to atrial arrhythmias between 10/2015 and 1/2020. To evaluate potential predictors for the choice of a higher initial discharge using one-dimensional logistic regression and to include parameters significant at the 10% level of significance (p&lt;0.1) in the multidimensional logistic regression model.

Results

1986 electrical cardioversions of 984 patients (382 repeated procedures of the same patients in a cohort). 1292 (65.1%) men and 694 (34.9%) women aged 67.0 (±10.2) years.

Mean energy of the first shock 118.9 (±19.2) J with a success rate of 77.8%, energy of the second shock 154.0 (±26.3) J, which increased the overall success to 80.0%, and mean high of the third shock 173.9 (±25.6) J, when the total efficacy of DCCV in sinus rhytm restitution reached 89.8%.

From the univariate binary regression, parameters significant at the 10% level of significance (p&lt;0.1) were selected and included in a multidimensional logistic regression model. Only the patient's weight and the use of amiodarone proved to be statistically significant. Weight with OR 1.21 and use of amiodarone with OR 1.43.

Conclusion

Patient weight and amiodarone use are predictors of the need to use higher energy electric cardioversion.

Discussion

Amiodarone medication does not appear to increase the defibrillation threshold, but rather is a feature that represents the group of patients treated with more aggressive antiarrhythmic therapy for advanced atrial arrhythmias with more significant structural impairment, but this attitude requires further study.

Funding Acknowledgement

Type of funding sources: Private hospital(s). Main funding source(s): VAVIA: IGS202009 - Racionální algoritmus při elektivní elektrické kardioverzi fibrilace síní.

Malignant arrythmic storm, stellate ganglion and diabetes mellitus

Funding Acknowledgements

Type of funding sources: None.

Introduction

Malignant arrhythmic storm (MAS) increases mortality more than three-fold according to current data. In the acute setting, besides resolving reversible causes, antiarrhythmics are the mainstay of treatment. The role of suppressing the local sympathetic nervous system activity, using stellate ganglion block (SGB) for example, is still being investigated. 

Purpose

To show short-term efficacy of SGB in suppressing the ventricular arrhythmia recurrence in MAS. To identify subgroups of patients with better clinical response after SGB.

Methods

All consecutive patients with MAS, with standard treatment failure and ventricular arrhythmia recurrence, treated with ultrasound guided SGB, instilating 7ml of 0,5% Bupivacain.

58 MAS treated with SGB durin 2017 – 2020. There were 49 men (84,5%), average age 68,7 +/- 11,4, with average left ventricular EF 28,9 +/- 8,43%. There were 17 diabetics (29,3%). 

Results

When we compare the numbers of defibrillations for sustained ventricular tachycardia 48 hours before and 48 hours after SGB, being the primary therapeutic endpoint in MAS, we see a 96,7% reduction (p &lt; 0,001). When we evaluate ventricular arrhythmias treated with both antitachycardia pacing and shocks, then we see 90% reduction (p &lt; 0,001). The effect of SGB in ventricular arrhythmia suppression was statistically significant during the entire follow-up of 8 days.

When we analyzed the cohort, looking for groups showing better response after SGB in terms of ventricular arrhythmia reduction, the only group showing statistical significance in this regard are patients with diabetes mellitus. 

Conclusions

In our cohort, stellate ganglion block is exceptionally effective in the treatment algorithm of malignant arrhythmic storm. SGB shows significantly higher efficacy in the subgroup of patients with diabetes mellitus. Abstract Figure. VA before and after BSG

Comparison of continuous versus intermittent enteral nutrition in critically ill patients (COINN): study protocol for a randomized comparative effectiveness trial

Background

Enteral nutrition is part of the treatment of critically ill patients. Administration of enteral nutrition may be associated with signs of intolerance, such as high gastric residual volumes, diarrhea, and vomiting. Clinical trials regarding the effects of the mode of administration of enteral nutrition on the occurrence of these complications have yielded conflicting results. This trial aims to investigate whether the mode of administration of enteral nutrition affects the time to reach nutritional targets, intolerance, and complications.

Methods

COINN is a randomized, monocentric study for critically ill adult patients receiving enteral nutrition. Patients will be randomly assigned to two groups receiving (1) continuous or (2) intermittent administration of enteral nutrition. Enhancement of enteral nutrition will depend on signs of tolerance, mainly the gastric residual volume. The primary outcome will be the time to reach the energetic target. Secondary outcomes will be the time to reach the protein target, tolerance, complications, hospital and ICU lengths of stay, and 28-day mortality.

Discussion

This trial aims to evaluate whether the mode of application of enteral nutrition affects the time to reach nutritional targets, signs of intolerance, and complications.

Trial registration

ClinicalTrials.gov NCT03573453. Registered on 29 June 2018

An Investigation into the Prevalence of Migraine and Its Prophylactic Treatment Patterns in the Czech Republic: An Observational Study

Purpose

A national primary and secondary healthcare-level study in the Czech Republic has not yet been conducted to evaluate the prevalence of migraine. We analyzed the current treatment patterns (acute and prophylactic) in migraine patients and the number of migraine patients potentially eligible for treatment with recent calcitonin gene-related peptide (CGRP) pathway-targeted therapies.

Methods

This retrospective study utilized the Ministry of the Interior Health Insurance Fund claims database of the Czech Republic wherein every citizen is insured. Migraine patients with or without aura, and potentially on triptan therapy were included in this study (index years 2012–2016). The prevalence approach included all patients (new and old) present in each index year. Prophylactic therapies were followed f0or three and seven years prior to the index year, including the index year, until 2010. The incidence approach included all patients first diagnosed in each index year. Prophylactic therapies were followed for the next three years, including the index year, until 2017 following incidence approach. The primary endpoint of this study was to determine the rate of migraine prevalence and diagnosis for each index year during the period 2012–2016. The study also evaluated prophylactic and acute treatment patterns and comorbidities among patients in 2016.

Results

The rate of migraine prevalence was 1% and the rate of diagnosis was 0.2–0.4%. By prevalence approach, approximately 39% of the patients were on prophylactics, and 11.2% and 21.6% of the patient population had two prior treatment failures (three- and seven-year recall period, respectively). Antiepileptics (26%) and beta blockers (15.8%) were the most prescribed prophylactics, and sumatriptan was the predominant triptan used (12%) for acute treatment.

Conclusion

Taking into account the number of inhabitants in the Czech Republic (10.7 million), there could be up to 23,000 adult patients eligible for novel CGRP therapies.

The experience with colorectal cancer screening in the Czech Republic: the detection at earlier stages and improved clinical outcomes

OBJECTIVES

Colorectal cancer (CRC) remains a major health burden. Although screening is recommended and considered beneficial, further data on its positive effects are needed for worldwide implementation.

STUDY DESIGN

The aim of our national multicentre prospective observational study was to reveal and document clinicopathological differences in CRC diagnosed by screening and presented by disease symptoms as well as assess the efficiency of the screening programme in the Czech Republic.

METHODS

Between March 2013 and September 2015, a total of 265 patients were enrolled in 12 gastroenterology centres across the Czech Republic. Patients were divided into screening and symptomatic groups and compared for pathology status and clinical characteristics. Screening was defined as a primary screening colonoscopy or a colonoscopy after a positive faecal occult blood test in an average-risk population.

RESULTS

The distribution of CRC stages was significantly (statistically and clinically) favourable in the screening group (predominance of stages 0, I and II) compared with the non-screening group (P < 0.001). The presence of distant and local metastases was significantly less frequent in the screening group than in the symptomatic group (P < 0.001). Patients in the screening group had a higher probability of radical surgery (R0) than those diagnosed based on symptoms (P < 0.001). Systemic palliative treatment was indicated in two patients in the screening group compared with 23 patients in the non-screening group (P = 0.018).

CONCLUSION

CRC diagnosed by screening disclosed less advanced clinicopathological characteristics and results in patients with a higher probability of radical surgery (R0) than diagnoses established based on symptoms, with subsequent management differing accordingly between both groups. These results advocate the implementation of a suitable worldwide screening programme.

Viral genome changes and the impact of viral genome persistence in myocardium of patients with inflammatory cardiomyopathy

INTRODUCTION

Viral infections are considered the most frequent cause of myocarditis and dilated cardiomyopathy (DCM).

MATERIAL AND METHODS

We investigated the changes in viral presence and the impact of viral genome persistence in the myocardium on echocardiographic parameters, functional status and some laboratory parameters in a 6-month follow-up. Fifty-four patients with recent onset DCM, left ventricular ejection fraction < 40% and biopsy-proven myocarditis (> 14 mononuclear leukocytes/mm² and/or > 7 T-lymphocytes/mm²) were enrolled. Polymerase chain reaction (PCR) was performed to detect pathogens in the myocardium. Patients were divided according to the administered therapy: standard heart failure medication (46 patients) and immunosuppressive therapy (8 patients).

RESULTS

In the standard heart failure medication group viral clearance was observed in 13 patients and viral persistence in 24 patients in the follow-up period. Comparing both groups, there was no statistically significant difference - LVEF improvement of 12.0 ±11.4% vs. 18.3 ±12.6%, decrease in NYHA class of 0.7 ±0.7 vs. 1.0 ±0.7, decline in NT-proBNP of 1335 ±1933 ng/l vs. 1942 ±3242 ng/l and decrease in infiltrating leukocytes of 11.1 ±15.8 vs. 6.7 ±23.0 cells/mm² and T-lymphocytes of 5.8 ±15.1 vs. 1.8 ±10.9 cells/mm² (all p = NS). A decrease in PCR positive patients from 37 to 29 was observed. The number of PVB19 positive PCR findings decreased from 5 to 4 in patients with immunosuppressive therapy.

CONCLUSIONS

A decrease in the number of positive PCR findings in control endomyocardial biopsy was observed. Viral genome persistence was not associated with worse outcome in short-term follow-up.

Improvement of left ventricular systolic function in inflammatory cardiomyopathy: What plays a role?

AIMS

To compare the differences between patients with inflammatory cardiomyopathy (ICM) with and without improvement in left ventricular (LV) systolic function and to identify the relevant predictors of LV improvement.

PATIENTS AND METHODS

The study included 63 patients with biopsy-proven ICM and heart failure symptoms of at least NYHA II, symptom duration ≤ 6 months, LV ejection fraction (LVEF) ≤ 40% assessed by echocardiography and presence of >14 mononuclear leukocytes (LCA+ cells)/mm² in biopsy samples. Patients were evaluated at baseline and after 6 months.

RESULTS

In the group with LVEF improvement of ≥ 10% (I+ group, n = 41), LVEF increased from 24 ± 7% to 47 ± 8% (P < 0.001). In 22 patients (group I-), there was no or minimal LVEF increase (< 10%). In the I+ group, there were more LCA+ cells/mm² at baseline (25.1 ± 16.5 vs. 18.5 ± 4.4 cells/mm²; P = 0.032) and a more significant decrease in LCA+ cells in the follow-up (reduction of 13.6 ± 14.3 cells/mm² vs. 5.0 ± 7.7 cells/mm² in the I- group; P = 0.009). The univariate logistic regression showed a possible association of number of LCA+ cells, LV end-diastolic diameter and N-terminal fragment of pro-brain natriuretic peptide (NTproBNP) value with LVEF improvement. In the multivariate analysis, only NTproBNP at diagnosis was confirmed as an independent predictor of LVEF improvement (OR=1.2; 1.003 to 1.394; P = 0.046).

CONCLUSION

The LV systolic function improvement was observed in 65% of the patients. In these patients, the number of inflammatory cells at baseline was higher and decreased more but the higher baseline NTproBNP value was the only independent predictor of LVEF improvement.

Longitudinal, circumferential and radial systolic left ventricular function in patients with heart failure and preserved ejection fraction

INTRODUCTION

Heart failure with preserved left ventricular ejection fraction (HFPEF) is an epidemiologically serious disease. Noninvasive diagnosis of HFPEF remains challenging. The current diagnosis is based on evidence of diastolic dysfunction, albeit systolic dysfunction is also present but not included in the diagnostic algorithm. The aim of this study was to analyze the longitudinal (long), circumferential (circ) and radial (rad) component of systolic left ventricular (LV) function in patients with exertional dyspnea of unexplained etiology and normal left ventricular ejection fraction (LVEF).

METHODS

One hundred and twenty-two patients with exertional dyspnea of unexplained etiology and normal LVEF and 21 healthy controls, underwent echocardiography examination at rest and at the end of symptom-limited exercise. We analysed the longitudinal, circumferential and radial deformation of myocardium using two dimensional speckle tracking echocardiography in all subjects.

RESULTS

Patients with exertional dyspnea and preserved LVEF were divided into group A1 (46 patients meeting the criteria for the diagnosis HFPEF) and group A2 (76 patients without HFPEF). Group A1 had significantly worse longitudinal and circumferential systolic LV function than group A2. Subjects in group A1 compared to group A2 showed significantly different strain rates during atrial contraction (SR A), circ and ratio of peak early trans-mitral flow velocity (E) and strain rate E wave (E / SR E) circ. Multivariate logistic regression analysis showed that the SR parameter A circ is an independent predictor of HFPEF (odds ratio 0.550, 95% confidence interval: 0.370 - 0.817, P value 0.003).

CONCLUSION

Longitudinal and circumferential LV deformation was significantly more impaired in patients with HFPEF than in patients with exertional dyspnea without HFPEF. In patients with exertional dyspnea and normal LVEF, the value of SRA circ appears to be a significant and independent predictor of HFPEF. This parameter may, in the future complement the diagnostic algorithm for HFPEF.

High prevalence of exercise-induced heart failure with normal ejection fraction in post-heart transplant patients

AIM

Post-heart transplant patients are at increased risk of diastolic dysfunction. The aim of this study was to assess the prevalence of isolated only exercise-induced heart failure with normal ejection fraction (HFNEF) in heart transplant recipients.

METHODS AND RESULTS

To determine pulmonary capillary wedge pressure (PCWP) at rest and during exercise, 81 patients after orthotopic heart transplantation with normal left ventricular ejection fraction (LVEF) underwent exercise right heart catheterization with simultaneous exercise echocardiography. Based on PCWP values, the patients were divided into three groups. Twenty-one patients had no evidence of HFNEF (PCWP at rest < 15 mmHg, maximal PCWP during exercise < 25 mmHg, prevalence 26%). Forty-seven subjects were found to have only exercise-induced HFNEF (PCWP at rest < 15 mmHg, maximal PCWP during exercise ≥ 25 mmHg, prevalence 58%). Thirteen patients had HFNEF already at rest (PCWP ≥ 15 mmHg at rest, prevalence 16%). Of the noninvasive parameters obtained at rest, multivariate regression analysis identified LV mass index adjusted for allograft age to be an independent predictor of exercise-induced HFNEF.

CONCLUSIONS

In heart transplant recipients with normal LVEF, there is a high prevalence of exercise-induced HFNEF. LV mass index adjusted for allograft age is predictive of exercise-induced HFNEF.

Assessment of the severity of acute pulmonary embolism using CT pulmonary angiography parameters

AIM

To evaluate the association between computed tomography parameters and clinical signs in patients with acute pulmonary embolism.

METHODS

109 patients retrospectivelly selected from hospital database with acute pulmonary embolism verified by CT pulmonary angiography. The following parameters were assessed: pulmonary artery diameter to aorta diameter ratio (PA/Ao), normalized pulmonary artery diameter (nPA), right ventricular to left ventricular diameter ratio from CT (RV CT/LV CT), normalized end-diastolic right ventricular diameter (nRVD echo) and right to left ventricular end diastolic diameter ratio (RV echo/LV echo) from echocardiography.

RESULTS

Multivariate regression analysis showed a significant association between PA/Ao and thrombolysed (0.99) to non-thrombolysed (0.90) patients, OR=1.56 P=0.012, and also RV CT/LV CT and thrombolysed 1.5 to non-thrombolysed (0.94) patients OR=1.24 P=0.002. The significant difference was also found in intensive care unit hospitalization necessity (ICU-Y/N) and RV CT/LV CT ratio (ICU-Y 1.42, ICU-N 0.91) OR=1.26 P=0.003, and RV echo/LV echo (ICU-Y 0.82, ICU-N 0.65) OR=1.83 P=0.033.

CONCLUSION

From the CT pulmonary angiography parameters, the RV CT/LV CT showed a significant association with both thrombolysis administration and ICU hospitalization. The PA/Ao had relation only to thrombolytic therapy as well as RV echo/LV echo only to ICU hospitalization.

Variability of post-exercise pulmonary capillary wedge pressure recovery. Implications for noninvasive echocardiographic diagnostics

AIM

The aim of our study was to assess the course of immediate post-exercise pulmonary capillary wedge pressure (PCWP) changes to identify the optimal time window for the noninvasive diagnostics of exercise-induced PCWP elevation.

METHODS AND RESULTS

Seventy-one patients at risk of heart failure with normal left ventricular ejection fraction underwent simultaneous exercise echocardiography and right heart catheterization. The ratio of early left ventricular filling velocity (E) to early diastolic mitral annular velocity (e') was used to predict noninvasively exercise-induced PCWP elevation. Fifty-one patients had exercise-induced PCWP elevation ≥ 8 mmHg and reached peak exercise PCWP ≥ 20 mmHg. Rapid post-exercise recovery of PCWP within 2 min was achieved in 18 (35.3%) patients. Intermediate post-exercise PCWP recovery at 3 and 4 min was found in 16 (31.4%) patients while late post-exercise PCWP recovery (≥ 5 min) was achieved in 17 (33.3%) patients.

CONCLUSION

The course of post-exercise PCWP recovery is highly variable, and a significant proportion of patients have only a brief period (≤ 2 min) of exercise-induced PCWP elevation. This fact should be taken into account in noninvasive assessment of exercise-induced PCWP.

HLA compatibility index: does it have a role in patients after heart transplantation?

AIMS

To determine the impact of HLA compatibility measured by the Compatibility Index, on survival, rate of rejections, malignancies and infections in patients after heart transplantation (HTx).

METHODS

We carried out a retrospective analysis of 182 consecutive patients who underwent heart transplantation in our center from January 2001 to April 2010. According to degree of HLA-A, B and DR matching (Compatibility Index, CI) the patients were divided in two groups, Group A (n=83) with an IC 0-17 and group B (n=99) with an IC 18-26. There was no significant difference in demographic parameters between recipients and donors.

RESULTS

We found no difference in rates of rejections or infections between Group A and Group B (AR: 22 (26.5%) vs. 34 (34.3%), P=0.2539; infections: 21 (25.3%) vs. 27 (27%) P=0.7637). The distribution of infections in terms of type (bacterial, viral, fungal, including Aspergillus) was similar in both groups. The incidence of malignant tumours was infrequent (3 (3.6%) vs. 4 (4.0%), P=0.8817). We found trend toward lower level of tacrolimus in Group A. Long term survival was similar in both groups.

CONCLUSIONS

Based on the results of our single-center trial, we found no impact of higher degree of HLA-A,-B, and -DR matching on survival, rejection episodes or infection. Further large studies are necessary to confirm our hypothesis that subjects with better HLA compatibility could require lower dose immunosuppression.