Right ventricular pressure overload directly affects left ventricular torsion mechanics in patients with precapillary pulmonary hypertension.

This study examined the impact of septal flattening on left ventricular (LV) torsion in patients with precapillary pulmonary hypertension (PH). Fifty-two patients with proven precapillary PH and 13 healthy controls were included. Ventricular function was assessed including 4D-measurements, tissue velocity imaging, and speckle tracking analysis. Increased eccentricity index (1.39 vs. 1.08, p<0.001), systolic pulmonary artery pressure (64 vs. 29mmHg, p<0.001) and right ventricular Tei index (0.55 vs. 0.28, p = 0.007), and reduced tricuspid annular plane systolic excursion (19.0 vs. 26.5mm, p<0.001) were detected in PH patients as compared to controls. With increasing eccentricity of left ventricle, LV torsion was both decreased and delayed. Torsion rate paralleled this pattern of change during systole, but not during diastole. In conclusion, right ventricular pressure overload directly affects LV torsion mechanics. The echocardiographic methodology applied provides novel insights in the interrelation of right- and left ventricular function.

Immature platelet fraction and thrombopoietin in patients with liver cirrhosis: A cohort study.

BACKGROUND AND AIMS: Thrombocytopenia occurs frequently in patients with cirrhosis. The immature platelet fraction (IPF%) is measured to differentiate the causes of thrombocytopenia. To date the relevance of thrombopoietin (TPO) in the context of cirrhosis is unknown. The aim of our study was to investigate the cause of thrombocytopenia in patients with liver cirrhosis by measuring IPF%, TPO and spleen size. In addition we examined the use of IPF% to evaluate the severity of cirrhosis and its complications. METHODS: Overall, we included 88 in-patients with cirrhosis in our study. The collected data comprises current health status, blood parameters, severity of cirrhosis evaluated by Child-Pugh score and MELD score, spleen diameter, ascites and esophageal varices. The IPF% was measured using an automatic hematology analyzer. TPO was measured with ELISA. RESULTS: IPF% (p = 0.003) and spleen diameter (p = 0.001) were significantly higher in patients with thrombocytopenia. There was no significant difference in TPO between patients with and without thrombocytopenia. The mean values of IPF% varied significantly (p = 0.044) in Child-Pugh stages. IPF% was significantly (p = 0.005) elevated in patients with esophageal varices. Moreover, IPF% higher than 3.85% displayed sensitivity of 76.6% and specificity of 52.4% with an area under receiver operating curve characteristics of 0.669 for the presence of esophageal varices. CONCLUSION: On closer examination of the three compartments known to have an influence on platelet count splenomegaly seems to be the major cause of thrombocytopenia in patients with cirrhosis according to current knowledge. Higher IPF% in patients with thrombocytopenia indicates peripheral consumption of platelets. The relation between spleen diameter and platelet count indicates the spleen to be the major place of platelets' consumption. TPO did not differ between patients with and without thrombocytopenia. Furthermore, we cannot exclude an influence of impaired thrombopoietin synthesis on platelet counts. The association between IPF% and platelet count suggests that there is physiological regulation of platelets in patients with cirrhosis. In our study IPF% is associated with esophageal varices and the stage of cirrhosis. Further studies are needed to confirm these results.

[Gallstones - Causes and Consequences]. / Gallensteine ­ Ursachen, Folgen und Therapieoptionen.

Gallstones and their complications are one of most frequent gastroenterological diseases leading to hospital admission in Europe. Cholesterol stones are the most common; except of few patients there is a direct link to lifestyle. Obesity, diabetes and insufficient physical activity represent the major risk factors. Abdominal ultrasound is the gold standard for detection of gallstones. ERCP is indicated only in the therapeutic setting. In case of symptomatic gallbladder stones as well as bile duct stones, cholecystectomy is necessary. Higher age is no contraindication. To avoid further biliary colic episodes and / or additional complications, cholecystectomy should be performed as early as possible. In case of acute cholecystitis, cholecystectomy should be performed within 24 h after admission.

Associations of circulating natriuretic peptides with haemodynamics in precapillary pulmonary hypertension.

BACKGROUND: While N-terminal B-type natriuretic peptide (NT-proBNP) has been examined extensively in pulmonary hypertension (PH), limited data exists on the subtype A, C and D. The aim of this prospective pilot study was a head-to-head comparison of NPs in respect to haemodynamic parameters and the influence of renal function. METHODS: Plasma samples were drawn during routine right heart catheterization in 62 patients with precapillary PH and 20 control patients. MR-proANP measurements were performed on the automated Kryptor platform, NT-proBNP by CLIA, NT-proCNP and DNP levels by ELISA. Results are expressed as median [range] and tested non-parametrically. Non-parametric locally linear multiple regression was performed to determine the influence of renal function on NP levels. P-values <0.05 were considered significant. RESULTS: Patients with PH had significantly higher MR-proANP and NT-proBNP levels. NT-proCNP showed a trend to higher levels, while DNP did not differ from control subjects. Both MR-proANP and NT-proBNP were associated with cardiac index (CI), right atrial pressure (RAP), mean pulmonary artery pressure (PAPm) and pulmonary vascular resistance index (PVRI). NT-proCNP was associated with RAP, while DNP showed no associations with haemodynamic variables. Associations of haemodynamic parameters with NPs were weakened in patients with in elevated serum creatinine and showed increased regression slopes. CONCLUSION: MR-proANP demonstrated equivalent associations with haemodynamics compared to NT-proBNP, but both markers depend on intact renal function. NT-proCNP was correlated with RAP and renal function, while DNP showed no associations. Larger studies should evaluate MR-proANP as candidate prognostic biomarker in PH.

Association of elevated plasma viscosity with small vessel occlusion in ischemic cerebral disease.

INTRODUCTION: Elevated plasma viscosity (PV) is observed in patients with vascular risk factors, such as diabetes mellitus or arterial hypertension. In this study we investigated the association of plasma viscosity and the different clinical and radiological entities of cerebral ischemia. METHODS: PV of 465 consecutively admitted patients with clinical symptoms of acute cerebral ischemia without radiological signs of bleeding was measured. Data is expressed as median [range] unless stated otherwise. p<0.05 was considered statistically significant. RESULTS: Patients with acute cerebral ischemia (TIA or Stroke) showed increased PV (TIA 1.27mPas [1.07-1.53], stroke 1.27mPas [1.07-1.56]) compared to patients without cerebral ischemia (Mimics) (1.23mPas [1.06-1.42]). The group with radiologically proven small vessel disease (SVD) had a significantly higher mean values of PV (1.29mPas [1.06-1.54]) compared to those with signs of large vessel disease or cardioembolic events (1.22mPas [1.07-1.56], p<0.001). Patients with chronic heart failure (p=0.007), arterial hypertension (p<0.001) and diabetes mellitus (p=0.002) had higher PV compared to patients without these cardiovascular risk factors. Hyperlipidemia or nicotine abuse showed no relation to PV. CONCLUSION: Elevated PV is not only associated TIA and Stroke but is also found in patients with radiological signs of cerebral SVD. High levels of PV could be an underestimated risk for TIA and Stroke and participate in the complex pathophysiology of SVD. Prospective observational and interventional studies are warranted for further evaluation of PV in neurological ischemic diseases.

Decreased TSP-1 following percutaneous coronary intervention is associated with major adverse cardiac events in ST-elevation myocardial infarction.

BACKGROUND: TSP-1 is a vasoconstrictive protein, which is released from both endothelium and cardiomyocytes during ischemia and promotes platelet aggregation and adhesion to subendothelial layers in atherosclerotic lesions. During myocardial ischemia and reperfusion, TSP-1 disturbs local microcirculation by disrupting both NO-signaling as well as VEGF-pathways by activation of CD47 and CD36. Furthermore, activation of TGF-ß might induce excessive fibrosis after infarction. It was assumed that TSP-1 is washed out after successful coronary reperfusion. In this study, we examined circulating TSP-1 post emergency PCI as a risk factor for major adverse cardiac events after STEMI with and without ventricular fibrillation. METHODS: TSP-1 levels in platelet poor plasma were measured in 54 patients after ST-elevation myocardial infarction. Major adverse cardiac events were monitored for 426 days. RESULTS: Patients with decreased TSP levels after coronary stenting showed a significantly higher risk for MACE than patient with higher TSP levels (TSP-1[d0]: n = 46, no MACE = 16.38 ± 1.98 ug/mL vs. MACE 7.11 ± 1.54 ug/mL; p = 0.003). Kaplan-Meyer-analysis for MACE showed a better outcome above 10 ug/mL (p = 0.02). For MACE later than 3 months post-STEMI, the corresponding Kaplan-Meier-analysis yielded a p-value of 0.01. The number needed to diagnose for late MACE was 2.158. CONCLUSION: Low plasma levels of TSP1 after PCI are associated with MACE. Due to its procoagulant effects and dysregulation of microvascular tone, adequately powered prospective studies are warranted to test the impact of TSP-1 on cardiac microcirculation, endothelial function and remodeling. TSP-1 might serve as a new diagnostic and therapeutic approach in cardiovascular disease.