Prognostic value of galectin-3 and right ventricular function for long-term mortality in heart failure patients treated with cardiac resynchronization therapy.

Recently, associations between the biomarker galectin-3 and numerous pathological processes involved in heart failure (HF) and right ventricular (RV) function have been observed. We aimed to assess the long-term prognostic ability of galectin-3 and RV function parameters for all-cause mortality in HF patients treated with cardiac resynchronization therapy (CRT). We prospectively studied 63 symptomatic HF patients with a left ventricular (LV) ejection fraction (EF) ≤ 35%. The median serum galectin-3 concentration was 13.4 ng/mL (IQR 11.05, 17.15). A detailed assessment of LV and RV geometry and function was performed with echocardiography. CRT defibrillator implantation was achieved in all patients without major complications. The follow-up lasted 5 years. In the multivariable Cox regression model, independent predictors for all-cause mortality were log baseline galectin-3 and baseline RV function expressed as tricuspid annular plane systolic excursion with HR 2.96 (p = 0.037) and HR 0.88 (p = 0.023), respectively. Analysis of subgroups defined by galectin-3 concentration and CRT response showed that patients with high baseline galectin-3 concentrations and a lack of response to CRT had a significantly lower probability of survival. In our patient cohort, the baseline galectin-3 concentration and RV function were independent predictors of long-term all-cause mortality in HFrEF patients following CRT implantation.

Echocardiographic predictors of exercise intolerance in patients with heart failure with severely reduced ejection fraction.

Decreased exercise capacity (EC) is an established predictor of cardiac and all-cause mortality in patients with chronic heart failure (HF). No correlation has been found between EC and left ventricular (LV) ejection fraction. Moreover, data about the effect of right ventricular (RV) function on EC in HF with severe LV dysfunction are limited and contradictory. In this study, we aimed to investigate the relationship between EC and myocardial mechanics in patients with HF with reduced ejection fraction.Consecutive patients with symptomatic HF and LV ejection fraction ≤35% were prospectively assessed. All patients were evaluated with enhanced echocardiography. A symptom-limited treadmill cardiopulmonary exercise test (CPX) was performed within 24-hour interval. Patients were stratified into 4 groups according to their EC defined by Weber's classification. Prognosis of EC, expressed as oxygen uptake at peak exercise (peak VO2), was evaluated in multivariate linear regression analysis model.Sixty-seven patients with New York Heart Association classes II to III and a mean LV ejection fraction of 26 ±â€Š7% were enrolled. A wide range of peak VO2 was observed in CPX with patient exercise performance distributed to all classes according to Weber's classification. Significant differences were found in RV systolic and diastolic functions between groups with different classes of EC: RV peak systolic myocardial velocity (S') (P < .001), tricuspid annular plane systolic excursion (TAPSE) (P = .003), RV E' (P = .003). In patients with functional decline, systolic pulmonary artery pressure (PASP) was higher (P = .029) and TAPSE/PASP ratio was lower (P = .006). No significant differences were found in LV diameter, systolic and diastolic function, and degree of mitral regurgitation. Thirty three patients with RV systolic dysfunction showed lower peak VO2 and oxygen uptake at anaerobic threshold (P = .008, P = .006, respectively), shorter exercise time (P = .003), and lower systolic blood pressure (P = .01) than in patients with normal RV systolic function. Logistic multivariate linear regression analysis with stepwise inclusion and exclusion revealed that gender, RV S', and RV free wall strain were independent predictors of peak VO2.RV function, assessed as S' and free wall strain, was independently related to EC, measured using CPX, in patients with HF and severe LV systolic dysfunction.

Bilateral primary pigmented nodular adrenal disease as a component of Carney syndrome - case report.

We report a case of a 20-year-old patient with Cushing's syndrome as a component of Carney syndrome. Carney syndrome is an autosomal dominant disease with co-existing bilateral pigmented nodular adrenal disease, heart and skin myxoma, skin pigmentation, breast fibroadenoma, testicular and ovarian tumours, thyroid tumours, and pituitary adenomas. (Endokrynol Pol 2017; 68 (1): 70-72).

Haemodynamic effects of etomidate, propofol and electrical shock in patients undergoing implantable cardioverter-defibrillator testing.

BACKGROUND: Anaesthetic drugs and internal electrical shock may alter the haemodynamic status of patients undergoing implantable cardioverter-defibrillator (ICD) testing. Comparative data on the mechanisms of etomidate and propofol-induced changes in haemodynamic parameters are inconsistent. Also the effects of ICD shock on haemodynamics have not been extensively studied. AIM: To compare the haemodynamic effects of etomidate and propofol as well as electrical shock during ICD testing in a prospective, randomised trial. METHODS: The study group consisted of 63 consecutive patients (mean age 66 ± 10 years, 51 males) who underwent ICD testing. Haemodynamic parameters were measured using impedance cardiography (Task Force Monitor Systems, CNSystems, Austria) before and after injection of etomidate (n = 30) or propofol (n = 33) as well as immediately after internal defibrillation of ventricular fibrillation (VF). Parameters measured included heart rate, systolic (sBP), diastolic (dBP) and mean (mBP) blood pressure, stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR). RESULTS: Propofol significantly decreased the values of all measured parameters (sBP: 123.4 ± 17.1 vs. 106.3 ± 18 mm Hg, p < 0.0001; dBP: 83.7 ± 12.2 vs. 74.1 ± 13.8 mm Hg, p < 0.0001; mBP: 93.9 ± 13.1 vs. 81.1 ± 16.1 mm Hg, p < 0.0001; SV: 61.1 ± 19.3 vs. 56.4 ± 15.7 mL, p < 0.003; CO: 4.51 ± 1.07 vs. 4.17 ± 0.73 L/min, p < 0.003; and TPR: 1,735.8 ± 532.6 vs. 1,573.9 ± 390.5 dyn×s/cm5), whereas the only significant change following etomidate infusion was a decrease in SV (60.6 ± 11 vs. 56.8 ± 10 mL, p < 0.022). The propofol-induced changes were similar in patients with reduced (< 40%) vs. preserved (≥ 40%) left ventricular ejection fraction (LVEF) and in patients in heart failure NYHA class 0-II vs. class III-IV. Induction of VF and internal electrical shock did not cause major haemodynamic changes apart from significant, albeit very modest, drops in dBP and mBP (77 ± 2 vs. 72.9 ± 18 mm Hg, p < 0.002, and 85.2 ± 17 vs. 81.8 ± 20 mm Hg, p < 0.017, respectively). There were no complications during ICD testing. CONCLUSIONS: Propofol significantly decreased BP probably by both reducing CO and causing vasodilatation, whereas etomidate only slightly decreased dBP and mBP without affecting other parameters. Propofol-induced changes were independent of LVEF or NYHA class. Induction of VF and internal defibrillation did not cause clinically significant changes apart from very modest drops in dBP and mBP values.

The diagnostic and prognostic value of right ventricular myocardial velocities in inferior myocardial infarction treated with primary percutaneous intervention.

BACKGROUND: Right ventricular (RV) involvement increases mortality and morbidity in inferior myocardial infarction (MI). There are sparse data on the usefulness of pulsed tissue Doppler imaging (TDI) in the diagnosis of RV dysfunction in ST segment elevation MI (STEMI) treated by primary percutaneous coronary intervention (pPCI). AIM: To evaluate the diagnostic and prognostic significance of RV myocardial velocities compared to classical electrocardiographic RVMI diagnostic criteria in this group of patients. METHODS: Consecutive patients with first, acute, inferior STEMI treated with pPCI were prospectively assessed. The RVMI was defined as an ST-segment elevation ≥ 0.1 mV in lead V4R. Echocardiography with TDI was performed after pPCI within 24 h of the onset of symptoms. Follow up including in-hospital events was performed. RESULTS: Out of 101 patients (58 males, mean age 63.7 ± 11.1 years), RVMI was found in 37 (37%). In multivariate analysis, peak systolic RV velocity (SmRV) (OR 5.12), peak early diastolic RV velocity (EmRV) (OR 5.03) and RV wall motion abnormalities (OR 4.94) were independent parameters for RVMI diagnosis. Receiver operating characteristics revealed high diagnostic significance of SmRV (C statistics = 0.90) and EmRV (C statistics = 0.89). The SmRV < 12 cm/s as a cut-off for a diagnosis of RVMI had a 89% sensitivity and a 83% specificity, whereas EmRV < 10 cm/s - 81% and 80%, respectively. Multivariate analysis showed that two variables - SmRV and ST-segment elevation ≥ 0.1 mV in lead V4R, were independent predictors of in-hospital prognosis. CONCLUSIONS: Right ventricular myocardial velocities derived from TDI predict ECG diagnosis of RVMI with relatively high sensitivity and specificity. Their high negative predictive value may be of practical importance when ECG tracings are equivocal. More importantly, decreased RV systolic myocardial Doppler velocity predicts unfavourable clinical outcomes in patients with inferior STEMI independently of ECG changes.

Implantation of additional defibrillation lead into the coronary sinus: an effective method of decreasing defibrillation threshold.

We report a case of successful implantation of an additional defibrillation lead into the coronary sinus due to high defibrillation threshold (DFT) in a seriously ill patient with a history of extensive myocardial infarction referred for implantable cardioverter- defibrillator implantation after an episode of unstable ventricular tachycardia. All previous attempts to reduce DFT, including subcutaneous electrode implantation, had been unsuccessful.

Tilt-induced changes in haemodynamic parameters in patients with cardiac resynchronisation therapy - a pilot study.

BACKGROUND: Cardiac resynchronisation therapy (CRT) has become a standard care in selected patients with advanced chronic heart failure (CHF). In order to achieve an adequate clinical response, CRT parameters have to be optimised following implantation. This procedure is usually performed on a patient in a supine position; however, measurement of haemodynamic parameters in an upright position may be clinically important. AIM: To compare haemodynamic parameters obtained in supine and erect positions in CRT patients undergoing optimisation procedures. METHODS: The study group consisted of 10 consecutive patients (mean age 69.6+/-9 years, all males) who were scheduled for control outpatient CRT follow-up visits. Apart from routine device check-up, haemodynamic parameters [impedance cardiography (ICG) Task Force Monitor Systems, CNSystems, Austria] were measured. The ICG parameters were recorded during 20-min periods while supine and while tilted to 80 degrees. The last 30 cardiac cycles from each period were taken for further analysis. Parameters measured included heart rate (HR), systolic and diastolic blood pressure, stroke volume, cardiac output (CO) and total peripheral resistance (TPR). RESULTS: Out of 60 measurements performed (6 parameters in 10 patients) all but nine differed significantly when comparing supine and erect positions. There was no uniform pattern regarding these changes. For example, HR increased after tilting in five patients, did not change in four, and slowed down in one patient. The changes in CO were significant in all but two patients, reaching a 50% increase in one patient. An abnormal response of TPR (significant decrease) was observed in 5 patients. There was no apparent association between tilt-induced changes in haemodynamic parameters and clinical response to CRT, whereas a significant negative correlation between tilt-induced changes in CO and left ventricular ejection fraction was found (r=-0.7, p <0.025). CONCLUSIONS: Tilting causes significant and often abnormal changes in haemodynamic parameters in CRT patients. The clinical significance of these findings needs further evaluation.

[Atrial fibrillation, heart failure and QT interval prolongation -- diastolic and therapeutic difficulties]. / Migotanie przedsionków, niewydolnosc serca i wydluzenie odstepu QT -- trudnosci diagnostyczno-terapeutyczne.

A case of a 51-year old female with persistent atrial fibrillation, decompensated heart failure and polymorphic ventricular tachycardia due to acquired long QT syndrome is presented. Difficulties in monitoring QT interval and factors associated with torsades de points are discussed.