Association polymorphism of guanine nucleotide-binding protein ß3 subunit (GNB3) C825T and insertion/deletion of the angiotensin-converting enzyme (ACE) gene with peripartum cardiomyopathy.

Introduction: Peripartum cardiomyopathy (PPCM) is a potentially life-threatening pregnancy-related heart disease. Genetic roles such as gene polymorphisms may relate to the etiology of PPCM. This study analyzes the association between single nucleotide gene polymorphism (SNP) guanine nucleotide-binding protein beta-3 subunit (GNB3) C825T and insertion/deletion (I/D) of the angiotensin-converting enzyme (ACE) gene with the incidence of PPCM. Methods: An analytic observational study with a case-control design was conducted at the Integrated Cardiac Service Center of Dr. Soetomo General Hospital, Surabaya, Indonesia. PPCM patients of the case and control groups were enrolled. Baseline characteristic data were collected and blood samples were analyzed for SNP in the GNB3 C825T gene and for I/D in the ACE gene by using the polymerase chain reaction, restriction fragment length polymorphism, and Sanger sequencing. We also assessed ACE levels among different ACE genotypes using a sandwich-ELISA test. Results: A total of 100 patients were included in this study, with 34 PPCM cases and 66 controls. There were significant differences in GNB3 TT and TC genotypes in the case group compared with that in the control group (TT: 35.3% vs. 10.6%, p = 0.003; TC: 41.2% vs. 62.5%, p = 0.022). The TT genotype increased the risk of PPCM by 4.6-fold. There was also a significant difference in the ACE DD genotype in the case group compared with that in the control group (26.5% vs. 9.1%, p = 0.021). DD genotypes increased the risk of PPCM by 3.6-fold. ACE levels were significantly higher in the DD genotype group than in the ID and II genotype groups (4,356.88 ± 232.44 pg/mL vs. 3,980.91 ± 77.79 pg/mL vs. 3,679.94 ± 325.77 pg/mL, p < 0.001). Conclusion: The TT genotype of GNB3 and the DD genotype of the ACE are likely to increase the risk of PPCM. Therefore, these polymorphisms may be predisposing risk factors for PPCM incidence. ACE levels were significantly higher in the DD genotype group, which certainly had clinical implications for the management of PPCM patients in the administration of ACE inhibitors as one of the therapy options.

The anatomical snuffbox for transradial access in arteriovenous fistula intervention: Case report and brief review of the literature.

Left distal transradial artery (dTRA) access in the anatomical snuffbox is a relatively novel technique and is considered beneficial when left TRA access is required. This technique offers essential advantages, including improved patient comfort and lower vascular complications. dTRA may provide an entry site for retrograde recanalization of the radial artery. We presented a case of a 65-year-old man with 5-stage chronic kidney disease (CKD) and had left a radio-cephalic arteriovenous fistula (AVF) for routine hemodialysis. There was obstruction of AVF a month after creation. The vascular intervention has been performed using left dTRA access for retrograde recanalization. Angiogram showed cephalic vein obstruction and non-significant stenosis of the proximal radial artery. Percutaneous transluminal angioplasty was successful in improving cephalic vein flow. Hemostatic performed without a hemostatic device. This case report highlights the dTRA access approach in the anatomical snuffbox to recanalize AVF occlusion in the wrist in a patient with CKD.

Recognizing dialysis access steal syndrome with central vein stenosis as arteriovenous fistula complication: A case report.

INTRODUCTION: Ischemic consequences of hemodialysis arteriovenous (AV) access are infrequent, yet they can cause substantial limb impairment or even loss. Ischemia can be caused by many factors, but the most common etiology is reduced blood supply to the distal extremities due to blood flow through the AV fistula (AVF) or AV graft. We reported a case of dialysis access steal syndrome (DASS) in a diabetes mellitus patient. CASE REPORT: A 69-year-old diabetic man with left brachiocephalic AVF on his left upper arm has main complaint of left-hand pain, swelling, and coldness. There are also trophic darkening changes in the distal first, third, and fourth fingers. A duplex doppler examination revealed a normal functional AV shunt with bidirectional distal retrograde inflow. There was also significant stenosis at axillary vein. So, a diagnosis of DASS with suspicion of distal anastomosis stenosis at axillary vein was made. The patient underwent digital amputation and surgical plication of the AV shunt. He also underwent percutaneous transluminal angioplasty at the level of axillary. After 10 days of care, he was later discharged. CLINICAL DISCUSSION: DASS is life and limb-threatening clinical disorder. Not only does the discomfort make it difficult for the patient to tolerate hemodialysis, but the ischemia can cause tissue necrosis and the eventual loss of fingers and possibly the patient's life. Doppler ultrasonography is a non-invasive technique that provides important information about vascular anatomy and hemodynamics. Aggressive treatment, including limb surgery and intensive blood glucose regulation, will result in favourable results. CONCLUSIONS: DASS is a rare condition usually encountered in hemodialysis patients with AVF. Proper diagnosis and management are needed to get an optimal outcome for the patient.

Acute Limb Ischemia in the Young: A Rare Case of Essential Thrombocytosis.

Acute limb ischemia (ALI) is rarely observed in young populations. The hypercoagulable state is a notable cause of ALI other than artery disease progression and cardiac embolization. A hypercoagulable state occurs in essential thrombocytosis because of the overproduction of hematopoietic cells secondary to the mutation of the JAK2, CALR, or MPL genes. We report a rare case of a 37-year-old woman presenting with Rutherford IIA ALI in the left lower extremity. Laboratory data revealed she had a platelet count reaching up to 1.38 mil/µL, with other blood profiles being normal. A JAK2 mutation examination was later performed and proved positive. After careful management with catheter-directed thrombolysis, surgical thrombectomy, and cytoreductive therapy using hydroxyurea, the symptoms subsided and eventually restored the patient to physical activity in less than one month.

Relationship of D-dimer with severity and mortality in SARS-CoV-2 patients : A meta-analysis.

INTRODUCTION: The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused a pandemic. Many studies have shown that several laboratory parameters are related to disease severity and mortality in SARS-CoV-2 cases. This meta-analysis aimed to determine the relationship of a prognostic factor, D-dimer, with disease severity, need for intensive care unit (ICU) care, and mortality in SARS-CoV-2 patients. METHODS: A systematic search for all observational studies and trials involving adult patients with SARS-CoV-2 that had any data related to D-dimer on admission was conducted using PubMed, Science Direct, Scopus, ProQuest, and MedRxiv databases. We performed random-effects inverse-variance weighting analysis using mean difference (MD) of D-dimer values for outcomes such as disease severity, mortality, and need for ICU care. RESULTS: A total of 29 studies (4,328 patients) were included in this meta-analysis, which revealed a higher mean of D-dimer levels on admission in severe patients than in nonsevere patients (MD = 0.95, [95% confidence interval (CI): 0.61-1.28], P < .05; I2  = 90%). The nonsurvivor group had a higher pooled MD of D-dimer values on admission (MD = 5.54 [95% CI: 3.40-7.67], P < .05; I2  = 90%). Patients who needed ICU admission had insignificantly higher D-dimer values than patients who did not need ICU admission (MD = 0.29, [95% CI: -0.05 to 0.63], P = .10; I2  = 71%). CONCLUSION: Elevated D-dimer levels on admission were associated with an increased risk of disease severity and mortality in patients with SARS-CoV-2 infection.

Elevated fibrinogen and fibrin degradation product are associated with poor outcome in COVID-19 patients: A meta-analysis.

INTRODUCTION: COVID-19 is a systemic infection with a significant impact on coagulation which manifests in thromboembolism. There is an unknown relationship of which coagulation profile parameter at presentation has an association with poor outcome in COVID-19. OBJECTIVE: This meta-analysis aimed to determine the relationship between fibrinogen and FDP with poor outcome in COVID-19 patients. METHODS: A systematic search of all observational studies or trials involving adult patients with COVID-19 that had any data fibrinogen or FDP on admission was carried out using the PubMed, Science Direct, Scopus, ProQuest, and MedRxiv databases. We assessed the methodological quality assessment using the NIH Quality Assessment Tool. We performed random-effects inverse-variance weighting analysis using mean difference (MD). RESULTS: A total of 17 studies (1,654 patients) were included in this meta-analysis. It revealed a higher mean of fibrinogen levels on admission in patients with severe case compared to those with non-severe case (MD = 0.69, [95% CI: 0.44 to 0.94], p < 0.05; I2 = 72%, p < 0.05). Non-survivor group had a pooled higher mean difference of fibrinogen values on admission (MD = 0.48 [95% CI: 0.13 to 0.83], p < 0.05; I2 = 38%, p = 0.18). Higher FDP on admission was found in poor outcome (composite of severity, critically ill, and mortality) compared to good outcome (4 studies, MD = 4.84 [95% CI: 0.75 to 8.93], p < 0.05; I2 = 86%, p < 0.05). CONCLUSION: Elevated fibrinogen and FDP level on admission were associated with an increase risk of poor outcome in COVID-19 patients.

Mechanical Occlusion Chemically Assisted Ablation (MOCA) for Saphenous Vein Insufficiency: A Meta-Analysis of a Randomized Trial.

PURPOSE: A previous meta-analysis has conducted nonrandomized trials for mechanochemical ablation (MOCA). Since medium-term follow-up data from randomized clinical trials (RCTs) are becoming available, we chose to perform a meta-analysis of RCTs to assess the efficacy and safety of MOCA for saphenous vein insufficiency. METHODS: A systematic search of all RCTs comparing the anatomical success of MOCA for saphenous vein insufficiency to thermal ablation was performed using the PubMed and Cochrane Library databases. We employed the Mantel-Haenszel random-effects meta-analysis of outcomes using RevMan 5.3. RESULTS: Four studies (615 patients) were included in this meta-analysis. The MOCA group had 93.4% and 84.5%, whereas the thermal ablation group had 95.8% and 94.8% of anatomical success rate at 1 month (short-term) and a period of more than 6 months but less than 1-year follow-up (mid-term), respectively. According to intention-to-treat analysis, there were similar anatomical successes in MOCA and thermal ablation groups at the short-term follow-up (low-quality evidence; relative risk (RR) = 0.98 (95% CI, 0.94-1.03); P = 0.44; I 2 = 53%). The estimated effect of MOCA on anatomical success showed a statistically significant reduction at the mid-term follow-up (moderate-quality evidence; RR = 0.89 (95% CI, 0.84-0.95); P = 0.0002; I 2 = 0%). MOCA had fewer incidence of nerve injury, deep vein thrombosis, and skin burns compared to the thermal ablation procedure (low-quality evidence; RR = 0.33 (95% CI, 0.09-1.28); P = 0.11; I 2 = 0%). CONCLUSION: MOCA offered fewer major complications but lesser anatomical success at the period of more than 6 months but less than 1-year follow-up than thermal ablation. Trial Registration. This trial is registered with UMIN Clinical Trial Registry (UMIN ID 000036727).

Takayasu arteritis in a rural hospital in Indonesia.

Takayasu arteritis (TA) is a rare chronic granulomatous inflammation of the aorta or its branches and is prevalent all around the world. It causes stenosis of large arteries and ischaemic damage to target organs. There is usually a delay in recognising TA because of the rarity and unfamiliarity with the disease, unspecific early symptoms and lack of diagnostic equipment for early diagnosis. In this report, we present a case of an 18-year-old woman from Pasuruan, East Java, Indonesia, with recurrent fever, headache, claudication of extremities and postprandial abdominal pain. She was diagnosed clinically with suspicion of TA and was sent to a tertiary hospital to confirm the diagnosis. Arteriography revealed that the patient had narrowing of the thoracic and abdominal aorta until the level of the aortic bifurcation. The patient was started on high-dose corticosteroid, cyclosporine A and diltiazem. The patient then showed improvement in her symptoms.

Modification on acute myocardial infarction model through left anterior descending coronary artery ligation: An experimental study on rats (Rattus norvegicus) using readily available materials.

BACKGROUND AND AIM: Several difficulties are involved in creating models for myocardial infarction (MI) in animals, such as low survival rates after acute MI, complicated techniques in creating animal models, complexities in confirming acute MI incidence, and complex surgical tools needed in the process. This study aimed to develop an animal model for acute MI using Wistar rats utilizing simple instruments that are readily available in standard animal laboratories. MATERIALS AND METHODS: We induced MI in 48 Wistar rats using the left anterior descending coronary artery ligation modification technique without tracheal incision and ventilator. This ligation technique was performed 1-2 mm distal to the left atrial appendage. MI occurrence was evaluated using heart enzyme parameters 24 h post-ligation and histological studies of the infarcted area 6 weeks after the ligation. Rats were divided into the coronary artery ligation group and sham group. RESULTS: Of the 48 rats, 24 (50%) died within 24 h post-ligation, but no further deaths occurred in the next follow-up period of 6 weeks. The average infarct size in six rats within 24 h of ligation was 35%±5.7%. The serum glutamic oxaloacetic transaminase level of the group treated with coronary artery ligation was statistically significantly higher than that of the sham group (p=0.000). CONCLUSION: We developed an MI rat model with consistent infarction size, in which the long-term death of rats was not observed. Our ligation technique for an MI rat model can be a reference for experimental settings without ventilators for small animals.

Carotid Intima-Media Thickness in Indonesian Subjects with Cardiovascular Disease Risk Factors Who Were Not Receiving Lipid-Lowering Agents.

Carotid intima-media thickness (CIMT) is frequently utilized for detection of subclinical atherosclerosis. This study aims to investigate the association between the CIMT values and demographic characteristics, cardiovascular disease (CVD) risk factors, lipid biochemistry profiles, and high-sensitivity C-reactive protein (hs-CRP) levels among the Indonesian population. Subjects who had two or more CVD risk factors but were not receiving lipid-lowering therapy were recruited from six hospitals of Indonesia. Measurements of CIMT are obtained by ultrasonography of 12 sites within the common carotid artery. CVD risk factors, lipid and glucose profiles, and hs-CRP values were analyzed with respect to distribution of CIMT. The mean-max CIMT was 0.805 ± 0.190 mm (minimum, 0.268 mm; maximum, 1.652 mm) and the mean-mean CIMT was 0.614 ± 0.190 mm (minimum, 0.127 mm; maximum, 1.388 mm). Multivariate analyses confirmed an independent association between increasing CIMT and increasing age (regression coefficient = 0.004; p = 0.004). Our data show normative mean-mean CIMT data for Indonesian subjects with two or more CVD risk factors who are not receiving lipid-lowering therapy, which may guide CVD risk stratification of asymptomatic individuals in Indonesia.

CT virtual intravascular endoscopy assessment of coronary artery plaques: a preliminary study.

PURPOSE: The purpose of this study was to investigate the potential value of CT virtual intravascular endoscopy (VIE) in the visualization and assessment of coronary plaques in patients suspected of coronary artery disease. MATERIALS AND METHODS: 20 (13 men, 7 women, mean age 54 years) consecutive patients with suspected coronary artery disease undergoing 64-slice CT angiography were included in the study. Four main coronary artery branches were assessed with regard to the presence of coronary plaques based on 2D axial, multiplanar reformation, 3D volume rendering and VIE visualizations. The coronary plaques were characterized into calcified, noncalcified and mixed plaques. The intraluminal appearances of these coronary plaques were demonstrated with VIE images and correlated with 2D and 3D images to determine the diagnostic value of VIE for the assessment of the plaques. RESULTS: VIE was able to identify and demonstrate the intraluminal appearances of coronary plaques in 18 patients involving 32 coronary artery branches which were shown as an irregularly intraluminal protruding sign in extensively calcified plaques and smooth protruding appearance in noncalcified or focally calcified plaques. An irregular intraluminal appearance was also noticed in the presence of mixed plaques due to variable components with different CT attenuations contained within the plaques. VIE accurately confirmed the degree of coronary stenosis or occlusion despite the presence of heavy calcification. CONCLUSION: VIE could be used as a complementary tool to conventional CT visualizations for the analysis of luminal changes and assessment of disease extent caused by the coronary plaques.