Neonatal survival and kidney function after prenatal interventions for obstructive uropathies.

OBJECTIVES: Prenatal interventions in LUTO (lower urinary tract obstruction) usually are still question of a debate between gynaecologist and paediatric nephrologist. We aimed the study to assess the early survival rate and renal outcome in LUTO foetuses. MATERIAL AND METHODS: The study was a prospective data analysis of 39 foetuses from singleton pregnancies. All pregnant women with LUTO in the foetus were qualified for VAS based on a local practice. The mean time of first urine analysis ranged between 13-30 weeks of pregnancy. Primary end-point analysis included live birth, 28d-survival, pulmonary and renal function assessment in neonatal period. RESULTS: From initial number of 39, six patients miscarried before the procedure was performed. Overall, 33 VAS were performer at the mean 21 week of pregnancy (range 14-30 weeks). 25/39 foetuses survived until delivery. Three neonates died in first 3 days of life. In the first month 3 children required peritoneal dialysis, but at 28 day all children were dialysis-free. Overall survival rate at 28 day was 56%. Renal function preservation of the initial group (39) turned out to be low - 18% (7/39). CONCLUSIONS: Our study showed average survival curves and complications. LUTO in the foetus had mostly unfavourable outcome in the neonatal period. The prenatal intervention did not increase it significantly and did not guarantee the preservation of normal kidney function.

Potential benefit of optimizing atrioventricular & interventricular delays in patients with cardiac resynchronization therapy.

BACKGROUND & OBJECTIVES: The clinical benefit of optimization (OPT) of atrioventricular delay (AVD) and interventricular delay (VVD) in cardiac resynchronization therapy (CRT) remains debatable. This study was aimed to determine the influence of AVD and VVD OPT on selected parameters in patients early after CRT implantation and at mid-term follow up (FU). METHODS: Fifty two patients (61±10 yr, 23 males) with left bundle branch block, left ventricular ejection fraction (LVEF) ≤35 per cent and heart failure were selected for CRT implantation. Early on the second day (2DFU) after CRT implantation, the patients were assigned to the OPT or the factory setting (FS) group. Haemodynamic and electrical parameters were evaluated at baseline, on 2DFU after CRT and mid-term FU [three-month FU (3MFU)]. Echocardiographic measures were assessed before implantation and at 3MFU. The AVD/VVD was deemed optimal for the highest cardiac output (CO) with impedance cardiography (ICG) monitoring. RESULTS: On 2DFU, the AVD was shorter in the OPT group, LV was paced earlier than in FS group and CO was insignificantly higher in OPT group. At 3MFU, improvement of CO was observed only in OPT patients, but the intergroup difference was not significant. At 3MFU in OPT group, reduction of LV in terms of LV end-diastolic diameter (LVeDD), LV end-systolic diameter, LV end-diastolic and systolic volume with the improvement in LVEF was observed. In FS group, only a reduction in LVeDD was present. In OPT group, the paced QRS duration was shorter than in FS group patients. INTERPRETATION & CONCLUSIONS: CRT OPT of AVD and VVD with ICG was associated with a higher CO and better reverse LV remodelling. CO monitoring with ICG is a simple, non-invasive tool to optimize CRT devices.

Difficulties in the hemodynamic assessment of the newborn with prenatally treated congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) is a malformation with a diverse clinical picture. Its severity can be assessed prenatally using the lung area to head circumference ratio (LHR). LHR lower than 1 as associated with high mortality is an indication for prenatal treatment involving occlusion of fetal trachea. Before such treatment other congenital malformations must be excluded. Assessment of circulatory system in these patients is difficult. Heart is compressed by viscera in the thorax that decreases blood return to the left atrium, and structures of the left heart may be smaller than in healthy fetuses. The echocardiographic picture may be similar to some congenital defects of the left heart. Differentiation between structural and functional cardiac abnormalities is difficult but essential for diagnostic and therapeutic decisions in the most severe type of CDH. The authors present problems with interpretation of hemodynamic disturbances in a neonate with prenatally diagnosed and treated severe CDH.

Cardiac tamponade and para-aortic hematoma post elective surgical myocardial revascularization on a beating heart - a possible complication of the Lima-stitch and sequential venous anastomosis.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery can be associated with some intrinsic, but relatively rare complications. A pericardial effusion is a common finding after cardiac surgeries, but the prevalence of a cardiac tamponade does not exceed 2% and is less frequent after myocardial revascularization.Authors believe that in our patient an injury of a nutritional pericardial or descending aorta vessel caused by the Lima stitch resulted in oozing bleeding, which gradually leaded to cardiac tamponade. The bleeding increased after introduction of double antiplatelet therapy and caused life-threatening hemodynamic destabilization. According to our knowledge it is the first report of such a complication after OPCAB. CASE PRESENTATION: We present a case of a 61-year old man, who underwent elective surgical myocardial revascularization on a beating heart. On the 11th postoperative day the patient was readmitted emergently to the intensive care unit for severe chest pain, dyspnoea and hypotension. Coronary angiographic control showed a patency of the bypass grafts and significant narrowing of circumflex artery, treated with angioplasty and stenting. The symptoms and hemodynamic instability exacerbated. A suspicion of dissection of the ascending aorta and para-aortic hematoma was stated on 16-slice cardiac computed tomography. The patient was referred to the Cardiovascular Surgery Clinic. Transthoracic echocardiography revealed cardiac tamponade. On transesophageal echocardiography there were no signs of the ascending aorta dissection, but a possible lesion of the descending aorta with para-aortic hematoma was visualized. Emergent rethoracotomy and cardiac tamponade decompression were performed. 12 days after intervention the control 64-slice computed tomography showed no lesions of the ascending or descending aorta. On one-year follow-up patient is in a good condition, the left ventricular function is preserved and there is no pathology in thoracic aorta on echocardiography. CONCLUSIONS: Mechanical complications of surgical myocardial revascularization on a beating heart should be considered as a cause of the clinical and hemodynamic instability relatively early in the postoperative period. Echocardiographic examination must be the first step in diagnostics process in a patient after cardiac surgery.

A second delivery after heart transplantation - a case study.

Pregnancy after organ transplantation is becoming relatively common. We present the case of a heart transplant recipient who gave birth to a second child. Despite the fact that the transplanted heart seems to adapt well to the changes caused by pregnancy, gestation in patients after heart transplantation may be complicated by hypertension, pre-eclampsia, or preterm labor. In this article, we consider the issues of preterm uterine contractions, anemia, thrombocytopenia, and several other complications in pregnant patients with transplanted hearts. We also present current opinions regarding the use of glucocorticoids as a form of preventing breathing disorders in neonates as well as breast-feeding by mothers receiving immunosuppressive agents. Pregnancies in heart transplant recipients should be considered high-risk. A second successful delivery of a healthy child remains a challenge for such patients and their doctors.

Clinical outcome, echocardiographic assessment, neurohormonal and collagen turnover markers in low-fl ow severe aortic stenosis with high transvalvular gradient.

INTRODUCTION: Patients with severe aortic stenosis (AS), high mean gradient (HMG), and preserved left ventricular ejection fraction (LVEF) may present with paradoxical "low flow" (LF). OBJECTIVES: The aim of the study was to assess the potential effect of cardiac collagen metabolism on the HMG/LF phenomenon in patients with severe AS and to determine a clinical and echocardiographic pattern of these patients. PATIENTS AND METHODS: We assessed a clinical status of 89 patients, aged over 64 years, with severe AS, HMG, and preserved LVEF (≥50%). Cardiac structure and function as well as systemic arterial hemodynamics were assessed with echocardiography, conventional Doppler, and tissue Doppler imaging. Moreover, plasma levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP), procollagen III N-terminal propeptide (PIIINP), carboxyterminal telopeptide of collagen type I, matrix metallopeptidase 9, and inhibitor of matrix metalloproteinase type 1 were evaluated. We analyzed 2 groups of patients: with normal flow (stroke volume index [SVI], ≥35 ml/m²; n = 70) and with LF (SVI, <35 ml/m²; n = 19). RESULTS: Patients with LF were older, had a larger left atrium and left atrial volume index, smaller aortic valve area, lower energy loss index, stroke work, mitral flow E velocity, mitral annular E' and S' velocities and systemic arterial compliance, higher relative left ventricular wall thickness, E/E', systemic arterial resistance and valvulo-arterial impedance. We observed a correlation between SVI and NT-proBNP, PIIINP, and selected parameters of cardiac structure and function. CONCLUSIONS: In patients with severe AS, HMG and preserved LVEF, the LF is related to a more severe obstruction, altered aortic hemodynamics, cardiac dysfunction, and higher blood levels of NT-proBNP. An inverse association between PIIINP and SVI may indicate enhanced tissue fibrosis as an underlying pathology.

[Primary pulmonary artery sarcoma in 36-year-old women: 3-years follow-up after partial resection and radiotherapy]. / Pierwotny miesak tetnicy plucnej u 36-letniej pacjentki: obserwacja 3-letnia po czesciowej resekcji i radioterapii.

Intimal sarcoma of the heart and pulmonary artery is a very rare, malignant, primary tumour. The prognosis in patients with primary sarcoma of the pulmonary artery, including intimal sarcoma, is poor. We present the case and 3-years follow-up of 36-year-old woman who was successfully treated with surgical, partial resection of the tumour followed by radiotherapy.

Long-term impact of vertical banded gastroplasty (VBG) on plasma concentration of leptin, soluble leptin receptor, ghrelin, omentin-1, obestatin, and retinol binding protein 4 (RBP4) in patients with severe obesity.

Restrictive type bariatric surgery is an effective therapeutic approach that decreases overall mortality in patients with severe obesity. Several new cytokines, including adipocytokines that control energy metabolism, have been discovered recently, but their role in obesity is not fully recognized. The aim of the study was to evaluate the influence of vertical banded gastroplasty (VBG), one of restrictive type bariatric surgery, on peripheral blood concentrations of some adipocytokines and hormones involved in the control of food intake and energy turnover. The studied group comprised 12 females and 2 males aged from 31 to 59years (46.6±7.4) with simple obesity (BMI: 44.9±7.2) and metabolic syndrome. The patients were examined both before and 3, 6, 12, 24months after bariatric surgery (eight patients were also checked after 36 and six patients after 48months). Measurements of peripheral blood concentration of glucose, insulin, leptin, soluble leptin receptor, obestatin, ghrelin, omentin-1, and retinol binding protein 4 (RBP4) by ELISA method have been performed. After the surgery body weight, BMI and waist circumference significantly decreased. Positive changes considering the components of metabolic syndrome have been noted. Namely glucose, insulin and triglycerides' levels decreased, accompanied by the significantly lower HOMA index. Conversely, HDL cholesterol concentrations increased. Furthermore, peripheral blood concentration of leptin decreased, but the blood levels of soluble leptin receptor and ghrelin gradually increased. The positive correlations between leptin and body weight and BMI were noted as well as between the RBP4 and total cholesterol and LDL cholesterol levels. We did not observe significant differences in levels of obestatin, omentin-1 and RBP4 after surgery. In conclusion, VBG is an effective type of bariatric surgery. Fast decrease of body weight in morbidly obese patients treated by restrictive bariatric surgery leads to significant changes in peripheral blood levels of some adipokines and hormones controlling energy turnover and appetite (leptin and soluble leptin receptor) as well as ghrelin but not omentin-1, obestatin or retinol binding protein (RBP-4).

[Tumour in left atrium diagnosed 6 years after ablation of pulmonary vein ostia and inferior right atrial isthmus: thrombus or myxoma?]. / Guz w lewym przedsionku rozpoznany 6 latpo ablacji ujsc zyl plucnych i ciesni dolnejprawego przedsionka: skrzeplina czy sluzak?

We present a case of the left atrial myxoma 6 years after atrial fibrillation ablation. The initial diagnosis of the mass revealed on echocardiography was a thrombus. Failure of anticoagulant treatment and transesophageal echocardiography led to diagnosis of myxoma, confirmed intraoperatively and histologically.

Sources of thromboembolism in patients with correctly functioning mechanical valves: a single-center transesophageal echocardiographic study.

BACKGROUND: In patients with mechanical prostheses (MP), thromboembolism is one of the most serious complications. The study aim was to assess the incidence of sources of thromboembolism in patients with correctly functioning MP with and without a history of thromboembolism. METHODS: Two hundred ninety-seven patients with correctly functioning MP were enrolled in this single-center, transesophageal echocardiographic (TEE), retrospective, observational study. Two groups were analyzed: Group A, 183 patients with a history of thromboembolism, and Group B, 114 patients with no history of thromboembolism. RESULTS: Definite sources of thromboembolism were revealed in 59% of patients in Group A, and sources of potential thromboembolism were revealed in 13% of patients in Group B (P < .001). Multiple sources of thromboembolism were present in 9% of patients in Group A and 1% of patients in Group B. Localization of sources of thromboembolism included MP ring (59% and 53% of patients in Groups A and B, respectively); left atrium/left atrium appendage (24%/21% and 13%/40% of patients in Groups A and B, respectively); and aorta (12% and 13% of patients in Groups A and B, respectively). Patients with multiple sources of thromboembolism were older (P < .001) and in a higher New York Heart Association (NYHA) class (P = .004). Patients with sources of thromboembolism in the aorta were older than the rest of the group (P < .01). CONCLUSIONS: In patients with correctly functioning MP, sources of thromboembolism are observed 4 times more often in case of the positive history of thromboembolism. The most common source of thromboembolism is thrombosis of MP ring. Age and heart failure predispose multiple sources of thromboembolism. One might consider control TEE after mechanical valve implantation, but only in selected group of patients without embolic events but with a higher risk of thromboembolism.

Impact of vertical banded gastroplasty on body weight, insulin resistance, adipocytokine, inflammation and metabolic syndrome markers in morbidly obese patients.

INTRODUCTION: Diet, exercise, and pharmacological therapy have been shown to be unsatisfactory treatments for severe obesity in the long term. Bariatric surgery is the most effective means to achieve weight loss in morbidly obese subjects. The aim of this study was to evaluate the action of a number of adipocytokines, as well as the metabolic syndrome parameters of obese patients, before and after vertical banded gastroplasty (VBG). MATERIAL AND METHODS: The test subjects comprised eight males and 20 females (total 28 patients) aged from 20 to 59 years (43.7 ± 10.0) with simple obesity and the presence of metabolic syndrome, both before and 3, 6, 12, and 24 months after bariatric surgery (six patients were also checked after 36 and 48 months). RESULTS: After surgical treatment (at 24 months), the values of body weight, BMI, waist circumference, blood pressure (RR-S, RR-D), HOMA-IR and blood concentrations of CRP, TG, IRI, AUC-IRI, and AUC-GLU gradually decreased. We did not observe any significant differences of fasting glucose, leptin, total cholesterol and LDL-cholesterol concentrations before or after surgery. The blood levels of HDL, adiponectin, resistin, and ghrelin gradually increased after treatment. CONCLUSIONS: The significant decrease of body weight after vertical banded gastroplasty, as well as improvement of the main metabolic syndrome parameters and some adipocytokine blood levels, indicate the use of bariatric surgery as a valuable method of treating morbidly obese patients.

Systemic blood osteopontin, endostatin, and E-selectin concentrations after vertical banding surgery in severely obese adults.

BACKGROUND: Obesity is associated with endothelial dysfunction and increased inflammation as well as with expansion of the capillary bed in regional adipose deposits, and a balance between these factors is involved in angiogenesis. Osteopontin (OPN) is a proinflammatory cytokine involved in regulating immune processes and mediating chronic inflammation. Its level is usually elevated in the plasma and adipose tissue of obese subjects. E-selectin, an adhesion molecule which is released by dysfunctional endothelial cells, is believed to be a marker of an early atherosclerotic process. Endostatin (END), an angiogenesis inhibitor, is present in the blood of obese subjects. The most effective treatment to achieve weight loss in morbidly obese subjects is bariatric surgery. The aim of the study was to evaluate and compare the circulating concentrations of OPN, E-selectin and END as well as the insulin resistance (HOMA-IR) of severely obese patients with metabolic syndrome before and after vertical banded gastroplasty (VBG). MATERIAL AND METHODS: The test cohorts comprised eight males and 20 females (total 28 patients) aged from 20 to 59 years with simple obesity and the presence of metabolic syndrome, both before and 3, 6, 12, 24 months after bariatric surgery (six patients were also checked after 36 and four after 48 months). RESULTS: Bariatric surgery significantly reduced (over 24 months) body weight, BMI, waist circumference, HOMA-IR and blood concentrations of CRP. Plasma OPN gradually increased after VBG and E-selectin in systemic blood decreased. We did not observe any differences in END concentrations from 12 to 48 months after surgery. CONCLUSION: VBG improves metabolic syndrome parameters, decreases E-selectin and gradually increases OST blood concentrations but it does not have any significant influence on END levels.

Biological artificial valve dysfunction - single-centre, observational echocardiographic study in patients operated on before age 65 years.

INTRODUCTION: Patients with implanted bioprostheses are at risk of structural dysfunction which results from the limited durability of biological valves. The aim of this study was to analyse the mechanism of bioprosthesis degeneration and to evaluate the usability of transthoracic and transoesophageal echocardiography in determining the indications for reoperation in 117 patients with a bioprosthesis implanted before 65 years old. MATERIAL AND METHODS: The study comprised 117 consecutive patients (M - 27, F - 90, age 48-74 years, 57.5 ±9.5 years) with a bioprosthesis implanted under the age of 65, who were examined in accordance with the accepted protocol and whose complete clinical and echocardiographic documentation was collected. The scheduled echocardiographic examination was performed annually from the 5 year after implantation of the bioprosthesis in patients with a valve implanted over the age of 35 years and from the 1 year after bioprosthesis implantation in patients with a prosthesis implanted at a younger age. Unscheduled echocardiographic examinations were performed only on clinical indications. RESULTS: During the period under observation, due to degeneration of the bioprosthesis 76 patients were reoperated, including 62 patients with mitral bioprostheses. In 88.7% of patients with degeneration of mitral valve bioprostheses, regurgitation was observed. In 69% of patients with aortic bioprostheses, valve dysfunction was the dominant mechanism of stenosis. CONCLUSIONS: The most common mechanism of structural dysfunction of a mitral bioprosthesis is regurgitation caused by prolapse or perforation of one of the leaflets. Degeneration of an aortic bioprosthesis usually results in aortic stenosis. In cases of bioprosthesis degeneration connected with stenosis, transthoracic echocardiography was sufficient for the evaluation of valve dysfunction. In the case of bioprosthesis dysfunction accompanied by regurgitation, transoesophageal echocardiography was more informative to decide when the operation should be performed.

Redo surgery risk in patients with cardiac prosthetic valve dysfunction.

INTRODUCTION: The aim of the study was to analyse the risk factors of early and late mortality in patients undergoing the first reoperation for prosthetic valve dysfunction. MATERIAL AND METHODS: A retrospective observational study was performed in 194 consecutive patients (M = 75, F = 119; mean age 53.2 ±11 years) with a mechanical prosthetic valve (n = 103 cases; 53%) or bioprosthesis (91; 47%). Univariate and multivariate Cox statistical analysis was performed to determine risk factors of early and late mortality. RESULTS: The overall early mortality was 18.6%: 31.4% in patients with symptoms of NYHA functional class III-IV and 3.4% in pts in NYHA class I-II. Multivariate analysis identified symptoms of NYHA class III-IV and endocarditis as independent predictors of early mortality. The overall late mortality (> 30 days) was 8.2% (0.62% year/patient). Multivariate analysis identified age at the time of reoperation as a strong independent predictor of late mortality. CONCLUSIONS: Reoperation in patients with prosthetic valves, performed urgently, especially in patients with symptoms of NYHA class III-IV or in the case of endocarditis, bears a high mortality rate. Risk of planned reoperation, mostly in patients with symptoms of NYHA class I-II, does not differ from the risk of the first operation.

Long-lasting durability of Carpentier-Edwards pericardial bovine bioprosthesis in mitral position - a case report of unfavourable post redo valve surgery course.

We describe a 73 year-old patient with mitral valve pericardial bioprosthesis Carpentier-Edwards 29M implanted due to the rheumatic mitral stenosis 21 years ago. Hemodynamic destabilisation had emerged 18 months before the admission. Echocardiography revealed significant bioprosthesis degeneration with calcification of its leaflets, small pannus on the bioprosthetic ring, moderate mitral stenosis, severe mitral and tricuspid regurgitation with high pulmonary hypertension and moderate aortic regurgitation. Redo valve surgery with mechanical Medtronic 27M valve implantation and tricuspid suture annuloplasty was successfully performed. The postoperative course was complicated by bleeding and severe respiratory insufficiency and the patient died 3 weeks after the surgery.

[Cardiological assessment before pregnancy in a female after surgical correction of tetralogy of Fallot - a case report]. / Ocena kardiologiczna przed planowana ciaza u kobiety po pelnej korekcji tetralogii Fallota - opis przypadku.

Pregnancy in a female with a history of surgical correction of tetralogy of Fallot is an important issue. We describe a cardiological assessment of a 28-year-old female who underwent echocardiography, exercise test, 24-hour ECG monitoring and genetic assessment.