Left Atrial Strain as a Predictor of Left Ventricular Diastolic Dysfunction in Patients with Arterial Hypertension.

Background and Objectives: There is emerging evidence of the usefulness of left atrial strain (LAS) in the assessment of diastolic dysfunction (DD). In this study we assess the sensitivity and specificity of LAS, to determine cut-off values and their association to DD with increased left atrial pressure (LAP) in patients with well-treated arterial hypertension. Materials and Methods: We performed a cross-sectional study on 180 subjects with well-treated arterial hypertension. All patients underwent transthoracic echocardiography. Patients were divided into two groups: a group without increased LAP and/or DD and a group with increased LAP DD. Results: In multivariate logistic regression, LAS proved to be the strongest statistically significant predictor of DD with increased LAP (OR 0.834, p < 0.0005), with AUC 0.885 and a set cut-off value of 24.27% with high sensitivity of 78.9% and specificity of 84.6%. The set cut-off for LAS > 24.27% was significantly highly prevalent in the group of DD with increased LAP 78.9% when compared to the group without increased LAP 15.4%, p < 0.0001. Conclusion: The findings of this study suggest that LAS could be a useful and highly sensitive and specific marker in the evaluation of DD. There is the potential for using LAS in everyday practice as a standard parameter in diastolic function assessment.

Case Report: Multimodality Imaging as a Lifeline for Fatal Localization of Valsalva Sinus Fibroelastoma.

Background: Papillary fibroelastomas are rare benign heart tumors, and is most likely to involve the cardiac valves. We will present an extremely rare localization of a large Valsalva sinus fibroelastoma, with occasional left coronary artery ostial obstruction presented as an acute coronary syndrome. The tumor was removed surgically and histologically confirmed as papillary fibroelastoma. This review points to the crucial importance of multidisciplinary team decision and multimodality imaging methods for diagnosing the fibroelastoma, determination of size, and localization, which avoided complications of fatal embolization during an invasive procedure. Case Summary: A healthy 55-year-old male with vigorous physical daily training and exercise was admitted to the acute coronary syndrome emergency department. Shortly after admission, expert transthoracic echocardiography was performed. Computed tomography of the chest observed a large irregular hypodense tumor-like lesion in the bulbar aorta that was occasionally prolapsing into the left main coronary artery ostium and which corresponded to fibroelastoma. A few hours after admission, an emergency cardiac surgery was performed with the excision of a Valsalva sinus tumor (size 2 × 2 cm) located between the right and left coronary cusp of the aortic valve. Conclusions: Focus cardiac ultrasound should be performed for any acute coronary syndrome because of the possible Valsalva sinus fibroelastoma etiology. Its localization next to the left main coronary artery ostium is rare, and dangerous. The timely diagnosis can be made by the multimodality imaging method, however, the final diagnosis will be made pathohistologically. Early cardiac surgery may be a necessitated recourse for these patients in order to prevent a fatal outcome.

Determination of topiramate in human plasma using liquid chromatography tandem mass spectrometry.

The LC-MS/MS method for determination of the anti-epileptic drug topiramate (TPM) in human plasma was developed and validated for pharmacokinetic and bioequivalence study purposes. For quantitative determination of TPM values the method with deuterated internal standard (topiramate-d12) and liquid chromatography with tandem mass spectrometry was used. TPM was extracted from the human plasma using the solid-phase extraction procedure on a Strata X extraction column. Negative ions were monitored in the selected reaction monitoring mode (SRM) and transitions m/z 338.2 > 78.2 and m/z 350.3 > 78.2 were used for the quantitative evaluation of TPM and the internal standard, respectively. The results obtained from validation were statistically evaluated according to the requirements of European Medicines Agency (EMA) and Food and Drug Administration (FDA) regulatory guidelines. The linearity of the method was checked within a concentration range from 10 to 2000 ng/mL. Successful validation confirmed that this method is precise, accurate, sensitive and therefore suitable for determination of topiramate plasma levels in pharmacokinetic and bioequivalence studies.

Development and validation of dried blood spots technique for quantitative determination of topiramate using liquid chromatography-tandem mass spectrometry.

An LC-MS/MS method for determination of the anti-epileptic drug topiramate (TPM) in dried blood spot (DBS) samples was developed and validated. DBS samples were prepared by spotting 30 µL of spiked whole blood onto FTA(TM) DMPK-C cards and drying for at least 3 h. Six-millimetre punched spots were then extracted by using a mixture of methanol and water (90:10, v/v) with deuterated internal standard (topiramate-d12). The extracted samples were injected into a liquid chromatograph equipped with a tandem mass spectrometric detector. Negative ions were monitored in the selected reaction monitoring mode and transitions m/z 338.2 → 78.1 and m/z 350.3 → 78.1 were used for the quantitative evaluation of TPM and internal standard, respectively. The results obtained from validation were statistically evaluated according to the requirements of the European Medicines Agency and US Food and Drug Administration regulatory guidelines. The linearity of the method was checked within a concentration range from 10 to 2000 ng/mL. The validation results indicate that the method is accurate, precise, sensitive, selective and reproducible.

Therapeutic hypothermia and neurological outcome after cardiac arrest.

INTRODUCTION/AIM: The most important clinically relevant cause of global cerebral ischemia is cardiac arrest. Clinical studies showed a marked neuroprotective effect of mild hypothermia in resuscitation. The aim of this study was to evaluate the impact of mild hypothermia on neurological outcome and survival of the patients in coma, after cardiac arrest and return of spontaneous circulation. METHODS: The prospective study was conducted on consecutive comatose patients admitted to our clinic after cardiac arrest and return of spontaneous circulation, between February 2005 and May 2009. The patients were divided into two groups: the patients treated with mild hypothermia and the patients treated conservatively. The intravascular in combination with external method of cooling or only external cooling was used during the first 24 hours, after which spontaneous rewarming started. The endpoints were survival rate and neurological outcome. The neurological outcome was observed with Cerebral Performance Category Scale (CPC). Follow-up was 30 days. RESULTS: The study was conducted on 82 patients: 45 patients (age 57.93 +/- 14.08 years, 77.8% male) were treated with hypothermia, and 37 patients (age 62.00 +/- 9.60 years, 67.6% male) were treated conservatively. In the group treated with therapeutic hypothermia protocol, 21 (46.7%) patients had full neurological restitution (CPC 1), 3 (6.7%) patients had good neurologic outcome (CPC 2), 1 (2.2%) patient remained in coma and 20 (44.4%) patients finally died (CPC 5). In the normothermic group 7 (18.9%) patients had full neurological restitution (CPC 1), and 30 (81.1%) patients remained in coma and finally died (CPC 5). Between the two therapeutic groups there was statistically significant difference in frequencies of different neurologic outcome (p = 0.006), specially between the patients with CPC 1 and CPC 5 outcome (p = 0.003). In the group treated with mild hypothermia 23 (51.1%) patients survived, and in the normothermic group 30 (81.1%) patients died, while in the group of survived patients 23 (76.7%) were treated with mild hypothermia (p = 0.003). CONCLUSION: Mild therapeutic hypothermia applied after cardiac arrest improved neurological outcome and reduced mortality in the studied group of comatose survivors.

Atrio-ventricular block as the first presentation of disseminated Lyme disease.

A 36 year old male patient presented to emergency cardiology department because of fatigability. ECG revealed high grade II atrio-ventricular block and bradycardia of 31 beats/min. An erythema increasing in size to up to 7-8 cm in diameter appeared a month earlier and spontaneously resolved within 10 days. ELISA testing for antibodies against Borrelia burgdorferi IgM was positive and IgG titer was 1:40. Intravenous ceftriaxone 2g qod, and 0.5 g metronidazole tid lead to regression of grade II block to grade I block within 2 days. Grade I block persisted for an additional 10 days. This is a relatively rare case of early occurrence of Lyme carditis within one month of exposure as the first sign of Lyme disease dissemination.