Prognosis of patients with implanted pacemakers in 4­year follow-up : Impact of right ventricular pacing site.

BACKGROUND: Pacing remains the method of choice for treatment of cardiac electrical conduction disorders. This study examined the interrelationship between the site of the right ventricular lead tip and patient prognosis in association with other cardiovascular risk factors over a 4­year follow-up period. PATIENTS AND METHODS: The study comprised 450 consecutive patients (223 women; aged 69.16 ± 9.63 years) who had their first SSI or DDD pacemaker implanted for typical indications. RESULTS: During follow-up, 91 (20.2%) patients died. The positive prognostic factors were: female sex (hazard ratio [HR] = 0.426), DDD pacemaker (HR = 0.526), oral anticoagulant use (HR = 0.330; all groups), sodium concentration (HR = 0.926), oral anticoagulant (HR = 0.115) and statin (HR = 0.260) use (female group), and non-apical location of the right ventricular lead tip (HR = 0.549; male group). Risk factors for death were: age (HR = 1.063), diabetes requiring insulin (HR = 2.832), creatinine concentration (HR = 1.005; all groups), age (HR = 1.11; female group), and elevated creatinine level (HR = 1.012; male group). In all patients, the non-apical location of the right ventricular lead tip was associated with an 18.92% reduced mortality rate during the 4­year follow-up, which was statistically significant for the male group. CONCLUSION: The non-apical location of the right ventricular lead tip was a positive prognostic factor and was statistically significant in the male subgroup.

The prevalence of Chlamydia pneumoniae in the aortic wall and in peripheral blood of patients scheduled for coronary artery bypass grafting.

Some reports confirm a potential role of Chlamydia pneumoniae (ChP) in atherogenesis. In order to explore possible association between ChP and atherosclerosis, investigations were carried out in which the frequency of ChP in the arterial wall and peripheral blood was assessed in a group of patients with chronic coronary artery disease (CAD). Fifty-seven patients were enrolled in the study, 13 women and 44 men aged 61.8±6.5 (47-74), with previously diagnosed CAD, scheduled for planned coronary artery bypass grafting due to clinical indications. Vessel specimens retrieved from the ascending aorta (as a part of routine proximal venous graft development procedure) and peripheral blood mononuclear cells (PBMCs) from venous blood were evaluated for the presence of ChP DNA. Genomic DNA was extracted from PBMCs and vessel specimens. Quantitative real-time polymerase chain reaction (qPCR) was performed to detect ChP DNA. A statistically more frequent occurrence of ChP was observed in aortic tissues compared to blood samples (70.2% vs 56.1%, respectively). Similarly, the number of ChP DNA genomic copies [n/1µg genomic DNA] was significantly higher in tissue specimens compared to blood samples (89±91 vs 41±77, respectively; p=0.0046). In patients without ChP in blood specimens, we observed significantly higher amounts of ChP in tissue specimens compared to patients with ChP in blood specimens (156±71 vs 107±88, respectively; p=0.0453). No correlation was found between the number of ChP DNA copies [n/1µg genomic DNA] in blood and in aortic specimens. The infection of ChP in the aortic wall was connected with hypercholesterolemia (p=0.029) and diabetes (p=0.03). We conclude that Chlamydia pneumoniae is a pathogen frequently occurring in the aortic wall of patients with CAD. The occurrence of ChP DNA in the aortic tissue is related to classic CAD risk factors such as diabetes and dyslipidemia.

Serum gastrin concentration and changes in G and D cell densities in gastric antrum in children with chronic gastritis.

BACKGROUND: Elevated gastrin concentration leading to gastritis is explained as the effect of change in the density of D and G cells. The aim of the study was to determine and compare fasting serum gastrin concentrations, G and D cell densities in gastric antrum mucosa in children with chronic gastritis and in children with no gastritis or Helicobacter pylori infection. MATERIAL AND METHODS: A total of 184 patients aged 6-18 years, with chronic abdominal pain underwent endoscopic examination. We created three groups: I--patients with chronic gastritis and H. pylori infection; II--patients with chronic gastritis but no H. pylori infection; III--patients with neither gastric mucosal abnormalities nor H. pylori infection. G and D cell densities were determined in the biopsy specimens (using Rbalpha H Gastrin & Somatostatin antibodies). Fasting serum gastrin concentrations were measured using a Beckmann gamma-counter and a GASK-PR kit. RESULTS: The mean serum gastrin concentration in group I was higher when compared with group II (p = 0.04) and group III (p = 0.019). No statistically significant differences were found between groups II and III (p = 0.91). There were no statistically significant differences in G and D cell densities between groups. CONCLUSION: The mean G/D cell ratios in groups I and III were almost identical. The mean fasting serum gastrin concentration was higher in children with both chronic gastritis and H. pylori infection compared with patients without infection or without antral inflammation. No difference in the G cell density or D cell density in children was found, regardless of the presence or absence of gastritis or H. pylori infection.

Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy: two-year follow-up results.

BACKGROUND: Previous studies have shown disappointing results for immunosuppressive treatment in patients with dilated cardiomyopathy. Therefore, we studied the effectiveness of such therapy in patients with HLA upregulation on biopsy. METHODS AND RESULTS: Of 202 patients with dilated cardiomyopathy, 84 patients with increased HLA expression were randomized to receive either immunosuppression or placebo for 3 months; they were then followed for 2 years. After 2 years, there were no significant differences in the primary end point (a composite of death, heart transplantation, and hospital readmission) between the 2 study groups (22.8% for the immunosuppression group and 20.5% for the placebo). The secondary efficacy end point included changes in ejection fraction, end-diastolic diameter, end-diastolic volume, end-systolic volume and NYHA class; left ventricular ejection fraction increased significantly in the immunosuppression group compared with the placebo group (95% CI, 4.20 to 13.12; P<0.001) after 3 months of follow-up. The early favorable effects of immunosuppressive therapy on left ventricular volume, left ventricular diastolic dimension, and New York Heart Association class were also present. This improvement was maintained in the immunosuppression group at 2 years (ejection fraction: 95% CI, 6.94 to 19.04; P<0.001). In addition, on the basis of the protocol-specified definition of improvement, 71.8% patients in the immunosuppression group versus 20.9% patients in the placebo group met the criteria of improvement after 3 months (P<0.001). At the end of the follow-up period, 71.4% patients from the immunosuppression group versus 30.8% patients from the placebo group were improved (P=0.001). CONCLUSIONS: These data demonstrate a long-term benefit of immunosuppressive therapy in patients with dilated cardiomyopathy and HLA upregulation on biopsy specimens. Thus, restoration of immunosuppressive therapy for such patients should be considered.

Statistical dependence of clinical data on the chosen treatment of patients with a multivessel coronary artery disease.

BACKGROUND: In this study we tried to check which clinical data are connected with the choice of treatment in patients with a multivessel coronary artery disease. MATERIAL AND METHODS: The data of 137 patients with a multivessel coronary artery disease, were analysed retrospectively. The patients were divided into three groups: treated conservatively, CABG and PTCA. Multivessel coronary artery disease was recognised when there were atherosclerotic changes in more a 2 vessels with a not less a 2 mm in diameter. Patients with previous CABG or a left main coronary artery disease were excluded. The data were analysed by means of several methods, variance analysis, correlation analysis, discriminant functions, chi-square test and T-Student test. RESULTS: For treatment decision making in multivessel coronary artery disease of statistical significance were: the state of the left anterior descendent artery below the first diagonal branch, the state of the first diagonal branch and peripheral parts of the left anterior descendent artery and right coronary artery, the systolic function of the antero-lateral, apical and phrenic segments of the left ventricle, the global left ventricular ejection fraction in angiography and echocardiography, local systolic disturbances of the left ventricular observed in echocardiography, the coexistence of symptoms of heart failure as well as unstable angina. CONCLUSION: Treatment decision making will always depend not only on diagnostic procedures but also on all the clinical data about the patient and the experience of coworking cardiology and surgery centres.

[Genetic changes and clinical management in familial hypertrophic cardiomyopathy]. / Zmiany genetyczne a obraz kliniczny rodzinnej kardiomiopatii przerostowej.

Hypertrophic cardiomyopathy (HCM) is phenotypically and genotypically heterogeneous disease of heart. Nine chromosomal loci responsible for this condition have been identified: beta-myosin heavy chain, essential and regulatory myosin light chains, troponin T and I subunits, alpha-tropomosin, cardiac myosin binding protein C, cardiac actin and titin. These genes code for proteins involved in the contraction mechanism or in the control of contraction, therefore HCM has been classified as a disease of cardiac sarcomere. Over 107 mutations have been identified. More then half of them have been detected in the beta-myosin heavy chain gene (beta-MHC). Some mutations in beta-MHC gene are associated with a benign prognosis, other are associated with high incidence of sudden cardiac death (SCD) and severe hypertrophy. Mutations in myosin binding protein C are associated with mild, delayed expression of cardiac hypertrophy and benign prognosis. Mutations in cardiac troponinT are associated with a mild degree of hypertrophy but a high incidence of SCD. Study of genes responsible for HCM will assume role in the context of clinical management of HCM, in particular regarding diagnosis and prognosis patients and families with HCM.

Various types of cholestatic jaundice in infants--causes and diagnostic problems.

The purpose of this review was to evaluate possible differentiation between various causes of different types of cholestatic jaundice in children. Analyses were performed in 33 infants from 3 weeks to 3.5 years old with symptoms of cholestatic jaundice. The most frequent causes of cholestasis were congenital atresia of extrahepatic bile ducts (30%) and the CMV infection (20%). On the basis of the performed examinations it should be concluded that in order to differentiate between the causes of cholestatic jaundice it is necessary to do a series of tests as there is no specific diagnostic method which would be effective.

Bleeding from alimentary tract in pseudo Zollinger-Ellison syndrome.

The report describes a case of a four-month-old infant, who developed acute gastric ulcer while being hospitalised because of pneumonia. One year's observation of the patient, additional tests, especially gastroscopy with histopathological evaluation of biopsy specimen, determination of gastrin level in blood serum, and therapy analysis allow to establish a diagnosis of pseudo Zollinger-Ellison syndrome.

[A procedure for bronchial dilatation using a balloon-based technique as a method for removing post-inflammatory stenosis]. / Zabieg poszerzenia oskrzela z wykorzystaniem techniki balonowej jako metoda usuniecia pozapalnego zwezenia.

18-years old girl was admitted to hospital because of recurrent infections after pulmonary tuberculosis treated 4 year ago. Chest X-ray was near normal but during bronchoscopy--narrowing of lingula bronchi was revealed. In order to dilate the bronchi, a balloon, bronchoscopically directed, coming from a set designed for percutaneous transluminal coronary angioplasty, was applied.

Immunohistological diagnosis of myocarditis. Potential role of sarcolemmal induction of the MHC and ICAM-1 in the detection of autoimmune mediated myocyte injury.

AIMS: The aim of this study was to characterize the up-regulation of major histocompatibility complex antigens class I (HLA-A, B, C) and class II (HLA-DR), and intercellular adhesion molecule-1 with special emphasis on de novo induction of these molecules on cardiac myocytes in patients with suspected myocarditis. METHODS: Endomyocardial biopsy specimens were obtained from 83 consecutive patients. Specimens were subdivided into two groups according to clinical presentation of the disease: Group A, 58 patients with idiopathic congestive heart failure and Group B, 25 patients without heart failure. In group A, 15% of patients had active myocarditis, 36% had borderline and 48% no myocarditis according to Dallas criteria. In group B, myocarditis distribution was 12%, 36% and 52%, respectively. The major histocompatibility complex was considered to be positive when the immunoreactivity index was > or = 3+; intercellular adhesion molecules were considered positive when the score was > or = 2+. RESULTS: We observed two characteristic staining patterns of the HLA molecules on cardiac myocytes: (i) multifocal sarcolemmal staining at the sites of mononuclear inflammatory infiltration, (ii) linear sarcolemmal staining with otherwise normal endomyocardium. Positive immunoreactivity was observed in 60% of patients in group A, and in 44% of patients in group B. We found no correlation between a histopathological diagnosis of myocarditis or left ventricular systolic function and positive immunoreactivity. CONCLUSION: The lack of correlation between immunohistological signs of active inflammation and clinical symptoms in patients with myocarditis may indicate independence of an immunological mechanism. The lack of correlation between immunoreactivity and histopathological diagnosis of myocarditis may suggest low sensitivity of traditional histological evaluation. In our opinion, the induction of major histocompatibility and intercellular adhesion molecules on cardiac myocytes may indicate an autoimmune inflammatory response in patients with inflammatory myocardial disease. Immunohistochemical methods may be helpful in selecting patients for immunosuppressive therapy.

[Arrhythmia in patients with hypertrophic cardiomyopathy during an exercise test with 24-hour Holter monitoring]. / Zaburzenia rytmu u chorych z kardiomiopatia przyrostowa w próbie wysilkowej i 24-godzinnym monitorowaniu ekg metoda Holtera.

Thirty patients with hypertrophic cardiomyopathy (HCM), (20 men and 10 women, age 16-55, mean 37 +/- 8 years) underwent exercise test done on bicycle twice to estimate effort tolerance before drugs. In all patients a 24-hour ekg Holter monitoring was also performed. During exercise test heart rhythm disturbances were noticed in 2 patients (7%). One had a 2-second sinus arrest, in the other ventricular bigeminity was observed. Twenty two patients (79%) had rhythm or conduction disturbances in Holter monitoring. In 2 (7%) rhythm generation and conduction abnormalities, in 7 (23%)-supraventricular and in 13 (43%)-ventricular arrhythmia. Ten of them (33%) had Lown class IVa and IVb arrhythmia. In conclusion we suggest that exercise test done on bicycle ergometer is a safe method to estimate effort tolerance in patients with HCM and usually does not induce rhythm disturbances. Holter monitoring is more effective than exercise test in revealing cardiac arrhythmia.

Evaluation of the efficacy of natural human interferon alpha lozenges on the clinical course of childhood neoplasia and in chronic hepatitis B virus infection in patients who were successfully treated for pediatric malignancies.

The immunostimulating and anti-cancer action of interferons (IFNs) has been known for many years. However, IFNs have not been introduced widely into the schemes of oncological treatment because of serious side effects potentiating untoward effects of chemotherapy. In addition using high doses of IFNs by parental routes the cost of such therapy is prohibitively high. Natural human interferon alpha lozenges produced from lymphoblastoid cell line by the Hayashibara Biochemical Lab. Okayama Japan (nHuIFN-alpha, HBL) is used in small doses delivered on oral mucosa. Thus, it might be expected not to cause severe side effects, and is less expensive. Children given antineoplastic and immunostimulatory treatment for cancer were also given nHuIFN-alpha--HBL lozenges containing 50-200 units of IFN per lozenge. Children treated age varied from 3-14 years. The average time of observation was 188 days. In 6 patients nHuIFN-alpha therapy was introduced at the time of the intensive oncological treatment during break periods. Those children had advanced malignant solid tumors. For the other children the IFN therapy was used after the successfully completed oncological treatment. The reason of using nHuIFN-alpha in this group was a long lasting hepatitis B virus antigenemia. The drug was well tolerated by children from both groups and a positive immunostimulating effect was observed. One prominent effect of the nHuIFN-alpha--HBL in children was a reduction of frequency of infections, improvement of appetite and psychological feeling of well being. It seems to us that IFN oral therapy may improve the tolerance of chemotherapy and radiotherapy.

[Ventricular arrhythmias and the ATc index in patients with ischemic heart disease]. / Komorowe zaburzenia rytmu serca a wskaznik QTc u chorych z choroba niedokrwienna serca.

In this multicenter study a group of 1,011 patients (233 females and 778 males, aged 23-68 years, mean 53) with ischaemic heart disease was included. Only nitrates, nifedipine and diuretics were administered during the investigation. Presence of other chronic disease excluded the patients from study group. In all patients a standard 12-lead electrocardiogram was obtained, from which the QT interval was measured, and its corrected value according to the Bazett's formula calculated [formula: see text] values greater than 440 ms were regarded to be abnormal. A 24-hour ecg ambulatory monitoring was also performed in each patient, and the detected ventricular ectopic activity was classified using the Lown's criteria. Mean QTc values were compared between each class of ventricular arrhythmia. No significant differences were disclosed. All the means were below 440 ms. Also the percentages of patients with a prolonged QTc were similar for all Lown classes of arrhythmia. The patients were then divided into two larger groups: Those with low grade (class 0-2) and high grade (class 3-5) arrhythmia. The portion of patients with the pathologic QTc was not significantly different (21% vs. 28%, NS). Such incidence of QTc prolongation was described for clinically healthy population. Since a 24-hour ecg fails to disclose the entire spectrum of arrhythmia in each individual, the fraction of patients with documented VT/VF in the past was analyzed separately. This subgroup was characterized by more frequent occurrence of QTc prolongation than other patients (35% vs. 20%, p = 0.043). Thus, no firm relationship was found between QTc prolongation and ventricular arrhythmias, but increased QTc favoured the occurrence of VT/VF.

[Effects of antiarrhythmic drugs on some echocardiographic parameters of left ventricular function in patients with ischemic heart disease]. / Wplyw leków przeciwarytmicznych na niektóre echokardiograficzne wskazniki czynnosci lewej komory u chorych z choroba niedokrwienna serca.

This study was performed to evaluate the effects of antiarrhythmic drugs on left ventricular function in 843 patients with ischaemic heart disease and ventricular arrhythmias (Lown classes 2-5). Rhythm abnormalities were observed by ambulatory electrocardiographic monitoring before and after 2-weeks of antiarrhythmic therapy. Haemodynamic variables such as cardiac output (CO), ejection fraction (EF), stroke volume (SV), and ratio of myocardial contractility (RMC) were derived from the cross sectional echocardiography. Efficacy of the applied drugs was 42-71%. Of these antiarrhythmic agents only propranolol caused the deterioration of left ventricular performance, measured by CO; in mono-therapy propranolol produced significant changes (p less than 0.05), in combination with amiodarone--at point of significance. Mexiletine produced significant improvement in EF and SV (p less than 0.05). There were no significant changes in haemodynamic parameters after treatment with the other drugs.

[Possibilities of echocardiographic evaluation of hemodynamic disorders in hypertrophic cardiomyopathy]. / Mozliwosci echokardiograficznej oceny zaburzen hemodynamicznych w kardiomiopatii przerostowej.

In a group of 59 patients with hypertrophic cardiomyopathy relationship between echocardiographic parameters (interventricular septal thickness, left ventrical diastolic diameter, presence of SAM, distribution of hypertrophy) and certain hemodynamic measurements (diastolic compliance, left ventricular end-diastolic pressure, intraventricular pressure gradient, mean wall thickness and left ventricular mass index) were assessed. Substantial elevation of left ventricular end-diastolic pressure (LVEDP greater than 20 mmHg) was significantly more prevalent among patients with small left ventricular diameter and gross septal hypertrophy. Extensive ventricular hypertrophy (Maron type III) was not characterized by any distinctive hemodynamic pattern. Presence of SAM reaching interventricular septum was indicative of left ventricular outflow obstruction.

[Relation between echocardiographic image and the electrocardiogram in hypertrophic cardiomyopathy]. / Zaleznosc miedzy obrazem echokardiograficznym a elektrokardiogramem w kardiomiopatii przerostowej.

Authors analyzed the correlation between anatomic changes estimated by echocardiographic examination and electrocardiographic recordings in group of 104 patients with hypertrophic cardiomyopathy. It was stated that morphological type III by Maron (8) is characterized, in comparison with other types, by significantly lower percentage of right ventricular hypertrophy and higher percentage of QTc interval prolongation, whereas percentage of patients with mitral or left ventricular hypertrophy was insignificantly higher. P Mitrale was significantly more often observed in patients with left ventricular diastolic dimension less than 35 mm. Generally ecg recordings had no distinct markers of the extent and localization of hypertrophic changes. Authors conclude that the unmistakable recognition of the anatomical type of hypertrophy basing on electrocardiogram is possible.