Prevalence of extracranial venous abnormalities: results from a sample of 586 multiple sclerosis patients.

The aim of this study was to assess the prevalence of chronic cerebrospinal venous insufficiency in an unselected cohort of multiple sclerosis (MS) patients. A total of 586 patients with clinically defined MS underwent catheter venography of the internal jugular veins, brachiocephalic veins and azygos vein. The following findings were regarded as pathologic: no outflow, slowed outflow, reversal of flow direction, prestenotic dilation accompanied by impaired outflow, outflow through collaterals, intraluminal structures obstructing the vein, hypoplasia, agenesia or significant narrowing of the vein. Venous abnormalities were found in 563 patients (96.1%). Lesions in one vein were found in 43.5%, in two veins in 49.5%, and in three veins in 3.1% of patients. Venous pathologies in the right internal jugular vein were found in 64.0% of patients, in the left internal jugular vein in 81.7%, in the left brachiocephalic vein in 1.0%, and in the azygos vein in 4.9%. Venous pathologies were found to be highly associated with MS, yet the clinical relevance of this phenomenon remains to be established.

Endovascular treatment for chronic cerebrospinal venous insufficiency: is the procedure safe?

OBJECTIVES: The aim of this report is to assess the safety of endovascular treatment for chronic cerebrospinal venous insufficiency (CCSVI). Although balloon angioplasty and stenting seem to be safe procedures, there are currently no data on the treatment of a large group of patients with this vascular pathology. METHODS: A total of 564 endovascular procedures (balloon angioplasty or, if this procedure failed, stenting) were performed during 344 interventions in 331 CCSVI patients with associated multiple sclerosis. RESULTS: Balloon angioplasty alone was performed in 192 cases (55.8%), whereas the stenting of at least one vein was required in the remaining 152 cases (44.2%). There were no major complications (severe bleeding, venous thrombosis, stent migration or injury to the nerves) related to the procedure, except for thrombotic occlusion of the stent in two cases (1.2% of stenting procedures) and surgical opening of femoral vein to remove angioplastic balloon in one case (0.3% of procedures). Minor complications included occasional technical problems (2.4% of procedures): difficulty removing the angioplastic balloon or problems with proper placement of stent, and other medical events (2.1% of procedures): local bleeding from the groin, minor gastrointestinal bleeding or cardiac arrhythmia. CONCLUSIONS: The procedures appeared to be safe and well tolerated by the patients, regardless of the actual impact of the endovascular treatments for venous pathology on the clinical course of multiple sclerosis, which warrants long-term follow-up.

Microvasculopathy observed in early or late endomyocardial biopsies is not related to angiographically confirmed transplanted heart coronary vasculopathy.

INTRODUCTION: The aim of the study was to examine the potential relation between microvasculopathy observed in endomyocardial biopsies (EMBs) and clinical coronary vasculopathy (CAV) after orthotopic heart transplantation (OHT). MATERIALS AND METHODS: We preformed a retrospective analysis involving 68 OHT patients in whom the procedure was performed before 1999. The CAV(+) group consisted of 37 subjects (35 males/2 females) of overall mean age of 45 +/- 11 years. Ischemic cardiomyopathy was the diagnosis in 57% of the cohort that displayed CAV established by angioplasty, myocardial infarction, or CAV-related death. The control group contained 31 subjects (24 male/7 female) of overall mean age of 43 +/- 16 years. The pretransplant diagnosis was ischemic c-pathy in 39%. These subjects displayed negative coronary angiography at 10 years after OHT. Based upon studies early after OHT 55 subjects were divided based on the myocardial blush grade (MBG) upon coronary angiography performed between 4th and 6th week after surgery: one cohort of six individuals showed decreased MBG (6 males) of mean age 52 +/- 7 years. There was prior ischemic c-pathy in 50%. In contrast, 49 subjects showed a normal MBG (43 males/67 females) of overall mean age of 45 +/- 12 years. Ischemic c-pathy had been present in 39%. Microvasculopathy was defined as the presence of prominent endothelial cells, vacuolation of the endothelium, thickening of the basal membrane and/or muscle layer, the presence of lymphocytes in the arteriolar wall, periarteriolar fibrosis, or stenotic arteriolar lumenia in the 12- and 36 month EMB (CAV groups) or the 4-week EMB (MBG groups). RESULTS: Rejection grades were comparable in CAV(+) and CAV(-) groups, but decreased in normal MBG group. The only significant difference was observed in the occurrence of basal membrane thickening, which was present in 22% of subjects from the CAV(+) group and 3% of individuals from the CAV(-) group in the 12-month EMB. CONCLUSION: Microvasculopathy observed early or late after OHT was not related to angiographically confirmed CAV.

Survival benefit in heart transplant recipients who have coronary artery disease confirmed using angiography and are receiving sirolimus.

INTRODUCTION: The aim of this study was to assess efficacy and safety of sirolimus (SIR) in heart transplant recipients to prevent further development of coronary artery disease (TxCAD) already confirmed by using coronary angiography. MATERIAL AND METHODS: We performed a retrospective case-control study involving all 60 heart transplant recipients receiving SIR in a number of combinations with other immunosuppressive drugs, and 60 matched individuals after heart transplantation treated without SIR. TxCAD was diagnosed using elective coronary angiography in 9 subjects in the study group (8 males and 1 female) of mean age 44 +/- 11 years, including ischemic cardiomyopathy in 4 members. The control group of 15 individuals 15 males of mean age 47 +/- 7 years, including ischemic cardiomyopathy in 8. We compared time to develop significant TxCAD and death caused by TxCAD, and all-cause deaths. Significance was assessed using log-rank and chi-square tests, when applicable. RESULTS: Significant TxCAD (critical coronary lesions, myocardial infarction or death) was observed in 5 (56%) patients receiving SIR and 11 (73%) without SIR (P = not significant [NS]). Time to develop significant TxCAD was comparable. There were 2 (22%) deaths in the SIR group and 8 (53%) in the control group (P = NS). Survival time was significantly longer among subjects receiving SIR (P = .02). None of deaths in the study group was caused by TxCAD compared with 6 (40%) deaths among controls (P = .09). Time of freedom from death caused by TxCAD was significantly longer in the study group (P = .023). CONCLUSION: SIR prolonged survival in heart transplant recipients with TxCAD confirmed using coronary angiography.

Comparison of long-term results of drug-eluting stent and bare metal stent implantation in heart transplant recipients with coronary artery disease.

UNLABELLED: The aim of the study was to compare long-term results of intracoronary implantation of drug-eluting stents (DES) and bare metal stents (BMS) in patients suffering from transplant coronary artery disease (TxCAD). MATERIAL AND METHODS: We performed a retrospective analysis of all intracoronary stent implantations for TxCAD among subjects with at least one follow-up coronary angiography. We identified 28 sirolimus-eluting DES (n = 17) patients, 24 BMS (n = 13 patients), and both DES and BMS (n = 7 patients) implantations among 23 recipients. Mean follow-up after DES was 14 months and after BMS implantation, 20 months. We compared the occurrence of in-stent restenosis (ISR), and patient survival in the context of risk factors that were identified separately for each stent type. Significance was assessed using the log-rank, chi(2) and Mann-Whitney U test. RESULTS: There were 2 (7%) ISR among DES versus 14 (58%) ISR among BMS (P = .0002) patients, with a longer time of freedom from IRS after DES implantation (P = .022). There were three deaths (18%) among DES, four (31%) with BMS, and one (14%) with DES and BMS (P = NS). Left anterior descending artery was the place of DES implantation in 17 (61%) versus 10 (42%) of BMS cases (P = NS). Risk factor profile was comparable except for a higher age at the time of transplantation (46 +/- 7 vs 41 +/- 6 years; P = .011) and stent implantation (54 +/- 7 vs 49 +/- 6 years; P = .0002) for DES. CONCLUSION: Favorable long-term results of sirolimus-eluting stents over BMS implanted for TxCAD suggested their preferential use in heart transplant recipients.

Usefulness of stanford scale of intimal hyperplasia assessed by intravascular ultrasound to predict time of onset and severity of cardiac allograft vasculopathy.

BACKGROUND: The purpose of this study was to assess the prognostic value of a single IVUS result described by the Stanford scale to predict CAV development. METHODS: Inclusion criteria were heart transplantation (OHT) before 1997 and at least one IVUS performed before 1998. IVUS studies were performed in 37 patients at 37 +/- 26 months after OHT. Based on the Stanford scale, were divided patients into Four groups: group I (grade 0 or 1): n = 4, 42 +/- 19 years, 2 men/2 women; group II (grade 2): n = 10, 44 +/- 15 years, 9 men/1 woman; group III (grade 3): n = 11, 48 +/- 11 years, 11 men; and group IV (grade 4): n = 12, 46 +/- 8 years, 12 men. We compared the incidence and time of onset of clinically significant CAV, namely significant coronary lesions, myocardial infarction and death caused by CAV. RESULTS: There was no CAV diagnosed in group I. The rates of CAV in coronary angiograms in groups II, III and IV were: 80%, 36%, and 75%, respectively. Significant CAV was found in 30%, 9%, and 50% of patients, respectively. Average times of onset of any CAV in groups II, III and IV were 4.9, 5.6, and 3.3 years, and for significant CAV were 4.1, 3.6, and 5.5 years, respectively. Deaths in groups I to IV were 1, 4, 2, and 5, respectively. CAV was the reason for death in 1 patient from group III, and 3 patients from group IV. CONCLUSIONS: Extreme grades on the Stanford scale (0, 1, and 4) describing a single IVUS study in OHT recipients appear useful to stratify patients with the lowest versus the highest risk of CAV development.

Usefulness of pulmonary hypertension reversibility test with sodium nitroprusside in stratification of early death risk after orthotopic heart transplantation.

AIM: To assess the prognostic value of a PH reversibility test with NPS to predict early death risk after orthotopic heart transplantation (OHT). MATERIALS AND METHODS: We analyzed the results of 94 consecutive OHT procedures performed from 2002 to 2003. Pulmonary vascular resistance (PVR) and transpulmonary gradient (TPG) were assessed as part of the routine pre-OHT evaluation. PH was excluded in 57 patients (61%, group A); TPG > or = 12 mmHg and/or PVR > 2.5 Wood units were observed in 37 patients (39%). Sixteen patients underwent a PH reversibility test with NPS: 9 patients (group B) achieved normal TPG and PVR without a drop in systolic arterial pressure (BP(s) > 85 mmHg), while a marked decrease of BP(s) (< 85 mmHg) during NPS infusion was observed in 7 patients (group C). Then, 21 patients were selected for OHT despite PH without any reversibility test. We compared the number of early deaths after OHT among groups (chi-square test). RESULTS: The 30-day death rate was 7% in group A, 11% in group B, 71% in group C, and 29% in group D. (A vs C, P = .0001 and A vs D, P = .03). Right ventricle or biventricular failure was the cause of death in 1 patient in group A, 1 patient in group B, 5 patients in group C, and 6 patients in group D (A vs C, P < .0001 and A vs D, P = .0012). CONCLUSION: PH reversibility revealed with NPS does not increase the risk of early death after OHT unless there is an absence of marked fall in systemic pressure.

Pathologic assessment of cardiomyocytes in heart transplant recipients treated with rapamycin or cyclosporine.

The aim of this study was to compare cardiomyocytes and stromal pathology in heart transplant recipients treated with rapamycin (RAPA) versus cyclosporine (CyA). We analyzed elective biopsies obtained during first 3 months after heart transplantation in four patients treated with RAPA (24 biopsies) and seven patients receiving CyA (49 biopsies). Additional medications in both groups consisted of mycophenolate mofetil or azathioprine and prednisone. The intensity of rejection was assessed using the ISHLT scale; it was comparable in both groups based upon the number of results showing significant rejection and the average biopsy scores. Each slide was also examined under high-power magnification to sarcoplasmic and nuclear changes. Sarcoplasmic vacuolation, premyocytolysis and myocytolysis, nuclear staining, stromal fibrosis and edema, presence of vasculopathy, and lymphocytes infiltrating the myocardium occurred more frequently in the CyA group. The difference in the degree of hyperchromasia of the nuclei was highly significant (67% versus 10%, P <.00001). Our findings suggest that despite comparable levels of rejection as assessed using the ISHLT scale, patients treated with RAPA display fewer signs of cardiomyocytic alterations early after heart transplantation.

[Use of intravascular ultrasonography (IVUS) for diagnosis and treatment of coronary artery disease--case report]. / Zastosowanie ultrasonografii wewnatrznaczyniowej (IVUS) w diagnostyce i leczeniu choroby niedokrwiennej serca--opis przypadku.

One of the additional methods of coronary artery assessment is intravascular ultrasound (IVUS). Contrary to coronary angiography this relatively new technic provides new information including precise calculations of stenosis degree, morphology of atheromatous plaque and differentiation of its structure. Coronary angiography was performed in 54 years old male patient with unstable angina, revealing 99% stenosis in distal RCA. Discrepancy between clinical presentation and angiographic findings and exercise test resulted in performing IVUS of LAD. Angiographically clear LM and LAD were found to be narrowed 52% and 58% on IVUS. Subsequent CABG resulted in symptoms withdrawal and increase of physical tolerance. Exercise test after CABG did not reveal ischaemia in area of LCA at 10 METs. IVUS is found to be an important technic in assessment of silent or ambiguous lesions and in many cases allows to choose the optimal method of treatment of coronary artery disease.