Blunted cerebral hemodynamic responses to incremental exercise in patients with end-stage renal disease.

PURPOSE: The aims of this study were to compare cerebral hemodynamics and maximal oxygen uptake (VO2peak) in patients with end-stage renal disease (ESRD) vs. age-matched healthy controls during maximal exercise. METHODS: Twelve patients with ESRD and twelve healthy adults (CTR group) performed exhaustive incremental exercise test. Throughout the exercise test, near-infrared spectroscopy allowed the investigation of changes in oxyhemoglobin (∆O2Hb), deoxyhemoglobin (∆HHb), and total hemoglobin (∆THb) in the prefrontal cortex. RESULTS: Compared to CTR, VO2peak was significantly lower in ESRD group (P < 0.05). Increase in ∆THb (i.e., cerebral blood volume) was significantly blunted in ESRD (P < 0.05). ESRD patients also had impaired changes in cerebral ∆HHb and ∆O2Hb during high intensity of exercise (P < 0.05). Finally, no significant correlation was observed between VO2peak and changes in cerebral hemodynamics parameters in both groups (All P > 0.05). CONCLUSION: Maximal exercise highlights subtle disorders of both hemodynamics and neuronal oxygenation in the prefrontal cortex in patients with ESRD. This may contribute to both impaired cognitive function and reduced exercise tolerance throughout the progression of the disease.

Hemodynamic and neuromuscular basis of reduced exercise capacity in patients with end-stage renal disease.

PURPOSE: The present study aimed to characterize the exercise-induced neuromuscular fatigue and its possible links with cerebral and muscular oxygen supply and utilization to provide mechanistic insights into the reduced exercise capacity characterizing patients with end-stage renal disease (ESRD). METHODS: Thirteen patients with ESRD and thirteen healthy males (CTR group) performed a constant-force sustained isometric contraction at 50% of their maximal voluntary isometric contraction (MVC) until exhaustion. Quadriceps muscle activation during exercise was estimated from vastus lateralis, vastus medialis, and rectus femoris EMG. Central and peripheral fatigue were quantified via changes in pre- to postexercise quadriceps voluntary activation (ΔVA) and quadriceps twitch force (ΔQtw,pot) evoked by supramaximal electrical stimulation, respectively. To assess cerebral and muscular oxygenation, throughout exercise, near-infrared spectroscopy allowed investigation of changes in oxyhemoglobin (∆O2Hb), deoxyhemoglobin (∆HHb), and total hemoglobin (∆THb) in the prefrontal cortex and in the vastus lateralis muscle. RESULTS: ESRD patients demonstrated lower exercise time to exhaustion than that of CTR (88.8 ± 15.3 s and 119.9 ± 14.6 s, respectively, P < 0.01). Following the exercise, MVC, Qtw,pot, and VA reduction were similar between the groups (P > 0.05). There was no significant difference in muscle oxygenation (∆O2Hb) between the two groups (P > 0.05). Cerebral and muscular blood volume (∆THb) and oxygen extraction (∆HHb) were significantly blunted in the ESRD group (P < 0.05). A significant positive correlation was observed between time to exhaustion and cerebral blood volume (∆THb) in both groups (r2 = 0.64, P < 0.01). CONCLUSIONS: These findings support cerebral hypoperfusion as a factor contributing to the reduction in exercise capacity characterizing ESRD patients.

Echocardiography Coupled with Strain Method in the Screening for Cardiac Involvement in Rheumatoid Arthritis.

OBJECTIVE: In this study, the usefulness of transthoracic echocardiography (TTE) in systematic screening was assessed for various cardiac abnormalities in patients with rheumatoid arthritis (RA). METHODS: We performed a comparative cross-sectional study from July 2020 to February 2021. Each patient underwent a TTE coupled with the strain technique. RESULTS: Seventy-two RA patients and 72 controls were included. Abnormalities detected by TTE were more frequent in RA patients (80.6% vs. 36.1%; p < 0.01), and they were asymptomatic in 65.5% of cases. Valvular involvement was found in 45.8% of RA patients, with a significant difference (p < 0.01). Left ventricular diastolic dysfunction was also more frequent in the RA group (36.1% vs. 13.9%; p < 0.01). Left ventricular systolic dysfunction was absent in our study, but subclinical left ventricular myocardial damage assessed by Global Longitudinal Strain (GLS) method was found in 37.5% of RA patients and 16.6% of controls (p < 0.01). The mean GLS in RA patients was -17.8 ± 2.9 (-22 to -10.7) vs. -19.4 ± 1.9 (-24.7 to -15.7) in controls. Left ventricular hypertrophy was detected in 22.2% of RA patients and in 6.9% of controls (p < 0.01). Pericardial effusion and pulmonary arterial hypertension were present only in the RA group (2.8% of cases). We found a significant relationship between echocardiographic damage and disease activity (p < 0.01), number of painful joints (p < 0.01), functional impact (HAQ) (p = 0.01), CRP level (p < 0.01) and the use and dose of Corticosteroids (p = 0.02; p = 0.01). CONCLUSION: Echocardiographic damage in RA is frequent and often asymptomatic, hence there has been an increased interest in systematic screening in order to improve the quality of life and vital prognosis of patients. Early management of RA can reduce the risk of occurrence of cardiac involvement.

Acute multifocal retinitis in a patient with Q fever (Coxiella Burnetii infection) with endocarditis.

OBJECTIVE: To report acute multifocal retinitis in association with serologically-proven Coxiella (C) Burnetii infection (Q fever) with endocarditis. MATERIAL AND METHODS: A single case report documented with multimodal imaging. RESULTS: A 67-year-old cattle breeder presented with a 2-week history of persistent fever, headache, and floaters in both eyes. On examination, his best-corrected visual acuity was 20/20, and there was 1+ vitreous cells in both eyes. Bilateral fundus examination showed multiple small superficial white retinal lesions scattered in the posterior pole and midperiphery associated with a few retinal hemorrhages. These retinal lesions did not stain on fluorescein angiography (FA) and showed focal hyperreflectivity and thickening primarily involving the inner retinal layers on optical coherence tomography (OCT). There also was a band-like hyper-reflective area in the middle retina consistent with paramacular acute middle maculopathy. Transthoracic echocardiogram (TTE) showed a mobile echodensity on the anterior aortic leaflet consistent with a diagnosis of endocarditis. Elisa assays performed on paired serum samples collected 2 weeks apart showed increase in antibodies against C burnetii from 60 IU/ml to 255 IU/ml. The patient was treated with doxycycline 100 mg twice a day for 18 months, with subsequent resolution of the endocarditis. Sequential ocular examinations showed gradual resolution of all acute retinal findings without visible scars. CONCLUSION: Acute Q fever, caused by C burnetii infection, should be considered in the differential diagnosis of acute multifocal retinitis. A systematic cardiac assessment with echocardiography is essential for early diagnosis of associated endocarditis and for prompt administration of appropriate antibiotic treatment to improve clinical outcomes.

Heterozygous factor V Leiden mutation manifesting with combined central retinal vein occlusion, cilioretinal artery occlusion, branch retinal artery occlusion, and anterior ischaemic optic neuropathy: a case report.

BACKGROUND: Our purpose was to describe a patient who developed combined central retinal vein occlusion (CRVO), cilioretinal artery occlusion, branch retinal artery occlusion (BRAO), and anterior ischaemic optic neuropathy (AION) followed by CRVO in the second eye because of the heterozygous factor V Leiden (FVL) mutation. CASE PRESENTATION: A 39-year-old female with a history of recurrent pregnancy losses presented with acute blurred vision in the right eye (RE), with visual acuity limited to counting fingers. She was diagnosed with combined impending CRVO, cilioretinal artery occlusion, BRAO, and AION. The results of thrombophilia testing, not including the FVL mutation, were negative. Retinal atrophy with vascular attenuation and optic disc pallor developed after resolution of acute retinal findings. Nine months after initial presentation, the patient developed an impending CRVO in the left eye (LE), with a secondary progression to a complete CRVO causing a decrease in best corrected visual acuity (BCVA) to 20/40. The patient was determined to be heterozygous for the FVL mutation. She subsequently was treated with acenocoumarol. At the last follow-up visit, the BCVA was 20/400 in the RE and 20/20 in the LE, and there was a complete resolution of the acute CRVO findings in the LE. CONCLUSION: Our case shows that the heterozygous FVL mutation may manifest with combined retinal vascular occlusion involving multiple sites in both eyes. Early recognition of such an inherited thrombophilic disorder is important because it implies the need for long-term anticoagulative therapy to reduce the patient's risk of recurrent, sight-threatening and life-threatening thrombotic events.

[Maladies cardiaques et Ramadan : revue de la littérature]. / Cardiovascular disease and Ramadan. A literature review.

We review the literature on the safety of fasting in cardiac patients. We examined the changes of blood pressure among hypertensive patients and the incidence of cardiac events during Ramadan in patients with coronary disease and heart failure. We also assess the modifications of INR levels in cardiac patients who take oral anticoagulant. We found that Ramadan fasting is safe in stable cardiac patients, even under several drugs. Fasting does not affect blood pressure. There is no difference in regards to cardiac event incidence between Ramadan and the non-fasting-months. The level of INR is slightly higher when fasting, it is thus recommended to monitor patients with high bleeding risk during Ramadan.

Predictive echocardiographic factors of severe obstructive sleep apnea.

INTRODUCTION: obstructive sleep apnea (OSA) is a common chronic pulmonary disease, characterized by repetitive collapse of the upper respiratory airways, leading to oxygen desaturation. This condition is recognized to be associated with cardiovascular disease. Several studies have shown the effects of OSA on both geometry and cardiac function, with conflicting results. We aimed to investigate the relationship between echocardiographic abnormalities and the severity of OSA. METHODS: this is a cross-sectional single center study including patients, without any cardiovascular or pulmonary comorbidities, with polygraphy proven OSA. All participants underwent a detailed transthoracic echocardiography (TTE). RESULTS: a total of 93 patients were included in the study, with 62.2% (n=56) females. According to the apnea hypopnea index (AHI), patients were divided into two groups: mild to moderate OSA (5≤ AHI< 30/H) and severe OSA (AHI≥ 30/H). There were no differences in baseline characteristics between the two groups. The assessment of echocardiographic parameters demonstrated that severe OSA have a higher left ventricular end-systolic (LVES) (47.6±7.2 VS 46.2±4.7), left ventricular end-diastolic (LVED) (31.3±6.2 VS 28.9±4.5) diameters and interventricular septum (IVS) thickness (12.7±2.4 VS11.7±2.5) diameters rather than mild to moderate OSA without a significant difference between the two groups. Furthermore, severe OSA patients had lower mean value of left ventricular ejection fraction (LVEF) and fractional shortening (FS) equal to 62.1±9.7 and 32.5±6.3 respectively. The difference between the two groups was not statistically significant. However, a significant association was shown between severity of OSA and left ventricular (LV) diastolic dysfunction, right ventricular internal diameter (RVID) and systolic pulmonary artery pressure (sPAP), with p=0.05, p=0.05 and p= 0.03 respectively. The RVID was also independently associated to the severity of the OSA (aOR 1.33, 95%CI: 0.99-1.79; p=0.05). CONCLUSION: using bidimensional echocardiography showed a relationship between severe OSA and right ventricular parameters (diastolic dysfunction and RVID) and sPAP.

Angioplasty of Anomalous Coronaries Arising from the Opposite Sinus with an Interarterial Course, is it Safe?

BACKGROUND: The coronary artery with an interarterial course CAIAC is the most threatening coronary anomaly, especially if it concerns the left coronary. Percutaneous coronary intervention PCI is scarcely described given its low prevalence and lack of long-term outcome data. Therefore, we assessed through this case series the feasibility and safety of PCI in this population. METHODS: This is an observational multicentric study including patients with CAIAC arising from the opposite sinus of Valsalva. The primary endpoints were immediate angiographic success and target lesion revascularization. RESULTS: During the period of the study, we performed 27235 PCI in six Cath labs, 26 procedures concerning abnormal coronaries including 12 with CAIAC. The median age was 57 years extremes: 43-78 with male predominance 1:11. Anomalous coronary artery was Right coronary artery RCA in eight patients, Left main LM in three patients, and left anterior descending LAD in one patient. The stenosis was located in all cases in proximal segments beyond the inter-arterial course proximal LAD, the superior genius of the RCA, or the proximal segment of mid-RCA. Five patients showed slit-like ostium and all have an angle take-off <45° on CT scan. After a median follow-up of 24 months, four subjects presented target lesion revascularization TLR, all were initially treated with either a bare-metal stent or with balloons. CONCLUSIONS: PCI of patients with CAIAC is feasible and appears safe. The operator should carefully analyze the angiogram before PCI to choose the appropriate guiding catheter and should be acquainted with the different techniques for improving backup.