Cardiovascular complications among hematopoietic cell transplantation survivors - the role of cardiomarkers.

BACKGROUND: Allogeneic hematopoietic stem cell transplantation (HSCT) offers potentially curative therapy for numerous malignant and nonmalignant diseases. The number of survivors and length of follow-up after successful HSCT is continually increasing. HSCT can induce damage of various organs and tissues - from minimal potentially progressive subclinical changes to life-threatening conditions. The aim of this thesis was to assess the prognostic value of high sensitive cardiac troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing and early identification of patients at high risk of a cardiac event after allogeneic HSCT. PATIENTS AND METHODS: Sixty-three patients with the median age of 37 years at the time of allogeneic HSCT for hematologic diseases were studied. Cardiac bio-markers were serially measured before conditioning regimen and at days 1, 14 and 30 after HSCT. Cardiac systolic and diastolic functions were assessed before the conditioning regimen and 1 month after HSCT by echocardiography. RESULTS: The differences in plasma NT-proBNP and hs-cTnT concentrations during the 30 days following HSCT were statistically significant (P < 0.001 vs. P = 0.02). Seven of 63 patients (11.1 %) developed a cardiac event defined as cardiovascular dys-rhythmias, pericarditis with cardiac tamponade and heart failure. By multivariate analysis, the strongest prognostic factor of cardiac event was an increased level of hs-cTnT and NT-proBNP persisted for a period of 14 days after HSCT (P < 0.0001). The area under the curve from hs-cTnT testing plus NT-proBNP testing together (AUC = 0.95) was superior to each dia-gnostic modality alone. CONCLUSION: Measurements of plasma NT-proBNP and hs-cTnT concentrations might be a useful tool for identification of high-risk patients requiring further cardiological follow up. Measurement of hs-cTnT plus NT-proBNP together was superior to hs-cTnT and NT-proBNP measurements alone.

Prognostic value of echocardiography and ECG in heart failure with preserved ejection fraction.

OBJECTIVE: The aim of this study was to evaluate characteristics of patients with heart failure (HF) with preserved ejection fraction (HFPEF) and to assess prognostic predictors in 2-year follow-up. METHODS: We included prospectively 109 patients admitted to the internal department for HF, grouped into HFPEF (EF>40 %, n = 63) and HF with reduced EF (HFREF) (EF≤40 %, n=46). Preserved right ventricular systolic function (PRV) was defined as the peak systolic tricuspid annular velocity (S') >10.8 cm/s. RESULTS: HFPEF and HFREF patients had non-significantly different 2-year all-cause and CV mortality (28.6 % vs 37.0 %, 17.5 % vs 21.7 %). Patients with HFPEF and PRV vs dysfunctional RV had a better survival (76.6  % vs 56.3 %, p=0.045). In HFPEF, the patients who survived had a trend to better S' (13.6±3.1 cm/s vs 11.9±3.4 cm/s, p=0.055), shorter QTc (427±42ms vs 454±42ms, p=0.058), and all-cause mortality was lowered only by anticoagulants (12.0 % vs 39.5 %, p=0.02). QTc interval and PRV emerged as predictors of all-cause mortality (HR 1.7 per 40 ms change, 95  % CI 1.1-2.6, p = 0.02, HR 0.38, 95 % CI 0.15-0.93, p=0.03). CONCLUSIONS: In HFPEF, we observed a trend to lower all-cause and CV mortality compared to HFREF and anticoagulants were the only therapy that significantly lowered mortality. PRV and QTc interval emerged as independent predictors of survival (Tab. 6, Fig. 2, Ref. 26).

Blood pressure impact on left ventricular geometry in chronic haemodialysis patients.

AIM: Left ventricular hypertrophy in chronic haemodialysis patients is multifactorial. Our aim was to evaluate retrospectively the relationship between 24-h blood pressure monitoring and geometry and function of left ventricle (LV). Patients a methods: We examined 50 patients (men/women 33/17) treated by chronic haemodialysis (>3 months) aged 57.5 years (53-63; median, interquartile range). We measured blood pressure during 24 hours in short interdialytic period using Spacelab monitor 90217. Echocardiography was provided in short interdialytic period. RESULTS: Left ventricular mass index significantly correlated with SBP (tau-b=0.21; p=0.030; 95%CI 0.01-0.42), DBP (tau-b=0.23; p=0.018; 95%CI 0.04-0.42) and MAP (tau-b =0.26; p=0.009; 95%CI 0.06-0.45). SBP, DBP, MAP and PP did add a significant information to the prediction of relative wall thickness. We did not find any relationship between BP and left ventricular ejection fraction, left ventricular enddiastolic diameter and left atrial size. CONCLUSION: We found out an important 24-hour blood pressure impact on left ventricular relative wall thickness and left ventricular mass index. Left ventricular ejection fraction, left ventricular enddiastolic diameter and left atrial size were not related to 24-hour blood pressure. We did not find a relationship between blood pressure and left ventricular enddiastolic diameter. From all diastolic parameters the strongest association was found between systolic blood pressure in all three phases and ratio of peak early to late diastolic filling velocity (Tab. 5, Ref. 19).

Mediastinal foregut duplication cyst of enteric type containing a persistent thymus, imitating a pericardial cyst.

UNLABELLED: Mediastinal foregut duplication cysts are rare congenital masses caused by developmental disorders of the anterior part of the embryonic primitive gut. In adults they can be discovered as an incidental finding on chest radiograph. They can mimic other intrathoracic pathologies as it was initially the case in our patient. A 51-year-old woman was incidentally found to have homogenous mass at the right cardiophrenic angle on the chest radiograph. Based on that finding and echocardiography a pericardial cyst was suspected. Computed tomography demonstrated a simple anterior mediastinal cyst. Because of the growth with a mild progression of the compression of the right atrium, the cyst was resected. Histology and immunohistochemistry revealed the mass to be a mediastinal foregut duplicatory cyst of enteric type containing persistent thymus. To our knowledge, this is the first report in which a mediastinal foregut cyst contained both enteric mucosa and ectopic persistent thymus (Fig. 9, Ref. 13). KEYWORDS: foregut cyst, mediastinal cyst, thymus, enteric cyst, pericardial cyst.

[The role of transesophageal echocardiopgraphy in detection of cardiogenic and aortic sources of embolism in stroke and transient ischaemic attacks]. / Význam transezofageálnej echokardiografie v detekdii kardiogénnej a aortálnej embolizácie pri loziskovej ischémii mozgu a tranzitórnych ischemických atakoch.

OBJECTIVES: To prospectively investigate the prevalence of definite and potential sources of cardiogenic embolism and embolism from ascending aorta and aortic arch in patients with a cryptogenic stroke or transient ischaemic attack (TIA). MATERIAL/METHODS: The study group consisted of 218 consecutive patients (146 males, mean age 59.4 +/- 11.5, range 38-83 years) without significant stenoses of carotic and vertebral arteries. All patients underwent biplane/multiplane transesophageal echocardiography (TEE). 77.5% of patients suffered a stroke and 22.5% had a TIA. Sinus rhythm was in 74.8% of the patients, atrial fibrillation in 22.0% and pacemaker rhythm in 3.2%. RESULTS: 1. Definite source of embolism was identified in 21.6% of patients. The most frequent finding was a thrombus of the left atrial (LA) appendage - 12.4%. Less frequently found were mobile thrombus of aortic arch - 3.7%, thrombus of LA body - 2.3%, left ventricular thrombus - 2.3%, thrombus of valvular prosthesis - 1.4% and heart tumor - 0.5%. 2. The total prevalence of potential sources of embolism was 61.5%. Only potential source (without definite source) was demonstrated in 52.3% of patients. Very frequently were found patent foramen ovale - 58.3% and atherosclerosis of ascending aorta or aortic arch - 53.7%. Further sources were LA spontaneous echocontrast - 21.1%, reduced function of LA appendage - 18.3%, atrial septal aneurysm - 7.8%, atrial septal defect - 1.4%, cardiac foreign body - 0.5%. 3. TEE did not reveal any source of embolism in 26.1% of patients. CONCLUSIONS: 1. 21.6% of the patients suffering from stroke/TIA without hemodynamically significant stenoses of extracranial cerebral arteries had a definite cardiogenic or aortic source of embolism, 2. additional 52.3% of patients had only potential source of embolism (without definite source), 3. we consider TEE necessary in patients with stroke/TIA without a known etiology, despite complete neurological examination and transthoracic echocardography.

[Effectiveness and safety of adenosine in the therapy and diagnosis of arrhythmias]. / Ucinnost' a bezpecnost' adenozínu v terapii a diagnostike arytmií.

Adenosine is a drug with unique clinical and electrophysiological properties. Despite this, its use in Slovakia is rare. The decisive reason, besides its price, is the physicians fear of potential adverse effects and their limited knowledge regarding its clinical use. This study was aimed at analysis of the contribution of adenosine to the treatment and diagnostics of arrhythmias and evaluation of its safety. We studied the effect of adenosine in 62 patients. Adenosine terminated paroxysmal supraventricular tachycardia (PSVT) in 16 of 44 patients (36.4%) and in another 21 patients (47.7%) we revealed the type of unclear PSVT. We observed contribution to the diagnostics of wide QRS complex tachycardia in 3 of 6 patients (50.0%). Latent ventricular preexcitation was induced in 2 of 12 patients (16.7%). Subjective complaints after adenosine were frequent (at least 1 symptom in 80.6% patients), but all of them were of short duration and clinically not significant. We did not observe any relevant complication of adenosine. The average maximal RR interval after adenosine was 1.75 sec. We consider adenosine in adequately indicated patients with respect for its contraindications as highly effective drug in the treatment and diagnostics of specific arrhythmias.

Relation of ventricular late potentials and intradialytic changes in serum electrolytes, ultrafiltration, left ventricular ejection fraction and left ventricular mass index in haemodialysis patients.

BACKGROUND: End-stage renal failure patients on haemodialysis (HD) suffer from increased risk of sudden cardiac death. Abnormal late potentials (LP) on signal-averaged electrocardiogram (SAAECG) has proved valuable for identification of increased risk of malignant ventricular tachyarryhythmias in various settings of patients. Abnormalities in LP were reported in HD patients, but their role is still not clear. The aim of the study was to evaluate: 1. the influence of HD on SAECG, 2. the correlation of intradialytic changes of serum electrolytes, weight change and ultrafiltration with intradialytic changes of LP, 3. the correlation of left ventricular ejection fraction (LVEF) and left ventricular mass index (LVMI) with LP before and after HD. METHODS: LP (parameters fQRSd, RMS40, LAS40) were obtained in 39 patients in sinus rhythm within one hour before and after chronic maintenance HD. Patients with permanent atrial fibrillation or on antiarrhythmic therapy (other than betablockers) were excluded. Echocardiography was performed within three days before HD. RESULTS: No difference in fQRSd before and after HD was found. Postdialytic RMS40 (47.0 +/- 30.1 microV vs 37.1 +/- 22.6 microV, p < 0.05) and LAS40 (25.9 +/- 9.7 ms vs 30.8 +/- 12.5 ms, p < 0.05) significantly improved. Weak significant negative correlation between intradialytic Na change and fQRSd change was found (R = -0.33, p < 0.05). Correlations between intradialytic changes of other electrolytes (K, Ca, P. Mg) and individual LP parameters were nonsignificant. There was no correlation found between intradialytic weight change/ultrafiltration and intradialytic differencies of SAECG. LVEF was weakly inversely correlated with predialytic fQRSd (R = -0.37, p < 0.05) and postdialytic fQRSd (R = -0.35, p < 0.05). LVMI was weakly positively correlated with predialytic fQRSd (R=0.39, p < 0.05) and postdialytic fQRSd (R = 0.40, p < 0.05). LVEF respectively LVMI did not correlate neither with RMS40 nor with LAS40 before or after HD. CONCLUSIONS: SAECG partially improved in end-stage renal failure patients after HD (RMS40 and LAS40 but not fQRSd). Intradialytic differencies of SAECG were not correlated neither with ultrafiltration nor with weight change. Pre-/postdialytic fQRSd inversely correlated with LVEF and positively correlated with LVMI. Further controlled, prospective studies investigating the impact of LP on HD patient care are needed. (Tab. 6, Ref. 19.).

Importance of echocardiography in atrial fibrillation.

Echocardiography influences at present in decisive manner therapeutic approach to atrial fibrillation (AF). The paper discusses current knowledge regarding the role of echocardiography in routine management of cardioversion for AF and regarding the echocardiographic prediction of: 1. the thromboembolism in AF, 2. the efficiency of cardioversion for AF, 3. the maintenance of sinus rhythm after successful cardioversion for AF. The advantage of TEE-guided cardioversion is particularly emphasized.

[Left ventricular remodeling in arterial hypertension and its therapy]. / Remodelácia l'avej komory pri artériovej hypertenzii a jej terapeutické ovplyvnenie.

Left ventricular (LV) hypertensive remodeling has polymorphic character with broad spectrum of its geometry. Echocardiographically it is simply possible to distinguish 4 LV remodeling types: normal geometry, concentric remodeling, eccentric hypertrophy and concentric hypertrophy. In an overview article morphological, functional and prognostic characteristics of remodeled hypertensive LV are presented. Most adverse prognosis as regards cardiovascular (CV) morbidity and mortality is in LV concentric hypertrophy. As to the current knowledge LV hypertrophy regression can be considered for potential aim of the management of arterial hypertension, independent from blood pressure normalization. Removal of structural changes of the CV system due to arterial hypertension could be more important function of antihypertensive drugs than blood pressure reduction alone. Until now minimally 147 articles regarding the influence of antihypertensive treatment on LV hypertrophy regression have been published. According to them most effective drugs are angiotensin-converting enzyme inhibitors. A new idea has brought the HYCAR study, which has demonstrated, that low dose of ramipril without any antihypertensive effect significantly reduces LV hypertrophy. The results of the study "evoke" change in the management of arterial hypertension: the treatment with low dose of ramipril in indication of LV hypertrophy regression also in those hypertensive patients with formerly normalized blood pressure. The importance of LV hypertrophy regression for the prognosis must be however specified in large designed trials, because until now it is not exactly known.

[Transthoracic echocardiography in the early phase of acute myocardial infarct]. / Transtorakálna echokardiografia vo casnej fáze akútneho infarktu myokardu.

The authors present an article reviewing the fundamental importance of transthoracic echocardiography in the early phase of acute myocardial infarction (AMI). They refer to its significance in the diagnostics and differential diagnostics statements of AMI and its complications, evaluation of left ventricular systolic and diastolic function. The authors emphasize its possibilities in risk stratification and prognostic evaluation of the patients after AMI. Regarding the valuable possibilities of transthoracic echocardiography which in a decisive manner often determine the further diagnostic and therapeutic procedures, the authors postulate that this procedure should be performed in each patient with AMI already in early phase. They consider the inaccessibility of early bed-side transthoracic echocardiography as a management failure. (Fig. 2, Ref. 72.).

[Specialized echocardiographic modalities in the early phases of acute myocardial infarct]. / Prínos specializovaných echokardiografických modalít vo vcasnej fáze akútneho infarktu myokardu.

The authors present the clinical contribution of specialized echocardiographic methods in the early phase of acute myocardial infarction (AMI)--stress echocardiography, myocardial contrast echocardiography, transesophageal echocardiography, as well as some latest technologic modalities (tissue doppler imaging, automatic endocardial detection, digital image processing). These methods frequently render fundamental information about the patient after AMI, but with regard to the relatively short period of their clinical use, some unsolved problems remain to be answered. Meanwhile, there exists only limited experience with specialized echocardiographic modalities after AMI in Slovakia. (Fig. 2, Ref. 53.)

[Coronary thrombosis--pathogenic basis of acute coronary syndromes]. / Koronárna trombóza--patogenetický základ akútnych koronárnych syndrómov.

Acute coronary syndromes (unstable angina pectoris, acute myocardial infarction, sudden heart death) present an important part of cardiovascular and total morbidity and mortality. The common pathogenetic mechanism of them is the break of integrity of "stable" atherosclerotic plaque through fissure or rupture with following dynamic occlusion of coronary artery. In dynamic occlusion take part coronary vasoconstriction and dominant coronary thrombogenesis. Summary review of pathogenesis of coronary thrombosis aimed at origin of "unstable" atherosclerosis plaque, importance of vessel wall factors, rheologic factors and thrombocytes is presented in the paper. Morphologic and structural characteristics of "primary" atherosclerotic plaque and of coronary artery lesions in concrete acute coronary syndromes are described. From the point of view of clinical practice the authors draw attention to the basic importance of thrombin and residual thrombosis in acute coronary syndromes. Presented pathogenetic aspects of coronary thrombogenesis justify newer therapeutic approaches, which are in the phase of intensive research.

[Neurohumoral activation and remodeling after acute myocardial infarct and the effect of angiotensin-converting enzyme inhibitors]. / Neurohumorálna aktivácia a remodelácia po akútnom infarkte myokardu a ich ovplyvnenie inhibítormi angiotenzín-konvertujúceho enzýmu.

Neuroendocrine activation, which begins early after myocardial injury, participates significantly in the pathogenesis of acute myocardial infarction and its complications. Plasma concentrations of catecholamines, arginine vasopressin and atrial natriuretic factor were highest on admission. Activation of the renin-angiotensin-aldosterone system reached its peak after 72 hours. In patients with acute myocardial infarction and heart failure the neuroendocrine activation was more intensively expressed. This study presents clinical consequences of neuroendocrine activation. Its relation to ventricular remodeling, as a potentially maladaptive mechanism is especially discussed. Angiotensin-converting-enzyme inhibitors influence favourably both neuro-endocrine activation and ventricular remodeling after myocardial infarction. At present 7 ongoing extensive multicenter trials are to determine if such a therapy would lead to a better survival and attenuate the progressive deterioration of heart function after myocardial infarction. (Fig. 2, Ref. 24.)

[Pathogenesis of myocardial ischemia and acute coronary syndromes]. / Patogenéza ischémie myokardu a akútnych koronárnych syndrómov.

Since the seventies, and in particular the eighties of this century, findings on pathogenetic mechanisms of ischaemic heart disease are expanding markedly and are becoming more accurate. This makes it possible to know and understand better factors which influence the genesis and development of myocardial ischaemia including the most serious clinical forms (unstable angina pectoris, acute myocardial infarction and sudden cardiac death). Diminution of the cardiac flow and/or increased oxygen demands of the heart muscle are not the only determinants of myocardial ischaemia which is influenced markedly also by neurohumoral, metabolic, prothrombotic (proaggregation and procoagulation) factors as well as antithrombotic and haemodynamic factors. Acute coronary syndromes have as a rule, in particular in patients with out severe atherosclerotic stenosis of the coronary arteries, a common pathophysiological mechanism of fissuration of the atherosclerotic plaque followed by different grades of dynamic coronary occlusion depending on vasoconstriction--spasm of the coronary arteries and thrombus formation. The coronary arteries, usually affected with atherosclerosis, may be due to the comprehensive action of various factors temporarily, intermittently or permanently occluded. In case of the development of acute coronary syndromes thrombosis plays a key role. Better knowledge of pathogenetic mechanism of IHD markedly changes views on treatment and management of patients with IHD in particular patients with acute coronary syndromes. The authors emphasize strategies focused (also preventively) on preventing progression of the disease with the aim to improve survival and the short-term and long-term prognosis.

[New pathogenic findings on the mechanism of heart failure and their importance in therapy]. / Novsie patogenetické poznatky o mechanizmoch srdcového zlyhania a ich význam pre liecbu.

Activation of the neuroendocrine system participates in a decisive way in the pathogenesis of cardiac insufficiency. The authors draw attention to the basic therapeutic impact of the phenomenon of so-called "down-regulation" of myocardial beta-adrenoreceptors which takes place during chronic cardiac insufficiency, contrary to acute cardiac failure. The authors deal from the pathogenetic aspect with different groups of positive inotropic substances used in the treatment of cardiac insufficiency with special attention to digoxin and cardiac glycosides. They evaluate the effect of digoxin as a neurohumoral modulator in acute and chronic cardiac insufficiency. Its potential asset is the positive modulation of excessive neuroendocrine activation and the favourable effect on cardiopulmonary baroreflexes. The authors explain also why at present among positive inotropic substances in the treatment of cardiac insufficiency only cardiac glycosides are indicated. They mention the theoretical possibility to extend the indication of digoxin to retard the progressive deterioration of cardiac function in asymptomatic dysfunction of the left ventricle caused by the neurohumoral modulating effect of digoxin.

[Pathogenesis and fundamentals of treatment in acute myocardial infarct]. / Patogenéza a zásady liecby akútneho infarktu myokardu v súcasnosti.

Recent findings which extend and render more accurate factors which influence the genesis and course of experimental and clinical acute myocardial infarction change in a significant way the treatment and management of patients with acute infarction. The authors discuss the basic factors and complex of interactions which play the most important part in the pathophysiology of acute infarction. They pay attention also to other factors which can influence in a significant way the course of acute infarction and the patient's prognosis (residual thrombosis, rethrombosis, extension, expansion of the infarction and remodelling of the left ventricle). In recent years it has become obvious that the most important determinants of the final extent of acute infarction is the duration and site of occlusion of the coronary artery, its recurrence and degree (magnitude), the condition of the collateral circulation and the consumption and requirements of the myocardium with respect to oxygen during the time of occlusion. The contemporary reperfusion-thrombotic era of treatment of acute myocardial infarction and management of the patient is based on logical multifactorial and to a certain extent preventive, active or aggressive approach and omission of all even potentially harmful approaches. All therapeutic operations (incl. invasive and radical ones) must be consistent with contemporary pathogenetic findings. They should be implemented before possible reinfarction, sudden cardiac death or treatment which has only little effect on heart failure which may be associated also with undesirable expansion of the infarction and remodelling of the left ventricle after acute myocardial infarction. Recent pathophysiological findings and the development of treatment of myocardial infarction are a challenge for cardiologists of the nineties to make use of these important findings in the treatment of patients with myocardial infarction and to ensure for them optimal treatment and management.