Altered plasma fibrin clot properties are associated with in-stent thrombosis.

OBJECTIVE: We sought to investigate whether patients with in-stent thrombosis (IST) display altered plasma fibrin clot properties. METHODS AND RESULTS: We studied 47 definite IST patients, including 15 with acute, 26 subacute and 6 late IST, and 48 controls matched for demographics, cardiovascular risk factors, concomitant treatment and angiographic/stent parameters. Plasma clot permeability (K(s)), which indicates a pore size, turbidity (lag phase, indicating the rate of fibrin clot formation, DeltaAbs(max), maximum absorbance of a fibrin gel, reflecting the fiber thickness), lysis time (t(50%)) and maximum rate of D-dimer release from clots (D-D(rate)) were determined 2 to 73 (median 14.7) months after IST. Patients with IST had 21% lower K(s), 14% higher DeltaAbs(max), 11% lower D-D(rate), 30% longer t(50%) (all P<0.0001) and 5% shorter lag phase compared to controls (P=0.042). There were no correlations between clot variables and the time of IST or that from IST to blood sampling. Multiple regression analysis showed that K(s) (odds ratio=0.36 per 0.1 microm(2), P<0.001), D-D(rate) (odds ratio=0.16 per 0.01 mg/L/min, P<0.001) and stent length (odds ratio=1.1 per 1 mm, P=0.043) were independent predictors of IST (R(2)=0.58, P<0.001). CONCLUSIONS: IST patients tend to form dense fibrin clots resistant to lysis, and altered plasma fibrin clot features might contribute to the occurrence of IST.

Aortic pulse wave velocity and carotid-femoral pulse wave velocity: similarities and discrepancies.

The objectives of this study were to determine the relationship between carotid-femoral (cfPWV) and aortic pulse wave velocity (aPWV) and to compare their modulators and association with coronary artery disease (CAD). We studied 107 consecutive patients (68 men) with a mean age of 60.49+/-8.31 years who had stable angina and had been referred for coronary angiography. cfPWV and aPWV were measured simultaneously during cardiac catheterization using the Complior device and aortic pressure waveform recordings, respectively. Based on the presence or absence of significant coronary artery stenosis (CAS) patients were subdivided into a CAS+ or CAS- group. The mean values of cfPWV and aPWV were 10.65+/-2.29 m/s and 8.78+/-2.24 m/s, respectively. They were significantly higher in the CAS+ (n=71) compared with the CAS- (n=36) group and predicted significant CAS independently of cardiovascular risk factors and mean or systolic aortic blood pressure. aPWV and cfPWV were significantly correlated (r=0.70; p<0.001) but the degree of correlation differed significantly (p<0.03) between the CAS+ (r=0.74, p<0.001) and CAS- group (r=0.46, p=0.003). Age and mean aortic blood pressure were independent predictors for aPWV as well as cfPWV. In the receiver operating characteristic (ROC) analysis, aPWV and cfPWV had similar accuracy in identification of significant CAS (AUC [area under the ROC curve]=0.76 and 0.69, respectively; p=0.13). However, neither cfPWV nor aPWV was effective at differentiating the extent of CAD. In conclusion, aPWV and cfPWV are highly correlated parameters with similar determinants and comparable accuracy in predicting significant CAS. The strength of correlation between these two indices differed significantly between subjects with and those without CAS.

[Alcohol ablation of the interventricular septum in a patient with hypertrophic obstructive cardiomyopathy complicated by an increase in the pressure gradient in the left ventricular outflow tract. A case report]. / Ablacja alkoholowa przegrody miedzykomorowej u chorej z kardiomiopatia przerostowa zawezajaca powiklana zwiekszeniem gradientu cisnien w drodze odplywu lewej komory.

A case of a 70 year old female with hypertrophic obstructive cardiomyopathy who underwent alcohol ablation of the interventricular septum, is presented. Following the procedure, the pressure gradient decreased from 120 mmHg to 80 mmHg. However, 30 minutes after ablation the patients developed hypotension and pulmonary oedema. Echocardiography revealed a significant systolic anterior movement of the anterior leaflet of the mitral valve and elevated pressure gradient up to 200 mmHg. The patient underwent urgent surgery (myectomy), followed by the mitral valve replacement with a favourable outcome.

Markers of pulmonary hypertension in potential candidates to heart transplantation.

BACKGROUND: Pulmonary hypertension (PH) with pulmonary vascular resistance (PVR) 320-480 ARU resistant to therapy is a contraindication for orthotopic heart transplantation (HTX). AIM OF THE STUDY: evaluation of pulmonary hypertension in candidates for heart transplantation. STUDY POPULATION AND METHODS: 44 patients (pts) with dilated cardiomyopathy (Group I) and 34 patients with ischemic heart disease (Group II) were assessed. Evaluation of PH was done according to the following protocol: 1st measurement (cardiac catheterization): PVR (pulmonary vascular resistance) > or = 320 ARU--infusion of NTG (nitroglycerine) 1 microg/kg/min. (during 10 min.), 2nd measurement: PVR > or = 320 ARU--infusion of NTG 2 microg/kg/min. (during 10 min.), 3rd measurement: final PVR evaluation. If PVR was less than 320 ARU in 2nd or 3rd measurement, the reversibility of PH was diagnosed, and when PVR > or = 320 ARU was observed in 3rd measurement, fixed PH was diagnosed. RESULTS: No significant difference in baseline PVR between the groups was observed (Group I--332,7 ARU and Group II--327.6 ARU). In 23 patients with PVR > or = 320 ARU reduction of mean values of PVR, MPAP (mean pulmonary artery pressure) and TPG (transpulmonary gradient) was seen (p < 0.001), significantly more prominent in 11 pts from Group I. There was no correlation between duration of the disease and degree of PH. HTX was performed in 25 patients. PVR at 72 hours after HTX was similar in 7 pts with reversible PH and 18 pts with PVR < 320 ARU in 1st measurement. CONCLUSIONS: 1. Nitroglycerine used according to the protocol is sufficient in determining PH. 2. The reversibility of PH could depend on type of cardiomyopathy but not directly on symptom duration.

[The use of tissue Doppler imaging for the diagnosis of restenosis after percutaneous coronary revascularisation]. / Zastosowanie tkankowej echokardiografii dopplerowskiej w diagnostyce nawrotu zwezenia tetnicy wiencowej po zabiegu rewaskularyzacji przezskórnej.

UNLABELLED: OBJECTIVE AND AIM OF THE STUDY: Diagnosis of restenosis after percutaneous transluminal coronary angioplasty (PTCA) is difficult due to low sensitivity and specificity of widely used methods. The aim of the study was to evaluate the usefulness of tissue Doppler Imaging (TDI) in the diagnosis of restenosis in comparison with the results of clinical examination, electrocardiographic exercise test (ETT) and wall motion score index (WMSI) analysis. MATERIAL AND METHODS: 22 patients (18 males, 4 females) aged 46-69 with coronary artery disease who underwent PTCA, with restenosis of widen artery found during one-year follow-up. The angioplasty of anterior descending artery was made in 16 patients, circumflex artery was widened in 2 patients, right coronary artery in 4 patients. Clinical and echocardiographic examinations, ETT and TDI were made in all the patients before PTCA, one month after PTCA and during restenosis before control coronary angiography. In TDI examination maximal systolic and maximal early diastolic velocities of myocardium were determined in 18 left ventricle segments. RESULTS: After the procedure significant decrease of clinical symptoms and ST depression during ETT were found. Restenosis resulted in recurrence of clinical symptoms and ETT parameter worsening. No significant changes in the mean values of left ventricle ejection fraction was observed after PTCA or during restenosis. Mitral inflow E/A ratio was decreased before PTCA, after PTCA and during restenosis. In 12 (55%) patients despite significant coronary artery stenosis, WMSI was normal (1.0) both before PTCA, after PTCA and during restenosis. In 10 (45%) patients with anterior descending artery stenosis regional contractility disturbances were found before PTCA. After revascularisation WMSI decreased in only 4 patients. During TDI examination in patients with contractility disturbances before PTCA, revascularisation resulted in significant systolic myocardial velocity increase, and restenosis was manifested by renewed systolic myocardial velocity decrease. Early diastolic myocardial velocities in ischaemic segments were significantly decreased before PTCA in all the patients, and no increase were found despite effective PTCA. CONCLUSIONS: Significant coronary artery stenosis leads to left ventricle diastolic function disturbances, however may not result in systolic dysfunction. After PTCA procedure significant systolic left ventricle function improvement, expressed by increase of systolic myocardial velocity in ischaemic segments, no changes of diastolic left ventricle function is seen. Restenosis in patients after PTCA is manifested by renewed decrease of systolic myocardial velocity in ischaemic segments.

[Right ventricular infarction: novel modalities of treatment]. / Zawal miesnia prawej komory serca: nowe sposoby leczenia.

Acute right ventricular infarction (RVI) is usually caused by proximal occlusion of the right coronary artery. RVI is frequent, as it occurs in as many as one out of every two left ventricular interior and/or posterior wall infarctions. The involvement of the right ventricle in acute myocardial infarction has been shown to be associated with an increased risk of life-threatening arrhythmias and sudden cardiac death. Clinical course of RVI can vary from being completely silent to cardiogenic shock (seen in 10-15% patients with inferior wall infarction). RVI diagnosis is based on clinical signs (hypotension and increased jugular venous pressure while pulmonary fields are clear), ECG (ST elevation by > or = 1 mm in V4R), echocardiography (right ventricular wall regional motion abnormalities and/or right ventricle distension, paradoxical motion of the interventricular septum, tissue Doppler), technetium pyrophosphate scanning with ventriculography, and invasive patient monitoring. In addition to its important diagnostic part, the invasive patient monitoring plays a key role in risk stratification and can dynamically guide the treatment (such as fluid loading). In most cases, successful reperfusion in the infarct-related artery territory can be achieved by interventional management (i.e. angioplasty) or--if the latter is not available--by thrombolytic therapy. Patients with arterial hypotension require volume expansion which is best guided by the central venous pressure (CVP; a measure of the right atrial pressure, RAP) and the pulmonary capillary wedge pressure (PCWP). If the hemodynamics does not improve despite optimal fluid loading, pharmacological (catecholamine infusion) or mechanical (intra-aortic balloon pump) circulatory assistance needs to be implemented. Patients with significant sinus bradycardia or 3rd degree AV block may require temporary cardiac pacing. In addition, inhalatory nitric oxide (iNO) has been shown to reduce right ventricular afterload in a selective manner and its potential clinical role is currently being evaluated. Within several months after RVI, the right ventricular performance improves in most patients, including those without successful reperfusion of IRA. Such patients, however, have an increased risk of complications (including sudden death) while the recovery of right ventricular function is slow.

[Vasodilatator testing with nitric oxide (bronchial control treatment system--BCTS) in patients with pulmonary hypertension]. / Testy wziewnego, sterowanego oddychaniem podawania tlenku azotu u chorych z nadcisnieniem plucnym.

Nitric oxide (NO) is one of the most important mediators produced in the human organism. It participates in the regulation of blood vessel lumens, activation of leucocytes and platelet; it is a mediator in the nervous system and in inflammation reactions. It was proved that in cases of patients with pulmonary hypertension, a decreased secretion of nitric oxide and an increased synthesis of endothelin-1 is observed. Therefore, in case of patients with pulmonary hypertension the exogenous, inhaled nitric oxide (iNO) is applied. It is added to the respiratory mixture and it passes through the alveolar-capillary barrier to the smooth muscle cells where it activates a guanyle cyclase, similarly to the physiologically produced nitric oxide. It was proved that it decreases pulmonary vascular resistance (PVR) and pulmonary artery pressure (PAP). Inhaled nitric oxide is applied for treatment purposes to patients after cardiosurgical operations, mainly heart transplantation and correction of valvular defects with accompanying pulmonary hypertension, as well as after implantation of the left ventricular assist device in order to relieve the right chamber. In case of patients qualified for cardiosurgical operations with the accompanying pulmonary hypertension as well as in case of patients with the arterial pulmonary hypertension a diagnostical test using iNO is carried out in order to determine further course of therapeutical treatment. The application of the new method of iNO administration by the BCTS (Bronchial Control Treatment System) method allows for a precise administration of accurately determined doses of iNO and its full utilisation through addition to the respiratory mixture in the initial phase of inspiration. The risk of side effects is also decreased; so far no influence on the circulatory system or an increase of the level of methemoglobin was observed.

[Angiosarcoma (hemangiosarcoma) cordis]. / Naczyniakomiesak krwionosny serca.

The case of a young 32 year old male with a primary cardiac angiosarcoma is reported. The neoplasm manifested itself by a quickly increasing cardiac tamponade but without metastases. The nonradical resection of the tumor was made because of local invasion with tumor tissue. The patient was followed-up for 3 years after the surgery and no recurrence of the malignant process was observed. Cardiac angiosarcoma is a very rare malignant tumor of soft tissues. In spite of significant progress in clinical treatment, for a patient diagnosed antemortem with cardiac angiosarcoma, the long-term expectations are usually very poor. Commonly known risk factors for this group of neoplasms (haemangioma of skin, chroniclymphedema, chronic post-tuberculosis pleurisy, X-ray, thorium dioxide) cannot be easily associated with the primary cardiac angiosarcoma cases. The search for chromosomal anomalies and gene mutations leading to cardiac angiosarcoma is ongoing. There is hope that recently obtained evidence for mutation of the p53gen, will provide a better understanding of this heart neoplasia.

[Prognostic value of results from clinical tests, echocardiographic, electrocardiographic and spiro-ergometric exercise test examinations in patients with heart failure]. / Wartosc rokownicza wyników badan klinicznych, echokardiograficznych, elektrokardiograficznych i wysilkowych testów spiroergometrycznych u chorych z niewydolnoscia serca.

UNLABELLED: The aim of this study was to assess the importance of the non invasive procedures in determinating prognosis of patients with heart failure (HF). MATERIAL AND METHODS: We investigated 110 patients with a mean age of 52.1 (65 patients--59%) with chronic (HF) due to coronary artery diseases and dilated cardiomyopathy (45 patients--41%). All the patients underwent baseline evaluations including a clinical status, echocardiography, Holter monitoring and a cardiopulmonary exercise test (CPX). After the mean follow-up period of 28.5 +/- 12 months, the patients were divided into 2 groups: Group I--in which 78 patients survived without heart transplantation (HTX) and Group II--in which 20 patients died and 12 underwent HTX. The relationship between the variables derived from noninvasive procedures was assessed using multivariate Cox proportional hazards models. RESULTS: Compared to group I, Group II had a significantly higher number of patients that were classified into NYHA class III. In addition, a third heart tone was identified more often in group II and an increased number of HF etiology was due to ischemia. Electrocardiographic recording showed an increased frequency of left bundle branch block and complex ventricular arrythmias. Markedly increased values of WSLK, OKSLK, WLP, OKRLK and FW were found in group II, as compared to group I. Cardiopulmonary exercise tests in group II revealed lower values of T, VO2AT, SBPpeak, VO2peak, VO2peak%N, PETCO2peak as well as VD/VTpeak, VE/VO2peak, and VE/VCO2peak. After multivariate analysis lope VE/VCO2peak (p = 0.009), peak oxygen uptake VO2peak-%N (p = 0.035), (p = 0.036), left ventricle end systolic volume (p = 0.045) and left bundle branch block (p = 0.046) were independent predictors of survival without heart transplantation. CONCLUSION: On multivariate analysis by the Cox proportional hazards method, the variables: VE/VCO2peak, VO2peak%N, etiology--CAD, OKSLK, and left bundle branch block were independent prognostic predictors. The echocardio-graphic evaluation play a significant role in the assessment of prognosis in patients, with HF. The ejection fraction of the left ventricle was not confirmed as an independent prognostic factor in HF.

[Evaluation of patency of coronary artery bypass grafts and stents using multislice spiral computed tomography in comparison with angiography]. / Ocena droznosci pomostów aortalnowiencowych i stentów implantowanych do tetnic wiencowych metoda wielorzedowej spiralnej tomografii komputerowej w porównaniu z angiografia.

UNLABELLED: The aim of the study was to assess usefulness of multislice spiral computed tomography--MSCT (Somatom Plus 4 Volume Zoom, Siemens) in non-invasive assessment of the potency of coronary artery bypass grafts both venous and arterial grafts as well as stents. METHODS: The study was performed using the MSCT method with Heart View Software with retrospective electrocardiographic gating. Nonionic, hypo-osmolar contract media was infused into a peripheral vein to highlight the coronary arteries and bypasses. All patients, due to clinical indications, underwent coronary and bypass angiography. MATERIAL: Two group of patients (82 persons) in total were evaluated: after aorto-coronary bypassing (Group I--57 persons, incl. 40 males and 17 females) and after stent implantation (Group II--25 persons, incl. 19 males and 6 females). The patients were referred to invasive diagnostics for recurrence and aggravation of clinical symptoms. RESULTS: In group I, the patency of 187 bypasses was evaluated (21 arterial and 166 venous). In MSCT, was found in 131 of the bypasses patency (114 venous and 4 arterial). 56 bypasses, (52 venous and 4 arterial) were obstructed. In the bypassography performed were obstructed 53 (5 venous and 3 arterial), 134 bypasses were patent (116 venous and 18 arterial). In the bypass patency assessment using MSCT compared to coronarography, specificity of 94.7% and sensitivity of 92.4% were achieved. In group II, patency was evaluated in 26 stents: 21 implanted to native vessels and 5 in venous bypasses. 19 stents in native vessels were found patent, whereas 2 were obstructed. In the coronary bypasses performed, patency was confirmed in 19 stents and 2 were obstructed. In MST obstruction was demonstrated in 4 stents in coronary bypasses, which was confirmed in bypassography. One stent was assessed patient in both methods. CONCLUSION: The MSCT method is useful for assessment of patency of venous and arterial bypasses as well as stents.