Complexity of changes in right ventricular morphology and function in patients undergoing cardiac surgery - 3D echocardiographic study.

BACKGROUND: An impairment of standard echocardiographic parameters of right ventricular (RV) function is a known phenomenon in patients undergoing cardiac surgery, but its significance remains unclear. AIMS: This study aimed to assess changes in RV function in patients undergoing cardiac surgery using speckle tracking and 3D echocardiography. METHODS: The study population comprised 122 patients referred for cardiac surgery. Transthoracic echocardiographic (TTE) examinations were performed: before the surgery (TTE1), 1 week after surgery (TTE2), and 1 year after surgery (TTE 3). Parameters measured during these examinations included both standard and advanced indices of the RV size and function, as well as a new parameter introduced by our team - RV shortening fraction (RV SF). RESULTS: TTE1 was performed on average (standard deviation [SD]) 24 (15) hours before surgery, whereas TTE2 and TTE3 were performed on average 7.2 (3) days and 346 (75) days after the surgery, respectively. A postoperative impairment of parameters of RV longitudinal function was observed (P <0.001). However, neither the RV size assessed by both 2D and 3D techniques changed, nor the global RV function measured with the use of fractional area change and ejection fraction. Additionally, during the postoperative period, an increase in the value of an RV SF by 12.9% was observed. After 12 months we observed an improvement in the parameters of the longitudinal RV function. CONCLUSIONS: Uncomplicated cardiac surgery causes transient impairment of the longitudinal systolic RV function, with no influence on the global RV function. The preservation of global function results from increased RV SF. After 12 months, an improvement of the longitudinal function can be observed.

Splenic abcesses as infectious complication following implantation of left ventricular asssist device - case report.

Left ventricular assist device (LVAD) is one of the modern management therapies in patients with advanced heart failure, and it serves as a bridge to heart transplantation or even as destination therapy. However, it is burdened with a high risk of thromboembolic, hemorrhagic, and infectious complications despite prophylactic management. Splenic abscesses, as septic complications following implantation of mechanical ventricular support, have not yet been described in the literature. We report of a patient with severe left ventricular insufficiency (NYHA II/III), pulmonary hypertension, and arrhythmia who underwent implantation of the Heart Ware® pump for left ventricular support with simultaneous tricuspidvalvoplasty, as a bridge therapy to heart transplantation. During two years after LVAD implantation, the patient had three MRSA skin infections, localized at the exit site of the drive-line connecting the artificial ventricle with external unit, that were complicated by sepsis and treated with broad-spectrum antibiotics. A few months later, abdominal CT revealed two abscesses in the spleen, and the patient was qualified for splenectomy. Open splenectomy was performed under full-dose anticoagulant therapy with continuous intravenous infusions of unfractionated heparin (UFH). The intra- and postoperative course was uneventful. UFH therapy was continued for 6 days, and oral anticoagulation was re-administered on day 4 after surgery. The patient was discharged on day 7 after surgery with primary healed wound. Open splenectomy, performed with full-dose anticoagulant therapy, proved to be an effective and definitive method of treatment without any complications.

Endogenic erythropoietin secretion in patients undergoing off-pump coronary artery bypass grafting.

BACKGROUND: Erythropoietin (EPO) deficiency or inadequate EPO secretion in response to bleeding may result in profound or prolonged anaemia after cardiac surgery. AIM: The aim of the study was to evaluate the changes in EPO secretion in patients undergoing off-pump coronary artery bypass grafting (OPCAB). METHODS: Blood samples from 43 patients (mean age 65.1 ± 7.6 years) were obtained before surgery and on the 1st, 2nd, and 6th day post isolated OPCAB. EPO levels ≥ 4.3 mIU/mL were considered normal. RESULTS: Thirteen (30%) patients had the preoperative EPO level below normal range even though their preoperative haemoglobin was ≥ 13 g/dL. In patients with basal EPO deficiency lower peak EPO levels were observed compared to the group with normal basal EPO levels, even though reduction in haemoglobin concentrations was comparable in both groups. Moreover, lower reticulocytosis was noted on day 1 (8.5 ± 4.0‰ vs. 11.7 ± 4.4‰; p = 0.04) and a tendency toward lower values was seen on day 2 (9.6 ± 4.3‰ vs. 13.0 ± 5.8‰; p = 0.07) among patients with preoperative EPO deficiency. CONCLUSIONS: Erythropoietin deficiency is common in patients scheduled for OPCAB, and it results in diminished increase in EPO secretion in response to bleeding. Consequently, in patients with EPO deficiency, reticulocytosis is lower than it could be predicted based on the observation of patients with normal EPO levels and similar blood loss.

The effect of the sequential therapy in end-stage heart failure (ESHF)--from ECMO, through the use of implantable pump for a pneumatic heart assist system, Religa Heart EXT, as a bridge for orthotopic heart transplant (OHT). Case study.

BACKGROUND: Modern Polish medicine offers patients various treatments for end-stage treatment-resistant heart failure. Methods applied at the right time before the occurrence of irreversible changes in organs give a chance for survival and prolong life. CASE REPORT: Here, we report on the safety and efficacy of the sequential use of the above treatments in a 58-year old patient with heart failure in dilatative cardiomyopathy (DCM). A 7-day mechanical blood circulatory support and extracorporeal membrane oxygenation of blood (ECMO), followed by a 13-day implantation of a left ventricular assist device, Religa Heart EXT, was used as a bridge to a successful orthotopic heart transplant (OHT). On Day 40 after OHT, the patient was discharged home with stable function of the circulatory system. We describe our experiences with the qualification, preparation, and procedure of sequential ECMO, Religa Heart EXT, and OHT. CONCLUSIONS: Application of short-term ECMO as a bridge-to-bridge helped save the patient from severe cardiogenic shock caused by increased left ventricular afterload. The experimental implantation of an innovative Religa Heart EXT prosthesis was a safe and efficacious bridge to transplantation. Too short time of Religa Heart EXT implantation in the discussed patient prevented the possibility to evaluate the occurrence of thromboembolic complications and infections compared to the documented complications of POLVAD implanted until now. OHT is a safe and efficacious method of treatment of patients previously supported by ECMO and Religa Heart EXT.

The BAG3 gene variants in Polish patients with dilated cardiomyopathy: four novel mutations and a genotype-phenotype correlation.

BACKGROUND: BAG3 gene mutations have been recently implicated as a novel cause of dilated cardiomyopathy (DCM). Our aim was to evaluate the prevalence of BAG3 mutations in Polish patients with DCM and to search for genotype-phenotype correlations. METHODS: We studied 90 unrelated probands by direct sequencing of BAG3 exons and splice sites. Large deletions/insertions were screened for by quantitative real time polymerase chain reaction (qPCR). RESULTS: We found 5 different mutations in 6 probands and a total of 21 mutations among their relatives: the known p.Glu455Lys mutation (2 families), 4 novel mutations: p.Gln353ArgfsX10 (c.1055delC), p.Gly379AlafsX45 (c.1135delG), p.Tyr451X (c.1353C>A) and a large deletion of 17,990 bp removing BAG3 exons 3-4. Analysis of mutation positive relatives of the probands from this study pooled with those previously reported showed higher DCM prevalence among those with missense vs. truncating mutations (OR = 8.33, P = 0.0058) as well as a difference in age at disease onset between the former and the latter in Kaplan-Meier survival analysis (P = 0.006). Clinical data from our study suggested that in BAG3 mutation carriers acute onset DCM with hemodynamic compromise may be triggered by infection. CONCLUSIONS: BAG3 point mutations and large deletions are relatively frequent cause of DCM. Delayed DCM onset associated with truncating vs. non-truncating mutations may be important for genetic counseling.

Comparative analysis of the quality of life for patients prior to and after heart transplantation.

BACKGROUND: The aim of this study was to assess the quality of life of patients before and after heart transplantation (HTX). MATERIAL AND METHODS: We included 63 patients after a heart transplant under the care of the Transplantation Clinic. The authors' questionnaire was used, which consisted of 2 parts: questions concerning the life of patients before and after a heart transplant. The significance level was p<0.05. RESULTS: In the group before the heart transplant, average quality of life (on a 10-point scale) was 3.16 ± 1.47 and in the group after the heart transplant this factor increased to 7.60 ± 1.21 (p<0.00001). Our study shows that after the heart transplant people consider their physical health to be better. In the group before the heart transplant, the average assessment of physical health on a scale from 1 to 5 was 2.079 ± 0.79 and after the heart transplant it was 4.10 ± 0.39 (p<0.0001). No statistically significant correlations were indicated between the quality of life after the heart transplant and the quality of life before the transplant, age, sex, and time elapsed after the heart transplant. There was a positive correlation between the assessment of quality of life and that of physical (r=0.53; p<0.05) and mental health (r=0.45; p<0.05). CONCLUSIONS: The study shows that the quality of life of patients after the heart transplant was significantly improved in all spheres of life under analysis: physical, mental, social, and family. The results of the study indicate that patients associated the quality of life with their physical and mental health status.

Five-year outcomes in patients with left main disease treated with either percutaneous coronary intervention or coronary artery bypass grafting in the synergy between percutaneous coronary intervention with taxus and cardiac surgery trial.

BACKGROUND: Current guidelines recommend coronary artery bypass graft surgery (CABG) when treating significant de novo left main coronary artery (LM) stenosis; however, percutaneous coronary intervention (PCI) has a class IIa indication for unprotected LM disease in selected patients. This analysis compares 5-year clinical outcomes in PCI- and CABG-treated LM patients in the Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) trial, the largest trial in this group to date. METHODS AND RESULTS: The SYNTAX trial randomly assigned 1800 patients with LM or 3-vessel disease to receive either PCI (with TAXUS Express paclitaxel-eluting stents) or CABG. The unprotected LM cohort (N=705) was predefined and powered. Major adverse cardiac and cerebrovascular event rates at 5 years was 36.9% in PCI patients and 31.0% in CABG patients (hazard ratio, 1.23 [95% confidence interval, 0.95-1.59]; P=0.12). Mortality rate was 12.8% and 14.6% in PCI and CABG patients, respectively (hazard ratio, 0.88 [95% confidence interval, 0.58-1.32]; P=0.53). Stroke was significantly increased in the CABG group (PCI 1.5% versus CABG 4.3%; hazard ratio, 0.33 [95% confidence interval, 0.12-0.92]; P=0.03) and repeat revascularization in the PCI arm (26.7% versus 15.5%; hazard ratio, 1.82 [95% confidence interval, 1.28-2.57]; P<0.01). Major adverse cardiac and cerebrovascular events were similar between arms in patients with low/intermediate SYNTAX scores but significantly increased in PCI patients with high scores (≥33). CONCLUSIONS: At 5 years, no difference in overall major adverse cardiac and cerebrovascular events was found between treatment groups. PCI-treated patients had a lower stroke but a higher revascularization rate versus CABG. These results suggest that both treatments are valid options for LM patients. The extent of disease should accounted for when choosing between surgery and PCI, because patients with high SYNTAX scores seem to benefit more from surgery compared with those in the lower tertiles. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00114972.

Tick-borne infections as a cause of heart transplantation.

Many bacterial species can be a cause of various heart diseases, such as: Borrelia burgdorferi sensu lato, Coxiella burnetii and Bartonella spp. The aim of the present studies was to establish if any tick-borne infections can contribute to serious heart disorders resulting in the need for heart transplantation. Myocardium, aortic and mitral valve samples from hearts removed from patients undergoing heart transplantation were tested. The presence of Bartonella spp., Borrelia afzeli and C. burnetii bacteria in malfunctioning human hearts has been shown. DNA of Bartonella spp., B. burgdorferi and C. burnetii were detected in various parts of tested hearts. DNA of B. afzelii and Bartonella spp. were found in the aortic valves. DNA of C. burnetii was detected in the myocardium. Mixed infections with Bartonella spp. and C. burnetii were also observed. Obtained results indicate that diagnosis of Bartonella spp., B. burgdorferi C. burnetii and Rickettsia spp. infections should be considered in cases of infectious endocarditis with negative blood cultures.

Usefulness of the ultrastructural and immunohistochemical analysis of cardiac biopsy in affected heart.

In the last few years endomyocardial biopsy becomes a useful diagnostic tool for the investigation of idiopathic dilated cardiomyopathy. The aim of our current study was to try to identify ultrastructural and immunohistochemical specificity of truncated cardiac proteins in affected heart. The focal loss of plasma membrane continuity together with the lack of dystrophin activity in affected myocytes facilitated to find mutation in dystrophin gene. The accumulation of granulofilamentous desmin-positive material in cytoplasm of myocytes was the main indicator of presented mutation in the desmin gene. Nuclear structure remodeling, concomitantly with loss of lamin A/C activity, contributed to identify mutation in lamin A/C gene. Analysis of hypertrophic heart with disarray of sarcomeres and lack of I-Z-I bands suggested embryonic faiulure in titin activity. All this findings indicate that endomyocardial biopsy reperesent a useful method for a correct diagnosis of heart dysfunction.

Ultrastructural evidence of myocardial capillary remodeling in peripartum cardiomyopathy.

BACKGROUND: The etiology of peripartum cardiomyopathy (PPCM) is not well understood. Potential causal mechanisms include infection, autoimmune disease, and abnormal response to the hemodynamic stress of pregnancy. Recently it was shown that the development of PPCM in an experimental model is associated with the generation of a cleaved antiangiogenic and proapoptotic 16-kDa form of the nursing hormone prolactin, which impairs the cardiac capillary network and its function. The purpose of this study was to evaluate the ultrastructure of the myocardium in a patient with PPCM and in a comparative group of patients and to identify structural characteristics that may predispose to myocardium dysfunction. CASE REPORT: A 28-year-old woman with PPCM had fulminant heart failure leading to the implantation of a biventricular assist device, but no myocarditis was found on histological examination of her myocardial tissue. An ultrastructural study of myocardial tissue taken from three patients (mean age: 22 years, 2 females) with fulminant heart failure not related to PPCM (2 myocarditis, 1 dilated cardiomyopathy) served as a comparison. The ultrastructural analysis revealed the presence of small capillary damage. Vascular lumen occlusion, endothelial cell remodeling, and apoptosis with the appearance of mast cells, plasma cells, and preadipocytes were the most characteristic features of the damaged myocardial tissue with secondary interstitial fibrosis. No vascular pathology of cardiac capillaries was observed in the comparative group. CONCLUSIONS: A myocardial tissue study in PPCM revealed ultrastructural remodeling of small capillaries with the presence of endothelial cell apoptosis and impairment of the microcirculation.

The influence of cardiac rhythm type and frequency on the prognosis of severe heart failure patients initially qualified for heart transplantation.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia among patients (pts) with heart failure and has significant influence on survival. AIM OF THE STUDY: to assess prognosis of pts with refractory heart failure (HF) qualified for heart transplantation (HTX). MATERIAL/METHODS: 872 pts (107 W and 765 M) were qualified for HTX between Dec 2003 and Oct 2007. Patient's death or super urgent heart transplantation were considered the end point in Kaplan-Meier survival curves. RESULTS: 680 pts were on sinus rhythm (SR) and 192(22.0%) had atrial fibrillation (AF). During follow-up (1-1464 days, mean 550 days) 155 pts (17.7%) died, 17.65% with SR and 18.23% with AF (ns). EF - mean 21,6 (SR) and 21,8 (FA), NYHA 3,1 (SR), NTproBNP- mean 3635, 4 (SR) and 4349,4 (FA), Arronson - mean 7,8 (SR) and 7,7 (FA). There were no significant differences between groups. We analyzed influence of heart rate (Kaplan-Maier method) on survival. The pts were divided according to HR: gr.I <70/min, gr II 71-89/min, gr III >90/min. The shortest survival rate was noticed in group III. There was no difference in survival between group I and II. CONCLUSIONS: The prognosis for patients qualified for heart transplant does not depend on the type of the dominant cardiac rhythm (atrial fibrillation or sinus rhythm). The prognosis is significantly better for those patients whose basic, resting heart rate does not exceed 90 bpm regardless of the rhythm type.

Genetic and ultrastructural studies in dilated cardiomyopathy patients: a large deletion in the lamin A/C gene is associated with cardiomyocyte nuclear envelope disruption.

Major nuclear envelope abnormalities, such as disruption and/or presence of intranuclear organelles, have rarely been described in cardiomyocytes from dilated cardiomyopathy (DCM) patients. In this study, we screened a series of 25 unrelated DCM patient samples for (a) cardiomyocyte nuclear abnormalities and (b) mutations in LMNA and TMPO as they are two DCM-causing genes that encode proteins involved in maintaining nuclear envelope architecture. Among the 25 heart samples investigated, we identified major cardiomyocyte nuclear abnormalities in 8 patients. Direct sequencing allowed the detection of three heterozygous LMNA mutations (p.D192G, p.Q353K and p.R541S) in three patients. By multiplex ligation-dependant probe amplification (MLPA)/quantitative real-time PCR, we found a heterozygous deletion encompassing exons 3-12 of the LMNA gene in one patient. Immunostaining demonstrated that this deletion led to a decrease in lamin A/C expression in cardiomyocytes from this patient. This LMNA deletion as well as the p.D192G mutation was found in patients displaying major cardiomyocyte nuclear envelope abnormalities, while the p.Q353K and p.R541S mutations were found in patients without specific nuclear envelope abnormalities. None of the DCM patients included in the study carried a mutation in the TMPO gene. Taken together, we found no evidence of a genotype-phenotype relationship between the onset and the severity of DCM, the presence of nuclear abnormalities and the presence or absence of LMNA mutations. We demonstrated that a large deletion in LMNA associated with reduced levels of the protein in the nuclear envelope suggesting a haploinsufficiency mechanism can lead to cardiomyocyte nuclear envelope disruption and thus underlie the pathogenesis of DCM.

[Transthoracic echocardiographic assessment of a biventricular assist device]. / Badanie echokardiograficzne po implantacji sztucznych komór serca.

We present the results of standard transthoracic echocardiographic assessment of a biventricular assist device implanted in a patient with progressive heart failure caused by acute giant-cell myocarditis.