Carcinoid syndrome with right-sided valve involvement - a case report and review of the literature.

BACKGROUND: The survival of patients with neuroendocrine tumors has substantially improved with modern treatment options. Although the associated carcinoid syndrome can be diagnosed early and controlled effectively, cardiologists still encounter patients with cardiac manifestations, particularly among individuals with persistently high levels of vasoactive mediators. Treatment options have been limited to surgical valve replacement in fully manifested disease. Since surgery is not always feasible, transcatheter valve implantation is becoming an interesting alternative. CASE: A case of a 50-year-old woman with carcinoid syndrome and right-sided valvular heart disease is presented. Moderate pulmonary valve stenosis and severe tricuspid valve regurgitation were diagnosed during the evaluation and treatment of neuroendocrine tumor. The possibility of rare valve involvement and the need for interdisciplinary cooperation in the diagnosis, monitoring and treatment of patients with neuroendocrine tumors producing vasoactive substances must be emphasized. CONCLUSION: The patient had a typically presenting carcinoid syndrome with a rare cardiac manifestation. Although monitoring and treatment were carried out in accordance with recommendations and appropriate to the clinical condition, rapid progression of the metastatic disease ultimately precluded invasive cardiac intervention.

Correction to 'Commodity-specific punishment for experimentally induced defection in cooperatively breeding fish'.

[This corrects the article DOI: 10.1098/rsos.191808.].

Sex-linked differences in the mortality in Ren-2 transgenic hypertensive rats with aorto-caval fistula: effects of treatment with angiotensin converting enzyme alone and combined with inhibitor of soluble epoxide hydrolase.

We found recently that in Ren-2 transgenic hypertensive rats (TGR) addition of soluble epoxide hydrolase inhibitor (sEHi) to treatment with angiotensin-converting enzyme inhibitor (ACEi), surprisingly, increased the mortality due to heart failure (HF) induced by creation of the aorto-caval fistula (ACF). Since TGR exhibit sex-related differences in mortality, we examined here if such differentiation exists also in the response to the treatment with ACEi (trandolapril), alone or combined with sEHi [cis-4-[4-(3-adamantan-1-yl-ureido)cyclohexyloxy]benzoic acid, (c-AUCB)]. ACEi improved survival in males to 74 % (vs. 0 %) and in females to 65 % (vs. 32 %). ACEi and sEHi combined also improved the survival in male ACF TGR, however, it was significantly less (38 %) than after ACEi alone. In contrast, in females the combined treatment significantly improved the final survival rate (84 %). There were no significant sex-linked differences in survival rate in untreated or treated normotensive Hannover Sprague-Dawley rats. In conclusion, in HF patients with co-existing hypertension and RAS hyperactivity, the sex may co-determine the rate of HF progression, and can influence the effectiveness of the therapeutic measures applied. Therefore, in the relevant pre-clinical studies the sex-linked differences should be seriously considered. Our data indicate that TGR might be an optimal model for such studies.

The impact of ECG synchronization during acquisition of left­atrium computed tomography model on radiation dose and arrhythmia recurrence rate after catheter ablation of atrial fibrillation - a prospective, randomized study.

BACKGROUND: The impact of ECG gating during computed tomography (CT) acquisition of left atrium (LA) model on radiation dose, image quality and ablation event-free survival rate after catheter ablation (CA) of atrial fibrillation (AF) is not well defined. METHODS: Sixty-two patients with paroxysmal atrial fibrillation were randomized for two types of LA CT (with vs without ECG gating) before CA. Pulmonary veins isolation was performed in all patients. Patients were followed for 12 months after CA. RESULTS: There was no difference between the groups in CA length (131.61±32.57 vs 119.84±33.18 min; p=0.108), CA fluoroscopy time (4.48±2.19 vs 3.89±1.83 min; p=0.251), CA fluoroscopy dose (3.99±2.79 vs 3.91 vs2.91 Gy*cm2; p=0.735), visual data quality (1.77±0.88 vs 2.0±0.63; p=0.102) and registration error (2.42±0.72 vs 2.43±0.46 mm; p=0.612). We found a significant difference in CT Dose index (89.55±5.99 vs 19.19±4.33 mGy; p<0.0001) and Dose Length product (1438.87±147.75 vs 328.21±73.83 mGy*cm; p<0.0001). Twelve months after CA, 25 of 31 patients in the gated group and 24 of 31 patients in the non-gated group were free of AF (80.65 vs 77.42 %; p=0.838). CONCLUSION: ECG gating of computed tomography of LA before AF ablation burdens patients with a four times higher radiation dose while improving neither the quality of CT model or fusion of CT with the electroanatomic map. As a result, it has no significant impact on arrhythmia recurrence rate after ablation (Tab. 3, Fig. 3, Ref. 25).

Evaluation of later morphologic alterations in renal artery wall and renal nerves in response to catheter-based renal denervation in sheep: comparison of the single-point and multiple-point ablation catheters.

This study evaluated the subacute morphologic alterations in renal artery wall and renal nerves in response to catheter-based renal denervation (RDN) in sheep and also compared the efficiency of single-point and multiple-point ablation catheters. Effect of each ablation catheter approved for the clinical use (Symplicity Flex(TM), Medtronic, Inc., or EnligHTN(TM), St. Jude Medical, INC.) was compared to intact contralateral renal artery in 12 sheep by histopathology and immunohistochemistry evaluation after a 10-day period post-RDN procedure. The safety was verified by extensive evaluation of kidney morphology. Vascular wall lesions and nerve injuries were more pronounced in those animals treated with multi-point EnligHTN catheter when compared with animals treated with single-point Symplicity Flex catheter. However, neither RDN procedure led to complete renal nerve ablation. Both systems, tested in the present study, provided only incomplete renal nerve ablation in sheep. Moreover, no appreciable progression of the nerve disintegration in subacute phase post-RDN procedure was observed. This study further supports the notion that the effectiveness remains fully dependent on anatomical inter-individual variability of the sympathetic nerve plexus accompanying the renal artery. Therefore, new systems providing deeper penetrance to targeted perivascular structure would be more efficient.

Effect of angiotensin-converting enzyme blockade, alone or combined with blockade of soluble epoxide hydrolase, on the course of congestive heart failure and occurrence of renal dysfunction in Ren-2 transgenic hypertensive rats with aorto-caval fistula.

We showed recently that increasing kidney epoxyeicosatrienoic acids (EETs) by blocking soluble epoxide hydrolase (sEH), an enzyme responsible for EETs degradation, retarded the development of renal dysfunction and progression of aorto-caval fistula(ACF)-induced congestive heart failure (CHF) in Ren-2 transgenic hypertensive rats (TGR). In that study the final survival rate of untreated ACF TGR was only 14 % but increased to 41 % after sEH blockade. Here we examined if sEH inhibition added to renin-angiotensin system (RAS) blockade would further enhance protection against ACF-induced CHF in TGR. The treatment regimens were started one week after ACF creation and the follow-up period was 50 weeks. RAS was blocked using angiotensin-converting enzyme inhibitor (ACEi, trandolapril, 6 mg/l) and sEH with an sEH inhibitor (sEHi, c-AUCB, 3 mg/l). Renal hemodynamics and excretory function were determined two weeks post-ACF, just before the onset of decompensated phase of CHF. 29 weeks post-ACF no untreated animal survived. ACEi treatment greatly improved the survival rate, to 84 % at the end of study. Surprisingly, combined treatment with ACEi and sEHi worsened the rate (53 %). Untreated ACF TGR exhibited marked impairment of renal function and the treatment with ACEi alone or combined with sEH inhibition did not prevent it. In conclusion, addition of sEHi to ACEi treatment does not provide better protection against CHF progression and does not increase the survival rate in ACF TGR: indeed, the rate decreases significantly. Thus, combined treatment with sEHi and ACEi is not a promising approach to further attenuate renal dysfunction and retard progression of CHF.

Red or white wine consumption effect on atherosclerosis in healthy individuals (In Vino Veritas study).

AIMS: Consumption of wine has a protective effect on cardiovascular diseases. Data from prospective, long-term, head-to-head comparisons of effects of different drinks on markers of atherosclerosis have been insufficient. METHODS AND RESULTS: In Vino Veritas (IVV) study is long-term, prospective, multi-centre, randomized trial comparing effects of red and white wine on atherosclerosis. 157 healthy subjects were randomized to white or red wine consumption for one year. We did not find increase in HDL-cholesterol in the whole group (1.66±0.58 vs 1.62±0.49, p=0.180) or difference between both groups (1.60±0.53 vs 1.64±0.46, p=0.634). At 12 months there was reduction of LDL-cholesterol in both groups, but with no difference between the groups (3.37±0.75 vs 3.60±1.10, p=0.134); there was no difference between the groups in total cholesterol, CRP, fasting blood glucose and liver function tests. Both groups had comparable differences from baseline in levels of parameters of oxidative stress. CONCLUSION: We did not find any clinically relevant differences in the lipid profile, CRP, fasting blood glucose and other markers of atherosclerosis, between long-term consumption of red and white wine. Moreover, we were unable to confirm the hypothesis that wine drinking is associated with an elevation of HDL (Tab. 7, Fig. 1, Ref. 30).

The evolution of strategic male mating effort in an information transfer framework.

Sperm competition theory predicts that males should use cues indicating the risk and intensity of sperm competition to tailor their sperm investment accordingly. Rival males are an important source of social information regarding sperm competition risk. However, revealing such information may not be in the rival males' interest. Here, we use a theoretical approach based on informed and uninformed games to investigate when information transfer about sperm competition risk to competitors is beneficial for a male, and when it is not. The results show that signalling to potential future mates that a female has already mated is beneficial when the signalling male has a sperm competition disadvantage, whereas it is unfavourable when the signaller has an advantage. The reason for this counterintuitive result is that the rival males' optimal response is to reduce sperm investment when the signaller has a disadvantage and, conversely, to increase investment when the signaller has an advantage. Furthermore, we analysed scenarios where males use alternative reproductive tactics. In this situation, signalling the awareness of sperm competition risk rarely pays; instead, it is beneficial to maintain an information advantage. Thus, it may be beneficial for bourgeois males to accept cuckoldry instead of revealing their sperm competition awareness to reproductive parasites. These results provide new insight into the evolution of communication between rivals in the context of sperm competition.

Early morphologic alterations in renal artery wall and renal nerves in response to catheter-based renal denervation procedure in sheep: difference between single-point and multiple-point ablation catheters.

Renal sympathetic hyperactivity is critically involved in hypertension pathophysiology; renal denervation (RDN) presents a novel strategy for treatment of resistant hypertension cases. This study assessed effects of two RDN systems to detect acute intravascular, vascular and peri-vascular changes in the renal artery, and renal nerve alterations, in the sheep. The procedures using a single-point or multi-point ablation catheters, Symplicity Flex(TM), Medtronic versus EnligHTN(TM), St. Jude Medical were compared; the intact contralateral kidneys served as controls. Histopathological and immunohistochemical assessments were performed 48 h after RDN procedures; the kidney and suprarenal gland morphology was also evaluated. Special staining methods were applied for histologic analysis, to adequately score the injury of renal artery and adjacent renal nerves. These were more pronounced in the animals treated with the multi-point compared with the single-point catheter. However, neither RDN procedure led to complete renal nerve ablation. Forty-eight hours after the procedure no significant changes in plasma and renal tissue catecholamines were detected. The morphologic changes elicited by application of both RDN systems appeared to be dependent on individual anatomical variability of renal nerves in the sheep. Similar variability in humans may limit the therapeutic effectiveness of RDN procedures used in patients with resistant hypertension.

TUGENDHAT: a pilot randomized study on effects of biventricular pacing in patients with bradycardia pacing indication and normal systolic function on heart failure, atrial fibrillation and quality of life (results of 12 month follow-up).

BACKGROUND: Since the late 1990s, a growing number of clinical studies have indicated that long-term permanent right ventricular (RV) apical pacing will induce severe complications such as development of heart failure, increased burden of atrial fibrillation leading to decreased quality of life. AIM OF THE STUDY: To investigate whether cardiac resynchronization therapy (CRT) using biventricular (BiV) pacing can prevent the development of left ventricular (LV) dysfunction, LV remodelling, worsening of the clinical status and quality of life in chronically RV paced patients with normal LV ejection fraction (EF). METHODS AND RESULTS: A total of 127 patients with Class I indication for permanent cardiac pacing and without established indication for CRT were subjected to 6 months of RV and BiV pacing in a patient-blinded, randomized crossover trial. Treatment effects of BiV pacing were evaluated for LV function, LV remodelling and clinical status. As compared with RV pacing, BiV pacing did not significantly prevent the decrease of LV function [LVEF 61.0 % (36.0; 68.0) vs 60.5 % (38.5; 67.5) in RV pacing], did not change the functional class according to the New York Heart Association [52 % in Class II vs 53.9 % in Class II in RV pacing, and 3.9 % in Class III vs 6.9 % in Class III in RV pacing], and did not present any changes in quality of life [32.5 (18.0; 80.0) vs 32.0 (21.0; 47.0) indexes in RV pacing]. CONCLUSION: BiV pacing, compared to RV pacing, did not change LV function and quality of life in patients with the absence of LV dysfunction or remodelling, standard bradycardia pacing indications in a pilot phase (12- month follow-up) of the TUGENDHAT trial. The final report will be published after 60-month follow-up termination (Tab. 5, Fig. 3, Ref. 30).

[Dabigatran etexilate in clinical practice for prevention of thromboembolic events in patients with atrial fibrillation]. / Dabigatran-etexilát v klinické praxi pro prevenci tromboembolických príhod u nemocných s fibrilací síní

Dabigatrane is the first new generation antiacoagulant that at a dose of 150 mg twice daily was, in the RE-LY study, more effective in cerebrovascular event and systemic embolisation prevention than well-controlled warfarin and had comparable or better safety profile than well-controlled warfarin. The 110 mg twice daily dose showed comparable efficacy and superior safety against warfarin. Crucial and unique among modern anticoagulants is its ability to significantly reduce ischemic as well as hemorrhagic CVEs at a dose of 150 mg twice daily. In addition, dabigatran significantly facilitates management of patients with atrial fibrillation as it does not require laboratory monitoring, has predictable pharmacokinetics, simple dosing regimen that does not require complicated dose adjustments, and does not interact with food. However, it is important to remember that it is an anticoagulant. Care should, therefore, be exercised when the treatment is indicated, renal function has to be known and it needs to be kept in mind that, as with any anticoagulant, the treatment may be associated with bleeding. However, when indication criteria are observed, the above listed advantages considered and careful patient monitoring put in place, the bleeding will be, compared to standard warfarin treatment, minimized. Key words: dabigatran - atrial fibrillation - tromboembolism.

[Hyperventilation echocardiography in vasospastic angina pectoris diagnosing]. / Hyperventilacní echokardiografie v diagnostice vazospastické anginy pectoris.

Hyperventilation echocardiography is an established diagnostic test in patients with suspected variant angina pectoris. It has got sufficient sensitivity (60-80%) and specificity (85-100%). Positive hyperventilation test is rarely found, which relates to low prevalence of variant angina. The diagnostic yield of the test depends on the population selected for testing: positive result can be expected in patients with a history of typical burning chest pain, ST segment elevation/depression and/or inversions of U wave during the chest pain episode, arrhythmias related to the chest pain, coronary artery stenosis less than 50% of artery diameter, multi-vessel disease, high activity of illness at the time of hyperventilation test. We present a case of 37 years old man with typical angina pectoris at rest and non-Q myocardial infarction, in whom the coronary angiography was negative. Variant angina pectoris was diagnosed by hyperventilation echocardiography. The ECG tracings showing typical ischemic patterns during the hyperventilation test are included.

A pilot randomized trial comparing long-term effects of red and white wines on biomarkers of atherosclerosis (in vino veritas: IVV trial).

BACKGROUND: Since early 90', growing body of evidence indicates that the Mediterranean diet with mild to moderate consumption of wine, mostly red wine, has a protective effect on cardiovascular diseases. Several mechanisms have been discussed to participate in the beneficial effect of red wine, such as antioxidant or vasodilating activity. However, later it has been shown that also other alcoholic beverages have a protective effect on atherosclerosis. Up to now, data from the prospective, long-term, head-to-head comparisons of the effects of different drinks on markers of atherosclerosis are insufficient. METHODS: The IVV (in vino veritas) study is a long-term, prospective, multicenter, randomized trial comparing the effect of red and white wines on the markers of atherosclerosis. One hundred and twenty healthy subjects with mild to moderate risk of atherosclerosis will be randomized to regular consumption of red wine (Pinot Noir) or white wine (Chardonnay-Pinot) for one year. The primary endpoint is the level of HDL-cholesterol at one year, while secondary endpoints are levels of other markers of atherosclerosis (LDL-cholesterol, C-reactive protein, myeloperoxidase, advanced oxidation protein product, interleukins 6 and 18, matrix metalloproteinases, glutathione s-transferase, monocyte chemoattractant protein 1, soluble CD40L). CONCLUSION: The IVV trial is the first study focusing on the long-term prospective comparison of the effects of red and white wines consumption on HDL-cholesterol and other markers of atherosclerosis. Results of the IVV trial may extend our understanding of the widely discussed "French paradox" (Tab. 1, Ref. 21)

Critical evaluation of the optimal medical therapy in the cardiac resynchronization therapy candidates--single centre experience.

UNLABELLED: The aim of the present study was to evaluate the optimal medical therapy in the chronic heart failure (CHF) patients referred from the comunity centres and the outpatients cardiology clinics for the cardiac resynchronization therapy with defibrilator (CRTD) to the Department of Cardiology, Na Homolce Hospital with the device implantation between 1st January 2008 and 30st September 2009. METHODS: The optimal medical therapy was analysed retrospectively from the medical records of 179 consecutive CHF patients NYHA class III-IV. Beta-blockers (BB) were used only in 81% subjects referred for CRTD, ACE inhibitors (ACEI) were used only in 68% patients Angiotensin receptor blockers (ARB) were used in 18% subjects. ACEI or ARB were used in 81%, spironolacton was use in 59%. Recommended target DD for BB (carvedilol 25 mg bid) was used only in 13% subjects, recommended target DD for ACEI (enalapril 10 mg bid) was used only in 9.4% patients. RESULTS: In the Department of Cardiology, the optimal medical therapy was changed after CRTD, BB were used in 95% subjects at discharge (p < 0.01) and the number of patients reaching at least of 50% of recommended daily dose (DD) of BB increased (p < 0.05). ACEI were recommended after CRTD in 80% subjects after implantation (p < 0.05), the number of patients reaching at least of 50% of recommended DD for ACEIs increased too (p < 0.05). There was no significant difference in ARB use recomended in the hospital (19% after CRTD - NS). ACEI or ARB were used in 98% patients after the device implanted (p < 0.05) and spironolacton in 77% after CRTD (p < 0.05). CONCLUSIONS: Despite optimal composition of the optimal medical heart failure therapy only small number of CRTD candidates are reaching recommended drug dose. The optimization of the medical therapy in the specialized center lead to significantly higher proportion of CHF using the optimal therapy with the increased dose of BB and ACEI.

[Diagnostic algorithm of syncope: integrative approach]. / Diagnostický algoritmus synkop: integrativní prístup.

Syncope is a symptom, defined as transient loss of consciousness and postural tone with spontaneous and mostly prompt recovery. At first it is necessary to differentiate other non-syncopal transient loss of consciousness and simple falls, where thorough history taking is pivotal. EGSYS and OESIL risk scores seem to be contributional in initial risk stratification, however they are neither widely accepted nor a part of national guidelines. They are part of the European society of cardiology guidelines, though. Next it is essential expert ECG evaluation, thorough physical status examination, supine and standing blood pressure measurement and carotid sinus massage, if not contraindicated. Successively one has to decide if hospitalization or outpatient management is more suitable. Recently it has been shown, that so-called syncope management units (aimed for short-term hospitalization or fast outpatient examination, including vital function monitoring, echocardiography and facile cathlab access) are effective in fast syncope evaluation. Echocardiography, ECG monitoring and head-up tilt test should be a part of complex diagnostic evaluation. If syncope is not clarified by upon stated methods moreover syncope is recurrent, electrophysiological study, ILR implantation or both are justified. Despite of entire health practitioner's effort, more than 1/3 of syncopes remain unexplained.

[Analysis of the sudden heart death causes in selected sample of dead]. / Rozbor prícin náhlé srdecní smrti ve vybraném vzorku zemrelých.

Sudden cardiac death (SCD) is death from cardiac causes within one hour of the onset of symptoms. In the Czech Republic, there is no SCD registry, analyses of SCD causes are rare and there is no functional connection between the results of an autopsy on a person with SCD and examination of relatives who are at risk of a similar disease. The authors reviewed available autopsy records of the Department of Forensic Medicine and Medical Law of the University Hospital Olomouc over a specified period of time to find persons with severe coronary artery disease, heart failure or deaths from unknown causes in a specific age range. Subsequently, the available information about the circumstances of SCD was analyzed.

[Infective endocarditis--crucial early diagnosis]. / Infekcní endokarditida--klícová vcasná diagnóza.

A 64-year old female patient with polymorbidity, including diabetes, was admitted to our clinic with a suspicion of silent myocardial infarction. However, no acute coronary lesion was subsequently confirmed. Transthoracal echocardiography performed just after the admission suggested infective endocarditis. The diagnosis was difficult due to a lack of collaboration by the patient who was disoriented and confused. Because of the suspicion ofendocarditis, a therapy with antibiotics was started immediately and the diagnosis was confirmed by oesophageal echocardiography and heart MR performed after the patient was stabilized. An early diagnosis and an intensive antibiotic treatment are crucial for the management of the frequently fatal infective endocarditis.

Reproductive parasitism: male and female responses to conspecific and heterospecific intrusions at spawning in a mouth-brooding cichlid Ophthalmotilapia ventralis.

A rare form of alternative reproductive behaviour without simultaneous parasitic spawning was observed in Ophthalmotilapia ventralis, a lekking mouth-brooding cichlid from Lake Tanganyika. Floater males attempted to sneak opportunistically into the territory to actively court the female, while the owner (bourgeois male) defended the territory against other potential intruders. Floater males had more body fat than territory owners and generally higher condition factors. In field experiments, the response of bourgeois males and courted females was tested towards floaters and egg predators (a catfish Synodontis multipunctatus) present in the territories. Territory owners responded aggressively particularly to floaters, and female responsiveness to bourgeois male courtship tended to decline when floaters were present. The potential influence of reproductive parasitism on sexual selection in mouth-brooding cichlids is discussed.

Significance of Borrelia infection in development of dilated cardiomypathy (a pilot study).

A heart involvement known as Lyme carditis (LC), a consequence of Lyme borreliosis (LB), is relatively rare in contrast to the involvement of skin, joints and nervous system; it accounts for < 4% of all these patients in European countries. However, the diagnosis of the disease belongs to the most difficult challenges. While various forms of AV blocks dominate in the USA as confirmed by the literature, there is a clear predominance of arrhythmias of various incidence in the Czech Republic. The authors of this article focused on the form belonging to the rarest manifestations of LC, namely dilated cardiomyopathy (DCMP). The goal was to elucidate the etiological participation of Borrelia infection in the development of DCMP, which has attracted controversial opinions so far. In total, 33 patients with DCMP were enrolled in the study, 23 males and 10 females, with mean age 57.7 years (range 24-76 years). ELISA NRLB KC 90 method was used in all blood samples for detection of Borrelia infection (BI), Western blot method was used for confirmation, followed by identification of DNA of pathogenic Borreliae using PCR method. Bioptic material was examined by electronmicroscopy with an attempt to detect Spirochaetae in myocardium. 16 patients were excluded from the study owing to the absence of signs of LB. The study group included 17 patients (3 females, 13 males) with mean age 58 years (range 43-76 years), in whom the presence of Bb was proved by identification of DNA of pathogenic Borreliae or by electronmicroscopic detection of Spirochetae in myocardial bioptic sample. The findings obtained during the study confirmed that BI very probably participated in the development of dilated cardiomyopathy. It may be concluded that most of cases were either unapparent forms of LB or insufficiently treated cutaneous forms of this disease.