Infrarenalis aortaaneurysma-műtétek országos eredményeinek elemzése a Nemzeti Érsebészeti Regiszter alapján (2010–2019) = Analysis of data from the National Vascular Registry on infrarenal aortic aneurysms (2010–2019)

Összefoglaló. Bevezetés: Az elmúlt évtizedekben számos országban jelentős mértékben változott a hasi aortaaneurysmák sebészi kezelése az eredményesebb ellátás céljából: endovascularis beavatkozások terjedése, nagy betegforgalmú aortacentrumok kialakítása. Célkitűzés: A Magyarországon, infrarenalis aortaaneurysmák miatt végzett beavatkozások rövid távú eredményeinek elemzése elsősorban műtéti technika (endovascularis vs. nyitott aortareconstructio), intézeti betegforgalom (kis vs. nagy betegforgalmú intézet) és időszak (2010-2014 vs. 2015-2019) alapján. Módszer: A Nemzeti Érsebészeti Regiszterben 2010. 01. 01. és 2019. 12. 31. között prospektíven rögzített multicentrikus adatok retrospektív feldolgozása. Eredmények: A regiszterben 3206 infrarenalis aortaaneurysma-műtétet rögzítettek. A második öt évben jelentősen nőtt az endovascularis aortareconstructio aránya a nyitotthoz képest (p<0,0001), illetve a nagy betegforgalmú intézetek szignifikánsan több rupturált aortaaneurysmát láttak el, mint a kis betegforgalmú intézetek (p<0,0001) az első öt évhez viszonyítva. A perioperatív mortalitás rupturált aortaaneurysma miatt a nagy betegforgalmú intézetekben végzett nyitott aortareconstructio esetén szignifikánsan alacsonyabb volt a kis betegforgalmú intézetekkel szemben az első öt évben (p = 0,0011), illetve a nagy betegforgalmú intézetekben végzett endovascularis aortareconstructio esetén szignifikánsan alacsonyabb volt a nyitottal szemben a második öt évben (p = 0,029). A nem rupturált aortaaneurysma-műtétek perioperatív mortalitása a nagy betegforgalmú intézetekben végzett nyitott aortareconstructio esetén szignifikánsan alacsonyabb volt a kis betegforgalmú intézetekhez képest az első és a második öt évben is (p = 0,0007; p = 0,004). Mind a nagy, mind a kis betegforgalmú intézetekben végzett endovascularis aortareconstructio esetén szignifikánsan alacsonyabb volt a perioperatív mortalitás a második öt évben (p<0,0001; p<0,0001). A rupturált és a nem rupturált aortaaneurysmák perioperatív mortalitásának független rizikófaktora az intézetek betegforgalma (p = 0,006; p = 0,004), a betegek életkora (p<0,0001; p = 0,001), a preoperatív renalis megbetegedés (p = 0,007; p = 0,007), a transzfúzióigény (p<0,0001; p<0,0001), illetve nem rupturált aortaaneurysmák esetében a műtéti technika (p<0,0001) is. Következtetés: Endovascularis aortareconstructio és nagy betegforgalmú intézetek esetében szignifikánsan alacsonyabb perioperatív mortalitás érhető el. Orv Hetil. 2021; 162(31): 1233-1243.The organisation of aortic disease care has changed significantly in many countries over the last decade: centralized, high-volume centers were established.To analyse the perioperative mortality and the number of the infrarenal aortic aneurysm repairs according to the type of procedure (endovascular vs. open), patient volume (low vs. high) and time period (2010-2014 vs. 2015-2019).The multicentric data registered prospectively in the Hungarian National Vascular Registry between 01. 01. 2010 and 31. 12. 2019 were analysed retrospectively.3206 infrarenal aortic aneurysms were recorded. The endovascular-open repair rate was significantly higher (p<0.0001) and the high-volume institutes managed significantly more ruptured aneurysms (p<0.0001) in the second period. The perioperative mortality of the open repair of ruptured aneurysms was significantly lower in the high-volume institutes than in the low-volume ones in the first period (p = 0.0011), and the mortality of endovascular repair was significantly lower compared with open repair in the high-volume institutes in the second period (p = 0.029). The perioperative mortality of the open repair of non-ruptured aneurysm was significantly lower in the high-volume institutes in both periods (p = 0.0007; p = 0.004). Furthermore, the mortality of endovascular repair was significantly lower compared with open repair both in the high- and the low-volume institutes in the second period (p<0.0001; p<0.0001). Patient volume (p = 0.006; p = 0.004), age (p<0.0001; p = 0.001), preoperative renal insufficiency (p = 0.007; p = 0.007) and the need of blood transfusion (p<0.0001; p<0.0001) were independent risk factors of the perioperative mortality of ruptured and non-ruptured aneurysms. Type of the procedure was also an independent risk factor in the case of non-ruptured aneurysms (p<0.0001).Endovascular repair and aortic surgery in the high-volume institutes result in significantly lower perioperative mortality. Orv Hetil. 2021; 162(31): 1233-1243

Risk scores in cardiac resynchronization therapy–A review of the literature

Cardiac resynchronization therapy (CRT) for selected heart failure (HF) patients improves symptoms and reduces morbidity and mortality; however, the prognosis of HF is still poor. There is an emerging need for tools that might help in optimal patient selection and provide prognostic information for patients and their families. Several risk scores have been created in recent years; although, no literature review is available that would list the possible scores for the clinicians. We identified forty-eight risk scores in CRT and provided the calculation methods and formulas in a ready-to-use format. The reviewed score systems can predict the prognosis of CRT patients; some of them have even provided an online calculation tool. Significant heterogeneity is present between the various risk scores in terms of the variables incorporated and some variables are not yet used in daily clinical practice. The lack of cross-validation of the risk scores limits their routine use and objective selection. As the number of prognostic markers of CRT is overwhelming, further studies might be required to analyze and cross-validate the data

Complement C5a inhibition improves late hemodynamic and inflammatory changes in a rat model of nonocclusive mesenteric ischemia

BACKGROUND: Nonocclusive mesenteric ischemia (NOMI) can evolve in a variety of low-flow states. Although the mechanisms leading to NOMI-related intestinal necrosis are largely unknown, circumstantial evidence suggests that excessive vasoconstriction and complement activation both play important roles in this process. Because targeting of the circulatory malfunction of the splanchnic area could be of therapeutic relevance, we set out to investigate the long-term effects of treatment with a complement C5a antagonist in a rat model of partial aortic occlusion (PAO)-induced transient mesenteric hypoperfusion. METHODS: The mean arterial pressure of the splanchnic area was kept between 30 and 40 mm Hg by 60 minutes of PAO in anesthetized male Sprague-Dawley rats. C5a inhibitor acetyl-peptide-A (AcPepA; 4 mg kg-1 intravenously) or vehicle administration was initiated at the 45th minute of PAO. After 24 hours, the animals were reanesthetized to record the macrohemodynamics and ileal microcirculation, and plasma and tissue samples were taken for determination of high-mobility group box protein-1 (HMGB-1), endothelin-1, tumor necrosis factor (TNF)-alpha levels, and small intestinal leukocyte infiltration. Epithelial structural changes were visualized by in vivo confocal laser scanning endomicroscopy. RESULTS: At 24 hours after PAO, mean arterial pressure, heart rate, and cardiac output were significantly greater, the intestinal intramural microcirculation was significantly impaired, and plasma HMGB-1, endothelin-1, TNF-alpha levels, the degree of epithelial damage and leukocyte infiltration was increased. The AcPepA treatment moderated the hemodynamic and microcirculatory changes, and decreased inflammatory activation and histologic signs of mucosal damage. CONCLUSION: C5a inhibition ameliorated the potentially harmful local mesenteric hypoperfusion and global long-term inflammatory consequences of PAO. This approach is of promise for use in NOMI-associated situations

The ratio of the neutrophil leucocytes to the lymphocytes predicts the outcome after cardiac resynchronization therapy

AIMS: The low lymphocyte counts and high neutrophil leucocyte fractions have been associated with poor prognosis in chronic heart failure. We hypothesized that the baseline ratio of the neutrophil leucocytes to the lymphocytes (NL ratio) would predict the outcome of chronic heart failure patients undergoing cardiac resynchronization therapy (CRT). METHODS AND RESULTS: The qualitative blood counts and the serum levels of N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) of 122 chronic heart failure patients and 122 healthy controls were analysed prospectively in this observational study. The 2-year mortality was considered as primary endpoint and the 6-month reverse remodelling (>/=15% decrease in the end-systolic volume) as secondary endpoint. Multivariable regression analyses were applied and net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were calculated. The NL ratio was elevated in chronic heart failure patients when compared with the healthy controls [2.93 (2.12-4.05) vs. 2.21 (1.64-2.81), P < 0.0001]. The baseline NL ratio exceeding 2.95 predicted the lack of the 6-month reverse remodelling [n = 63, odds ratio = 0.38 (0.17-0.85), P = 0.01; NRI = 0.49 (0.14-0.83), P = 0.005; IDI = 0.04 (0.00-0.07), P = 0.02] and the 2-year mortality [n = 29, hazard ratio = 2.44 (1.04-5.71), P = 0.03; NRI = 0.63 (0.24-1.01), P = 0.001; IDI = 0.04 (0.00-0.08), P = 0.02] independently of the NT-proBNP levels or other factors. CONCLUSION: The NL ratio is elevated in chronic heart failure and predicts outcome after CRT. According to the reclassification analysis, 4% of the patients would have been better categorized in the prediction models by combining the NT-proBNP with the NL ratio. Thus, a single blood count measurement could facilitate the optimal patient selection for the CRT

Measurement of the Red Blood Cell Distribution Width Improves the Risk Prediction in Cardiac Resynchronization Therapy

Objectives. Increases in red blood cell distribution width (RDW) and NT-proBNP (N-terminal pro-B-type natriuretic peptide) predict the mortality of chronic heart failure patients undergoing cardiac resynchronization therapy (CRT). It was hypothesized that RDW is independent of and possibly even superior to NT-proBNP from the aspect of long-term mortality prediction. Design. The blood counts and serum NT-proBNP levels of 134 patients undergoing CRT were measured. Multivariable Cox regression models were applied and reclassification analyses were performed. Results. After separate adjustment to the basic model of left bundle branch block, beta blocker therapy, and serum creatinine, both the RDW > 13.35% and NT-proBNP > 1975 pg/mL predicted the 5-year mortality (n = 57). In the final model including all variables, the RDW [HR = 2.49 (1.27-4.86); p = 0.008] remained a significant predictor, whereas the NT-proBNP [HR = 1.18 (0.93-3.51); p = 0.07] lost its predictive value. On addition of the RDW measurement, a 64% net reclassification improvement and a 3% integrated discrimination improvement were achieved over the NT-proBNP-adjusted basic model. Conclusions. Increased RDW levels accurately predict the long-term mortality of CRT patients independently of NT-proBNP. Reclassification analysis revealed that the RDW improves the risk stratification and could enhance the optimal patient selection for CRT

Effect of single ventricular premature contractions on response to cardiac resynchronization therapy

BACKGROUND: We lack data on the effect of single premature ventricular contractions (PVCs) on the clinical and echocardiographic response after cardiac resynchronization therapy (CRT) device implantation. We aimed to assess the predictive value of PVCs at early, 1 month-follow up on echocardiographic response and all-cause mortality. METHODS: In our prospective, single-center study, 125 heart failure patients underwent CRT implantation based on the current guidelines. Echocardiographic reverse remodeling was defined as a ≥ 15% improvement in left ventricular ejection fraction (LVEF), end-systolic volume (LVESV), or left atrial volume (LAV) measured 6 months after CRT implantation. All-cause mortality was investigated by Wilcoxon analysis. RESULTS: The median number of PVCs was 11,401 in those 67 patients who attended the 1-month follow-up. Regarding echocardiographic endpoints, patients with less PVCs develop significantly larger LAV reverse remodeling compared to those with high number of PVCs. During the mean follow-up time of 2.1 years, 26 (21%) patients died. Patients with a higher number of PVCs than our median cut-off value showed a higher risk of early all-cause mortality (HR 0.97; 95% CI 0.38–2.48; P = 0.04). However, when patients were followed up to 9 years, its significance diminished (HR 0.78; 95% CI 0.42–1.46; P = 0.15). CONCLUSIONS: In patients undergoing CRT implantation, lower number of PVCs predicted atrial remodeling and showed a trend for a better mortality outcome. Our results suggest the importance of the early assessment of PVCs in cardiac resynchronization therapy and warrant further investigations. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s12872-022-02725-3

Measurement of the Red Blood Cell Distribution Width Improves the Risk Prediction in Cardiac Resynchronization Therapy

Objectives. Increases in red blood cell distribution width (RDW) and NT-proBNP (N-terminal pro-B-type natriuretic peptide) predict the mortality of chronic heart failure patients undergoing cardiac resynchronization therapy (CRT). It was hypothesized that RDW is independent of and possibly even superior to NT-proBNP from the aspect of long-term mortality prediction. Design. The blood counts and serum NT-proBNP levels of 134 patients undergoing CRT were measured. Multivariable Cox regression models were applied and reclassification analyses were performed. Results. After separate adjustment to the basic model of left bundle branch block, beta blocker therapy, and serum creatinine, both the RDW &gt; 13.35% and NT-proBNP &gt; 1975 pg/mL predicted the 5-year mortality ( = 57). In the final model including all variables, the RDW [HR = 2.49 (1.27-4.86); = 0.008] remained a significant predictor, whereas the NT-proBNP [HR = 1.18 (0.93-3.51); = 0.07] lost its predictive value. On addition of the RDW measurement, a 64% net reclassification improvement and a 3% integrated discrimination improvement were achieved over the NT-proBNP-adjusted basic model. Conclusions. Increased RDW levels accurately predict the long-term mortality of CRT patients independently of NT-proBNP. Reclassification analysis revealed that the RDW improves the risk stratification and could enhance the optimal patient selection for CRT

A myocardialis necrosis mértékének vizsgálata eltérő supraventricularis szívritmuszavarok rádiófrekvenciás katéterablatiós kezelését követően = Assessment of the extent of myocardial necrosis following radiofrequency catheter ablation of different supraventricular arrhythmias

Absztrakt: Bevezetés: Ismert, hogy katéteres ablatio által okozott szívizom-károsodás következtében megnő a szívizom-specifikus nekroenzimek koncentrációja. Célkitűzés: A magas érzékenységű troponin T (hsTnT) és a szívizom-specifikus kreatin-kináz (CKMB) szintje középtávú változásának elemzése pitvarfibrilláció (PF), pitvari flutter (PFlu), AV-csomó reentry tachycardia (AVNRT) rádiófrekvenciás katéteres ablatióját követően, illetve elektrofiziológiai vizsgálat után. Módszer: Rádiófrekvenciás ablatión, illetve elektrofiziológiai vizsgálaton átesett betegeket vontunk be konszekutívan prospektív vizsgálatunkba. Sorozatvérmintákból meghatároztuk a hsTnT- és a CKMB-szinteket a procedúra előtt és után közvetlenül, majd 4 és 20 órával és 3 hónappal később. Eredmények: Negyvenhét, 55 ± 13 év átlagéletkorú beteget (10 elektrofiziológiai vizsgálat, 12 AVNRT, 13 PFlu és 12 PF) vontunk be vizsgálatunkba. A hsTnT-szintek minden csoportban szignifikánsan megemelkedtek a beavatkozást követően, a CKMB csak a PF-csoportban változott. A hsTnT-szint négy órával a beavatkozást követően az összes ablatión átesett betegnél és az elektrofiziológiai vizsgálaton átesett betegek 80%-ánál meghaladta a referenciatartományt. A legmagasabb átlagos hsTnT-koncentrációk EFV, AVNRT, PFlu esetén 24 ± 11, 260 ± 218 és 541 ± 233 ng/l-nek bizonyultak. A legmagasabb hsTnT-szint a PF-ablatiós csoportban volt kimutatható 20 órával az ablatio után (799 ± 433 ng/l). Pozitív korrelációt találtunk a rádiófrekvenciás ablatiót követő hsTnT-szint és az ablatio ideje között. Következtetések: A hsTnT alkalmas a rádiófrekvenciás ablatio és az elektrofiziológiai vizsgálat utáni myocardialis necrosis vizsgálatára, az ablatión átesett betegek mindegyikénél; elektrofiziológiai vizsgálat után 80%-ban pozitív a hsTnT. A necrosis mértéke jelentősen függ a beavatkozás típusától, és korrelál az ablatio kiterjedtségével. A fentiekben leírt megfigyelések iránymutatásként szolgálnak a rádiófrekvenciás ablatio utáni hsTnT-szint megfelelő értelmezéséhez. Orv Hetil. 2019; 160(14): 540–548. | Abstract: Introduction: Levels of cardiac necroenzymes, high-sensitive troponin (hsTnT) and creatine kinase muscle-brain (CKMB) increase as a result of a myocardial damage following catheter ablation. Aim: To analyze the mid-term alteration of hsTnT and CKMB levels following radiofrequency ablation (RFCA) for atrial fibrillation (AF), atrial flutter (AFlu), AV-nodal reentry tachycardia (AVNRT) and electrophysiological studies (EPS) without ablation. Method: Patients undergoing RFCA for various indications and EPS were consecutively enrolled in our prospective study. Concentrations of hsTnT and CKMB were measured from serial blood samples directly before and after the procedure, 4 and 20 hours later and at 3 months follow-up. Results: Forty-seven patients (10 EPS, 12 AVNRT, 13 AFlu, 12 AF) with mean age of 55 ± 13 were included. hsTnT levels increased significantly in all groups after the procedures, while CKMB changed only in the AF group. hsTnT exceeded the reference value in all patients with ablation and in 80% of patients with EPS 4 hours post-ablation. Peak average hsTnT levels for EPS, AVNRT, AFlu were 24 ± 11, 260 ± 218 and 541 ± 233 ng/L, respectively. The highest hsTnT level was measured in the AF group (799 ± 433 ng/L). We found a positive correlation between hsTnT levels and ablation time after RFCA. Conclusions: The hsTnT levels significantly change after EPS and RFCA, in all patients who underwent ablation, and in 80% of those with EPS had hsTnT positivity in the early post-procedural phase. hsTnT levels depended significantly on the type of the subgroups and correlated with the ablation time. Awareness of those observations is essential to correctly interpret elevated hsTnT levels following RFCA. Orv Hetil. 2019; 160(14): 540–548

Role of Right Ventricular Global Longitudinal Strain in Predicting Early and Long-Term Mortality in Cardiac Resynchronization Therapy Patients.

BACKGROUND: Right ventricular (RV) dysfunction has been associated with poor prognosis in chronic heart failure (HF). However, less data is available about the role of RV dysfunction in patients with cardiac resynchronization therapy (CRT). We aimed to investigate if RV dysfunction would predict outcome in CRT. DESIGN: We enrolled prospectively ninety-three consecutive HF patients in this single center observational study. All patients underwent clinical evaluation and echocardiography before CRT and 6 months after implantation. We assessed RV geometry and function by using speckle tracking imaging and calculated strain parameters. We performed multivariable Cox regression models to test mortality at 6 months and at 24 months. RESULTS: RV dysfunction, characterized by decreased RVGLS (RV global longitudinal strain) [10.2 (7.0-12.8) vs. 19.5 (15.0-23.9) %, p<0.0001] and RVFWS (RV free wall strain) [15.6 (10.0-19.3) vs. 17.4 (10.5-22.2) %, p = 0.04], improved 6 months after CRT implantation. Increasing baseline RVGLS and RVFWS predicted survival independent of other parameters at 6 months [hazard ratio (HR) = 0.37 (0.15-0.90), p = 0.02 and HR = 0.42 (0.19-0.89), p = 0.02; per 1 standard deviation increase, respectively]. RVGLS proved to be a significant independent predictor of mortality at 24 months [HR = 0.53 (0.32-0.86), p = 0.01], and RVFWS showed a strong tendency [HR = 0.64 (0.40-1.00), p = 0.05]. The 24-month survival was significantly impaired in patients with RVGLS below 10.04% before CRT implantation [area under the curve = 0.72 (0.60-0.84), p = 0.002, log-rank p = 0.0008; HR = 5.23 (1.76-15.48), p = 0.003]. CONCLUSIONS: Our findings indicate that baseline RV dysfunction is associated with poor short-term and long-term prognosis after CRT implantation