The role of hemostatic markers as venous stenosis or occlusion predictors following first transvenous cardiac device implantation

Background: Among patients with an implanted cardiac implantable electronic device (CIED), ipsilateral upper extremity vein stenosis or occlusion (VSO) is observed more frequently than in the general population. However, there are no data available concerning the relationship between hemostatic markers (and their dynamics) and the occurrence of VSO. The aim of this study was to assess the predictive value of beta-thromboglobulin, the von Willebrand factor (vWF), fibrynogen and D-dimer for VSO development among first time CIED recipients.Methods: This is a single-center, prospective study of consecutive first time CIED recipients without upper extremity VSO in baseline ultrasound examination. Biochemical data were collected from all the patients before CIED implantation (first measuring), up to 7 days subsequent (second measuring) and 6 months after the operation (third measuring). Primary endpoint was defined as the presence of upper extremity VSO at the implantation site during the ultrasound examination 6 months after the operation.Results: The study included 71 patients (mean age 73.1 ± 10.5 years; 39 [55%] male). The incidence of VSO within 6-months follow up was 21.1%. Average concentrations of hemostatic markers increased significantly in all patients immediately after CIED implantation. Serial hemostatic marker concentrations were similar in patients who met or did not meet the primary endpoint, apart from vWF. The mean concentration was significantly elevated in the group of 15 patients who reached the primary endpoint (p = 0.032).Conclusions: A significant increase in vWF concentration at 6 months post implantation may be a marker for VSO occurrence

Success rate and safety of catheter ablation in preexcitation syndrome: A comparison between adult and pediatric patients

Background: In contrast to adults, in whom cardiac rhythm disorders are mainly conditioned by coronary artery disease, in children, arrhythmias are most often associated with inherited heart disorders. Catheter ablation (CA) has an important role in the management of cardiac arrhythmias, in adults and children. The aim of the study was to assess and compare the efficacy and safety of CA in children and adults with preexcitation syndrome. Methods: The study population comprised 43 adults and 43 children diagnosed with a Wolff-Parkinson-White syndrome (WPW). The mean age of the study population was 41 ± 15 years for adults and 14 ± 2.5 years for children. In all patients, an electrophysiological study and CA were performed. Analysis with respect to the procedure duration, fluoroscopy exposure time, location of accessory pathways (AP), immediate success rate and complications were performed. Results: Electrophysiological study revealed the most frequent presence of left-sided AP (56% in children and 70% in adults). The mean procedure duration was 96 ± 36 min and 106 ± 51 min in children and adults, respectively (p = NS). The mean fluoroscopy duration was 8.5 ± 4.3 min and 5.9 ± 5.8 min in children and adults, respectively p < 0.05. The CA procedure was successful in 40 out of 43 (93%) adults and in 36 out of 43 (83.7%) children (p = NS). In 2 (4%) children minor complications occurred. Conclusions: Ablation in children and adults are equally effective with respect to short-term clinical observation

„Duszek” w miejscu cewnika centralnego

A case of 51-year-old male patient with a history of malabsorption, nephrolithiasis, chronic pancreatitis, insulin-dependent diabetes, suspicion of celiac disease and ankylosing spondylitis was reported. Patient was admitted to the hospital to remove infected central catheter. Six days after the catheter removal short fragment of the catheter was found in computed tomography angiography in the internal jugular vein, at the junction with the subclavian vein. In fact, it was not the catheter as several days ago it was removed entirety from the patient, but the fibrous sheath covering venous catheter called “ghost”.Długotrwałe użytkowanie centralnego dostępu dożylnego (CVC) jest związane z kilkoma powikłaniami — uszkodzeniem ściany naczynia lub infekcjami, co wymaga jego usunięcia. Może to być trudne lub niemożliwe, zwłaszcza gdy dochodzi do rozwoju otoczki włóknistej wokół cewnika. Co ciekawe, po interwencji usunięcia CVC można zaobserwować resztki włóknistej tkanki w miejscu usuniętego CVC, która w praktyce radiologicznej określana jest mianem „duszka”. Wspomniane zjawisko jest zwykle obserwowane podczas badania echokardiograficznego, po usunięciu elementów rozruszników serca z powodu infekcyjnego zapalenia wsierdzia (CDRIE), ale jak pokazuje opisywany przypadek, może być także zaobserwowane za pomocą angiografii tomografii komputerowej, po usunięciu zainfekowanego cewnika żylnego

Bezpieczeństwo pacjentów poddawanych badaniu scyntygrafii perfuzyjnej mięśnia sercowego po obciążeniu dipirydamolem

Introduction. Myocardial perfusion scintigraphy (MPS) with dipyridamole is an accepted method for assessment of is- chaemic heart disease, in case of contraindication to exercise testing. However, very often we observe clinical symptoms and changes in ECG while monitoring patients during the study with pharmacologic stress with dipyridamole. The aim of this study was to investigate the safety of patients diagnosed with MPS with dipyridamole.  Material and methods. Twenty-five patients with stable coronary artery disease participated in a 2-day protocol (0.56 mg/ kg dipyridamole i.v. and then rest) using Tc-MIBI imaging. Continuous clinical monitoring and 12-lead serial ECG has been used since the beginning of the MPS up to 20 minutes after the examination. High-sensitive cardiac troponin I (hscTnI) concentration was measured before, four hours and the next day after stress test. Primary endpoint included hscTnI concentration above 99th percentile of the upper reference limit in second or third measurement or new persistent ST-T segment changes. Secondary endpoints were: new persistent or transient ECG changes (ST-T segment elevation or depression or negative T waves, prolongation of QRS complex, PR interval or QTc), or any drug-related adverse event.  Results. The concentrations of hscTnI were below 99th percentile of the upper limit among all the patients. Primary and secondary endpoint were observed in 6 (24%) and 23 (92%) patients, respectively. Transient ST-T segment elevation occurred in 4 (16%) patients, transient ST-T segment depression or negative T wave — in 7 (25%) patients, QRS complex prolongation — in 11 (44%) patients, PR interval prolongation — in 18 (75%) patients, QTc prolongation — in 22 (88%) patients, any clinical adverse event related to dipyridamole — in 16 (64%) patients. Following endpoints were correlated with positive MPS results: ST-T segment changes, RP interval prolongation, and with a history of chest pain: ST-T seg- ment changes, QRS complex and QTc prolongation.  Conclusions. MPS with dipyridamole stress is relatively safe, as hscTnI concentration remains within normal in prolon- ged observation after the examination. While there is a significant risk of minor clinical and electrocardiographic adverse events it is not related with a myocardial necrosis. Wstęp. Scyntygrafia perfuzyjna mięśnia sercowego (MPS) z obciążeniem dipirydamolem jest szeroko akceptowaną metodą oceny niedokrwienia mięśnia sercowego, szczególnie u pacjentów z przeciwwskazaniami do elektrokardiogra- ficznego testu wysiłkowego. Jednak podczas obciążenia dipirydomolem często obserwuje się objawy kliniczne i zmiany w badaniu elektrokardiograficznym (EKG). Celem badania jest określenie bezpieczeństwa badań MPS z obciążeniem dipirydamolem.  Materiał i metody. Do badania włączono kolejnych 25 pacjentów, u których wykonywano badanie MPS w celu diagno- styki niedokrwienia mięśnia sercowego w protokole dwudniowym (po obciążeniu dipirydamolem w dawce 0,56 mg/kg mc. i.v. i w spoczynku). Badania wykonywano z wykorzystaniem Tc-MIBI. W trakcie badania pacjenci byli monitorowani za pomocą 12-odprowadzeniowaego EKG. U wszystkich pacjentów oznaczono stężenie troponiny I metodą wysokoczułą (hscTnI) przed badaniem, 4 godziny po obciążeniu dipirydamolem i następnego dnia. Pierwszorzędowym punktem koń- cowym było stężenie hscTnI ponad 99. percentyla górnej granicy wartości referencyjnej w 2. lub 3. oznaczeniu albo nowe i utrzymujące się zmiany odcinka ST-T. Drugorzędowym punktem końcowym były nowe przemijające lub utrzymujące się zmiany w zapisie EKG (uniesienie lub obniżenie odcinka ST-T, wydłużenie czasu trwania zespołu QRS, odstępu PR lub skorygowanego czasu QT [QTc]) lub jakiekolwiek zdarzenie niepożądane związane z dipirydamolem.  Wyniki. Stężenia troponiny w kolejnych pomiarach mieściły się w wartościach referencyjnych u wszystkich pacjentów. Pierwszorzędowy i drugorzędowy punkt końcowy obserwowano u odpowiednio 6 (24%) i 23 (92%) badanych. Przemi- jające uniesienie odcinka ST-T wystąpiło u 4 (16%) badanych, przemijające obniżenie odcinka ST lub ujemne załamki T u 7 (25%) badanych, wydłużenie zespołu QRS u 11 (44%) badanych, odstępu PR u 18 (75%) badanych, QTc u 22 (88%) badanych, a jakiekolwiek zdarzenie niepożądane związane z lekiem u 16 (64%) badanych. Obecność punktów końcowych korelowała z dodatnim wynikiem badania MPS (zmiany odcinka ST-T, wydłużenie odstępu PR) i wywiadem dolegliwości dławicowych (zmiany odcinka ST-T, wydłużenie zespołu QRS i QTc).  Wnioski. Stężenie hscTnI w granicy normy w przedłużonej obserwacji pacjentów po badaniu MPS z obciążeniem dipiry- damolem wskazuje na to, że jest to względnie bezpieczna procedura diagnostyczna. W trakcie badania obserwuje się zmiany elektrokardiograficzne i kliniczne zdarzenia niepożądane niezwiązane z martwicą miokardium.

Initial experience with the subcutaneous implantable cardioverter-defibrillator with the real costs of hospitalization analysis in a single Polish center

Background: The recent introduction of an entirely subcutaneous implantable cardioverter-defibril­lator (S-ICD) represents an important progress in the defibrillation technology towards a less invasive approach. This is a single-center observational study of S-ICD implantations in Poland. Methods: The S-ICD was implanted in 11 patients with standard indications for an ICD. Patients in whom the device was implanted were evaluated for adverse events and device function at hospital discharge. All hospitalization costs were calculated and summed up for all patients. Costs were divided into following categories: medical materials, pharmaceuticals, operating theatre staff, cardiology depart­ment staff, laboratory tests, non-laboratory tests and additional non-medical costs. Results: The mean age of patients was 51.6 ± 16.4 years, 9 were men and 2 were women. Four pa­tients had atrial fibrillation as the basal rhythm, 1 patient had atrial flutter and 6 patients had sinus rhythm. All patients had at least one condition that precluded the use of a traditional ICD system or the S-ICD was preferred due to other conditions, i.e. a history complicated transvenous ICD therapy (18%), anticipated higher risk of infection (27%), lack or difficult vascular access (18%), young age and anticipated high cumulated risk of lifetime device therapy (36%). The mean duration of the im­plantation procedure was 2 h. One patient developed a postoperative pocket hematoma. Mean total time of hospitalization was 28 (6–92) days. Average cost of hospitalization per patient was 21,014.29 EUR (minimal = 19,332.71 EUR and maximal = 24,824.14 EUR). Conclusions: S-ICD implantation appears to provide a viable alternative to transvenous ICD, espe­cially for patients without pacing requirements

Wpływ rehabilitacji kardiologicznej po zawale serca na mikrowoltowy alternans załamka T oraz czynniki ryzyka wyniku nieujemnego

  Background: Exercise based cardiac rehabilitation is a mainstay in improving quality of life and reducing mortality rates after myocardial infarction (MI). Patients recovering from an MI are at an increased risk for sudden cardiac death (SCD). Monitoring the microvolt t-wave alternans (MTWA) allows us to identify patients at low risk for SCD in ventricular tachycardia or ventricular fibrillation (negative result for MTWA). Previous studies showed positive influence of cardiac rehabilitation on cardiac electrical instability. However, further trials accessing this effect seem to be essential. The aim of the study was to assess influence of cardiac rehabilitation on MTWA, as well as to identify predictors of non-negative MTWA results in patients who underwent cardiac rehabilitation after myocardial infarction treated with PCI. Material and methods: Our study included 76 post-MI outpatients, mean age of 52.6 ± 7.0 years, awaiting planned cardiac rehabilitation after PCI treatment. MTWA analysis, ergospirometry, echocardiography and 24-hour Holter were performed before and after a course of stationary bicycle training. The statistical analysis of the potential predictors of non-negative MTWA resultswas performed on demographical data and test results. Results: Before cardiac rehabilitation MTWA was present in 17 (25%) patients, 46 (68%) patients had a negative result and 5 (7%) of the patients were indeterminate. After rehabilitation MTWA was positive in 13 (19%), negative in 45 (66%) and unspecified in 10 (15%) patients. Physical exercise did not have a significant effect on the number of non-negative results of MTWA even though a better tolerance for physical exertion was achieved. The left ventricular ejection fraction (LVEF) was also improved and we observed a lower occurrence of premature ventricular contractions without any significant effect on the risk factors of SCD i.e. heart rate variability (HRV) (SDNN), QTc, and apnea-hypopnea index (AHI). The risk of non-negative MTWA was lower for patients administered diuretics before rehabilitation (OR: 0.18; 95% CI: 0.04–0.91; p = 0.038). It also negatively correlated with VO2@AT after rehabilitation (OR: 0.893; 95% CI: 0.803–0.994; p = 0.038). The risk was higher in older patients after completing rehabilitation (OR: 1.14; 95% CI: 1.04–1.24; p = 0.005). Conclusion: In patients after myocardial infarction treated with PCI, physical exercise did not significantly effect MTWA (non-negative results). The results demonstrate that administration of diuretics before rehabilitation and VO2@AT values after rehabilitation lower the risk of non-negative results of MTWA. The risk of non-negative MTWA was higher amongst older patient after rehabilitation.Wstęp: Trening fizyczny jako podstawa kompleksowej rehabilitacji kardiologicznej poprawia jakość życia i rokowanie chorych po zawale serca. Pacjenci po przebytym zawale serca, względem osób zdrowych, znajdują się w grupie zwiększonego ryzyka nagłego zgonu sercowego (NZS). Badanie mikrowoltowego alternansu załamka T (MTWA, Microvolt T-wave alternans), pozwala identyfikować pacjentów niskiego ryzyka NZS w mechanizmie częstoskurczu komorowego (VT) czy migotania komór (VF) (wyniki ujemne MTWA). Wcześniejsze prace wykazywały pozytywny wpływ rehabilitacji kardiologicznej na niestabilność elektryczną. Ocena tego zjawiska wymaga jednak dalszych badań. Celem pracy była ocena czynników wpływających na występowania nieujemnego (dodatniego lub nieokreślonego) wyniku MTWA u pacjentów poddanych treningowi fizycznemu po zawale serca, leczonych angioplastyką wieńcową (PCI). Materiał i metody: Do badania włączono 76 pacjentów w wieku 52,63 ± 7,02 roku, poddanych ambulatoryjnej rehabilitacji kardiologicznej po zawale serca leczonym PCI. Oceniano MTWA, ergospirometrię, echokardiografię serca oraz 24-godzinne monitorowanie EKG metodą Holtera, przed i po cyklu treningowym wykonywanym na cykloergometrze rowerowym. Analizie statystycznej w kontekście wystąpienia nieujemnego MTWA poddano dane demograficzne oraz wyniki badań wykonywanych przed i po rehabilitacji. Wyniki: MTWA było dodatnie u 17 pacjentów (25%), ujemne u 46 pacjentów (68%) i nieokreślone u 5 pacjentów (7%) przed rehabilitacją oraz odpowiednio dodatnie u 13 (19%), ujemne u 45 (66%) i nieokreślone u 10 (15%) pacjentów po rehabilitacji. Trening fizyczny nie wpłynął istotnie na liczbę nieujemnych wyników mikrowoltowego alternansu załamka T, mimo poprawy tolerancji wysiłku. Poprawiła się frakcja wyrzutowa lewej komory, zmniejszyła się również liczba komorowych pobudzeń przedwczesnych, jednak bez wpływu na dodatkowe parametry oceny ryzyka NZS, to jest zmienność rytmu zatokowego — HRV (SDNN), QTc, wskaźnik bezdechów — AHI. Niezależnymi czynnikami zmniejszającymi ryzyko wystąpienia nieujemnego MTWA przed rehabilitacją było stosowanie diuretyków (OR: 0,18; 95% CI: 0,04–0,91; p = 0,038) oraz pochłanianie tlenu na progu beztlenowym (VO2@AT) (OR: 0,89; 95% CI: 0,80–0,99; p = 0,038). Czynnikiem zwiększającym ryzyko był starszy wiek po zakończeniu cyklu rehabilitacji (OR: 1,14; 95% CI: 1,04–1,24; p = 0,005). Wnioski: U pacjentów po zawale serca, leczonych angioplastyką wieńcową i poddanych rehabilitacji, trening fizyczny nie wpływa na liczbę nieujemnych wyników MTWA. Wykazano, że niezależnymi czynnikami zmniejszającymi ryzyko nieujemnego wyniku MTWA było stosowanie diuretyków przed rehabilitacją oraz wartość VO2@AT po rehabilitacji. Ryzyko nieujemnego MTWA było większe wśród starszych pacjentów po rehabilitacji

Comparative effectiveness of torasemide versus furosemide in symptomatic therapy in heart failure patients: Preliminary results from the randomized TORNADO trial

Background: Recent reports suggest that torasemide might be more beneficial than furosemide inpatients with symptomatic heart failure (HF). The aim was to compare the effects of torasemide andfurosemide on clinical outcomes in HF patients.Methods: This study pilot consisted of data from the ongoing multicenter, randomized, unblindedendpoint phase IV TORNADO (NCT01942109) study. HF patients in New York Heart Association(NYHA) II–IV class with a stable dose of furosemide were randomized to treatment with equipotentialdose of torasemide (4:1) or continuation of unchanged dose of furosemide. On enrollment andcontrol visit (3 months after enrollment) clinical examination, 6-minute walk test (6MWT) andassessment of fluid retention by ZOE Fluid Status Monitor were performed. The primary endpoint wasa composite of improvement of NYHA class, improvement of at least 50 m during 6MWT and decreasein fluid retention of at least 0.5 W after 3-months follow-up.Results: The study group included 40 patients (median age 66 years; 77.5% male). During follow-up7 patients were hospitalized for HF worsening (3 in torasemide and 4 in furosemide-treated patients).The primary endpoint reached 15 (94%) and 14 (58%) patients on torasemide and furosemide, respectively(p = 0.03).Conclusions: In HF patients treated with torasemide fluid overload and symptoms improved more thanin the furosemide group. This positive effect occurred already within 3-month observation

Risk of left atrial appendage thrombus in patients with atrial fibrillation and chronic kidney disease

Background: Atrial fibrillation (AF) and chronic kidney disease (CKD) are associated with an increased risk of ischemic stroke. The aim of this study was to compare the clinical characteristics, the incidence of left atrial appendage (LAA) thrombus and its predictors, and spontaneous echo contrast (SEC) in a population of patients with AF depending on estimated glomerular filtration rate (eGFR) values. Methods: This study included 1962 patients who underwent transesophageal echocardiographic examination (TEE) prior to cardioversion or ablation in the years 2014–2018 in three cardiac centers. Results: More than a quarter of AF patients had decreased eGFR ( < 60 mL/min/1.73 m2) and were characterized as a high-risk population, with more comorbidities, higher thromboembolic and bleeding risk compared to those with normal renal function. Oral anticoagulation (OAC) was prescribed in 97% and 93% of patients with decreased and normal eGFR, respectively, with a higher prevalence of prescribed non-vitamin K antagonist oral anticoagulants (NOACs). The incidence of LAA thrombus (24%, 9% and 4%) and SEC (25%, 25% and 19%) increases simultaneously with a decrease in eGFR ( < 30, 30–59 and > 60 mL/min/1.73 m2, respectively). Among patients prescribed reduced doses of NOAC, those with decreased eGFR were more often observed with LAA thrombus (10% vs. 2.5%). Non-paroxysmal AF, heart failure and previous bleeding were predictors of LAA thrombus, irrespective of eGFR value. CKD was the predictor of LAA thrombus in all patients including those with non-paroxysmal AF, males, without diabetes, without hypertension and with CHA2DS2-VASc < 2. Conclusions: Despite OAC, patients with concomitant AF and CKD remain at high risk for LAA thrombus formation