Computed tomography of coronary artery anomaly : case report

Background: Anomalies of coronary vessels can be described as varies group of congenital heart disease, which can have different level of clinical manifestation and changeable pathophysiological mechanisms. Diagnosis and imaging of vessel course is essential before percutaneous angioplasty intervention and coronary artery bypass grafting as well as before implantation of artificial valve. Case Report: Patient with cardiologic history, previously percutaneus intervention were performed and left circumflex coronary artery were assessed as occluded. Computed tomography revealed anomalous origin of patent circumflex branch arising from right Valsava sinus. Conclusions: Selective percutaneus coronary angiography is challenging in case of coronary anomalies, there are only few indirect symptoms of anomalies. The advantage of computed tomography over classic coronarography is visibility of all patent coronary vessels after single administration of contrast medium. It is possible to describe its anatomic relations, evaluation of walls and its changes

Severe degenerative aortic stenosis with preserved ejection fraction does not change adipokines serum levels

Background: The role of the adipokines in the pathogenesis of aortic stenosis (AS) is not well established. The aim was to evaluate the relationship between adipokines and clinical characteristics as well as echocardiographic indices and noninvasive markers of vascular remodeling in patients with severe AS with preserved ejection fraction (EF). Methods: Sixty-five patients (F/M: 38/27; age: 68.3 ± 9.0 years; body mass index [BMI]: 29.6 ± 4.3 kg/m2) with severe AS with preserved EF: 33 patients with paradoxical low-flow low-gradient AS (PLFLG AS) and 32 patients with normal flow high-gradient AS (NFHG AS) were prospectively enrolled into the study. Twenty-four subjects (F/M: 14/10; age: 65.4 ± 8.7 years; BMI: 29.6 ± 4.3 kg/m2) who matched as to age, sex, BMI and coronary artery disease (CAD) constituted the control group (CG). Clinical data and markers of vascular remodeling were related to the serum adipokines. Results: There were no differences in the adipokines concentrations in the AS/CG. Patients with AS and coexisting CAD were characterized by decreased serum adiponectin (9.9 ± 5.5 vs. 12.7 ± 5.8 μg/mL, p = 0.040) and leptin (8.3 ± 7.8 vs. 21.6 ± 17.1 ng/mL, p < 0.001) levels compared to subjects without CAD. There were no differences in the serum adipokines concentrations between patients with PLFLG AS and NFHG AS. Systemic hypertension, diabetes, hyperlipidemia or markers of vascular remodeling did not discriminate adipokines concentrations. Multivariate regression analysis indicated that age (F = 3.02; p = 0.015) and E/E’ index (F = 0.87, p = 0.032) were independent predictors of the adiponectin level in the AS group. Conclusions: The presence of AS with preserved EF did not change the adipokine serum profile. Adipokines levels were modified by coexisting atherosclerosis but not the typical cardiovascular risk factors or the hemodynamic type of AS

Mój pacjent leczony przeciwkrzepliwie – dwa oblicza chorych

This paper presents two patients with atrial fibrillation. The first patient is a young 46-year-old, working, active male, who has only hypertension and pharmacologically well-controlled hyperthyroidism. He was diagnosed with persistent atrial fibrillation lasting four days (EHRA III, CHA2DS2-VASc 1 point, HAS-BLED 0 point). After excluding embolic material based on the transesophageal echocardiography and implementation of non-vitamin K antagonist oral anticoagulant (NOAC), effective electrical cardioversion was performed. Due to poorly tolerated recurrences of atrial fibrillation (EHRA III) in the clinical observation, the patient has been classified for circumferential pulmonary vein isolation (PVI), which was performed after a routine transesophageal echocardiography. The patient continued anticoagulation with NOAC before and post procedure for 2 months. Another patient is a 78-year-old man, treated chronically, so far only because of hypertension. He was admitted to the cardiology department due to the cardiovascular decompensation and increased symptoms of heart failure for 3 weeks prior to hospitalization. During the hospitalization, the patient was diagnosed with persistent atrial fibrillation (EHRA II, CHA2DS2-VASc 4 points, HAS-BLED 3 points), moderate mitral and tricuspid valve regurgitation, chronic renal failure stage III, microcytic anemia, thrombocytopenia, iron deficiency, benign prostatic hypertrophy and osteoarthritis of the spine. Additional aggravating factors were newly diagnosed cognitive function decline and considerable fragility of the patient (4th degree according to the Canadian Study of Health and Aging Clinical Frailty Scale). After the improvement of the patient status, taking into account the limitations and contraindications to anticoagulation, NOAC was administered. Electrical cardioversion was planned during next hospitalization. 1. January C.T., Wann L.S., Alpert J.S. i wsp. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J. Am. Coll. Cardiol. 2014; 64: e1–e76. 2. Ezekowitz M.D., Cappato R., Klein A.L. i wsp. Rationale and design of the eXplore the efficacy and safety of once-daily oral riVaroxaban for the prEvention of caRdiovascular events in patients with nonvalvular aTrial fibrillation scheduled for cardioversion trial: a comparison of oral rivaroxaban once daily with dose-adjusted vitamin K antagonists in patients with nonvalvular atrial fibrillation undergoing elective cardioversion. Am. Heart J. 2014; 167: 646–652. 3. Moneta G.L., Edwards J.M., Chitwood R.W. i wsp. Correlation of North American Symptomatic Carotid Endarterectomy Trial (NASCET) angiographic definition of 70% to 99% internal carotid artery stenosis with duplex scanning. J. Vasc. Surg. 1993; 17: 152–157; dyskusja 7–9. 4. Flaker G.C., Pogue J., Yusuf S. i wsp. Cognitive function and anticoagulation control in patients with atrial fibrillation. Circ. Cardiovasc. Qual. Outcomes 2010; 3: 277–283. 5. Cacciatore F., Testa G., Langellotto A. i wsp. Role of ventricular rate response on dementia in cognitively impaired elderly subjects with atrial fibrillation: a 10-year study. Dement Geriatr. Cogn. Dis. 2012; 34: 143–148. Multidisciplinary approach to the choice of appropriate anticoagulant therapy, depending on the patient’s condition, the planned treatment for restoring sinus rhythm (cardioversion or PVI) with regard to comorbidities, should be a priority in everyday clinical practice.W niniejszym opracowaniu przedstawiono 2 chorych z migotaniem przedsionków (AF). Pierwszym pacjentem jest młody mężczyzna, w wieku 46 lat, czynny zawodowo, obciążony jedynie nadciśnieniem tętniczym i dobrze kontrolowaną farmakologicznie nadczynnością tarczycy. Zdiagnozowano u niego przetrwałe od 4 dni AF (EHRA III, 1 pkt w CHA2DS2-VASc, 0 pkt. w HAS-BLED). Po wykluczeniu w przezprzełykowej echokardiografii (TEE) materiału zatorowego oraz po wdrożeniu leczenia przeciwkrzepliwego lekiem przeciwzakrzepowym niebędącym antagonistą witaminy K (NOAC) wykonano skuteczną kardiowersję elektryczną. Ze względu na nawracające, źle tolerowane epizody AF w obserwacji klinicznej pacjenta zakwalifikowano do ablacji okrążającej żyły płucne (PVI), którą wykonano po rutynowym TEE. U chorego — zarówno około-, jak i pozabiegowo — przez 2 miesiące kontynuowano stosowanie NOAC. Kolejnym chorym jest 78-letni mężczyzna, leczący się do tej pory przewlekle jedynie z powodu nadciśnienia tętniczego. Został przyjęty na oddział kardiologii z powodu postępującej dekompensacji układu krążenia i nasilonych od 3 tygodni przed przyjęciem objawów niewydolności serca. W trakcie hospitalizacji dodatkowo rozpoznano: przetrwałe AF (EHRA II, CHA2DS2-VASc 4 pkt, HAS-BLED 3 pkt), umiarkowaną niedomykalność zastawki mitralnej oraz zastawki trójdzielnej, przewlekłą niewydolność nerek w 3. stadium, niedokrwistość mikrocytarną, trombocytopenię, niedobór żelaza, przerost prostaty i chorobę zwyrodnieniową stawów kręgosłupa. Dodatkowym obciążeniem były nieopisywane wcześniej zaburzenia funkcji poznawczych oraz znaczna kruchość pacjenta (4. stopień wg Canadian Study of Health and Aging Clinical Frailty Scale). Po wyrównaniu klinicznym chorego, uwzględnieniu ograniczeń i przeciwwskazań do leczenia przeciwkrzepliwego włączono NOAC i zaplanowano kardiowersję elektryczną w trybie odroczonym. Multidyscyplinarne podejście do odpowiedniego doboru leczenia przeciwkrzepliwego, zależnie od stanu chorego, planowanych zabiegów przywracających rytm zatokowy (kardiowersji elektrycznej czy PVI) wraz z uwzględnieniem schorzeń współistniejących powinno być priorytetem w codziennej praktyce klinicznej

N-3 polyunsaturated fatty acids do not influence the efficacy of dual antiplatelet therapy in stable angina pectoris patients after percutaneous coronary intervention

Background: We aimed to prospectively assess the influence of the recommended dose, 1.0 g of polyunsaturated fatty acids (N-3 PUFA) daily, on platelet reactivity in patients with stable angina pectoris (SAP) after elective percutaneous coronary intervention (PCI).Methods: Forty consecutive patients with SAP and successful PCI were randomized to the study group (group PUFA: n = 20; age 65 ± 8; standard therapy + 75 mg acetylsalicylic acid + 75 mgclopidogrel + N-3 PUFA/Omacor 1 g daily) and the control group (group C: n = 20; age 65 ± 9; standard therapy + 75 mg acetylsalicylic acid + 75 mg clopidogrel). Platelet reactivity tests (COL, TRAP, ASPI, ADP) were performed using whole blood aggregometry (multiplate platelet [PLT] function analysis) on the 2,nd and 30th day after PCI.Results: Baseline patients’ characteristics and clinical outcomes were comparable between the groups. There were no differences between both groups in the mean values of the PTL tests measured 30 days after PCI (PUFA vs. C: ASPI: 18.5 ± 17 vs. 27 ± 29 U, COL: 30.4 ± 14.3 vs. 30.3 ± 13.4 U, ADP: 25.4 ± 16.1 vs. 20 ± 10.7 U, TRAP: 65.8 ± 25.6 vs. 57.1 ± 20.4 U, p = NS). The mean delta values of the PTL tests (18–24 h post-PCI/30 days post-PCI) were also comparable between the groups. The PTL aggregometry results were related to time — the baseline values of the ADP (p = 0.003), COL (p = 0.037) and TRAP (p < 0.001) tests were smaller and the ASPI (p = 0.027) test was higher than those measured after 1-month.Conclusions: N-3 PUFA supplementation does not affect the efficacy of dual antiplatelettherapy in patients with SAP after PCI

Does higher gadolinium concentration play a role in the morphologic assessment of brain tumors? Results of a multicenter intraindividual crossover comparison of gadobutrol versus gadobenate dimeglumine (the MERIT Study).

BACKGROUND AND PURPOSE: Gadobenate dimeglumine has proved advantageous compared with other gadolinium-based contrast agents for contrast-enhanced brain MR imaging. Gadobutrol is a more highly concentrated agent (1.0 mol/L). This study intraindividually compared 0.1-mmol/kg doses of these agents for qualitative and quantitative evaluation of brain tumors. MATERIALS AND METHODS: Adult patients with suspected or known brain tumors underwent 2 identical MR imaging examinations at 1.5T, 1 with gadobenate dimeglumine and the other with gadobutrol, both at a dose of 0.1-mmol/kg body weight. The agents were injected in randomized order separated by 3–14 days. Imaging sequences and acquisition timing were identical for the 2 examinations. Three blinded readers evaluated images qualitatively for diagnostic information (lesion extent, delineation, morphology, enhancement, global preference) and quantitatively for CNR and LBR. RESULTS: One hundred fourteen of 123 enrolled patients successfully underwent both examinations. Final diagnoses were intra-axial tumors, metastases, extra-axial tumors, "other" tumors, and "nontumor" (49, 46, 8, 7, and 4 subjects, respectively). Readers 1, 2, and 3 demonstrated preference for gadobenate dimeglumine in 46 (40.7%), 54 (47.4%), and 49 (43.0%) patients, respectively, compared with 6, 7, and 7 patients for gadobutrol ( P < .0001, all readers). Highly significant ( P < .0001, all readers) preference for gadobenate dimeglumine was demonstrated for all other qualitative end points. Inter-reader agreement was good for all evaluations (κ = 0.414–0.629). Significantly superior CNR and LBR were determined for gadobenate dimeglumine ( P < .019, all readers). CONCLUSIONS: Significantly greater morphologic information and lesion enhancement are achieved on brain MR imaging with 0.1-mmol/kg gadobenate dimeglumine compared with gadobutrol at an equivalent dose. CNR : contrast-to-noise ratio GBCA : gadolinium-based contrast agent GRE : gradient-recalled echo LBR : lesion-to-background ratio NSF : nephrogenic systemic fibrosis SE : spin-echo SI : signal intensit