Ostra niewydolność serca po embolizacji guza nerki. Opis przypadku

Renal cell carcinoma (RCC) is the most common primary malignant renal tumor. The classic triad of symptoms includes palpable abdominal mass, hematuria and flank pain. However, some of the patients diagnosed with RCC first present with paraneoplastic symptoms occurring as a consequence of secretion of various substances from the tumor. We present a case of a woman diagnosed with large kidney tumor, who developed acute heart failure soon after being treated with percutaneous embolization. We discuss toxic myocarditis as one of the possible causes for the acute hemodynamic compromise and the fatal outcome of the patient. Our case report highlights the complexity of this pathology and the importance of awareness of the various possible life-threatening complications.Rak nerkowo-komórkowy jest najczęstszym pierwotnym nowotworem złośliwym nerki. Klasyczna triada objawów z nim związanych obejmuje guz w jamie brzusznej, krwiomocz i ból w okolicy lędźwiowej. Jednak niektórzy pacjenci z rakiem nerkowo-komórkowym najpierw mają objawy paraneoplastyczne wywoływane przez substancje produkowane przez guz. W pracy przedstawiono przypadek kobiety, u której zdiagnozowano duży guz nerki i u której bezpośrednio po jego embolizacji rozwinęły się objawy ostrej niewydolności serca. Jako jedną z możliwych przyczyn ostrych zaburzeń hemodynamicznych i zgonu pacjenta rozważono toksyczne zapalenie mięśnia sercowego. Przedstawiony opis przypadku podkreśla złożoność patologii, jak również potrzebę świadomości różnych możliwych zagrażających życiu powikłań związanych z jego leczeniem

A novel technique of proximal optimization with kissing balloon inflation in bifurcation lesions

Background: Percutaneous coronary interventions (PCI) of bifurcation lesions poses a technical challenge with a high complication rate. Kissing balloon inflation (KBI) and proximal optimization technique (POT) are used to correct bifurcation carina after stenting. However, both may still lead to uncomplete strut apposition to the side branch (SB) lateral wall. Proposed herein, is a new stent-optimization technique following bifurcation stenting consisting of a combination of POT and KBI called proximal optimization with kissing balloon inflation (POKI). Methods: Bench and in-vivo evaluations were performed. For the bench visualization bifurcated silicone mock vessel was used. The POKI technique was simulated using a 3.5 mm POT balloon. For the in-vivo evaluation patients with angiographic bifurcation lesions in a native coronary artery with diameter ≥ 2.5 mm and ≤ 4.5 mm, SB diameter ≥ 2.0 mm, and percentage diameter stenosis (%DS) more than 50% in the main vessel (MV) were included. Provisional stenting was the default strategy. Results: In total 41 vessels were evaluated. The target vessel was left main in 9 (22.0%) patients, left anterior descending artery — in 26 (63.4%), left circumflex artery — in 4 (9.8%) and right coronary artery — in 2 (4.9%). The predominant type of bifurcation was Medina 1-1-1 (61.8%). Baseline proximal MV DS% was 60.0 ± 23.7%, distal MV DS% — 58.8 ± 28.9% and SB DS% 53.0 ± 32.0%. The application of POKI was feasible in 41 (100%) of the vessels. Post-PCI residual DS at proximal MV was 11.5 ± 15.4%, distal MV — 6.6 ± 9.3%, and SB — 22.9 ± 28.5%. Both procedural and angiographic success was 100%. Conclusions: POKI is a novel stent-optimization technique for bifurcation lesions. It showed excellent feasibility and success rate both in bench and in-vivo evaluation

Prevalence of Coronary Microvascular Disease and Coronary Vasospasm in Patients With Nonobstructive Coronary Artery Disease: Systematic Review and Meta-Analysis

Background A relevant proportion of patients with suspected coronary artery disease undergo invasive coronary angiography showing normal or nonobstructive coronary arteries. However, the prevalence of coronary microvascular disease (CMD) and coronary spasm in patients with nonobstructive coronary artery disease remains to be determined. The objective of this study was to determine the prevalence of coronary CMD and coronary vasospastic angina in patients with no obstructive coronary artery disease. Methods and Results A systematic review and meta-analysis of studies assessing the prevalence of CMD and vasospastic angina in patients with no obstructive coronary artery disease was performed. Random-effects models were used to determine the prevalence of these 2 disease entities. Fifty-six studies comprising 14 427 patients were included. The pooled prevalence of CMD was 0.41 (95% CI, 0.36-0.47), epicardial vasospasm 0.40 (95% CI, 0.34-0.46) and microvascular spasm 24% (95% CI, 0.21-0.28). The prevalence of combined CMD and vasospastic angina was 0.23 (95% CI, 0.17-0.31). Female patients had a higher risk of presenting with CMD compared with male patients (risk ratio, 1.45 [95% CI, 1.11-1.90]). CMD prevalence was similar when assessed using noninvasive or invasive diagnostic methods. Conclusions In patients with no obstructive coronary artery disease, approximately half of the cases were reported to have CMD and/or coronary spasm. CMD was more prevalent among female patients. Greater awareness among physicians of ischemia with no obstructive coronary arteries is urgently needed for accurate diagnosis and patient-tailored management. Keywords: angina with nonobstructive coronary artery disease; ischemia with no obstructive coronary artery disease; vasospastic angina

Intracoronary Electrocardiography-guided Strategy for the Treatment of Coronary Bifurcation Lesions

Introduction: Revascularization of bifurcation lesions remains an interventional challenge. Intracoronary electrocardiograms can predict the functional significance of side branch stenosis after bifurcation stenting. Aim: This study was aimed at evaluating the effects of an intracoronary ECG electrocardiography (icECG)-guided revascularization strategy, compared with the currently accepted standard of care, on the clinical outcomes of patients after coronary bifurcation stenting. Methods: Patients with coronary bifurcation lesions who underwent percutaneous revascularization were enrolled in a prospective all-comers’ registry. Clinical outcomes were compared between patients who underwent icECG-guided revascularization versus the current standard of care (SOC), provisional stenting. Results: A total of 768 patients were included in the analysis: 349 were treated with an icECG-guided strategy, and 419 received SOC. The overall all-cause death rate was 23.2%, and the cardiovascular death rate was 15.9%. Patients with icECG guidance had significantly lower all-cause mortality (20.3% vs. 25.5% for icECG vs. SOC, log-rank P = 0.006) and cardiovascular mortality (12.6% vs. 18.6% for icECG vs. SOC, log-rank P = 0.004). The decrease in mortality was most pronounced in patients with no increase or a moderate increase in troponin post-PCI, or with higher-than-normal baseline troponin concentrations. Conclusion: An icECG-guided strategy for coronary bifurcation PCI led to lower patient mortality than the provisional stenting strategy

Infarct size, inflammatory burden, and admission hyperglycemia in diabetic patients with acute myocardial infarction treated with SGLT2-inhibitors: a multicenter international registry

Background: The inflammatory response occurring in acute myocardial infarction (AMI) has been proposed as a potential pharmacological target. Sodium-glucose co-transporter 2 inhibitors (SGLT2-I) currently receive intense clinical interest in patients with and without diabetes mellitus (DM) for their pleiotropic beneficial effects. We tested the hypothesis that SGLT2-I have anti-inflammatory effects along with glucose-lowering properties. Therefore, we investigated the link between stress hyperglycemia, inflammatory burden, and infarct size in a cohort of type 2 diabetic patients presenting with AMI treated with SGLT2-I versus other oral anti-diabetic (OAD) agents. Methods: In this multicenter international observational registry, consecutive diabetic AMI patients undergoing percutaneous coronary intervention (PCI) between 2018 and 2021 were enrolled. Based on the presence of anti-diabetic therapy at the admission, patients were divided into those receiving SGLT2-I (SGLT-I users) versus other OAD agents (non-SGLT2-I users). The following inflammatory markers were evaluated at different time points: white-blood-cell count, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-platelet ratio (NPR), and C-reactive protein. Infarct size was assessed by echocardiography and by peak troponin levels. Results: The study population consisted of 583 AMI patients (with or without ST-segment elevation): 98 SGLT2-I users and 485 non-SGLT-I users. Hyperglycemia at admission was less prevalent in the SGLT2-I group. Smaller infarct size was observed in patients treated with SGLT2-I compared to non-SGLT2-I group. On admission and at 24 h, inflammatory indices were significantly higher in non-SGLT2-I users compared to SGLT2-I patients, with a significant increase in neutrophil levels at 24 h. At multivariable analysis, the use of SGLT2-I was a significant predictor of reduced inflammatory response (OR 0.457, 95% CI 0.275-0.758, p = 0.002), independently of age, admission creatinine values, and admission glycemia. Conversely, peak troponin values and NSTEMI occurrence were independent predictors of a higher inflammatory status. Conclusions: Type 2 diabetic AMI patients receiving SGLT2-I exhibited significantly reduced inflammatory response and smaller infarct size compared to those receiving other OAD agents, independently of glucose-metabolic control. Our findings are hypothesis generating and provide new insights on the cardioprotective effects of SGLT2-I in the setting of coronary artery disease. Trial registration: Data are part of the ongoing observational registry: SGLT2-I AMI PROTECT. Clinicaltrials: gov Identifier: NCT05261867

Intravascular ultrasound imaging in evaluation of aortic stiffness: A proof-of-concept study

Background: Aortic stiffness is a well-known cardio-vascular risk factor. For years, different methods have been studied in the assessment of aortic elastic properties and large arterial stiffness for risk stratification. Herein is an assessment of the role of intravascular ultrasound (IVUS) imaging for the evaluation of aortic elastic properties. Methods: Intravascular ultrasound imaging of the aorta was performed in 12 patients with transthoracic echocardiography (TTE) and computed tomography (CT) evidence for enlargement of the ascending aorta — diameter ≥ 40.0 mm. Mechanical properties of the aorta were derived from the measured diameters and intra-aortic pressure. Paired samples T-test analyses were performed to determine differences between measurements derived by TTE, CT and IVUS. Results: Mean values of the calculated elastic properties via IVUS of the ascending aorta were as follows: compliance 0.021 ± 0.02; strain 205 ± 4.3; aortic stiffness index 4.3 ± 0.75; elastic modulus 0.31 ± 0.05. On paired T-test analysis maximum ascending aortic diameter measured by CT aortography and IVUS did not differ significantly (t = –0.19, p = 0.985), but a significant difference between IVUS measurements and TTE derived diameters was found (t = 13.118, p = 0.034). On average, IVUS diameters were 2.3 mm larger than the results acquired by TTE (95% confidence interval: 14.21–17.13). Conclusions: Intravascular ultrasound examination of the ascending aorta provided larger diameters than the ones collected by means of TTE. However, IVUS measurements did not differ significantly from diameters derived by CT aortography

Economic evaluation and analysis of the budget effect of the measuring of fractional flow reserve in Bulgaria

Въведение: Частичният (фракциониран) резерв на кръвотока (FFR) представлява съотношението на максималния миокарден кръвоток в случай на патологично променена артерия и максималния миокарден кръвоток, ако същата артерия е нормална. Цел: Целта на настоящата статия е да се направи икономическа оценка и анализ на бюджетното въздействие на медицинската дейност по измерване на фракционирания резерв на кръвотока при приложението ѝ в локална среда в България. Материал и методи: За целите на анализа са разработени два модела с помощта на Microsoft Excel и TreeAge Pro, оценяващи разходната ефективност на FFR-базирана перкутанна коронарна интервенция (PCI) спрямо PCI с класическата ангиографскибазирана стратегия при пациенти с исхемична болест на сърцето (ИБС) с една функционално-сигнификантна стеноза и при пациенти с многоклонова ИБС. Анализът използва здравна перспектива и гледна точка на платеца – НЗОК. Резултати: Mедикодиагностичната дейност FFR при пациенти с многоклонова коронарна болест се определя като разходно ефективен терапевтичен подход спрямо ангиографски-базираната PCI (ICER = 50 455,71 лв./QALY) при праг от 51 510 лв./QALY. FFR-базираната стратегия за PCI при пациенти с една функционално-сигнификантна стеноза e разход-спестяващ подход (-853 лв. на пациент) спрямо ангиографски-базираната стратегия за PCI (съответно 3297 лв. спрямо 4150 лв.). Заключение: Анализът на бюджетното въздействие показва, че FFR-базираната стратегия за PCI е разход-спестяваща алтернатива на ангиографскибазираната стратегия. Спестяванията за НЗОК през първата година от реимбурсирането на FFR са -1,1 млн. лв. и достигат до -1,6 млн. лв. през третата година. Introduction: Fractional fl ow reserve (FFR) implies the ratio of the maximal hyperemic myocardial blood fl ow in the case of a pathologically changed coronary artery to the maximal hyperemic myocardial blood fl ow in the case of a healthy coronary artery. Aims: The aim of the current study is to perform an economic evaluation and budget impact analysis of measuring FFR as a medical activity in Bulgaria. Material and Methods: For the purpose of the current analysis, two models using Microsoft Excel and TreeAge Pro were developed to evaluate the cost-effectiveness of the FFR-guided percutaneous coronary intervention (PCI) compared to the classic angiography-guided PCI in patients with ischemic heart disease (IHD) with one-vessel coronary artery disease (CAD) or multivessel CAD. The analysis will focus on the health perspective and the payer perspective - National Health Insurance Fund (NHIF). Results: The medico-diagnostic activity related to measuring FFR in patients with multi-vessel coronary artery disease is shown to be a cost-effective therapeutic approach in Bulgaria compared to the angiography-guided PCI (ICER = 50 456 BGN/QALY) with a cost-effectiveness threshold of 51 510 BGN/QALY. FFR- guided PCI strategy in one-vessel coronary artery disease patients is a cost-saving approach (-853 BGN) when compared to the angiography-guided PCI (4 150 BGN). Conclusion: Budget impact analysis revealed that the FFR-guided PCI strategy is a cost-saving alternative approach to the angiographyguided PCI. The savings of the NHIF during the fi rst year of reimbursement of FFR would be -1,1 million BGN and could reach -1,6 million BGN in the third year

Misdiagnosed Aortic Intramural Hematoma and the Role of Intravascular Ultrasound Imaging in Detection of Acute Aortic Syndrome: A Case Report

Acute aortic syndrome includes classic aortic dissection, aortic intramural hematoma, and penetrating atherosclerotic ulcer – a group of conditions that are defined by their dynamic evolution and similar clinical manifestation. Accurate diagnosis and prompt treatment are essential as all the aforementioned conditions are a significant threat to a patient’s life. However, acute aortic syndrome and especially aortic intramural hematoma may be challenging diagnostic problems. Intravascular ultrasound imaging is a diagnostic method that can be useful for more thorough evaluation of the aortic lesion and can particularly aid in discerning the different forms of acute aortic syndrome. We present a case of a patient with aortic intramural hematoma that was missed by conventional imaging studies but was successfully visualized with intravascular ultrasound imaging

Endothelial Dysfunction and Pregnant COVID-19 Patients with Thrombophilia: A Narrative Review

Pregnancy with SARS-CoV-2 infection can raise the risk of many complications, including severe COVID-19 and maternal–fetal adverse outcomes. Additionally, endothelial damage occurs as a result of direct SARS-CoV-2 infection, as well as immune system, cardiovascular, and thrombo-inflammatory reactions. In this narrative review, we focus on endothelial dysfunction (ED) in pregnancy, associated with obstetric complications, such as preeclampsia, fetal growth retardation, gestational diabetes, etc., and SARS-CoV-2 infection in pregnant women that can cause ED itself and overlap with other pregnancy complications. We also discuss some shared mechanisms of SARS-CoV-2 pathophysiology and ED

Development, validation, and reproducibility of the pullback pressure gradient (PPG) derived from manual fractional flow reserve pullbacks

Fractional flow reserve (FFR) pullbacks assess the location and magnitude of pressure drops along the coronary artery. The pullback pressure gradient (PPG) quantifies the FFR pullback curve and provides a numeric expression of focal versus diffuse coronary artery disease. This study aims (1) to validate the PPG using manual FFR pullbacks compared with motorized FFR pullbacks as a reference; and (2) to determine the intra- and interoperator reproducibility of the PPG derived from manual FFR pullbacks. Patients with stable coronary artery disease and an FFR ≤ 0.80 were included. All patients underwent FFR pullback evaluation either with a motorized device or manually, depending on the study cohort. The agreement of the PPG between repeated pullbacks was assessed using the Bland-Altman method. Overall, 116 FFR pullback maneuvers (96 manual and 20 motorized) were analyzed. There was excellent agreement between the PPG derived from manual and motorized pullbacks (mean difference -0.01 ± 0.07, 95% limits of agreement [LOA] -0.14 to 0.12). The intra- and interoperator reproducibility of PPG derived from manual pullbacks were excellent (mean difference <0.01, 95% LOA -0.11 to 0.12, and mean difference <0.01, 95% LOA -0.12 to 0.11, respectively). The duration of the pullback maneuver did not impact the reproducibility of the PPG (r = 0.12, 95% CI: -0.29 to 0.49, p = 0.567). Manual pullbacks allow for an accurate PPG calculation. The inter- and intraoperator reproducibility of PPG derived from manual pullbacks were excellent