Atrial fibrillation as a contributing factor in the diagnostic algorithm for coronary subclavian steal syndrome and cardiac tamponade following coronary artery bypass graft surgery: a case study

Coronary subclavian steal syndrome (CSSS) is a complica - tion of coronary artery bypass graft (CABG) surgery in pa - tients with coexistent significant subclavian artery stenosis (SAS). It is characterized by a retrograde blood flow through the left internal mammary artery graft from the coronary to subclavian circulation, leading to myocardial ischemia. Current screening for CSSS includes bilateral blood pres - sure measurement for the detection of a significant interarm blood pressure difference. However, the commonly used automated sphygmomanometers have limited accu - racy in patients with atrial fibrillation. Consequently, these patients are often underdiagnosed. We present a case of a 73-year-old man with a medical history of atrial fibrillation, peripheral artery disease, and CABG surgery four months before the current event, who came to the emergency de - partment due to progressive dyspnea. The initial diagnos - tic management showed a large circulatory pericardial effusion, so the patient was admitted to the coronary care unit and underwent pericardial drainage. In the following days, due to a sudden high increase in cardiac troponin, the patient underwent an urgent coronary angiography, which revealed severe left SAS with functional CABG, indi - cating the occurrence of CSSS. Percutaneous transluminal angioplasty was then performed with an optimal angio - graphic result. The patient was discharged in good condi - tion with adequate medicament therapy and instructions. This case report highlights atrial fibrillation as a contribut - ing factor for the diagnosis of CSSS and pericardial tam - ponade after CABG surgery. Furthermore, we suggest a di - agnostic approach that can reduce the incidence of both these severe complication

DJEVOJKA S TAKAYASU ARTERITISOM PROGRESIVNOG TIJEKA S MULTIPLIM KIRURŠKIM INTERVENCIJAMA

Takayasu arteritis is a rare large-vessel vasculitis but it can be associated with high mortality rates in childhood. Granulomatous vasculitis usually affects the aorta and/or main branches but also coronary and pulmonary arteries. The course of the disease is unpredictable and management is based on controlling infl ammation and preventing end-organ damage. In this case we describe a patient with progression of vasculitis but so far successful prevention of possible ischemic consequences using immunosupressive and biologic therapy and multiple surgical interventions over the course of the disease. A 14-year-old girl presented with precordial pain and numbness of the left arm. Physical examination revealed the absence of the radial pulse in the left arm. Computed tomography angiography showed subtotal occlusion of the left main coronary artery, subtotal occlusionof the left common carotid artery, subtotal occlusion of the left subclavian artery and stenosis of thoracic aorta below isthmus of aortae. Despite aggresive conservative therapy and cardiosurgical treatment the course of the disease was complicated with restenoses which were resolved with subsequent revascularization procedures. Here we present an adolescent girl with progressive vasculitis and with multiple surgical interventions. Carefully monitoring of the patient and good collaboration between pediatric cardiologist and rheumatologist with radiologists and cardiac surgeons improved life-quality of the patient which now studies at the University and has good physical and mental status.Takayasu arteritis je vaskulitis velikih krvnih žila koji zahvaća aortu i njezine ogranke ali i pulmonalne i koronarne krvne žile. Tijek bolesti je nepredvidiv i terapija obuhvaća smirivanje upalnog procesa i prevenciju oštećenja organa. Prikazujemo bolesnicu s progresivnim tijekom bolesti koji je zasada uspješno obuzdavan uz pomoć imunosupresivne i biološke terapije kao i multiplim kirurškim postupcima. 14-godišnja djevojčica se očitovala prekordijalnim bolovima i utrnućem lijeve ruke s gubitkom pulsa radijalne arterije. CT angiografi jom je nađena totalna okluzija debla lijeve koronarne arterije, subtotalna okluzija lijeve zajedničke karotidne arterije i lijeve potključne arterije te stenoza torakalne descendentne aorte ispod razine istmusa. Unatoč agresivnoj konzervativnoj terapiji i kardiokirurškom tretmanu daljnji tijek bolesti je kompliciran restenozama koje su razriješene postupcima revaskularizacije. Pažljivim praćenjem bolesnice kao i dobrom suradnjom pedijatrijskih kardiologa i reumatologa s kardiokirurzima te radiolozima omogućena je dobra kvaliteta života u djevojke koja se uspješno školuje te je u dobrom fi zičkom i mentalnom stanju

DJEVOJKA S TAKAYASU ARTERITISOM PROGRESIVNOG TIJEKA S MULTIPLIM KIRURŠKIM INTERVENCIJAMA

Takayasu arteritis is a rare large-vessel vasculitis but it can be associated with high mortality rates in childhood. Granulomatous vasculitis usually affects the aorta and/or main branches but also coronary and pulmonary arteries. The course of the disease is unpredictable and management is based on controlling infl ammation and preventing end-organ damage. In this case we describe a patient with progression of vasculitis but so far successful prevention of possible ischemic consequences using immunosupressive and biologic therapy and multiple surgical interventions over the course of the disease. A 14-year-old girl presented with precordial pain and numbness of the left arm. Physical examination revealed the absence of the radial pulse in the left arm. Computed tomography angiography showed subtotal occlusion of the left main coronary artery, subtotal occlusionof the left common carotid artery, subtotal occlusion of the left subclavian artery and stenosis of thoracic aorta below isthmus of aortae. Despite aggresive conservative therapy and cardiosurgical treatment the course of the disease was complicated with restenoses which were resolved with subsequent revascularization procedures. Here we present an adolescent girl with progressive vasculitis and with multiple surgical interventions. Carefully monitoring of the patient and good collaboration between pediatric cardiologist and rheumatologist with radiologists and cardiac surgeons improved life-quality of the patient which now studies at the University and has good physical and mental status.Takayasu arteritis je vaskulitis velikih krvnih žila koji zahvaća aortu i njezine ogranke ali i pulmonalne i koronarne krvne žile. Tijek bolesti je nepredvidiv i terapija obuhvaća smirivanje upalnog procesa i prevenciju oštećenja organa. Prikazujemo bolesnicu s progresivnim tijekom bolesti koji je zasada uspješno obuzdavan uz pomoć imunosupresivne i biološke terapije kao i multiplim kirurškim postupcima. 14-godišnja djevojčica se očitovala prekordijalnim bolovima i utrnućem lijeve ruke s gubitkom pulsa radijalne arterije. CT angiografi jom je nađena totalna okluzija debla lijeve koronarne arterije, subtotalna okluzija lijeve zajedničke karotidne arterije i lijeve potključne arterije te stenoza torakalne descendentne aorte ispod razine istmusa. Unatoč agresivnoj konzervativnoj terapiji i kardiokirurškom tretmanu daljnji tijek bolesti je kompliciran restenozama koje su razriješene postupcima revaskularizacije. Pažljivim praćenjem bolesnice kao i dobrom suradnjom pedijatrijskih kardiologa i reumatologa s kardiokirurzima te radiolozima omogućena je dobra kvaliteta života u djevojke koja se uspješno školuje te je u dobrom fi zičkom i mentalnom stanju

Usporedba ostijalnog i trunkalnog suženja bubrežne arterije: prediktor proširenosti ateroskleroze velikih arterija i veće smrtnosti

The aim of this study was to determine arterial stiffness and the effect of stenting in patients with renal artery stenosis. We hypothesized that ostial renal artery stenosis is not only a marker of more pronounced atherosclerosis of large arteries, but is also a predictor of higher cardiovascular mortality. We enrolled 33 patients with renal artery stenosis refractory to pharmacological treatment and divided them according to the renal artery stenosis location, ostial and truncal (23 vs. 10 patients). We analyzed patient survival at five-year follow up. After the intervention and at sixmonth follow up, there was a significant decrease in blood pressure values, as well as in pulse wave velocity (PWV) and augmentation index. PWV was significantly lower in patients with truncal renal artery stenosis and these patients were significantly younger. Twelve patients with ostial and one patient with truncal renal artery stenosis (52% vs. 10%, p<0.001) died from cardiovascular events. Our study is the first to confirm the predictive role of PWV and arterial stiffness in patients with renal artery stenosis, especially ostial one, and to emphasize its ability of detecting future higher incidence of cardiovascular events.Cilj ovog istraživanja bio je utvrditi krutost arterija i učinak stentiranja u bolesnika sa suženjem bubrežne arterije. Hipoteza je bila da ostijalno suženje bubrežne arterije nije samo pokazatelj izraženije ateroskleroze velikih arterija, nego je i prediktor veće kardiovaskularne smrtnosti. U istraživanje smo uključili 33 bolesnika sa suženjem bubrežne arterije koji su bili refraktorni na farmakološko liječenje i podijelili ih prema položaju suženja bubrežne arterije, ostijalnom i trunkalnom (23 naspram 10 bolesnika). Analizirali smo preživljenje bolesnika nakon petogodišnjeg praćenja. Neposredno nakon intervencije i šest mjeseci nakon intervencije došlo je do značajnog smanjenja vrijednosti krvnog tlaka, kao i brzine pulsnog vala (PWV) i indeksa augmentacije. Brzina pulsnog vala (pulse wave velocity, PWV) je bila značajno niža u bolesnika s trunkalnim suženjem arterije i ti su bolesnici bili značajno mlađi. Dvanaest bolesnika s ostijalnom i jedan bolesnik s trunkalnim suženjem bubrežne arterije (52% naspram 10%, p<0,001) umrlo je od kardiovaskularnih događaja. Naša studija je prva koja potvrđuje prediktivnu ulogu PWV i arterijske krutosti u bolesnika sa suženjem bubrežne arterije, osobito ostijalnim, te naglašava njezinu sposobnost otkrivanja buduće veće incidencije kardiovaskularnih događaja

Intermittent Claudication – Functional Status Assessment in Patient Follow-up after Successful Percutaneous Revascularization

Porast angiointervencijskih zahvata posljedica je rastuće incidencije okluzivne bolesti perifernih arterija, ali i boljih tehničkih mogućnosti perkutane revaskularizacije. Odluka o načinu liječenja temelji se na pomnoj kliničkoj procjeni bolesnika s intermitentnom klaudikacijom Fontaine II klase i odabira terapijskih mogućnosti: endovaskularne ili kirurške revaskularizacije ili pak konzervativnog medikamentnog liječenja uz intenzivan nadzirani trening hodanja. Posebno je važna racionalizacija u načinu praćenja bolesnika nakon provedenog revaskularizacijskog zahvata u eri različitih novih tehničkih mogućnosti medicinske prakse 21. stoljeća. Cilj ovoga retrospektivnog istraživanja odnosio se na skupinu bolesnika s bolešću perifernih arterija, funkcionalne klase Fontaine II u kojih smo nakon uspješne angiointervencije analizirali promjene vrijednosti ABI-ja (od engl. ankle brachial index) i dužine HP-a (hodna pruga) kroz vremenski slijed: prije i neposredno nakon intervencije te u kontrolnom razdoblju. Uspješna endovaskularna revaskularizacija (PTA od engl. percutaneous transluminal angioplasty) u usporedbi sa standardnom farmakoterapijom i nenadziranim vježbama hodanja u bolesnika funkcionalne klase Fontaine II rezultirala je produljenjem HP-a i porastom ABI-ja, a koji nisu pokazali poboljšanje nakon inicijalnog 6 mjesečnog razdoblja primijenjene optimalne farmakoterapije i nekontroliranoga tjelesnog treninga. Prisutnosti komorbiditeta nisu utjecale na rezultate ispitivanih parametara. Vrijednost je ABI-ja kontralateralnog ekstremiteta tijekom praćenja porasla i korelira s porastom ABI-ja ekstremiteta podvrgnuta angiointervenciji. Porast duljine HP-a i porast vrijednosti ABI-ja u analizi statistički vrlo značajno prati angiografski uspješnu revaskularizaciju. Rezultati ispitivanja potvrđuju važnost procjene uspjeha PTA-a primjenom ABI-ja, a posebno procjenu dužine HP-a u praćenju uspješne endovaskularne revaskularizacije koja se u svim ispitivanim podskupinama višestruko pratila i pokazala se statistički značajnim parametrom koji obilježava promjenu funkcionalnoga statusa. Smatramo da bi se naoko zanemareni podatak o dužini hodne pruge trebao repozicionirati u rutinskoj procjeni i praćenju funkcionalnog statusa nakon endovaskularne revaskularizacije u bolesnika s intermitentnom klaudikacijom.The rate of percutaneous endovascular treatment is increasing because of the high incidence of peripheral artery disease and improved endovascular techniques. Therapeutic decisions in patients with intermittent claudication are based on the patient’s functional impairment, specifically in the Fontaine II class. Endovascular or surgical revascularization versus optimal medical therapy with supervised exercise training is a very frequent dilemma in clinical practice. Patient surveillance and follow up after angiointerventions requires a rational approach in the era of new technical advancements in the 21st century. The aim of this retrospective study was to analyze changes in ankle brachial index (ABI) values and walking distance changes as functional status parameters after successful angiointerventions in the observational period: before intervention, after the procedure, and in follow-up. Increased ABI values and walking distance were associated with successful revascularization in the group of patients who did not respond to the initial standard medical treatment in the 6-month period. Comorbidities had no influences on data evaluated in the study. ABI values on the contralateral leg revealed a positive correlation with the incremental ABI values in the leg where revascularization was successfully performed. Significant increase in walking distance after percutaneous revascularization and significantly greater ABI values in follow-up confirmed the importance of both parameters that reflect successful angiographic findings after percutaneous transluminal angioplasty (PTA). Both parameters were consistent with successful revascularization and improved functional status in the follow-up period. Walking distance deserves to be reevaluated in the assessment of functional status in patients after successful percutaneous angiointerventional revascularization. It should not be neglected as a valuable parameter in estimating functional status after PTA

Utjecaj klinoptilolita dodanog u hranu na profil minerala u krvnom serumu mliječnih krava

The objectives of this study were to determine whether or not dietary clinoptilolite (CPL) has an influence on the levels of calcium (Ca), magnesium (Mg), phosphorus (P), potassium (K) and sodium (Na) in the blood serum of dairy cows during gravidity and early lactation. The study was conducted on 78 dairy cows of Holstein-Friesian breed. The cows were randomly assigned into two groups: the CPL- fed treated group (n = 38) which received 50 g of natural powdered zeolite CPL twice a day from day 180 days before to 60 days after parturition, and the control non-treated group (n = 40). Blood samples were taken on days 180, 90, 60, 30 and 10 before parturition, on the day of calving and on days 5, 12, 19, 26, 33, 40 and 60 following parturition. There were no significant differences in the Ca concentrations between the CPL-fed and the control group. However, after parturition it was noticeable that the Ca concentration was higher in the CPL-fed group, especially on day 33 (P = 0.06). The concentration of P was significantly lower (P<0.05) in the CPL-fed group on day 0 and day 5 in comparison to the control group. A significantly higher ratio of Ca:P was calculated in the CPL- fed group vs. the control group on days 0, and 12. There were no significant differences observed in Mg, K, and Na concentrations between the cows in the CPL-fed group and the control group throughout the duration of the study. The results of the study suggest that dietary CPL influenced the blood levels of Ca and P in dairy cows, and improved the serum Ca:P ratio of dairy cows during the early postpartal period. The CPL applied did not produce any clinically visible disorders in the metabolism of the tested minerals. In addition, the blood levels of all tested minerals were within physiological ranges, which indicates that CPL did not alter their homeostasis in dairy cows.Cilj je ovoga istraživanja bio ustvrditi utjecaj klinoptilolita (KPL) dodanog u hranu na razine kalcija (Ca), magnezija (Mg), fosfora (P), kalija (K) i natrija (Na) u krvnom serumu mliječnih krava tijekom gravidnosti i rane laktacije. Istraživanje je provedeno na ukupno 78 krava holštajnsko-frizijske pasmine. Krave su nasumično podijeljene u dvije skupine: krave s dodatkom KPL-a u hranu (pokusna skupina) (n = 38) koje su primale dva puta dnevno po 50 g prirodnoga praškastog zeolita KPL-a, počevši 180. dan prije porođaja do 60 dana nakon porođaja, i na kontrolnu skupinu (n = 40). Uzorci krvi uzeti su 180., 90., 60., 30. i 10. dan prije teljenja, na dan teljenja te 5., 12., 19., 26., 33., 40. i 60. dana nakon porođaja. Nisu ustanovljene znakovite razlike u koncentraciji Ca između krava pokusne i kontrolne skupine. No nakon porođaja bilo je vidljivo da je koncentracija kalcija bila viša u pokusnoj KPL skupini, posebice 33. dan (P = 0,06). Koncentracija P bila je znakovito niža (P<0,05) u pokusnoj skupini nulti i 5. dan u odnosu na kontrolnu skupinu. Znakovito viši omjer Ca i P izračunan je u pokusnoj skupini u odnosu na kontrolnu skupinu nulti i 12. dan. Nisu ustanovljene znakovite razlike u koncentraciji Mg, K i Na u krava iz pokusne i kontrolne skupine tijekom istraživanja. Rezultati ovog istraživanja upućuju na to da je KPL dodan u hranu utjecao na razine Ca i P u krvi mliječnih krava te da je poboljšao omjer Ca i P u serumu tijekom ranog puerperija. Primijenjeni pripravak KPL-a nije prouzročio klinički vidljive poremećaje metabolizma istraživanih minerala Osim toga razine svih istraživanih minerala u krvi bile su unutar fizioloških raspona što pokazuje da KPL nije promijenio njihovu homeostazu u mliječnih krava

Traumatska protrahirana hematurija i pseudoaneurizma segmentalne arterije bubrega u 16-godišnjeg dječaka, liječena endovaskularnom embolizacijom

Većina ozljeda bubrega u djece liječi se neoperativno, no protrahirana krvarenja i ozljede većih krvnih žila često zahtijevaju aktivno zaustavljanje krvarenja. Traumatske pseudoaneurizme segmentalne arterije nastaju u oko 2,5% ozljeda bubrega. Manifestiraju se protrahiranim, intermitentnim ili sekundarnim hematurijama, ali mogu biti i asimptomatske. Liječenje većinom započinje praćenjem, a oko trećine djece zahtijeva aktivni kirurški ili endovaskularni postupak. Dvije su osnovne tehnike endovaskularne embolizacije zavojnicama: „sandwich“ i „coil packing“, a moguća je okluzija uz pomoć stenta. Traumatska protrahirana hematurija, pseudoaneurizma segmentalne arterije bubrega i postupak liječenja rijetko su opisani, osobito u djece. U ovom radu prikazujemo dječaka s tupom ozljedom bubrega, protrahiranim krvarenjem i traumatskom pseudoaneurizmom segmentalne arterije bubrega, liječenog endovaskularnom embolizacijom u lokalnoj anesteziji i sedaciji pristupom kroz desnu femoralnu arteriju. Mikrokateterom 2,7 Fr selektivno je kateterizirana dominantna kranijalna bubrežna arterija i prikazana pseudoaneurizma sa zonom krvarenja interlobarnog ogranka segmentalne arterije. Zavojnicom 2 × 4 mm (Interloc 18, Boston scient) emboliziran je interlobarni ogranak segmentalne arterije s pseudoaneurizmom, bez znakova krvarenja ili značajnijeg ispada vaskularizacije parenhima bubrega na kontrolnim serijama. Endovaskularna metoda ima brojne prednosti nad klasičnom kirurgijom, no i nedostatke poput izlaganja relativno visokim dozama zračenja i kontrasta. Zadnjih godina, uporabom robota u urologiji, opisana je primjena minimalno invazivne robotske tehnike operacijskog liječenja pseudoaneurizme renalne arterije. Smanjenje broja nefrektomija i porast udjela neoperativnog liječenja i endovaskulanih zahvata danas predstavljaju trend u pristupu traumatskim ozljedama burega. KBC Zagreb ima sve specijalnosti i subspecijalnosti potrebite za kirurške i endovaksularne zahvate u djece, čime predstavlja nacionalni centar za zbrinjavanje sveobuhvatne traume bubrega u djece