Adrian Gwizdała

The BNP concentrations and exercise capacity assessment with cardiopulmonary stress test in cyanotic adult patients with congenital heart diseases

Cyanosis is observed in patients with complex congenital heart disease (CHD) and pulmonary hypertension, heart failure represents an important clinical problem in such patients. The aim of this study was to evaluate the exercise capacity in patients with cyanotic CHDs using cardiopulmonary exercise test, measuring serum BNP levels as well as to seek correlation between BNP levels and cardiopulmonary exercise test parameters and identify the effects of blood oxygen desaturation and pulmonary hypertension on these indices. The study group consisted of 53 patients (21 males) at the mean age of 39.4 ± 14.3 years, of whom 19 were operated on at the mean age of 9.6 ± 8.6 years. Mean blood oxygen saturation (SO(2)) in patients was 81.2 ± 6.2%. Twenty four patients presented with Eisenmenger syndrome, 16--univentricular hearts, 4--transposition of the great arteries, 6--Fallots tetralogy, and 3--Ebstein anomaly. The control group comprised 32 healthy individuals (16 males) at the mean age of 40.7 ± 9.9 years. Cardiopulmonary stress test showed significantly lower exercise capacity in patients with cyanosis than in controls: maximal oxygen uptake (VO(2max)) 15.5 ± 4.9 vs. 31.6 ± 7.1 ml/kg/min (p=0.00001), maximum heart rate at peak exercise (HR max): 139.5 ± 22.5 bpm vs. 176.6 ± 12.1 (p=0.0001), VE/VCO(2) slope: 46.4 ± 10.1 vs. 27.3 ± 2.9 (p=0.00001), forced vital capacity FVC: 3.1 ± 1.1 l vs. 4.4 ± 0.8 l (p=0.00001). Subjects with the evidence of pulmonary hypertension (PH+) had lower exercise capacity than those without (PH-): VO(2max): 17.2 ± 4.2 vs. 12.8 ± 4.8 ml/kg/min (p=0.002), VE/VCO(2): 43.7 ± 11.1 vs. 50.9 ± 6.4 (p=0.01), FVC: 3.46 ± 1.05 l vs. 2.37 ± 0.91 l (p=0.0002). Plasma BNP levels in the study group were higher than in controls: 122.4 ± 106.7 vs. 21.1 ± 20.2 pg/ml p=0.00001 and did not differ between PH+ and PH- groups (115.7 ± 99.0 vs. 127.9 ± 114.1 pg/ml p=0.78). Negative correlations between BNP levels and VO(2max) (r=-0.389, p=0.006), FVC (r=-0.395 p=0.005), FEV1 (r=-0.386 p=0.006), SO(2) (r=-0.445 p=0.00001), and positive correlation between BNP level and VE/VCO(2) (r=0.369 p=0.009) were found.

Evaluation of exercise capacity with cardiopulmonary exercise testing and BNP levels in adult patients with single or systemic right ventricles.

Introduction The aim of the study was to evaluate exercise capacity using cardiopulmonary exercise test (CpET) and serum B-type natriuretic peptide (BNP) levels in patients with single or systemic right ventricles. Material and methods The study group included 40 patients (16 males) – 17 with transposition of the great arteries after Senning operation, 13 with corrected transposition of the great arteries and 10 with single ventricle after Fontan operation, aged 19–55 years (mean 28.8 ±9.5 years). The control group included 22 healthy individuals (10 males) aged 23–49 years (mean 30.6 ±6.1 years). Results The majority of patients reported good exercise tolerance – accordingly 27 were classified in NYHA class I (67.5%), 12 (30%) in class II, and only 1 (0.5%) in class III. Cardiopulmonary exercise test revealed significantly lower exercise capacity in study patients than in control subjects. In the study vs. control group VO2max was 21.7 ±5.9 vs. 34.2 ±7.4 ml/kg/min (p = 0.00001), maximum heart rate at peak exercise (HRmax) 152.5 ±32.3 vs. 187.2 ±15.6 bpm (p = 0.00001), VE/VCO2 slope 34.8 ±7.1 vs. 25.7 ±3.2 (p = 0.00001), forced vital capacity (FVC) 3.7 ±0.9l vs. 4.6 ±0.3 (p = 0.03), forced expiratory volume in 1 s (FEV1) 3.0 ±0.7 vs. 3.7 ±0.9l (p = 0.0002) respectively. Serum BNP concentrations were higher in study patients than in control subjects; 71.8 ±74.4 vs. 10.7 ±8.1 (pg/ml) respectively (p = 0.00001). No significant correlations between BNP levels and CpET parameters were found. Conclusions Patients with a morphological right ventricle serving the systemic circulation and those with common ventricle physiology after Fontan operation show markedly reduced exercise capacity. They are also characterized by higher serum BNP concentrations, which do not however correlate with CpET parameters.

Evaluation of Exercise Capacity with Cardiopulmonary Exercise Testing and Type B Natriuretic Peptide Concentrations in Adult Patients with Patent Atrial Septal Defect

Adults with patent atrial septal defect (ASD) usually find their exercise capacity satisfactory, and therefore hesitate to accept proposed surgical treatment of the heart disease. The aim of our study was to evaluate both the exercise capacity, using the cardio-pulmonary stress test, and brain natriuretic peptide (BNP) levels in asymptomatic adults with ASD. Thirty-six patients with patent secundum type ASD (aged mean 44.7 ± 8.2 years) were studied. The control group consisted of 25 healthy subjects at the mean age of 45.6 ± 6.1 years. Echocardiography and CPST were performed and BNP levels measured in all subjects. Oxygen uptake (VO2 max) was lower in ASD patients than in controls (22.1 ± 5.6 vs. 30.0 ± 6.8 ml/kg/min, p = 0.00001); the VE/VO2 slope was elevated in ASD patients compared with healthy subjects (31.3 ± 6.6 vs. 26.9 ± 3.3, p = 0.001), and exceeded 34 in 5 patients. VO2 max showed a negative correlation with the pulmonary to systemic flow ratio Qp:Qs (r = –0.46, p = 0.004), and a positive correlation was found between the VE/VO2 slope and Qp:Qs (r = 0.32, p = 0.05). BNP levels were higher in the ASD group than in the controls (60.6 ± 49.9 vs. 32.6 ± 24.5 pg/ml, p = 0.02). BNP correlated positively with RV diameter and Qp:Qs (r = 0.38 and 0.39 respectively, p = 0.03) and negatively with maximum VO2 (r = –0.5, p = 0.004) and VO2% (r = –0.32, p = 0.07). Conclusions: Although most adult patients with ASD perceive their exercise capacity as satisfactory, objective assessment reveals that in fact it is significantly decreased. BNP levels are increased comparing to healthy individuals. Decreased exercise capacity and increased BNP levels seem to result from right ventricular volume overload.

Safety, feasibility and effectiveness of first in‐human administration of muscle‐derived stem/progenitor cells modified with connexin‐43 gene for treatment of advanced chronic heart failure

To assess the safety and efficacy of transendocardial delivery of muscle‐derived stem/progenitor cells with connexin‐43 overexpression (Cx‐43‐MDS/PC) in advanced heart failure (HF).

Shortening baroreflex delay in hypertrophic cardiomyopathy patients -- an unknown effect of β-blockers.

AIMS Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy and impaired diastolic and systolic function. Abnormal sympathetic-parasympathetic balance is a potential stimulus for left ventricular hypertrophy in HCM patients. β-Blockers are routinely used in HCM for their strong negative inotropic effect; however, these drugs also influence the sympathetic-parasympathetic balance. This study aimed to determine the autonomic control of the cardiovascular system and the autonomic effects of β-blockers in HCM patients treated or untreated with β-blockers. METHODS Among 51 HCM outpatients (18-70 years old; 29 men) there were 19 individuals with no medication and 32 subjects treated with a β-blocker. Fourteen age- and gender-matched (23-70 years old; nine men) healthy volunteers were enrolled in the control group. Continuous, non-invasive finger blood pressure was recorded during supine rest for 30 min. Autonomic regulation of the cardiovascular system was measured by heart rate variability and spontaneous baroreflex function (cross-correlation sequence method). RESULTS The mean pulse interval, time domain and spectral measures of heart rate variability and baroreflex sensitivity were comparable between HCM patients, treated or not with β-blockers, and the control group. However, the delay of the baroreflex was significantly longer in HCM patients who were not treated with β-blockers [2.0 (1.6-2.3) s] in comparison with HCM patients receiving β-blockers [1.4 (1.1-1.8) s; P = 0.0072] or control subjects [1.2 (0.8-1.8) s; P = 0.0025]. This delay did not differ between HCM patients treated with β-blockers and the control group. CONCLUSIONS Hypertrophic cardiomyopathy not treated with β-blockers is accompanied by prolonged baroreflex delay. The use of β-blockers normalizes this delay.

Patients treated with bivalirudin are still at higher risk of stent thrombosis: a comprehensive meta-analysis of randomised clinical trials of bivalirudin and heparin for percutaneous coronary interventions

BACKGROUND Although the current practice guidelines recommend using both heparin and bivalirudin for percutaneous coronary interventions (PCI), the research data are ambiguous. AIM The aim of the study was to compare the impact of bivalirudin and heparin on major clinical endpoints in PCI patients with particular emphasis on periprocedural stent thrombosis. METHODS A total of 18 randomised clinical trials involving 41,752 subjects were included. The endpoints comprised: net adverse clinical event (NACE: death, myocardial infarction [MI], unscheduled revascularisation, major bleeding), major adverse cardiovascular event (MACE: death, MI, or stroke), and acute/subacute stent thrombosis (ST). A subanalysis for planned and provisional glycoprotein IIb/IIIa inhibitor (GPI) use with heparin was performed. Results were presented as risk ratios (RR) and 95% confidence intervals (CI). RESULTS Bivalirudin significantly reduced NACE risk (RR 0.85, 95% CI 0.76-0.96) and increased the incidence of MI (RR 1.09, 95% CI 1.01-1.18), ST (RR 1.50, 95% CI 1.13-1.99), and MACEs (RR 1.06, 95% CI 0.99-1.13). Comparing to heparin with provisional or planned GPI use, there was higher risk of acute ST with bivalirudin (RR 2.14, 95% CI 1.01-4.56 and RR 5.53, 95% CI 2.32-13.18, respectively). Comparing to heparin and provisional GPIs, bivalirudin failed to reduce NACEs and major bleeding. However, it decreased rates of NACEs (RR 0.81, 95% CI 0.69-0.96) and major bleeding (RR 0.64, 95% CI 0.48-0.85) compared with heparin and planned GPI use. CONCLUSIONS The advantages of bivalirudin are undoubtedly related to GPI use in the heparin arms. Bivalirudin-based regimens are more beneficial when compared with heparin and planned GPI use in terms of NACE and major bleedings; this was not observed when compared to heparin and provisional GPI use. Regardless of adjunctive GPI use, stent thrombosis episodes were significantly more common in bivalirudin-treated subjects. Therefore, the safety and economic issues may urge revision of this aspect of current clinical practice and guidelines.

Double atrial potentials in left-sided accessory pathways are associated with paroxysmal atrial fibrillation

Muscular connections between the coronary sinus (CS) and left atrium probably impact distribution of electrical activity. Double atrial potentials (DP) may be their presentation.

Sakubitril/walsartan w leczeniu przewlekłej niewydolności serca z upośledzoną frakcją wyrzutową. Czy dla wszystkich chorych? Opinia ekspertów Sekcji Niewydolności Serca Polskiego Towarzystwa Kardiologicznego

11st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland 2University Hospital of Lord’s Transfiguration, Poznan, Poland 3Department of Coronary Disease and Heart Failure, Jagiellonian University, Medical College, John Paul II Hospital, Krakow, Poland 41st Department of Cardiology, Gdansk Medical University, Gdansk, Poland 5Department of Cardiology, Medical University of Bialystok, Bialystok, Poland 6Department of Population Medicine and Civilisation Disease Prevention, Medical University of Bialystok, Bialystok, Poland 7Department of Cardiology, Medical University of Lodz, Lodz, Poland 8Heart Failure and Transplantology Department, Institute of Cardiology, Warsaw, Poland 91st Department of Cardiology, Medical University of Silesia, Katowice, Poland 103rd Department of Cardiology, School of Medicine with the Division of Dentistry in Zabrze, Medical University of Silesia in Katowice, Silesian Centre for Heart Disease, Zabrze, Poland 11Cardiology Department, Military Hospital, Wroclaw, Poland 12Department of Heart Disease, Wroclaw Medical University, Wroclaw, Poland

Cardiac and neurogenic syncope and atrial flutter misdiagnosed as ventricular tachycardia in a patient after myocardial infarction

A 61-year-old male presented with a history of transient ischaemic cerebral episode (ten years earlier), previous myocardial infarction (MI) treated with percutaneous coronary intervention of the left circumflex artery, and deployment of a drug-eluting stent (four years earlier). Initially, he was admitted to hospital because of retrosternal pain and recurrent syncope that followed a wide QRS complex tachycardia (WCT). The arrhythmia was originally diagnosed as ventricular tachycardia (VT) and reverted to sinus rhythm (SR) using a direct current cardioversion (DCCV) followed by an intravenous amiodarone infusion. Despite the treatment, the same arrhythmia reoccurred and was accompanied by two episodes of syncope and retrosternal pain. Therefore, he was referred to cardiology department as recurrent VT secondary to acute coronary syndrome (troponin I 0.25 ng/mL) was suspected. On admission, he reported fatigue, dizziness, and preor syncope episodes that started two days earlier. The electrocardiogram (ECG) revealed WCT (HR = 210 bpm) of left bundle branch block (LBBB) morphology (QRS = 140 ms) (Fig. 1A). Intravenous amiodarone bolus plus a gentle carotid sinus massage (CSM) produced significant vasovagal reaction revealing atrial flutter (AFl) wave (Fig. 1B). Ultimately, DCCV to SR was performed (100 J), but AFl recurred shortly. Echocardiography and coronary angiography documented no abnormalities. The patient was qualified to cavotricuspid isthmus (CTI) radiofrequency ablation. Anticlockwise AFl (CL = 217 ms) with 2:1 atrioventricular conduction was confirmed at invasive procedure. During the manipulation with the coronary sinus catheter introduced via the external jugular vein, accidental tapping of the right carotid sinus region produced a 14-second vasovagal syncope deteriorating to ventricular fibrillation (Fig. 1C). Immediate defibrillation (200 J) restored SR and a success ful CTI ablation was completed. No VT was induced with a programmed ventricular stimulation. The patient was sent for thoracic angio-magnetic resonance imaging. As well as fibrotic tissue, it revealed blood flow limitation at the right carotid sinus level. Ultimately, a dual-chamber pacemaker was implanted. No recurrent syncope or arrhythmias were observed during the subsequent 12 months. Syncope can precede cardiac arrest, especially in patients with organic heart disease. A male with previous MI and fast LBBB-WCT resulting in syncope must be suspected of VT requiring eventual implantation of a cardioverter-defibrillator. However, if excluded, it needs further differential diagnosis of WTC. Valsalva manoeuvre and CSM may be helpful in aberrated atrial arrhythmias that can be treated with radiofrequency ablation. In this patient, WCT initially misdiagnosed as VT could contribute to cardiac syncope. Moreover, in our case, the response to mild CSM was enormous, suggesting substantial carotid sinus hypersensitivity leading to neurocardiogenic syncope. The disease is also treatable, and symptoms may be resolved with implantation of a pacemaker. In the presented case the ECG diagnosis of WCT may be quite error-prone.

Clinical presentation, surgical management, and outcomes of patients treated for aortic stenosis and coronary artery disease. Does age matter?

BACKGROUND Aortic stenosis and coronary artery disease (CAD) sharing similar risk factors are associated with aging of the human population. AIM The purpose of this study was to examine whether age affects clinical presentation, intraoperative management, and outcomes of patients who undergo simultaneous operations of aortic valve replacement (AVR) and coronary artery bypass grafting (CABG). METHODS The study involved 452 consecutive patients aged 64.8 ± 8.2 years (range 38-79 years), who underwent combined AVR and CABG between 2005 and 2015. They were divided into three groups: Y (young; below the first quartile; n = 114), M (middle-aged; 58-71 years; n = 225) and E (elderly; above the third quartile; n = 113). Pre- and intraoperative variables were analysed. The deaths that occurred in hospital and throughout follow-up were defined as cardiac- or non-cardiac-related. The probability of survival was calculated with the use of Kaplan-Meier curves. RESULTS Coronary artery disease was more extensive in group E than in group Y (p < 0.05). Complete myocardial revasculari-sation was performed in 94.1%, 76.2%, and 62.8% in groups Y, M, and E, respectively (p < 0.05). In-hospital mortality was 2.0%, 5.3%, and 6.4%, in groups Y, M, and E, respectively. Early morbidity was significantly higher in group E than in groups M or Y. The 12- and 60-month freedom from cardiac-related death was higher in group Y (0.98 ± 0.02 and 0.94 ± 0.03) than in group E (0.93 ± 0.02 and 0.85 ± 0.03; p = 0.023, respectively). Left ventricular ejection fraction below 0.4 and incomplete revascularisation were associated with worse prognosis, particularly in group E. CONCLUSIONS Elderly patients undergoing combined procedures of AVR and CABG having more extensive CAD less often receive complete revascularisation, are at higher risk of early organ failure, and present markedly reduced rates of freedom from cardiac-related deaths throughout follow-up than younger subjects.