Andrzej Łabyk

Mean Platelet Volume Predicts Early Death in Acute Pulmonary Embolism

Background Recently, mean platelet volume (MPV) was reported to predict venous thromboembolism. Moreover, MPV correlates with platelet reactivity and indicates poor outcome in acute coronary syndromes. Objective To examine the hypothesis that in acute pulmonary embolism (APE) MPV is elevated and may predict mortality. Methods and results The study included consecutive 192 patients with APE, (79M/113F, 64±18 years) and 100 controls matched for age, sex and concomitant diseases. On admission blood samples were collected for MPV and troponin measurements. Although MPV did not differ between patients with APE and controls (10.0±1.2 vs 10.1±0.8 fl), it differed between low- and intermediate- or high-risk APE (9.4±1.2 fl, 10.3±1.1 fl, 10.3±1.8 fl; respectively, p<0.0001). Eighteen (9%) patients with APE died during the 30-day observation. MPV was higher in non-survivors than survivors (10.7±1.4 fl vs 9.9±1.2fl, p<0.01). The areas under receiver operating characteristic curves of MPV were 0.658 (95% CI 0.587 to 0.725) for predicting 30-day mortality, and 0.712 (95% CI 0.642 to 0.775) for 7-day mortality. MPV >10.9 fl, showed sensitivity, specificity, positive predictive value and negative predictive value for death within 30 days (39%, 81%, 18%, 93%, respectively) and for 7-day mortality (54%, 82%, 18%, 96%). Multivariable analysis showed that MPV was an independent mortality predictor for 7- and 30-day all-cause mortality (HR=2.0 (95% CI 1.3 to 3.0), p<0.001)) and 1.7 (95% CI 1.2 to 2.5), p<0.01)), respectively). MPVs were higher in patients with myocardial injury than in those without troponin elevation (10.2±1.1 fl vs 9.8±1.2 fl; p=0.02). There were correlations between MPV and right ventricular diameter and right ventricular dysfunction (r=0.28, p<0.01 and r=0.19, p<0.02, respectively). Conclusion MPV is an independent predictor of early death in APE. Moreover, MPV in APE is associated with right ventricular dysfunction and myocardial injury.

Assessment of renal dysfunction improves troponin‐based short‐term prognosis in patients with acute symptomatic pulmonary embolism

Summary.  Objective: Current risk stratification in acute pulmonary embolism (APE) includes assessment of clinical status, right ventricular overload and plasma troponin concentrations. As impaired renal function is one of the important predictors of mortality in cardiovascular diseases, we hypothesized that it is an independent early mortality marker in APE. Material and methods: In prospective cohort study, we observed 220 consecutive patients (86M/134F, 64 ± 18 years) with APE proven by spiral computed tomography (CT). On admission, echocardiography was performed and blood samples were collected for troponin and creatinine assays. Results: The calculated glomerular filtration rate (GFR) differed significantly between 81 pts with low‐, 131 pts with moderate‐ and 8 pts with high‐risk APE [71 (19–181) vs. 55 (9–153) vs. 41 (14–68) mL min−1; respectively P < 0.0001]. Twenty‐three patients died during the 30‐day observation. Importantly, GFR was lower in non‐survivors than in survivors [35 (9–92) vs. 63 (14–181) mL min−1, P < 0.0001]. The area under the curve (AUC) of the GFR receiver‐operating characteristic (ROC) curve for predicting mortality was 0.760 (95% CI: 0.698–0.815). In multivariable analysis, independent mortality predictors were GFR, troponin, heart rate and history of chronic heart failure. In normotensive patients, the GFR and cardiac troponins (cTn) ROC curves for prediction of mortality showed no difference (AUC 0.789 and 0.781, respectively). However, Kaplan–Meier analysis showed an additive prognostic value of renal dysfunction. Thus, troponin‐positive patients with a GFR ≤ 35 mL mn−1 showed 48% 30‐day mortality, whereas troponin‐positive patients with a GFR > 35 mL mn−1 had 11% mortality, and troponin‐negative patients with a GFR > 35 mL mn−1 had good prognosis, P < 0.0001. Conclusion: Impaired kidney function, present in 47% of APE patients, is related to all‐cause mortality. In initially normotensive patients, a GFR < 35 mL min−1 predicts 30‐day mortality. Moreover, GFR assessment can improve troponin‐based risk stratification of APE.

Refined balloon pulmonary angioplasty driven by combined assessment of intra-arterial anatomy and physiology – Multimodal approach to treated lesions in patients with non-operable distal chronic thromboembolic pulmonary hypertension – Technique, safety and efficacy of 50 consecutive angioplasties

BACKGROUND/OBJECTIVES Balloon pulmonary angioplasty (BPA) is an emerging therapeutic method in CTEPH. We aimed to prove the safety and efficacy of refined BPA driven by combined assessment of intra-arterial anatomy (IVUS/OCT) and physiology (pulmonary pressure ratio, PPR) in non-operable distal CTEPH. METHODS 11 pts (mean age 76, 59–84, 7 males) were enrolled in the BPA program according to the following inclusion criteria: 1. Non-operable CTEPH; 2. RHC with mPAP > 30 mm Hg; 3. At least one segmental perfusion defect at lung scintigraphy; 4. WHO class > II. Overall, 9 pts underwent 27 BPA sessions (mean 3 sessions per patient, range 1–5), 50 pulmonary arteries were dilated (mean 6 vessels per patient, range 3–9; 2.03 dilated arteries per session). All the angioplasties were performed according to an algorithm, which incorporated anatomical and functional assessment of targeted lesions. RESULTS We performed BPA of 32 web lesions, 5 ring-like stenosis and 13 complete obstructions. BPA resulted in clinical and hemodynamic improvement. WHO class improved from pre-BPA to post-BPA (p = 0.018), and 6 MWD increased from 304 m to 384 m (p = 0.03), NT-proBNP dropped from 1248 pg/ml to 730 pg/ml (p < 0.001). Mean PAP and PVR decreased (p = 0.01), while CO and CI increased (p = 0.01). All dilated arteries were patent at angiographic reassessment. No significant complications occurred and all treated patients are still alive. Insignificant transient reperfusion pulmonary oedema occurred in only 2 patients, who responded well to supplemental oxygen. CONCLUSIONS Refined BPA with assessment of intrapulmonary physiology using a pressure wire and precise evaluation of anatomy with IVUS and OCT provides hemodynamic and functional improvement, with minimal complications in distal non-operable CTEPH. This observation requires further validation in a large prospective study.

Neutrophil gelatinase-associated lipocalin, cystatin C and eGFR indicate acute kidney injury and predict prognosis of patients with acute pulmonary embolism

Objective Risk stratification in acute pulmonary embolism (APE) includes the assessment of clinical status, right ventricular dysfunction and troponin concentrations. Since acute renal impairment is one of the important predictors of mortality in cardiovascular diseases, the authors hypothesised that it is an independent mortality marker in APE. Material and methods The authors observed 142 consecutive patients (52 M/90 F, 64±18 years) with APE diagnosed with contrast enhanced multislice CT. On admission, blood samples were collected for neutrophil gelatinase-associated lipocalin (N-GAL), cystatin C and creatinine assays. Estimated glomerular filtration rate (eGFR) was calculated using MDRD formula. Results Fourteen (10%) of 142 patients died by the 30th day of observation. eGFR≤60 ml/min was noted in 68 (48%) patients and eGFR≤30 ml/min in 11 (8%) patients. eGFR was higher in survivors than in non-survivors (66 (17–169) vs 46 (10–119) ml/min, respectively, p=0.02). In 80 (56%) patients, N-GAL was >50 ng/ml indicating acute kidney injury. N-GAL was higher in non-survivors than in survivors (88.8 (28.4–200.0) vs 53.0 (7.1–200.0) ng/ml, p<0.01). N-GAL level >50 ng/ml was found in 11 (79%) patients with fatal outcome. Area under the curve of N-GAL for all-cause mortality in ROC analysis was 0.715. N-GAL>75 ng/ml was present in 44 (31%) patients, while cystatin C >1900 ng/ml in 14 (10%) subjects. They showed sensitivity, specificity, positive predictive value and negative predictive value for prediction of all-cause death ((64%, 73%, 21%, 95%) and (36%, 91%, 30% 93%), respectively). N-GAL>75 ng/ml and cystatin C>1900 ng/ml increased the risk of death (HR 4.4 (95% CI 1.48 to 13.2, p<0.01) and 4.7 (95% CI 1.56 to 13.9, p=0.01), respectively). Conclusions Acute kidney injury assessed by N-GAL occurs in 30% of APE and may contribute to the impairment of renal function present in half of them. Moreover, N-GAL, cystatin C elevation and low eGFR are associated with a poor 30-day prognosis in APE.

Electrocardiographic differentiation between acute pulmonary embolism and non-ST elevation acute coronary syndromes at the bedside.

Background: Clinical picture of acute pulmonary embolism (APE), with wide range of electrocardiographic (ECG) abnormalities can mimic acute coronary syndromes.

Refined balloon pulmonary angioplasty—A therapeutic option in very elderly patients with chronic thromboembolic pulmonary hypertension

INTRODUCTION/OBJECTIVES Balloon pulmonary angioplasty (BPA) is a developing treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, to our knowledge there are no published data on BPA in CTEPH subjects aged 75 or over. The aim of the study was to analyze clinical and hemodynamic outcomes of sequential BPA in very elderly patients disqualified from pulmonary endarterectomy (PEA). PATIENTS AND METHODS We enrolled 10 patients (4 male, 6 female, median age 81 [75-88]) with confirmed CTEPH, mPAP > 30 mmHg, and WHO class > II, disqualified from PEA. Overall, 10 patients underwent 39 BPA sessions (mean 3.9 sessions per patient, range 1-9), and 70 pulmonary arteries were dilated, (mean 6.5 vessels per patient, range 1-14). RESULTS Pulmonary angioplasty resulted in significant clinical and hemodynamic improvement in every patient: 6 MWT distance increased from a median of 221 m (80-320) to 345 (230-455) and plasma NT-proBNP levels decreased (P < 0.01). Sequential BPA resulted in normalization of mPAP (<25 mmHg) in 6 of 10 patients and mPAP decreased to 25-30 mmHg in three others. In the whole group mPAP decreased from 41 (31-53) mmHg to 23 (17-33) mmHg (P < 0.01). Overall, mean PAP and PVR decreased significantly in all cases, while CO and CI increased (P < 0.01). No severe complications occurred during BPA and over a median follow-up of 553 days (range 81-784), and all patients are still alive and in good general health. CONCLUSION This study demonstrated the safety and efficacy of refined BPA in CTEPH patients aged 75 or over, disqualified from PEA. Refined BPA may emerge as an alternative therapeutic strategy in very elderly CTEPH patients who are suitable for surgery, but this requires further validation in a large prospective study.

High prevalence of severe coronary artery disease in elderly patients with non-operable chronic thromboembolic pulmonary hypertension referred for balloon pulmonary angioplasty

Introduction Balloon pulmonary angioplasty (BPA) is a new emerging catheter-based alternative treatment option for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Aim To show that all elderly CTEPH patients referred for BPA are at higher risk of obstructive coronary artery disease and that, in daily practice, they should undergo invasive coronary angiography. Material and methods Eleven patients at the age of at least 65 years (6 males, 5 females, 77.2 ±5.9 years) with confirmed non-operable type II or type III CTEPH, considered for BPA, underwent elective coronary angiography. Severe obstructive coronary artery disease (CAD) was diagnosed when stenosis of left main coronary artery ≥ 50% or stenosis of ≥ 70% of epicardial arteries was angiographically confirmed. We also screened for CAD consecutive age- and sex-matched 114 PE survivors (52 males, 62 females, 74.8 ±7.2 years) with excluded CTEPH. Results Severe CAD was more frequent in elderly patients with non-operable type II or type III CTEPH candidates for BPA than in elderly acute PE survivors with excluded CTEPH (54.5% vs. 16.7%, p < 0.01), and therefore elderly CTEPH patients referred for BPA were at higher risk of CAD (OR = 5.9, 95% CI: 1.64–21.46, p = 0.007) when compared to elderly survivors after acute PE with excluded CTEPH. Conclusions All elderly CTEPH patients referred for BPA are at higher risk of severe CAD and should routinely undergo invasive coronary angiography before BPA.

Acute ST-segment elevation myocardial infarction treated with delayed angioplasty in a patient with anomalous origin of the right coronary artery in the early phase after kidney transplantation

This case demonstrates a rare anomalous of origin of right coronary artery from the left sinus of Valsalva in patients who underwent kidney transplantation complicated by an acute ST elevation myocardial infarction treated with delay angioplasty.

TCT-602 Refined Balloon Pulmonary Angioplasty in Patients With Chronic Thromboembolic Pulmonary Hypertension - 100 BPA Sessions Without Major Complications in a Single Center

Balloon pulmonary angioplasty (BPA/PTPA) is a novel promising therapeutic method in CTEPH. Our aim was to prove the safety and efficacy of refined BPA/PTPA driven by combined assessment of intra-arterial anatomy (IVUS/OCT) and physiology (pulmonary pressure ratio, PPR) in “all comers” CTEPH pts