Artur Radziemski

Transient renal artery stenosis during renal sympathetic denervation in a patient with resistant hypertension.

A 52-year-old female was admitted to the Department of Hypertension with resistant hypertension coexistent with type 2 diabetes mellitus, two episodes of transient ischaemic attack in the past, and obesity. The patient’s arterial hypertension was uncontrolled on 6 antihypertensive medications, which included a loop diuretic and an aldosterone antagonist. During the course of the patient’s previous hospitalisation, secondary hypertension was excluded. Angio-computed tomography (CT) results showed a bilateral double renal artery with a diameter of the main trunks of more than 4 mm (corresponding angiography, Fig. 1). A denervation procedure Simplicity cathether (Medtronic) was applied. In the main left renal artery, 6 ablations were performed, with a mean impedance change of 8.82 (D,%) and temperature of 52°C without any complications. During the first ablation of the main right renal artery, with an impedance change of 20 (D,%) and a temperature of 75.3°C, oedema of the arterial wall with a significant stenosis of 80% occurred (Fig. 2). A local administration of nitroglycerine and verapamil (injected via a catheter) was ineffective. Due to the above, no further ablations have been performed. A follow-up arteriography of the right renal artery was performed 24 h later, showing a minimal stenosis in the previously affected area (corresponding angiography, Fig. 3). No clinical complications have been observed during this adverse event based on blood pressure parameters and control laboratory tests including serum creatinine level. A follow-up angio-CT of the right renal artery is scheduled in 3 months. Based on published papers, there have been no case reports of acute transient renal artery stenosis during renal denervation procedures. One case of a single structural renal artery stenosis, which occurred in the form of a late complication (i.e. after 6 months), was reported by Kaltenbach et al. (J Am Coll Cardiol, 2012; 60: 2694–2695).

Atypical location of granulomatosis with polyangiitis (Wegener's) with heart involvement--effectiveness of treatment with rituximab.

A patient at the age of 52 years, with a diagnosis of granulomatosis with polyangiitis, was admitted to the Department of Rheumatology and Rehabilitation due to disease progression. The first symptoms of the disease occurred 3 years earlier. Initially, recurrent otitis media were seen. The patient was subsequently treated in the Department of Otolaryngology. On the basis of clinical symptoms, the results of additional tests, and histopathological examination, granulomatosis with polyangiitis was diagnosed. In the process of treatment the following were used: methylprednisolone (500 mg IV pulses), prednisone (max. 50 mg/day), cyclophosphamide (600 mg IV pulses), and azathioprine (75 mg/day). Despite the treatment, disease progression was observed, as follows: central nervous system involvement with accompanying depression and cardiac involvement. Echocardiography revealed discrete hypokinesia and heterogeneous echogenicity of intraventricular septum. Magnetic resonance imaging (MRI) confirmed oval change of heart in the pericardium, infiltrating the right ventricular outflow tract, and pulmonary trunk, with dimensions of 32 × 30 × 17 mm (Fig. 1A, B). The results of laboratory tests found high levels of antibodies cANCA (79.0 RU/mL) and the presence of inflammation (ESR = 48 mm/h, CRP = 11.6 mg/L). Due to the high activity of the disease with cardiac involvement, immunosuppressive therapy was intensified — applied pulses of cyclophosphamide (600 mg IV) and glucocorticosteroids (methylprednisolone 1000 mg IV). In spite of the treatment remission was not obtained. After 2 months, in a control cardiac MRI a persistent mass (28 × 27 × 13 mm) was found in the pericardium. Therefore, it was decided to apply a biological treatment. After obtaining the approval of the Bioethics Committee of the Medical University in Poznan the patient received a total rituximab dose of 2.0 g in four divided administrations (500 mg) at 7-day intervals, while continuing treatment with glucocorticosteroids (prednisone 50 mg/day). Following the treatment achieved clinical improvement and normalisation of laboratory results (negative cANCA and absence of inflammatory markers). In the control MRI a reduction of the mass in the pericardium to the dimensions of 18 × 8 × 16 mm was observed. Another 6 months after treatment with rituximab a total reduction of the mass in the heart was observed. This case confirms that granulomatosis with polyangiitis is a systemic disease with a broad spectrum of organ involved and indicates the effectiveness of treatment with rituximab. Figure 1. A, B. Magnetic resonance: an oval change in the pericardium, infiltrating the right ventricular outflow tract and pulmonary trunk A

Altered course of non-affected left coronary artery as a reason for symptoms of coronary artery disease

Anomalies of coronary arteries are rare (about 0.3–1.3% of patients undergoing a coronary angiography procedure), and left coronary artery (LCA) going from the right sinus of Valsalva (RSV) is described in 0.09–0.15% of cases. We present the case of a 61-year-old female who complained of typical angina symptoms for two years. A cardiac stress test was performed with positive result. The patient was admitted to hospital for coronary catheterisation. Electrocardiogram (ECG) revealed: sinus rhythm 66/min, with T-wave inversion in leads III and aVF and ST depression in leads V4–V6. Echocardiography showed: no segmental wall motion abnormalities and ejection fraction 65%. A coronary angiography was performed. Anomalous origin of LCA from the RSV was observed. Apart from that, the coronary arteries were not affected. Because coronary angiography reveals only two-dimensional views, coronary computed tomography angiography was performed to evaluate the detailed anatomy and course of the coronary arteries. A study was performed with ECG gating at 56–61 bpm using a retrospective acquisition technique. Anatomy and patency of coronary arteries was evaluated using dedicated coronary software. Coronary arteries and their braches were free of plaques, which might have caused significant stenoses and related symptoms. RSV was a source of short common trunk, which bifurcated into the right coronary artery (RCA) and LCA (Fig. 1). The RCA followed its typical anatomical course, and the LCA ran to the left, initially between the right ventricular outflow tract and ascending aorta, and subsequently within the basal anterior segment of the intraventricular septum (Fig. 2A, B). Intramuscular segment supplied the branch corresponding with the diagonal (D1) branch of left anterior descending artery (LAD) and a tiny branch that seemed to supply the intraventricular septum. Further segments of the LCA anatomically corresponding to the LAD ran in epicardial fat tissue giving an origin to the left circumflex artery and its obtuse marginal branches. The type of anomalous course of LCA described in our patient (inter-arterial) has the worst prognosis and is associated with sudden cardiac death (> 50%), especially connected with exercise. For that reason the case of our patient is also unusual. As a young woman she practiced athletics for several years. Her professional work was connected with great physical effort. And finally she gave birth to three children (forces of nature). None of these situations provoked any symptoms. At the time of writing, the state of the patient is stable, so she has been offered optimal medical treatment.

Effect of unilateral catheter-based renal sympathetic denervation in a patient with resistant hypertension.

A 52-year-old woman was admitted to the Department of Hypertension with resistant hypertension coexistent with type 2 diabetes mellitus, two episodes of transient ischaemic attack in the past, and obesity. The patient’s arterial hypertension was uncontrolled on six antihypertensive medications. A denervation procedure Simplicity cathether (Medtronic) was applied. In the main left renal artery, six ablations were performed without any complications. During the first ablation of the main right renal artery, oedema of the arterial wall with a significant stenosis of 80% occurred. Due to the above, no further ablations were attempted. A follow-up arteriography of the right renal artery was performed 24 h later, showing a minimal stenosis in the previously affected area. On the qualification visit, the average office blood pressure (BP) was 203.33/107.66 mm Hg, and on ambulatory BP monitoring mean BP was 189/109 mm Hg in the day and 139/77 mm Hg in the night. In the central BP measurement (Sphygmocor, AtCor Medical), systolic BP was 172 mm Hg, diastolic BP — 98 mm Hg, augmentation index (AIx) — 40, AIx standarised to a heart rate of 75 bpm (AIx@HR75) — 40% (Fig. 1A). In the follow-up visits after six and 12 months, we observed significant falls in all measured parameters (Table 1, Fig. 1B). There was no modification of antihypertensive therapy in the follow up. There are just a few publications concerning unilateral renal denervation, and the presented results are contradictory. The measurement of central BP in hypertensive patients is of increasing interest because of both its predictive value for cardiovascular events and the differential effect of antihypertensive therapies compared to brachial BP. In our opinion, central BP should be considered as a valuable and objective marker of the effectiveness of invasive therapies. Our case shows that even unilateral renal ablation can be fully successful and decrease BP values to a remarkable extent in a 12 month observation.