Bogdan Jegier

Detection of infectious agents by polymerase chain reaction in human aortic wall

INTRODUCTION Several studies have been suggested that infectious agents may induce or progress the process of atherosclerosis in humans. In the present study, the samples of visually healthy human aortic wall were examined for the presence of Chlamydia pneumoniae, Mycoplasma pneumoniae, Helicobacter pylori, herpes simplex virus (HSV), and cytomegalovirus (CMV). METHODS Bacterial DNA of C. pneumoniae, M. pneumoniae, and H. pylori and viral DNA of HSV and CMV were analyzed by polymerase chain reaction. The specimens were obtained from 40 patients with atherosclerotic three-vessel stable coronary artery disease referred to surgical revascularization (coronary group) and 20 controls referred to aortic valve replacement (valve group). RESULTS C. pneumoniae was detected in 11 of 40 samples of aorta in coronary group (27.5%) and 5 of 20 in valve group (25%). M. pneumoniae was found in 6 of 40 (15%) and 5 of 20 (25%) samples, and CMV was found in 22 of 40 (55%) and 10 of 20 (50%) samples. The most frequent detected pathogens were H. pylori and HSV. H. pylori was found in 32 of 40 samples of aortic wall in coronary group (80%) and 17 of 20 samples in valve group (85%), whereas HSV was found in 27 of 40 (67.5%) and 17 of 20 (85%) aortic wall specimens. CONCLUSION Results demonstrate that C. pneumoniae, M. pneumoniae, H. pylori, CMV, and HSV can be detected in macroscopically healthy aortic wall of coronary and valve patients in similar frequency, which do not support hypothesis concerning the role of microorganisms in atherosclerosis etiology.

EuroSCORE II does not show better accuracy nor predictive power in comparison to original EuroSCORE: a single-centre study.

BACKGROUND EuroSCORE is used to predict postoperative mortality in patients undergoing cardiac surgery. Its updated version was published in 2011. AIM To assess whether EuroSCORE II (ESII) predicts more accurately postoperative mortality after cardiac surgery in comparison with additive (addES) and logistic EuroSCORE (logES). METHODS A total of 461 patients (aged 21-88 years, 63.4% of men) who underwent cardiac surgery (December 2010 - June 2011) were included into the prospective research. For each patient ESII, addES and logES were calculated. Accuracy, calibration, and clinical performance of these models were assessed with receiver operating characteristics analyses using the area under the curve and the Hosmer-Lemeshow test. Out of this population, a group of 300 coronary artery bypass grafting (CABG) patients (aged 42-85 years, 73% of men) was selected and statistically analysed using the same methods. RESULTS The mortality rate was 5.21%. Predicted mortality rates were as follows: addES 4.68%, logES 4.57%, and ESII 1.89%; the accuracy was: 0.589, 0.728, and 0.726, respectively. Only logES presented good predictive power (Hosmer-Lemeshow test: c2 = 12.79, p = 0.12). In the CABG patients, the postoperative mortality rate was 5.33%. Predicted mortality rates were as follows: addES 4.69%, logES 4.59%, and ESII 1.88%; the accuracy was: 0.512, 0.691, and 0.687, respectively. In the Hosmer-Lemeshow test also logES presented good predictive power (c2 = 10.72, p = 0.218). CONCLUSIONS EuroSCORE II did not estimate mortality risk better in comparison to its previous versions, in the entire studied population or in the CABG patients. On the basis of the analysed data, it seems that the closest to the actual risk of death for the Polish population is the EuroSCORE logistic model.

Late outcome of mitral valve replacement with the Cross-Jones prosthesis 36 years after initial surgery

A 60 year-old woman with rheumatic mitral stenosis underwent re-replacement of Cross- Jones caged lens mitral valve prosthesis, 36 years after valve implantation. In 1968, she underwent mitral commissurotomy. In 1992, she had a stroke, and in July 2009 echocardiography revealed the malfunction of the prosthesis with pannus and reduced mitral prosthetic area < 1.0 cm(2) with the elevated transprosthetic gradient of 30 mm Hg. To begin with, she did not approve of the reoperation. Finally, she consented to this therapeutic option. In October 2009 Medtronic prosthesis Advantage 27 was re-implanted. We report the longest period of working Cross-Jones mitral valve in the literature.

Progression of coronary artery disease in a HIV-infected patient previously treated for ascending aorta aneurysm

The pathophysiology of increased cardiovascular risk in HIV infection is complex and multifactorial but chronic inflammation and immune activation seem to play a crucial role. Direct effects of HIV, leakage of bacteria from the gut, damage of lymphoid tissues as well as co-infections are responsible for the activation of the immune system [1], resulting in proinflammatory and pro-thrombotic status [2]. Pro-inflammatory high density lipoprotein (HDL) is dysfunctional with high redox activity and easy non-calcified coronary atherosclerotic plaque rupture [3]. Endothelial and macrophage cell function is significantly impaired. Some antiretroviral agents (either directly or via associated dyslipidemia and insulin resistance) may also contribute to the increased rate of cardiovascular disease in HIV and therefore require careful selection according to the underlying cardiovascular risk factors. A 35-year-old man was diagnosed (02.09.2009) with syphilis and HIV infection classified as stage A3. The patient was a cigarette smoker and had arterial hypertension and a family history of coronary artery disease (CAD). Combined antiretroviral therapy (cART) was composed of lamivudine, abacavir atazanavir and ritonavir. One year later atazanavir was replaced with darunavir due to potential drug-to-drug interaction with protein pump inhibitor (PPI). The patient remained asymptomatic and HIV RNA was undetectable. The CD4 T lymphocyte count was 386 cells/μl. Due to exercise capacity impairment control transthoracic echocardiography (TTE) was performed and revealed: aneurysm of the ascending aorta with maximal diameter 60 mm, aortic bulb 50 mm, aortic annulus 26 mm with good left ventricular ejection fraction (LVEF) – 66%. The aortic valve function was preserved. Preoperative coronarography revealed no significant atherosclerosis in coronary vessels. Initial lipid profile revealed hypertriglyceridemia (LDL 130 mg/dl, HDL 41 mg/dl, TG 240 mg/dl). Lipid-lowering therapy was initiated (atorvastatin 40 mg, fenofibrate 267 mg). Supracoronary ascending aorta replacement with a vascular prosthesis (Vascutek 28) and aortic commissure suspension were performed (25.03.2011) without complications. The patient was discharged on the 5th day after the surgery. The patient had outpatient check-ups regularly. Eighteen months later (22.08.2012) the patient had lateral ST elevation myocardial infarction (STEMI). Coronary angiography revealed narrowing of the circumflex artery (Cx), treated with bare metal stent (BMS) implantation. At that moment 50% de novo stenosis in the proximal segment of the left anterior descending artery (LAD) was also diagnosed (Fig. 1). Double antiplatelet therapy was introduced and continuation of antihypertensive and lipid-lowering medication was recommended. HIV RNA remained undetectable and the CD4 T lymphocyte count was 200– 300 cells/μl. Combined antiretroviral therapy was modified to tenofovir, emtricitabine, darunavir and ritonavir, due to the suspected adverse impact of abacavir on the cardiovascular risk. Six months later (1.03.2013) the patient was admitted again to the cardiology department with diagnosis of NSTEMI. Coronary angiography revealed de novo 95% narrowing in the 3rd segment of the right coronary artery (RCA) (without progression in the proximal LAD), treated with BMS implantation. The lipid profile showed a good response to cholesterol-lowering treatment (LDL 49 mg/dl, HDL 41 mg/dl). Due to hypertriglyceridemia (TG 249 mg/dl) lipid-lowering therapy was changed (rosuvastatin 40 mg and fenofibrate 267 mg, BioCardine Omega-3). Lifestyle modifications (cigarette and alcohol cessation) were once again recommended to the patient. At that time the CD4 T lymphocyte count increased to 660 cells/μl. In a 10-month follow-up the deterioration of angina pectoris (to CCS class III) was observed, and was confirmed with non-invasive tests. Coronary angiography revealed progression of proximal LAD stenosis (90%), and elec-

Computed tomography angiography for imaging results of neochordal mitral valve repair

Introduction Degenerative mitral regurgitation is currently the most frequent indication for mitral valve repair. Aim To visualize and assess the mid-term results of mitral valve repair with neochordae implantation, using computed tomography angiography (CTA) imaging. Material and methods The CTA with ECG gating and without modulation was applied in 10 patients to assess the results of a mitral valve sparing procedure. The results of 3 patients are presented. The patients were operated on for severe symptomatic degenerative mitral regurgitation, defined according to a modified Carpentier’s functional classification. Results Neochordal repair, by placing expanded polytetrafluoroethylene sutures between the leading edge of the prolapsing segment and the corresponding papillary muscle, was conducted. From 1 to 3 double Gore-Tex loops were used. Leaflet clefts, if present, were sutured. All repairs included mitral valve ring annuloplasty. The CTA was performed at 20–24 months after the surgery. Long-axis views, reconstructed during mid-systole, seemed to be the most valuable. Good quality cardiac images, precisely presenting the mitral valve complex with its constituents, were obtained in the case of patients without obesity, with a relatively small anterior-posterior thorax dimension, with sinus, slow heart rhythm and quite good left ventricle contractility. The evaluation of the mitral valve included presence of calcifications, fibrosis or thickening, chordal insertion and coaptation points, and papillary muscle locations. Primary and secondary native chordae tendineae and artificial chordae were visualized. Conclusions Contrast material-enhanced ECG-gated CTA applied after mitral valve repair with Gore-Tex neochordae allows one to obtain satisfactory mitral valve images, especially during mid-systole, and evaluate mid-term results of the surgery in chosen patients.

Giant aneurysm of the right coronary artery and magnetic resonance coronary angiography.

Coronary artery aneurysm (CAA) is generally defined as coronary dilatation that exceeds the diameter of normal adjacent segments or the diameter of the patient’s largest coronary vessel by 1.5 times. The prime cause of CAAs is atherosclerosis, and the most commonly affected artery is the right coronary artery. CAAs are quite commonly detected during X-ray coronary angiography. However, Coronary artery aneurysm (CAA) is generally defined as coronary dilatation that exceeds the diameter of normal adjacent segments or the diameter of the patient’s largest coronary vessel by 1.5 times. The prime cause of CAAs is atherosclerosis, and the most commonly affected artery is the right coronary artery. CAAs are quite commonly detected during X-ray coronary angiography. However, giant CAAs, especially with the diameter exceeding 100 mm, are extremely rare. The treatment method of choice of giant CAAs is the excision of aneurysm with coronary artery bypass grafting. We present a case of a 41-year-old apparently healthy woman with a giant right CAA. This was detected by noninvasive methods, including magnetic resonance coronary angiography, and its maximum diameter exceeded 100 mm. In emergency, the aneurysmal sac was excised and the aortocoronary saphenous vein graft was performed. We also present a review of the published studies of giant CAAs with the diameter exceeding 100 mm.

Arterial hypertension in degenerative non-severe aortic stenosis

Degenerative aortic stenosis (AS) is an active inflammatory process similar to that in atherosclerosis plaque. The aim was to evaluate the atherosclerotic risk factors, concomitant diseases and risk of cardiovascular death using the SCORE system in degenerative AS-patients aged 60 and over with preserved left ventricle ejection fraction related to severity of AS.MaterialThe database contains retrospectively consecutive series of 126 patients (mean age 69). Patients were analyzed related to severity of AS: severe AS with mean gradient of 64.6±8.7mmHg (n=79) and non-severe AS with mean gradient of 24.4±8.4mmHg (n=47). There were analyzed: age, gender, BMI, laboratory data, presence of hypertension (HA), diabetes, CAD, smoking cigarettes, positive family history, results of 12-lead ECG and coronary arteriography. There was estimated 10 year risk of cardiovascular death using the SCORE system.ResultsBoth studied populations presented high 10-year risk of cardiovascular death with higher SCORE in non-severe AS (5.64+/-3.3% vs. 6.95+/-3.13%, P=0.006). Multivariate analysis revealed that only HA was an independent parameter determining higher SCORE in non-severe AS (P<0.05).ConclusionsThe non-severe degenerative AS-population had higher 10 years risk of cardiovascular death based on SCORE system than severe AS-patients, what was probably resulted from arterial hypertension.