Eftihia Sbarouni

Relationship between hemostatic abnormalities and neuroendocrine activity in heart failure

Thromboembolism is an important complication of heart failure. To test the hypothesis that heart failure may be associated with hemostatic dysfunction, we studied hemostatic function in 21 patients with stable chronic heart failure and related these measures to the severity of heart failure as assessed by clinical evaluation, neuroendocrine activation, radionuclide ventriculography, and cardiopulmonary exercise testing. Plasma and blood viscosity were elevated; all patients showed evidence of platelet activation, and many had elevated plasma concentrations of fibrinopeptide A, D-dimer, and von Willebrand factor. The plasma concentrations of these variables were poorly interrelated and related poorly to the severity of heart failure. Plasma concentrations of angiotensin II and endothelin were correlated, and the latter was also correlated with the plasma concentration of von Willebrand factor. Patients with chronic heart failure have hemostatic abnormalities that may predispose them to thromboembolic events and may be in part due to neuroendocrine activation.

Significant changes in platelet count, volume and size in acute aortic dissection

Mean platelet volume (MPV) and platelet size distribution width (PDW) are markers of platelet (PLT) size and variability in PLT size as well as PLT activation [1–3]. Reduced PLT count and increased MPV values have been reported in unruptured abdominal aortic aneurysms [4,5]. Others, however, have noted lower PLT indices (MPV and PDW) in patients with aortic aneurysm compared to age-matched controls [6]. High-grade inflammation is associated with low MPV whereas low-grade inflammation is associated with high MPV; inflammation may play a role in pathogenesis of aneurysm formation and rupture [3]. We studied PLT indices in patients with acute aortic dissection (AAD), chronic aortic aneurysms and age and sex matched normal subjects. We studied, prospectively, 100 consecutive patients with AAD admitted to our hospital for emergency surgery (group I), 100 patients with chronic aneurysms of the ascending aorta scheduled for coronary angiography prior to elective surgical repair (group II) and 100 age and sex matched normal subjects who served as controls (group III). The diagnosis was confirmed for all patients with computed tomography. Dissection was classified according to the Stanford criteria. In patients with AAD, blood samples were obtained as soon as the patient came to hospital and for patients in group II the morning of the admission, prior to catheterization. All patients gave informed consent and the study protocol was approved by the Ethics Committee of our institution. The authors of this manuscript have certified that they comply with the PrinciplesofEthicalPublishingintheInternationalJournalofCardiology. PLT indices were evaluated with anautomatic counter, including PLT count, MPV, PDW and MPV/PLT ratio (Coulter LH780, Hematology Analyzer, Beckman, Miami, USA).Bloodsamples were collected in tubes with potassium ethylenediaminetetraacetate and were analyzed 1 h after venipuncture. We also measured D-dimers with Elisa (Vidas Ddimer, Biomerieux, France) and CRP with an immunoturbidimetric method (Cobas Integra, Roche, Mannheim, Germany). The groups were compared by means of chi-square or Fishers exact test, Kruskal Wallis test or non-parametric one-way analysis of variance, Mann–Whitney test and Spearman rank correlation coefficient, as appropriate. Baseline characteristics for all three groups are presented in Table 1. In type A dissection, 8 patients died before surgery and the remaining were all but one operated; this patient declined surgery. There were 3 deaths in the operating room and 7 post-operative deaths. In type B dissection, 2 patients died on arrival to our unit; 2 patients were transferred elsewhere for vascular surgery and 1 was operated on site; the remaining 10 were managed conservativelyand did well. Ingroup II, there were 2 deaths. As expected, aortic cross clamping time and cardiopulmonary bypass time were significantly longer in group I than in group II (p b 0.001) whereas the duration of hospitalization was similar in the 2 groups (p = 0.192). Table 2 illustratestheresultsofstudiedbiochemicalvariablesamong groups. Within group I, PLT count was lower [186 (146,212) vs 222 (195,264)] and the MPV/PLT ratio was higher [0.047(0.036, 0.059) vs 0.037(0.033, 0.04)] in type A dissection compared to type B (p = 0.009 and p = 0.008, respectively). In addition, MPV as well as the MPV/PLT ratiowere significantlylowerinpatientswithmore extensivedissection with involvementof the abdominal aorta and the iliacarteries; in detail, when comparing thoracic vs thoracic–abdominal vs thoracic–abdominal–iliacdissection,MPVwas8.7(8.1,9.5),7.9(7.4,8.4)and8.1(7.1,8.7), respectively (p = 0.013) and MPV/PLT ratio was 0.05 (0.037, 0.062), 0.041 (0.036, 0.047) and 0.038 (0.034, 0.048), respectively (p = 0.042).

High homocysteine and low folate concentrations in acute aortic dissection

BACKGROUNDnBiomarkers for monitoring progression and prognosis of thoracic aneurysm are of great interest. Homocysteine (Hcy) induces elastolysis in arterial media and may directly affect fibrillin-1 or collagen whereas lipoprotein (Lp) (a) inhibits elastolysis by reducing activation of matrix metallopeptidase-9.nnnMETHODSnWe studied 31 consecutive patients with acute aortic dissection (AAD) admitted for emergency surgery (group I, 60 ± 13 years old, 25 men), 30 consecutive patients with chronic aneurysms of the ascending aorta (group II, 67 ± 12 years old, 24 men) and 20 healthy controls (group III, 58 ± 15 years old, 14 men). We evaluated Hcy, folate, B12, Lp(a) and methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism at baseline.nnnRESULTSnHcy, folate and B12 differed significantly among the 3 studied groups (P=0.016, P=0.004 and P=0.001, respectively). The levels of Hcy and B12 were significantly higher in group I compared to both groups II and III (P=0.05 and P=0.002, P<0.001 and P=0.017, respectively) and without significant differences between groups II and III (P=0.083 and P=0.124). Folate was significantly lower in group I compared to both groups II and III (P=0.001 and P=0.006, respectively) and without marked difference between groups II and III (P=0.409). No significant difference was found in serum levels of Lp (a) (P=0.074) or among the frequency of MTHFR C677T genotypes.nnnCONCLUSIONSnPatients with AAD present with higher Hcy and lower folate compared to both chronic aneurysms and controls.

Transcatheter aortic valve implantation: restoring the qualities of life in old age

Transcatheter aortic valve implantation (TAVI) is a tremendous therapeutic advance for patients with severe aortic stenosis and high-surgical risk. Since TAVI-treated patients are elderly with multiple co-existing conditions, limited life expectancy and disproportionate health-care expenditures, the aspect of the health-related quality of life (HRQoL) benefits becomes of fundamental importance. Based on recent evidence, TAVI appears to improve significantly HRQoL measures compared with optimal standard care, which are restored to age-adjusted population norms over time.

Significant peri-operative reduction in plasma osteopontin levels after coronary artery by-pass grafting.

OBJECTIVESnOsteopontin (OPN) is a multifunctional protein associated with vascular injury and has been linked to atherosclerosis and inflammation. We sought to investigate whether OPN changes in relation to coronary artery by-pass grafting (CABG) surgery.nnnDESIGN AND METHODSnWe studied 50 consecutive patients (63 ± 10 years old, 6 women and 44 men) undergoing elective CABG. Plasma OPN levels were determined by an enzyme-linked immunosorbent assay at baseline and in 24 and 72 h, post-operatively. Cardiac enzymes - creatine kinase, the MB isoenzyme of creatine kinase, troponin-I- and C-reactive protein (CRP) were also determined at all three time points.nnnRESULTSnOPN levels 72 h post-op decreased significantly compared to pre-op and 24h post-op levels (p<0.001) whereas there was no difference between the pre-op and first post-op values (p=0.57). The relative change in OPN levels between pre-op and 72 h post-op correlated negatively with absolute troponin-I levels at 72 h post-op (-0.51, p=0.005). OPN levels 72 h post-op correlated significantly with CRP at baseline (r=0.73, p=0.002).nnnCONCLUSIONSnOPN plasma concentrations decreased after CABG surgery in the early post-operative period. The significance of this observation needs further investigation.

Anomalous origin of coronary arteries: When one sinus fits all

A right coronary artery origin from the left coronary sinus and a left coronary origin from the right sinus although rarely encountered during routine cardiac catheterization, they represent two relatively common autopsy findings in young patients suffering sudden cardiac death. The interarterial course of the aberrant artery, between the aortic root and the pulmonary artery has been considered as a malignant variant, because of the higher risk of myocardial ischemia and sudden death. We present two rare cases of ectopic coronary origin from the opposite sinus of Valsalva.

Heart-type fatty acid binding protein in elective cardioversion of atrial fibrillation

OBJECTIVESnWe sought to investigate whether heart-type fatty acid binding protein (H-FABP), a new marker of myocardial necrosis, increases in relation to elective cardioversion of atrial fibrillation (AF).nnnMETHODSnWe studied 25 consecutive patients (61 ± 16 years old, 21 men) admitted to our hospital for elective cardioversion of AF. Peripheral venous samples were drawn immediately before cardioversion, one hour and 24h after the procedure and assayed for H-FABP.nnnRESULTSnA mean of 309 ± 183 J was used for cardioversion. Successful cardioversion in sinus rhythm was achieved in 18 patients (72%). Serum levels of H-FABP did not change significantly either in relation to the procedure [1385 (256-17,127)pg/mL at baseline, 1125 (290-15,238)pg/mL 1h post and 1045.5 (66-2981)pg/mL 24 h post cardioversion, p=0.37] or to the success of the procedure.nnnCONCLUSIONnH-FABP does not significantly change following elective cardioversion for AF and we, therefore, speculate that myocardial necrosis does not occur during cardioversion.

Heart type fatty acid binding protein in relation to pharmacologic scintigraphy in coronary artery disease.

Abstract Background: Heart-type fatty acid-binding protein (H-FABP) is a marker of myocardial necrosis, but whether it increases during myocardial ischemia is not known. This study investigated whether serum levels of H-FABP change during adenosine stress testing and nuclear imaging in patients with stable coronary artery disease. Methods: Thirty stable patients with established coronary artery disease on their medications were studied. Sampling was performed before the stress test, at the end of adenosine infusion, as well as 1, 2 and 3 h after the completion of the infusion. Results: No difference in H-FABP serum levels were found at the five pre-specified time points in the overall group (p=0.99); furthermore, there was no significant difference regardless of the test result – positive (p=1) or negative (p=0.98). Conclusions: It is concluded that H-FABP does not change significantly during pharmacologic stress testing in patients with known coronary artery disease and there is no difference whether there is inducible ischemia or not.

Platelet to lymphocyte ratio in acute aortic dissection

Inflammation plays an important role in the initiation and progression of acute aortic dissection (AAD). New inflammatory indices derived from full cell blood count and its differential may be associated with increased risk. We evaluated platelet‐lymphocyte (PLR), red cell distribution width (RDW) and RDW/PLTs (platelets) (RPR) in AAD.

Dyspnoea on exertion in a 53-year-old woman

Clinical introduction A 53-year-old woman with no previous medical history complained of easy fatigue over the last 6 months. She had a positive family history for coronary artery disease but no other risk factors. On physical examination, a 3/6 pansystolic murmur was heard over the apex, and the lung auscultation was unremarkable. Her ECG showed a left anterior fascicular block, with poor R wave progression in the anterior leads (see online supplementary image A). A subsequent echocardiogram revealed a slightly dilated for the patient’s body surface area (BSA) (1.73u2009m2) left ventricle (55/35u2009mm), with preserved systolic function and a moderate functional mitral regurgitation. The estimated pulmonary artery pressure was 45u2009mm Hg. During treadmill radionuclide scintigraphy, her exercise tolerance was normal, with good inotropic response, and 96% oxygen saturation at rest and at peak exercise. A 2u2009mm ST segment depression was noted at peak effort, which persisted well into recovery (see online supplementary image B). The scintigraphy scan showed extensive reversible anteroapical wall ischaemia (see online supplementary image C). At this point she was referred to us for right and left heart catheterisation. Intracardiac pressures and saturations were: right atrium (RA)RA=3u2009mm Hg, right ventricle (RV)=26/3u2009mm Hg, Pulmonary artery (PA)=26/10/mean 16u2009mm Hg, pulmonary capillary wedge pressure (PCWP)=11u2009mm Hg, left ventricle (LV)=110/10u2009mm Hg, Aorta (Ao)=110/60/mean 80u2009mm Hg, Superior vena cava saturation (SVCsat)=62%, RAsat=62%, PAsat=78%, Aosat=96%u2009and estimated pulmonary to systematic flow ratio (Qp/Qs)=1.8. Her coronary angiography and CT angiography are shown in figure 1A,B. 10.1136/heartjnl-2017-311256.supp1 Supplementary material 1 10.1136/heartjnl-2017-311256.supp2 Supplementary material 2 10.1136/heartjnl-2017-311256.supp3 Supplementary material 3 Figure 1 Coronary and CT angiograms. Question What is the most likely diagnosis? Right coronary fistula to right ventricle Kawasaki disease with fistula Anomalous origin of the left coronary artery from the pulmonary artery Persistent truncus arteriosus