Ioanna Koniari

Antiphospholipid syndrome; its implication in cardiovascular diseases: a review

Antiphospholipid syndrome (APLS) is a rare syndrome mainly characterized by several hyper-coagulable complications and therefore, implicated in the operated cardiac surgery patient. APLS comprises clinical features such as arterial or venous thromboses, valve disease, coronary artery disease, intracardiac thrombus formation, pulmonary hypertension and dilated cardiomyopathy. The most commonly affected valve is the mitral, followed by the aortic and tricuspid valve. For APLS diagnosis essential is the detection of so-called antiphospholipid antibodies (aPL) as anticardiolipin antibodies (aCL) or lupus anticoagulant (LA). Minor alterations in the anticoagulation, infection, and surgical stress may trigger widespread thrombosis. The incidence of thrombosis is highest during the following perioperative periods: preoperatively during the withdrawal of warfarin, postoperatively during the period of hypercoagulability despite warfarin or heparin therapy, or postoperatively before adequate anticoagulation achievement. Cardiac valvular pathology includes irregular thickening of the valve leaflets due to deposition of immune complexes that may lead to vegetations and valve dysfunction; a significant risk factor for stroke. Patients with APLS are at increased risk for thrombosis and adequate anticoagulation is of vital importance during cardiopulmonary bypass (CPB). A successful outcome requires multidisciplinary management in order to prevent thrombotic or bleeding complications and to manage perioperative anticoagulation. More work and reporting on anticoagulation management and adjuvant therapy in patients with APLS during extracorporeal circulation are necessary.

Pharmacologic prophylaxis for atrial fibrillation following cardiac surgery: a systematic review

Atrial Fibrillation (AF) is the most common arrhythmia occurring after cardiac surgery. Its incidence varies depending on type of surgery. Postoperative AF may cause hemodynamic deterioration, predispose to stroke and increase mortality. Effective treatment for prophylaxis of postoperative AF is vital as reduces hospitalization and overall morbidity. Beta - blockers, have been proved to prevent effectively atrial fibrillation following cardiac surgery and should be routinely used if there are no contraindications. Sotalol may be more effective than standard b-blockers for the prevention of AF without causing an excess of side effects. Amiodarone is useful when beta-blocker therapy is not possible or as additional prophylaxis in high risk patients. Other agents such as magnesium, calcium channels blocker or non-antiarrhythmic drugs as glycose-insulin - potassium, non-steroidal anti-inflammatory drugs, corticosteroids, N-acetylcysteine and statins have been studied as alternative treatment for postoperative AF prophylaxis.

Vascular Complications Following Transradial and Transulnar Coronary Angiography in 1600 Consecutive Patients

Background: Major, noncoronary complications are rarely encountered following transradial coronary procedures. Methods and Results: Among 1600 prospectively studied patients with complete follow-up, 7 patients experienced major complications following coronary forearm procedures corresponding to an incidence of 0.44%. We found inadvertent symptomatic intramyocardial contrast medium injection, 2 cases with compartment syndrome of which 1 was managed surgically, exertional hand ischemia due to radial artery occlusion, a large ulnar artery pseudoaneurysm, an ulnar arteriovenous fistula, and 1 critical hand ischemia due to late occlusion of the distal brachial artery. Conclusions: Although infrequent, surveillance for major complications should be encouraged after forearm coronary procedures.

Structural and biomechanical alterations in rabbit thoracic aortas are associated with the progression of atherosclerosis

BackgroundAtherosclerosis is a diffuse and highly variable disease of arteries that alters the mechanical properties of the vessel wall through highly variable changes in its cellular composition and histological structure. We have analyzed the effects of acute atherosclerotic changes on the mechanical properties of the descending thoracic aorta of rabbits fed a 4% cholesterol diet.MethodsTwo groups of eight male New Zealand White rabbits were randomly selected and fed for 8 weeks either an atherogenic diet (4% cholesterol plus regular rabbit chow), or regular chow. Animals were sacrificed after 8 weeks, and the descending thoracic aortas were excised for pressure-diameter tests and histological evaluation to examine the relationship between aortic elastic properties and atherosclerotic lesions.ResultsAll rabbits fed the high-cholesterol diet developed either intermediate or advanced atherosclerotic lesions, particularly American Heart Association-type III and IV, which were fatty and contained abundant lipid-filled foam cells (RAM 11-positive cells) and fewer SMCs with solid-like actin staining (HHF-35-positive cells). In contrast, rabbits fed a normal diet had no visible atherosclerotic changes. The atherosclerotic lesions correlated with a statistically significant decrease in mean vessel wall stiffness in the cholesterol-fed rabbits (51.52 ± 8.76 kPa) compared to the control animals (68.98 ± 11.98 kPa), especially in rabbits with more progressive disease.ConclusionsNotably, stiffness appears to decrease with the progression of atherosclerosis after the 8-week period.

Serum CXCL10 and CXCL12 chemokine levels are associated with the severity of coronary artery disease and coronary artery occlusion

BACKGROUND Cardiovascular disease constitutes a major cause of death worldwide. Inflammation plays an important role in atherosclerosis formation, coronary artery disease progression, acute coronary thrombosis and occlusion. Chemokines are inflammatory mediators disposing several bio-functions, as leukocyte migration towards inflammatory signals and vascular injuries. The present study was designed to evaluate the potential correlation between serum levels of chemokines CXCL-10 and CXCL-12 and the degree of coronary artery occlusion. METHODS Eighty eight patient candidates for coronary angiography with coronary artery disease symptoms and potentially high risk of coronary artery occlusion were recruited. Chemokine serum levels were measured with the ELISA method and patients underwent coronary angiography. All patients with coronary artery disease (CAD) were divided into four groups according to the Gensini score. Data were presented as mean±SD. All P values <0.05 were considered significant. RESULTS Our demographic data showed that of the 88 patients, 46 were male and 42 female. The mean age of patients was 57.95±11.13. Following increased coronary artery occlusion the serum levels of chemokines were significantly increased (CXCL-10 and CXCL-12; P<0.0001 and P<0.0001, respectively). CONCLUSION In this novel study, a significant correlation between the serum levels of CXCL-10 and CXCL-12 and the severity of coronary artery occlusion was found. This could be attributed to the role of these chemokines in the processes of angiogenesis and angiostasis, a biological phenomenon that can play key role in the development of collateral circulation.

Acute left main coronary artery thrombosis due to cocaine use

It is common knowledge that cocaine has been linked to the development of various acute and chronic cardiovascular complications including acute coronary syndromes. We present a young, male patient, drug abuser who underwent CABG due to anterolateral myocardial infarction. Our presentation is one of the very rare cases reported in literature regarding acute thrombosis of left main coronary artery related to cocaine use, in a patient with normal coronary arteries, successfully operated. Drug-abusers seem to have increased mortality and morbidity after surgery and high possibility for stent thrombosis after percoutaneous coronary interventions, because of their usually terrible medical compliance and coexistent several problems of general health. There are no specific guidelines about treatment of thrombus formation in coronary arteries, as a consequence of cocaine use. So, any decision making concerning the final treatment of these patient is a unique and individualized approach. We strongly recommend that all these patients should be treated surgically, especially patients with thrombus into the left main artery.

Thrombotic responses to coronary stents, bioresorbable scaffolds and the Kounis hypersensitivity-associated acute thrombotic syndrome

Percutaneous transluminal coronary angioplasty with coronary stent implantation is a life-saving medical procedure that has become, nowadays, the most frequent performed therapeutic procedure in medicine. Plain balloon angioplasty, bare metal stents, first and second generation drug-eluting stents, bioresorbable and bioabsorbable scaffolds have offered diachronically a great advance against coronary artery disease and have enriched our medical armamentarium. Stented areas constitute vulnerable sites for endothelial damage, endothelial dysfunction, flow turbulence, hemorheologic changes, platelet dysfunction, coagulation changes and fibrinolytic disturbances. Implant surface attracts several proteins such as albumin, fibronectin, fibrinogen, and complement that lead to complement system activation. Macrophages recognize the implant as foreign substance due to protein adsorption and its continuous presence results in macrophage differentiation and fusion into foreign body giant cells. Polymer coating, stent metallic platforms and the released drugs can act as strong antigenic complex that apply continuous, repetitive, persistent and chronic hypersensitivity irritation to the coronary intima. The concomitant administration of oral antiplatelet drugs and environmental exposures can induce hypersensitivity inflammation. A class of platelets, activated via high-affinity and low-affinity IgE hypersensitivity receptors FCγRI, FCγRII, FCεRI and FCεRII, can induce Kounis hypersensitivity-associated thrombotic syndrome inside the stented coronaries. Type III variant of this syndrome is diagnosed when coronary artery stent thrombosis is associated with thrombus infiltrated by eosinophils or mast cells and/or when coronary intima, media and adventitia adjacent to stent, is infiltrated by eosinophils or mast cells. Careful history of hypersensitivity reactions to all implanted materials and concomitant drugs with monitoring of inflammatory mediators as well as lymphocyte transformation studies to detect hypersensitivity must be undertaken in order to avoid disastrous consequences. Food and Drug Administration recommendations for coronary stent implantation should be applied also to bioresorbable scaffolds. Further studies with inert and non-allergenic implants are necessary.

Radial Artery and Ulnar Artery Occlusions Following Coronary Procedures and the Impact of Anticoagulation: ARTEMIS (Radial and Ulnar ARTEry Occlusion Meta‐AnalysIS) Systematic Review and Meta‐Analysis

Background Incidence of radial artery occclusions (RAO) and ulnar artery occclusions (UAO) in coronary procedures, factors predisposing to forearm arteries occlusion, and the benefit of anticoaggulation vary significantly in existing literature. We sought to determine the incidence of RAO/UAO and the impact of anticoagulation intensity. Methods and Results Meta‐analysis of 112 studies assessing RAO and/or UAO (N=46 631) were included. Overall, there was no difference between crude RAO and UAO rates (5.2%; 95% confidence interval [CI], 4.4–6.0 versus 4.0%; 95% CI, 2.8–5.8; P=0.171). The early occlusion rate (in‐hospital or within 7 days after procedure) was higher than the late occlusion rate. The detection rate of occlusion was higher with vascular ultrasonography compared with clinical evaluation only. Low‐dose heparin was associated with a significantly higher RAO rate compared with high‐dose heparin (7.2%; 95% CI, 5.5–9.4 versus 4.3%; 95% CI, 3.5–5.3; Q=8.81; P=0.003). Early occlusions in low‐dose heparin cohorts mounted at 8.0% (95% CI, 6.1–10.6). The RAO rate was higher after diagnostic angiographies compared with coronary interventions, presumably attributed to the higher intensity of anticoagulation in the latter group. Hemostatic techniques (patent versus nonpatent hemostasis), geography (US versus non‐US cohorts) and sheath size did not impact on vessel patency. Conclusions RAO and UAO occur with similar frequency and in the order of 7% to 8% when evaluated early by vascular ultrasonography following coronary procedures. More‐intensive anticoagulation is protective. Late recanalization occurs in a substantial minority of patients.

Specific IgE levels in pericardial and cerebrospinal fluids in forensic casework

Immunoglobulins E (IgE) constitute an important regulator of allergic reactions as they bind to high and low affinity FceRI and FceRII receptors respectively. These antibodies get attached on the eosinophil, platelet, mast, macrophage, monocyte and dendritic cell surface thus contributing to immunological procedures. IgE’s targets likely extend beyond these cells to contribute to immunological procedures or to induce coronary events [1] but even to diagnostic purposes in the forensic setting. In the very interesting paper published in Forensic Science International [2]. Palmiere et al. measured levels of total and specific IgE in 54 postmortem serum samples from femoral blood, pericardial and cerebrospinal fluid in 3 groups of deaths: nonallergic deaths in non-atopic individuals, fatal allergic anaphylaxis deaths and non-allergic deaths in individuals without medical records. In an effort to evaluate the usefulness of measuring total and specific IgE in pericardial and cerebrospinal fluid for diagnostic purposes in case of blood unavailability. IgE levels were reported to be significantly higher in femoral blood and pericardial fluid than in the cerebrospinal fluid samples. Specific IgE antibodies were revealed only in postmortem serum from femoral blood and pericardial fluid. It was concluded that, total IgE measurements, using a cutoff value of 60 kU/l in femoral blood and 52 kU/l in pericardial fluid, were suggestive of an atopic disposition for the concerned patients. Specific IgE measurements, using a cutoff value of 0.35 kU/l, in both postmortem serum and pericardial fluid, were also suggestive of an atopic disposition. The authors correctly emphasized that increased IgE levels “do not prove that death was preceded by IgE-mediated anaphylaxis but can only suggest antemortem atopic disposition and the degree of specific allergen sensitization in individual cases”. The principal aim of Palmiere’s et al. work was to evaluate the usefulness of IgE determination in pericardial and cerebrospinal fluid so as to diagnose the cause as well as the conditions of such a death. Sudden death accounts for approximately two-thirds of all autopsies in forensic medicine [3]. Cardiac deaths account for 50% of all deaths in developed and 25% in the developing world [4]. On the other hand anaphylaxis via mast cell activation may accompany up to 13% of sudden unexpected deaths in adults [5]. Indeed, the heart is considered as the primary door through which life crosses to death. Since the heart and especially the coronary arteries are regarded as the primary targets of anaphylaxis [6] and the pericardial fluid is considered as plasma ultrafiltrate from both epicardial capillaries and from interstitial fluid within the underlying myocardium, the pericardium could hide the secret and the cause of undiagnosed sudden deaths. In this aspect, searching for molecules, related to anaphylaxis, in the sac

Use of sodium bicarbonate in cardiac arrest: Current guidelines and literature review

The aim of the review was to summarize the literature over the last 25 years regarding bicarbonate administration in out-of-hospital cardiac arrest. A PubMed search was conducted using the terms “bicarbonates” and “cardiac arrest”, limited to human studies and reviews published in English (or at least with a meaningful abstract in English) in the last 25 years. Clinical and experimental data raised questions regarding the safety and effectiveness of sodium bicarbonate (SB) administration during cardiac arrest. Earlier advanced cardiac life support (ACLS) guidelines recommended routine bicarbonate administration as part of the ACLS algorithm, but recent guidelines no longer recommend its use. The debate in the literature is ongoing, but at the present time, SB administration is only recommended for cardiac arrest related to hypokalemia or overdose of tricyclic antidepressants. Several studies challenge the assumption that bicarbonate administration is beneficial for treatment of acidosis in cardiac arrest. At the present time, there is a trend against using bicarbonates in cardiac arrest, and this trend is supported by guidelines published by professional societies and organizations.