Justyna Rybicka

Independent association of obstructive sleep apnea with left ventricular geometry and systolic function in resistant hypertension: the RESIST-POL study

OBJECTIVE We investigated the impact of obstructive sleep apnea (OSA) and night blood pressure (BP) on left ventricular geometry and systolic function in patients with resistant hypertension (RHTN). METHODS AND RESULTS Data from 155 patients with RHTN were analyzed. All patients underwent biochemical evaluations, ambulatory blood pressure monitoring (ABPM), and polysomnography. Left ventricular mass index (LVMI), relative wall thickness (RWT), left ventricular ejection fraction (LVEF), midwall fractional shortening (mwFS) and global longitudinal strain (GLS) were measured. Patients were divided into four groups based on the presence of metabolic syndrome (MS) and OSA: group 1: OSA(-), MS(-) [n = 42]; group 2: OSA(+), MS(-) [n = 14]; group 3: OSA(-), MS(+) [n = 46]; and group 4: OSA(+), MS(+) [n = 53]. In group 3 and 4 concentric geometry was present in 53.2% and 79.6% respectively (P = 0.004). There were no differences in LVEF between groups. Group 3 and 4 had lower mwFS as compared with group 1 (16.40 ± 1.9 and 15.38 ± 2.2 vs 17.44 ± 1.9; P < 0.049 and P < 0.0001 respectively). Group 4 had significantly lower GLS as compared with group 1 (-12.64 ± 3.3 vs -15.59 ± 4.0; P < 0.001). In the multivariable analysis, factors independently associated with concentric geometry were age, nighttime SBP (OR -1.04; 95%Cl 1.019-1.082; P < 0.0001) and OSA (OR -3.97; 95%Cl 1.835-8.590; P < 0.0001). In the other multivariable analysis, factors independently associated with GLS were OSA (beta = 0.279; P = 0.001), and nighttime DBP (beta = 0.168; P = 0.048) whereas factors independently associated with mwFS were age, gender, nighttime SBP, concentric geometry, and metabolic syndrome. CONCLUSIONS In patients with true RHTN without diabetes concentric geometry and systolic dysfunction are independently associated with moderate and severe OSA and nighttime BP levels.

Left aberrant subclavian artery. Systematic study in adult patients

BACKGROUND Left aberrant subclavian artery (LASA), is a type of right aortic arch (RAA) branching, which takes-off distally to the right subclavian artery and usually crosses behind the esophagus to the left upper limb. Taking into account the rarity of RAA, LASA is much more rarely seen than the right aberrant subclavian artery (RASA) originating from the left aortic arch. However, RAA may be associated with much more frequent presence of LASA, than left aortic arch with RASA. Anatomical LASA characteristics were not described up to date. METHODS Individual patient records filed in the electronic database from a single high-volume tertiary cardiac center were retrospectively screened for the presence of RAA in the consecutive patients who underwent chest computed tomography from 2008 to 2016. RESULTS 14 patients with LASA were identified. Only 3 were free of coexisting intra- or extra-cardiac anomalies. The most common defect was tetralogy of Fallot (3 patients). One patient had five congenital defects. Kommerells diverticulum (KD) was present in 9 patients. In all patients the LASA course was retrotracheal and retroesophageal. In all but one patients esophageal modelling or compression by KD or LASA was present. CONCLUSIONS Knowledge of Kommerells diverticulum presence and morphology as well as the LASA course during preinterventional work-up of patients with congenital heart defects is critical, since it may have surgical implications during corrective procedures.

Pulmonary artery dilation indicates severe obstructive sleep apnea in patients with resistant hypertension: the Resist-POL Study.

INTRODUCTION The effect of obstructive sleep apnea (OSA) on right ventricular (RV) function and pulmonary circulation parameters is unclear. OBJECTIVES The aim of this study was to determine whether newly diagnosed OSA and its severity has any impact on RV performance and echocardiographic parameters of pulmonary circulation in patients with true resistant hypertension. PATIENTS AND METHODS The study included 155 patients (93 men and 62 women; mean age, 47.5 ±10 years). The apnea-hypopnea index (AHI), end-diastolic and end-systolic area of the right ventricle, main pulmonary artery diameter (MPAd) at diastole, acceleration time (AccT), tricuspid annular systolic velocity wave, and tricuspid annular plane systolic excursion were evaluated. RESULTS Patients were divided into 4 groups: without OSA (AHI <5; n = 43), with mild OSA (AHI = 5-15; n = 45), moderate OSA (AHI = 15-30; n = 27), and severe OSA (AHI >30; n = 40). There were no differences in RV systolic function between the groups. Patients with severe OSA had a wider MPAd (26.0 ±2.6 vs 23.1 ±3.7 mm; P <0.0001) and shorter AccT (114.2 ±15.7 vs 133.4 ±22.1 ms; P <0.001) in comparison with patients without OSA. The cut-off for the best predictive value of severe OSA was an MPAd of 25 mm or higher with a sensitivity of 63.6% and specificity of 78.9%. The area under the receiver operating characteristic curve for severe OSA in relation to an MPAd of 25 mm or higher was 0.766 (95% confidence interval, 0.673-0.859; P <0.0001). Factors independently associated with an MPAd of 25 mm or higher were severe OSA and nighttime diastolic blood pressure levels. CONCLUSIONS Our study showed a relationship between pulmonary artery dilation and the presence of newly diagnosed severe OSA. Among the parameters studied, an MPAd of 25 mm or higher turned out to be the most useful parameter in identifying patients with severe OSA.

Successful reoperation of the valveless calcified right atrium to right ventricle conduit in an adult patient with tricuspid atresia after Fontan procedure

A 31-year old woman with tricuspid atresia, after Bjork Fontan modification and reoperation due to homograft narrowing, was evaluated because of progressive exercise intolerance; she was planning a pregnancy. The right atrium (RA) to right ventricle (RV) homograft narrowing and calcification with significant reversal flow were found. Successful reoperation was performed-calcified conduit was excised and extracardiac pulmonary homograft tipped with vascular prosthesis was implanted between the RA and the RV.

Parachute mitral valve in a young adult with recurrent pulmonary oedema

A parachute mitral valve is a rare congenital malformation resulting from fusion of the mitral chordae tendineae and their attachment to the one prominent papillary muscle. It can be found either as an isolated lesion or, more often, associated with left heart obstructive lesions, patent ductus arteriosus or ventricular septal defect. Congenital mitral stenosis usually presents with severe symptoms in early childhood, otherwise remains stable and hardly ever requires surgical intervention. We present a case of a young adult with severe stenosis of a parachute mitral valve and history of recurrent pulmonary oedema treated by mitral commissurotomy.

Transthoracic ultrasonic tissue indices identify patients with severe left anterior descending artery stenosis. Correlation with fractional flow reserve. Pilot study

BACKGROUND AND AIM The aim of this study was to evaluate the potential clinical application of ultrasonic tissue indices, with a focus on systolic strain (SS) and systolic strain rate (SSR) parameters derived from transthoracic echocardiography, in the assessment of left anterior descending artery (LAD) stenosis. METHODS The data of 30 patients with significant LAD stenosis were analysed. All patients underwent transthoracic echocardiography to obtain systolic myocardial velocity (Sm), longitudinal SS, and SSR from basal, mid, and apical segments of anterior and inferior walls in two-chamber apical view. Severity of LAD obstruction was measured by means of fractional flow reserve (FFR) during coronary catheterisation. RESULTS Systolic velocities, strain, and strain rate measured in basal, middle, and apical segments of the anterior left ventricular (LV) wall were lower when compared to those obtained from the corresponding, i.e. unaffected, inferior LV wall. There was a significant correlation between FFR and the value of SS, SSR characterising the apical LV segment of the anterior wall (r = -0.583, p = 0.01; r = -0.598, p = 0.01, respectively). Moreover, we found significant correlation between FFR and Sm in the mid-segment of the LV anterior wall (r = 0.611, p = 0.009). CONCLUSIONS We conclude that SS and SSR obtained from the apical segment of the anterior LV wall may be related to the severity of LAD stenosis.

Multiple congenital arteriovenous fistulas draining into the right internal mammary vein with a large internal mammary varicose vein

A 35-year-old asymptomatic woman was referred for percutaneous closure of patent ductus arteriosus (PDA). Loud continuous murmur at the left and right sternal border was detected. Successful percutaneous closure of PDA with an Amplatzer 9-PDA-005 Duct Occluder was performed. The next day, however, loud continuous murmur was still present. Echo showed Amplatzer Duct Occluder in the site of PDA. CT …

Newly diagnosed aortic arch interruption in an adult presenting with heart failure

A 52-year-old man diagnosed in childhood with bicuspid aortic valve (BAV) was admitted with heart failure. Echo showed severe BAV stenosis ( Panel A ) (gradient 80/50 mmHg, AVA 0.8 cm2), significant LV dysfunction [ejection fraction (EF) 27%, global longitudinal strain −8%], severe pulmonary hypertension (RVSP ≈ 115 mmHg), and narrowing/interruption of the descending aorta with holodiastolic forward flow …