Leszek Gromadziński

Hypocalcemia is related to left ventricular diastolic dysfunction in patients with chronic kidney disease.

BACKGROUND Left ventricular (LV) diastolic dysfunction in patients with chronic kidney disease (CKD) is of a complex nature and is the predominant cause of congestive heart failure in this group of patients. This work aimed to evaluate the potential effect of disturbances in calcium-phosphorus (Ca-P) metabolism in patients with CKD on LV diastolic function as assessed by echocardiography. MATERIALS AND METHODS The study group consisted of 81 ambulatory patients with CKD, stages 2-5, with preserved LV systolic function-LV ejection fraction >50% and with sinus rhythm. Standard echocardiography was performed in all patients with tissue Doppler echocardiography for the evaluation of the systolic velocity and both diastolic velocities of LV (EmLV and AmLV). The following laboratory parameters were measured: serum creatinine concentration, estimated glomerular filtration rate, and the levels of urea, P, Ca, parathormone, platelet count, hemoglobin level, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. Patients were divided into two groups according to the results of EmLV: group with LV diastolic dysfunction (EmLV<8cm/s) DF (+) and group with normal LV diastolic function DF (-), when EmLV was ≥8cm/s. RESULTS Patients in DF (+) group, as compared to DF (-) patients, manifested a lower serum Ca level and an elevated NT-proBNP level [9.03±0.76mg/dL vs 9.44±0.78mg/dL, p=0.02, and 257.9 (32.6-12,633)pg/ml vs 149 (11.7-966)pg/ml, p=0.035, respectively]. The area under the receiver operating characteristics (ROC) curve of Ca for diastolic dysfunction was 0.627, 95% CI (0.511-0.734), p=0.04, whereas ROC derived Ca value of ≤9.82mg/dL was characterized by a sensitivity of 91.8% and specificity of 38.1% for diagnosing LV diastolic dysfunction. The only independent variable predicting LV diastolic dysfunction as measured by a multivariate logistic regression analysis was Ca level≤9.82mg/dL with odds ratio=8.81 (95% CI 1.49-51.82), p=0.014. CONCLUSIONS Hypocalcemia is an independent predictive factor for LV diastolic dysfunction in patients with CKD.

Diagnostic value of mitral and tricuspid annular excursion in the diagnostics of acute pulmonary embolism patients with chronic heart failure.

causing coronary artery steal. In view of ongoing symptoms despite medical therapy the decision was made to close this vessel percutaneously. Initial attempts via the radial approach were unsuccessful due to poor guide support but a repeated attempt via the femoral arterywas successful. A 7FAL 2 guiding catheter was used, awhisper wire (Abbott, UK) was placed in the vessel and a 4 F delivery catheter was advanced into the vessel (Panel C). An Amplatzer Vascular Plug 4, (image courtesy of AGA medical corporation) (Panel D) was subsequently deployed (Panel E) and occlusion of the vessel after several minutes was confirmed by repeat angiography (Panel F). The patient experienced mild discomfort following the procedure but was otherwise well and discharged home the following morning. He was reviewed 2 months later and reported a significant improvement in his anginal symptoms, (CCS grade I) Fig. 1. The authors have no conflicts of interest to declare in relation to this manuscript. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [1].

The influence of acute pulmonary embolism on early and delayed prognosis for patients with chronic heart failure

BACKGROUND Patients with acute pulmonary embolism (APE) with concomitant chronic heart failure (CHF) are characterized by higher mortality rates than APE patients without CHF. The aim of this study is to evaluate the potential impact of APE on early and long-term prognosis in patients with CHF. METHODS This study included 87 patients with CHF with suspected APE. Patients were divided into two groups according to spiral computed tomography results: one group with confirmed APE and one with excluded APE. Total and cardiovascular mortality in patients of both groups during a 6- and 36-month follow up period was assessed. Potential risk factors for mortality in patients with CHF in short and long-term observations were identified. RESULTS APE was diagnosed in 35 patients, and excluded in the remaining 52 patients. Total and cardiovascular 6-month mortality was higher in APE patients than in patients without APE: 34.3% and 28.5% vs. 13.4% and 11.5%, p = 0.02, p = 0.02, respectively. In 6-month follow-up the only independent risk factor for mortality was the presence of APE (HR = 2.7, 95% CI 1.1-24.4, p = 0.04). However, in the 36-month follow-up APE had no effect on mortality. CONCLUSIONS Patients with CHF and acute episode of PE are characterized by a higher 6-month total and cardiovascular mortality rate following discharge from hospital compared to patients hospitalized due to acute CHF decompensation. Moreover, recent episode of PE in patients with CHF is an independent risk factor for early mortality in a 6-month follow-up.

Hyperuricemia is an Independent Predictive Factor for Left Ventricular Diastolic Dysfunction in Patients with Chronic Kidney Disease

BACKGROUND It has been reported that elevated serum uric acid (UA) levels is an independent factor of poor prognosis in patients with chronic heart failure and chronic kidney disease (CKD). OBJECTIVES In our study, we assessed the potential impact of hyperuricemia on left ventricular (LV) diastolic dysfunction (DD) in patient with CKD. MATERIAL AND METHODS The study group consisted of 50 patients with CKD, stages 2-5. Standard echocardiography and tissue Doppler imaging (TDI) were performed. The levels of UA and N-terminal prohormone brain natriuretic peptide (NT-proBNP) were determined. Patients were divided into two groups according to the results of peak mitral annular early diastolic velocity (EmLV): group with LV diastolic dysfunction (EmLV < 8 cm/s) DD (+) and group with normal LV diastolic function DD (-), when EmLV ≥ 8 cm/s. RESULTS Patients DD (+) group, as compared to DD (-) patients were characterized by significantly higher serum UA levels [6.7 (4.4-14.3) mg/dL vs 5.8 (1.9-8.9) mg/dL, p = 0.004] respectively. The area under the receiver operating characteristic (ROC) curve was of serum UA levels for the detection of LV diastolic dysfunction was 0.734, 95% confidence interval (CI) 0.590-0.849, p = 0.001, whereas ROC derived UA value of > 6.0 mg/dL was characterized by a sensitivity of 76.9% and specificity of 62.5% for diagnosing LV diastolic dysfunction. The independent variable predicting LV diastolic dysfunction as measured by a multivariate logistic regression analysis was UA level > 6.0 mg/dL with odds ratio (OR) = 14.3 (95% CI 2.0-103.2), p = 0.006. CONCLUSIONS Hyperuricemia is an independent predictive factor for LV diastolic dysfunction in patients with CKD.

The significance of mitral and tricuspid valve systolic lateral annular velocities in the diagnosis of acute pulmonary embolism in patients with chronic heart failure.

Introduction The diagnosis of acute pulmonary embolism (APE) in patients with chronic heart failure (CHF) remains a difficult task, despite the refinement of imaging techniques. The goal of this study was to assess the value of measuring tricuspid and mitral valve systolic annular velocities in CHF patients with suspected PE by tissue Doppler imaging (TDI). Material and methods The study included 75 patients with previously diagnosed CHF, admitted due to resting dyspnea, with a maximum tricuspid regurgitation pressure gradient (TRPG) of ≥ 35 mm Hg and positive D-dimer assay. Spiral computed tomography (sCT) was performed on all subjects to confirm APE. Acute pulmonary embolism was diagnosed in 35 patients (PE+), and excluded in 40 others (PE–). Tissue Doppler imaging was performed to measure maximum systolic lateral annular velocities in the mitral (SmLV) and tricuspid (SmRV) valves, as well as the SmRV/SmLV ratio. Results PE+ subjects were found to have higher SmLV than PE– subjects (6.0 cm/s (2.0–13.8 cm/s) vs. 4.2 cm/s (1.3–9.1 cm/s), p = 0.003). SmRV/SmLV ratios were 1.05 (0.50–2.50) and 1.56 (0.62–4.30), respectively (p < 0.0001). Areas under ROC curves for diagnosis of APE were 0.700 for SmLV and 0.789 for SmRV/SmLV. In multivariate logistic regression analysis, only SmRV/SmLV was statistically significant, with an odds ratio for APE of 6.26 (95% CI: 1.53–25.59; p = 0.009). Conclusions Tissue Doppler imaging of the lateral tricuspid and mitral annuli is a useful clinical tool that can help identify PE in CHF patients. Those patients who fulfill these criteria should be considered for further diagnostic studies to confirm PE.

Right atrial rupture following a blow with a wooden block in the sternal region

1Department of Internal Medicine, Gastroenterology and Hepatology, University Clinical Hospital, University of Warmia and Mazury, Olsztyn, Poland 2Department of Internal Medicine and Cardiology, Medica Health Centre, Ostroda, Poland 3Department of Cardiac Surgery, Provincial Specialist Hospital, Olsztyn, Poland 4Department of Internal Medicine and Cardiology, Warsaw Medical University, Warsaw, Poland

Echocardiographic changes in patients with stage 3-5 chronic kidney disease and left ventricular diastolic dysfunction.

Background: Left ventricular (LV) diastolic dysfunction in chronic kidney disease (CKD) patients frequently leads to the development of congestive heart failure. We evaluated changes in echocardiographic parameters among CKD patients with LV diastolic dysfunction. Methods: We examined 70 ambulatory patients with CKD at stages 3-5 and 26 patients without CKD as a control group. Standard echocardiography and tissue Doppler imaging were performed on all patients. Patients with CKD were divided into two groups according to the results of lateral mitral early diastolic velocity (EmLVlat): a group with diastolic dysfunction (DD group; EmLVlat <8 cm/s) and a group without diastolic dysfunction (WDD group; EmLVlat ≥8 cm/s). Results: Compared to the patients in the WDD group, those in the DD group were characterized by lower values of mitral annular plane systolic excursion [MAPSE; 13 (11-17) vs. 14 (11-16) mm, p < 0.0001] and lateral mitral annular systolic velocity [SmLVlat; 7 (5-14) vs. 8 (5-13) cm/s, p = 0.006]. The area under the receiver operating characteristic (ROC) curve of the MAPSE level for the detection of LV diastolic dysfunction was 0.801 [95% CI 0.684-0.890, p < 0.0001], whereas a ROC-derived MAPSE value of ≤13 mm was characterized by a sensitivity of 84.4% and a specificity of 75.8% for diagnosing LV diastolic dysfunction. The only independent variable predicting LV diastolic dysfunction was MAPSE [OR = 0.39; 95% CI 0.21-0.74, p = 0.003]. Conclusion: We showed that reduced MAPSE, but not SmLVlat, is an independent predictive factor for LV diastolic dysfunction in CKD patients.

Patient with purulent pericarditis: a case doomed to fail?

Exudative pericarditis, and in particular a purulent type, is a rare condition which requires emergency medical intervention. In our paper we present a case report concerning a patient with purulent pericarditis.