Mariusz Skowerski

Comparison of pulmonary veins anatomy in patients with and without atrial fibrillation: analysis by multislice tomography.

UNLABELLED A possible role of anomalies in number and insertion of pulmonary veins (PV) in initiating atrial fibrillation (AF) has been suggested. It has been shown as well that changes in anatomy of PVs such as enlargement may have an effect on arrhythmogenesis. The aim of the study was to compare anatomy of the left atrium (LA) and PVs in patients with AF and control subjects. METHODS Eighty two patients were evaluated with 64-slice computed tomography (MSCT). Fifty one of them were referred to catheter ablation with history of highly symptomatic AF--AF(+) group. Thirty one control subjects had no history of AF and were referred to MSCT for noninvasive evaluation of different pathologies which finally were excluded--AF(-) group. Study groups did not differ in regard to age, sex, presence of hypertension and left ventricular systolic function. Diameters of PV ostia were measured in anterior-posterior (AP) and superior-inferior (SI) directions. Venous ostium index was calculated as a ratio between these measurements. RESULTS The diameter of LA was higher in AF(+) patients than in the AF(-) patients (39±6 mm vs. 35±4 mm, p<0.005). In 68.6% of AF(+) patients and in 83.9% of AF(-) patients the anatomical pattern was typical with two right and two left PVs. Additional PVs were detected in 6 patients, only in AF(+) group (p<0.05). Common ostia were more frequently found in AF(+) subjects (37.2% vs. 19.3, p=0,08), mainly left-sided. In AF(+) group mean SI diameters of both-sided superior PVs and left inferior veins were larger. All AP diameters except for right inferior PVs were also larger in AF(+) group than in control cases. CONCLUSIONS Variations in the PVs anatomy are more common and diameters of ostial portions of the veins are larger in AF patients than in control subjects. These findings suggest that further studies on the role of structural abnormalities of PVs in arrhythmogenesis are needed.

Oligonucleotide Microarray Analysis of Genes Regulating Apoptosis in Chronically Ischemic and Postinfarction Myocardium

The pathology of cardiomyocyte death during and after myocardial infarction involves both necrosis and apoptosis. Although both mechanisms lead to cell death, participation of apoptosis in this process carries the potential of developing therapies influencing at least part of the population of dying cells. Therefore the aim of this study was to determine (using oligonucleotide microarrays) expression profiles of apoptosis-regulating genes in postinfarction myocardium, comparing chronically ischemic and healthy heart muscle. Tissue samples were obtained during elective surgery from the right cardiac auricles of three patients. The expression of 141 genes involved in fibrosis was assessed using the Affymetrix HG_U133A microarray. The patients’ transcriptomes were compared using hierarchical clusterization. Differentiating genes were determined using regression analysis and Bland–Altman graph analysis. Hierarchical clusterization demonstrated that the profile of gene expression in postinfarction myocardium was different from that in the remaining specimens. Further statistical analysis showed two important differentiating genes: FOXO3A (underexpressed in post-MI sample) and CFLAR (overexpressed in post-MI sample). The expression of apoptosis-regulating genes is significantly different in post-MI myocardium from chronically ischemic and a nonischemic myocardium. Our results suggest that CFLAR is important in the induction of apoptosis in postinfarction cardiac tissue.

Coronary artery calcium score assessed by a 64 multislice computed tomography and early indexes of functional and structural vascular remodeling in cardiac syndrome X patients.

Background. Regardless of normal coronary angiograms, coronary artery calcium (CAC) can be found in cardiac syndrome X (CSX) patients. According to some data, a relationship between the CAC score and markers of early atherosclerosis in CSX has been observed. Our aim was to assess whether the extent of the CAC score assessed by multislice computed tomography (MSCT) with a 64-slice system in CSX patients is related to brachial artery reactivity, intima-media thickness (IMT), and arterial compliance indexes.Methods and Results. High-resolution ultrasound was used to measure flow-mediated dilatation (FMD) and nitroglycerin-mediated vasodilatation, as well as the following parameters of arterial structural changes: IMT, pulse wave velocity, total arterial compliance, and stiffness index. MSCT was used to assess the presence and the quantity of CAC. The study group consisted of 46 CSX patients (mean age, 56.3±9 years), whereas the control group comprised 21 healthy subjects (mean age, 54.9±7 years). The assessment of the vascular parameters showed significantly decreased FMD and increased IMT in the CSX subjects (9.06%±3.2% and 0.67±0.1 mm, respectively) in comparison to the control subjects (17.42%±8.4% [P=.008] and 0.57 ± 0.2 mm [P=.021], respectively). CAC was detectable in 19 CSX patients (41%) (CAC range according to Agatston score, 2–500; mean, 101.6; median, 26.5) and in 1 control subject (4.8%) (CAC value, 13). CSX patients with detectable CAC were characterized by a significantly higher age (P=.001), lower body mass index (P=.017), and increased stiffness index (P=.020); there were no differences in FMD and IMT values. In a multivariate logistic and linear regression analysis, age was the only risk factor independently associated with the presence of CAC (P=.001) and the log(CAC+1) value (P=.01). In the subgroup of women, log(CAC+1) significantly correlated with age (r=0.587, P=.002) and stiffness index (r=0.427, P=.024), and in a borderline significant manner, it correlated with weight (r=−0.329, P=.07) and waist-hip ratio (r=0.315, P=.07). There were no significant correlations in the male subgroup.Conclusions. Low ranges of CAC are frequently detectable in CSX patients, and the results are age-related and independent of impaired early indexes of functional and structural vascular remodeling.

Pulmonary embolism in a patient with mild factor VII deficiency after administration of recombinant activated factor VII during a urological procedure

285 antibiotic therapy were initiated. A transthorac‐ ic echocardiography (TTE) showed significant right ventricular overload (right ventricular out‐ flow tract, 40 mm; right ventricular inflow tract [RVIT], 52 mm; tricuspid annular plane systolic excursion [TAPSE], 11 mm; severe tricuspid regur‐ gitation jet, 3.2 m/s). Because of high risk, the pa‐ tient was excluded from a surgery or an invasive procedure by a cardiothoracic surgeon. Alteplase, followed by heparin infusion, was administered, which in this case was a life ‐saving treatment and the only possibility left. Two hours later, a mas‐ sive bleeding from the urethral catheter occurred. The hemoglobin level decreased from 12.5 g/dl to 7.6 g/dl, and the patient was excluded from ur‐ gent surgery by a general surgeon. The heparin infusion was terminated. Then, 3 units of red blood cells were transfused and the heparin infu‐ sion was restarted. The patient’s condition stabi‐ lized after 3 days. The anticoagulant therapy was switched to enoxaparin, while dobutamine and adrenaline infusions were gradually tapered off and discontinued. A control TTE revealed signif‐ icant improvement in right ventricular function (RVIT, 40 mm; TAPSE, 24 mm; mild tricuspid re‐ gurgitation jet, 2.7 m/s), and the patient was dis‐ charged 10 days later. He was prescribed enoxa‐ parin (2 × 0.6 ml subcutaneously) for 3 months, torasemide (1 × 5 mg), perindopril (1 × 5 mg), and iron supplementation. A TTE performed after 3 months showed normal right ventricular func‐ tion (RVIT, 31 mm; TAPSE, 21 mm; mild tricus‐ pid regurgitation), and no symptoms of chronic thromboembolic pulmonary hypertension were observed. The current guidelines recommend rVIIa sup‐ plementation in patients with factor VII deficiency A 58 ‐year ‐old white man with a history of mild factor VII deficiency and superficial urinary blad‐ der cancer, treated with bacillus Calmette–Guérin therapy and transurethral tumor resection, was transferred from a urology department to our hospital due to pulmonary embolism (PE). In the past, the patient underwent several transure‐ thral mapping biopsies of the urinary bladder ac‐ cording to postoperative management protocol. Recombinant factor VII (rVIIa) as a prophylaxis of hemorrhage was used during each procedure. No history of hemorrhagic or thrombotic com‐ plications was revealed. Recently, the patient underwent urgent surgery at the urology department because of massive ex‐ traperitoneal bleeding after the latest transure‐ thral procedure, performed a week earlier. Dur‐ ing the surgery, rVIIa was administered again. The surgery was successful, without any local com‐ plications. On the fifth day after the procedure, the patient fainted. Because of persistent dys‐ pnea and hypoxia, PE was suspected. Comput‐ ed tomography angiography (FIGURE 1) was per‐ formed, revealing massive PE. On admission to our hospital, the patient was in cardiogenic shock. Oxygen saturation was 85% despite oxygen therapy, and blood pressure was 80/60 mm Hg during adrenaline infusion. The pa‐ tient’s Pulmonary Embolism Severity Index (PESI) score was 148 points, which corresponds to high‐ ‐risk PE (PESI class V).1 The D ‐dimer level ex‐ ceeded 34 690 ng/ml, the high ‐sensitivity tro‐ ponin level was 0.131 ng/ml, activated partial thromboplastin time index was 0.95 (reference range, 0.88–1.2), prothrombin time was 38 s (ref‐ erence range, 9.4–13.4 s), and international nor‐ malized ratio was 2.9. Dobutamine infusion and CLINICAL IMAGE

Quality of life in patients with paroxysmal atrial fibrillation after circumferential pulmonary vein ablation.

BACKGROUND Atrial fibrillation (AF) is the most common arrhythmia and is associated with a deterioration of quality of life (QoL). Catheter ablation is a therapeutic strategy for some patients with AF. The effectiveness of pulmonary vein isolation is still under assessment. AIM To assess the long-term influence of circumferential pulmonary vein ablation (CPVA) on QoL in patients with AF. METHODS The study population consisted of 33 patients (26 males, age 54.2 ± 9 years) with highly symptomatic (EHRA II-III) drug refractory paroxysmal AF, who underwent CPVA. A clinical examination, electrocardiogram (ECG), and Holter ECG were performed before and during a one-year follow-up. The SF-36 Medical Outcomes Survey Short-Form QoL questionnaire, scored on a 0-100 scale for each of eight domains: bodily pain (BP), general health (GH), mental health (MH), physical functioning (PF), role-emotional (RE), role-physical (RP), social functioning (SF), and vitality (V), was collected before and one year after CPVA. RESULTS In the one-year follow-up 27 (82%) patients were free of AF. EHRA symptoms were improved one-year after CPVA regardless of CPVA efficacy. After the follow-up the SF-36 questionnaire results improved significantly in all of the subscales in patients without a recurrence of AF after CPVA. In subjects with a recurrence of AF, all of the subscales did not indicate any statistically significant differences. There was an association between the CPVA and the following QoL domains: GH (p = 0.018), PF (p = 0.042), and V (p = 0.041). The highest values of the GH and V domains were found in the non-recurrence patients one year after CPVA. CONCLUSIONS CPVA results in the clinical improvement of patients with symptomatic AF regardless of the final arrhythmia termination. Patients after successful CPVA experienced a significant improvement in all of the subscales of the QoL.

Long-term follow-up after radio-frequency catheter-based denervation in patients with resistant hypertension

UNLABELLED The aim of this single-center study was to asses the long-term clinical data of patients with resistant hypertension who underwent radiofrequency renal denervation (RND). METHODS Out of 86 patients with resistant-hypertension, 15 pts fulfilled the study criteria for performing RND using Simplicity system by Medtronic. RESULTS Baseline office systolic BP was 204±32.7 and diastolic BP 107.7±15.1mmHg. Baseline 24h ambulatory systolic BP was 151.8±13.9 and diastolic BP 86.8±13.8mmHg. Patients were treated with an average of 5 antihypertensive agents in maximally tolerated doses (including diuretic) during the whole trial and were followed up at 1,6,24month after RND. At every appointment an echocardiography, blood test, and blood pressure (office and ABMP) measurements were performed. The mean reduction in office systolic (SBP) and diastolic (DBP) blood pressure were the following: There were no procedural complications. All denervations were performed by experienced operator. CONCLUSIONS We regard RND as a safe and effective procedure in resistant hypertension, although more studies and trials are needed to find the most adequate model of a patient that would be a good responder to RND.