Marta Kałużna-Oleksy

Patients with heart failure and concomitant chronic obstructive pulmonary disease participating in the Heart Failure Pilot Survey (ESC-HF Pilot) – Polish population

Introduction There is an increasing interest in comorbidities in heart failure patients. Data about chronic obstructive pulmonary disease (COPD) in the Polish population of heart failure (HF) patients are scarce. The aim of this study was to investigate the clinical characteristics, treatment differences and outcome according to COPD occurrence in the Polish population of patients participating in the ESC-HF Pilot Survey Registry. Material and methods We analyzed the data of 891 patients with HF recruited in 2009–2011 in Poland: 648 (72.7%) hospitalized patients and 243 (27.3%) patients included as outpatients. Results The COPD was documented in 110 (12.3%) patients with HF in the analyzed population. Patients with – compared to those without COPD were older, more often smokers, had higher NYHA class, and higher prevalence of hypertension. Ejection fraction (EF) was higher in hospitalized patients with COPD compared to patients without COPD (40.5 ±14.6% vs. 37.2 ±13.7%, p < 0.04), without a significant difference in the outpatient group. There was a significant difference in β-blocker use between patients with and without COPD (81.8% vs. 94.7%, p < 0.0001). Most patients received them below target doses. At the end of the 12-month follow-up, there was no significant difference in mortality between COPD and no-COPD patients (10.9% vs. 11.1%, p = 0.66). Conclusions The findings from the Polish part of the ESC-HF registry indicate that COPD in patients with HF is associated with older age, smoker status, hypertension and higher NYHA class. The use of β-blockers was significantly lower in patients with than without COPD. There were no significant differences in mortality between groups.

Initial clinical experience with the first drug (sacubitril/valsartan) in a new class — angiotensin receptor neprilysin inhibitors in patients with heart failure with reduced left ventricular ejection fraction in Poland

BACKGROUND Sacubitril/valsartan is the first drug from a new class of angiotensin receptor neprilysin inhibitors (ARNIs) recommended in the new European Society of Cardiology guidelines instead of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARB) that are used if ACEI are not tolerated. Sacubitril/valsartan is recommended for further reduction in the risk of hospitalisation or death in outpatients with heart failure with reduced ejection fraction (HFrEF) if symptoms continue despite optimal treatment with ACEI/ARB, beta-blockers, and mineralocorticoid antagonists. AIM The aim of this study is to present the initial experience with regard to the effectiveness, tolerance, and safety of sacubitril/valsartan in the outpatient cardiology practice in Poland. METHODS The study is a retrospective analysis of data obtained through a questionnaire filled in by the physicians who initiated the sacubitril/valsartan treatment in patients with HFrEF between 1 June 2016 and 30 September 2016. Patients were followed-up for three months. RESULTS The analysis included data on 28 patients aged 61 ± 16 years, of whom 85.7% were males. The drug was used in patients in New York Heart Association (NYHA) class I-III. In 25 (89.2%) patients sacubitril/valsartan was started at the lowest dose (24/26 mg BID). During follow-up the sacubitril/valsartan-treated patients had a reduction in HF symptoms assessed using the NYHA functional class (p = 0.001), a significant drop in N-terminal-pro B-type natriuretic peptide levels (mean, from 2900 to 2270 pg/mL; p = 0.008), and improved exercise tolerance, which occurred shortly after treatment initiation - after a mean of 28 days. CONCLUSIONS It was demonstrated that the use of sacubitril/valsartan in outpatients with HFrEF is safe and is associated with a significant clinical improvement.

Atypical presentation of cardiac device related infectious endocarditis and complicated follow-up

780 pneumonia. His medical history included pre‐ vious inferior wall myocardial infarction treat‐ ed with coronary artery bypass grafting, dual chamber implantable cardioverter ‐defibrillator (ICD) implanted as secondary prophylaxis, arte‐ rial hypertension, and type 2 diabetes. Empiri‐ cal antibiotic treatment was employed (ceftriax‐ one, rifampicin, and vancomycin). Echocardiog‐ raphy performed during hospitalization suggest‐ ed vegetations on the tricuspid valve. The patient was transferred to the Department of Cardiolo‐ gy with suspicion of LDIE. On admission, he had no fever, inflammato‐ ry parameters were as follows: C ‐reactive pro‐ tein, 10.30 mg/l (mild elevation); procalcitonin, 0.06 ng/ml (within normal limits). The suspicion of LDIE was confirmed using transthoracic echo‐ cardiography, which demonstrated vegetations on Infectious endocarditis (IE) is a potentially fa‐ tal disease that is difficult to diagnose. Patients often present with unspecific signs and symp‐ toms, which delays diagnosis and proper treat‐ ment. The incidence of IE in patients with car‐ diac implantable electronic devices is estimated at 1% to 2%.1 Cardiac device–related infections vary from pocket infection and lead ‐dependent IE (LDIE) to sepsis. A 51 ‐year ‐old man presented to the Depart‐ ment of Neurology with recurrent lower back pain, which started suddenly 2 months earli‐ er, and a considerable weight loss and conflu‐ ent sweats during 6 months prior to admission. Magnetic resonance imaging (MRI) of the lum‐ bar spine showed inflammation of L4/L5 inter‐ vertebral disc and L4 and L5 vertebral bodies (FIGURE 1A), and chest X ‐ray demonstrated bilateral CLINICAL IMAGE

Left ventricular noncompaction cardiomyopathy with severe coronary artery disease in a young patient with familial hypercholesterolemia

554 mmol/l; and triglycerides, 1.19 mmol/l; moreover, the patient had elevated levels of liver enzymes (alanine transaminase, 72 U/l; aspartate transaminase, 63 U/l) and brain natriuretic peptide (527.7 pg/ml). Troponin levels were within the reference range. Transthoracic echocardiography showed enlargement of the left atrium (48 mm) and the left and right ventricles (65 mm and 33 mm, respectively), with thin walls and restrictive flow through the mitral valve, with moderate mitral regurgitation and increased trabeculation of the apex and apical and mid segments of the lateral A 34-year-old man was admitted to the hospital because of worsening of exercise tolerance and exertional dyspnea for about 3 months, without chest pain. A medical history revealed familial hypercholesterolemia (FH) diagnosed 8 years earlier (also in his brother), which was treated with rosuvastatin (20 mg) and ezetimibe, to poor effect. On admission, an electrocardiogram showed sinus rhythm and left ventricular hypertrophy (FIGURE 1A). Laboratory tests showed the following lipid levels: total cholesterol, 8.19 mmol/l; low-density lipoprotein cholesterol, 5.9 mmol/l; high-density lipoprotein cholesterol, 1.76 CLINICAL IMAGE

Significant stenosis of the left anterior descending artery in a young woman without cardiovascular risk and with above-average physical activity

Address for correspondence: Marta Kałużna-Oleksy, MD, PhD, 1st Department of Cardiology, University of Medical Sciences, ul. Długa 1/2, 61–848 Poznań, Poland, e-mail: marta.kaluzna@wp.pl Conflict of interest: none declared Kardiologia Polska Copyright

Aortoesophageal aneurysmal sac and aorto-left pleural fistula — a rare complication of aortic aneurysm

A 62-year-old female with history of descending aortic aneurysm after stentgraft implantation four years ago was diagnosed with endoleak within the aneurysmal sac (Fig. 1A). The new stentgraft ZENITH 2D 38-186 (femoral approach) was implanted. The reason for admission was paroxysmal atrial fibrillation (AF) and left pleural effusion. At the time of admission, the patient presented with severe dyspnoea, cough, haematemesis, nausea, dysphagia, and stabbing chest pain radiating to the left shoulder. The clinical state was severe but stable. In physical examination pain during palpation along the left edge of the sternum and in ribs III–IV were observed, auscultation revealed increased bronchial murmur in the upper part and muted blistering noise in lower part of the left lung. The blood pressure was 90/60 mm Hg, and the heart rate was 85 bpm (AF in ECG). Laboratory tests showed elevated levels of procalcitonin (0.52 ng/mL) and D-dimer (2893 ng/mL) with leucocytosis and very high level of C-reactive protein (CRP) (increasing during hospitalisation 322.4 — 447.7 — 453.0 mg/L) and alkalosis. Chest X-rays showed haemopneumothorax. Initially the new implanted stentgraft was patent (Fig. 1B, C). Computed tomography showed pneumomediastinum, and haemopneumothorax left (Fig. 1D, E; 2A), and contrast leakage into the left pleura and mediastinal cavities (Fig. 1F; 2B). Antibiotic treatment was immediately initiated (empiric cefazolin IV without effect, changed to ciprofloxacin + metronidazole IV) obtaining lower levels of CRP and procalcitonin. With suspicion of mediastinitis the patient was handed over to the thoracic surgery department for surgical treatment. This case presents a very rare complication of aortic aneurysm like aortoesophageal aneurysmal sac and aorto-pleural fistula. Contact with mediastinum usually results in mediastinitis. Diagnosis of those complications is very difficult, resulting in a high rate of mortality.

Right heart catheterization procedures in patients with suspicion of pulmonary hypertension – experiences of a tertiary center

Introduction Right heart catheterization (RHC) is an invasive procedure providing direct and accurate measurements of hemodynamics of the cardiovascular system. Acute pulmonary vasoreactivity testing (APVT) following basal RHC in some patients is an established tool evaluating the reversibility of hypertension in the pulmonary vasculature. Aim We sought to assess the most common indications, vascular approaches and complications during RHC in a single high-volume center. Material and methods A total of 534 RHC procedures in 348 patients (64% male) were performed. The prospective registry was carried out for 28 months. Collected data included indications for RHC, vascular approaches, hemodynamic and clinical data, complications and response of pulmonary vessels in APVT. Results In 401 (75%) procedures pulmonary hypertension (mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg) was confirmed. Left heart failure was the most common indication (55.8%), mainly ischemic (26%) or dilated cardiomyopathy (19.9%). Other indications included a suspicion of arterial (21.7%), or chronic thromboembolic pulmonary hypertension (14.6%). The right internal jugular vein approach was used in 89.1% of procedures. Acute pulmonary vasoreactivity testing was performed in 143 patients, and it was positive in 67 (46.9%) cases. Complications occurred in 21 (3.9%) procedures and included pulmonary edema (0.2%), pneumothorax (0.2%) and puncture of the artery followed by the insertion of a vascular sheath (0.4%), atrial arrhythmia (0.2%), superior vena cava dissection (0.2%), incidental artery puncture (1.1%) and local hematoma (2.2%). Conclusions The most frequent indication for RHC was left heart failure, and the most common approach was the right internal jugular vein. RHC is safe procedure with a low rate of major complications.

Is there a Place for the Fullerton Test in Evaluation of Heart Failure Patients? The Relationship between Exertional Gas Exchange Parameters and Functional Fitness in Patients with Heart Failure: A Pilot Study

Background: To minimize the effect of heart failure (HF) on quality of life and to reduce the economic burden, it is necessary to provide means of rehabilitation and prognosis evaluation for patients. Patients with severe HF might not be able to perform the most commonly used cardiopulmonary exercise test (CPET), even using the easiest protocols. The Fullerton functional fitness test, developed for the elderly, might be suitable for evaluation of such patients. Our aim was to determine relationship between functional fitness and exertional gas exchange parameters in HF patients, and if they performed worse in functional fitness tests than patients without HF. Methods: Twenty-one male patients were included in this prospective registry; twelve with HF and nine without. They underwent the standard Fullerton test; the six-minute-walk test (6MWT; patient walks for six minutes along a corridor, and the distance covered is measured; it is a submaximal exercise test for healthy individuals) was modified by using a portable CPET device to record exertional gas exchange parameters. Results: The HF patients had lower left ventricular ejection fraction and were younger; they presented significantly worse “chair sit-and-reach” results (-0.18 vs. 1.81 cm, p=0.041) and 6-minute walking distance (334.8 vs. 508.4 m, p=0.002), less exercise repetitions in “chair stand” (10.7 vs. 15.1, p<0.001) and “arm curl” (13 vs. 16.8, p<0.001), longer time to perform “8-foot up-and-go” (7.1 vs. 5.6 s, p=0.030), higher VE/VCO2 slope (34.1 vs. 29, p=0.005), and tended to present lower peak oxygen uptake parameters (VO2/kg 11.8 vs. 14, p=0.13; VO2 0.99 vs. 1.22, p=0.10; VO2 as percentage of predicted 43.1 vs. 55.4, p=0.14). 6 MWT, “chair stand” and “arm curl” showed the strongest correlations with AT VE/VCO2 (r=-0.58, p=0.006; r=-0.57, p=0.007; r=-0.62, p=0.003 respectively) and VE/VCO2 slope (r=-0.60, p=0.004; r=-0.52, p=0.015; r=-0.50, p=0.021 respectively) and VO2 as percentage of predicted (r=0.59, p=0.005; r=0.55, p=0.009; r=0.47, p=0.031 respectively); 6MWT correlated strongly with VO2/kg (r=0.61, p=0.004). Conclusion: HF patients perform worse in the Fullerton test than patients without HF. Physical fitness is related to CPET parameters taken during 6MWT. Lower physical fitness is related to lower exercise capacity and worse ventilatory efficiency. The Fullerton test may be useful in complex evaluation of HF patients.

An asymptomatic giant thoracoabdominal aortic aneurysm

Giant ascending and descending aorta aneurysm with coexistent abdominal aorta aneurysm in a non-Marfan patient is a very rare condition; however, huge ascending aorta aneurysms, alone or with concomitant aortic arch enlargement, are frequently reported in literature. The occurrence of chest pain is one of the most common symptoms accompanying thoracic aorta aneurysm, so the complete absence of the patient’s symptoms in such a large aortic pathology is interesting for physicians involved in the management of elderly patients with aortic aneurysms. A 52-year-old man was admitted to our hospital due to casual disclosure of a giant aneurysm of ascending, descending, and abdominal aorta for further evaluation. Thoracic aortic aneurysm was suspected at the chest X-ray, performed due to scheduled orthopaedic surgery. Imaging revealed suggestive enlargement of the mediastinum (Fig. 1A). Besides a diagnosis of epilepsy since childhood the patient was generally asymptomatic. He had no family history of connective tissue diseases and no signs of Marfan syndrome. Blood inflammatory parameters, antinuclear and antineutrophil cytoplasmic antibodies, as well as syphilis tests (VDRL) were negative. The trans-thoracic echocardiography showed enlargement of left ventricle (67 mm), hypertrophy of posterior wall (13 mm) and interventricular septum (12 mm), and an ascending aortic aneurysm with severe aortic regurgitation with backflow in the descending aorta and preserved ejection fraction of 55%. Computed tomography angiography (CTA) confirmed an aneurysm of ascending aorta maximally 82 mm in diameter (Fig. 1B, C). The thoracic aorta reduced stepwise in size and reached 30 mm in the aortic arch. The descending aorta was also enlarged to 74 mm in diameter with an eccentric thrombus in its lumen (Fig. 1D). Additionally performed magnetic resonance angiography showed the spread of the aneurysm into the suprarenal part of the abdominal aorta (Fig. 1E). Moreover, in CTA of coronary arteries aneurysmal enlargement of proximal part of left anterior descending artery was found at the level of the first diagonal branch (10 × 6 mm). The patient did not consent to invasive treatment. Although ascending aortic aneurysm is a frequent entity, the size and range of aortic pathology in our patient make such a case rare. Furthermore, the natural history of untreated aortic aneurysm indicates very high incidence of death because of rupture or dissection, and the size of the aneurysm is the most important predictor. However, the benefit-risk ratio of surgical treatment requires thorough evaluation.

Pierwsze doświadczenia kliniczne z przedstawicielem nowej grupy leków ARNI (sakubitril/walsartan) u pacjentów z niewydolnością serca z obniżoną frakcją wyrzutową lewej komory w Polsce

BACKGROUND Sacubitril/valsartan is the first drug from a new class of angiotensin receptor neprilysin inhibitors (ARNIs) recommended in the new European Society of Cardiology guidelines instead of angiotensin converting enzyme inhibitors (ACEI), or angiotensin receptor blockers (ARB) that are used if ACEI are not tolerated. Sacubitril/valsartan is recommended for further reduction in the risk of hospitalisation or death in outpatients with heart failure with reduced ejection fraction (HFrEF) if symptoms continue despite optimal treatment with ACEI/ARB, beta-blockers, and mineralocorticoid antagonists. AIM The aim of this study is to present the initial experience with regard to the effectiveness, tolerance, and safety of sacubitril/valsartan in the outpatient cardiology practice in Poland. METHODS The study is a retrospective analysis of data obtained through a questionnaire filled in by the physicians who initiated the sacubitril/valsartan treatment in patients with HFrEF between 1 June 2016 and 30 September 2016. Patients were followed-up for three months. RESULTS The analysis included data on 28 patients aged 61 ± 16 years, of whom 85.7% were males. The drug was used in patients in New York Heart Association (NYHA) class I-III. In 25 (89.2%) patients sacubitril/valsartan was started at the lowest dose (24/26 mg BID). During follow-up the sacubitril/valsartan-treated patients had a reduction in HF symptoms assessed using the NYHA functional class (p = 0.001), a significant drop in N-terminal-pro B-type natriuretic peptide levels (mean, from 2900 to 2270 pg/mL; p = 0.008), and improved exercise tolerance, which occurred shortly after treatment initiation - after a mean of 28 days. CONCLUSIONS It was demonstrated that the use of sacubitril/valsartan in outpatients with HFrEF is safe and is associated with a significant clinical improvement.