Nenad Ratkovic

Elevations in soluble CD40 ligand in patients with high platelet aggregability undergoing percutaneous coronary intervention.

High aggregatory responses despite antiplatelet treatment is associated with an increased risk of thrombotic complications following percutaneous coronary intervention (PCI). In the present study, we investigated the relationship between platelet aggregatory responses to ADP and the release of CD40L (sCD40L): an immunomodulatory compound involved in atherothrombosis – in patients undergoing PCI. ADP-induced platelet aggregation, sCD40L and soluble P-selectin (sP-selectin) were determined before and 24 h after PCI, in samples from 52 patients receiving aspirin and thienopyridines. Platelet aggregation to ADP above the median was defined as ‘high aggregation’, and aggregation below the median as ‘low aggregation’. Data below are medians and interquartile ranges. Patients with ‘high platelet aggregability’ had a significantly higher increase in both sCD40L (Δ-values: 0.78 (−0.19–3.18) vs. −0.65 (−2.10–0.00) ng/ml, P = 0.002) and sP-selectin (Δ-values: 8.0 (−2.00–16.00) vs. 4.50 (−13.00–0.50) ng/ml, P = 0.001) compared with patients with ‘low platelet aggregability’. In a multivariate linear regression analysis adjusted for clinical characteristics and type of preintervention therapy, the only independent predictors of sCD40L and sP-selectin were platelet aggregation to ADP before PCI (P < 0.001) and the combination of platelet aggregation to ADP before PCI and urgency of PCI (P < 0.001). Circulating CD40L is more markedly increased after PCI in patients with high ADP-induced platelet aggregation.

THERAPEUTIC APPROACH IN PATIENTS WITH A FLOATING THROMBUS IN THE RIGHT HEART

BACKGROUND The occurrence of a floating thrombus in the right heart, although rare, is a life-threatening condition requiring a specific approach. In most cases, these thrombi are a result of embolization from deep venous thrombosis, and have lodged temporarily in the right heart. The management of this condition is variable, depending on whether or not there is a thrombus entrapped within a foramen ovale (FO). OBJECTIVES To present the management of 2 patients with a free-floating thrombus in the right heart, and a third patient with an entrapped thrombus in the FO. CASE REPORTS Two patients with a free-floating thrombus in the right atrium who were treated with thrombolytic therapy had an immediate excellent outcome. The patient with a thrombus entrapped within the FO was scheduled for surgical removal of the thrombus due to an unacceptable risk of systemic embolization if treated with thrombolytic and anticoagulant therapy. Unfortunately, he developed an ischemic stroke on the fifth day of presentation, just a few hours before the scheduled surgery, despite meticulous monitoring of continuous heparin infusion with activated partial thromboplastin time. CONCLUSION Thrombolytic therapy is recommended in patients with a free-floating thrombus in the right heart. However, in patients with a thrombus entrapped within an FO, delaying surgical removal of the thrombus may be deleterious due to unpredictable systemic embolization.

Diagnostic significance of three-dimensional echocardiography in asymptomatic unicuspid aortic valve

Unicuspid aortic valve (UAV) is a rare congenital anomaly of aorta associated with a faster progress of valvular dysfunction, aortic dilatation and with necessity for more frequent controls and precise evaluation Asymptomatic 35 year old man had abnormal systolic diastolic murmur on aortic valve during routine examination. Initial diagnostic with transthoracic echocardiography (TTE) supposed bicuspid aortic valve, while three‐dimensional transesophageal echocardiography (3D TEE) and multidetector computed tomography defined unicuspid, unicomissural aortic valve with moderate aortic stenosis and regurgitation. This case report confirmed that 3D TEE gives us opportunity for early, improved and precise diagnosis of UAV.

Left ventricular noncompaction in a patient presenting with a left ventricular failure

Introduction. Left ventricular noncompaction (LVNC) is a congenital disorder characterised by prominent trabeculations in the left ventricular myocardium. This heart condition very often goes completely undetected, or is mistaken for hypertrophic cardiomyopathy or coronary disease. Case report. A middle-aged female with a positive family history of coronary disease was admitted with chest pain, electrocardiography (ECG) changes in the area of the inferolateral wall and elevation in cardiac specific enzymes. Initially, she was suspected of having acute coronary syndrome. However, in the left ventricular apex, especially alongside the lateral and inferior walls, cardiac ultrasound visualised hypertrabeculation with multiple trabeculae projecting inside the left ventricular cavity. A short-axis view of the heart above the papillary muscles revealed the presence of two layers of the myocardium: a compacted homogeneous layer adjacent to the epicardium and a spongy layer with trabeculae and sinusoids under the endocardium. The thickness ratio between the two layers was 2.2:1. The same abnormalities were corroborated by multislice computed tomography (MSCT) of the heart. Conclusion. Left ventricular noncompaction is a rare, usually hereditary cardiomyopathy, which should be considered as a possibility in patients with myocardial hypertrophy. It is very often mistaken for coronary disease owing to ECG changes and elevated cardiac specific enzymes associated with myocardial hypertrophy and heart failure.

Association between serum concentration of parathyroid hormone and left ventricle ejection fraction, and markers of heart failure and inflammation in ST elevation myocardial infarction patients treated with primary percutaneous coronary intervention

Background/Aim. Previous studies have shown increased serum concentration of parathyroid hormone (PTH) in acute myocardial infarction and heart failure. In this study we examined the relationships between parathyroid hormone status and biochemical markers of myocardial injury and heart failure, as well as electrocardiographic (ECG) and echocardiographic indicators of infarction size and heart failure. Methods. In 390 consecutive patients with ST segment elevation myocardial infarction (STEMI), average age 62 ± 12 years, laboratory analysis of serum concentrations of creatine kinase MB isoenzyme (CK-MB), C-reactive protein (CRP) and intact PTH and plasma concentration of brain natriuretic peptide (BNP) were done during the first three days after admission. All patients were treated with primary percutaneous coronary intervention (PCI). Exclusion criterion was severe renal insufficiency (glomerular filtration rate ≤ 30 mL/min). Serum concentration of PTH was measured on the 1st, 2nd and, in some cases, on the 3rd morning after admission and maximum level of PTH was taken for analysis. Patient cohort was divided into four groups according to quartiles of PTH maximum serum concentration (I ≤ 4.4 pmol/L; II > 4.4 pmol/L and < 6.3 pmol/L; III ≥ 6.3 pmol/L and < 9.2 pmol/L; IV ≥ 9.2 pmol/L). Selvester’s ECG score, left ventricle ejection fraction and wall motion index (WMSI) were determined at discharge between 5–14 days after admission. Results. We found that LVEF at discharge significantly decreased (p < 0.001) and WMSI at discharge and ECG Selvester ́s score significantly increased across the quartiles of PTH max. level (p < 0.001 for both parameters). BNP, CRP and CK-MB isoenzyme level significantly increased across the quartiles of PTH max. level (p < 0.001; p < 0.001 and p = 0.004, retrospectively). Conclusion. The patients in the 4th quartile of PTH had significantly lower LVEF and higher WMSI and Selvester’s ECG score at discharge. This group of patients also had higher levels of BNP, CRP and CK-MB in blood in the early course of STEMI.

COMPARISONS OF THREE BLEEDING SCORES FOR ACUTE AND SIX MONTHS MAJOR BLEEDING IN PATIENTS WITH PULMONARY EMBOLISM

Background: The stratification of bleeding risk for patients with pulmonary embolism (PE) and establishment of its role in the management of PE is urgently needed. Methods: In a group of 206 consecutive PE patients, in a single center, three scores were assessed at baseline: HASS3B2E2D as newly

Nuclear Cardiology — In the Era of the Interventional Cardiology

The strength and breadth of nuclear cardiology lie in its great potential for future creative growth. This growth involves the development of new biologically derived radiopharmaceut‐ icals, avdanced imaging techologies, and a broad/based set of research and clinical aplications involving diagnosis, functional categorization, prognosis, evaluation of therapeutic interven‐ tions, and the ability to deal with many of the major investigative issues in contemporary cardiology such as myocardial hibernation, stunning, and viability. The past decade has been caracteriyed by major advances in nuclear cardiology that have greatly enhanced the clinical utility of the various radionuclide techniques used for the assessment of regional myocardial perfusion and regional and global left ventricular function under resting and stress condotions. Despite the emergence of alternative noninvasive techniques for the diagnosis of coronary aretry disease (CAD) and the assessment of prognosis of viability, such as ergostress tests, stress echocardiography, the use and application of nuclear cardiology techniques have continued to increase. The establishment of the American Society of Nuclear Cardiology (ASNC) and its educational programs has led to a greater diffusion on nuclear cardiology technology in the community hospital setings and has promoted the emergence and dissem‐ ination of imaging and procedural guidelines for nuclear cardiology methods. The establish‐ ment of the Journal of Nuclear Cardiology, the official journal of ASNC, allowed a greater number of manuscript to be published in the field [1, 2, 3]

Echocardiographic findings of mitral valve prolapse

Prolaps mitralnog zalistka predstavlja najcescu urođenu srcanu manu kod odraslih osoba. Ehokardiografski nalaz ima kljucnu ulogu prilikom postavljanja dijagnoze, ustanovljavanja lokalizacije zahvacenih segmenata i procene obima bolesti. Takođe, omogucuje identifikaciju bolesnika sa najvecim rizikom za pojavu komplikacija i daje kljucne podatke pri donosenju odluke o rekonstrukciji mitralnog zalistka.