Piotr Dobrowolski

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.

Renal resistive index in patients with true resistant hypertension: results from the RESIST-POL study

BACKGROUND Increased ultrasound Doppler renal resistive index (RRI) is a marker of atherosclerotic and hypertensive organ damage both at renal and systemic level. AIM To evaluate RRI in patients with true resistant hypertension (TRHT) in the RESIST-POL study. METHODS From 204 patients diagnosed with TRHT in the RESIST-POL study, 151 patients (90 male, 61 female, mean age: 47.7 ± 10.4, range: 19-65 years) without secondary hypertension were included into the analysis. All patients were characterised by estimated glomerular filtration rate > 60 mL/min/1.73 m2 and no history of diabetes prior to the study. As a control group we included 50 age- and gender-matched patients (35 male, 15 female, mean age: 46.8 ± 10.4, range: 19-65 years) with primary well-controlled hypertension. The groups also did not differ in respect to the number of years of known history of hypertension. The RRIs were evaluated on the basis of the Doppler ultrasound examination. Increased RRI was defined as ≥ 0.7. RESULTS Both groups did not differ in terms of renal function. Patients with TRHT were characterised by higher RRI as compared with the group with well-controlled hypertension (0.62 ± 0.05 vs. 0.60 ± 0.05, p < 0.05). In the TRHT group RRI correlated significantly with age, clinic and ambulatory blood pressure measurement, diastolic blood pressure (DBP) levels, as well as with clinic pulse pressure (PP) (r = 0.297; p = 0.001), with daytime (r = 0.355; p < 0.001) and nighttime (r = 0.313; p < 0.001) PP, and with fasting glucose concentration (r = 0.215; p = 0.008) and E/E’ ratio (r = 0.289; p = 0.001) on echocardiography. RRI values were significantly higher in TRHT patients with newly diagnosed diabetes as compared with TRHT patients without diabetes (0.65 ± 0.05 vs. 0.62 ± 0.05, p = 0.022). Age, daytime DBP, daytime PP, and E/E’ ratio but not fasting glucose concentration correlated independently with RRI in the model. Among patients with TRHT, patients with increased RRI were characterised by older age (52.2 ± 4.9 vs. 47.3 ± 10.6 years, p = 0.012), higher body mass index (32.8 ± 6.0 vs. 29.7 ± 4.5 kg/m2, p = 0.034), as well as lower daytime and nighttime DBP values and lower daytime and nighttime heart rate, as compared to patients with RRI < 0.7. The TRHT patients with increased RRI as compared to patients with RRI < 0.7 were characterised also by higher daytime and nighttime PP. Both groups did not differ in respect of renal function. CONCLUSIONS Our study showed that the patients with TRHT were characterised by significantly higher RRI values as compared to the subjects with well-controlled hypertension. It may also be suggested that in the subjects with TRHT renal vascular resistance is related to blood pressure values, selected echocardiographic abnormalities, and some surrogate markers for metabolic and cardiovascular events, including fasting glucose plasma concentration and PP, respectively.

Renal Denervation in Resistant Hypertension and Obstructive Sleep Apnea: Randomized Proof-of-Concept Phase II Trial

It has been postulated that catheter-based renal denervation (RDN) may lower blood pressure (BP) and improve severity of obstructive sleep apnea (OSA) in resistant hypertensive patients. The aim of our study (NCT01366625) was to investigate in a prospective randomized trial the effect of RDN on BP and clinical course of OSA. Sixty patients with true resistant hypertension coexisting with moderate-to-severe OSA (apnea/hypopnea index, ≥15) were randomly allocated to RDN group (30 patients) and to control group (30 patients). The primary end point was reduction in office systolic BP at 3 months. Secondary end points included reduction in diastolic office and ambulatory BP, change in apnea/hypopnea index and biochemical measurements at 3 months, and change in echocardiographic measurements at 6 months. There were no differences in clinical characteristics between the groups. At 3 months in the RDN group, both office and ambulatory BP were significantly reduced, and a significant decrease in OSA severity (apnea/hypopnea index, 39.4 versus 31.2 events per hour; P=0.015) was observed. Between-group difference in apnea/hypopnea index change was significant at 0.05. At 6 months in the RDN group, reductions in office and ambulatory BP were sustained and were accompanied by significant improvement in echocardiographic measures of global longitudinal strain. There were no differences in metabolic variables in follow-up in both groups. In a randomized controlled trial, RDN lowered both office and ambulatory BP in patients with resistant hypertension and OSA. This was accompanied by improvement of the clinical severity of OSA. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01366625.

Exercise- induced changes in left ventricular global longitudinal strain in asymptomatic severe aortic stenosis.

BACKGROUND The management of patients with asymptomatic severe aortic stenosis (ASAS) is still under discussion. Therefore, it is advisable to search for the parameters of early damage to left ventricular (LV) function. AIM The aim of the study was to assess exercise-induced changes in LV global longitudinal strain (GLS) in ASAS. METHODS The ASAS group consisted of 50 patients (26 women and 24 men, aged 38.4 ± 18.1 years) meeting the echocardiographic criteria of severe aortic stenosis (AVA < 1 cm², AVAI < 0.6 cm²/m², Vmax > 4 m/s, mean aortic gradient > 40 mm Hg), with normal LV ejection fraction (LVEF ≥ 55%) and sinus rhythm on electrocardiogram, and without significant concomitant valvular heart diseases. The control group consisted of 21 people matched for age and sex. Echocardiographic examinations and echocardiographic stress tests with the assessment of GLS using the speckle tracking imaging were performed. RESULTS The ASAS group was characterised by statistically significantly higher LV mass index (LVMI) and higher LVEF. GLS values at rest in both groups were within normal limits but were significantly higher in the control group (-18.9 ± 2.4% vs. -20.7 ± 1.7%, p = 0.006). An increase in GLS at peak exercise in both groups was observed, lower in the ASAS group (the difference was not statistically significant: -0.8 ± 3.0% vs. -2.2 ± 3.1%, p = 0.086). Changes in GLS during exercise (ΔGLS) did not correlate with the parameters of the severity of aortic stenosis. In the multivariate model, LVMI proved to be a factor associated with GLS at rest and during exercise. CONCLUSIONS In patients with ASAS, GLS is a non-invasive marker of an early stage of LV myocardial damage associated with myocardial hypertrophy. An increase in GLS during exercise in the ASAS group, smaller than in the control group, indicates a preserved functional reserve of the LV myocardium but smaller than in healthy individuals. The assessment of the clinical usefulness of exercise-induced changes in GLS requires further research.

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.

Anomalous origin of the right coronary artery from the pulmonary artery coexisting with aortopulmonary window and partial abnormal drainage of the pulmonary vein.

Anomalous origin of the right coronary artery from pulmonary artery (ARCAPA) is an exceedingly rare congenital pathology. We present a 22-year-old male with a clinical recognition of ARCAPA established earlier by angiography. Repeated evaluation of our Institute discovered associated congenital pathologies—small aortopulmonary …

Altered plasma fibrin clot properties in hypertensive patients with obstructive sleep apnoea are improved by continuous positive airway pressure treatment

Aim: We investigated plasma fibrin clot properties in high-risk hypertensive patients with obstructive sleep apnoea (OSA) and assessed the impact of continuous positive airway pressure (CPAP) treatment on clot phenotype. Methods: We studied 50 hypertensive patients with clinically significant OSA (age 50.0 ± 8.8 years, 39 M, 11 F). In total, 38 hypertensive patients without OSA balanced for age, sex, blood pressure, cardiovascular risk factors, and metabolic status served as controls. Plasma fibrin clot properties, including clot permeability coefficient, clot lysis time (CLT), and turbidimetric parameters of clot formation were determined. Patients underwent transthoracic echocardiography, carotid ultrasonography, evaluation of endothelial function and calcium score index of coronary arteries, and Doppler imaging of renal arteries. Results: Compared with controls, OSA patients were characterized by more compact fibrin structure (lower median clot permeability coefficient, 6.00 vs. 7.25 10−9 cm2; P < 0.001), impaired fibrinolysis (longer median CLT, 108.00 vs. 92.50 min; P < 0.001), and by faster clot formation (shorter median lag phase, 40.50 vs. 42.50 s; P = 0.041), and higher median maximum clot absorbency indicating denser fibrin networks (0.87 vs. 0.81; P = 0.028). Clot permeability coefficient and CLT correlated with apnoea–hypopnoea index (r = −0.46; P < 0.001 and r = 0.44; P < 0.001, respectively) as well with mean (r = 0.31; P = 0.003; r = −0.36; P = 0.001, respectively) and minimal oxygen saturation (r = 0.46; P < 0.001; r = −0.49; P < 0.001, respectively). After 3 months of CPAP treatment we observed an increase in clot permeability coefficient (5.95 vs. 7.60 10−9 cm2; P = 0,001), shortened CLT (107.00 vs. 87.00; P = 0.006), a longer lag phase of fibrin formation (40.00 vs. 43.50 s; P = 0.013), and a trend toward lower maximum clot absorbency (0.86 vs. 0.81; P = 0.058). Conclusion: In hypertensive patients at high cardiovascular risk, OSA was associated with unfavourable prothrombotic fibrin clot characteristics, including hypofibrinolysis, which significantly improve as early as after 3 months of CPAP treatment.

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.

EVALUATION OF INTRA-RENAL BLOOD FLOW PARAMETERS IN PATIENTS WITH RENAL FIBROMUSCULAR DYSPLASIA - THE POLISH REGISTRY FOR FIBROMUSCULAR DYSPLASIA (ARCADIA-POL STUDY)

Objective: To assess intra-renal blood flow parameters in patients with renal fibromuscular dysplasia (FMD) in patients with renal FMD enrolled to ARCADIA-POL study. Design and method: We analyzed 143 patients with renal FMD enrolled in the ARCADIA-POL study since 2015 (Polish-French collaboration). All patients underwent evaluation including ABPM, biochemical evaluation, biobanking, duplex Doppler of carotid and abdominal arteries and whole body angio-CT. We divided patients with renal FMD into two groups – 31 patients with significant renal artery stenosis (RAS) (26F, 5 M, mean age:19.8 ± 12.7 years) and 112 patients with non-significant RAS (93 F, 19 M, mean age:47.2 ± 14.9 years). We compared those two groups to the matched control groups – 60 normotensive individuals (44F, 16 M, mean age:42.5 ± 9.1 years) and 60 patients with primary hypertension (40F, 20 M), mean age: 43.3 ± 11.4 years. Results: FMD patients with non-significant RAS, FMD patients with significant RAS, normotensives and patients with primary hypertension differed significantly in resistive indexes values (RI) (0.59 ± 0.08 vs 0.53 ± 0.09 vs 0.61 ± 0.06 vs 0.62 ± 0.06, respectively p < 0.001; FMD patients with significant RAS vs normotensives: p < 0.001; vs patients primary hypertension: p < 0.001). In patients with FMD with significant RAS there was a significant correlation between RI and IMT (r = −0.658; p = 0.008). Subsequently we performed analysis “per kidney” and we compared three groups of renal arteries in FMD patients-renal arteries with no FMD lesions (n = 75), renal arteries with FMD with non-significant RAS (n = 180) and renal arteries with FMD with significant RAS (n = 31). FMD renal arteries with significant RAS were characterized by lower RI value, higher maximal blood flow velocity (Vmax), higher renal aortic ratio (RAR) and higher acceleration time (AT) as compared to both FMD renal arteries with non-significant RAS and renal arteries with no FMD lesions. No differences in intra-renal blood flow parameters were found between FMD renal arteries with non-significant RAS and renal arteries with no FMD lesions. Conclusions: Our results indicate that FMD patients with significant RAS are characterized by changes in intra-renal blood flow parameters as those observed in atherosclerotic RAS. Moreover those changes were related to carotid arteries IMT.