Robert Kowalik

Use of fondaparinux in a pregnant woman with pulmonary embolism and heparin-induced thrombocytopenia.

Summary Background A serious complication of heparin treatment, heparin-induced thrombocytopenia (HIT) is rarely observed in pregnant women. Drug therapy during pregnancy should always be chosen to minimize fetal risk. The management of HIT in pregnancy represents a medical challenge. Unlike heparins, the anticoagulants used in patients with HIT do cross the placenta, with unknown fetal effects. Case Report We present a case of a 24-year-old female presenting for care at 34 weeks of gestation with acute pulmonary embolism treated initially with unfractionated heparin (UFH) and low molecular weight heparin (LMWH), who developed HIT. She was then successfully treated with fondaparinux. Conclusions To the best of our knowledge, this is one of the first case reports describing a successful use of fondaparinux in the treatment of HIT in a third-trimester pregnant woman, providing a novel approach for this subset of patients.

Cardiac arrest survivors treated with or without mild therapeutic hypothermia: performance status and quality of life assessment

BackgroundHypoxic-ischaemic encephalopathy is the main determinant of clinical outcome after cardiac arrest. The study was designed to determine long-term neurological and psychological status in cardiac arrest survivors, as well as to compare neuropsychological outcomes between patients treated with mild therapeutic hypothermia (MTH) and patients who did not undergo hypothermia treatment.MethodsThe article describes a single-center, retrospective, observational study on 28 post-cardiac arrest adult patients treated in the cardiac intensive care unit who qualified for MTH vs. 37 control group patients, hospitalized at the same center following cardiac arrest in the preceding years and fulfilling criteria for induced hypothermia, but who were not treated due to unavailability of the method at that time. Disability Rating Scale (DRS), Barthel Index and RAND-36 were used to assess performance status and quality of life in both study groups after hospital discharge.ResultsThere were no statistically significant differences in physical functioning found between groups either at the end of hospital treatment or at long-term follow-up (DRS: p = 0.11; Barthel Index: p = 0.83). In long-term follow-up, MTH patients showed higher vitality (p = 0.02) and reported fewer complaints on role limitations due to emotional problems (p = 0.04) compared to the control group. No significant differences were shown between study groups in terms of physical capacity and independent functioning.ConclusionTo conclude, in long-term follow-up, MTH patients showed higher vitality and reported fewer complaints on role limitations due to emotional problems compared to the control group. This suggest that MTH helps to preserve global brain function in cardiac arrest survivors. However, the results can be biased by a small sample size and variable observation periods.

The oldest patient with takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a rare condition that affects mainly aging women. According to a retrospective review, patients with TTC accounted for approximately 2% of all the patients with suspected acute coronary syndrome (ACS). A few reports indicated that the average age of TTC patients was 68 years, although children or young adults may also be affected. In US and Europe, a number of contemporary TTC studies report that 90% of patients with TTC are women aged 65–70 years. Meta analysis showed that the age ranged from 10 to 89 years. [1] There was also one case study of a 90-year-old patient with TTC ― the oldest patient known so far. In that case, the patient died during the course of treatment from severe multi-organ failure. [2] In the present case report, we present a 98-years old woman with TTC admitted to our clinic. A 98-years old patient was admitted to our clinic because of significant chest pain and general weakness accompanied by hypotension that required catecholamine administration with ST-segment elevation in the anterolateral leads in ECG. The patient suffered from hypertension and third stage of chronic kidney disease. Urgent cardiac catheterization and ventriculography confirmed the absence of any critical coronary disease, but also the presence of a typical apical ballooning and midventricular hypokinesis. Troponin I (TnI) at admission was 5.555 ng/mL and creatine kinase soenzyme MB (CK-MB) mass was 14.5 ng/mL. Inflammatory parameters were not elevated, whereas N-terminal pro brain natriuretic peptide (NT-proBNP) concentration was markedly elevated, at 18,623 pg/mL. NT-proBNP/TnI ratio was 3352.48 on the first day and even higher after 24 h, at 7113.36. This markers profile is characteristic of TTC. There is a relatively small increase in creatine kinase and troponin concentrations in relation to the extent of wall motion abnormalities. BNP is always elevated in patients with TTC and is higher than in patients with ST-segment elevation myocardial infarction. Some researchers suggest that TTC can be distinguished from ACS on the basis of the characteristic profile of cardiac markers consisting of a sudden increase in the concentration of NT-proBNP in the first few days when there is only a small increase in markers of myocardial necrosis (the ratio of NT-pro BNP/troponin). [3]

The prevalence of sexual dysfunction before myocardial infarction in population of Polish men: a retrospective pilot study.

BACKGROUND AND AIM To assess the frequency of sexual dysfunction in men before myocardial infarction (MI). METHODS Sixty-two men with cardiovascular disease risk factors who were admitted to the hospital because of a first MI, were asked to fill the IIEF-15 questionnaire to assess sexual dysfunction before MI. RESULTS Erectile dysfunction (ED), decreased orgasmic function, decreased sexual desire, decreased intercourse satisfaction, and decreased overall satisfaction were reported by 51.6%, 14.5%, 50%, 69.4%, and 48.4% of men, respectively. Men with ED had significantly higher serum C-reactive protein (CRP) levels than men without ED (5.8 mg/L, 95% confidence interval [CI] 8.3-21.7) vs. 4.6 mg/L, 95% CI 3.0-11.3; p = 0.01). Men with decreased orgasmic function had significantly higher serum triglyceride levels (259.5 mg/dL, 95% CI 176.9-362.1 vs. 150 mg/dL, 95% CI 146.8-187.4; p = 0.01), and men with normal sexual desire had significantly higher serum high-density lipoprotein (HDL) cholesterol levels than men with decreased sexual desire (41 mg/dL, 95% CI 39.9-47.8 vs. 36 mg/dL, 95% CI 34.1-40.5; p = 0.01). Men with decreased sexual desire had significantly higher serum CRP levels (7 mg/L, 95% CI 7.7-21.4 vs. 5 mg/L, 95% CI 3.6-12.1; p = 0.03). CONCLUSIONS 1. ED was present in more than half of men before MI and it may be the first symptom of coronary artery disease. 2. Men with ED and decreased sexual desire have higher serum CRP levels in the acute peri-infarction period. 3. Serum triglyceride level is a factor that significantly affects orgasmic function, and serum HDL cholesterol level is a factor that significantly affects sexual desire.

Prognostic value of troponin I and NT-proBNP concentrations in patients after in-hospital cardiac arrest.

OBJECTIVES Cardiac arrest (CA) is a complex event with a dismal survival rate. The aim of this study was to determine whether N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels measured on admission and serial cardiac troponin I determination in patients with in-hospital cardiac arrest (IHCA) are predictive of 30-day mortality. METHODS Out of 9877 patients hospitalized in the cardiac intensive care unit during the study, we enrolled consecutive patients experiencing cardiac arrest within 12 hours of admission. Baseline characteristics, information about circumstances of CA and cardiopulmonary resuscitation, and initial biochemical parameters were retrospectively collected. RESULTS A total of 106 patients (61 male, age 71.4±12.6 years) were enrolled. Thirty-four (32.1%) had a history of myocardial infarction, and 13 (12.3%) a history of stroke. Total 30-day mortality was 60.4%. Deceased patients were older (73.7±11.9 vs. 67.8±13.0 years; p=0.01) and had lower systolic (89.4±37.0 vs. 115.0±24.0 mmHg; p=0.0001) and diastolic (53.6±24.8 vs. 66.1±15.0 mmHg; p=0.008) blood pressure on admission. Shockable initial rhythm was more often noted in the survivor group (54.8% vs. 28.1%; p=0.01). Deceased patients had higher median NT-proBNP levels (9590.0 [25-75% interquartile range (IQR), 5640.0-26450.0] vs. 3190.0 [25-75% IQR, 973.8-5362.5] pg/ml; p=0.02) on admission. There were no differences in the first two troponin I measurements, but values were higher on the third measurement in non-survivors (98.2 [25-75% IQR, 76.4-175.8] vs. 18.7 [25-75% IQR, 5.2-50.6]; p=0.009). CONCLUSIONS The survival rate of patients after in-hospital CA is poor. Deceased patients have higher NT-proBNP levels on admission, along with higher troponin I concentrations on the third measurement. Those biomarkers are useful in predicting 30-day mortality in IHCA patients.

Transcatheter aortic valve implantation (TAVI) in a patient with severe aortic insufficiency of aortic valve homograft

We present the case of a 64-year-old female who was admitted to our centre with severe aortic insufficiency and advanced heart failure symptoms (NYHA class III–IV). Her medical history included: surgical homograft aortic valve replacement due to severe aortic insufficiency 14 years ago, chronic atrial fibrillation, and hypothyroidism. The patient’s logistic EuroSCORE was 32%, EuroSCORE II 9.1%, and STS score 3.95%. Preprocedural transthoracic echocardiographic examination revealed akinesis of the basal and mid segments of interventricular septum, global hypokinesis of remaining segments with ejection fraction of 19%, enlargement of the left ventricle and atrium (diameter of 68 and 43 mm, respectively), regurgitant orifice area of 0.3 cm2, regurgitant volume of 58 mL, and regurgitant jet width to left ventricular outflow tract ratio of 66% (Fig. 1). An additional transoesophageal echocardiographic examination was performed for more precise measurement: this showed aortic annulus diameter of 24 mm. Angiography and computed tomography were also performed, showing no lesions in either the coronary or peripheral arteries. On the basis of the abovementioned clinical conditions, the Heart Team decided to refer the patient to transcatheter aortic valve implantation (TAVI) via femoral access. The procedure was performed under general anaesthesia with a temporary pacemaker placed through the jugular vein and vascular access obtained with 18 Fr sheath by puncture of the right femoral artery. Due to lack of calcifications, two pig-tail catheters were placed in order to mark the plane of the annulus (Fig. 2) and 29 mm Medtronic CoreValveTM bioprosthesis was implanted under rapid pacing. Despite these preventive measures, the final position of prosthesis was too low with moderate-to-severe aortic insufficiency (Fig. 3) that persisted even after postdilatation with a 28 mm balloon. Therefore, the decision to implant another 29 mm CoreValve 10 to 15 mm higher was made. Finally, in control imaging, only a mild paravalvular leak was present (Fig. 4), and on discharge the ejection fraction had improved to 43%. TAVI is an effective treatment option for severe aortic stenosis in inoperable and high-risk patients. However, failure (mostly insufficiency) of a previous homograft aortic valve poses a challenge for any interventional treatment. In selected patients, TAVI can be a feasible alternative for high risk re-operation. TAVI may also be considered in some cases of native aortic insufficiency where there is favourable anatomy.

Efficacy and safety of prolonged mild therapeutic hypothermia treatment in patients after out-of-hospital cardiac arrest: preliminary data

INTRODUCTION The only proven method of neuroprotection in patients after out-of-hospital cardiac arrest (OHCA) is target temperature management (TTM). Results of a recent survey study showed that the prevalence of TTM in Poland is still low. Only about one-third of the intensive care units that responded to the survey use such a method [1]. According to the current European Resuscitation Council (ERC) 2015 Guidelines, a constant temperature of between 32°C and 36°C should be maintained for at least 24 h; however, the optimal duration of TTM remains unclear [2]. When we started conducting the study, ERC 2010 Guidelines recommended maintaining a temperature of between 32°C and 34°C [3]. Thus, the term mild therapeutic hypothermia (MTH) will be used instead of the now preferred TTM or temperature control [2]. The efficacy, safety, and risk factors for unfavourable neurological outcomes of prolonged external MTH in OHCA patients are presented.

Risk factors for adverse outcomes of patients with acute coronary syndrome: single-centre experience with long-term follow-up of treated patients

BACKGROUND For patients experiencing an acute coronary syndrome (ACS), a crucial time to assess their prognosis and to plan management is at discharge from hospital. AIM The aim of the study was to identify risk factors of mortality during post-discharge period following a hospitalisation for ACS. METHODS We studied 672 consecutive ACS patients hospitalised and discharged alive between 2002 and 2004. The analysis was done with respect to the type of ACS, i.e. unstable angina/non-ST-segment elevation myocardial infraction (UA/NSTEMI; n = 255) vs. ST-segment elevation myocardial infarction (STEMI; n = 417). All patients underwent coronary angiography and, if indicated, primary angioplasty (STEMI: 417 patients; UA/NSTEMI: 157 patients). The Cox proportional hazards regression model was used to evaluate the independent effect of the risk factors on the occurrence of primary endpoint, i.e. all-cause mortality during six-year follow-up. Survival status and date of death were obtained from the National Registry of Population (PESEL database). RESULTS A total of 123 patients (18.3%) died within the post-discharge period. The multivariate analysis identified 11 highly significant independent predictors of mortality (in order of predictive strength): diabetes mellitus (all types), higher creatinine level, older age, and more frequent occurrence of: supraventricular arrhythmias during hospitalisation, peripheral artery disease, recurrent angina pectoris with documented ischaemia on electrocardiogram, male sex, prior myocardial infarction, treatment with intra-aortic balloon pump counterpulsation, heart failure, and higher peak levels of creatine kinase-MB. CONCLUSIONS The risk factors obtained from the medical history and during the hospitalisation improve the risk stratification during the post-discharge period after hospitalisation for ACS.

Severe mitral stenosis secondary to eosinophilic granulomatosis resolving after pharmacological treatment

We present a case of 44‐year‐old woman who underwent effective pharmacological treatment of severe mitral stenosis. The patient was hospitalized due to rapidly progressive dyspnea. Her medical history included asthma, perennial rhinitis, and nasal polyps. Echocardiography showed a mass of the left ventricle involving the mitral valve; cardiac MRI suggested acute endocarditis. Severe peripheral blood eosinophilia was found. Eosinophilic granulomatosis with polyangiitis was diagnosed; treatment with prednisone and cyclophosphamide was started. Despite the clinical improvement, severe mitral stenosis persisted, surgical treatment was planned. However, evaluation after 6 cycles of cyclophosphamide pulse therapy revealed a significant regression of the valvular disease.

Simultaneous acute closure of the right coronary artery and left anterior descending artery in a young male.

A 28-year-old man with no cardiovascular history or cardiovascular risk factors, who denied cigarette smoking or taking any medications, drugs, supplements or steroids, was referred to the cardiology department after an outof-hospital cardiac arrest preceded by a four-hour angina episode. The initial rhythm (ventricular fibrillation) was successfully defibrillated. Subsequently, the electrocardiogram suggested inferior and inferobasal ST-elevation myocardial infarction (Figure 1). The coronary angiogram showed simultaneous acute thrombosis of the right coronary artery (RCA) (Figure 2a) and of the left anterior descending (LAD) artery (Figure 3a). Initially, to visualize suspected plaque rupture and to aid the decision whether to implant stents, multiple aspiration thrombectomies were performed, resulting in removal of substantial amounts of thrombotic material (Figure 4). After intravenous and intracoronary admin-