Stanisław Jankiewicz

The Management of Supraventricular Tachyarrhythmias in Patients with Pulmonary Arterial Hypertension.

BACKGROUND Atrial remodelling in pulmonary arterial hypertension (PAH) may lead to higher incidence of supraventricular arrhythmias (SVA). The purpose of this study was to evaluate the efficiency and safety of various methods for treatment of SVA in this group. METHODS This was a single centre study. Forty-eight patients (33 women and 15 men) aged 19-77 years (median 49 years) were enrolled. There were 30 patients with idiopathic PAH, 10 had PAH associated with connective tissue disease, and eight with congenital heart disease. A retrospective analysis was performed to estimate the prevalence and type of supraventricular arrhythmias, as well as efficiency and safety of treatment methods. Mean follow-up period was 28.8±17.7 months. RESULTS Supraventricular arrhythmias occurred in 17 patients (35%) and appeared to be atrial fibrillation, flutter or tachycardia. Supraventricular arrhythmias coexisted with elevated mean right atrial pressure in 75%. Four patients had more than one type of SVA. A flutter-like macro-reentrant form of atrial tachycardia dependent on cavo-tricuspid isthmus was found in four cases. The treatment of SVA included typical methods: antiarrhythmic drugs, direct current cardioversion (DCC), and radiofrequency (RF) ablation. All of the therapeutic methods were effective in managing acute arrhythmia. Three patients required re-ablation. Overall mortality: 14 patients (29%) in the whole study group, including six in SVA group (35%) and eight without SVA (26%). CONCLUSIONS In patients with PAH DCC, pharmacological cardioversion and RF ablation can be applied safely and effectively. Flutter-like macro-reentrant atrial tachycardia dependent on cavo-tricuspid isthmus is observed in this group. It is more challenging, but possible, to successfully treat this arrhythmia with RF ablation.

Red Blood Cells Distribution Width as a Potential Prognostic Biomarker in Patients With Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension

BACKGROUND Red blood cells distribution width (RDW) predicts survival in cardiovascular diseases. Little is known about the variability of RDW level over time among patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH). To our knowledge, RDW has never been analysed as a marker of response to specific treatment. MATERIALS AND METHODS We retrospectively analysed 77 patients for: i) RDW measured during the last hospitalisation before death or during the last follow-up (RDWlast); ii) mean RDW from all hospitalisations during the entire follow-up of the patient (RDWmean); iii) maximum RDW of all hospitalisations of each patient (RDWmax). In order to assess response to specific treatment and association with prognosis, we compared RDW levels (obtained from 56 patients) before and 3 to 6 months after introduction or intensification of treatment in both the alive and deceased group. RESULTS Twenty-eight of 77 patients died, whereas in specific drugs treatment response analysis, 22 of 56 patients died during follow-up. The cut-off values derived from the ROC analysis and assessed using the log-rank test were significant for RDWlast (p<0.0001), RDWmean (p<0.001) and RDWmax (p=0.02). A decrease in RDW levels after introduction or intensification of specific treatment was significant (p=0.015) in survivors, whereas there was no significance (p=0.29) in decrease in RDW levels in non-survivors after change of therapy. CONCLUSIONS Red blood cells distribution width might be a potential prognostic biomarker in patients with PAH and inoperable CTEPH. The decrease in RDW level after introduction or escalation of PAH-targeted and CTEPH-targeted drugs is associated with a good treatment response and better prognosis.

Acute coronary syndrome as a result of left main coronary artery stenosis after aortic valve replacement. A report of three cases.

Acute coronary syndrome (ACS) as a result of iatrogenic coronary ostial stenosis (ICOS) is a rare but potentially life-threatening complication of aortic valve replacement (AVR). We present three cases of patients with ACS shortly after AVR, in whom ICOS were revealed. They refused an operation and thus they were treated with percutaneous coronary intervention. The potential pathomechanisms of ICOS and treatment options are discussed.

Neopterin as a Biomarker in Patients with Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension

Background: Upregulation of the immune system is regarded to play an important role in the etiopathobiology of pulmonary arterial hypertension (PAH) and inoperable chronic thromboembolic pulmonary hypertension (CTEPH). To the best of our knowledge, neopterin (NP) has never been investigated in patients with PAH and CTEPH. Objectives: The aim of the study was to evaluate the concentration of NP in blood in order to examine its impact on outcome and relationship with disease severity in that population. Methods: Serum concentration of NP was analysed prospectively in 50 patients (36 with PAH and 14 with CTEPH vs. 31 healthy controls) and assessed in relation to clinical parameters and outcome. Results: NP concentration in the PAH and CTEPH groups combined was significantly higher than in the control group (8.68, 6.39–15.03 vs. 5.14, 4.16–5.98 nmol/L, p < 0.0000001). During 9 months of follow-up, clinical deterioration occurred in 18 patients (including 8 deaths), and NP concentration in this group was higher when compared to stable patients (15.6, 8.52–25.13 vs. 7.87, 6.18–9.89, p = 0.002). The cutoff value of NP derived from ROC curve analysis was 15.3 nmol/L (p = 0.002, AUC 0.77, p = 0.0004, HR = 4.35, 95% CI 1.43–13.18, log-rank test). On Cox regression analysis, NP predicted clinical deterioration (p = 0.009, 95% CI 1.01–1.06). NP correlated positively with NT-proBNP (p < 0.001), red blood cell distribution width (p < 0.001), and right atrium area (p = 0.002) and inversely with 6-min walking test (p = 0.002) and peak oxygen consumption (p = 0.001). Conclusions: NP concentration is increased in patients with PAH and inoperable CTEPH. Elevated NP concentration is associated with adverse clinical outcomes and correlates with clinical parameters.

Balloon pulmonary angioplasty for the treatment of residual or recurrent pulmonary hypertension after pulmonary endarterectomy

BACKGROUND Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). However, persistent pulmonary hypertension continues in 5-35% of patients after PEA. Recently, balloon pulmonary angioplasty (BPA) showed promise as a strategy for patients with non-operable CTEPH. Therefore, we investigated the usefulness of BPA for residual pulmonary hypertension after PEA. METHODS Fifteen patients with residual pulmonary hypertension after PEA received 71 BPA sessions (4.7 ± 1.4 sessions/patient). The mean time between the PEA and the first BPA session was 28.1 ± 25.8 months. All patients underwent a comprehensive diagnostic work-up, including right heart catheterization, functional and laboratory tests, before, and 6-4 weeks after the BPA sessions. RESULTS After BPA, the mean pulmonary arterial pressure decreased from 44.7 ± 6.4 to 30.8 ± 7.5 mm Hg (31% decline; p < 0.001). Pulmonary vascular resistance decreased from 551.9 ± 185.2 to 343.8 ± 123.8 dyn∗s/cm-5 (38% decline; p < 0.001). The 6-min walking distance increased from 383 ± 104 to 476 ± 107 m (mean change +93 m; p < 0.001). In two sessions (2.8%), serious periprocedural complications occurred. During a mean follow-up of 18 ± 14.3 months, one patient died two months after the last BPA session. Fourteen patients survived. CONCLUSIONS BPA could be a promising therapeutic strategy for persistent pulmonary hypertension after PEA in patients with CTEPH.

Optical coherence tomography reveals the mechanisms of balloon pulmonary angioplasty in inoperable chronic thromboembolic pulmonary hypertension

Figure 1. Angiography and optical coherence tomography (OCT) cross-sections of the eighth segmental branch of the left pulmonary artery, before and after balloon pulmonary angioplasty (BPA). A 6-French right Judkins guiding catheter was introduced to the ostium of the artery and 0.0014” coronary guidewire was placed distally in the vessel. Then optical coherence tomography (OCT) catheter (DragonFly, St. Jude Medical, USA) was advanced. Iodinated contrast was infused at a flow rate of 5 mL/s over 4 s at 400 psi of pressure and OCT images were acquired. Subsequently the vessel was accurately measured in several locations and the proper size of the balloon was selected. OCT images revealed the potential mechanisms of BPA: expansion of internal lumen of the artery was achieved by breaking the meshwork lesions inside the artery lumen and by compression of the boundary white thrombus. A 76-year-old female patient with chronic thrombo-embolic pulmonary hypertension (CTEPH) as a result of previous pulmonary embolism was admitted for balloon pulmonary angioplasty. Right heart catheterization showed mean pulmonary artery pressure of 61 mm Hg. Selective pulmonary angiography revealed subtotal occlusion of the A8 segmental branch of the left pulmonary INTERVENTIONAL CARDIOLOGY

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.

Optical coherence tomography improves the resultsof balloon pulmonary angioplasty in inoperable chronicthrombo-embolic pulmonary hypertension

Corresponding author: Aleksander Araszkiewicz MD, Department of Cardiology, Poznan University of Medical Sciences, 1/2 Długa St, 61-848 Poznan, Poland, phone: +48 608 574 375, fax: +48 618 549 094, e-mail: aaraszkiewicz@interia.pl Received: 23.12.2016, accepted: 12.02.2017. Optical coherence tomography improves the results of balloon pulmonary angioplasty in inoperable chronic thrombo-embolic pulmonary hypertension

Znaczna poprawa kliniczna pacjenta leczonego sildenafilem z powodu nadciśnienia płucnego związanego z nadciśnieniem wrotnym

We report a case of the 59-year-old men with portal hypertension and liver cirrhosis, who developed pulmonary arterial hypertension. The first line treatment with sildenafil 20 mg 3 times daily was introduced as part of a Polish National Treatment Program. At a 6-month follow-up we noticed a significant clinical improvement: the patient’s exercise capacity and echocardiographic parameters were substantially better. In addition, the B-type natriuretic propeptide significantly decreased.

One patient: double massive pulmonary embolism with haemodynamic collapse managed by emergent surgery.

A 55-year-old male was transferred to the Cardiology Clinic with a pulmonary embolism diagnosed in a suburban hospital 3 days earlier (via computed tomography). Transthoracic echocardiography (TTE) revealed no embolism in the heart ventricles and no changes in right ventricular function. After 3 days (i.e. 6 days on from the first admission), the patient suffered swift progressive clinical deterioration; sinus tachycardia, T-wave inversion V1–V3, arterial hypotension, drop in systolic blood pressure (SBP) > 40 mm Hg in 10 min, accompanied by anxiety and lightheadedness. The TTE revealed a flattening thrombus sized 8 × 4 cm in the right atrium (RA) and an unknown echo at the connection of inferior vena cava (IVC) with RA. These 2 new embolisms had not been recorded 3 days earlier. Shortness of activated clotted-time and right ventricular systolic pressure > 120 mm Hg was counted. The patient was qualified to urgent surgery. Doppler examination of lower extremities revealed a massive embolism of the right popliteal vein. After induction, the patient required cardiopulmonary resuscitation because of pulseless electrical activity. Urgent chest opening and cardiopulmonary bypass (CPB) was performed. The RA near IVC was incised and a thrombus similar to IVC shape was removed (Fig. 1, point 2); after that, a venous cannula was placed there. Revision of RA did not show a known thrombus in TTE examination. CPB had been performed with aortic cross clamping in middle hypothermia. The pulmonary trunk had been incised revealing a saddle thrombus with total occlusion of pulmonary artery bifurcation (PAB) (Fig. 1, point 1) and two more, smaller in size (3 cm). Thrombus was removed from left and right pulmonary arteries (Fig. 1, point 3). In the post operation period, intubation time was prolonged up to 5 days. The patient was aggressively treated with non-fractionated heparin with target activated partial thromboplastin time > 100 s. On the 7th day after the operation, the patient suffered from quick progressive clinical deterioration with sinus tachycardia, SBP of 70 mm Hg, Sp02 60%. Echocardiography performed on the intensive care unit revealed thrombus inside the RA. Within 30 min before the operation, the patient needed high doses of catecholamine. After admission to the operating room, transoesophageal echocardiography (TEE) revealed the RA thrombus and again the saddle thrombus with partial occlusion of PAB (Fig. 2). After CPB, the RA was opened and Y shaped thrombus from tricuspid valve to PAB was removed (Fig. 3, point 1). Revision of pulmonary trunk, right and left pulmonary arteries were made with no thrombus discovered. After circulation restoration on CPB, the TEE examination was performed. Superior vena cava (SVC) was partially occluded with no external symptoms (Fig. 4). With small incision of the SVC, the thrombus 8 cm in size was removed (Fig. 3, point 2). The next day, an OPTEASE Cordis Corporation IVC filter was placed below the kidney veins. The patient was on a respirator for 4 days, and after that he passed rehabilitation with no problems. After the IVC filter positioning, the patient was treated with non-fractionated heparin, acenocumarin and 75 mg of acetylsalicylic acid (ASA). After 20 postoperative days, there were no signs of deep vein system thrombus in either leg or the IVC so the filter was removed. The patient was dismissed from the hospital on the 26th postoperative day in a good condition on acenocumarin and ASA 75 mg.