Tatiana Mularek-Kubzdela

Chronic infarct‐related artery occlusion is associated with a reduction in capillary density. Effects on infarct healing

To assess the relationship between infarct‐related artery (IRA) stenosis and capillary density and to assess its effect on scar formation in the human heart.

Impact of Atrial Remodeling on Heart Rhythm After Radiofrequency Ablation and Mitral Valve Operations

BACKGROUND This study was conducted to determine the effect of left atrial structural remodeling on heart rhythm after radiofrequency ablation concomitant to mitral valve operation. METHODS Sixty-six consecutive patients with of atrial fibrillation (AF) and mitral valve disease underwent radiofrequency ablation and mitral valve operation. Heart rhythm was evaluated before and at 3, 6, and 12 months postoperatively. Biopsy specimens of the posterior wall of the left atrium were evaluated for the extent of fibrosis, myocyte diameter, intensity of inflammatory infiltrates, degree of myocytolysis, and capillary density. RESULTS Ten patients died and 1 patient was lost to follow-up. Heart rhythm at 12 months was used to divide the remaining 55 patients into two groups: group I, 34 with sinus rhythm; group II, 21 with AF. Paroxysmal AF preoperatively was more frequent among group I patients, and persistent/long-standing persistent AF in group II (p=0.0006). Groups I and II differed significantly in myocyte diameter (17.9±3.5 vs 20.3±4.6 μm, p=0.04), fibrosis percentage (38.7%±11.2% vs 47.6%±12.3%, p=0.009), inflammatory infiltrates (p=0.02), and preoperative left atrial diameter (5.03±0.7 vs 5.5±0.8 cm, p=0.04). No differences were found in capillary density (797.9±500.6 vs 946.0±373.7/mm2, p=0.3) and myocytolysis (p=0.4). Multivariate analysis showed myocyte diameter (p=0.047) and fibrosis (p=0.014) were independent predictors for an AF persistence at 12 months. CONCLUSIONS Left atrial structural remodeling strongly affects heart rhythm after concomitant radiofrequency ablation and mitral valve operation.

Comparison of the antiplatelet effect of two clopidogrel bisulfate formulations: Plavix and generic-Egitromb

Abstract Due to expansion of the pharmaceutical market it seems necessary to prove the efficacy of the generic drugs. The aim of this study is to compare the effects of two clopidogrel formulations: brand-name-Plavix and generic drug – Egitromb. This is a prospective, randomized study comparing two groups of patients treated with two clopidogrel: brand-name Plavix and generic drug– Egitromb. The 53 consecutive patients with stable coronary artery disease qualifying for coronary angiography and PCI were enrolled in this trial. They were randomized into two groups. In the group A (n = 28) patients received Egitromb 300 mg at admission followed by 8 days of 75 mg Egitromb daily. In the group B (n = 25) patients received Plavix 300 mg on the admission followed by 8 days of 75 mg Plavix maintenance therapy. Blood samples for multiple electrode aggregometry testing were drawn at baseline, 5 hours and 8 days after taking the loading dose. Median values of platelet aggregation inhibition did not differ between the Plavix and Egitromb groups when assessed at baseline: 239AU/min (IQR:329) vs. 209 (IQR:406; p = 0.894), 5 hours after loading: 183 AU/min (IQR:107) vs. 165 (IQR:171; p = 0.831) or at day 8: 174 AU/min (IQR:133) vs. 211 (IQR:133; p = 0.332. The study showed no difference in the therapeutic effect of two clopidogrel formulations (Egitromb and Plavix).

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.

Significance of antiplatelet therapy in emergency myocardial infarction treatment

Antiplatelet drugs play a crucial role in the treatment of patients with myocardial infarction, particularly in association with percutaneous coronary intervention. Their main advantage is the reduction of adverse ischemic incidents and the major disadvantage is the increase in the frequency of hemorrhages. Thus, the choice of appropriate drug depends on the right risk assessment of the development of these complications in individual patients. The aim of this article is to provide an update of antiplatelet therapy in emergency myocardial infarction treatment. Currently, the most important role in the process of platelet inhibition is played by ADP P2Y12 blockers: clopidogrel, prasugrel and ticagrelor. Clopidogrel and prasugrel belong to thienopyridines, and ticagrelor, a drug of irreversible action, is an analogue of adenosine triphosphate. By 2011 clopidogrel, alongside aspirin, had the highest recommendations of world cardiology associations for acute coronary syndrome treatment. The position on clopidogrel was changed following the publication of European Society of Cardiology guidelines for STEMI in 2012 which advocate the administration of acetylsalicylic acid (ASA) and ADP receptor blocker (in combination with ASA). It needs to be stressed that prasugrel and ticagrelor received class IB recommendation, while clopidogrel received only IC. However, the most recent studies aimed at introducing a new generation of antiplatelet drugs of high efficacy in prevention of ischemic incidents and of reversible action: cangrelor and elinogrel, which raise hopes for better prognosis for myocardial infarction patients.

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.

The "bouncing" catheter.

Treprostinil sodium, as a prostacyclin analogue, is a specific drug used for treatment of pulmonary arterial hypertension (PAH) [1]. One way of administration — intravenous — may be provided by implantation of a subcutaneous pump (LenusPro) in the subcostal region. It administers the drug continuously to the superior caval vein by means of a catheter inserted through the subclavian vein [2–4]. This method is generally safe and adverse events occur rarely [5]. A 38-year-old man with PAH treated with treprostinil had a LenusPro pump (Fig. 1A, E) implanted. The chest X-ray after 2 months revealed the tip of the catheter placed in the right internal jugular vein (Fig. 1B). As the patient had been in a good clinical condition, we decided to observe it. Four months after implantation the patient reported a strong pain and swelling in the right subclavian region without significant clinical deterioration. The chest X-ray revealed the tip of the catheter below the right clavicle (Fig. 1C) — the catheter slipped out of the vascular system and the drug was being delivered into the soft tissues. Due to tissue edema, the repositioning of the catheter attempted in the implanting center was difficult and required carrying the cannula through the supraclavicular region into the right internal jugular vein (Fig. 1D). After next 2 months, while checking the position of the catheter in the fluoroscopy, we suspected another dislocation (Fig. 1F). On closer assessment in the implanting center, the cannula was seen to be folding and straightening in the jugular vein broadened due to chronically elevated pressure (Fig. 1G, H). This time the cannula apparently remained within the vascular lumen and those moves did not result in clinical deterioration of the patient’s condition during several months of follow-up. However, the residual volume in the pump had been higher than expected and finally the outflow stopped, giving an alarm. This time the patient required an urgent repositioning of the catheter, which were placed again through the proximal subclavian vein, whereas the distal part appeared to be occluded with well-developed collateral circulation. In patients with PAH and a LenusPro pump for treprostinil infusion, there is a possibility for catheter dislocation. It is reasonable to check the position of the catheter regularly with an imaging method (i.e. chest X-ray, fluoroscopy). A strong pain in the subclavian region may suggest that the cannula is slipping out of the subclavian vein. In the presented case, such a situation required urgent repositioning of the catheter due to the pain and worse absorption of the drug from the soft tissues. An unstable position of the tip of the cannula without its slipping outside the vessel also does not appear to be benign, because one day it may result in complete wedging of the catheter with an outflow blockade.

Balloon atrial septostomy in pulmonary arterial hypertension: A beneficial effect on the control of rhythm abnormalities.

Balloon atrial septostomy (BAS) is a palliative procedure, but actually, interatrial shunt tends to be self-closing within a few months. However, in countries with a large number of donors, time to lung transplantation (LuTx) for a patient on a waiting list it is approximately 2–4 months [2]. Such a short waiting time allows the procedure to be performed only once or even offers the possibility of extracorporeal membrane oxygenation if the patient requires bridging treatment [3]. In cases with an essentially longer waiting list, there is a need for methods which allow a deteriorating patient to survive for a year or even up to 2 years. Using one of the devices available on the market in addition to BAS, to keep the interatrial connection opened within this time period, prevents the patient from having the procedure repeated. These devices are very promising — especially the atrial flow regulator (AFR) invented by Vettukattil’s group [4]. However, currently, some significant disadvantages exist comprising: i) the limited availability for commercial use, ii) high price and iii) lack of reimbursement for the procedure. Patients disqualified from LuTx would probably benefit significantly from the implantation of such a device as their life would be prolonged without the need for repeated invasive BAS procedure [5]. On the other hand, however, there are patients referred for LuTx for which another question arises: what to do with such devices in patients undergoing LuTx. The only device which is retrievable is the AFR. However, after a period of implantation, the device gets endothelialized and retrieval becomes impossible. Thus, the only remaining option seems to be an AFR closure with an atrial septal occluder or vascular plug. But when? During transplantation or some time later? Perhaps such a patent connection between the atria could be helpful in the initial period after LuTx, because the flow direction in the shunt would reverse, causing a bigger preload and in this way improving its function before adapting to the lower vascular resistance of the new lungs. The current ongoing multicenter trial in which the AFR device is being tested will perhaps tell us more precisely, how to face these challenges.

Recurrent acute myocardial infarction as an initial manifestation of antiphospholipid syndrome: treatment and management.

The antiphosholipid syndrome (APS) is an autoimmune disorder, characterized by the presence of vascular thrombosis and/or pregnancy morbidity in a patient with positive laboratory tests for antiphospholipid antibodies. The patients with APS are in the high risk of rethrombosis. We report the case of 43-year-old female presenting with recurrent acute myocardial infarction with ST-segment elevation because of recurrent coronary thrombosis in coronary left anterior descending artery (LAD) and circumflex coronary artery (Cx) resulting in four percutaneous coronary interventions (PCI), associated with the presence of plasma antiphospholipid antibodies. Patient received seven stents to LAD and the aspiration of thrombus from Cx artery was performed. Pharmacotherapy included full antithrombotic treatment consisted with antiplatelet drugs such as: aspirin, clopidogrel followed by prasugrel, glycoprotein IIb/IIIa receptor antagonists and anticoagulants such as heparin followed by warfarin as well as steroids. At 1-year follow-up, controlled coronary angiography confirmed the good effect of PCI without any signs of stenosis or rethrombosis and highlighted the important role of antithrombotic treatment in patients with APS.

Relations of diabetes mellitus, microvascular reperfusion and left ventricular remodelling in patients with acute myocardial infarction treated with primary coronary intervention

BACKGROUND AND AIM The aim of our study was to determine the influence of diabetes mellitus (DM) on myocardial reperfusion and left ventricular (LV) remodelling in patients with an acute myocardial infarction undergoing primary percutaneous coronary intervention. METHODS The study population consisted of 218 patients with first anterior ST-segment elevation myocardial infarction (STEMI) successfully treated with primary coronary angioplasty. We evaluated microvascular reperfusion using angiographic (Myocardial Blush Grade [MBG]) as well as electrocardiographic methods (ST-segment resolution > 70%). LV remodelling was defined asan increase in end-diastolic volume ≥ 20%, based on repeated measurements in individual patients. The study population was divided into two groups according to the presence, n = 43 (20%), or absence, n = 175 (80%), of DM. RESULTS Patients with DM showed a significantly higher rate of MBG ≤2 (45.7% vs. 62.8%, p = 0.04) and lower incidence of ST-segment resolution > 70% (48% vs. 18.6%, p = 0.0003) compared to non-diabetics. Despite a similar incidence of LV remodelling in DM and non-DM groups (30.2% vs. 22.4%, p = 0.27), echocardiographic features of diastolic impairment and overt symptoms of heart failure were significantly more frequent in diabetic patients (55.2% vs. 27.1%, p = 0.006 and 36.1% vs. 18.3%, p = 0.02, respectively) at six-month follow-up. CONCLUSIONS Despite worse microvascular reperfusion in STEMI patients with diabetes, the incidence of LV remodelling was similar compared to non-DM patients. DM was associated with the development of diastolic heart failure.