Zofia Oko-Sarnowska

The BNP concentrations and exercise capacity assessment with cardiopulmonary stress test in cyanotic adult patients with congenital heart diseases

Cyanosis is observed in patients with complex congenital heart disease (CHD) and pulmonary hypertension, heart failure represents an important clinical problem in such patients. The aim of this study was to evaluate the exercise capacity in patients with cyanotic CHDs using cardiopulmonary exercise test, measuring serum BNP levels as well as to seek correlation between BNP levels and cardiopulmonary exercise test parameters and identify the effects of blood oxygen desaturation and pulmonary hypertension on these indices. The study group consisted of 53 patients (21 males) at the mean age of 39.4 ± 14.3 years, of whom 19 were operated on at the mean age of 9.6 ± 8.6 years. Mean blood oxygen saturation (SO(2)) in patients was 81.2 ± 6.2%. Twenty four patients presented with Eisenmenger syndrome, 16--univentricular hearts, 4--transposition of the great arteries, 6--Fallots tetralogy, and 3--Ebstein anomaly. The control group comprised 32 healthy individuals (16 males) at the mean age of 40.7 ± 9.9 years. Cardiopulmonary stress test showed significantly lower exercise capacity in patients with cyanosis than in controls: maximal oxygen uptake (VO(2max)) 15.5 ± 4.9 vs. 31.6 ± 7.1 ml/kg/min (p=0.00001), maximum heart rate at peak exercise (HR max): 139.5 ± 22.5 bpm vs. 176.6 ± 12.1 (p=0.0001), VE/VCO(2) slope: 46.4 ± 10.1 vs. 27.3 ± 2.9 (p=0.00001), forced vital capacity FVC: 3.1 ± 1.1 l vs. 4.4 ± 0.8 l (p=0.00001). Subjects with the evidence of pulmonary hypertension (PH+) had lower exercise capacity than those without (PH-): VO(2max): 17.2 ± 4.2 vs. 12.8 ± 4.8 ml/kg/min (p=0.002), VE/VCO(2): 43.7 ± 11.1 vs. 50.9 ± 6.4 (p=0.01), FVC: 3.46 ± 1.05 l vs. 2.37 ± 0.91 l (p=0.0002). Plasma BNP levels in the study group were higher than in controls: 122.4 ± 106.7 vs. 21.1 ± 20.2 pg/ml p=0.00001 and did not differ between PH+ and PH- groups (115.7 ± 99.0 vs. 127.9 ± 114.1 pg/ml p=0.78). Negative correlations between BNP levels and VO(2max) (r=-0.389, p=0.006), FVC (r=-0.395 p=0.005), FEV1 (r=-0.386 p=0.006), SO(2) (r=-0.445 p=0.00001), and positive correlation between BNP level and VE/VCO(2) (r=0.369 p=0.009) were found.

Evaluation of exercise capacity with cardiopulmonary exercise testing and BNP levels in adult patients with single or systemic right ventricles.

Introduction The aim of the study was to evaluate exercise capacity using cardiopulmonary exercise test (CpET) and serum B-type natriuretic peptide (BNP) levels in patients with single or systemic right ventricles. Material and methods The study group included 40 patients (16 males) – 17 with transposition of the great arteries after Senning operation, 13 with corrected transposition of the great arteries and 10 with single ventricle after Fontan operation, aged 19–55 years (mean 28.8 ±9.5 years). The control group included 22 healthy individuals (10 males) aged 23–49 years (mean 30.6 ±6.1 years). Results The majority of patients reported good exercise tolerance – accordingly 27 were classified in NYHA class I (67.5%), 12 (30%) in class II, and only 1 (0.5%) in class III. Cardiopulmonary exercise test revealed significantly lower exercise capacity in study patients than in control subjects. In the study vs. control group VO2max was 21.7 ±5.9 vs. 34.2 ±7.4 ml/kg/min (p = 0.00001), maximum heart rate at peak exercise (HRmax) 152.5 ±32.3 vs. 187.2 ±15.6 bpm (p = 0.00001), VE/VCO2 slope 34.8 ±7.1 vs. 25.7 ±3.2 (p = 0.00001), forced vital capacity (FVC) 3.7 ±0.9l vs. 4.6 ±0.3 (p = 0.03), forced expiratory volume in 1 s (FEV1) 3.0 ±0.7 vs. 3.7 ±0.9l (p = 0.0002) respectively. Serum BNP concentrations were higher in study patients than in control subjects; 71.8 ±74.4 vs. 10.7 ±8.1 (pg/ml) respectively (p = 0.00001). No significant correlations between BNP levels and CpET parameters were found. Conclusions Patients with a morphological right ventricle serving the systemic circulation and those with common ventricle physiology after Fontan operation show markedly reduced exercise capacity. They are also characterized by higher serum BNP concentrations, which do not however correlate with CpET parameters.

Evaluation of Exercise Capacity with Cardiopulmonary Exercise Testing and Type B Natriuretic Peptide Concentrations in Adult Patients with Patent Atrial Septal Defect

Adults with patent atrial septal defect (ASD) usually find their exercise capacity satisfactory, and therefore hesitate to accept proposed surgical treatment of the heart disease. The aim of our study was to evaluate both the exercise capacity, using the cardio-pulmonary stress test, and brain natriuretic peptide (BNP) levels in asymptomatic adults with ASD. Thirty-six patients with patent secundum type ASD (aged mean 44.7 ± 8.2 years) were studied. The control group consisted of 25 healthy subjects at the mean age of 45.6 ± 6.1 years. Echocardiography and CPST were performed and BNP levels measured in all subjects. Oxygen uptake (VO2 max) was lower in ASD patients than in controls (22.1 ± 5.6 vs. 30.0 ± 6.8 ml/kg/min, p = 0.00001); the VE/VO2 slope was elevated in ASD patients compared with healthy subjects (31.3 ± 6.6 vs. 26.9 ± 3.3, p = 0.001), and exceeded 34 in 5 patients. VO2 max showed a negative correlation with the pulmonary to systemic flow ratio Qp:Qs (r = –0.46, p = 0.004), and a positive correlation was found between the VE/VO2 slope and Qp:Qs (r = 0.32, p = 0.05). BNP levels were higher in the ASD group than in the controls (60.6 ± 49.9 vs. 32.6 ± 24.5 pg/ml, p = 0.02). BNP correlated positively with RV diameter and Qp:Qs (r = 0.38 and 0.39 respectively, p = 0.03) and negatively with maximum VO2 (r = –0.5, p = 0.004) and VO2% (r = –0.32, p = 0.07). Conclusions: Although most adult patients with ASD perceive their exercise capacity as satisfactory, objective assessment reveals that in fact it is significantly decreased. BNP levels are increased comparing to healthy individuals. Decreased exercise capacity and increased BNP levels seem to result from right ventricular volume overload.

Safety, feasibility and effectiveness of first in‐human administration of muscle‐derived stem/progenitor cells modified with connexin‐43 gene for treatment of advanced chronic heart failure

To assess the safety and efficacy of transendocardial delivery of muscle‐derived stem/progenitor cells with connexin‐43 overexpression (Cx‐43‐MDS/PC) in advanced heart failure (HF).

Sustained Improvement of Clinical Status and Pulmonary Hypertension in Patients with Severe Heart Failure Treated with Sildenafil

BACKGROUND Sildenafil, a phosphodiesterase-5 inhibitor, has been shown to decrease pulmonary vascular resistance (PVR) in patients with heart failure. The purpose of the study was to evaluate the effect of sildenafil on clinical status and pulmonary vascular reactivity in patients with congestive heart failure. MATERIAL AND METHODS We enrolled 20 patients (18 men and 2 women, mean age 51 ± 12 years, diagnosed with congestive heart failure and pulmonary hypertension. This was a prospective, single-center study. Patients were treated with sildenafil 25 mg TDS for 12 months. Protocol included NYHA evaluation and repeated echocardiography, cardiac pulmonary stress tests, and right- sided catheterization. RESULTS Initially, there were 16 (80%) patients in III NYHA status and 4 (20%) patients in II NYHA. After 12 months, 8 patients were in NYHA III (40%) status and 12 patients in NYHA II (60%). Peak oxygen consumption increased from 12 ± 3 ml/kg/min to 19 ± 4 ml/kg/min after 1-year therapy (p<0.001). The cardiac index increased from 3.1 ± 0.6 L/min/m2 to 3.6 ± 0.4 L/min/m2 (p<0.05). Pulmonary vasculature resistance decreased after 1-year therapy (4.7 ± 1 vs. 1.6 ± 0.5 Woods units (p<0.005) comparing to initials. Mean pulmonary artery pressure decreased to 23 ± 6 mmHg from 42 ± 5 mmHg (p<0.001) after 1-year therapy. CONCLUSIONS One-year sildenafil therapy effectively improved clinical status and pulmonary vascular resistance in patients diagnosed with congestive heart failure.

Shortening baroreflex delay in hypertrophic cardiomyopathy patients -- an unknown effect of β-blockers.

AIMS Hypertrophic cardiomyopathy (HCM) is characterized by left ventricular hypertrophy and impaired diastolic and systolic function. Abnormal sympathetic-parasympathetic balance is a potential stimulus for left ventricular hypertrophy in HCM patients. β-Blockers are routinely used in HCM for their strong negative inotropic effect; however, these drugs also influence the sympathetic-parasympathetic balance. This study aimed to determine the autonomic control of the cardiovascular system and the autonomic effects of β-blockers in HCM patients treated or untreated with β-blockers. METHODS Among 51 HCM outpatients (18-70 years old; 29 men) there were 19 individuals with no medication and 32 subjects treated with a β-blocker. Fourteen age- and gender-matched (23-70 years old; nine men) healthy volunteers were enrolled in the control group. Continuous, non-invasive finger blood pressure was recorded during supine rest for 30 min. Autonomic regulation of the cardiovascular system was measured by heart rate variability and spontaneous baroreflex function (cross-correlation sequence method). RESULTS The mean pulse interval, time domain and spectral measures of heart rate variability and baroreflex sensitivity were comparable between HCM patients, treated or not with β-blockers, and the control group. However, the delay of the baroreflex was significantly longer in HCM patients who were not treated with β-blockers [2.0 (1.6-2.3) s] in comparison with HCM patients receiving β-blockers [1.4 (1.1-1.8) s; P = 0.0072] or control subjects [1.2 (0.8-1.8) s; P = 0.0025]. This delay did not differ between HCM patients treated with β-blockers and the control group. CONCLUSIONS Hypertrophic cardiomyopathy not treated with β-blockers is accompanied by prolonged baroreflex delay. The use of β-blockers normalizes this delay.

Atypical presentation of cardiac device related infectious endocarditis and complicated follow-up

780 pneumonia. His medical history included pre‐ vious inferior wall myocardial infarction treat‐ ed with coronary artery bypass grafting, dual chamber implantable cardioverter ‐defibrillator (ICD) implanted as secondary prophylaxis, arte‐ rial hypertension, and type 2 diabetes. Empiri‐ cal antibiotic treatment was employed (ceftriax‐ one, rifampicin, and vancomycin). Echocardiog‐ raphy performed during hospitalization suggest‐ ed vegetations on the tricuspid valve. The patient was transferred to the Department of Cardiolo‐ gy with suspicion of LDIE. On admission, he had no fever, inflammato‐ ry parameters were as follows: C ‐reactive pro‐ tein, 10.30 mg/l (mild elevation); procalcitonin, 0.06 ng/ml (within normal limits). The suspicion of LDIE was confirmed using transthoracic echo‐ cardiography, which demonstrated vegetations on Infectious endocarditis (IE) is a potentially fa‐ tal disease that is difficult to diagnose. Patients often present with unspecific signs and symp‐ toms, which delays diagnosis and proper treat‐ ment. The incidence of IE in patients with car‐ diac implantable electronic devices is estimated at 1% to 2%.1 Cardiac device–related infections vary from pocket infection and lead ‐dependent IE (LDIE) to sepsis. A 51 ‐year ‐old man presented to the Depart‐ ment of Neurology with recurrent lower back pain, which started suddenly 2 months earli‐ er, and a considerable weight loss and conflu‐ ent sweats during 6 months prior to admission. Magnetic resonance imaging (MRI) of the lum‐ bar spine showed inflammation of L4/L5 inter‐ vertebral disc and L4 and L5 vertebral bodies (FIGURE 1A), and chest X ‐ray demonstrated bilateral CLINICAL IMAGE

Unusual case of infective endocarditis after Dor’s procedure

480 Staphylococcus aureus were grown. Coronary an‐ giography showed a proximally occluded left an‐ terior descending artery (LAD) without a visible distal vascular bed. After 14 days of targeted an‐ tibiotic treatment (cefazolin, rifampin), the heart team decided to perform cardiac surgery. Follow‐ ing cardiopulmonary bypass, aneurysmal pouch incision revealed a massive thrombus and dehis‐ cent patch in two ‐thirds of its circuit. The patch and aneurysm were excised, and the ventriculot‐ omy orifice was closed with double 2‐0 sutures. After the surgery, episodes of paroxysmal atrial fibrillation were successfully treated with amio‐ darone. Control echocardiographic and CMR ex‐ aminations revealed successful reconstruction of the LV with reduced volumes (Supplementary material, Figures S2 and S3). At 1 ‐year follow ‐up, the patient is stable and free of exercise intoler‐ ance (NYHA class I) or arrhythmia. MI may have serious consequences; in 10% to 35% of patients, especially in those with anterior MI, it results in LV aneurysm formation.1 There A 66 ‐year ‐old male patient was referred to our unit in a severe condition (New York Heart Associ‐ ation [NYHA], class IV) with suspicion of infective endocarditis. In 1988, he suffered from anterior ST ‐segment elevation myocardial infarction (MI) resulting in apical aneurysm formation, which was subsequently treated by the Dor procedure (left ventriculoplasty; endoventricular circular patch plasty) without any coronary artery intervention (FIGURE 1A). On admission, transthoracic echocar‐ diography showed an akinetic left ventricular (LV) aneurysm (3.8×8.7 cm), incorporating apex and subapical segments separated from the LV by a previously implanted patch. Due to patch dehis‐ cence of 4 cm in length and with numerous vege‐ tations, there was a spontaneous blood flow be‐ tween LV and aneurysmal cavity (FIGURE 1B–1D). Cardiac magnetic resonance (CMR) imaging con‐ firmed the presence of a true LV apical aneurysm (surface, 62 cm2) and patch dehiscence (FIGURE 1F; Supplementary material, Figure S1). On admis‐ sion, blood samples were drawn, and cultures of CLINICAL IMAGE

The new generation is coming. Percutaneous implantation of the fully repositionable Lotus® aortic valve prosthesis: the first Polish experience

Transcatheter aortic valve implantation (TAVI) is nowadays an accepted method of treatment for patients with symptomatic severe aortic stenosis who are inoperable or at very high risk of classic surgical aortic valve replacement. The Lotus valve system is a new generation TAVI device composed of a self-expanding stent prosthesis with implemented bovine pericardial leaflets, which is designed to facilitate repositioning, resheathing, and retrieval, even in the fully expanded and functioning position before the final release. In addition, the Lotus valve is surrounded by a flexible membrane to seal paravalvular gaps between the prosthesis and native valve. We present the first Polish experiences with the Lotus valve system. Due to its unique features, the Lotus valve may improve the prognosis in patients with inoperable or high risk critical aortic stenosis.

Mitral valvuloplasty with sutures used for aortic prosthesis implantation.

BACKGROUND The purpose of this study was to analyze surgical treatment for aortic valve lesions with coexisting mitral regurgitation (MR). METHODS Seventy-five patients were divided into two groups according to intensity of MR (group 1, MR less than or equal to II; group 2, MR greater than or equal to II/III). There were two control groups (control 1, only patients with implantation of aortic valve; control 2, patients with implantation of both aortic and mitral prostheses). During implantation of a mechanical aortic prosthesis, the same suture for fixation of a mechanical prosthesis and for suspension of mitral commissural regions and lifting the base of anterior mitral cusp was used. RESULTS In all patients, no early death occurred. There were two late deaths, one due to endocarditis, and the other to heart failure. All patients from both groups had decreased MR. Selected echocardiographic parameters improved: end diastolic and end systolic diameter and ejection fraction in group 2 improved in proportion to patients in whom mitral valves were implanted (control 2). CONCLUSIONS Simultaneous suspension of the mitral commissure area during mechanical aortic prosthesis implantation reduces associated MR. This technique seems to be efficient during implantation of aortic prostheses in patients with coexisting MR.