Variations and angulation of the coronary sinus tributaries: Implications for left ventricular pacing.

BACKGROUND: Variations of the coronary sinus tributaries might result in difficulties in left ventricle electrode insertion during cardiac resynchronizing therapy. Morphometric features of tributaries, especially angulation of the coronary sinus tributaries, are crucial for coronary sinus procedures. METHODS: This study was carried out on 200 formaldehyde-fixed human hearts (22.0% females, mean age of 48.7 ± 15.6 years). RESULTS: The inferolateral aspect of the left ventricle was accessible from the coronary venous tree in 77.0% (in 35% from one, 29% from two, and 13.0% from three tributaries). The middle cardiac vein was present in all cases, with a diameter of 1.8 ± 0.5 mm, cannulation distance of 5.3 ± 3.2 mm, and angle of 82.0 ± 12.8°. The inferolateral vein of the left ventricle varied greatly in number: single in 63.5%, multiple in 30.5%. The ostium diameter for a single vein was 1.3 ± 0.5 mm, cannulation distance was 21.1 ± 9.8 mm, and the angle was 98.1 ± 13.5°. The left marginal vein was present in 39.5% with an ostium diameter of 0.9 ± 0.5 mm, cannulation distance of 46.0 ± 12.0 mm, and angle of 92.0 ± 13.4°. Finally, the oblique vein of the left atrium was present in 71.0% with a diameter of 1.3 ± 0.8 mm, cannulation distance of 27.2 ± 9.4 mm, and angle of 136.8 ± 16.6°. CONCLUSIONS: This study shows the clinically relevant morphometric characteristic of coronary sinus tributaries. The middle cardiac vein is the most constant among coronary veins. However, it is usually not suitable for left ventricular pacing. The inferolateral vein of the left ventricle is highly variable in number, but its morphology makes it a suitable target for left ventricular lead placement.

Assessment to access to social and medical help- for homeless people in Cracow in the context to health problems

INTRODUCTION: Although homelessness is a worldwide problem also present in Poland and the Malopolska region, the data about it are not sufficient. AIM OF THE STUDY: Assessment of the general situation in Cracow and help options for homeless people. MATERIALS AND METHODS: A survey study conducted in 11 places offering refuge to homeless people in Cracow. RESULTS: In Cracow, there were 691 places to sleep in 11 institutions. Nine out of 11 were open all year long and most of them were available only for men. Five institutions offered meals, all of them had bathrooms, 7 places provided medical help. DISCUSSION: The expected number of homeless people in Poland and in Cracow seems to be underestimated. Basic needs of homeless people remain unsatisfied which decreases the possibility of transitioning out of homelessness. CONCLUSIONS: Help available for homeless people in Cracow needs improvements in all of the areas examined.

Comparative iTRAQ analysis of protein abundance in the human sinoatrial node and working cardiomyocytes.

Our objective was to assess the changes in protein abundance in the human sinoatrial node (SAN) compared with working cardiomyocytes to identify SAN-specific protein signatures. Four pairs of samples (the SAN and working cardiomyocytes) were obtained postmortem from four human donors with no evidence of cardiovascular disease. We performed protein identification and quantitation using two-dimensional chromatography-tandem mass spectrometry with isobaric peptide labeling (iTRAQ). We identified 451 different proteins expressed in both the SAN and working cardiomyocytes, 166 of which were differentially regulated (110 were upregulated in the SAN and 56 in the working cardiomyocytes). We identified sarcomere structural proteins in both tissues, although they were differently distributed among the tested samples. For example, myosin light chain 4, myosin regulatory light chain 2-atrial isoform, and tropomyosin alpha-3 chain levels were twofold higher in the SAN than in working cardiomyocytes, and myosin light chain 3 and myosin regulatory light chain 2-ventricular/cardiac muscle isoform levels were twofold higher in the ventricle tissue than in SAN. We identified many mitochondrial oxidative phosphorylation, ß-oxidation, and tricarboxylic acid cycle proteins that were predominantly associated with working cardiomyocytes tissue. We detected upregulation of the fatty acid omega activation pathway proteins in the SAN samples. Some proteins specific for smooth muscle tissue were highly upregulated in the SAN (e.g. transgelin), which indicates that the SAN tissue might act as the bridge between the working myocardium and the smooth muscle. Our results show possible implementation of proteomic strategies to identify in-depth functional differences between various heart sub-structures.

Spatial relationship of blood vessels within the mitral isthmus line.

Aims: The aim of this study was to assess the spatial relationship of blood vessels and the thickness of the atrial wall within the mitral isthmus line. Methods and results: A total of 200 randomly selected autopsied adult human hearts (Caucasian) were examined. The mitral isthmus line was cut longitudinally and the thickness of the left atrial wall was measured. The blood vessels within the isthmus were identified and their relationship with the endocardial surface (ES), mitral annulus (MA), and the left inferior pulmonary vein (LIPV) ostium was assessed. The mean myocardial thickness in the upper, middle, and lower 1/3 of the mitral isthmus section were 1.9 ± 1.0, 3.0 ± 1.5, and 2.7 ± 1.3 mm, respectively. The great cardiac vein (GCV) was present within the isthmus in 98.0%, the left circumflex artery (LCx) in 57.0%, and the Marshall vein in 35.0% of all hearts. The GCV was located 4.5 ± 2.2 mm from the ES, 7.3 ± 5.3 mm from the MA, and 24.3 ± 7.3 mm from the LIPV. The LCx was situated 3.8 ± 2.3 mm from the ES, 7.9 ± 5.1 mm from the MA, and 25.3 ± 8.0 mm from the LIPV. We were able to detect eight different patterns of GCV and LCx mutual arrangement within the mitral isthmus line. Conclusion: The myocardium is the thinnest in the upper 1/3 sector, and the blood vessels are mainly located in the middle and lower 1/3. In 49.1%, the LCx is situated at a distance of less than 3 mm from the ES. In 55.3%, the LCx is located between the GCV and ES of the left atrium.

Mid-esophageal bicaval versus short-axis view of interatrial septum in two-dimensional transesophageal echocardiography for diagnosis and measurement of atrial septal pouches.

BACKGROUND: Recent studies suggest that the left-sided septal pouch (SP) may increase the risk of cryptogenic stroke and act as an arrhythmogenic substrate. The aim of this study was to compare two transesophageal echocardiography (TEE) projections of the interventricular septum: mid-esophageal bicaval and short-axis views toward evaluating their ability to detect SPs. MATERIALS AND METHODS: A total of 146 patients with both bicaval and short-axis TEE views were included in this study. The presence of SPs was determined, and they were evaluated for morphology. RESULTS: Irrespective of TEE projection view, the left SP was detected in 74 cases (50.7%), right SP in 16 cases (11.0%), and double in one case (0.7%). Agreement between both projections occurred in 119 cases (81.5%) with a weighted kappa coefficient of 0.68 (good agreement). We detected more left SPs from the bicaval view compared to the short-axis view; however, the observed difference was statistically insignificant (72 vs 59, P = .13). The detection of right SPs was higher in the short-axis view, but also statistically insignificant (9 vs 13, P = .38). Bland-Altman analysis revealed a significant difference in the left SP depth with higher values in the bicaval than short-axis view (systematic difference = 1.17 mm, LoA: -4.88-7.22 mm, P = .02, ICC = 0.58). CONCLUSIONS: The mid-esophageal bicaval view should be preferable over mid-esophageal short-axis view of interatrial septum for the diagnosis and measurement of the left SP.

Blood Vessels and Myocardial Thickness within the Left Atrial Appendage Isthmus Line.

Electric isolation of the left atrial appendage (LAA) and linear ablations in the area of the LAA base are gaining popularity. However, very little is known about the myocardial architecture and the presence of epicardial blood vessels within this region, which could significantly influence the course of such procedures. We examined 200 autopsied hearts (22.5% females, 46.7 ± 16.8 years old). The LAA isthmus (i.e., the line between the LAA ostium and the mitral annulus) was cut longitudinally. The myocardium was thickest at the LAA end of the isthmus (2.4 ± 0.7 mm) followed by its middle sector (2.1 ± 0.7 mm) inside the LAA, 5 mm from its ostium (1.9 ± 0.7 mm), and the mitral annulus end of the isthmus (1.8 ± 0.6 mm) (P < 0.0001). At least one artery was found in 96.5% of all samples (89.5% were single branched, 7% had two branches). The great cardiac vein was found in 77.0% and the left marginal vein in 2.5%. The artery was interposed between the endocardium and the great cardiac vein in 31.5% of cases. The smallest distance between the endocardium and the artery was 0.5 mm and between the endocardium and the vein was 0.7 mm. In total, we were able to distinguish fifteen different types of vascular arrangements within the LAA isthmus line in this study. The myocardium within the LAA isthmus is thickest at its LAA end. The left circumflex coronary artery branches are the most frequently-occurring vessels within the isthmus and are present in almost all cases, while the great cardiac vein is present in three quarters of hearts. Clin. Anat. 31:1024-1030, 2018. © 2018 Wiley Periodicals, Inc.

The median nerve penetrating through the radial head of the flexor digitorum superficialis muscle: Case report.

The forearm is a body region of numerous anatomical variations. Due to its favorable anatomy flexor digitorum superficialis muscle (FDS) is commonly used in tendon transfer surgeries. In this study a unique combination of abnormalities was found in a single forearm: the flexor digitorum superficialis muscle penetrated by the median nerve, one of the flexor digitorum superficialis tendons early division and absence of the palmaris longus muscle. Described variation potentially may lead to the clinical manifestation of the median nerve compression and should be also considered during FDS surgery.

Geometry of Koch's triangle.

AIMS: The first aim of this study was to determine the size of the Koch's triangle. The second one was to investigate relation between its dimensions and other individual-specific and heart-specific parameters as well as to create universal formula to estimate triangle dimensions based on these parameters. METHODS AND RESULTS: This study is a prospective one, presenting 120 randomly selected autopsied hearts dissected from adult humans (Caucasian) of both sexes (31.7% females), with mean age of 49.3 ± 17.4 years. The length of triangle sides and angles were measured and the triangle area was calculated as well. Sixteen additional heart parameters were measured in order to analyse potential relationship between the dimensions of Koch's triangle and other dimensions of the heart, using linear regression analysis. The mean (±SD) length of the anterior edge was approximated to 18.0 ± 3.8 mm, the posterior edge to 20.3 ± 4.3 mm, and the basal edge to 18.5 ± 4.0 mm. The average values of the apex angle, the Eustachian angle, and the septal leaflet angle were 58.0 ± 14.4°, 53.8 ± 10.6°, and 67.6 ± 14.4°, respectively. The mean value of the Koch's triangle area was 151.5 ± 55.8 mm2. The 95th percentile of triangle's height (the distance from the apex to the coronary sinus) was 21.8 mm. CONCLUSION: Mean values and proportions of triangle's sides and angles were presented. Koch's triangle showed considerable individual variations in size. The dimensions of the triangle were strongly independent from individual-specific and heart-specific morphometric parameters; however, the maximum triangle's height can be estimated as 22 mm.

Penetration of formaldehyde based fixatives into heart.

OBJECTIVES: To investigate the penetration depth of formaldehyde-based fixatives into cardiac muscle samples over the course of fixation. BACKGROUND: Fixation is the essential step in anatomical studies. However, very little is known about penetration of most common fixatives into cardiac tissue. METHODS: A total of 40 heart samples were investigated. 4 study groups (n=10 in each case) were formed in such manner they differed only in concentration and type of fixative (1) - 2% formaldehyde phosphate-buffered solution (FPBS); (2) - 4% FPBS (formalin); (3) - 10% FPBS; (4) - alcoholic formalin. Samples were measured before fixation and in the following time points: 24 hours, 72 hours, 168 hours. RESULTS: The penetration depth differed significantly among studied fixatives (p<0.0001). 100% penetration occurred in all samples after 72 hours in alcoholic formalin solution and after 168 hours in 10% FPBS. After alcoholic formalin fixation, the tissue is more brittle and sub-epicardial blisters were observed in some cases. CONCLUSIONS: Alcoholic formalin solution is the fastest fixative among the studied ones, however it has several adverse effects on tissue structure. It was found that 10% FPBS is the best and a relatively fast fixative for cardiac morphometric studies.

Residua of thymus in the mediastinum - clinical aspects - cadaveric study.

The main goal of this study was to investigate possible residua of thymic tissue in 100 adult cadavers with no thoracic pathology known before, by dissection of standard locations of thymic tissue in perithyroid, periaortic, peritracheal and retrotracheal spaces, as well as areas located next to the course of phrenic, vagus and left recurrent laryngeal nerves. Thus obtained tissue samples were studied by two pathologists independently. The remnants of the thymic tissue were found in 61 out of 100 specimens studied. It means that residua of ectopic thymic tissue is common, which may have a huge impact on the results of treatment of many diseases i.e. myasthenia gravis in course of thymoma.

Influence of different fixation protocols on the preservation and dimensions of cardiac tissue.

Recent extensive progress in invasive cardiac procedures has triggered a wave of dozens of heart morphometric anatomical studies that are carried out largely using autopsied samples fixed in formaldehyde solution prior to observations and measurements. In reality, very little is known about changes in heart tissue dimensions during fixation. The aim of this study was therefore to investigate how fixation affects the dimensions of cardiac tissue, and if different types and concentrations of reagents affect this phenomenon. A total of 40 pig heart samples were investigated, and seven different measuring sites were permanently marked in every heart prior to fixation. Four study groups (n = 10 each) were assembled that differed only in concentration and the type of fixative: (i) 2% formaldehyde solution; (ii) 4% formaldehyde solution (formalin); (iii) 10% formaldehyde solution; (iv) alcoholic formalin. The samples were measured before and after fixation at the following time points: 24 h, 72 h and 168 h. It was found that different fixatives significantly affected different parameters. Almost all of the heart dimensions that were measured stabilized after 24 h; later changes were statistically insignificant in the point-to-point comparison. Change in the length of the interatrial septum surface was not altered significantly in any of the fixatives after 24 h of preservation. It was found that 10% formaldehyde increased the thickness of muscular tissue only after 24 h; this thickening was reduced after 72 h and was insignificant at 168 h. Other heart parameters in this group do not present significant changes over the entire fixation time duration. In conclusion, the 10% formaldehyde phosphate-buffered solution appeared to be the best fixative among the fixatives that were studied for cardiac morphometric purposes; this solution caused the smallest changes in tissue dimensions. Measurements should be obtained at least after 1 week of preservation when most parameters exhibit the smallest changes compared with the non-preserved samples.

Anatomical variations of the coronary sinus valve (Thebesian valve): implications for electrocardiological procedures.

AIMS: The Thebesian valve (TV) can be a significant obstacle to coronary sinus (CS) cannulation. The aim of this study was to evaluate the characteristic features of the CS valve--TV anatomy. In particular, emphasis was placed on identifying specific structures of the TV that could potentially complicate CS cannulation. METHODS AND RESULTS: We examined 273 autopsied human hearts. The height of the TV and the diameter of the CS were measured. The valves were classified according to their shape into five types: remnant, semilunar, fold, cord, and mesh and fenestrated. The mean transverse CS ostium (CSO) diameter was 12.2 ± 3.5 mm. The TV was present in 224 (82.1%) cases. The most common type of TV was semilunar: 32.6%; followed by remnant: 25.5%; fold: 17.4%; cord: 14.3%; and lastly mesh and fenestrated: 10.3%. The mean TV height for remnant-semilunar-fold types was 5.8 ± 3.0 mm. In seven cases, the present TV (2.6%) covered the entire orifice of the CS. Hearts with larger CSO diameter had lower TV height (P < 0.001). CONCLUSIONS: We propose a new classification of the TV shapes based on the largest sample to date. We assessed that only in 2.6% of all 273 cases the presence of an obstructive TV can cause unsuccessful cannulation. The height of the TV was inversely correlated to the CSO diameter (r = -0.33; P < 0.001).

Anatomical variations of the anterior communicating artery complex: gender relationship.

PURPOSE: The anatomy of the anterior communicating artery complex plays a critical role in surgical treatment of anterior cerebral circulation aneurysms. A thorough description of vascular variations of the anterior communicating artery complex seems to be lacking. The aim of this study was to describe the anatomical variations of the anterior communicating artery complex. METHODS: The study group consisted of 411 subjects (52.31% women), without any intracranial pathologies, that had undergone head computed tomography angiography. We used maximum intensity projections, volume rendering and multi planar reconstructions to study and classify the anatomical variations of the anterior communicating and anterior cerebral arteries. RESULTS: Male subjects had a significantly higher prevalence of the typical anterior communicating artery complex (59.69 vs. 46.05%; p < 0.01). The aplastic anterior communicating artery (23.26 vs. 15.88%; p = 0.04) and triple A2 segment of the anterior cerebral artery (1.86 vs. 0.00%; p = 0.05) were more common in women than in men. CONCLUSION: Female subjects have a higher incidence of variations in the anterior communicating artery complex. There is a higher incidence of anterior communicating artery aplasia among women.

Human coronary sinus - from Galen to modern times.

Based on the review of the current literature and our own experiences we reviewed the literature paying most attention to human venous coronary system with special respect to coronary sinus - the largest vein of the heart. Many details still remain obscure, although most of modern procedures require deep anatomical knowledge on cardiac veins. Many of developmental remarks are still not clear, regarded to development of the vessels of the heart in association with origin of heart conductive system.

Morphology of tributaries of coronary sinus in humans - corrosion casting study.

The study was carried out on 80 human hearts obtained during autopsies. The vascular beds were filled with synthetic resin and next corroded. In all 80 hearts we have been found both: great, middle and small cardiac veins. In two out of 80 hearts we did not find oblique vein of the left atrium. Posterior vein of the left ventricle was double in four hearts. Right marginal vein was found in 5 hearts, left marginal vein was seen in 9 hearts. We also compared the dimensions of all of the above mentioned tributaries of the coronary sinus.

Variations and morphometric analysis of the proximal segment of the superior cerebellar artery.

INTRODUCTION: The superior cerebral artery is a clinically significant vessel, but little is known about its radiological anatomy. The aim of this study was to describe the anatomical variations of the proximal segment of the superior cerebellar artery using Computed Tomography Angiography. MATERIALS AND METHODS: The study group consisted of 200 subjects (54.5% female, mean age ± SD 56.2 ± 17.2 years) that had undergone head Computed Tomography Angiography. Subjects with any intracranial pathologies were excluded. Images in Maximum Intensity Projections were used to study the anatomical anomalies of the superior cerebellar artery. RESULTS: In 200 subject 388 superior cerebellar arteries were found. Twelve (3.09%) SCAs were duplicated in 11 patients and all originated from the basilar artery. In 8 (4.00%) patients the superior cerebellar artery was absent. The origin of the SCA was most often bilateral, mainly from the basilar artery (76.29%). The superior cerebellar artery diameter, measured at the site of the origin, was statistically significantly different depending on the place of the origin: wider when originating from the basilar artery as a single vessel (1.48 ± 0.42 mm vs. 1.34 ± 0.52 mm; p=0.03) and narrower when originating as duplicated one (1.38 ± 0.48 mm vs. 1.46 ± 0.44 mm; p=0.55). CONCLUSION: Superior cerebellar artery usually originates bilaterally from the basilar artery as a single trunk. Its diameter is significantly wider in that type in comparison to other anatomical variations.

Anatomy of Guyon's canal - a systematic review.

Carpal tunnel syndrome is the first on the list of peripheral nerve lesions in the upper limb. Most of the anatomical facts about this syndrome are widely known. The Guyoun's canal is the second reason for compression syndrome in the wrist. Anatomy of this is region still remains controversial. This is why authors tried to compile some latest findings accompanied by their own observation, and added some clinical notes, which might be useful both for orthopedic surgeons and well as for representatives of basic sciences.

Variations of the anterior communicating artery complex and occurrence of anterior communicating artery aneurysm: A2 segment consideration.

INTRODUCTION: The anterior communicating artery (ACoA) is the most frequent site of intracranial aneurysm location. Despite many studies the frequency of aneurysm occurrence with anatomical anomalies is still poorly described. Moreover the significance of the A2 segment of anterior cerebral artery anomalies has been neglected. The aim of this study was to determine the frequency and types of variations of the anterior cerebral circulation in patients with ACoA aneurysms and to analyze their relation to aneurysm occurrence in the Polish population. MATERIALS AND METHODS: We studied 50 patients with an established radiological diagnosis of ACoA aneurysm and 100 healthy age- and sex-matched controls using Computed Tomgraphy Angio- graphy. Maximum Intensity and Volume Rendering Projections were used to examine the cerebral arterial circulation. Univariate logistic regression was used to determine the statistical association between ACoA complex anomalies and aneurysm occurrence. RESULTS: Patients in the study group had a significantly higher incidence of hypoplastic A1 seg- ment of the anterior cerebral artery (24% vs. 7%; p <0.01) and aplastic A1 segment of the anterior cerebral artery (12% vs. 3%; p = 0.03). The frequency of A1 segment hypoplasia or aplasia in the study group was 36%. There was a statistical trend regarding A2 segment aplasia/hypoplasia as a potential predictor of ACoA aneurysm (6% vs. 1%; p = 0.07). CONCLUSION: Occurrence of an ACoA aneurysm is associated with hypoplasia or aplasia of the A1 segment of the anterior cerebral artery. A2 segment anomalies may potentially be associated with aneurysm formation.

Synthesis of quaternary α-amino acid-based arginase inhibitors via the Ugi reaction.

The Ugi reaction has been successfully applied to the synthesis of novel arginase inhibitors. In an effort to decrease conformational flexibility of the previously reported series of 2-amino-6-boronohexanoic acid (ABH) analogs 1, we designed and synthesized a series of compounds, 2, in which a piperidine ring is linked directly to a quaternary amino acid center. Further improvement of in vitro activity was achieved by adding two carbon bridge in the piperidine ring, that is, tropane analogs 11. These improvements in activity are rationalized by X-ray crystallography analysis, which show that the tropane ring nitrogen atom moves into direct contact with Asp202 (arginase II numbering). The synthetic routes described here enabled the design of novel arginase inhibitors with improved potency and markedly different physico-chemical properties compared to ABH. Compound 11c represents the most in vitro active arginase inhibitor reported to date.