Coronary Slow-Flow Phenomenon in Takotsubo Syndrome: The Prevalence, Clinical Determinants, and Long-Term Prognostic Impact.

Patients with takotsubo syndrome (TTS) may present coronary slow flow (CSF) in angiography performed in the acute myocardial infarction (MI). However, the detailed clinical relevance and its long-term impact remain poorly understood. Among 7771 MI patients hospitalized between 2012 and 2019, TTS was identified in 82 (1.1%) subjects. The epicardial blood flow was assessed with thrombolysis in myocardial infarction (TIMI) scale and corrected TIMI frame count (TFC), whereas myocardial perfusion with TIMI myocardial perfusion grade (TMPG). CSF was defined as TIMI-2 or corrected TFC > 27 frames in at least one epicardial vessel. CSF was identified in 33 (40.2%) TTS patients. In the CSF-TTS versus normal-flow-TTS group, lower values of left ventricular ejection fraction on admission (33.5 (25-40) vs. 40 (35-45)%, p = 0.019), more frequent midventricular TTS (27.3 vs. 8.2%, p = 0.020) and the coexistence of both physical and emotional triggers (9.1 vs. 0%, p = 0.032) were noted. Within a median observation of 55 months, higher all-cause mortality was found in CSF-TTS compared with normal-flow TTS (30.3 vs. 10.2%, p = 0.024). CSF was identified as an independent predictor of long-term mortality (hazard ratio 10.09, 95% confidence interval 2.12-48.00, p = 0.004). CSF identified in two-fifths of TTS patients was associated with unfavorable long-term outcomes.

Cardiac Post-Chest Radiotherapy Complications in a 50-Year-Old Patient with Hodgkin Lymphoma.

Lymphomas are a group of malignant tumors that originate in the lymphatic system. It is the most common type of blood cancer. It affects the lymph nodes, spleen, bone marrow, blood, and other organs. They can be aggressive or chronic. Hodgkin lymphoma survival rate is 2 in 100,000 people. Young adults aged 20-30 and people over 50 are most often affected. The prognosis of Hodgkin's lymphoma is good, with a survival rate of up to 80 percent. Nevertheless, in 20-30 percent of patients who initially respond to treatment, the disease has a tendency to progress. The positive effect of radiotherapy (RT) on patients' survival rates has been proven in many randomized clinical trials. Although the dose of chest RT has significantly reduced over the years, we still struggle with the long-term complications of post-RT repercussions, mainly because there is no established safe dose of RT affecting the heart. Other complications include earlier onset of coronary artery disease, early and late onset of pericarditis, valve degeneration (predominantly of the left heart), calcification of the aorta and its branches, heart failure, and arrhythmias. One patient can manifest each of the abovementioned complications, as in the present case. That is why choosing the right treatment strategy is crucial.

Recent Advances in the Treatment of Pulmonary Arterial Hypertension Associated with Connective Tissue Diseases.

Pulmonary hypertension (PH) is a severe vascular complication of connective tissue diseases (CTD). Patients with CTD may develop PH belonging to diverse groups: (1) pulmonary arterial hypertension (PAH), (2) PH due to left heart disease, (3) secondary PH due to lung disease and/or hypoxia and (4) chronic thromboembolic pulmonary hypertension (CTEPH). PAH most often develops in systemic scleroderma (SSc), mostly in its limited variant. PAH-CTD is a progressive disease characterized by poor prognosis. Therefore, early diagnosis should be established. A specific treatment for PAH-CTD is currently available and recommended: prostacyclin derivative (treprostinil, epoprostenol, iloprost, selexipag), nitric oxide and natriuretic pathway: stimulators of soluble guanylate cyclase (sGC: riociguat) and phosphodiesterase-five inhibitors (PDE5i: sildenafil, tadalafil), endothelin receptor antagonists (ERA: bosentan, macitentan, ambrisentan). Moreover, novel drugs, e.g., sotatercept, have been intensively investigated in clinical trials. We aim to review the literature on recent advances in the treatment strategy and prognosis of patients with PAH-CTD. In this manuscript, we discuss the mechanism of action of PAH-specific drugs and new agents and the latest research conducted on PAH-CTD patients.

Microcirculatory Disease in Patients after Heart Transplantation.

Although the treatment and prognosis of patients after heart transplantation have significantly improved, late graft dysfunction remains a critical problem. Two main subtypes of late graft dysfunction are currently described: acute allograft rejection and cardiac allograft vasculopathy, and microvascular dysfunction appears to be the first stage of both. Studies revealed that coronary microcirculation dysfunction, assessed by invasive methods in the early post-transplant period, correlates with a higher risk of late graft dysfunction and death during long-term follow-up. The index of microcirculatory resistance, measured early after heart transplantation, might identify the patients at higher risk of acute cellular rejection and major adverse cardiovascular events. It may also allow optimization and enhancement of post-transplantation management. Moreover, cardiac allograft vasculopathy is an independent prognostic factor for transplant rejection and survival rate. The studies showed that the index of microcirculatory resistance correlates with anatomic changes and reflects the deteriorating physiology of the epicardial arteries. In conclusion, invasive assessment of the coronary microcirculation, including the measurement of the microcirculatory resistance index, is a promising approach to predict graft dysfunction, especially the acute allograft rejection subtype, during the first year after heart transplantation. However, further advanced studies are needed to fully grasp the importance of microcirculatory dysfunction in patients after heart transplantation.

Abandoned Intracardiac Electrodes in an Oncological Patient.

Cardiological and oncological patients comprise the majority of patients admitted to the emergency unit with chronic or acute conditions that are the dominant cause of death worldwide. However, electrotherapy and implantable devices (pacemakers and cardioverters) improve the prognosis of cardiological patients. We present the case report of a patient who, in the past, had a pacemaker implanted due to symptomatic sick sinus syndrome (SSS) without removing the two remaining leads. Echocardiography revealed severe tricuspid valve regurgitation. The tricuspid valve septal cusp was in a restricting position due to the two ventricular leads passing through the valve. A few years later, she was diagnosed with breast cancer. We present a 65-year-old female admitted to the department due to right ventricular failure. The patient manifested symptoms of right heart failure, predominated by ascites and lower extremity edema, despite increasing doses of diuretics. The patient underwent a mastectomy two years ago due to breast cancer and was qualified for thorax radiotherapy. A new pacemaker system was implanted in the right subclavian area as the pacemaker generator occupied the radiotherapy field. In the case of right ventricular lead removal and the need for pacing and resynchronization therapy, guidelines allow a coronary sinus for LV pacing to avoid passing the leads through the tricuspid valve. We facilitated this approach in our patient, suggesting that the percentage of ventricular pacing was very low.

Open-Heart Cardio-Thoracic Biological Valve Replacement Following Complicated Transcatheter Aortic Valve Implantation.

Transcatheter aortic valve implantation (TAVI) is currently becoming the method of choice in high-risk patients with severe aortic valve stenosis. Post-TAVI complications are more common owing to the increasing use of the method. The majority of TAVI complications derive from concomitant aortic stenosis with moderate/severe aortic insufficiency, paravalvular leak, and atrioventricular block. The contemporary TAVI qualification process includes a thorough echocardiography and angio-CT of the aorta, which is crucial in assessing valve measurements, determining the position of the coronary arteries branching from the aorta, and choosing the optimal valve size. We present the case report of an 81-year-old patient admitted to our hospital because of exacerbation of the clinical condition and development of pulmonary edema a few days after TAVI. Despite the reduction of the initial leak, an echocardiographic examination revealed the remaining severe paravalvular aortic leakage. We performed open-heart cardio-thoracic surgery, explanted the TAVI valve, and implanted the biological prosthesis (Edwards Perimount Magna size 25). Introduction of new interventional treatment approaches and the availability of imaging tools have substantially reduced the incidence of significant paravalvular leak and offered a better prognosis for patients undergoing TAVI.

Circulating miRNA-451a and miRNA-328-3p as Potential Markers of Coronary Artery Aneurysmal Disease.

MicroRNAs (miRNAs) are currently investigated as crucial regulatory factors which may serve as a potential therapeutic target. Reports on the role of miRNA in patients with coronary artery aneurysmal disease (CAAD) are limited. The present analysis aims to confirm the differences in the expression of previously preselected miRNAs in larger study groups and evaluate their usefulness as potential markers of CAAD. The study cohort included 35 consecutive patients with CAAD (Group 1), and two groups of 35 patients matched Group 1 regarding sex and age from the overall cohort of 250 patients (Group 2 and Group 3). Group 2 included patients with angiographically documented coronary artery disease (CAD), while Group 3 enrolled patients with normal coronary arteries (NCA) assessed during coronary angiography. We applied the RT-qPCR method using the custom plates for the RT-qPCR array. We confirmed that the level of five preselected circulating miRNAs was different in patients with CAAD compared to Group 2 and Group 3. We found that miR-451a and miR-328 significantly improved the CAAD prediction. In conclusion, miR-451a is a significant marker of CAAD compared to patients with CAD. In turn, miR-328-3p is a significant marker of CAAD compared to patients with NCA.

Neopterin as a predictive biomarker of postoperative atrial fibrillation following coronary artery bypass grafting.

BACKGROUND: The pathophysiology of postoperative atrial fibrillation (POAF) is multifactorial. Inflammation and increased oxidative stress play a significant role in POAF development. Neopterin, a biomarker of cellular immune response that enhances oxidative stress and increases the cytotoxic potential of activated macrophages and dendritic cells, was recently found as an independent predictive biomarker of non-operative atrial fibrillation. However, as far as we know, neopterin has never been investigated in POAF. AIMS: The study aimed to assess neopterin concentration as a prognostic biomarker of POAF following coronary artery bypass grafting (CABG). METHODS: One hundred one patients (80.2% males, 85% off-pump, 15% on-pump) were included. Blood samples were taken from patients for analysis of serum neopterin and high-sensitive C-reactive protein (hs-CRP) at three time points: (1) before operation (NP0); (2) on the first day after operation (NP1); and (3) between the fifth and eighth day after the procedure (NP5-8). All factors (preoperative, echocardiographic, and surgical), significant in univariate analysis, were included in a multivariable logistic regression analysis. RESULTS: POAF occurred in 30 patients (30%). In the analyzed multivariable logistic regression models, the independent predictors of POAF occurrence were: higher NP0 concentration (odds ratio [OR], 1.16; 95% confidence interval [CI], 1.02-1.38 for continuous and OR, 3.75; 95% CI, 1.39-10.1 for NP0 cut-off >8.7 nmol/l), higher body mass index (OR, 1.15; 95% CI 1.02-1.29), history of pulmonary disease (OR, 6.72; 95% CI 1.57-28), increased diastolic thickness of the interventricular septum (OR, 1.45; 95% CI, 1.14-1.83), and duration of operation (OR, 1.01; 95% CI, 1.03-1.36). CONCLUSIONS: We found that elevated neopterin concentration before CABG may be a predictive biomarker of POAF.