Electro-anatomically-guided endomyocardial biopsy in a patient with focal myocardial infiltration and chronic lymphocytic leukemia.

A 53-year-old female was admitted to the cardiology department on account of signs and symptoms of congestive heart failure (HF) with severe peripheral edema and dyspnea on exertion (New York Heart Association class III) for the past 3 months.

Clinical characteristics and risk factors of in-hospital mortality among patients undergoing percutaneous pericardiocentesis.

Background: Percutaneous pericardiocentesis represents a salvage procedure in case of cardiac tamponade and diagnostic procedure in chronic pericardial effusion of unknown source. The study aimed to analyze the clinical characteristics of patients subject to pericardiocentesis and the predictors of in-hospital mortality. Methods: The study represents a registry that covered consecutive patients undergoing percutaneous pericardiocentesis from 2011 to 2022 in high-volume tertiary reference center. Electronic health records were queried to obtain demographic and clinical variables. The primary endpoint was in-hospital mortality, while secondary endpoint was the need for recurrent pericardiocentesis. Results: Out of 132 456 patients hospitalized in the prespecified period, 247 patients were subject to percutaneous pericardiocentesis (53.9% women; median age of 66 years) who underwent 273 procedures. In-hospital death was reported in 14 patients (5.67%), while recurrent pericardiocentesis in 24 patients (9.72%). Iatrogenic cause was the most common etiology (42.5%), followed by neoplastic disease (23.1%) and idiopathic effusion (14.57%). In logistic regression analysis in-hospital mortality was associated with myocardial infarction (MI)-related etiology (p = 0.001) and recurrent/persistent cardiogenic shock (p = 0.001). Conclusions: Iatrogenic etiology and neoplastic disease seem to be the most common indications for pericardiocentesis, while in-hospital mortality was particularly high in patients with spontaneous tamponade in the course of MI.

Repeated Dose of Contrast Media and the Risk of Contrast-Induced Acute Kidney Injury in a Broad Population of Patients Hospitalized in Cardiology Department.

Contrast-induced acute kidney injury (CI-AKI) can lead to the development of chronic kidney disease (CKD) and impaired in-hospital and long-term outcomes among cardiac patients. The aim of this study was to evaluate the impact of repeated contrast media (CM) administration during a single hospitalization on the rate of CI-AKI. The study group (n = 138) comprised patients with different diagnoses who received CM more than once during hospitalization, while the control group (n = 153) involved CAD patients subject to a single CM dose. Following propensity score matching (PSM), both groups of n = 84 were evenly matched in terms of major baseline variables. CI-AKI was defined by an absolute increase in SCr ≥ 0.3 mg/dL or >50% relative to the baseline value within 48-72 h from the last CM dose. Patients in the study group were older, had a higher prevalence of diabetes and CKD, received a higher total volume of CM, had a lower left ventricular ejection fraction, lower prevalence of multivessel coronary artery disease (MV-CAD), and a trend towards a lower prevalence of arterial hypertension and smoking. SCr did not differ between the study and control groups at 72 h after the CM use. CI-AKI occurred in 18 patients in the study (13.0%) and in 18 patients (11.8%) in the control group (p = 0.741). The rate of CI-AKI was also comparable following the PSM (13.1% vs. 13.1%, p = 1.0). Logistic regression analysis revealed that CKD, diabetes mellitus, MV-CAD, age, and non-steroidal anti-inflammatory drugs use, but not repeated CM use, were independent predictors of CI-AKI.

Heart Failure with Improved Ejection Fraction: Insight into the Variable Nature of Left Ventricular Systolic Function.

The progress of contemporary cardiovascular therapy has led to improved survival in patients with myocardial disease. However, the development of heart failure (HF) represents a common clinical challenge, regardless of the underlying myocardial pathology, due to the severely impaired quality of life and increased mortality comparable with malignant neoplasms. Left ventricular ejection fraction (LVEF) is the main index of systolic function and a key predictor of mortality among HF patients, hence its improvement represents the main indicator of response to instituted therapy. The introduction of complex pharmacotherapy for HF, increased availability of cardiac-implantable electronic devices and advances in the management of secondary causes of HF, including arrhythmia-induced cardiomyopathy, have led to significant increase in the proportion of patients with prominent improvement or even normalization of LVEF, paving the way for the identification of a new subgroup of HF with an improved ejection fraction (HFimpEF). Accumulating data has indicated that these patients share far better long-term prognoses than patients with stable or worsening LVEF. Due to diverse HF aetiology, the prevalence of HFimpEF ranges from roughly 10 to 40%, while the search for reliable predictors and genetic associations corresponding with this clinical presentation is under way. As contemporary guidelines focus mainly on the management of HF patients with clearly defined LVEF, the present review aimed to characterize the definition, epidemiology, predictors, clinical significance and principles of therapy of patients with HFimpEF.

Renal resistive index and long-term outcome in patients with coronary artery disease.

BACKGROUND: The study aimed to evaluate the application of intra-renal Doppler flow indices for the prediction of major adverse cardiac and cerebrovascular events (MACCE) during 24-month follow-up in patients with coronary artery disease (CAD) subject to coronary angiography (CA). METHODS: This prospective study comprised 111 consecutive patients with stable and unstable CAD (68.5% men; median age 65 years), referred for CA. Ultrasonographic parameters of intra-renal blood flow in arcuate/interlobular arteries, including renal resistive index (RRI) and pulsatility index (RPI), were acquired directly before and 1 h after the procedure. Endpoint of MACCE (cardiovascular death, myocardial infarction, myocardial revascularization or stroke) were recorded during 24-month follow-up. RESULTS: MACCE occurred in 14 patients (12.6%). Patients with MACCE had more diffuse CAD reflected by Syntax score (23.6 vs.14.4 pts., p = 0.02), higher platelet level (242.4 vs. 207.2 × 1000/µl, p = 0.01), higher rate of left main CAD (42.9% vs.5.2%, p < 0.001) and left ventricular ejection fraction < 50% (50% vs.23.7%,p = 0.045). Patients with MACCE had higher pre-procedural (0.68 ± 0.06 vs. 0.62 ± 0.06, p < 0.001) and post-procedural RRI (0.72 ± 0.06 vs.0.66 ± 0.06, p = 0.01), but comparable RPI (p = 0.63 and p = 0.36, respectively). Cox proportional hazards model revealed that pre-procedural RRI (OR = 1.11 per 0.01; p = 0.02) and left main CAD (OR = 5.75, p = 0.002) were the only independent predictors of MACCE occurrence. Receiver operator characteristic curve analysis revealed that preprocedural RRI > 0.645 accurately predicted the composite endpoint (AUC = 0.78, p = 0.001) and identified patients with impaired 24-month prognosis according to Kaplan-Meier curve (log-rank p < 0.001). CONCLUSIONS: Increased pre-procedural RRI, together with left main CAD, are associated with worse 24-month prognosis in patients with CAD referred for CA.

Increased serum levels of Galectin-9 in patients with chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in adults. Despite improvements in treatment, CLL is still considered an incurable disease. The aim of the present study was to evaluate galectin-1, -3 and -9 (Gal-1, -3 and -9) and Gal-3 binding protein (Gal-3BP) as prognostic and predictive factors in patients with CLL. Serum concentrations of Gal-1, -3 and -9 and Gal-3BP were measured in 48 patients with CLL and 30 control patients, using multiplex bead arrays. In patients with CLL, galectin concentrations were assessed prior to, during and following treatment. In patients with CLL who were untreated, galectin concentrations were measured twice with a 6-month interval. The serum level of Gal-9 was significantly increased (P<0.0001) in patients with CLL compared with the control group, and was associated with the clinical stage according to Binet classification, as well as poor cytogenetic and serum CLL prognostic factors. In addition, patients with CLL, who exhibited treatment failure, exhibited higher concentrations of Gal-9 (P=0.06) and Gal-3BP (P=0.009) at the end of the treatment when compared with patients under complete remission or stabilization of the disease. The serum level of Gal-3 was significantly decreased (P=0.012) in patients with CLL compared with the control group. These results suggest that Gal-9 is a potential prognostic factor in patients with CLL. The predictive value of Gal-9 requires further study in larger cohorts of patients.

Metamizole and Platelet Inhibition by Aspirin Following On-Pump Coronary Artery Bypass Grafting.

OBJECTIVE: The purpose of the study was to evaluate the impact of intravenous metamizole on platelet inhibition by aspirin in patients with coronary artery disease early after on-pump coronary artery bypass grafting (CABG). DESIGN: Prospective, single-blind, randomized trial. SETTING: Tertiary referal hospital. PARTICIPANTS: The study comprised 43 patients with multivessel coronary artery disease undergoing CABG. INTERVENTIONS: Patients were randomized to postoperative intravenous metamizole ± opioids (study group; n = 23) or opioids alone (control group; n = 20). Aspirin was withheld at least 7 days before the surgery and reinitiated (300 mg) immediately after the procedure prior to metamizole use, and continued daily thereafter (150 mg). Platelet function was evaluated using multielectrode impedance aggregometry (acid-induced platelet activation [ASPI] and collagen-induced platelet activation [COL] test), P-selectin expression and urinary 11-dehydro-thromboxane B2 (11-DTXB2) level at baseline, postoperative day (POD) 0, POD 1, POD 2, and POD 6. Residual platelet reactivity (RPR) was defined as ASPI test >400 AU*min. MEASUREMENTS AND MAIN RESULTS: In all study participants, postoperative ASPI test value moderately decreased (1058.2 v 966.6 AU*min, p = 0.047), urinary 11-DTXB2 level increased (923.4 v 4367.3 pg/mg, p < 0.001), and P-selectin expression and COL test value remained stable postprocedure. The decreases of ASPI (p = 0.146) and COL test (p = 0.642), and P-selectin expression (p = 0.318) did not differ between both groups. Patients in the control group had higher postoperative increase of urinary 11-DTXB2 level (p = 0.001). The prevalence of RPR was high and comparable between study and control groups (day 1, 95.6% v 100%, p = 0.535; day 6, 100% v 90%, p = 0.21). Multivariate analysis revealed that metamizole use did not predict the fluctuations of ASPI and COL test values and P-selectin expression, yet it independently predicted postoperative change of 11-DTXB2 level (b = -0.518, p = 0.001). CONCLUSIONS: Intravenous metamizole preceded by a loading dose of aspirin did not modify platelet response to aspirin in the postoperative period after CABG.

Chemotherapy and echocardiographic indices in patients with non-Hodgkin lymphoma: the ONCO-ECHO study.

The cardiotoxicity of chemotherapy (CTx) for non-Hodgkin's lymphomas is not well recognized. In order to facilitate individual risk counseling for patients, we analyzed the effect of CTx on echocardiographic indices in regard to clinical data in patients treated for non-Hodgkin's lymphoma (NHL). A prospective multicenter ONCO-ECHO trial included 67 patients with NHL (45 patients with DLBCL (diffuse large B cell lymphoma) and 22 with non-DLBCL). Patients received standard CTx, primarily R-CHOP, CHOP, R-COP and COP regimens. Clinical data and echocardiographic indices were obtained at baseline, 3-, 6- and 12-month follow-up. The primary end point representing CTx cardiotoxicity was defined as a ≥ 10% decrease in the left ventricular ejection fraction (LVEF) during 12-month observation. In a 12-month follow-up five (7.5%) deaths occurred, while no clinical manifestations of heart failure were reported. There was an increase in left ventricular end-systolic diameter (p = 0.002) and E/e' index (p = 0.036) in 12-month observation. Preexisting coronary artery disease was associated with significant decrease in the ΔLVEF (p = 0.008), increase in ΔLVEDV (p = 0.03) and ΔLVESV (p = 0.02) and increase in the Δ left atrium diameter (p = 0.02); while history of arterial hypertension was related to significant decrease in the ΔLVEF (p = 0.039), diabetes mellitus was related to significant increase in the ΔE/e' index (p = 0.002). The primary end point was reported in ten (14.9%) patients. There were no independent risk factors for cardiotoxicity in the study population. Chemotherapy administered to NHL patients may induce dilatation and impaired LV diastolic function. Standard cardiovascular risk factors may predispose patients to negative LV remodeling.

Left ventricular diverticulum mimicking cardiac tumor.

Left ventricular (LV) diverticulum represents a rare and frequently asymptomatic congenital anomaly, which is incidentally discovered during routine transthoracic echocardiography. We present a case of a 66-year-old female patient who was admitted to the cardiology department due to incidental finding of a tumor-like mass associated with the posterior mitral leaflet. Preliminary echocardiographic evaluation revealed a solid structure, suspected of mitral annulus calcification or LV malignancy. However, cardiac contrast-enhanced computed tomography confirmed the presence of LV diverticulum, partially filled with calcified thrombus. Conservative management was recommended. This case underscores the importance of multimodality imaging for differentiation of LV tumor-like structures.

A study to evaluate the prevalence and determinants of stress coping strategies in heart failure patients in Poland (CAPS-LOCK-HF sub-study).

BACKGROUND AND AIM: We aimed to evaluate the prevalence and determinants of different stress coping strategies in Polish patients suffering from heart failure with reduced ejection fraction (HFREF). METHODS: This manuscript is a sub-study of the CAPS-LOCK-HF multicentre psychological status assessment of patients with HFREF. Patients with > six-month history of HFREF and clinical stability for ≥ three months and left ventricular ejection fraction (LVEF) < 45% were enrolled in the study. Demographic and clinical variables were obtained from medical records, while a standardised Coping Inventory for Stressful Situations (CISS) was applied to all subjects. RESULTS: The study comprised 758 patients (599 men; 79%) with a median age of 64 years (IQR 58-71). Median LVEF was 33% (25-40). Subjects most commonly used task-oriented coping strategies (median CISS score 55 points; IQR 49-61), followed by avoidance (45 points; 39-50) and emotion-oriented coping strategies (41 points; 34-48). Distraction-based avoidance coping strategies (20 points; 16-23) were more pronounced than social diversion strategies (16 points; 14-19). Multiple regression analysis showed that higher New York Heart Association (NYHA) class and lower systolic blood pressure were independent predictors of task-oriented style. Emotion-oriented coping was more common among females and higher NYHA classes, and in patients who did not take angiotensin-converting enzyme inhibitors. Patients who used avoidance-oriented strategies were more frequently those in sinus rhythm on assessment and those who had less history of neoplastic disease. CONCLUSIONS: Patients with HFREF most commonly use favourable task-oriented coping strategies. However, female patients and those with higher NYHA classes tend to use potentially detrimental emotion-oriented coping strategies.

Eptifibatide infusion versus placebo in high risk patients with non-ST segment elevation acute coronary syndromes managed with urgent coronary artery bypass graft surgery. A prospective multicenter randomized placebo-controlled clinical trial.

BACKGROUND: This randomized prospective clinical trial aimed to evaluate safety and efficacy of preoperative use of eptifibatide in high risk patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), requiring urgent coronary artery bypass graft surgery (CABG). METHODS: A total of 140 patients with NSTE-ACS eligible for urgent surgical revascularization received either eptifibatide (bolus plus infusion) 12-48 hours prior to surgery (N.=72 patients) or placebo (normal saline; N.=68 patients) followed by routinely administered enoxaparin and aspirin. Patients were regarded as unsuitable for percutaneous coronary intervention by the heart team. CABG was performed 4 hours after discontinuation of eptifibatide or placebo infusion. The primary end point was major adverse cardiac and cerebrovascular events (MACCE) defined as death, nonfatal myocardial infarction (MI), stroke and the need for rehospitalization due to recurrent ischemia at 12-month follow-up. Secondary endpoints included MACCE rate at 1 month, bleeding complications, platelet inhibition efficacy and correlation of platelet activity with MACCE rate. RESULTS: Cumulative one year MACCE rate was 35% vs. 14% in the control and treated group respectively (P=0.012). Mortality rate at 30 days follow-up was 10% vs. 3% (P=0.021) and was not changed at 12-month follow-up. There was a significant difference between both groups regarding perioperative MI (22% vs. 8%, P=0.03). The rates of stroke, blood loss and blood transfusion were similar in both groups. CONCLUSION: Preoperative use of eptifibatide vs. placebo is linked to significantly reduced 12-month MACCE rate in patients with NSTE-ACS requiring urgent CABG, while it simultaneously seems not to confer a greater risk of postoperative bleeding.

Glycaemic Control in Cardiac Surgery Patients: a Double-Edged Sword.

Glycaemic management is of paramount importance in the cardiac surgery setting. A growing body of evidence confirms a J-shaped relationship between blood glucose (BG) level and perioperative morbidity and mortality. On one hand, acute hypoglycaemia causes irreversible cerebral damage. On the other hand, hyperglycaemia increases the risk of infections, acute kidney injury, atrial fibrillation, low cardiac output syndrome, cerebrovascular accidents and cognitive impairment. Also, high BG variability, even within the therapeutic window, may deteriorate the outcome. Therefore, moderate perioperative insulin management is usually recommended, with target BG adjusted to individual needs and possibilities. Continuous BG monitoring is a promising tool that should help practitioners in everyday decision-making process of glycaemic control. This review summarises the current evidence-based knowledge on the perioperative management of hyperglycaemia.

Delirium Screening in Cardiac Surgery (DESCARD): a useful tool for nonpsychiatrists.

BACKGROUND: The aim of the study was to set up and validate a predictive scoring system for nonpsychiatrists to facilitate screening of postoperative delirium in cardiac surgery patients. METHODS: The project was conducted as a cohort study in 5781 subjects. More than 100 pre- and perioperative somatic variables were collected to build up an algorithm. Delirium was diagnosed using Diagnostic and Statistical Manual of Mental Disorders 4th edition. The patient cohort was divided into a training and validation set to perform cross-validation. Scoring systems (Delirium Screening in Cardiac Surgery [DESCARD] tool) were developed for the set of sole preoperative and all perioperative risk factors. RESULTS: Delirium was found in 236 patients (4.1%). The preoperative model comprised age, weight, total protein concentration, arterial hypertension, mode of surgery (elective/urgent/emergent), preoperative fasting glucose, and form of diabetes treatment (diet/oral agents/insulin). Taking into account all the perioperative variables, the scoring system included postoperative cerebral ischemia and the need for red blood cell transfusion, and arterial hypertension and mode of surgery were excluded. Both pre- and perioperative tools had an excellent overall diagnostic accuracy (area under receiver operator characteristics curve = 0.83 and 0.89, respectively) with higher specificity (92% and 93%, respectively) than sensitivity (60% and 69%, respectively). CONCLUSIONS: The DESCARD tool might be effective in screening of patients at risk of postoperative delirium and can be easily used by all nonpsychiatrists involved in the care of cardiac surgery patients.

Low plasma renalase concentration in hypertensive patients after surgical repair of coarctation of aorta.

The study aimed to evaluate plasma renalase level, a recently discovered kidney-derived catecholamine-metabolizing enzyme in patients after successful repair of aortic coarctation, with special consideration of arterial hypertension in the context of underlying process of arterial remodeling. This case-control study covered 50 consecutive patients after Dacron patch repair of aortic coarctation (31 men; median age 33 [26; 40]; age at surgery 10 [5; 16] years), matched in terms of age and gender with 50 controls. Both groups were stratified depending on the presence of hypertension and assessed in terms of renalase, C-reactive protein, and carotid intima-media thickness. Additionally ultrasound and tonometric markers of vascular remodeling were obtained in the study group. Hypertension was found in 21 patients (42%) in the study group and 29 (58%) in the control group (P = .11). Renalase level was significantly lower in patients in the study than control group (5825.1 vs. 6592.7 ng/mL; P = .041). Significant difference in terms of renalase concentration between hypertensive and normotensive patients was confirmed both in subjects with coarctation of aorta (P = .027) and in control group (P < .0001). Renalase level inversely correlated with serum creatinine (r = -0.36) and arterial blood pressure in the whole population, and with central systolic (r = -0.29) and diastolic pressure (r = -0.35) in study group. Multivariate regression revealed that serum creatinine and pulse pressure were independent predictors of renalase. Surgical intervention >7 years was linked to lower renalase (P = .018) and unfavorable vascular parameters. Renalase level <4958 ng/mL accurately predicted presence of hypertension in patients after coarctation of aorta repair (odds ratio, 3.8; P = .032). Renalase deficiency is associated with the presence of hypertension in both patients after surgical repair of aortic coarctation and the control group. In coarctation of aorta, its action is probably parallel to underlying arterial remodeling.

Detailed insight into the impact of postoperative neuropsychiatric complications on mortality in a cohort of cardiac surgery subjects: a 23,000-patient-year analysis.

OBJECTIVES: This study sought to evaluate the impact of postoperative delirium with/without cerebral ischemia on short- and long-term mortality in a large cohort of cardiac surgery patients. DESIGN: The study constituted a prospective cohort observation of patients following various cardiac surgery procedures. SETTING: The investigation was conducted in a single high-volume tertiary cardiac surgery center. PARTICIPANTS: Consecutive candidates for cardiac surgery (n = 8,792) from 2003 to 2008 were subjected to the following exclusion criteria: History of any psychiatric disorders, alcohol abuse and intake of psychoactive drugs and incomplete data. INTERVENTIONS: No additional interventions were performed, except for standard perioperative management. MEASUREMENTS AND MAIN RESULTS: 5,781 patients finally were assigned to cohorts depending on the presence of postoperative delirium with/without cerebral ischemia and then prospectively followed up over the median time of 46 months. Overall 30-day mortality in patients with delirium was 15.25%, including 6.43% of patients without and 38.46% of subjects with cerebral ischemia. After adjustment for more than 100 perioperative variables, short-term mortality was associated independently with delirium (OR = 3.735), stroke (OR = 5.698), hypertension (OR = 0.333), urgency of surgery (OR = 13.018), baseline plasma glucose and protein concentrations and blood transfusions (AUROC for the model 0.94). Long-term mortality in patients who developed delirium was 23.31%, including 15.2% of patients without and 44.62% of those with postoperative stroke. Long-term mortality independently corresponded with stroke (HR = 3.968), urgent surgery (HR = 27.643), baseline plasma glucose and protein concentrations, chronic obstructive pulmonary disease and blood transfusions. Impact of postoperative delirium was insignificant (p = 0.2). Compared to subjects with cerebral ischemia, death in patients only with delirium was less frequently of cardiovascular cause (p < 0.01). CONCLUSIONS: Delirium with/without cerebral ischemia significantly worsened the short-term prognosis. Stroke, yet not delirium, considerably increased the long-term mortality, especially of cardiovascular origin.

Complex assessment of the incidence and risk factors of delirium in a large cohort of cardiac surgery patients: a single-center 6-year experience.

BACKGROUND: Previous reports provided inconsistent data on the occurrence of postoperative delirium and emphasized its considerable impact on outcome. This study sought to evaluate the incidence and predictors of delirium, together with its relation to cerebral ischemia in a large cohort of cardiac surgery patients in a tertiary high-volume center. METHODS AND RESULTS: Consecutive patients (n = 8792) were prospectively enrolled from 2003 to 2008. Exclusion criteria were history of psychiatric disorders, use of psychoactive drugs, alcohol abuse, and data incompleteness. Finally, 5781 patients were analyzed in terms of 100 perioperative patient-specific and treatment variables. The incidence of postoperative delirium (DSM IV criteria) was 4.1% and it coexisted with cerebral ischemia in 1.1% of patients. In bivariate analysis, 49 variables were significantly linked to postoperative delirium. Multivariate analysis confirmed that delirium was independently associated with postoperative stroke (logistic odds ratio (logOR) = 2.862, P = 0.004), any blood transfusions (logOR = 4.178, P < 0.0001), age > 65 years (logOR = 2.417, P = 0.002), carotid artery stenosis (logOR = 2.15, P = 0.01), urgent/emergent surgery (logOR = 1.982, P = 0.02), fasting glucose level, intraoperative oxygen partial pressure fluctuations, and hematocrit. Area under ROC curve for the model was 0.8933. CONCLUSIONS: Early identification of nonpsychiatric perioperative determinants of delirium facilitates its diagnosis and might help develop preventive strategies to improve long-term outcome after cardiac surgery procedures.