Natriuretic Peptides in Heart Failure with Preserved Left Ventricular Ejection Fraction: From Molecular Evidences to Clinical Implications.

The incidence of heart failure with preserved ejection fraction (HFpEF) is increasing and its challenging diagnosis and management combines clinical, imagistic and biological data. Natriuretic peptides (NPs) are hormones secreted in response to myocardial stretch that, by increasing cyclic guanosine monophosphate (cGMP), counteract myocardial fibrosis and hypertrophy, increase natriuresis and determine vasodilatation. While their role in HFpEF is controversial, most authors focused on b-type natriuretic peptides (BNPs) and agreed that patients may show lower levels. In this setting, newer molecules with an increased specificity, such as middle-region pro-atrial natriuretic peptide (MR-proANP), emerged as promising markers. Augmenting NP levels, either by NP analogs or breakdown inhibition, could offer a new therapeutic target in HFpEF (already approved in their reduced EF counterparts) by increasing the deficient cGMP levels found in patients. Importantly, these peptides also retain their prognostic value. This narrative review focuses on NPs' physiology, diagnosis, therapeutic and prognostic implication in HFpEF.

Multimodality Imaging in Right Heart Tumors: Proposed Algorithm towards an Appropriate Diagnosis.

A right heart tumor can be identified by transthoracic echocardiography during a routine examination or due to cardiac symptoms. The first step is the assessment by echocardiography, with its multiple techniques, and the obtained information must be judged in a clinical and biological context. The second step comprises one, sometimes even two, of the more complex modality imaging methods. The choice is driven not only by the advantages of each imaging technique but also by local expertise or the preferred imaging modality in the center. This step is followed by staging, follow-up, and/or imaging-guided excision or biopsy, which is performed in selected cases in order to obtain anatomopathological confirmation. In the presence of features suggestive of malignancy or causing hemodynamic impairment, a transvenous biopsy is essential before the more complex imaging modalities (which are still relevant in the staging process). Using a structured imaging approach, it is possible to reach an appropriate diagnosis without a biopsy. Frequently, these imaging techniques have a complementary role, so an integrated imaging approach is recommended. This proposed algorithm for appropriate diagnosis of right heart tumors could serve as a practical guide for clinicians (not only imaging specialists).

An Overview of the Pharmacokinetics and Pharmacodynamics of Landiolol (an Ultra-Short Acting ß1 Selective Antagonist) in Atrial Fibrillation.

Landiolol is an ultra-short-acting, selective ß1-adrenergic receptor blocker that was originally approved in Japan for the treatment of intraoperative tachyarrhythmias. It has gained attention for its use in the management of tachyarrhythmias and perioperative tachycardia, especially atrial fibrillation for both cardiac and non-cardiac surgeries. It can be the ideal agent for heart rate control due to its high ß1-selectivity, potent negative chronotropic effect, a limited negative inotropic potential, and an ultrashort elimination half-life (around 4 min); moreover, it may have a potential therapeutic effects for sepsis and pediatric patients. Landiolol seems to be superior to other short-acting and selective beta-blockers such as esmolol. This review aims to provide a comprehensive overview of landiolol, a new ultra-short-acting ß1 selective antagonist, including its pharmacology, clinical applications, efficacy, safety profile, and future directions in research and clinical data.

Accidental Hypothermia in the Largest Emergency Hospital in North-Eastern Romania.

INTRODUCTION: Accidental hypothermia (AH) presents a significant mortality risk, even in individuals with good health. Early recognition of the parameters associated with negative prognosis could save more lives. METHODS: This was a pilot, retrospective observational study, conducted in the largest Emergency Hospital in North Eastern Romania, which included all patients with AH (defined as body temperature below 35°C), hospitalized and treated in our hospital between 2019 and 2022. RESULTS: A total of 104 patients with AH were included in our study, 90 of whom had data collected and statistically analyzed. The clinical, biological, and therapeutic parameters associated with negative outcomes were represented by a reduced GCS score (p=0.024), diminished systolic and diastolic blood pressure (p=0.007 respectively, 0.013), decreased bicarbonate (p=0.043) and hemoglobin levels (p=0.002), the presence of coagulation disorders (p=0.007), as well as the need for administration of inotropic or vasopressor medications (p=0.04). CONCLUSION: In this pilot, retrospective, observational study, the negative outcomes observed in patients with AH hospitalized in the largest Emergency Hospital in North-Eastern Romania were associated with several clinical, biochemical, and therapeutic factors, which are easy to identify in clinical practice. Recognizing the significance of these associated factors empowers healthcare practitioners to intervene at an early stage to save more lives.

Mitral Annular Calcification and Thromboembolic Risk.

Thromboembolic (TE) risk scores used for atrial fibrillation (AF) patients do not include mitral annular calcification (MAC) as a potential indicator of vascular disease. This research evaluated the correlation between MAC and TE risk scores (CHADS2 and CHA2DS2-VASc). We compared TE risk score values and clinical and echocardiographic data in patients with and without MAC. We included, prospectively, 103 patients: 40.8% with AF, 83.5% with hypertension, 30.1% with type II diabetes mellitus, 79.6% with chronic heart failure, and 7.8% with a history of stroke. We identified MAC in 50.5% of patients. The mean CHADS2 and CHA2DS2-VASc scores were 2.56 ± 1.135 and 4.57 ± 1.61, respectively. In MAC patients, both scores tended to increase significantly compared with the control (2.88 ± 1.114 versus 2.24 ± 1.06, p = 0.005, and 5.21 ± 1.51 versus 3.92 ± 1.46, p < 0.001, respectively). The left ventricular ejection fraction negatively correlated with the presence of MAC (r = -0.254, p = 0.01). The presence of MAC was a risk factor for vascular disease (OR = 2.47, χ2 = 34.32, p < 0001). Conclusions: The presence of MAC is associated with greater TE risk scores and a higher risk of vascular disease. It appears that adding MAC as a vascular disease parameter to TE risk scores may have benefits for patients by improving their predictive value.

Gastro-Esophageal Reflux Disease and Paroxysmal Atrial Fibrillation Ablation.

Patients undergoing ablation for atrial fibrillation may be at increased risk of developing gastroesophageal reflux disease. We prospectively studied the presence of symptomatic gastroesophageal reflux disease in naïve patients who underwent atrial fibrillation ablation. METHODS: The presence of typical symptoms suggestive of gastroesophageal reflux disease was clinically assessed by the gastroenterologist at baseline and at 3 months after ablation. In addition to that, all patients underwent upper gastrointestinal endoscopy. RESULTS: Seventy-five patients were included in two groups: 46 patients who underwent atrial fibrillation ablation (study group) and 29 patients without ablation (control group). Patients with atrial fibrillation ablation were younger (57.76 ± 7.66 years versus 67.81 ± 8.52 years; p = 0.001), predominantly male (62.2% versus 33.3%; p = 0.030) and with higher body mass index (28.96 ± 3.12 kg/m2 versus 26.81 ± 5.19 kg/m2; p = 0.046). At three months after the ablation, in the study and control groups, there were 88.9% and 57.1% patients in sinus rhythm, respectively, (p = 0.009). Symptomatic gastroesophageal reflux disease was not more frequent in the study group (42.2% versus 61.9%; p = 0.220). There was no difference in terms of sinus rhythm prevalence in patients with versus without symptomatic gastroesophageal reflux disease (89.5% versus 88.5%; p = 0.709). CONCLUSION: In this small prospective study, typical symptoms suggestive of gastroesophageal reflux disease were not more frequent three months following atrial fibrillation ablation.

VENOUS ULCER--A NEW THERAPEUTIC APPROACH.

Trophic leg ulcer is a major health problem affecting approximately 1-2% of the population, the incidence being higher in the elderly (70-80 years). It is a multifactorial condition, but the most common cause is chronic venous insufficiency. This can be attributed to reflux in the saphenous system and calf perforator vein incompetence. These were first described by Linton, the first intervention designed to correct perforator vein incompetence bearing his name. Today Linton's operation has been abandoned due to the large unaesthetic incision and great postoperative pain. Also, ulcer healing time is long (2 months) and recurrence rate is high. Currently a series of minimally invasive procedures are used to close these perforator veins, such as ultrasound-guided sclerotherapy. The advantages of these techniques are less discomfort to the patients, low rate of complications, short hospital stay.

SURGICAL TREATMENT OF POSTPARTUM ILIOFEMORAL DEEP VEIN THROMBOSIS--CASE REPORTS.

The writing committee for Antithrombotic Therapy for Venous Thromboembolic Disease of the 2008 ACCP guidelines made the following recommendations for thrombus removal strategies in patients with deep vein thrombosis (DVT): open surgical thrombectomy is recommended in patients with acute iliofemoral DVT to reduce symptoms and post-thrombotic morbidity; whenever available, catheter-directed thrombolysis is preferred to surgical venous thrombectomy, the risk of hemorrhage being diminished; surgical venous thrombectomy is recognized to be efficient in cases where catheter-directed thrombolysis is unavailable or the patients are not suitable candidates for such a procedure. Randomized studies comparing surgical thrombectomy and anticoagulant therapy in patients with iliofemoral DVT (IFDVT) showed that at 6 months, 5 years, and 10 years the patients in the thrombectomy group presented increased permeability, lower venous pressure, less edema, and fewer postthrombotic symptoms compared to the patients receiving anticoagulant therapy. In this article we present 3 cases of IFDVT in postpartum patients diagnosed by Doppler ultrasound of the deep venous system. The 3 patients received anticoagulant therapy prior to surgery. Surgery consisted in thrombectomy of the common, superficial and deep femoral veins, external and internal iliac veins, and femoral-saphenous arteriovenous fistula. The patients received postoperative antithrombotic therapy and were followed-up at 3, 6 and 9 months by Doppler ultrasound of the deep venous system.

Paraganglioma of the carotid body: case report.

With an incidence of 0.03% of all tumors, carotid body tumors (CBTs) are extremely rare. We present the case of a 63 year old female patient with an asymptomatic right sided neck mass of 3 cm diameter. Doppler ultrasound and contrast-enhanced CT confirmed the clinical suspicion of carotid body tumor. The patient underwent complete surgical excision of the Shamblin group II tumor and an adjacent lymph node, without preoperative embolization. The histopathological examination diagnosed a benign CBT. There were no postoperative complications at 1 and 6 months follow-ups.

Surgical revascularization in chronic mesenteric ischemia.

Chronic mesenteric ischemia (CMI) is a disease causing death either by starvation or enteromesenteric infarction. Diagnosis is often delayed before the patient is referred to a vascular surgery unit. Atherosclerosis is the main cause of CMI. Arteriography is essential in diagnosing CMI and delineating the atherosclerotic lesions. The revascularization procedure consists in an aortomesenteric bypass reconstructing 1-3 visceral arteries. This paper presents two consecutive CMI cases treated at the Vascular Surgery Unit of the Iasi "Sf Spiridon" Hospital during 2010. Both patients had symptoms suggestive of mesenteric and aortoiliac diseases. CT angiography revealed specific lesions both for aortoiliac disease and stenotic or occlusive lesions in the celiac trunk and mesenteric arteries. Both cases benefited from aortobifemural bypass surgery using a synthetic graft associated with aortic-superior mesenteric artery bypass with reversed vein graft (in the first case both mesenteric arteries were revascularized). Immediate and remote results were favorable, with remission of intestinal symptoms and weight gain. Bypass patency was followed-up by CT angiography and Doppler ultrasound. CMI is a diagnostic and therapeutic challenge. Open surgery provides symptom remission in 90% of cases. Permeability at 5 years is 80-90% for open surgery, higher than by endovascular therapy. Average permeability of the two types of intervention is 70% at 5 years, similar to the infraaortic bypasses.

Complex utrasound study of the atherosclerotic plaque.

UNLABELLED: Carotid surgery concept is wining ground both among neurologists who recommend and vascular surgeons who perform an increased number of interventions. Regardless of the technique, we are interested in the tendency of the plaque to grow and determine stenosis. Ultrasound (US) is 91-94% sensitive and 85-99% specific in detecting a significant stenosis of the internal carotid artery. AIM: To establish a correlation between the preoperative US and intraoperative plaque characteristics in order to determine the restenosis rate. MATERIAL AND METHODS: From January 1, 2012 to December 31, 2012, 70 consecutive patients were included in this study. Two groups were formed: 35 patients with stenotic ICA and 35 patients presenting stenosis at the femoral artery bifurcation (control group). The comparison between these two groups started from the premise of a similar pattern for internal carotid artery--deep femoral artery and external carotid artery- superficial femoral artery. US scans were performed on admission in all patients. All images were normalized and Gray Scale Median (GSM) was calculated. RESULTS: Femoral plaque GSM values were higher in relation with hyperechogenicity highlighting the intensely calcified structure. Unstable plaques were more heterogenic, with higher transparency and lower GSM than stable plaques. This was the case of carotid plaques. During follow-up US revealed no restenosis. CONCLUSIONS: Femoral bifurcation plaques are calcified and determine chronic ischemic symptoms, while carotid bifurcation plaques are unstable and determine cerebral symptoms. US remain the gold standard non-invasive technique both for screening and diagnosis and set the therapeutic coordinates.

Epidemiological characteristics of peripheral artery disease: retrospective study.

UNLABELLED: Peripheral artery disease (PAD) is a common condition. Over the past 20 years the risk factors for PAD have changed. AIMS: To identify the regional characteristics of the patients with PAD and the sex- and urban/rural-related differences. MATERIAL AND METHODS: Retrospective study on patients admitted to the Iasi "St. Spiridon' University Hospital in the interval 2007-2012. The dataset was prepared for t student analysis in in view of determining statistical significance. RESULTS: Of the 361,248 patients admitted to the 20 units of the hospital, 2,623 patients were diagnosed with advanced stages of PAD (Leriche--Fontain III and IV). Significant statistical differences were found between men and women, and between rural and urban men (p = 0.001). 20.5% of the patients underwent amputations. CONCLUSIONS: This is one of the first studies that has identified urban/rural differences. The characteristics specific to PAD patients from North-Eastern Romania are presented.

[Surgical therapeutic strategy in vital risk polytrauma with multiple organ injuries, case report]. / Strategia terapeutica chirurgicala in plagile cu risc vital cu leziuni multiple de organ. Prezentare de caz.

The medical interest for trauma pathology is incresing, due to the gravity of the given injuries. The surgical therapeutic strategy used is directly related to the localization and to the type of the trauma. The supplementary lesions and their vital risk also matter. The multidisciplinary team approach is the key to resolve this type of lesions with a good outcome. We recently observed an increasing tendency toward the rise of number and variety of patients with trauma, due to the great diversity of the etiopathogenic agents. The most important factor, during the assessment of a politraumatised patient is to diagnose correctly the functional deficits of vital organs and establish the vital prognosis. It is necessary to adopt the best and fast therapeutic strategy in order to obtain rapid life-saving decisions.

Partial infection of the aorto-uni(bi)femoral graft partial conservation and replacement with autologous material. Is it a reality?

UNLABELLED: The infection of the aorto-uni(bi)femoral graft is a serious complication, associated with high morbidity and mortality rates - severe implications on the vital prognosis (haemorrhage, sepsis) or of the peripheral vascularisation. Frequently, the infections of aorto-uni (bi) femoral grafts first appear at the level of the distal anastomosis, in Scarpa's triangle. MATERIAL AND METHODS: We are going to discuss a number of 6 cases of localised unilateral infection, situated in Scarpa's triangle. The infections appeared either during the first 3 months after the initial implantation of the graft, or later on (2 cases), after 2 and 5 years, respectively. The cases span over a period of 10 years covering a total number of 226 patients with aorto-uni(bi)lateral grafts. Our treatment of choice was to use autologous material, namely the superficial femoral vein, as replacement for the partially infected graft, which was harvested and placed in the iliac position during the same procedure. The surgical intervention was divided into an aseptic time, which involved harvesting the autologous conduit (superficial femoral vein), the proximal anastomosis between the non-contaminated portion of the graft and the venous graft, followed by closure; next, there was a septic time, that included entering the infected wound, extracting the contaminated segment of the graft and distal anastomosis between the femoral vein graft and the receptive artery. In five of the cases the venous conduit was passed through the same anatomical space from where the graft was extracted; in one case it was passed through the obturator channel and anastomosed to the superficial femoral artery at a lower level. The patients received pre- and postoperative intravenous antibiotics in accordance to the cultures taken from the infected wound, up to a period of 2-3 weeks, followed by another 3 weeks of oral antibiotics after discharge. RESULTS: All the patients survived the intervention. Postoperatively oedema of the lower leg and thigh was observed in all of the patients, similar to that appearing in deep venous thrombosis, and required treatment with low molecular weight heparin and long term oral anticoagulation with antivitamin K products.Patients were monitored postoperatively at intervals of one, three and six months followed by two annual check-ups. Biological tests and colour Duplex scans showed no signs of recurrent infection. CONCLUSIONS: Localized partial graft infections are a reality, confirmed by clinical, biological, ultrasound examinations, intra-operative explorations and postoperative results achieved by selective surgical resection. Infectious reoccurrence was not observed during the period of study.

Usage of venous grafts in aorto-iliac reconstructive surgery.

UNLABELLED: The authors present their clinical experience utilizing venous grafts (greater saphenous vein and superficial femoral vein) in the aorto-femoral position. MATERIALS AND METHODS: Span of study is five years. The situations when these techniques were implemented are as follows:-(A). Infected synthetic prosthesis and (B). aorto-iliac occlusive disease in younger patients. A. In synthetic prosthetic infections there are 2 situations: (1) IMMEDIATE INFECTION. Observed in 10 cases, from which 2 cases where of severe infection and 8 cases of superficial infection--localized in the postoperative wound--Scarpa triangle region (7 cases) and left para-rectal (1 case). Superficial infections were treated successfully by daily dressings, excision of necrotic debris, antibiotic-therapy according to local antibiogram (only cases involving local invasion), and of course secondary wound closure at a later on date. The 2 cases of severe graft infection required harvesting of the superficial femoral vein and its usage in the aorto-femoral position. (2) LATE INFECTIONS. 3 patients were diagnosed with late infection of the synthetic prosthesis. In 2 cases, the infection was localized in the Scarpa triangle region, and the third in the abdomen (at the level of the aortic anastomosis). B. Aorto-iliac occlusive disease in younger patients--2 cases benefited from an aorto-bifemoral bypass reconstruction using the superficial femoral vein, and 5 cases where the greater saphenous vein was used in the iliac position. RESULTS: Only 1 patient with severe prosthetic infection died due to multiple organ dysfunctions after the operation; the rest survived without any major amputation. CONCLUSIONS: the harvesting and usage of these venous grafts is sometimes the final solution for patients with synthetic prosthesis infection.