To Close, Observe, or Reconstruct: The Third Way of Managing Dialysis Fistula Aneurysms in Kidney Transplant Recipients.

BACKGROUND: The management of patent dialysis fistulas in patients after kidney transplantation (KTx) is controversial-the options that are usually considered are the fistula's closure or observation. Many complications of dialysis fistulas occur in patients after KTx, and immunosuppression increases the risk of fistula aneurysms and hyperkinetic flow. This study aimed to evaluate the results of dialysis fistula aneurysm treatment in patients after KTx and to compare them to procedures performed in an end-stage renal disease (ESRD) dialyzed population. METHODS: We enrolled 83 renal transplant recipients and 123 ESRD patients with dialysis fistula aneurysms qualified for surgical revision to this single-center, prospective study. The results of the surgical treatment of dialysis fistula aneurysms were analyzed, and the primary, assisted primary and secondary patency rate, percentage and type of complications were also assessed. RESULTS: For the treatment of dialysis fistula aneurysms in transplant patients, we performed dialysis fistula excisions with fistula closure in 50 patients (60.2%), excision with primary fistula reconstruction (n = 10, 12.0%) or excision with PTFE bypasses (n = 23, 27.7%). Postoperative complications occurred in 11 patients (13.3%) during a follow-up (median follow-up, 36 months), mostly in distant periods (median time after correction procedure, 11.7 months). The most common complication was outflow stenosis, followed by hematoma, dialysis fistula thrombosis and the formation of a new aneurysm and postoperative bleeding, infection and lymphocele. The 12-month primary, primary assisted and secondary patency rates of fistulas corrected by aneurysm excision and primary reconstruction in the KTx group were all 100%; in the control ESRD group, the 12-month primary rate was 70%, and the primary assisted and secondary patency rates were 100%. The 12-month primary, primarily assisted and secondary patency rates after dialysis fistula aneurysm excision combined with PTFE bypass were better in the KTx group than in the control ESRD group (85% vs. 71.8%, 90% vs. 84.5% and 95% vs. 91.7%, respectively). Kaplan-Meier analysis showed a significant difference in primary patency (p = 0.018) and assisted primary (p = 0.018) rates and a strong tendency in secondary patency rates (p = 0.053) between the KTx and ESRD groups after dialysis fistula excisions combined with PTFE bypass. No statistically significant differences in patency rates between fistulas treated by primary reconstruction and reconstructed with PTFE bypass were observed in KTx patients. CONCLUSIONS: Reconstructions of dialysis fistula aneurysms give good long-term results, with a low risk of complications. The reconstruction of dialysis fistulas can be an effective treatment method. Thus, this is an attractive option in addition to fistula ligation or observation in patients after KTx. Reconstructions of dialysis fistula aneurysms enable the preservation of the dialysis fistula while reducing various complications.

Comparative analysis of conservative, percutaneous, and surgical treatment outcomes in patients with significant stenosis of the left main coronary artery during five-year follow-up.

BACKGROUND AND AIM: Significant left main coronary artery stenosis (LMS) conveys adverse prognosis and until recently its treatment has been restricted to surgical intervention. We evaluated the long term outcome of patients with LMS treated using different approaches i.e. medical treatment, surgical (CABG, coronary artery bypass graft) and percutaneous (PCI, percutaneous coronary intervention). METHODS: We analysed 450 patients with significant LMS (%DS > 50%). Group 1 (G1) included 105 patients who did not qualify for invasive treatment. Group 2 (G2) included 282 patients who underwent CABG. Group 3 (G3) comprised 67 patients who received stent into LMS. We analysed the incidence of invasive treatment complications in G2 and G3 and the overall incidence of adverse cardiac events that comprised death, repeated myocardial infarction, and the necessity of repeated revascularisation during hospital stay and long term follow-up. RESULTS: During the 5-year follow-up, the highest mortality was noted in the G1 in comparison to G2 and G3 (31.3% vs 24.5% vs 26.8% respectively). There was no difference in mortality between G2 and G3. The incidence of myocardial infarction was the lowest in G3 (22.2%) followed by G1 (40.8%) and G2 (45.1%). No difference was detected in the occurrence of repeated PCI in LMS (G2 - 19.85%, G3 - 13.4%) and CABG (G1 - 12.2%, G2 - 10.2%, G3 - 9.0%). The incidence of target vessel revascularisation was the highest in G1, followed by G2 and G3 (69.49% vs 53.19% vs 31.35% respectively). CONCLUSIONS: Our study showed that CABG and PCI provide similar long-term outcome in patients with LMS.

[The Bland-White-Garland syndrome detected during qualification for surgery, due to significant mitral regurgitation]. / Zespól Blanda-White'a-Garlanda ujawniony w trakcie badan diagnostycznych u chorego kwalifikowanego do operacji z powodu duzej niedomykalnosci mitralnej.

A case of a 57-year-old patient admitted to the hospital due to aggravation of heart failure symptoms is presented. In ECHO examination severe mitral insufficiency was found. During coronary angiography ostium of left coronary artery from pulmonary trunk was found. The patient underwent cardiosurgery: artificial mitral valve implantation, bypass LIMA-LAD grafting and natural opening left coronary artery ligation.

[Suspected acute coronary syndrome in a patient with systemic scleroderma]. / Podejrzenie ostrego zespolu wiencowego u pacjentki z twardzina ukladowa.

We present a case of a 53-year-old female with systemic scleroderma who was admitted to the hospital due to suspected acute coronary syndrome. Coronary angiography revealed normal coronary arteries.

[The floating structure connected with endocavitary electrode--thrombus or bacterial vegetation?]. / Balotujaca struktura na elektrodzie endokawitarnej--skrzeplina czy wegetacja bakteryjna?

A case of a 52-year-old woman with complete atrioventricular block, treated with pacemaker implantation, is presented. During the control transthoracic echo exam we observed floating structure connected with the endocavitary electrode. After diagnostic examinations bacterial vegetation was excluded and thrombus was diagnosed. The therapy with unfractionated heparin and warfarin was successfully performed.

[Acute coronary syndrome in a female patient with multilevel atherosclerosis]. / Ostry zespól wiencowy u kobiety z wielopoziomowa miazdzyca.

A case of 74-years-old woman who was admitted to Department of Interventional Cardiology due to acute coronary syndrome is presented. The multilevel atherosclerosis was diagnosed. The patient was successfully treated with two-stage percutaneous coronary and peripheral revascularisation. During 6-months follow-up patient was in good condition.

[Borreliosis--simultaneous Lyme carditis and psychiatric disorders--case report]. / Borelioza--jednoczesne zajecie serca oraz zaburzenia psychiczne--opis przypadku.

Borreliosis is a multisystemic disease transmitted by ticks. Its diagnosis still remains a challenge because of the varied clinical picture and of difficulties in detection of the etiological agent (Borrelia burgdorferi). We report a case of a 53-years-old woman admitted to the Clinic of Cardiology due to life-threatening arhythmias with simultaneous deficits in concentration and memory. A suspicion of borreliosis was driven from the presence of cardiac symptoms as well as of psychiatric and from the case histories of a tick bite. The diagnosis was confirmed both by specific serological test and endomyocardial biopsy which revealed spirochetes. The patient responded to treatment with doxycyclin and ceftriaxone. Cardiologic disorders retreated entirely, while cognitive deficits did only partly.

[Lyme carditis--a bitter lesson or a delayed diagnostic success--a case report]. / Borelioza serca - gorzka lekcja czy spózniony sukces diagnostyczny? Opis przypadku.

Lyme carditis is a well known disorder; however, its diagnosis still remains a challenge because of varied clinical picture, low incidence rate and difficulties in detection of the aetiological agent (Borrelia burgdorferi). We report a case of a 60-year-old man with a 2.5-year history of dilated cardiomyopathy, recurring episodes of acute heart failure and arrhythmias which finally were diagnosed as Lyme carditis. The diagnosis was confirmed by endomyocardial biopsy that revealed spirochetes as well as by serological tests which showed complexed Borrelia antibodies. The patient responded to treatment with ceftriaxone and doxycycline.

Effects of renal sympathetic denervation on blood pressure and glycaemic control in patients with true resistant hypertension: results of Polish Renal Denervation Registry (RDN-POL Registry).

BACKGROUND AND AIM: The assessment of percutaneous renal sympathetic denervation (RDN) efficacy in patients with true-resistant hypertension (true-RH) in a newly established net of Polish centres (RDN-POL Registry). METHODS AND RESULTS: Forty-four patients with true-RH (23 men, mean age 52.3 years) with daytime systolic blood pressure (SBP) in ambulatory blood pressure monitoring (ABPM) ≥ 135 mm Hg, on ≥ three antihypertensive agents, including diuretic, underwent RDN and completed 12-month follow-up. Mean reductions of office SBP/diastolic blood pressure were -23.8/-10.0, -12.5/-4.6, and -12.6/-6.1 mm Hg at 3, 6, and 12 months, respectively (all significant except diastolic at 6 months). Diabetes was the only predictor of office SBP reduction at 6 months (OR 9.6, 95% CI 1.4-66.5, p < 0.05). Mean 24-h SBP change was -8.3 mm Hg at 6 months and -4.6 mm Hg at 12 months. Increased 2 h-glucose in oral glucose tolerance test was the only predictor of 24-h SBP reduction at 6 months (OR 1.24 for 10 mg/dL glucose increase, 95% CI 1.04-1.48, p < 0.05). At 12 months, 24-h SBP change predictors were: baseline office SBP (OR 4.93 for 10 mm Hg SBP increment, 95% CI 1.01-24.1, p < 0.05) and 2 h-glucose (OR 1.47, 95% CI 1.08-2.00, p < 0.05). In ABPM responders, significant reduction of 2 h glucose was found as compared to the non-responders (-45.8 vs. -7.7 mg/dL, p < 0.005). CONCLUSIONS: The RDN-POL Registry demonstrated moderate blood pressure decrease after RDN. The predictors of blood pressure reduction were diabetes, 2 h-glucose, and baseline office SBP. Analysis of ABPM responders indicates a probable positive impact of RDN on glycaemic control.

Stenting of culprit lesions in unstable angina leads to a marked reduction in plaque burden: a major role of plaque embolization? A serial intravascular ultrasound study.

BACKGROUND: Intravascular ultrasound (IVUS) studies have shown that a mechanism of plaque compression/embolization contributes toward the poststenting increase in lumen area. The aim of this IVUS study was to compare the mechanisms of lumen enlargement after coronary stenting in 54 consecutive patients with unstable angina (UA) (group 1) and 56 with stable angina (group 2) to verify whether plaque embolization plays a major role in the former. METHODS AND RESULTS: Both groups underwent the IVUS assessment (speed, 0.5 mm/sec) before the intervention and after stent implantation. The lumen area, the external elastic membrane area, and the plaque+media area (PA) were measured at 0.5-mm intervals. PA reduction in the lesion site was significantly greater in group 1 (-2.50+/-1.97 versus -0.53+/-1.43 mm2, P<0.001). After stenting, 47% of the lumen area increase in group 1 was obtained by means of PA reduction, and 53% was attributable to external elastic membrane area increase; the corresponding figures in group 2 were 13% and 87% (P<0.05). Decrease in PA after stenting was the only significant predictor of the MB fraction of creatinine kinase (CK-MB) release in a multiple regression model (P=0.047). CONCLUSIONS: Serial volumetric IVUS assessment revealed in UA lesions a marked poststenting reduction in plaque volume, which is significantly greater than in stable angina and is associated with postprocedural CK-MB release. The decrease in PA during the procedure predicts CK-MB release in a multiple regression model. These findings suggest that stent deployment is often associated with plaque embolization in patients with UA.

Threshold parameters of left main coronary artery stem stenosis based on intracoronary ultrasound examination.

INTRODUCTION: The left main coronary stem (LMS) provides blood supply to the left ventricle, and its stenosis is associated with serious clinical consequences. The accurate assessment of LMS stenosis determines appropriate treatment and long term prognosis. So far no criteria have been established to correctly estimate the magnitude of problematic lesions as indicated by quantitative angiography (QCA). AIM: An attempt to establish intracoronary ultrasound (ICUS) threshold values of significant LMS stenosis. METHODS: The studied group consisted of 197 patients (mean age 69.72+/-8.51) who underwent percutaneous coronary intervention (PCI) of the left coronary artery. Group 1 (G1) consisted of 99 patients who had LMS diameter reduction (%DS) of less than 30%. Group 2 (G2) consisted of 77 patients with %DS between 30% and 50%, and the remaining 21 patients with %DS higher than 50% were classified as Group 3 (G3). The quantitative angiography (QCA) analysis included lumen diameter (Ldmin) which was LMS lumen diameter at the most stenotic segment as well as LMS diameter reduction (%DS). The parameters that were analysed during ICUS study included maximum plaque burden (%) (Pbmax), minimal lumen area (LAmin) and lumen stenosis (%LS) calculated according to the formula: (LAmin/LAref) x 100%. Additionally, correlations between the corresponding parameters measured using QCA and ICUS were investigated. RESULTS: Both diagnostic techniques showed the most advanced degree of atherosclerosis in G3. All the G3 patients and 5 G2 patients had MLD values less than or equal to 2 mm. In G1 LAmin values exceeded 9 mm(2) in all patients, whereas among G2 patients 12 (15.5%) had LAmin lower than 6 mm(2), 29 pts. (37.66%) within the range of 6-9 mm(2) and in the remaining 36 pts. (46.75%) it exceeded 9 mm(2). In G3 LAmin values in 17 pts. (80.95%) did not exceed 6 mm(2) and in the remaining 4 pts. (19.05%) were slightly higher. Lumen reduction higher than 50% was noted in all G3 patients and 3 G2 patients (in all these 3 G2 patients LAmin values were lower than 6 mm(2)). All G3 pts. and 3 G2 pts. with LAmin value <6 mm(2) and %LS >50% had angina and a positive stress ECG test. All of these patients (n=24) underwent LMS stent implantation. CONCLUSIONS: 1. Minimal lumen diameter of LMS < or = 2 mm in quantitative angiography indicates a very high probability of significant stenosis of this vessel. 2. Ultrasound data analysis shows that besides LMS lumen area (<9 mm(2)) stenosis significance is determined by lumen reduction of more than 50%.

[Right ventricular and tricuspid insufficiency following two ventricular pacemaker implantation]. / Prawokomorowa niewydolnosc serca z istotna niedomykalnoscia trójdzielna jako powiklanie implantacji stymulatora dwujamowego.

A case of a 76-year-old woman with a right ventricular failure and severe tricuspid insufficiency following permanent pacemaker implantation is presented.

[Acute myocardial infarction in pregnant woman]. / Ostry zawal serca u kobiety w ciazy.

The article presents a case of 30-year-old patient at her 30th week of pregnancy who was admitted to our clinic with non-ST elevation myocardial infarction resulting from coronary artery embolism. A successful recanalisation of the occluded artery by balloon angioplasty was performed.