The Initial Experience of Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension in Latvia.

Background: Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or persistent pulmonary hypertension after pulmonary endarterectomy (PEA) include targeted medical therapy and balloon pulmonary angioplasty (BPA). BPA is an emerging treatment modality that has been reported to improve functional capacity, pulmonary hemodynamics, and right ventricular function. Reports from expert centers are promising, but more data are needed to make the results more generalizable. Materials and Methods: We conducted a prospective analysis of nine consecutive CTEPH patients who underwent balloon pulmonary angioplasty (BPA) sessions at Pauls Stradins Clinical University Hospital in Riga, Latvia between 1 April 2022 and 1 July 2023. We assessed World Health Organization (WHO) functional class, 6 min walk distance (6MWD), blood oxygen saturation (SpO2), brain natriuretic peptide (BNP) level at baseline and 3 months after the first BPA session. For two patients on whom repeated BPA sessions were performed, we additionally assessed cardiac output (CO), pulmonary vascular resistance (PVR), and mean pulmonary artery pressure (mPAP). Results: A total of 12 BPA procedures for nine patients were performed; repeated BPA sessions were performed for two patients. Our results show a reduction in BNP levels and improvement in WHO functional class, 6MWD, and SpO2 after the first BPA session. Improvement in 6MWD was statistically significant. Additionally, an improvement in pulmonary hemodynamic parameters was observed. Conclusions: Our data show that BPA is an effective interventional treatment modality, improving both the pulmonary hemodynamics and functional status. Moreover, BPA is safe and excellently tolerated.

Baseline Clinical Characteristics and Incidence of Chronic Thromboembolic Pulmonary Hypertension Patients in Latvia, 2019-2020.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and progressive condition; however, the true characteristics of CTEPH are still unknown, as notable regional variations exist in terms of patients' age, baseline hemodynamic data, and management choices. This report aims to investigate the baseline clinical characteristics, incidence, and risk factors associated with CTEPH patients in Latvia from 2019 to 2020. Methods: The data were analyzed from a prospective, nationwide, Latvian pulmonary hypertension registry for incident CTEPH cases. The patients' clinical characteristics were assessed at the time of diagnosis. Results: During the course of this study, a cohort of 13 patients with CTEPH were included for analysis. Among the enrolled CTEPH patients, most exhibited low exercise and functional capacity, with a median (±IQR) 6 min walk distance of 300.0 (±150.0) m. The median values (±IQR) for mean pulmonary artery pressure and pulmonary vascular resistance were 40.0 ± 13.0 mmHg and 7.35 ± 2.82 Wood units, respectively. The most common risk factors for CTEPH were a history of acute pulmonary embolism and a blood group other than O. Conclusions: The findings of this report revealed the characteristics of the Latvian CTEPH population, indicating that a significant proportion of patients are elderly individuals with multiple comorbidities.

Protective Effects of Meldonium in Experimental Models of Cardiovascular Complications with a Potential Application in COVID-19.

Right ventricular (RV) and left ventricular (LV) dysfunction is common in a significant number of hospitalized coronavirus disease 2019 (COVID-19) patients. This study was conducted to assess whether the improved mitochondrial bioenergetics by cardiometabolic drug meldonium can attenuate the development of ventricular dysfunction in experimental RV and LV dysfunction models, which resemble ventricular dysfunction in COVID-19 patients. Effects of meldonium were assessed in rats with pulmonary hypertension-induced RV failure and in mice with inflammation-induced LV dysfunction. Rats with RV failure showed decreased RV fractional area change (RVFAC) and hypertrophy. Treatment with meldonium attenuated the development of RV hypertrophy and increased RVFAC by 50%. Mice with inflammation-induced LV dysfunction had decreased LV ejection fraction (LVEF) by 30%. Treatment with meldonium prevented the decrease in LVEF. A decrease in the mitochondrial fatty acid oxidation with a concomitant increase in pyruvate metabolism was noted in the cardiac fibers of the rats and mice with RV and LV failure, respectively. Meldonium treatment in both models restored mitochondrial bioenergetics. The results show that meldonium treatment prevents the development of RV and LV systolic dysfunction by enhancing mitochondrial function in experimental models of ventricular dysfunction that resembles cardiovascular complications in COVID-19 patients.

Glomerular Filtration Rate as a Prognostic Factor for Long-Term Mortality after Acute Pulmonary Embolism.

BACKGROUND: In-hospital mortality for patients presenting with acute pulmonary embolism (PE) has been reported to be up to 7 times higher for patients with decreased estimated glomerular filtration rate (eGFR). However, few studies have assessed its effect on long-term mortality. OBJECTIVE: To determine the impact of eGFR and creatinine clearance (CrCl) on long-term all-cause mortality following acute PE in association with other routine laboratory analyses and comorbidities. PATIENTS/METHODS: The prospective study enrolled 141 consecutive patients presenting with objectively confirmed acute PE. Demographic, clinical data, comorbidities, and laboratory values were recorded. CrCl and GFR were estimated using the Cockcroft-Gault, MDRD, and chronic kidney disease (CKD)-EPI equations. Patients were followed up at 90 days and 1 year after the event. RESULTS: In univariate analyses, age, active cancer, PE severity index (PESI), CrCl and eGFR, D-dimer value, and high-density lipoprotein level were found to be significantly associated with mortality in 90 days and 1 year. Additionally, body mass index was significant in the 1-year follow-up. CrCl by Cockcroft-Gault (90-day: area under the curve [AUC] 0.763; 1-year: AUC 0.718) demonstrated higher discriminatory power for predicting mortality than eGFR by the MDRD (AUC 0.686; AUC 0.609) and CKD-EPI (AUC 0.697; AUC 0.630) equations. In multivariate analyses, active cancer, CrCl by Cockcroft-Gault (90-day: hazard ratio [HR] 0.948, 95% CI 0.919-0.979; 1-year: HR 0.967, 95% CI 0.943-0.991), eGFR by CKD-EPI (90-day: HR 0.948, 95% CI 0.915-0.983; 1-year: HR 0.971, 95% CI 0.945-0.998) were found to be independent predictors of mortality. eGFR by MDRD, D-dimer, and PESI value were significant prognostic factors for 90-day mortality. CONCLUSION: Decreased renal function is a prognostic factor for increased all-cause mortality 90 days and 1 year after acute PE.

Venous Thromboembolism Recurrence in Latvian Population: Single University Hospital Data.

Background and objectives: Recurrence of venous thromboembolism (VTE) after a primary event is common; however, no sufficient risk scores have been widely introduced in clinical practice. The aim of this study was to assess the risk factors for VTE recurrences, as well as the effect of treatment strategies on the recurrence rate in a single-center patient cohort. Materials and Methods: The prospective cohort study included consecutive patients in a single center from June 2014 till June 2018 presenting with acute VTE confirmed by imaging tests. All patients were followed up for at least one year or till death. Statistical analyses were conducted using IBM SPSS Statistics 23 and Stata 13. Competing risk of death was considered. Results: A total of 219 eligible patients were identified during the study period. Pulmonary embolism with or without deep vein thrombosis (DVT) was present in 95.9% (n = 210), isolated DVT was present in 4.1% (n = 9) of patients. The total number of documented recurrences was 13 (5.9%). Incidence rate was 5.6 per 100 person-years. Recurrent VTE predicted significantly higher mortality rate (hazard ratio (HR) 6.64 [95% CI 2.61-16.93]). In univariate analysis, active cancer was associated with higher recurrence rate (p = 0.036). In competing-risks regression model (with death as the competing risk), active cancer (subdistribution hazard ratio (SHR) 2.11 (95% CI 0.58-7.76)) did not retain statistical significance for VTE recurrence. Discontinuation and duration of anticoagulant treatment (≤6 or >6 months), and drug class in acute or long-term therapy (parenteral, vitamin K antagonist (VKA), direct oral anticoagulant (DOAC)) were not associated with recurrences (p > 0.05). Conclusions: Patients who experienced recurrent VTE had 6.6-fold higher mortality rate than patients with no recurrences. The presence of active cancer was not a statistically significant risk factor for recurrence when taking into account the competing risk of death. Duration and drug class of anticoagulation did not seem to impact recurrence rate.

Individualized Decision-Making and Outcomes for the 87-Year-Old Living Kidney Donor: A Case Report.

Introduction: Latvia faces a challenging shortage of available kidney donors, leading to a significant mismatch between demand for kidney transplantation and supply. Although older adult donors require a thorough pre-donation workup to rule out significant medical comorbidities, it offers hope for potential kidney transplantation candidates. Case Presentation: This case study presents the unique scenario of an 87-year-old living kidney donor, where individualized decision-making resulted in outstanding outcomes for both the donor and recipient. Conclusions: The initial assessment for donation, which involves renal scintigraphy, serves as a preventive measure. In cases where one of the kidneys exhibits insufficient function, this approach avoids the necessity for further costly tests, thus preserving resources in the healthcare budget. The decision concerning an older donor should undergo thorough discussion by a multidisciplinary team to minimize perioperative and long-term risks. Nonetheless, a thoughtful approach to elderly donors offers a valuable opportunity to expand the living donor pool in the context of the organ shortage problem.

Chronic Thromboembolic Pulmonary Hypertension Mimicking Acute Pulmonary Embolism: A Case Report.

BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare form of pulmonary hypertension which is often caused by recurrent emboli. The reported prevalence in Latvia is 15.7 cases per million inhabitants. Several risk factors predispose patients to develop chronic thromboembolic pulmonary hypertension, including the presence of chronic myeloproliferative diseases and splenectomy. CASE REPORT We present a case of a 68-year-old woman with a variant of chronic myeloproliferative disease, essential thrombocythemia, splenectomy, and chronic thromboembolic pulmonary hypertension, in whom chronic thromboembolic pulmonary hypertension was mimicking acute pulmonary embolism. On admission, the patient had progressive dyspnea, elevated right ventricular systolic pressure (RVSP) 60-70 mmHg, and elevated thrombocytes, C-reactive protein, BNP, and d-dimer levels. These results, as well as the results of thoracic computed tomography angiography with contrast, supported the diagnosis of acute pulmonary embolism. During the sequent follow-up visit after 3 months of effective anticoagulant therapy, the patient had elevated RVSP: 55-60 mmHg. Therefore, right heart catheterization was performed, in which it was found that mPAP was 37 mmHg with PCWP 5 mm Hg and PVR 8.9 Wood units, confirming the CTEPH diagnosis. CONCLUSIONS Patients who are at high risk of thrombosis need an increased level of monitoring to be properly evaluated. An easy solution to misdiagnosis of CTEPH with an acute pulmonary embolism could be taking scrupulous patient history, which can reveal multiple risk factors of CTEPH development. The subsequent assessment of risk factors can lead to a more appropriate consideration of CTEPH diagnosis vs acute pulmonary embolism.

Management of a primary malignant melanoma of uterine cervix stage IVA patient with radical surgery and adjuvant oncolytic virus Rigvir® therapy: A case report.

Primary malignant melanoma of the uterine cervix is a rare disease with poor prognosis and high recurrence rate. We used Rigvir® as adjuvant therapy for a stage IVA patient. Tolerability, overall and progression-free survival are good.