The Effectiveness of Eplerenone vs Spironolactone on Left Ventricular Systolic Function, Hospitalization and Cardiovascular Death in Patients With Chronic Heart Failure-HFrEF.

Background: Heart failure remains one of the most prevalent clinical syndromes associated with significant morbidity and mortality. According to current guidelines, the prescription of a MRA is recommended to reduce the risk of HF hospitalization and death in all patients with symptomatic heart failure and no contraindications for this therapy. Objective: The aim of our study was to determine the efficacy of eplerenone vs. spironolactone on left ventricular systolic function by measuring left ventricle ejection fraction (LVEF) in patients with chronic heart failure, especially their effect on preventing hospitalization, reducing mortality, and improving clinical status among patients with chronic HF. Methods: From June 2021 to June 2022, the study was a randomized, prospective clinical trial single blind study. A total of 142 patients of chronic heart failure with reduced ejection fraction were selected by random sampling. Each patient was randomly allocated into either of the two groups and was continued receiving treatment with either spironolactone (Spiron-HF group) or eplerenone (Epler-HF group). Patients in Epler-HF group were compared with an arm of the same size and matched by age and gender patients in Spiron-HF group for management of chronic HFrEF. Each patient was evaluated clinically, biochemically, and echocardiographically at the beginning of treatment (baseline) after 6 months and at the end of 12th month. Echocardiography was performed to find out change in left ventricular systolic function. Results: After 12 months of treatment, significant improvement of left ventricular ejection fraction was observed in eplerenone treated arm (37.9 ± 3.8 ± 4.6 in Spiron-HF group versus 40.1 ± 5.7 in Epler-HF group; P < 0.05). A significant reduction in left ventricular end-systolic volume (6.3 ± 2.5ml in Spiron-HF versus 17.8± 4.4ml in Epler-HF group; P < 0.05) and left ventricular systolic diameter volume (2.7 ± 0.5ml in Spiron-HF versus 6.7 ± 0.2ml in Epler-HF group; P < 0.05), occurred after 12 months of treatment. Left ventricular global longitudinal strain (LV GLS) was significantly improved in Epler-HF group compared with Spiron-HF group (0.6 ± 0.4 versus 3.4 ± 0.9; P < 0.05). There were no significant differences observed in reduction of left ventricular end-diastolic volume (2.2 ± 0.5 ml versus 4.7 ± 1.1ml; P =0.103) and left ventricular diastolic diameter (1.2 ± 0.6 versus 1.7 ± 0.3; P=0.082) in both arms. The effects of both MRA agents spironolactone and eplerenone on the primary composite outcome, each of the individual mortality and hospital admission outcomes are shown in Figure 1 and 2. Patients of the Epler-HF group showed statistically significant lower cardiovascular mortality (HR 0.53; 95% CI 0.34-0.82; p= 0.007) and all-cause mortality (HR 0.64; 95% CI 0.44-0.93; p= 0.022) than patients of the Spiron-HF group. The statistical analysis did not show a statistically significant difference between Epler -HF and Spiron-HF study groups regarding the risk of the primary composite outcome; cardiovascular death or hospitalization due to HF (Hazard Ratio (HR) eplerenone vs. spironolactone = 0.95; 95% Confidence Interval (CI) 0.73- 1.27; p= 0.675). Conclusion: Our study has demonstrated favorable effects of eplerenone on cardiac remodeling parameters and reduction of cardiovascular mortality and all-cause mortality compared with spironolactone in the treatment of HFrEF. The ability of eplerenone to effectively block the mineralocorticoid receptor while minimizing side effects and a significant reduction in the risk of hospitalization and cardiovascular death confirms its key role in the treatment of patients with chronic HFrEF.

Acquisition of New Philips Affiniti 30 Vascular Color Doppler Ultrasound Device - Cost Benefit Analysis to Reduce Cardiosurgical Patients' Treatment.

Background: Cerebrovascular accidents (CVI) are considered the second most serious complication in cardiac surgery patients with a frequency of 10%. By preventing complications of surgical treatment, using a Color Doppler ultrasound (CDU) device, in the population of cardiac surgery patients, the unplanned costs of prolonged postoperative treatment would be reduced. Objective: To prove that the acquisition and use of the newly developed CDU device "Affinit 30" is completely economical, profitable and medically justified. Methods: Numerical parameters of the treatment of cardiovascular patients were analyzed (number of procedures, number of days in the intensive care unit, cost of additional consultative services of the clinic for radiology and neurology), and the calculated economic value of the potential investment, as well as the cost of preventing surgical complications, by purchasing and installing a new modern CDU device. Results: The profitability of the investment was assessed using the economic parameters Net Present Value (NPV) of the investment, Internal rate of return (IRR) and Profitability Index (PI). A mathematical calculation with the given parameters yields NPV = 948,850 KM and IRR of 273% when applied to the given parameters. The PI value is 12.6, which matches the previously calculated NPV and IRR values. Conclusion: The acquisition and use of the newly developed CDU device "Affinit 30" is economically profitable and medically justified. This is shown by the calculated values of the economic parameters Net Present Value of the investment (NPV), Internal rate of return (IRR) and the Profitability Index (PI).

Left Ventricular Free Wall Rupture After Acute Myocardial Reinfarction Due to In-Stent Thrombosis in COVID-19 Patient.

Background: Acute left ventricular free wall rupture (LVFWR) is a life-threatening complication of myocardial infarction that requires urgent intervention. Surgical repair has continued to be the treatment of choice. Studies suggest a posterolateral or inferior infarction is more likely to result in free wall rupture than an anterior infarction. LVFWR generally results in death within minutes of the onset of recurrent chest pain, and on average was associated with a median survival time of 8 hours. Prompt diagnosis and management can lead to successful treatment for LVFWR. Objective: The aim of this article was to present an emergency case with an LVFWR in a COVID-19 patient who suffers from AMI and was treated with PCI stents in the ramus intermedius and circumflex coronary artery. Case report: We present an emergency case with an LVFWR in a COVID-19 patient who suffers from AMI and was treated with PCI stents in the ramus intermedius and circumflex coronary artery. Although dual antiplatelet therapy introduction and good outcome of PCI were achieved, soon after instant thrombosis of both stents appear to result in transmural necrosis and LVFWR. Urgent catheterization was performed and diagnosed in-stent thrombosis where the ventriculography confirmed LVFWR of the posteroinferior wall. Urgent surgery was performed. Transmural necrosis was noticed alongside the incision line. The incision is sawn with 4 U-stitches (Prolen 2.0 with Teflon buttressed stitches). Another layer of fixation was made by Prolen 2.0 running stitches reinforced with Teflon felts from both sides. A large PTFE patch was fixed to epicardium over the suture line by Prolen 6.0 running stitch and BioGlue was injected in-between patch and LV (Figures 8 and 9). After aortic cross-clamp removal, the sinus rhythm was restored. Conclusion: Despite the high mortality, the urgency and the complexity of surgical treatment the early diagnosis plays a key role in the management of postinfarction LVFWR patients presenting a case of preserved postoperative left ventricular function and accomplished good functional status, as presented in our case.

Reversed L-type Upper Partial Sternotomy in Aortic Valve Replacement: an Initial Experience.

INTRODUCTION: Degenerative aortic stenosis (AS) is the most frequent cause among aortic valve stenotic changes. Mini Sternotomy Aortic Valve Replacement is a replacement of aortic valve through upper partial sternotomy. AIM: The aim of this approach is to improve postoperative convalescence by leaving pleural spaces closed and do not compromise respiratory function, to decrease bleeding, and reduce post op ventilation time and ICU stay. All these advantages decrease cost during hospital stay by reducing ICU stay, respiration time, bleeding and using blood products, pain killers and shortening hospital stay. Esthetic effect is also considerable result of this method. CASE REPORT: This case report presents an initial experience with Reversed L-Type Upper Partial Sternotomy in Aortic Valve Replacement. The goal is to demonstrate that minimally invasive advanced cardiac surgery procedures can be performed in our country.

Anaortic technique in off-pump coronary artery bypass surgery.

INTRODUCTION: Techniques of coronary artery revascularisation on the beating heart have evolved with an attempt to reduce the potential deleterious effects of extracorporeal circulation. It is of particular value in those with a calcified or atheromatous ascending aorta. Total arterial revascularisation is ideal. CASE REPORT: We describe a case of 66 year-old male patient, previously suffered mild cerebrovascular incident, schedueled for myocardial revascularisation of double coronary disease with Left main stenosis. METHOD: Sternotomy was done in standard fashion. Both mamary artery were harvested and distal anastomoses were made in standard fashion by Prolen 8/0. For local stabilisation Medtronic Octopus vaccum stabiliser was used. DISCUSSION: Feasibility to perform arterial revascularistion by using off-pump aorta no-thouch techniqe (anaortic technique) on the patient previously suffered stroke and with increasd risk of the same complication was presented. This technique is recommended whenever technically feasible.

Identifying candidate genes for Parkinson's disease by integrative genomics method.

INTRODUCTION: The recent studies of Parkinson's disease (PD) indicate that genetics and environmental factors may play an important role in developing of PD. Nowadays, the cell death and cell adhesion are pathogenetic mechanisms which could be related with PD. On the basis of relationship of those mechanisms with PD, the aim of this study was to identify new candidate genes for PD by integration of results of transcriptomics studies and results obtained by Biomedical Discovery Support System (BITOLA). MATERIALS AND METHODS: For the detection of functional relationship between potential candidate gene and pathogenetic mechanisms associated with PD, we designed strategy of integration of results of transcriptomics studies with discovery approach in bibliographic data bases and BITOLA. Data of chromosome location, tissue-specific expression, function of potential candidate genes and their association with genetics disorders were obtained from Medline, Locus Link, Gene Cards and OMIM. RESULTS: Integration and comparison of results obtained using the BITOLA system and analysis of transcriptomics studies identified six genes (MAPT, UCHL1, NSF, CDC42, PARK2 and GFPT1) that occur simultaneously in both group of results. The function of genes NSF, CDC42 and GFPT1 in the pathogenesis of PD has not been studied yet. CONCLUSIONS: According to our result that aforementioned genes appeared in both groups of results and partially match the criteria set for the selection of candidate genes and their potential role in the development of PD, they should be tested by methods specifically intended for those three genes.

Using the BITOLA system to identify candidate genes for Parkinson's disease.

Complexity of multifactorial diseases as Parkinson's disease (PD) often complicate identifying causal genetic factors by traditional approaches such as positional cloning and candidate gene analyses. PD is etiologically and genetically complex disease and second most common neurodegenerative disorder after Alzheimer's disease. The most cases of PD are idiopathic and small growing subset of individuals have single gene defect as the cause. The main goal of this research was to identify the potential candidate genes for idiopathic PD by using biomedical discovery support system (BITOLA). For detecting the potential candidate genes for PD was used opened system of bioinformatics tool BITOLA. Data of chromosome location, tissue specific expression of potential candidate genes and their potential association with PD were obtained from Medline, Locus Link, Gene Cards and OMIM. By using BITOLA system is identified 17 genes as potential candidate genes for PD. The role of three genes (MAPT, PARK2, UCHL1) in PD were confirmed earlier. Discovering the novel candidate genes for multifactiorial diseases by using specially mentioned bioinformatics tool BITOLA could offer the new opportunity for researching genetics base of PD without using tissue samples of patients.

Aorto-caval fistula as a complication of ruptured infrarenal aortic aneurysm.

We present a case of 71 year old man operated in our clinic for ruptured abdominal aneurysm complicated with aorto-caval fistula, which was revealed during the surgery and successfully repaired by direct sutures within the aorta. This is the first record of the aorto-caval fistula that was so far noticed in our clinic. Urgent surgery and repair of the defect conneting aorta and vena cava by direct sutures within the aorta followed by ruptured aneurysm repair with tube graft is only way of treatment. Despite its infrequent occurrence, aorto-caval fistula should always be considered in any case of ruptured abdominal aneurysm.

Results of coronary bypass grafting in treatment of left main stenosis.

Study comparing the results of coronary artery bypass grafting (CABG) with and without cardiopulmonary bypass (CPB) in the treatment of left main stenosis (LMS) has not yet been made in Bosnia and Herzegovina. The main aim of this study was to compare result of CABG performed on 176 patients, in Cardiovacular clinic of University Clinical Center in Tuzla from May 1999 to January 2005, by these two methods in LMS group of patients in the early and late postoperative period. The study was divided in two parts. In the first part, early postoperative period (30 days after the surgery) has been analysed, which encompasses results of CABG in 92 patients revascularisied without CPB (OPCAB) method (Group A), and 84 patients with LMS revascularisied with CPB method (ONCAB, CCAB) (Group B). In the second part, late postoperative period (one year after surgery) has been analysed. Patients from both groups were contacted and interviewed. Total number (276 versus 278), same as average number of grafts per patients (3.0 +/- 1.45 versus 3.31 +/- 0.86 p = 0.096), was insignificantly higher in group B. Perioperative and postoperative results revealed significant differences between two groups in reduced mechanical ventilation time (2.9 versus 7.3 hours, p = 0.039), less blood transfusion requirement (200.3 versus 419.9 ml, p = 0.035) and postoperative length of stay (7.4 versus 8.3 days). Inotrop support requirement was significantly higher in group B during the surgery (14.1% versus 29.8%, p = 0.019) and postoperative period longer than 12 hours (7.6 versus 22.6%; p = 0.009). Significant difference for mortality was noticed in early postoperative period in group A (0.0 versus 5.95%, p = 0.023). There was no significant difference for any of additional procedures (7.9 versus 7.8, p = 0.802), for major complications (8.0 versus 9.1%; p = 0.985) or for mortality (7.9 versus 5.2%; p = 0.692). Patients' survival after CABG for period of 12, 24, 36 and 48 months after surgery was not statistically significant (97.0 versus 96.1%, p = 0.802; 95.5 versus 96.1%, p = 0.857; 93.2 versus 94.8%, p = 0.913; 92.0 versus 94.8%, p = 0.692). This study revealed that OPCAB is effective and safe method for treatment of LMS, and there are certain advantages in comparison to classical method in short-term follow up, with no difference in long-term results.

Clinically silent deep vein thrombosis in patients with superficial thrombophlebitis and varicose veins at legs.

Although superficial thrombophlebitis is a common disorder until recently it was considered as benign disorder. Also it is associated with varicose vein at legs and it was treated effectively with conservative methods, walking and non-steroid anti-inflammatory drugs. Aims of our investigation were: determine frequency of clinically silent deep vein thrombosis at legs in patient with and without superficial thrombophlebitis, determine correlation between superficial thrombophlebitis and deep vein thrombosis regardless of localization of superficial thrombophlebitis in superficial veins of legs and determine adequacy and safety vein phlebography in early diagnosis clinically silent deep vein thrombosis in patients with superficial thrombophlebitis. Using flebography in prospective study was evaluated incidence of clinically silent deep vein thrombosis in 92 patients with varicose veins at legs. By phlebograpy in patients with varicose veins at legs and superficial thrombophlebitis at legs and without clinical signs of DVT at legs of the 49 patients we detected DVT in 12 patients (24, 48%), in three male and nine female. We detected localization of DVT in ilijacofemoral junction in 4,08% patients, although localization of DVT in femoropopliteal region was observed in 6, 12% patients and localization in crural region was in 14.28% patients. Localization of DVT at legs was detected in iliac vein in 16.66% patients, in femoral vein in 25% patients, popliteal vein 8.33% patients, anterior tibial vein 16.66%, posterior tibial vein in 25% and crural veins 8.33% patients. Also we deduced significant difference between two group of patients (chi2 = 10, 76). Such result proves thesis that in most patients with superficial thrombophlebitis and varicose veins is possibility of developing of DVT.

[Off-pump coronary bypass grafting in patient with left main occlusion and 75% stenosis of right coronary artery]. / Off-pump koronarni bajpas kod pacijenta s okluzijom glavnog stabla lijeve i 75% stenozom desne koronarne arterije.

Patients with significant stenosis (>50%) of the left main coronary artery (LM) are considered high risk for coronary artery bypass grafting (CABG). LM disease is mainly considered a relative contraindication for off pump coronary artery bypass grafting (OPCAB) because of the reduced tolerancy of hamodynamic disturbances which occurs during mobilisation and exposition of the heart, necessary for this type of operations. The aim of the study is to show feasibility of OPCAB for patient with occlusion of the LM and 75% stenosis of the right coronary artery. Operation was carried out through median sternotomy, LIMA stitch was used for the exposure, CTS stabilisator was used for local myocardial stabilisation, intracoronary shunt was inserted intraluminary. Three aortocoronary bypasses were created, operation passed without any hamodynamic instability. Main peri and postoperative results: total length of the operation: 265 min; time on respirator: 1 hour; total blood drainage on chest tubes: 532 ml; transfused blood: 0 ml; time in the intensive care unit: 1 day; total hospitalisation time: 7 days. This case review suggest that OPCAB is feasible and safe in the treatment of patients with LM occlusion and significant stenosis of RCA.

[Beating heart surgery in the treatment of stenoses of the main branch of the left coronary artery]. / Operacije na kucajucem srcu u tretmanu stenoze glavnog stabla lijeve koronarne arterije.

This study reviewed the early experience with off-pump coronary artery bypass surgery in treatment of patients with severe left main coronary artery stenosis. From May 2002-December 2003, 75 patients with significant left main coronary artery stenosis (> or = 50%) underwent coronary artery bypass grafting. 35 patients were operated without the use of cardiopulmonary bypass (OPCAB) and compared with 40 patients operated with the use of cardiopulmonary bypass (ONCAB). Mean age, ejection fraction and EUROSCORE were similar in both groups. Average grafts per patients was also similar (OPCAB 3.0 vs. ONCAB 3.2). The incubation time (3.1 vs. 5.8 hours), blood loss (445 vs. 610 ml) and hospital stay (6.8 vs. 8.1 days) were less in OPCAB group. There was no mortality in OPCAB group whereas 2 patients (5.0%) died in ONCAB group. Our early experience suggests that off-pump coronary artery bypass surgery is effective in treatment of patient with severe left main coronary artery stenosis and has advantages compare to operations with the use of cardiopulmonary bypass.