Cardiopulmonary Resuscitation With Mechanical Chest Compression Device During Percutaneous Coronary Intervention. A Case Report.

Sudden cardiac death is a leading cause of death worldwide, whereby myocardial infarction is considered the most frequent underlying condition. Percutaneous coronary intervention (PCI) is an important component of post-resuscitation care, while uninterrupted high-quality chest compressions are key determinants in cardiopulmonary resuscitation (CPR). In our paper, we evaluate a case of a female patient who suffered aborted cardiac arrest due to myocardial infarction. The ambulance crew providing prehospital care for sudden cardiac arrest used a mechanical chest compression device during advanced CPR, which enabled them to deliver ongoing resuscitation during transfer to the PCI laboratory located 20 km away from the scene. Mechanical chest compressions were continued during the primary coronary intervention. The resuscitation, carried out for 2 h and 35 min, and the coronary intervention were successful, as evidenced by the return of spontaneous circulation and by the fact that, after a short rehabilitation, the patient was discharged home with a favorable neurological outcome. Our case can serve as an example for the effective and safe use of a mechanical compression device during primary coronary intervention.

Subcellular Dissection of a Simple Neural Circuit: Functional Domains of the Mauthner-Cell During Habituation.

Sensorimotor integration is a pivotal feature of the nervous system for ensuring a coordinated motor response to external stimuli. In essence, such neural circuits can optimize behavioral performance based on the saliency of environmental cues. In zebrafish, habituation of the acoustic startle response (ASR) is a simple behavior integrated into the startle command neurons, called the Mauthner cells. Whereas the essential neuronal components that regulate the startle response have been identified, the principles of how this regulation is integrated at the subcellular regions of the Mauthner cell, which in turn modulate the performance of the behavior, is still not well understood. Here, we reveal mechanistically distinct dynamics of excitatory inputs converging onto the lateral dendrite (LD) and axon initial segment (AIS) of the Mauthner cell by in vivo imaging glutamate release using iGluSnFR, an ultrafast glutamate sensing fluorescent reporter. We find that modulation of glutamate release is dependent on NMDA receptor activity exclusively at the AIS, which is responsible for setting the sensitivity of the startle reflex and inducing a depression of synaptic activity during habituation. In contrast, glutamate-release at the LD is not regulated by NMDA receptors and serves as a baseline component of Mauthner cell activation. Finally, using in vivo calcium imaging at the feed-forward interneuron population component of the startle circuit, we reveal that these cells indeed play pivotal roles in both setting the startle threshold and habituation by modulating the AIS of the Mauthner cell. These results indicate that a command neuron may have several functionally distinct regions to regulate complex aspects of behavior.

Improved Inhibitory and Absorption, Distribution, Metabolism, Excretion, and Toxicology (ADMET) Properties of Blebbistatin Derivatives Indicate That Blebbistatin Scaffold Is Ideal for drug Development Targeting Myosin-2.

Blebbistatin, para-nitroblebbistatin (NBleb), and para-aminoblebbistatin (AmBleb) are highly useful tool compounds as they selectively inhibit the ATPase activity of myosin-2 family proteins. Despite the medical importance of the myosin-2 family as drug targets, chemical optimization has not yet provided a promising lead for drug development because previous structure-activity-relationship studies were limited to a single myosin-2 isoform. Here we evaluated the potential of blebbistatin scaffold for drug development and found that D-ring substitutions can fine-tune isoform specificity, absorption-distribution-metabolism-excretion, and toxicological properties. We defined the inhibitory properties of NBleb and AmBleb on seven different myosin-2 isoforms, which revealed an unexpected potential for isoform specific inhibition. We also found that NBleb metabolizes six times slower than blebbistatin and AmBleb in rats, whereas AmBleb metabolizes two times slower than blebbistatin and NBleb in human, and that AmBleb accumulates in muscle tissues. Moreover, mutagenicity was also greatly reduced in case of AmBleb. These results demonstrate that small substitutions have beneficial functional and pharmacological consequences, which highlight the potential of the blebbistatin scaffold for drug development targeting myosin-2 family proteins and delineate a route for defining the chemical properties of further derivatives to be developed. SIGNIFICANCE STATEMENT: Small substitutions on the blebbistatin scaffold have beneficial functional and pharmacological consequences, highlighting their potential in drug development targeting myosin-2 family proteins.

Single Residue Variation in Skeletal Muscle Myosin Enables Direct and Selective Drug Targeting for Spasticity and Muscle Stiffness.

Muscle spasticity after nervous system injuries and painful low back spasm affect more than 10% of global population. Current medications are of limited efficacy and cause neurological and cardiovascular side effects because they target upstream regulators of muscle contraction. Direct myosin inhibition could provide optimal muscle relaxation; however, targeting skeletal myosin is particularly challenging because of its similarity to the cardiac isoform. We identified a key residue difference between these myosin isoforms, located in the communication center of the functional regions, which allowed us to design a selective inhibitor, MPH-220. Mutagenic analysis and the atomic structure of MPH-220-bound skeletal muscle myosin confirmed the mechanism of specificity. Targeting skeletal muscle myosin by MPH-220 enabled muscle relaxation, in human and model systems, without cardiovascular side effects and improved spastic gait disorders after brain injury in a disease model. MPH-220 provides a potential nervous-system-independent option to treat spasticity and muscle stiffness.

Effect of allosteric inhibition of non-muscle myosin 2 on its intracellular diffusion.

Subcellular dynamics of non-muscle myosin 2 (NM2) is crucial for a broad-array of cellular functions. To unveil mechanisms of NM2 pharmacological control, we determined how the dynamics of NM2 diffusion is affected by NM2's allosteric inhibitors, i.e. blebbistatin derivatives, as compared to Y-27632 inhibiting ROCK, NM2's upstream regulator. We found that NM2 diffusion is markedly faster in central fibers than in peripheral stress fibers. Y-27632 accelerated NM2 diffusion in both peripheral and central fibers, whereas in peripheral fibers blebbistatin derivatives slightly accelerated NM2 diffusion at low, but markedly slowed it at high inhibitor concentrations. In contrast, rapid NM2 diffusion in central fibers was unaffected by direct NM2 inhibition. Using our optopharmacological tool, Molecular Tattoo, sub-effective concentrations of a photo-crosslinkable blebbistatin derivative were increased to effective levels in a small, irradiated area of peripheral fibers. These findings suggest that direct allosteric inhibition affects the diffusion profile of NM2 in a markedly different manner compared to the disruption of the upstream control of NM2. The pharmacological action of myosin inhibitors is channeled through autonomous molecular processes and might be affected by the load acting on the NM2 proteins.

Electrocardiographic markers for the prediction of ventricular arrhythmias in patients with systemic sclerosis.

SSc is an autoimmune disease characterized by microvascular damage, endothelial dysfunction and fibrosis of the skin and the internal organs. Cardiac manifestation in patients with SSc is one of the major organ involvements. Approximately 20% of SSc patients suffer from primary cardiovascular disease and another 20% may have secondary cardiac involvement. Although cardiac arrhythmias are mostly linked to myocardial fibrosis, atrioventricular conduction abnormalities are secondary to the fibrosis of the pulse conduction system. Despite the severe consequences of ventricular rhythm disturbances in patients with SSc, the exact role of electrocardiographic markers in the prediction of these arrhythmias has not yet been clearly elucidated. Therefore, the question is whether certain ECG parameters reflecting ventricular repolarization may help to recognize scleroderma patients with increased risk for ventricular arrhythmias and sudden cardiac death.

The Impact of Obesity on the Cardiovascular System.

Obesity is a growing health problem worldwide. It is associated with an increased cardiovascular risk on the one hand of obesity itself and on the other hand of associated medical conditions (hypertension, diabetes, insulin resistance, and sleep apnoea syndrome). Obesity has an important role in atherosclerosis and coronary artery disease. Obesity leads to structural and functional changes of the heart, which causes heart failure. The altered myocardial structure increases the risk of atrial fibrillation and sudden cardiac death. However, obesity also has a protective effect on the clinical outcome of underlying cardiovascular disease, the phenomenon called obesity paradox. The improved cardiac imaging techniques allow the early detection of altered structure and function of the heart in obese patients. In this review, we attempt to summarize the relationship between obesity and cardiovascular diseases and outline the underlying mechanisms. The demonstrated new techniques of cardiac diagnostic procedures allow for the early detection and treatment of subclinical medical conditions and, therefore, the prevention of cardiovascular events.

Cardiovascular risk factors differently affect the survival of patients undergoing manual or mechanical resuscitation.

BACKGROUND: Chest compression is a decisive element of cardio-pulmonary resuscitation (CPR). By applying a mechanical CPR device, compression interruptions can be minimised. We examined the efficiency of manual and device-assisted resuscitation as well as the effects of cardiovascular risk factors on the outcome of resuscitation. METHODS: In our retrospective, randomised 3-year study the data of adult patients suffering non-traumatic, out-of-hospital, sudden cardiac death (SCD) were analysed (n = 287). The data were retrieved by processing case reports, Utstein sheets and acute coronary syndrome sheets. We compared the data of patients undergoing manual (n = 232) and device-assisted resuscitation (LUCAS-2, n = 55). The primary endpoint was the on-site restoration of spontaneous circulation (ROSC). RESULTS AND CONCLUSION: In 37% of the cases ROSC happened. With respect to ROSC an insignificantly more favourable tendency was demonstrated in the case of device-assisted resuscitation (p = 0.072). In the Lucas group, a higher success rate occurred even in the case of prolonged resuscitation. We found a better outcome in the Lucas group in the case of CPR started a longer time after the SCD (p < 0.05). A positive correlation was established between age and unsuccessful resuscitation (p = < 0.017; r = 0.125). An unfavourable correlation was observed between hypertension and the outcome of resuscitation (p = 0.018; r = 0.143). According to our results the presence of left ventricular hypertrophy poses 5.1-fold risk of unsuccessful CPR (CI: 4.97-5.29). Advanced age and structural heart diseases can play a role in the genesis of SCD. Importantly, left ventricular hypertrophy and hypertension negatively affect survival.

Hemodiafiltration and hemodialysis differently affect P wave duration and dispersion on the surface electrocardiogram.

AIM: The incidence of atrial fibrillation is increased during hemodialysis (HD); however, the effects of hemodiafiltration (HDF) on atrial arrhythmias have not been evaluated. The prolongation of the P wave and P dispersion (Pd) can predict atrial arrhythmias. METHODS: Data from 30 patients receiving HDF over a period of 3 months were collected; the same group of patients was then evaluated during treatment with conventional HD for at least another 3 months. Electrolyte values were obtained, and surface electrocardiograms (ECG), echocardiography, and Holter ECGs were performed. RESULTS: The duration of the P wave and Pd increased significantly during HD. The left atrial diameter decreased significantly only during HDF. During HDF, the left atrial cross diameter measured at the beginning of the session was positively correlated with the incidence of supraventricular premature beats (p = 0.011, r = 0.4556). The decrease in left atrial diameter during HDF was negatively correlated with the incidence of supraventricular premature beats (p = 0.016, r = -0.43). During HDF, the changes in sodium and Pd were significantly positively correlated (p < 0.05, r = 0.478). During HD, the changes in ionized calcium levels and Pd were positively correlated (p < 0.05, r = 0.377). CONCLUSION: Our results suggest that HDF has a more beneficial effect on P wave duration and Pd than HD. The alterations in the ECG markers may be the result of the simultaneous occurrence of certain electrolyte imbalances and renal replacement methods.

[End stage renal disease and ventricular arrhythmia. Hemodialysis and hemodiafiltration differently affect ventricular repolarization]. / Végstádiumú vesebetegség és kamrai szívritmuszavarok. A hemodialízis és a hemodiafiltráció a kamrai repolarizációt eltéroen befolyásolja.

Various factors (hypertension [27%], diabetes mellitus [40%]) and their cardiovascular complications play an important role in the genesis of end stage renal disease. Furthermore, primary kidney diseases (glomerulonephritis, tubulointerstitial nephritis, obstructive uropathy, analgesic nephropathy, polycystic kidney disease, autoimmune diseases) have an unfavorable effect on the cardiovascular outcome of this particular population. Increased susceptibility for arrhythmias may be caused by intermittent volume overload, metabolic disturbance, renal anemia, structural and electrophysiological changes of the myocardium, inflammatory mechanisms that may worsen the mortality statistics of these patients. A novel renal replacement method, hemodiafiltration - based on a convective transport - ensures reduced mortality that may be attributed to a decreased occurrence of arrhythmias. The aim of this paper is to review the pathogenetic factors taking part in the arrhythmogenesis of end stage renal disease and to provide diagnostic and therapeutic opportunities that can help in the prediction and prevention of arrhythmias.

Hemodiafiltration beneficially affects QT interval duration and dispersion compared to hemodialysis.

BACKGROUND/AIMS: The prolongation of the QT interval and dispersion could predict ventricular arrhythmias. It is not yet established whether there is a difference between the effects of hemodialysis and hemodiafiltration on QT interval duration and dispersion. METHODS: Data of thirty patients was investigated while they were receiving hemodiafiltration over a period of 3 months; then the same group of patients was evaluated during treatment with conventional hemodialysis for at least another 3 months. Ionic parameters and surface electrocardiograms (ECG) were analyzed five times during each session, and 2D, M-mode echocardiography and Holter ECGs were performed to acquire additional information. RESULTS: QT interval duration (QTmax) and dispersion (QTd) showed a significant increase during hemodialysis, but not during hemodiafiltration. QTmax was 388.66 ± 31.81 ms at the beginning of hemodialysis and increased to 400.66 ± 39.12 ms even at the 30th minute (p < 0.05). QTd was found to be 31.33 ± 10.08 ms before the commencement of hemodialysis with the largest prolongation being seen at the 240th minute (51.33 ± 14.56 ms, p < 0.05). The occurrence of ventricular premature beats was significantly higher during hemodialysis (p = 0.018). The left atrial diameter significantly decreased at the end of hemodiafiltration (at the beginning 45.1 ± 5.25 mm, at the end 40.77 ± 5.76 mm; p < 0.05). CONCLUSION: Our results suggest a beneficial effect of hemodiafiltration on the studied electrocardiographic parameters compared to hemodialysis. The larger decrease in the left atrial diameter suggests a more efficient intracardiac volume-decreasing potential of hemodiafiltration.

Hemodialysis and hemodiafiltration differently modulate left ventricular diastolic function.

BACKGROUND: Renal replacement therapy may have a favorable effect on diastolic left ventricular function, but it is not clear whether hemodiafiltration is superior to hemodialysis in this field. Nitric oxide (NO) and asymmetric dimethylarginine (ADMA) may play a role in the changes of intracardiac hemodynamics, but it is not clear whether the different renal replacement methods have disparate influence on the metabolism of these materials. METHODS: Thirty patients on renal replacement therapy were investigated. First, data was analyzed while patients received hemodiafiltration over a period of three months. Then, the same patients were evaluated during treatment with hemodialysis for at least another three months. Echocardiography was performed before and after renal replacement therapy. RESULTS: No significant difference was found in the volume removals between hemodialysis and hemodiafiltration. The left atrial diameter and transmitral flow velocities (E/A) decreased significantly only during hemodiafiltration. A positive correlation was observed between the left atrial diameter and E/Ea representing the left ventricular pressure load during hemodiafiltration. Significant correlations between NO and A and E/A were observed only in the case of hemodiafiltration. CONCLUSION: Hemodiafiltration has a beneficial effect on echocardiographic markers representing left ventricular diastolic function. This could be attributed to the differences between the dynamics of volume removal and its distribution among liquid compartments.

[Molecular and genetic background of sudden cardiac death]. / A hirtelen szívhalál molekuláris és genetikai háttere.

Despite recent findings on the functional, structural and genetic background of sudden cardiac death, the incidence is still relatively high in the entire population. A thorough knowledge on susceptibility, as well as pathophysiology behind the development of malignant arrhythmias will help us to identify individuals at risk and prevent sudden cardiac death. This article presents a review of the current literature on the role of altered intracellular Ca2+ handling, acute myocardial ischaemia, cardiac autonomic innervation, renin-angiotensin-aldosterone system, monogenic and complex heritability in the pathogenesis of sudden cardiac death.

Effects of ropinirole on action potential characteristics and the underlying ion currents in canine ventricular myocytes.

In spite of its widespread clinical application, there is little information on the cellular cardiac effects of the dopamine receptor agonist ropinirole. In the present study, therefore, the concentration-dependent effects of ropinirole on action potential morphology and the underlying ion currents were studied in enzymatically dispersed canine ventricular cardiomyocytes using standard microelectrode, conventional whole-cell patch clamp, and action potential voltage clamp techniques. At concentrations > or = 1 microM, ropinirole increased action potential duration (APD(90)) and suppressed the rapid delayed rectifier K(+) current (I (Kr)) with an IC(50) value of 2.7 +/- 0.25 microM and Hill coefficient of 0.92 +/- 0.09. The block increased with increasing depolarizations to more positive voltages, but paradoxically, the activation of I (Kr) was accelerated by 3 muM ropinirole (time constant decreased from 34 +/- 4 to 14 +/- 1 ms). No significant changes in the fast and slow deactivation time constants were observed with ropinirole. At higher concentrations, ropinirole decreased the amplitude of early repolarization (at concentrations > or = 10 microM), reduced the maximum rate of depolarization and caused depression of the plateau (at concentrations > or = 30 microM), and shortened APD measured at 50% repolarization (at 300 microM) indicating a concentration-dependent inhibition of I (to), I (Na), and I (Ca). Suppression of I (Kr), I (to), and I (Ca) has been confirmed under conventional patch clamp and action potential voltage clamp conditions. I (Ks) and I (K1) were not influenced significantly by ropinirole at concentrations less than 300 microM. All these effects of ropinirole were fully reversible upon washout. The results indicate that ropinirole treatment may carry proarrhythmic risk for patients with inherited or acquired long QT syndrome due to inhibition of I (Kr)-especially in cases of accidental overdose or intoxication.

[Microvolt T-wave alternant: pathomechanism and evaluation of a new marker of arrhythmia risk]. / A fokozott arrhythmiarizikó új markere: a mikrovolt T-hullám-alternáns patomechanizmusa és vizsgálati módszerei.

Microvolt T-wave alternant (microV-TWA) is a beat-to-beat fluctuation in the amplitude of T-wave at a microvolt level. The amount of variation is small, on the order of microvolts, so sensitive digital signal processing techniques are required to detect microV-TWA. The appearance of microV-TWA has been suggested as a predictor of susceptibility to lethal ventricular tachyarrhythmias, and sudden cardiac death in different patients' populations. During the last decade, theoretical, experimental and clinical research efforts have focused primarily on microV-TWA, examining its mechanisms and predictive value using time-invariant cutoff values. The cellular mechanisms involved are not well-defined and are the subject of this investigation. This review discusses the bench-to-bedside literature that, over decades, has linked alternans of repolarization in cellular, whole-heart, and human studies with spatial dispersion of repolarization, alternans of cellular action potential, and fluctuations in ionic currents, intracellular calcium regulation, role of the beta adrenergic receptors and connexins that may lead to ventricular arrhythmias. This review then provides a contemporary framework for the use of microV-TWA methods to enhance risk stratification for sudden cardiac death, identifying populations for whom microV-TWA is best established.

The effect of sleep apnea on QT interval, QT dispersion, and arrhythmias.

BACKGROUND: QT interval (QT) and QT dispersion (QTd) are electrocardiograph (ECG) parameters for the evaluation of myocardial repolarization. The inhomogeneity of ventricular repolarization is associated with ventricular arrhythmias. An increased QT, QTd, and increased incidence of nocturnal cardiac rhythm disturbances have been described in patients with obstructive sleep apnea (OSA), while other investigators did not find a relationship between ventricular arrhythmias and OSA. HYPOTHESIS: The aim of this study was to examine the occurrence of ventricular arrhythmias and to measure QT parameters in patients with untreated OSA using an ambulatory Holter-ECG. METHODS: A total of 25 patients with untreated OSA were studied. After routine biochemical investigation and 2-dimensional, M-mode echocardiography, a 24-hour Holter-ECG was recorded to detect cardiac arrhythmias and QT parameters. QT parameters were measured by the QT Guard system. RESULTS: Only the QT interval increased significantly during the nighttime period (nocturnal QT interval: 423.1 +/- 34.6 ms, daytime QT interval: 381.6 +/- 33.8 ms, 24-hour QT interval: 394.7 +/- 31.1 ms). However, during the nighttime QT interval (422.8 +/- 14.9 ms), QTd (31.2 +/- 11.0 ms) and QT dispersion (30.5 +/- 10.2 ms) did not show any change compared to 24-hour (QTc interval: 423.7 +/- 14.2 ms, QTd: 28.8 +/- 9.4 ms, QTcd: 30.5 +/- 9.43 ms) and daytime levels (QTc interval: 423.9 +/- 14.3 ms, QTd: 27.3 +/- 10.7 ms, QTcd: 29.9 +/- 11.1 ms). None of the patients had ventricular arrhythmias. CONCLUSIONS: QTd and QTcd did not increase during the nighttime period. Our study did not show an increased risk of ventricular arrhythmias in this population during the monitoring period.

Myocardial adrenergic innervation in patients with vasovagal syncope measured with 123I-MIBG uptake.

BACKGROUND: Data about biochemical abnormalities (catecholamines) during vasovagal syncope (VVS) are available, but adrenergic myocardial structural damage may be hypothesized as well. AIM: To study the global and regional adrenergic myocardial innervations in patients with VVS that was shown by head-up tilt table testing. PATIENTS AND METHODS: Fifteen adult patients with VVS were studied. The age of patients was 44+/-18 years (17-73), nine were female and six were male. According to the tilt test results, five patients had cardioinhibition, six patients had vasodepressor syncope and four patients suffered from mixed-type VVS. Ischemic heart diseases were excluded by normal Tc-MIBI rest-stress dipyridamol single-photon emission computed tomography (SPECT) results. A control group was formed from six healthy adult volunteers. To investigate cardiac sympathetic innervations 250-370 MBq iodine-123 meta-iodobenzylguanidine (I-MIBG) was used. Fifteen minutes after the intravenous administration of I-MIBG early, and 2-3 h later, delayed planar myocardial and tomographic (SPECT) scintigraphies were performed. The heart-to-mediastinum count ratio (H/M) was calculated for both early and delayed images, together with the decay-corrected change rates. The regional I-MIBG uptake was visualized on SPECT slices and polar map images. The regional uptake was considered pathological below 50% compared with normal uptake sites. RESULTS: Delayed H/M ratios significantly depended on group (analysis of variance: P=0.005), whereas early H/M values did not. Although the decay-corrected myocardial MIBG uptake increased in time in controls, less wash-in or even wash-out could be observed in the VVS groups; however, difference from the controls was significant only in the vasodepressor group (Dunnett's t-test: P<0.05). All patients had regional I-MIBG uptake deficit in different regions. CONCLUSION: In our patients with VVS, global I-MIBG deficit was present frequently, and all patients had regional adrenergic nerve function deficit. These alterations may play a role in causing clinical symptoms and have importance in staging and treatment planning.

[Atrial fibrillation and the autonomous nervous system]. / A pitvarfibrilláció és a vegetatív idegrendszer.

The autonomic nervous system has a crucial role in the genesis, maintenance and abruption of atrial fibrillation. The substrate and trigger mechanism of atrial fibrillation can be influenced by the changing autonomic tone. The authors summarize the current knowledge on the relationship between autonomic nervous system and atrial fibrillation. The special neuroanatomical status and the role of autonomic reflexes and baroreflex in the initiation, maintenance, and termination of arrhythmia are reviewed. Furthermore, the mechanism and consequences of autonomic effect of the curative radiofrequency catheter ablation of pulmonary vein with atrial vagal neuroablation are discussed. At the end we also summarize the pharmacologic therapy of atrial fibrillation. Classification of atrial fibrillation, as either vagal or adrenergic, has only limited impact on current management.

[Arrhythmias in patients with obstructive sleep apnea]. / Szívritmuszavarok obstruktív alvási apnoéban.

The authors summarize the current knowledge on the types, prevalence, reasons, diagnosis and current therapy of arrhythmias occurring in patients with obstructive sleep apnea. Most of the patients with obstructive sleep apnea have nocturnal bradycardia (5-50%), paroxysmal tachyarrhythmia (atrial 35%; ventricular 0-15%), or both. The frequency of rhythm disturbances associated with the severity of the sleeping disorder. It is important to recognize the factors predisposing to arrhythmias and the early appropriate therapy of patients is essential, in order to protect patients from life threatening arrhythmias which may worsen the clinical outcome.