Very rare minor homozygous GG genotype of tissue factor +5466A>G mutation in a patient with two cryptogenic cerebrovascular ischemic events.

We identified a male Polish patient with a very rare minor homozygous GG genotype of the tissue factor (TF) +5466A>G polymorphism, who within two months experienced a transient ischemic attack (TIA) and ischemic stroke of unknown origin associated with the presence of patent foramen ovale below 40 years of age. A relationship between the TF +5466GG genotype and cerebrovascular thromboembolic events could be explained by detectable coagulant TF activity determined in a clotting assay and increased immunoreactive TF levels detected in plasma 5 years after the previous TIA and stroke. Given the role of TF-induced pathway in blood coagulation, it might be speculated that the TF +5466A>G polymorphism, especially in the homozygous GG form, predisposes to increased risk of cerebrovascular ischemic events. There is a need to conduct a prospective study on the effect of TF +5466A>G polymorphism on the risk of cryptogenic stroke.

Transcatheter closure as an alternative and equivalent method to the surgical treatment of atrial septal defect in adults: comparison of early and late results.

BACKGROUND: The clinical efficacy of transcatheter atrial septal defect (ASD) closure with the Amplatzer Septal Occluder (ASO) can only be judged against the results of contemporaneous surgery. The present study compared early and late results of ASD closure using ASO versus open-heart surgery. METHODS: Forty-eight adult patients were found eligible for transcatheter closure in transesophageal echocardiography. The surgical group consisted of 52 patients with isolated ostium secundum ASD. All patients underwent standard ECG, 24-hour ECG recording, and transthoracic echocardiography pre-procedure at 1-month and at 1-year follow-up. Physical fitness was assessed by cardiopulmonary exercise testing (CPX) prior to ASD closure and at 1-year follow-up. RESULTS: ASD closure was successful in all surgical patients and in 94% of the ASO group (0% mortality). The total complication rate for surgical vs. device closure was not significantly different (19.2% vs. 26.7%; p=0.383), despite more serious complications in the surgical group. Hospital stay was significantly shorter in the ASO group (5.4+/-2.2 vs. 9.1+/-1.2 days; p<0.001). Although echocardiographic parameters did not differ significantly between the respective groups at 1-year follow-up, CPX revealed a higher decrease in the VE/VCO2 slope in the ASO group (-3.7+/-3.4 vs.-1.2+/-4.8; p=0.003). CONCLUSIONS: As surgical and device closure appear similarly effective in adults with ASD, avoidance of thoracotomy and cardiopulmonary bypass, in conjunction with a shorter hospital stay, argues in favour of device closure in selected patients.

Altered fibrin clot structure/function in patients with cryptogenic ischemic stroke.

BACKGROUND AND PURPOSE: We tested the hypothesis that fibrin structure/function is unfavorably altered in patients with cryptogenic ischemic stroke. METHODS: Ex vivo plasma fibrin clot permeability, turbidimetry, and efficiency of fibrinolysis were determined in 89 patients with patent foramen ovale (PFO) and a history of first-ever stroke, 58 patients with first-ever stroke and no PFO, and 120 healthy controls. RESULTS: Stroke patients, evaluated 3 to 19 months after the event, and controls did not differ with regard to age, sex, smoking, and fibrinogen. Stroke patients with or without PFO had lower clot permeability (P<0.0001), faster fibrin polymerization (P<0.0001), prolonged clot lysis time (P<0.0001), higher maximum D-dimer levels released from clots (P<0.0001), and maximum rate of D-dimer release (P=0.02) than controls. Time from stroke occurrence showed no association with any clot variables. Scanning electron microscopy of fibrin clots showed increased fiber diameter and density in stroke patients. Clots from stroke patients with PFO were more permeable and showed shorter lysis time compared to those without PFO, and this was related to lower proportion of smokers in the former group. CONCLUSIONS: Altered fibrin clot structure and resistance to fibrinolysis are associated with cryptogenic stroke.

[Evaluation of left ventricular function in patients with chronic obstructive pulmonary disease]. / Ocena czynnosci lewej komory u chorych na przewlekla obturacyjna chorobe pluc.

INTRODUCTION: Patients with right ventricle (RV) pressure overload often have impaired left ventricular (LV) diastolic function. Objectives. The aim of study was to evaluate LV function in patients with chronic obstructive pulmonary disease (COPD). Patients and methods. Thirty-five patients (mean age: 62.1 +/- 7.7 y) with COPD without additional cardiac diseases and 25 age--and sex-matched healthy subjects were enrolled into the study. All patients underwent resting ECG tracing, blood pressure, spirometry, standard and tissue Doppler echocardiography. RESULTS: The mean value of forced expiratory volume in one second (FEV1) in the COPD group was 40 +/- 8.9% of the predicted value. We found no significant differences in LV end-diastolic and systolic diameter and interventricular septum as well between COPD patients and controls. RV end-diastolic diameter and RV wall thickness were significantly larger and right ventricle systolic pressure--RVSP (38 +/- 11.2 vs. 20 +/- 2.5 mm Hg) significantly higher in the COPD group. Both peak early to peak atrial filling velocities ratio--E/A and peak annular velocity during early diastole to peak annular velocity during atrial contraction--Em/Am were significantly lower in COPD compared to controls. Moreover, there was a strong inverse correlation between Em/Am and RVSP (r = -0.75; p < 0.001) and between E/A (r = -0.6; p < 0.001) as well. We found no significant differences in parameters assessing the LV systolic function between both groups. CONCLUSIONS: In COPD patients LV diastolic function is significantly impaired and its magnitude is related with increase in pulmonary artery pressure, while systolic LV function is well preserved.

[Early haemodynamic changes after transcatheter closure of atrial septal defect]. / Przezskórne zamykanie ubytków w przegrodzie miedzyprzedsionkowej przy pomocy zapinki Amplatza: wyniki i zmiany hemodynamiczne w obserwacji 6-miesiecznej.

OBJECTIVE: To evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) using the Amplatzer Septal Occluder (ASO). METHODS: Between December 2000 and December 2002, 27 adult patients (20 females, 7 males) with a mean age of 41.1 +/- 13.3 (range 18-62) years were enrolled for an attempt at ASD closure with the ASO device. All patients had an isolated secundum ASD with a large left-to-right shunt (ratio of pulmonary to systemic blood flow or Qp:Qs >1.5:1). Transthoracic color Doppler echocardiographic examination was performed on all patients before procedure, 24 hours, 1 and 6 months after surgery. Clinical observation (NYHA class) was performed 1 and 6 months after surgery. RESULTS: The ASO device was successfully implanted in all patients (procedure time 19-63 minutes, median 43 minutes, fluoroscopy time 4-40 minutes, median 12.6 minutes), with only 3 patients with a trivial residual shunt. The defect echo diameter was 14.2 +/- 4.3 (7-24). At one month of follow-up transthoracic echocardiography showed that the device was correctly positioned in all cases and no predictors for a residual shunt were identified. Residual trivial shunt in one month follow-up was shaded in 3 patients. Paradoxical septal motion abnormalities normalized in all patients. The right ventricular dimension evaluated by 2D echocardiography decreased in 20 pts (74.1%), mean 5.0 +/- 3.4 mm (range 1.5-8), the right atrium dimension decreased in 21 pts (77.8%), mean 8.65 +/- 4.3 mm (range 2-20) and the left atrium dimension decreased in 15 pts (55.6%), mean 6.36 +/- 3 mm (range 2-21). We didn't find correlations between ratio of left-to-right shunt before ASD closure and the decrease of right heart dimension as well as the decrease of pulmonary artery systolic pressure. CONCLUSIONS: Transcatheter closure of secundum ASD using the ASO is a safe and effective procedure, with excellent short-term follow-up results. During one month observation it caused partial normalization of echocardiographic parameters.

[Early results of atrial septal defect closure with the Amplatzer Septal Occluder are impacted by tricuspid insufficiency]. / Przezskórne zamykanie ubytków w przegrodzie miedzyprzedsionkowej przy pomocy zapinki Amplatza: wczesne rezultaty w zaleznosci od niedomykalnosci trójdzielnej.

OBJECTIVE: Our study reports the results of a comparison of transcatheter closure of secundum atrial septal defect (ASD) using the Amplatzer Septal Occluder (ASO) in patients with and without tricuspid insufficiency. METHODS: Consecutive 27 adult patients (20 females, 7 males) with a mean age of 41.1 +/- 13.3 (range 18-62) years having an ASD II and a transcatheter closure between December 2000 and December 2002 were analyzed. All the patients had an isolated secundum ASD with a significant left-to-right shunt (ratio of pulmonary to systemic blood flow or Qp:Qs >1.5:1). Patients were divided in two groups: group I--without tricuspid abnormalities (8 patients, 29.6%), group II--patients with tricuspid insufficiency I-III stage, (19 patients, 70.4%). Transthoracic color Doppler echocardiographic study was performed in all patients before discharge and was repeated one month after discharge. RESULTS: The mean age, the diameter of defect, the degree of left-to-right shunt, the diameter of implanted device were comparable in both groups. Before implantation the dimension of right heart cavities differed between groups. The right ventricular dimension was larger in group II (mean 36.2 mm vs. 29.1 mm; p<0.009), the right atrium diameter was larger in group II (46.2 mm vs. 24.3 mm; p<0.007). Pulmonary artery systolic pressure before the procedure was higher in group II (36.6 mmHg vs. 20.43 mmHg; p<0.006). The ASO device was successfully implanted in all the patients. At one month follow-up septal motion abnormalities normalized in all patients in both groups. The mean decrease of right atrium diameter in group I was 6.2 mm (range 1.5-12 mm) compared to 9.6 mm (range 2-20) in group II, (p<0.001), the mean decrease of right ventricular diameter in group I was 5.8 mm (range 2-8 mm) compared to 3.1 mm (range 1-5.9) in group II, (p<0.006). CONCLUSIONS: Short-term follow-up demonstrated excellent results of ASD closure in both groups. In one month follow-up the decrease of right cavities dimensions was significantly higher in the patients without tricuspid abnormalities. The pulmonary artery systolic pressure before ASD closure was significantly higher in the patients with tricuspid abnormality.

[Atrial septal defect associated with mitral valve prolapse--prevalence and clinical significance]. / Ubytek przegrody miedzyprzedsionkowej skojarzony z wypadaniem platków zastawki mitralnej--czestosc wystepowania i znaczenie kliniczne.

AIM: High incidence of mitral valve prolapse (MVP) associated with atrial septal defect (ASD) has been reported. The study aimed to evaluate the prevalence, etiology and clinical significance of MVP in patients with ASD. METHODS: Forty-seven consecutive patients with secundum type ASD (30 F; 17 M; mean age: 37.9 +/- 14.0; range: 16-62 years) were enrolled into the study. All patients underwent M-mode and two dimensional echocardiography to check for MVP, defined as the superior systolic displacement of mitral leaflets > or = 2 mm above annulus with coaptation point at, or superior to the annular plane. Pulmonary to systemic flow ratio (Qp/Qs), diastolic right ventricle dimension (RV), left ventricle dimension (LV) and left to right ventricle ratio (LV/RV) were measured. Furthermore, mitral and tricuspid valve insufficiency and right ventricle systolic pressure (RVSP) were evaluated. A symptom-limited, incremental exercise test (CPX)--modo Bruce on Marquette 2000 Treadmill was performed in every patient. We determined: time of exercise--Time (min), peak oxygen uptake--VO2peak (ml/kg/min), VO2peak expressed as % of predicted value--VO2% and anaerobic threshold--AT (expressed as % VO2 max). The study population was divided into two groups: Group I--patients with ASD and MVP and Group II--patients with ASD without MVP. RESULTS: MVP was recognized in 17 patients (36%); anterior MVP was found in 14, two cases revealed posterior MVP and one was diagnosed with both anterior and posterior MVP. MVP was not associated with significant mitral regurgitation. Echocardiographic and CPX data are summarized in table I. There were no significant differences in age, RVSP, RV and LV diastolic dimensions between groups, although Qp/Qs was significantly higher (p=0.01) and LV/RV significantly lower (p=0.02) in the MVP group. Moreover, there was a significant negative correlation between Qp/Qs and LV/RV ratio (r=-0.70; p<0.001) in a study group. No significant difference in time of exercise, VO2peak, VO2%, and AT was observed between respective groups. CONCLUSIONS: Our data support the thesis that MVP associated with secundum ASD is a functional disorder due to the atrial shunt and leftward shift of interventricular septum. MVP does not affect cardiopulmonary capacity in ASD patients.

[Transcatheter closure of atrial septal defect using the amplatzer septal occluder--early haemodynamic and exercise capacity changes]. / Ocena zmian hemodynamicznych i wydolnosci fizycznej u chorych po przezskórnym zamknieciu ubytków w przegrodzie miedzyprzedsionkowej przy pomocy zapinki amplatza.

AIM: To evaluate the outcomes of transcatheter closure of secundum atrial septal defect (ASD) using the Amplatzer Septal Occluder (ASO). METHODS: Between December 2000 and December 2002, 27 adult patients (20 females, 7 males) with a mean age of 41.1 +/- 13.3 (range 18-62) years were enrolled for an attempted ASD closure with a ASO device. All patients had an isolated secundum ASD with a large left-to-right shunt (ratio of pulmonary to systemic blood flow, Qp:Qs > 1.5;1). Transthoracic color Doppler echocardiographic study was performed on all patients before procedure, after 24 hours, and after one six months of follow-up. Symptom-limited treadmill exercise tests with respiratory gas exchange analysis (Bruce protocol) were performed on all patients before procedure, and six months of follow-up. RESULTS: The ASO device was successfully implanted in all patients, with only 3 patients with a trivial residual shunt. The ASD diameter ranged from 7 to 24 mm. No predictors for a residual shunt were identified. At one month of follow-up transthoracic echocardiography showed that the device was correctly positioned in all cases. Residual trivial shunt in one month follow-up was shaded in 3 patients. Septal motion abnormalities normalized in all patients. The right ventricular and atrium dimensions evaluated by 2D echocardiography decreased in most of the patients after one and six months of follow-up. After 6 months of ASD closure, all the pts showed a significant improvement of VO2max, VEN/VCO2, VO2peak as well as lengthened of time of exercise. The mean increase of VO2max in pts 40 years old or younger was 9.5 +/- 6.4 (4-10.7) ml/kg/min; compared to 3.9 +/- 4.1 (2-8) in older pts (p < 0.003), the mean increase of time of exercise in pts 40 years old or younger was 12.7 +/- 7.0 (7-14) compared to 9.1 +/- 7.0 (4.3-11) in others (p < 0.008). CONCLUSIONS: Transcatheter closure of secundum ASD using the ASO is a safe and effective procedure, with excellent short-term follow-up results. During six months observation it caused partial normalization parameters of echocardiography. During six months observation it caused significant improvement of exercise capacity in most of the patients. Younger patients (up to 40 years) can benefit more in exercise capacity after ASD closure in comparison to the older group.

[Reproducibility of spiro-ergometric exercise test parameters in patients with heart failure]. / Powtarzalnosc parametrów wysilkowych testów spiroergometrycznych u chorych z niewydolnoscia serca.

UNLABELLED: The aim of the study was to determine the degree of reproducibility of parameters of cardiopulmonary exercise (CPX) tests in patients with chronic heart failure (HF). MATERIAL AND METHODS: We investigated 30 patients (7 women, 23 men) with ages ranging from 44 to 68 and a mean age of 56 +/- 14.5 years with HF due to dilated cardiomyopathy (5 patients) and coronary artery diseases (25 patients). The mean ejection fraction was 24 +/- 6.2%. All the patients were symptomatically stable during the preceding 4 weeks. After a preliminary test, the patients underwent two treadmill CPX tests using modified Naughton protocol with a 1-week interval between tests. CPX tests were performed at the same time of the day, using the same equipment and the patients were receiving constant medication. The reproducibility was assessed for: Rest heart rate (HRrest), oxygen uptake at the anaerobic threshold (VO2AT) and peak exercise (VO2peak), carbon dioxide production (VCO2peak), ventilatory equivalent of carbon dioxide (VE/VCO2peak) and oxygen (VE/VO2peak), end-tidal partial pressure for carbon dioxide (PETCO2peak), exercise time (T) and respiratory exchange ratio (RER). RESULTS: The reproducibility was found for all analyzed parameters of CPX tests: HRpeak (p < 0.0001), VO2AT (p < 0.0001), T (p < 0.001), HRpeak (p < 0.0001), VO2peak (p < 0.0001), VO2peak%N (p < 0.0001), VE/VCO2peak (p < 0.0001), VE/VO2peak (p < 0.0001), PETCO2peak (p < 0.0001), RER (p < 0.004). CONCLUSION: On adherence to standardized conditions, an excellent reproducibility exists for the most important parameters of cardiopulmonary exercise tests. CPX tests provide a useful and objective method of assessing functional capacity and diseases progression in patients with heart failure.