Left atrial appendage closure - new choice for no-option patients with atrial fibrillation.

AIM: Remodeling and impaired blood flow in left atrial appendage (LAA), which occurs in patients with atrial fibrillation (AF), may lead to thrombus formation and possible thromboembolic complications. Although there are several pharmacological antithrombotic possibilities, some patients with several co-morbidities and contraindications to such treatment cannot be offered any of them. Therefore LAA closure systems may be an attractive alternative. We present our early experience with two currently available different LAA transcatheter closure systems (Watchman and Amplatzer Cardiac Plug). METHODS: Twenty three patients (mean age 69.1±6.8 years, 12 male) with non-rheumatic AF and high risk of thromboembolic complications (CHA2DS2-VASc score ≥2 (mean 4.5±1.5), who could not be treated with the long-term oral anticoagulation because of contraindications or significant side effects, were qualified to the LAA closure. RESULTS: The Amplatzer Cardiac Plug (St Jude Medical, St Paul, MN, USA) was implanted in 7 patients and Watchman Occluder (Boston Scientific, Boston, MA, USA) in the other 15 patients. The implantation was not performed in one patient as the transoesophageal echocardiography during the procedure revealed a new thrombus in LAA. The procedural details and follow-up data are presented. Neither severe pericardial effusion nor device related thrombus were observed. In long term follow-up transient ischemic attack was noted only in one patient (diagnosed with thrombophilia). One patient died 14 months after the procedure due to non-cardiac reason. CONCLUSION: The LAA occluder implantation seems to be a safe and reasonable alternative for oral anticoagulation and should be considered in patients with AF who have contraindications or complications of pharmacological treatment.

The BNP concentrations and exercise capacity assessment with cardiopulmonary stress test in cyanotic adult patients with congenital heart diseases.

Cyanosis is observed in patients with complex congenital heart disease (CHD) and pulmonary hypertension, heart failure represents an important clinical problem in such patients. The aim of this study was to evaluate the exercise capacity in patients with cyanotic CHDs using cardiopulmonary exercise test, measuring serum BNP levels as well as to seek correlation between BNP levels and cardiopulmonary exercise test parameters and identify the effects of blood oxygen desaturation and pulmonary hypertension on these indices. The study group consisted of 53 patients (21 males) at the mean age of 39.4 ± 14.3 years, of whom 19 were operated on at the mean age of 9.6 ± 8.6 years. Mean blood oxygen saturation (SO(2)) in patients was 81.2 ± 6.2%. Twenty four patients presented with Eisenmenger syndrome, 16--univentricular hearts, 4--transposition of the great arteries, 6--Fallot's tetralogy, and 3--Ebstein anomaly. The control group comprised 32 healthy individuals (16 males) at the mean age of 40.7 ± 9.9 years. Cardiopulmonary stress test showed significantly lower exercise capacity in patients with cyanosis than in controls: maximal oxygen uptake (VO(2max)) 15.5 ± 4.9 vs. 31.6 ± 7.1 ml/kg/min (p=0.00001), maximum heart rate at peak exercise (HR max): 139.5 ± 22.5 bpm vs. 176.6 ± 12.1 (p=0.0001), VE/VCO(2) slope: 46.4 ± 10.1 vs. 27.3 ± 2.9 (p=0.00001), forced vital capacity FVC: 3.1 ± 1.1 l vs. 4.4 ± 0.8 l (p=0.00001). Subjects with the evidence of pulmonary hypertension (PH+) had lower exercise capacity than those without (PH-): VO(2max): 17.2 ± 4.2 vs. 12.8 ± 4.8 ml/kg/min (p=0.002), VE/VCO(2): 43.7 ± 11.1 vs. 50.9 ± 6.4 (p=0.01), FVC: 3.46 ± 1.05 l vs. 2.37 ± 0.91 l (p=0.0002). Plasma BNP levels in the study group were higher than in controls: 122.4 ± 106.7 vs. 21.1 ± 20.2 pg/ml p=0.00001 and did not differ between PH+ and PH- groups (115.7 ± 99.0 vs. 127.9 ± 114.1 pg/ml p=0.78). Negative correlations between BNP levels and VO(2max) (r=-0.389, p=0.006), FVC (r=-0.395 p=0.005), FEV1 (r=-0.386 p=0.006), SO(2) (r=-0.445 p=0.00001), and positive correlation between BNP level and VE/VCO(2) (r=0.369 p=0.009) were found.

Twenty-four hour ambulatory blood pressure monitoring in young and elderly hypertensive subjects.

The aim of our study was to compare blood pressure (BP) measured by 24-h ambulatory monitoring in young and elderly hypertensives and to find a dependency between left ventricular mass (LVM) and different pressure ratios. We also estimated the calcium ionized concentration and serum lipids in all subjects. Two hypertensive groups divided accordingly by age were studied. The duration of hypertension was similar in both groups. The Oxford Medilog ABP was used for the arterial BP recordings. Mean arterial BP, BP loads and night/day mean arterial pressure ratio were evaluated. In both groups left ventricular mass index (LVMI) were calculated. The serum calcium ionized concentration (Ca++) was estimated and serum lipids were determined. We found 10 non-dippers in the young group and seven non-dippers in the elderly hypertensives. LVM and LVMI were comparable in both groups. We showed the correlation of the nocturnal mean arterial pressure with LVM in elderly hypertensives and the dependency of nocturnal BP load with LVM in this group. Serum calcium ionized concentration was significantly decreased in the elderly patients, and LDL-cholesterol was significantly higher in this group. We found a negative correlation between serum calcium and triglycerides in young and elderly hypertensives. We found more non-dippers in the young hypertensives and a positive correlation between LVM and nocturnal mean arterial pressure and nocturnal BP load in elderly subjects. These results suggest the cardiovascular prognosis is not good in both groups. The prognosis in elderly hypertensives was also worsened by the low serum calcium ionized and high LDL-cholesterol concentrations.

Restoration of mechanical atrial function after electrical cardioversion of chronic atrial fibrillation in patients after surgical treatment of mitral valve disease--hemodynamic effects and prognostic value of maintenance of sinus rhythm.

There are controversies regarding the possibility of returning of A wave (mitral flow at left atrial contraction) after electroconversion (EC) in patients with persisting chronic atrial fibrillation in spite of successful surgical treatment of mitral valve disease. Twenty-four hours before successful EC, thereafter daily for 1 week and then on the 14th, 21st and 28th day and 6 months after EC, ECG, M-mode, two-dimensional and Doppler echocardiography were performed in 55 patients. A wave (>0.1 m/s) appeared on the 1st day in 31 patients, on the 2nd day in the next 6, on the 3rd in 5 patients, on the 4th and 5th days in 1 patient and on the 7th day in 4 patients. In 7 patients A wave did not restore. Maximum velocity of A wave increased from 0.48 +/- 0.22 to 0.86 +/- 0.28 m/s (p < 0.05) during the follow-up. In 92% of patients with A wave 24 h after EC, significant increases in stroke index from 35 +/- 12 to 47 +/- 15 ml/m2 (p < 0.04), ejection fraction from 46 +/- 9 to 55 +/- 8% (p < 0.01) and pulmonary acceleration time from 94 +/- 26 to 107 +/- 22 ms (p < 0.05) were observed. Sinus rhythm was still present on the 28th day in 34 patients (62%) and after 6 months in 31 patients (57%), all of them with A wave. observation shows the increase in pulmonary acceleration time, the decrease in the left atrial area and the increase in its systolic function in patients with A wave. Appearance of A wave determined the hemodynamic improvement, but we did not observe a correlation between maximal velocity of A wave and hemodynamic improvement. Appearance of A wave had a low predictive value for maintaining sinus rhythm (sensitivity 58% and specificity 45%). Relative increase in A wave velocity during the 1st week after EC correlated positively with long-term maintenance of sinus rhythm (r = 0.62; p < 0.001).

[Unusual clinical course of ruptured aortic aneurysms--reports of three cases]. / Niezwykly przebieg kliniczny peknietych tetniaków aorty--opis trzech przypadów.

Three cases of unexpected clinical course of ruptured aortic aneurysm have been presented in patients of their 7th decade life. All of them had arterial hypertension. Signs and symptoms on admission to hospital (dysphagia, chest and interscapular pain, hematemesis, abdominal pain, elevated body temperature and diminished exercise tolerance) were non-specific of aortic aneurysm, suggesting other disease. Dramatic clinical course with hypovolemic shock in two cases led to death. One of them refused surgery. In the third one, in spite of blood effusions to pleural cavity, pericardial sac and mediastinum, effective hypotensive therapy with a preservation of the slow heart rate and fluid evacuation from pericardial sac, gave the opportunity to perform elective surgery. Aortic dissection often presents an atypical course and when suspected, all available imaging technics including computed tomography and nuclear magnetic resonance must be used.

[Unusual clinical course of ruptured aortic aneurysms--report of three cases]. / Niezwykly przebieg kliniczny peknietych tetniaków aorty--opis trzech przypadków.

Three cases of unexpected clinical course of ruptured aortic aneurysm have been presented in patients of their 7th decade life. All of them had arterial hypertension. Signs and symptoms on admission to hospital (dysphagia, chest and interscapular pain, hematemesis, abdominal pain, elevated body temperature and diminished exercise tolerance) were non-specific of aortic aneurysm, suggesting other disease. Dramatic clinical course with hypovolemic shock in two cases led to death. One of them refused surgery. In the third one, in spite of blood effusions to pleural cavity, pericardial sac and mediastinum, effective hypotensive therapy with a preservation of the slow heart rate and fluid evacuation from pericardial sac, gave the opportunity to perform elective surgery. Aortic dissection often presents an atypical course and when suspected, all available imaging technics including computed tomography and nuclear magnetic resonance must be used.