Association of glomerular hyperfiltration with carotid artery plaque in the general population.

BACKGROUND AND AIMS: Glomerular hyperfiltration (GHF) is a hemodynamic change of the kidney as an adaptive response to nephron loss. Although GHF is associated with metabolic risk factors and cardiovascular disease (CVD), the mechanisms that explain these relationships remain largely unknown. This is partially caused by a non-unified definition of GHF based on pathophysiologic vascular changes. Thus, the objective of this study was to evaluate the association between various definitions of GHF and carotid plaque in a health checkup cohort. METHODS: A total of 4493 individuals without history of CVD who had carotid ultrasonography (USG) results available between January 2016 and June 2018 were enrolled. GHF was defined as >90th percentile of eGFR residuals after adjusting for confounding factors. Carotid plaque score was calculated based on carotid USG results. RESULTS: Of 4493 individuals (mean age, 52.3 ± 10.1 years; 3224 [71.8%] males), 449 subjects were included in the GHF group (mean eGFR, 107.0 ± 7.1 ml/min/1.73 m2) and 4044 subjects were included in the non-GHF group (mean eGFR, 92.5 ± 12.3 ml/min/1.73 m2). When the GHF group was compared to the non-GHF group, GHF was associated with the presence of significant carotid plaque (carotid plaque score ≥2) (adjusted OR: 1.46; 95% CI: 1.16 to 1.83; p = 0.001). GHF defined in this study showed higher sensitivity to the presence of carotid plaque than other definitions of GHF. CONCLUSIONS: GHF status was associated with risk of carotid plaque in individuals without history of CVD. Presence of subclinical carotid plaque was associated with risk of future CVD. Therefore, GHF based on creatinine could be a useful surrogate marker for surveillance of CVD in asymptomatic individuals.

Increased EAT volume after anthracycline chemotherapy is associated with a low risk of cardiotoxicity in breast cancer.

PURPOSE: Chemotherapy-induced cardiotoxicity is a critical issue for patients with breast cancer. Change of epicardial adipose tissue (EAT) is associated with cardiac dysfunction. The objective of this study was to investigate the relationship between EAT and chemotherapy-induced cardiotoxicity. METHODS: This retrospective study analyzed EAT on chest computed tomography (CT) of patients with early breast cancer using automatic, quantitative measurement software between November 2015 and January 2020. Changes in EAT before and after initiation of chemotherapy were compared according to the type of anticancer drug. Subclinical cardiotoxicity was defined as worsening ≥ 10% in left ventricular ejection fraction to an absolute value > 50% with a lower limit of normal measured with standard echocardiography. RESULTS: Among 234 patients with breast cancer, 85 were treated with adjuvant anthracycline-based (AC) and 149 were treated with non-anthracycline-based (non-AC) chemotherapy. There was a significant increase in EAT volume index (mL/kg/m2) at the end of chemotherapy compared to that at the baseline in the AC group (3.33 ± 1.53 vs. 2.90 ± 1.52, p < 0.001), but not in the non-AC group. During the follow-up period, subclinical cardiotoxicity developed in 20/234 (8.6%) patients in the total population [13/85 (15.3%) in the AC group and 7/149 (4.8%) in the non-AC group]. In the multivariable analysis, EAT volume index increment after chemotherapy was associated with a lower risk of subclinical cardiotoxicity in the AC group (Odds ratio: 0.364, 95% CI 0.136-0.971, p = 0.044). CONCLUSIONS: Measurement of EAT during anthracycline-based chemotherapy might help identify subgroups who are vulnerable to chemotherapy-induced cardiotoxicity. Early detection of EAT volume change could enable tailored chemotherapy with cardiotoxicity prevention strategies.

Epicardial adipose tissue radiodensity is associated with all-cause mortality in patients undergoing hemodialysis.

The radiodensity and volume of epicardial adipose tissue (EAT) on computed tomography angiography (CTA) may provide information regarding cardiovascular risk and long-term outcomes. EAT volume is associated with mortality in patients undergoing incident hemodialysis. However, the relationship between EAT radiodensity/volume and all-cause mortality in patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis remains elusive. In this retrospective study, EAT radiodensity (in Hounsfield units) and volume (in cm3) on coronary CTA were quantified for patients with ESRD using automatic, quantitative measurement software between January 2012 and December 2018. All-cause mortality data (up to December 2019) were obtained from the Korean National Statistical Office. The prognostic values of EAT radiodensity and volume for predicting long-term mortality were assessed using multivariable Cox regression models, which were adjusted for potential confounders. A total of 221 patients (mean age: 64.88 ± 11.09 years; 114 women and 107 men) with ESRD were included. The median follow-up duration (interquartile range) after coronary CTA was 29.63 (range 16.67-44.7) months. During follow-up, 82 (37.1%) deaths occurred. In the multivariable analysis, EAT radiodensity (hazard ratio [HR] 1.055; 95% confidence interval [CI] 1.015-1.095; p = 0.006) was an independent predictor of all-cause mortality in patients with ESRD. However, EAT volume was not associated with mortality. Higher EAT radiodensity on CTA is associated with higher long-term all-cause mortality in patients undergoing prevalent hemodialysis, highlighting its potential as a prognostic imaging biomarker in patients undergoing hemodialysis.

Prediction of Judkins Left Catheter Size during Left Transradial Coronary Angiography by Simple Chest Radiographic and Echocardiographic Index.

Background and Objectives: Appropriate catheter selection when conducting transradial coronary angiography (CAG) helps shorten examination time, preventing vascular complications and lowering medical expense. However, catheter selection is made based on the practitioner's experience in almost all cases. Therefore, we undertook this study to define radiologic and echocardiographic indices that would enable physicians to anticipate appropriate catheter selection. Materials and Methods: This is a retrospective study of 244 undergoing transradial diagnostic CAG at an established center from February 2006 to April 2014. Patients who successfully underwent angiography with a JL3.5 catheter were defined as the control group, and patients who successfully underwent angiography after the catheter was replaced with a JL4.0 or higher were defined as the switched group. To identify predictors for appropriate catheter selection, radiologic and echocardiographic indices were analyzed. Results: A total of 122 patients in the switched group and 122 patients in the control group were analyzed in this study. Average age was 64.65 ± 8.6 years. In the radiographic index, the switched group exhibited a significantly higher mediastinal-thoracic ratio (0.27 ± 0.05 vs. 0.23 ± 0.03, p < 0.001. Additionally, the mediastinal-cardiac ratio was significantly greater in the switched group (0.50 ± 0.08 vs. 0.45 ± 0.05, p < 0.001). Aortic root diameter, which is used here as the echocardiographic index, was significantly larger in the switched group compared to the control group (34.94 ± 4.18 mm vs. 32.66 ± 3.99 mm, p < 0.001). In the multivariable logistic regression model, mediastinal-cardiac ratio (OR 5.197, 95% CI 2.608-10.355, p < 0.001) and increased aortic root (OR 2.115, 95% CI 1.144-3.912, p = 0.017) were significantly associated with catheter change. Conclusions: Mediastinal-cardiac ratio and aortic root diameter provide helpful and effective indices for appropriate catheter selection during transradial coronary angiography.

Clinical characteristics and outcomes of infective endocarditis: impact of haemodialysis status, especially vascular access infection on short-term mortality.

BACKGROUND: Patients on haemodialysis (HD) are at high risk of infective endocarditis (IE). Research comparing the microbiological features as well as clinical characteristics and outcomes of HD and non-HD patients with IE is limited. Specifically, no data focussed on vascular access infections (VAIs) have been reported. METHODS: The medical records of patients with IE were retrospectively reviewed from January 2010 to February 2020 in a referral hospital in Korea. Those with definite or possible IE by modified Duke criteria were included in the study. The clinical characteristics, microbiological features, echocardiographic findings and outcomes of the patients were analysed. RESULTS: Of the 80 patients with IE, 34 had undergone HD and 46 had not. HD patients with IE had a higher in-hospital mortality rate (50% vs. 17.4%, p = .004) than non-HD patients. In multivariable stepwise Cox proportional hazards regression analysis, HD (hazard ratio = 2.633; 95% confidential interval: 1.053-6.582; p = .038) was predictors of 60-day mortality in IE patients. In HD patients, the presence of VAI was associated with a high in-hospital mortality rate (70.59% vs. 29.41%, p = .039) and all of the patients with VAIs (100%) had methicillin-resistant S. aureus (MRSA) as a causative pathogen. CONCLUSIONS: HD patients with IE showed high in-hospital mortality. HD, high C-reactive protein levels and lower left ventricular ejection fraction were predictors of 60-day mortality in IE patients. In particular, HD patients with VAIs had higher mortality rates and MRSA should be considered as the causative microorganism.

Association of low T3 level with increased in-hospital mortality in patients with stress cardiomyopathy.

BACKGROUND: Stress cardiomyopathy (SCMP) is an acute but reversible heart failure syndrome with varying clinical outcomes. Although low triiodothyronine (T3) levels are closely associated with heart failure, it is uncertain whether total T3 levels on admission might be correlated with clinical outcomes in patients with SCMP. The aim of this study was to investigate the prognostic value of total T3 level for in-hospital mortality in patients with SCMP. METHODS: Patients presenting with SCMP at a single tertiary hospital between January 2013 and May 2019 were retrospectively reviewed. The diagnosis of SCMP was confirmed using the International Takotsubo Diagnostic Criteria and echocardiography was performed at least twice at the time of admission. Comorbidities, antecedent triggers, and other cardiac and metabolic parameters were measured in the survivor group compared with the non-survivor group. We evaluated the correlation between these parameters, especially total T3 and the prevalence of in-hospital mortality and the predictive values of total T3. RESULTS: Of the 134 SCMP patients (69.4 ± 15.5 years old, 94 women), 29 (21.6%) died during hospitalisation. The median follow-up period (interquartile range) was 480 days (63.25-1052.50). Total T3 levels were significantly lower in the non-survival group than in the survival group (33.38 ± 22.58 ng/dL vs. 65.72 ± 34.68 ng/dL, p < 0.0001). Receiver operating characteristic curve analysis showed the cut-offs of total T3 levels (≤64.37 ng/dL) for in-hospital mortality (area under curve [AUC] = 0.764, p < 0.001). In multivariable analysis, the T3 level (odds ratio [OR], 0.957; 95% confidential interval [CI], 0.934 to 0.982; p < 0.001), left ventricular ejection in follow-up echocardiography (OR, 0.935; 95% CI, 0.889-0.983; p = 0.008), and shock at initial presentation (OR, 3.389; 95% CI, 1.076-10.669; p = 0.037) were independent predictors for in-hospital mortality in SCMP patients. In patients with low T3 (<64.37 ng/dL), the 30-day survival rate was also significantly lower (81.58 vs. 100%, Log rank p = 0.001). CONCLUSIONS: Lower levels of total T3 were strongly correlated with in-hospital mortality in patients with SCMP. A low T3 level might suggest poor prognosis in patients with SCMP.

Acute Traumatic Arterial Occlusions Combined with Massive Morel-Lavallée Lesions Treated by Percutaneous Angioplasty, Multiple Debridements and Skin Grafts.

Morel-Lavallée lesions (MLL) create pre-fascial space by shearing the subcutaneous tissues away from the underlying fascia, in a patient with trauma. Necrosis of the overlying skin can develop over a wide area of the lesion. The lesion might be contaminated by the surgical site due to careless intrusion when treating the combined arteriopathy. A 70-year-old woman presented with avulsion of the skin over the right foot and bilateral leg pain following a car accident. Computed tomography showed bilateral popliteal artery occlusion with large hematoma on both legs. Percutaneous angioplasty was performed with successful restoration of the flow. However, the skin color changes over time. Necrosis of the skin occurred over a wide area of the right leg. Extensive debridement was performed, and the defect was covered with a skin graft. MLLs can occur in patients with multiple traumas, multiple vascular injuries, and complex skeletal injury. Vascular surgeons treating multiple traumas should be aware of the diagnostic and management options for MLL. It should be diagnosed early because it can be difficult to manage once the overlying skin develops necrosis.

Role and Prognosis of Extracorporeal Life Support in Patients Who Develop Cardiac Arrest during or after Office-Based Cosmetic Surgery.

BACKGROUND: Cardiac arrest during or after office-based cosmetic surgery is rare, and little is known about its prognosis. We assessed the clinical outcomes of patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics. METHODS: Between May 2009 and May 2016, 32 patients who developed cardiac arrest during or after treatment at cosmetic surgery clinics were consecutively enrolled. We compared clinical outcomes, including complications, between survivors (n=19) and non-survivors (n=13) and attempted to determine the prognostic factors of mortality. RESULTS: All 32 of the patients were female, with a mean age of 30.40±11.87 years. Of the 32 patients, 13 (41%) died. Extracorporeal life support (ECLS) was applied in a greater percentage of non-survivors than survivors (92.3% vs. 47.4%, respectively; p=0.009). The mean duration of in-hospital cardiopulmonary resuscitation (CPR) was longer for the non-survivors than the survivors (31.55±33 minutes vs. 7.59±9.07 minutes, respectively; p=0.01). The mean Acute Physiology and Chronic Health Evaluation score was also higher among non-survivors than survivors (23.85±6.68 vs. 16.79±7.44, respectively; p=0.01). No predictor of death was identified in the patients for whom ECLS was applied. Of the 19 survivors, 10 (52.6%) had hypoxic brain damage, and 1 (5.3%) had permanent lower leg ischemia. Logistic regression analyses revealed that the estimated glomerular filtration rate was a predictor of mortality. CONCLUSION: Patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics experienced poor prognoses, even though ECLS was applied in most cases. The survivors suffered serious complications. Careful monitoring of subjects and active CPR (when necessary) in cosmetic surgery clinics may be essential.

Association between lower urinary tract symptoms and cardiovascular risk scores in ostensibly healthy women.

OBJECTIVES: To investigate the association between lower urinary tract symptoms (LUTS) and cardiovascular disease (CVD) risk in women, as severe LUTS are known to be associated with CVD risk in men but few studies have focused on this issue in women. SUBJECTS AND METHODS: A total of 1014 ostensibly healthy women, who participated in a voluntary health check in a health promotion centre from November 2013 to October 2015, were enrolled. LUTS were assessed using the International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS). CVD risk scores were calculated using the Framingham risk score and the American College of Cardiology/American Heart Association Atherosclerotic Cardiovascular Disease (ASCVD) score. Correlation, partial correlation, and multiple logistic regression analyses were conducted. RESULTS: The mean age and body mass index (BMI) of the women were 51 years and 22.6 kg/m2 , respectively. The ASCVD score showed significant positive correlations with IPSS items Question 2 (Q2), Q3, Q5, and Q7 (all P < 0.05), total IPSS (P = 0.001), IPSS storage (P = 0.006) and IPSS voiding symptoms scores (P = 0.001) based on partial correlation analysis after adjustment for BMI. For the OABSS, the ASCVD score showed significant positive correlations with OABSS items Q2, Q3, and Q4 (P < 0.001, P = 0.017, and P < 0.001, respectively) and total OABSS (P < 0.001). Multiple logistic regression analysis showed that the moderate-severe risk groups of the OABSS and IPSS were associated with the ASCVD risk score in adjusted models (P < 0.001) compared to the none-mild OABSS and mild IPSS groups. After adjustment for age and BMI, IPSS storage score was significantly related with the ASCVD risk score (B = 0.855, P = 0.016) CONCLUSIONS: LUTS, especially storage symptoms, might be risk factors for predicting future CVD risk in women. Further prospective or cohort studies are needed to validate this possibility.

Left Ventricular Ejection Fraction Predicts Poststroke Cardiovascular Events and Mortality in Patients without Atrial Fibrillation and Coronary Heart Disease.

BACKGROUND AND OBJECTIVES: It is controversial that decreased left ventricular function could predict poststroke outcomes. The purpose of this study is to elucidate whether left ventricular ejection fraction (LVEF) can predict cardiovascular events and mortality in acute ischemic stroke (AIS) without atrial fibrillation (AF) and coronary heart disease (CHD). METHODS: Transthoracic echocardiography was conducted consecutively in patients with AIS or transient ischemic attack at Soonchunhyang University Hospital between January 2008 and July 2016. The clinical data and echocardiographic LVEF of 1,465 patients were reviewed after excluding AF and CHD. Poststroke disability, major adverse cardiac events (MACE; nonfatal stroke, nonfatal myocardial infarction, and cardiovascular death) and all-cause mortality during 1 year after index stroke were prospectively captured. Cox proportional hazards regressions analysis were applied adjusting traditional risk factors and potential determinants. RESULTS: The mean follow-up time was 259.9±148.8 days with a total of 29 non-fatal strokes, 3 myocardial infarctions, 33 cardiovascular deaths, and 53 all-cause mortality. The cumulative incidence of MACE and all-cause mortality were significantly higher in the lowest LVEF (<55) group compared with the others (p=0.022 and 0.009). In prediction models, LVEF (per 10%) had hazards ratios of 0.54 (95% confidence interval [CI], 0.36-0.80, p=0.002) for MACE and 0.61 (95% CI, 0.39-0.97, p=0.037) for all-cause mortality. CONCLUSIONS: LVEF could be an independent predictor of cardiovascular events and mortality after AIS in the absence of AF and CHD.

Short stature is associated with the development of lower limb ischaemia during extracorporeal life support.

BACKGROUND: Percutaneous cannulation of femoral vessels has been widely used for the rapid deployment of extracorporeal life support (ECLS). Limb ischaemia is a devastating complication in patients receiving ECLS. Our aim was to evaluate the predictors of limb ischaemia during ECLS and to determine the role of preventative distal perfusion. METHODS: Two hundred and fifty-five consecutive patients who received veno-arterial ECLS due to cardiac and/or respiratory failure were enrolled from January 2009 to December 2015. All patients received ECLS for more than 6 hours and the data was reviewed retrospectively. Distal perfusion to minimise lower limb ischaemia was performed at the discretion of the physician. Predictors for lower limb ischaemia during ECLS were analysed using multivariate regression analysis. RESULTS: For the 255 patients, the mean age was 58 and 177 (69.4%) were male. Limb ischaemia developed in 24 patients (9.4%); 178 patients (69.8%) died within 30 days. Among the 24 patients, one patient (4.2%) developed limb ischaemia with preventative distal perfusion. Fourteen patients (58.3%) received therapeutic distal perfusion. After distal perfusion, two patients (8.3%) still required surgical intervention. Limb ischaemia was more frequent in female patients (54.2% in the ischaemia group versus 28.1% in the non-ischaemia group, p=0.008) and shorter patients (162.0 ± 9.5 cm in the ischaemia group versus 166.3 ± 9.1 cm in the non-ischaemia group, p=0.027). Patients shorter than 165 cm were more commonly diagnosed with ischaemia compared to those who were taller than 165 cm (79.2% versus 40.7%, p<0.001). In a multivariate regression analysis, height under 165 cm was the only predictor for limb ischaemia (Odds ratio (OR) [95% confidence interval (CI)] = 12.645 [3.190-50.118]). CONCLUSION: Smaller female patients are more prone to developing limb ischaemia from femoral ECLS. Our findings might support preventative distal perfusion and more careful observation of these patients.

Ultrasound-guided catheterization of the left subclavian vein without recognition of persistent left superior vena cava: A case report.

RATIONALE: A persistent left superior vena cava (PLSVC) is rare, but the most common thoracic venous anomaly. We report a case of PLSVC unrecognized during left subclavian vein catheterization using real-time ultrasound-guided supraclavicular approach. PATIENT CONCERNS: A 79-year-old man with history of hypertension presented with traumatic subdural hemorrhage, subarachnoid hemorrhage, and epidural hemorrhage. Before the operation, a central venous catheter (CVC) was placed into the left subclavian vein. DIAGNOSES: A dilated coronary sinus on echocardiogram and subsequent agitated saline test confirmed the diagnosis of PLSVC. INTERVENTIONS: A CVC was placed into the left subclavian vein under real-time ultrasound guide, with supraclavicular approach. A postoperative chest X-ray revealed a left-sided paramediastinal course of the CVC; the CVC was removed under the impression of malposition. OUTCOMES: The CVC functioned properly. LESSONS: Ultrasound is used for safe and correct placement of CVC; however, the presence of PLSVC could not be detected by ultrasonography in this case. When the chest radiograph shows the central venous catheter passing along the border of the left heart and a dilated coronary sinus detected on echocardiogram, we should have suspicion of a PLSVC.

Beta 2-adrenergic receptor agonists are novel regulators of macrophage activation in diabetic renal and cardiovascular complications.

Macrophage activation is increased in diabetes and correlated with the onset and progression of vascular complications. To identify drugs that could inhibit macrophage activation, we developed a cell-based assay and screened a 1,040 compound library for anti-inflammatory effects. Beta2-adrenergic receptor (ß2AR) agonists were identified as the most potent inhibitors of phorbol myristate acetate-induced tumor necrosis factor-α production in rat bone marrow macrophages. In peripheral blood mononuclear cells isolated from streptozotocin-induced diabetic rats, ß2AR agonists inhibited diabetes-induced tumor necrosis factor-α production, which was prevented by co-treatment with a selective ß2AR blocker. To clarify the underlying mechanisms, THP-1 cells and bone marrow macrophages were exposed to high glucose. High glucose reduced ß-arrestin2, a negative regulator of NF-κB activation, and its interaction with IκBα. This subsequently enhanced phosphorylation of IκBα and activation of NF-κB. The ß2AR agonists enhanced ß-arrestin2 and its interaction with IκBα, leading to downregulation of NF-κB. A siRNA specific for ß-arrestin2 reversed ß2AR agonist-mediated inhibition of NF-κB activation and inflammatory cytokine production. Treatment of Zucker diabetic fatty rats with a ß2AR agonist for 12 weeks attenuated monocyte activation as well as pro-inflammatory and pro-fibrotic responses in the kidneys and heart. Thus, ß2AR agonists might have protective effects against diabetic renal and cardiovascular complications.

Delayed Surgery for Aortic Dissection after Intravenous Thrombolysis in Acute Ischemic Stroke.

We report a case of aortic dissection masquerading as acute ischemic stroke followed by intravenous thrombolysis. A 59-year-old man presented with dizziness. After examination, the patient had a seizure with bilateral Babinski signs. Soon after identifying multiple acute infarctions in both hemispheres on diffusion-weighted brain magnetic resonance (MR) imaging, tissue plasminogen activator (t-PA) was administered. Both common carotid arteries were invisible on MR angiography, and subsequent chest computed tomography revealed an aortic dissection. The emergency operation was delayed for 13 hours due to t-PA administration. The patient died of massive bleeding.

Successful extracorporeal life support in sudden cardiac arrest due to coronary anomaly.

Extracorporeal life support (ECLS) has recently been reported to have a survival benefit in patients with cardiac arrest. It is now used widely as a lifesaving modality. Here, we describe a case of sudden cardiac arrest (SCA) in a young athlete with an anomalous origin of the right coronary artery from the left coronary sinus. Resuscitation was successful using ECLS before curative bypass surgery. We highlight the efficacy of ECLS for a patient with SCA caused by a rare, unexpected aetiology. In conclusion, ECLS was a lifesaving modality for SCA due to an anomalous coronary artery in this young patient.