Balloon pulmonary angioplasty - efficient therapy of chronic thromboembolic pulmonary hypertension in the patient with advanced sarcoidosis - a case report.

BACKGROUND: Approximately a quarter of patients with advanced sarcoidosis develop pulmonary hypertension (PH), which affects their prognosis. We report unusual case of confirmed chronic thromboembolic pulmonary hypertension (CTEPH) in a patient with stage IV sarcoidosis successfully treated with balloon pulmonary angioplasty (BPA). CASE PRESENTATION: A 65 years old male with a history of colitis ulcerosa, and pulmonary sarcoidosis diagnosed in 10 years before, on long term oral steroids, with a history of deep vein thrombosis and acute pulmonary embolism chronically anticoagulated was referred to our center due to severe dyspnea. On admission he presented WHO functional class IV, mean pulmonary artery pressure (mPAP) in right heart catheterization (RHC) was elevated to 54 mmHg. Diagnosis of CTEPH was definitely confirmed with typical V/Q scan, and with selective pulmonary angiography (PAG) completes by intravascular imagining (intravascular ultrasound, optical coherent tomography). The patient was deemed inoperable by CTEPH team and two sessions of BPA with multimodal approach resulted in significant clinical and haemodynamical improvement to WHO class II and mPAP decrease to 27 mmHg. CONCLUSIONS: Balloon pulmonary angioplasty, rapidly developing method of treatment of inoperable CTEPH patients, is also extremely useful therapeutic tool in complex PH patients.

Management of high risk pulmonary embolism - a single center experience.

BACKGROUND AND AIM: Patients with acute pulmonary embolism (APE) associated with hemodynamic instability, i.e. high-risk APE (HR-APE), are at risk for early mortality and require urgent reperfusion therapy with thrombolysis or embolectomy. However, a considerable proportion of HR-APE subjects is not reperfused but only anticoagulated due to high bleeding risk. The aim of the present study was to assess the management of HR-APE in a single large-volume referral center. METHODS: A single-center retrospective study of 32 HR-APE subjects identified among 823 consecutive patients hospitalized for symptomatic APE. RESULTS: Out of 32 subjects with HR-APE (19 women, age 69 ± 19 years), 20 patients were unstable at admission and 12 subsequently deteriorated despite on-going anticoagulation. Thrombolysis was applied in 20 (62.5%) of HR-APE subjects, limited mainly by classical contraindications in the remainder. Percutaneous pulmonary embolectomy was performed in 4 patients. In-hospital PE-related mortality tended to be higher, albeit insignificantly, in the patients who developed hemodynamic collapse during the hospital course compared to those unstable at admission (67% vs. 40%, p = 0.14). Also, survival was slightly better in 22 patients treated with thrombolysis or percutaneous embolectomy in comparison to 10 subjects who received only anticoagulation (54% vs. 40%, p = 0.2). Major non-fatal bleedings occurred in 7 of 20 patients receiving thrombolysis (35%) and in 2 (17%) of the remaining non-thrombolysed 12 HR-APE subjects. CONCLUSIONS: Hemodynamically instability, corresponding to the definition of HR-APE, affects about 4% of patients with APE, developing during the hospital course in approximately one-third of HR-APE subjects. As almost 40% of patients with HR-APE do not receive thrombolytic therapy for fear of bleeding, urgent percutaneous catheter-assisted embolectomy may increase the percentage of patients with HR-APE undergoing reperfusion therapy. Further studies are warranted for a proper identification of initially stable intermediate-risk APE subjects at risk of hemodynamic collapse despite appropriate anticoagulation.

Refined balloon pulmonary angioplasty-A therapeutic option in very elderly patients with chronic thromboembolic pulmonary hypertension.

INTRODUCTION/OBJECTIVES: Balloon pulmonary angioplasty (BPA) is a developing treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). However, to our knowledge there are no published data on BPA in CTEPH subjects aged 75 or over. The aim of the study was to analyze clinical and hemodynamic outcomes of sequential BPA in very elderly patients disqualified from pulmonary endarterectomy (PEA). PATIENTS AND METHODS: We enrolled 10 patients (4 male, 6 female, median age 81 [75-88]) with confirmed CTEPH, mPAP > 30 mmHg, and WHO class > II, disqualified from PEA. Overall, 10 patients underwent 39 BPA sessions (mean 3.9 sessions per patient, range 1-9), and 70 pulmonary arteries were dilated, (mean 6.5 vessels per patient, range 1-14). RESULTS: Pulmonary angioplasty resulted in significant clinical and hemodynamic improvement in every patient: 6 MWT distance increased from a median of 221 m (80-320) to 345 (230-455) and plasma NT-proBNP levels decreased (P < 0.01). Sequential BPA resulted in normalization of mPAP (<25 mmHg) in 6 of 10 patients and mPAP decreased to 25-30 mmHg in three others. In the whole group mPAP decreased from 41 (31-53) mmHg to 23 (17-33) mmHg (P < 0.01). Overall, mean PAP and PVR decreased significantly in all cases, while CO and CI increased (P < 0.01). No severe complications occurred during BPA and over a median follow-up of 553 days (range 81-784), and all patients are still alive and in good general health. CONCLUSION: This study demonstrated the safety and efficacy of refined BPA in CTEPH patients aged 75 or over, disqualified from PEA. Refined BPA may emerge as an alternative therapeutic strategy in very elderly CTEPH patients who are suitable for surgery, but this requires further validation in a large prospective study.

Evaluation of the InterTAK Diagnostic Score in differentiating Takotsubo syndrome from acute coronary syndrome. A single center experience.

BACKGROUND: The aim of this study was to evaluate the usefulness of a novel clinical score - the InterTAK Diagnostic Score in differentiating Takotsubo syndrome (TTS) from acute coronary syndrome (ACS). METHODS: Medical records of 40 consecutive patients with ACS and 20 patients with TTS were managed and retrospectively analyzed at the documented center. Each patient was evaluated using the Inter- TAK Diagnostic Score. To illustrate the diagnostic ability of the score, a receiver operating characteristic (ROC) curve was performed. RESULTS: Takotsube syndrome patients were more often female compared to the ACS group (70% vs. 27.5%, p = 0.002), an emotional trigger was more prevalent among the TTS group (65% vs. 7.5%, p < 0.001). The area under the curve (AUC) for the score was 0.885 (95% confidence interval [CI] 0.78-0.97). Using a cut-off value of 45 points, the sum of sensitivity and specificity was the highest. However, when patients with a score of ≥ 50 were diagnosed as TTS, 85% were diagnosed correctly. When patients with score ≤ 31 were diagnosed as ACS, 92% were diagnosed correctly. CONCLUSIONS: The InterTAK Diagnostic Score might help in differentiating TTS from ACSs with high sensitivity and specificity. This finding requires further investigation to confirm its clinical utility.

Ticagrelor-Related Severe Dyspnoea: Mechanisms, Characteristic Features, Differential Diagnosis and Treatment.

With a growing number of patients on ticagrelor therapy after stent implantation, we observe many cases of side effects of the drug, mostly dyspnoea and bradycardia. In our article we present 2 patients, in which the symptoms were particularly severe. Then we describe possible mechanisms of these complications, explain how to carry out differential diagnosis, discuss when to switch ticagrelor to other antiplatelet drug and finally we present the way to deal with the symptoms.

Increased systemic arterial stiffness in patients with chronic thromboembolic pulmonary hypertension.

BACKGROUND: Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of venous thromboembolism (VTE) resulting from non-dissolving thromboemboli in the pulmonary arteries. Previous observations indicate a higher prevalence of atherosclerosis and cardiovascular risk factors in patients with VTE and CTEPH. The purpose of the present study was to evaluate the arterial stiffening assessed by pulse wave velocity (PWV), a marker of arterial stiffness, in CTEPH patients in comparison with a matched control group (CG). METHODS: The study group consisted of 26 CTEPH patients (9 male and 17 female, age 69 ± 10 years) and 22 CG (10 male, 12 female, age 67 ± 8 years). In all subjects a physical examination, carotid-femoral PWV and transthoracic echocardiography were performed. Right heart catheterization was done in all CTEPH. RESULTS: Chronic tromboembolic pulmonary hypertension patients had significantly higher PWV than CG (10.3 ± 2.5 m/s vs. 9 ± 1.3 m/s, p < 0.05), even though systolic blood pressure was higher in CG (120 ± 11 vs. 132 ± 14 mmHg, p = 0.002). PWV correlated only with age and pulmonary vascular resistance (PVR) in CTEPH (r = 0.45, p = 0.03 and r = 0.43, p = 0.03, respectively). Arterial stiffening defined as PWV > 10 m/s was found in 11 (42%) CTEPH patients and in 5 (23%) cases from CG (p = 0.13). CTEPH patients with PWV > 10 m/s were older (74 ± 8 vs. 66 ± 10 years, p < 0.05), had decreased oxygen saturation (SaO2 89 [73-96]% vs. 96 [85-98]%, p < 0.01) and tended to have higher PVR (8.1 [3.1-14.0] vs. 5.2 [3.1-12.7] HRU, p = 0.10). CONCLUSIONS: Arterial stiffness, assessed with PWV, is increased in CTEPH. The elevated PWV is associated with older age, lower SaO2 and higher PVR in CTEPH.

Very distal transradial approach (VITRO) for coronary interventions.

INTRODUCTION: Radial access is a standard approach for coronary interventions. However, it carries some risk of local or long-term complications such as hematoma or radial artery occlusion. AIM: To assess the feasibility of a very distal left and right transradial approach (VITRO) for coronary interventions. MATERIAL AND METHODS: Three hundred and twenty consecutive patients were submitted to diagnostic or therapeutic coronary interventions. In 102 patients the distal radial artery was not palpable or the pulse was too weak. In 218 selected patients (142 male, 76 female, age: 69 ±11 years) we decided to perform a distal transradial approach. RESULTS: The VITRO access was suitable in 195 patients with a success rate of 89.4%. In 9 patients arterial puncture failed, while in 14 others despite successful arterial puncture the wire could not be advanced towards the forearm part of the radial artery. Not only elective diagnostic angiographies were performed with VITRO but also urgent ad hoc coronary interventions in subjects with unstable angina or NSTEMI (48 subjects; 24.3%). Moreover, this very distal approach allowed 11 rotablations and 11 FFR/iFR examinations to be performed in 22 patients. No major bleeding, requiring prolonged hospital stay, surgery or transfusion occurred. One patient on oral anticoagulation with DAPT had conservatively managed minor forearm bleeding. CONCLUSIONS: Very distal radial artery access is feasible, safe and comfortable in 60% of patients referred for elective or urgent coronary arteries angiography, or coronary interventions.

High prevalence of severe coronary artery disease in elderly patients with non-operable chronic thromboembolic pulmonary hypertension referred for balloon pulmonary angioplasty.

INTRODUCTION: Balloon pulmonary angioplasty (BPA) is a new emerging catheter-based alternative treatment option for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). AIM: To show that all elderly CTEPH patients referred for BPA are at higher risk of obstructive coronary artery disease and that, in daily practice, they should undergo invasive coronary angiography. MATERIAL AND METHODS: Eleven patients at the age of at least 65 years (6 males, 5 females, 77.2 ±5.9 years) with confirmed non-operable type II or type III CTEPH, considered for BPA, underwent elective coronary angiography. Severe obstructive coronary artery disease (CAD) was diagnosed when stenosis of left main coronary artery ≥ 50% or stenosis of ≥ 70% of epicardial arteries was angiographically confirmed. We also screened for CAD consecutive age- and sex-matched 114 PE survivors (52 males, 62 females, 74.8 ±7.2 years) with excluded CTEPH. RESULTS: Severe CAD was more frequent in elderly patients with non-operable type II or type III CTEPH candidates for BPA than in elderly acute PE survivors with excluded CTEPH (54.5% vs. 16.7%, p < 0.01), and therefore elderly CTEPH patients referred for BPA were at higher risk of CAD (OR = 5.9, 95% CI: 1.64-21.46, p = 0.007) when compared to elderly survivors after acute PE with excluded CTEPH. CONCLUSIONS: All elderly CTEPH patients referred for BPA are at higher risk of severe CAD and should routinely undergo invasive coronary angiography before BPA.

Refined balloon pulmonary angioplasty driven by combined assessment of intra-arterial anatomy and physiology--Multimodal approach to treated lesions in patients with non-operable distal chronic thromboembolic pulmonary hypertension--Technique, safety and efficacy of 50 consecutive angioplasties.

BACKGROUND/OBJECTIVES: Balloon pulmonary angioplasty (BPA) is an emerging therapeutic method in CTEPH. We aimed to prove the safety and efficacy of refined BPA driven by combined assessment of intra-arterial anatomy (IVUS/OCT) and physiology (pulmonary pressure ratio, PPR) in non-operable distal CTEPH. METHODS: 11 pts (mean age 76, 59­84, 7 males) were enrolled in the BPA program according to the following inclusion criteria: 1. Non-operable CTEPH; 2. RHC with mPAP > 30 mm Hg; 3. At least one segmental perfusion defect at lung scintigraphy; 4. WHO class > II. Overall, 9 pts underwent 27 BPA sessions (mean 3 sessions per patient, range 1­5), 50 pulmonary arteries were dilated (mean 6 vessels per patient, range 3­9; 2.03 dilated arteries per session). All the angioplasties were performed according to an algorithm, which incorporated anatomical and functional assessment of targeted lesions. RESULTS: We performed BPA of 32 web lesions, 5 ring-like stenosis and 13 complete obstructions. BPA resulted in clinical and hemodynamic improvement. WHO class improved from pre-BPA to post-BPA (p = 0.018), and 6 MWD increased from 304 m to 384 m (p = 0.03), NT-proBNP dropped from 1248 pg/ml to 730 pg/ml (p < 0.001). Mean PAP and PVR decreased (p = 0.01), while CO and CI increased (p = 0.01). All dilated arteries were patent at angiographic reassessment. No significant complications occurred and all treated patients are still alive. Insignificant transient reperfusion pulmonary oedema occurred in only 2 patients, who responded well to supplemental oxygen. CONCLUSIONS: Refined BPA with assessment of intrapulmonary physiology using a pressure wire and precise evaluation of anatomy with IVUS and OCT provides hemodynamic and functional improvement, with minimal complications in distal non-operable CTEPH. This observation requires further validation in a large prospective study.

Prognostic value of B-type natriuretic peptide levels on admission in patients with acute ST elevation myocardial infarction.

OBJECTIVE: To assess the relation between B-type natriuretic peptide (BNP) levels on admission in ST elevation myocardial infarction (STEMI) and short-term, all-cause mortality. METHODS AND RESULTS: Blood samples for BNP determination were obtained on admission in 88 patients (mean age 60.6 +/- 10.7 years old) with STEMI. In a 15-minute period, BNP was measured by using simple bedside test for rapid quantification of BNP. Thirty days follow-up was performed. During the period of follow-up 12 (13.6%) patients died. Mean BNP was 228.74 +/- 269.98 pg/ml. The lowest value was 5 pg/ml, the highest value 1300 pg/ml due to limitations of the method. The baseline level of BNP was higher among patients who died than among those who were alive at 30 days (mean, 545.6 vs. 178.7 pg/ml; P = 0.001). Mortality increased among patients in increasing quartiles (p = 0.009). The unadjusted odds ratio for 30-day risk of death in the fourth quartile was 5.6 (95 percent confidence interval, 1.6 to 20.5; P < 0.001). When BNP was added to a multivariate Cox regression model including clinical and electrocardiographic variables, BNP levels were independently associated with the prognosis. CONCLUSIONS: BNP levels obtained on admission are a powerful, independent indicator of short-term mortality in patients with STEMI. Rapid tests for BNP assay seem to be a new tool in risk stratification of patients with STEMI.

Serum B-type natriuretic peptide levels on admission predict not only short-term death but also angiographic success of procedure in patients with acute ST-elevation myocardial infarction treated with primary angioplasty.

BACKGROUND: B-type natriuretic peptide (BNP) levels are predictive of short-term death in patients with acute coronary syndromes. Few data are available for BNP levels obtained on admission in patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). METHODS: Blood samples for BNP estimation, obtained on admission in 126 consecutive patients (mean age, 58.8 +/- 10.7 years) with STEMI, were measured at the bedside by using a simple point-of-care test in a 15-minute period before PCI. Follow-up up to 42 days was performed. RESULTS: A baseline BNP value of 331 pg/mL had a sensitivity of 87.9% and a specificity of 90% for predicting death in a follow-up study. There was no difference in subgroups by median BNP (100 pg/mL) in Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 before PCI, although higher BNP levels were observed among patients with TIMI <3 after PCI than among those with TIMI 3 (356.7 +/- 350.8 vs 144.9 +/- 191.2 pg/mL; P <.0001). In multivariate logistic regression analysis, admission BNP was the independent predictor for the following: death (odds ratio [OR], 16.3; 95% confidence interval [CI], 1.4 to 186.7; P =.03), TIMI grade <3 after PCI (OR, 3.4; 95% CI, 1.2 to 9.6; P =.02), and the no-reflow phenomenon (OR, 6.2; 95% CI, 1.7 to 23; P =.007) after adjusting for other variables. CONCLUSIONS: BNP levels obtained on admission are a powerful, independent predictor of short-term death and angiographic success after PCI in patients with STEMI. The no-reflow phenomenon may be predicted in STEMI on the basis of high serum BNP values on admission.

Diagnostic value of BNP in suspected perimyocarditis--a preliminary report.

BACKGROUND: Diagnosis of perimyocarditis is often very challenging. Clinical presentation includes chest pain and ECG changes which are difficult to interpret. Clinical course is usually mild, however, some patients develop heart failure symptoms and require aggressive treatment. Plasma b-type natriuretic peptide (BNP) is a marker of the hemodynamical impairment of the heart. Its diagnostic role in patients with acute perimyocarditis has not yet been examined. AIM: To assess the usefulness of BNP measurement in the diagnosis of perimyocarditis. METHODS: The study group consisted of 14 consecutive patients (13 males, mean age 32.1+/-12.4 years) with suspected perimyocarditis (history of influenza, typical symptoms, ECG and echocardiographic results as well as myocardial necrotic markers). Plasma BNP was assessed at bedside at the time of admission. RESULTS: Plasma BNP, measured in 12 patients, was 163+/-154 pg/mL (max. 519 pg/mL) and exceeded upper normal level in 6 (50%) patients. When normal levels were adjusted for age and gender, 9 (80%) patients had elevated BNP. One patient had heart failure symptoms and a BNP level of 205 pg/mL. In all 4 patients who had transient myocardial contractility disturbances, detected by echocardiography, BNP level exceeded 100 pg/mL. CONCLUSIONS: BNP level is increased in some patients with acute perimyocarditis. BNP elevation is probably associated with hemodynamical stress caused by transient contractility abnormalities. Diagnostic and prognostic role of BNP in acute perimyocarditis requires further studies.

Acute ST-segment elevation myocardial infarction treated with delayed angioplasty in a patient with anomalous origin of the right coronary artery in the early phase after kidney transplantation.

This case demonstrates a rare anomalous of origin of right coronary artery from the left sinus of Valsalva in patients who underwent kidney transplantation complicated by an acute ST elevation myocardial infarction treated with delay angioplasty.