Novel Diagnostic Methods for Infective Endocarditis.

Infective endocarditis (IE) remains a dangerous disease and continues to have a high mortality rate. Unfortunately, despite continuous improvements in diagnostic methods, in many cases, blood cultures remain negative, and the pathogen causing endocarditis is unknown. This makes targeted therapy and the selection of appropriate antibiotics impossible. Therefore, we present what methods can be used to identify the pathogen in infective endocarditis. These are mainly molecular methods, including PCR and MGS, as well as imaging methods using radiotracers, which offer more possibilities for diagnosing IE. However, they are still not widely used in the diagnosis of IE. The article summarizes in which cases we should choose them and what we are most hopeful about in further research into the diagnosis of IE. In addition, registered clinical trials that are currently underway for the diagnosis of IE are also presented.

The potential association between a new angiogenic marker fractalkine and a placental vascularization in preeclampsia.

PURPOSE: Impaired angiogenesis is one of the most common findings in preeclamptic placentas. A new angiogenetic role of fractalkine (CX3CL1) is recently recognized apart from inflammatory activity. In this study, a link between CX3CL1 and the development of placental vasculature in preeclampsia was examined. METHODS: The study comprised 52 women allocated to Group 1 (normotensive, n = 23) and Group 2 (preeclampsia, n = 29). In each group Doppler parameters, serum levels of CX3CL1, soluble fms-like tyrosine kinase-1 (sFlt-1), and placental growth factor (PlGF) were assessed between 30 and 32 week of pregnancy. After the delivery, placental samples were taken and the vascularization and expression of CX3CR1 receptor were assessed after immunostaining. RESULTS: CX3CL1 and sFlt-1 serum levels were significantly higher levels in Group 2 vs Group 1, while PlGF serum levels was significantly lower in Group 2. Lower cerebroplacental ratio (CPR) was observed in Group 2. The vascular/extravascular tissue index (V/EVTI) was significantly lower in Group 2, while compared to Group 1, with the lowest value in the fetus growth restriction (FGR) subgroup (0.18 ± 0.02; 0.24 ± 0.03; 0.16 ± 0.02, respectively). The expression of examined CX3CR1 was higher in Group 2, while compared to Group 1, reaching the highest values in FGR subgroup. There was a moderate negative correlation between birth weight, V/EVTI and CX3CL1 serum level and CX3CR1 placental expression in the group of pregnancies complicated with preeclampsia. CONCLUSION: The significant underdevelopment of placental vascular network in preeclampsia is associated with the change in the CX3CL1/CX3CR1 system, especially in FGR complicated pregnancies.

Non-obstetric complications in preeclampsia.

Preeclampsia is a multisystem disorder of pregnancy that remains a leading cause of maternal and foetal morbidity and mortality. It is still an underestimated risk factor for future cardiovascular, cerebrovascular, and kidney disease, developing often in the perimenopausal period of a woman's life. It remains unclear whether preeclampsia is an individual risk factor for future cardiovascular, cerebrovascular, and renal events or an early marker of women with high-risk profiles for these diseases. Risk factors for cardiovascular disorders and preeclampsia are very similar and include the following: obesity, dyslipidaemia, insulin resistance, pro-inflammatory and hypercoagulable state, and endothelial dysfunction. Thus, the pregnancy can only be a trigger for cardiovascular alterations that manifest in development of preeclampsia. On the other hand, there is strong evidence that changes in cardiovascular, endothelial, and metabolic systems occurring in the course of preeclampsia may not fully recover after delivery and can be a cause of future disease, especially in the presence of other metabolic risk factors regarding, for example, perimenopause. In this review the authors present current knowledge about short- and long-term maternal consequences of preeclampsia, such as: cardiovascular disease, cerebrovascular incidents (posterior reversible encephalopathy and stroke), kidney injury (including the risk of end-stage renal disease), liver failure, and coagulopathy (thrombocytopenia and disseminated intravascular coagulation).

Severe mitral stenosis secondary to eosinophilic granulomatosis resolving after pharmacological treatment.

We present a case of 44-year-old woman who underwent effective pharmacological treatment of severe mitral stenosis. The patient was hospitalized due to rapidly progressive dyspnea. Her medical history included asthma, perennial rhinitis, and nasal polyps. Echocardiography showed a mass of the left ventricle involving the mitral valve; cardiac MRI suggested acute endocarditis. Severe peripheral blood eosinophilia was found. Eosinophilic granulomatosis with polyangiitis was diagnosed; treatment with prednisone and cyclophosphamide was started. Despite the clinical improvement, severe mitral stenosis persisted, surgical treatment was planned. However, evaluation after 6 cycles of cyclophosphamide pulse therapy revealed a significant regression of the valvular disease.

The Impact of Coexisting Gestational Diabetes Mellitus on the Course of Preeclampsia.

A strict correlation between gestational diabetes mellitus (GDM) and preeclampsia (PE) has been shown in previous studies. This case-control observational study evaluates the influence of concomitant GDM on the severity of PE. Ninety-nine patients were included: thirty-eight with PE without GDM (group 1), fourteen with PE and concomitant GDM (group 2), and forty-seven with uncomplicated pregnancies (group 3). Adverse maternal/fetal and neonatal outcomes were registered. Patients underwent blood sample analysis of serum PlGF, sFlt-1, creatinine levels, and platelet count (PLT). The incidence of preterm birth, FGR, HELLP syndrome, and NICU admission was significantly higher in group 1 in comparison to groups 2 and 3, whereas RDS was diagnosed most often in group 2 in comparison to groups 1 and 3. All studied biochemical parameters differed between the control group and both PE groups; however, there were no differences between patients with PE with and without GDM. The presented study indicates that the coexistence of GDM may mitigate the course of PE. The lack of differences between patients with PE with and without GDM in serum levels of studied biomarkers may also confirm its usefulness in the diagnosis and management of PE in patients with coexisting GDM.

Gestational weight gain and blood pressure control in physiological pregnancy and pregnancy complicated by hypertension.

BACKGROUND: Obesity is a widely recognised risk factor for chronic and gestational hypertension. Influence of gestational weight gain on blood pressure control throughout the pregnancy is not well characterised. MATERIAL AND METHODS: Women in the third trimester of a singleton pregnancy were recruited to the study. Medical records were analysed and a special survey was conducted to obtain history on hypertensive disorders in pregnancy and weight changes during pregnancy. Blood pressure measurements were taken during the office visit in line with international guidelines. Relationships between gestational weight gain and maximal and office values of systolic and diastolic blood pressure values were analysed. RESULTS: Data of 90 women in normal pregnancy, 40 with gestational hypertension and 21 with chronic hypertension were analysed. Gestational weight gain was 11.9 ± 4.6 kg in the normal pregnancy group, 13.0 ± 5 kg in the gestational hypertension group and 10.6 ± 3.4 kg in the chronic hypertension group. Gestational weight gain positively correlated with both office (r = 0.48; p < 0.001) and maximal blood pressure values (r = 0.34; p = 0.004) in normal pregnancy and with maximal blood pressure values (r = 0.57; p = 0.02) in women with chronic hypertension. No correlation was observed between gestational weight gain and blood pressure values among women with gestational hypertension. CONCLUSION: In normal pregnancy and in women with chronic hypertension greater gestational weight gain is related to higher blood pressure values in the third trimester.

Predicting survival in out-of-hospital cardiac arrest patients undergoing targeted temperature management: The Polish Hypothermia Registry Risk Score.

BACKGROUND: Prompt reperfusion and post-resuscitation care, including targeted temperature management (TTM), improve survival in out-of-hospital cardiac arrest (OHCA) patients. To predict inhospital mortality in OHCA patients treated with TTM, the Polish Hypothermia Registry Risk Score (PHR-RS) was developed. The use of dedicated risk stratification tools may support treatment decisions. METHODS: Three hundred seventy-six OHCA patients who underwent TTM between 2012 and 2016 were retrospectively analysed and whose data were collected in the Polish Hypothermia Registry. A multivariate logistic regression model identified a set of predictors of in-hospital mortality that were used to develop a dedicated risk prediction model, which was tested for accuracy. RESULTS: The mean age of the studied population was 59.2 ± 12.9 years. 80% of patients were male, 73.8% had shockable rhythms, and mean time from cardiac arrest (CA) to cardiopulmonary resuscitation (CPR) was 7.2 ± 8.6 min. The inputs for PHR-RS were patient age and score according to the Mild Therapeutic Hypothermia (MTH) Scale. Criteria for the MTH score consisted of time from CA to CPR above 10 min, time from CA to the return of spontaneous circulation above 20 min, in-hospital CA, unwitnessed CA, and non-shockable rhythm, each counted as 1 point. The predictive value of PHR-RS was expressed as an area under the curve of 0.74. CONCLUSIONS: PHR-RS is one of the simplest and easiest models to use and enables a reliable prediction of in-hospital mortality in OHCA patients treated with TTM.

Downregulated expression of microRNAs associated with cardiac hypertrophy and fibrosis in physiological pregnancy and the association with echocardiographically-evaluated myocardial function.

The aim of the present study was to analyze the profiles of cardiac microRNAs (miRNAs/miRs) in healthy pregnant women and non-pregnant controls. A total of 61 healthy women >18 years of age with singleton pregnancies in the third trimester were compared with 19 non-pregnant controls. Specifically, expression of miRNAs associated with cardiac hypertrophy (miR-1, miR-17-5, miR-22, miR-34a, miR-124, miR-133a, miR-195, miR-199a-3p, miR-199b, miR-210, miR-222 and miR-1249) and miRNAs associated with cardiac hypertrophy and fibrosis (miR-15b, miR-21, miR-26a, miR-29-a, miR-29c, miR-30c, miR-101, miR-146a, miR-191, miR-208a-5p and miR-328) were analyzed and compared with echocardiographic examination results. Both groups had similar cardiac miRNA expression profiles, but differed in quantitative evaluation. Women in the third trimester of physiological pregnancy exhibited downregulation of certain profibrotic miRNAs (miR-21, miR-30c and miR-328), decreased expression of a hypertrophic and antimetabolic miRNAs (miR-146a), downregulation of an antifibrotic miRNA (miR-222), and downregulation of a hypertrophic miRNA (miR-195). In pregnant women, the indices of systolic function were associated with miR-195 expression, and an interplay between miR-17-5p and diastolic function was observed. While the profiles of cardiac miRNAs expressed in healthy pregnant women and healthy non-pregnant controls were similar, these two groups differed in terms of expression of specific miRNAs. In the third trimester of physiological pregnancy, a downregulation of miR-17-5p, miR-21, miR-30c, miR-146a, miR-195, miR-222 and miR-328 was observed. The differences in the association between echocardiographic indices with miRNAs in pregnant and non-pregnant women suggest that miRNAs regulate both the structure and function of the pregnant heart, influencing cardiac muscle thickness as well as systolic and diastolic function.

Rise in antifibrotic and decrease in profibrotic microRNA protect the heart against fibrosis during pregnancy: A preliminary study.

BACKGROUND: Physiological pregnancy is associated with volume overload. Unlike cardiac pathologies linked with volume overload, such as mitral or aortic regurgitation, pregnancy is thought to be unrelated to fibrosis of the heart. However, changes in the cardiac extracellular matrix during pregnancy remain poorly understood. OBJECTIVES: The aim of the study was to examine the expression of 11 microRNAs associated with cardiac fibrosis (miR-21, miR-26a, miR-26b-5p, miR-29b-3p, miR-29c-3p, miR-101a, miR-146a, miR-208a, miR-223 and miR-328) during pregnancy and to compare them with a healthy control group. MATERIAL AND METHODS: Six women in singleton pregnancy (30-36 weeks) and 6 non-pregnant women as a control group were included in the study. Each woman underwent an echocardiographic examination, and had blood pressure on both arms measured and a blood sample taken. MicroRNAs expression was analyzed using Custom TaqMan® Array MicroRNA Cards (Applied Biosystems, Foster City, USA). RESULTS: Median age of the pregnant women was 34 years (range 25-39 years) and of the control group 32 years (range 29-43 years). Median week of pregnancy was 34 years (range 31-36 years). Most of the examined microRNAs had a lower expression in the pregnancy group (fold change 1.0). CONCLUSIONS: In the 3rd trimester of physiological pregnancy, there is a 244% increase in expression of miR-101a and a decrease by 73% in expression of miR-328. Both of these changes can protect against fibrosis during volume overload occurring in physiological pregnancy.

Pregnancy as a predictor of deviations from the recommended diagnostic pathway in women with suspected pulmonary embolism: ZATPOL registry data.

INTRODUCTION: Pulmonary embolism (PE) is a leading cause of mortality in pregnancy and a great diagnostic challenge. Deviations from the recommended diagnostic pathway in suspected PE contribute to greater mortality in the general population. The deviations from the guidelines of the European Society of Cardiology (ESC) for diagnosis of PE were analyzed, with particular emphasis on pregnant women with suspected PE. MATERIAL AND METHODS: ZATPOL is a prospective national registry including data of all patients with suspected PE admitted to 86 Polish cardiology departments between January 2007 and September 2008. We analyzed diagnostic pathways used in all 2015 patients (mean age: 67 ±15 years, 60% women) with suspected PE. Detailed analysis included diagnostic pathways used in 12 pregnant patients and 85 non-pregnant women in childbearing age. RESULTS: Pregnancy was the strongest predictor of deviations from the recommended diagnostic pathway in the whole study group (HR = 4.0, 95% CI: 1.28-12.5, p = 0.02). Pregnant patients did not differ significantly from non-pregnant women in most risk factors and symptoms of PE, and diagnostic tests used in this condition. Deviations from the recommended diagnostic pathway were found in 7 (58%) and 36 (42%) pregnant and non-pregnant women, respectively (p = 0.297), and the preliminary diagnosis of PE was eventually confirmed in 42% and 67% of the patients, respectively (p = 0.086). CONCLUSIONS: Despite the lack of significant differences in PE symptomatology in pregnant and non-pregnant women, pregnancy seems to be the strongest predictor of deviations from the diagnostic pathway recommended in PE by the ESC. Further studies are required to evaluate the adherence to current guidelines in pregnant women.

Readmissions and repeat procedures after catheter ablation for atrial fibrillation.

BACKGROUND: The aim of this study was to assess the frequency of all-cause rehospitalization and due to atrial fibrillation/flutter (AF/AFl), repeat ablation of AF/AFl, mortality within 30 days and 1-year follow-up in patients after AF/AFl ablation procedure. METHODS: Using data from the National Health Fund we identified a database comprising 2,022 patients who underwent AF/AFl ablation between January, 2012 and December, 2012 in Poland. The primary endpoint was readmission to hospital with discharge diagnosis AF/AFl. The secondary endpoints included: repeat AF/AFl ablation, cardiovascular hospitalization, all-cause hospitalization, all-cause mortality assessed in 30-day and 1-year time frame. RESULTS: The mean age was 58.6 ± 10.9 years (66.8% male). The mean time of the index ablation hospitalization was 3.8 ± 2.6 days. After discharge, 123 (6.1%) and 540 (26.7%) patients were hospitalized because of AF/AFl within 30 days and 1 year, respectively. During 1-year follow-up, 192 (9.5%) patients underwent subsequent AF/AFl ablations. The patients that underwent the second ablation were younger (56.6 ± 11.0 vs. 59.1 ± 10.8; p = 0.019) and the time of the index hospitalization was shorter (3.75 ± 2.16 vs. 4.45 ± 3.26; p = 0.03). Within 30 days 194 (9.6%) patients were hospitalized and 747 (36.9%) in 1-year follow-up. All-cause mortality was 0.1% and 1.4% in 30-day and 1-year follow-up, respectively. In a 1-year follow-up patients hospitalized from AF/AFl recurrence were more frequently hospitalized due to cardiovascular diseases other than AF/AFl (9.6% vs. 6.7%; p = 0.026), especially due to hypertension (2.9% vs. 0.7%; p < 0.001). CONCLUSIONS: Over 1 out of 4 patients who underwent AF/AFl ablation were hospitalized due to arrhythmia recurrence in 1 year.

Cardiac arrest survivors treated with or without mild therapeutic hypothermia: performance status and quality of life assessment.

BACKGROUND: Hypoxic-ischaemic encephalopathy is the main determinant of clinical outcome after cardiac arrest. The study was designed to determine long-term neurological and psychological status in cardiac arrest survivors, as well as to compare neuropsychological outcomes between patients treated with mild therapeutic hypothermia (MTH) and patients who did not undergo hypothermia treatment. METHODS: The article describes a single-center, retrospective, observational study on 28 post-cardiac arrest adult patients treated in the cardiac intensive care unit who qualified for MTH vs. 37 control group patients, hospitalized at the same center following cardiac arrest in the preceding years and fulfilling criteria for induced hypothermia, but who were not treated due to unavailability of the method at that time. Disability Rating Scale (DRS), Barthel Index and RAND-36 were used to assess performance status and quality of life in both study groups after hospital discharge. RESULTS: There were no statistically significant differences in physical functioning found between groups either at the end of hospital treatment or at long-term follow-up (DRS: p = 0.11; Barthel Index: p = 0.83). In long-term follow-up, MTH patients showed higher vitality (p = 0.02) and reported fewer complaints on role limitations due to emotional problems (p = 0.04) compared to the control group. No significant differences were shown between study groups in terms of physical capacity and independent functioning. CONCLUSION: To conclude, in long-term follow-up, MTH patients showed higher vitality and reported fewer complaints on role limitations due to emotional problems compared to the control group. This suggest that MTH helps to preserve global brain function in cardiac arrest survivors. However, the results can be biased by a small sample size and variable observation periods.

Epithelioid hemangioendothelioma of the liver as a rare indication for liver transplantation.

AIM: To investigate the indications and outcomes of liver transplantation for hepatic epithelioid hemangioendothelioma (HEHE). METHODS: Between 1989 and August 2013, in the Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, 1306 orthotopic liver transplantations (OLTx) were performed, including 72 retransplantations. Unresectable HEHE was an indication for OLTx in 10 patients (0.8% of primary OLTx), the mean age of the patients was 40.5 ± 13.3 years (range 23-65 years), and the male-to-female ratio was 2:8. Kaplan-Meier survival analysis in HEHE, hepatocellular carcinoma (HCC), and other OLTx recipients groups was performed. The differences in mortality were compared using the χ(2) test. A P-value < 0.05 indicated statistical significance. RESULTS: No concomitant liver disease was found in any patient. There was no neoadjuvant chemotherapy or radiotherapy. Liver function test results were normal in most of the patients. The levels of alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9 were normal. In immunohistochemical staining, the neoplastic cells were positive for factor VIII-related antigen, CD31, and CD34, which are endothelial cell markers, and negative for cytokeratin 19, cytokeratin 7, and HepPar-1. Nine patients were alive without tumor recurrence. One patient died 2 mo after OLTx due to septic complications. No morbidity was observed. Maximum follow-up was 11.4 years, with a minimum of 1 mo. The cumulative survival rate at the end of follow-up in HEHE patients was 87.5% compared with 54.3% in the HCC group and 76.3% in the other OLTx recipients group (χ(2) test = 1.784, df = 2, P = 0.409). CONCLUSION: Unresectable HEHE, without extrahepatic metastases is an excellent indication for liver transplantation. Long-term survival is very good and much better than in HCC patients and the entire group of OLTx patients.

Association of blood groups with prognosis in acute coronary syndrome.

INTRODUCTION:  Multiple factors that affect the prognosis of acute coronary syndromes (ACS) have been identified. There are scarce data on the effect of the blood group on prognosis in this patient group. OBJECTIVES: We investigated the effect of ABO and Rh (D antigen) status on the prognosis of ACS. PATIENTS AND METHODS: A group of 418 consecutive hospitalized patients with ACS were analyzed. The follow­up period was 2075 ±794 days. The primary endpoint was all­cause mortality. A statistical analysis was performed for the following subgroups: ABO blood group, ABO blood group including Rhesus (Rh) factor (D antigen), Rh­positive vs. Rh­negative blood group, O blood group vs. non­0 blood group, blood group with vs. without the B antigen, and blood group with vs. without the A antigen. RESULTS:  A total of 348 patients (83.25%) were Rh-positive, while 70 (16.75%) were Rh­negative. The Kaplan-Meier survival plots showed 7­year mortality of 22.7% in patients with blood groups with Rh antigen and of 10% in patients without Rh antigen (P = 0.014). Other comparisons were not statistically significant. A multivariable Cox proportional hazards model identified blood group with D antigen as an independent predictor of mortality (hazard ratio, 7.758; 95% confidence interval, 1.748-34.417; P = 0.007). CONCLUSIONS:  Of all blood groups, only the Rh­positive blood group was an independent predictor of mortality in patients with ACS.