Transcatheter Aortic Valve Implantation Induces Transient Drop in Platelet Reactivity.

ABSTRACT: Although recent studies described platelet reactivity (PR) changes in days after transcatheter aortic valve implantation (TAVI), precise time course and duration of these changes have not been fully investigated. The aim of this study was to investigate PR pattern during and after TAVI in multiple time points. Study included 40 consecutive patients undergoing TAVI. All patients underwent the procedure on dual antiplatelet therapy. PR was measured in 7 time points: before induction of anesthesia (T1), after heparin administration (T2), 10 minutes after initial valve implantation (T3), at the end of procedure (T4), and on 3rd, 6th, and 30th postoperative day (T5-T7). PR was measured using impedance aggregometer using 3 different platelet aggregation agonists (arachidonic acid in ASPItest, adenosine diphosphate in ADPtest and thrombin receptor activating peptide 6 in TRAPtest). All patients underwent successful TAVI procedure. Mean PR on T1 was 22.9 ± 23.0 U for ASPItest, 40.5 ± 23.7 U for ADPtest and 91.7 ± 32.5 U for TRAPtest. There was no significant difference in PR on T2. On T3, significant reduction of PR in all 3 tests was observed [ASPI 10.4 ± 11.6 U (P = 0.001), ADP 24.2 ± 14.1 U (P < 0.001) and TRAP 69.3 ± 26.6 U (P < 0.001)]. PR nadir for all tests was reached on T5, with subsequent PR incline. PR values in all tests returned to baseline levels on T7. Our results show that successful TAVI procedure induces transient decrease in PR regardless of the platelet activation pathway.

Staged management of a giant cardiac hydatid cyst: a case report.

BACKGROUND: We report on a 21-year-old patient with a giant symptomatic hydatid cyst of the interventricular septum, to whom a staged management approach was employed. Induction medical therapy led to a reduction in the size of the cyst, which was then completely removed via surgical excision. CASE PRESENTATION: A 21-year-old male Caucasian, with main complaints of fatigue and palpitations, was referred to our Centre due to a cystic formation in his left ventricle. The workup consisted of transthoracic echocardiography and cardiac magnetic resonance, which revealed a huge hydatid cyst in an active stage of disease, occupying the basal and mid part of the interventricular septum. Due to the size of the lesion and lack of viable myocardium in the affected area, the patient was declared inoperable and medical therapy was initiated. Serial echocardiography revealed a significant reduction in the size of the lesion and degradation to transitional and inactive stage, after which successful surgical excision of the cyst was performed. In the course of the medical treatment, the patient experienced sustained ventricular tachycardia causing loss of consciousness, which did not reoccur after surgical excision. CONCLUSION: Medical therapy can result in the degradation of a giant heart hydatid cyst, enabling surgical excision. Heart hydatid cyst can lead to potentially lethal arrhythmia irrespective of its size and stage, which does not reoccur after successful surgical excision.

Takotsubo cardiomyopathy after the first electroconvulsive therapy regardless of adjuvant beta-blocker use: a case report and literature review.

Takotsubo cardiomyopathy (TC) is a rare complication of electroconvulsive therapy (ECT), an effective and safe treatment for severe cases of depression and psychosis. There are reports on 16 patients who developed TC after ECT, and these were predominantly female patients treated with antidepressants for depressive disorder. We describe a case of a 40-year-old male patient, with a history of schizophrenia and heavy caffeine and nicotine use, treated for acute psychotic episode with haloperidol and clozapine. Propranolol was administered because of clozapine-induced tachycardia. After 8 weeks without therapeutic response, the patient was referred for standard ECT procedure, which included premedication and bifrontotemporal stimulation. Two hours later, the patient experienced gastric pain and had increased troponin and natriuretic peptide levels and ST-elevation. After inotrope and anticoagulant treatment and replacement of antipsychotics, the patient remained stable. Contrary to common opinion, previous adrenergic blockade in this patient did not prevent TC occurrence. TC pathophysiology remains unclear although it has been related to the burst of norepinephrine neurons. Psychosis has also been associated with catecholamine dysfunction, and excessive psychological stress with long-term norepinephrine dysfunction. Animal models have shown that ECT, clozapine, and nicotine and caffeine use could considerably increase catecholamine levels. Clinical understanding of rare cardiac ECT complications could improve early recognition of patients at risk for TC and ensure safe ECT protocols.

Liver steatosis replaced with non-invasive viral and host parametars can serve as negative predictive model in patients with chronic hepatitis-C.

Almost 70% of chronic hepatitis C (CHC) patients will have concomitant hepatic steatosis (HS) usually determined with invasive method. HS serve as negative predictive factor for lower sustained viral response (SVR) in CHC patients treated with standard of care (SOC) (PEG-IFN and Rib). Retrospective analysis of biochemical, virological and histological data in CHC patients treated with PEG-IFN and Ribavarin. Statistical analysis was carried out by Biometriha Healthcare Research. Level of significance was set to 95% (p < 0.05). 72 patients (43 M; 29 F; median age 41 y) with CHC (60 G1; 12 G3) with no concomitant metabolic syndrome were analyzed. HS ranged from 5 to 30% (median 15%). Overall accuracy of prediction of SVR based on the levels of HS was AUC=0.71 (95% CI=0.58-0.84; p=0.005). When HS was split regarding cut-off value of 5% significant difference was found between responders and non-responders to treatment (chi2 = 10.025; df = 1; p = 0.002). Overall sensitivity was 48% and specificity 91%. Conventional predictive variables (gender, age, fibrosis and genotype) where combined with HS (>5%) and all together achieved Nagelherke R squared of 34.0% in prediction of SVR, with accuracy rate of 75.0%. Further, invasive variables (fibrosis and HS) where replaced with vire mia and body mass index (BMI). All noninvasive variables together achieved Nagelkerke R squared of 26.5% in prediction of SVR with 74% accuracy rate of the logistic regression model. Very low HS (<5%) is negative predictor of SVR and can be replaced with noninvasive variables (gender, age, viremia and BMI) with same accuracy rate of the logistic regres- sion model.

Extracorporeal blood purification is associated with improvement in biochemical and clinical variables in the critically-ill COVID-19 patients.

This study tried to investigate the impact of oXiris filter on both clinical and laboratory parameters in critically-ill COVID-19 intensive care unit (ICU) patients receiving extracorporeal blood purification and the clinical setting for the initiation of therapy. A consecutive sample of 15 ICU patients with COVID-19 was treated with oXiris membrane for blood purification or for support of renal function due to acute kidney injury. We have included 19 non treated ICU COVID-19 patients as a control group. Two chest x-rays were analyzed for determining the chest x-ray severity score. We have found a significant decrease of SOFA score, respiratory status improved and the chest x-ray severity score was significantly decreased after 72 h of treatment. IL-6 significantly decreased after 72 h of treatment while other inflammatory markers did not. Respiratory status in the control group worsened as well as increase in SOFA score and chest x-ray severity score. Survived patients have shorter time from the onset of symptoms before starting with extracorporeal blood purification treatment and shorter time on vasoactive therapy and invasive respiratory support than deceased patients. Critically-ill patients with COVID-19 treated with extracorporeal blood purification survived significantly longer than other ICU COVID-19 patients. Treatment with oXiris membrane provides significant reduction of IL-6, leads to improvement in respiratory status, chest x-ray severity score, and reduction of SOFA score severity. Our results can suggest that ICU COVID-19 patients in an early course of a disease could be potentially a target group for earlier initiation of extracorporeal blood purification.

Safety and efficacy of dual antiplatelet therapy after percutaneous coronary interventions in patients with end-stage liver disease.

The prevalence of coronary artery disease (CAD) increases in patients with end-stage liver disease, with part of them receiving the percutaneous coronary intervention (PCI) as a treatment option. Dual antiplatelet therapy (DAPT), a standard of care after PCI, could result in catastrophic consequences in this population. Before PCI and the start of DAPT, it is recommended to assess patient bleeding risk. Based on novel findings, liver cirrhosis does not necessarily lead to a significant increase in bleeding complications. Furthermore, conventional methods, such as the international normalized ratio, might not be appropriate in assessing individual bleeding risk. The highest bleeding risk among cirrhotic patients has a subgroup with severe thrombocytopenia (< 50 × 109/L) and elevated portal pressure. Therefore, every effort should be made to maintain thrombocyte count above > 50 × 109/L and prevent variceal bleeding. There is no solid evidence for DAPT in patients with cirrhosis. However, randomized trials investigating short (one month) DAPT duration after PCI with new drug-eluting stents (DES) in a high bleeding risk patient population can be implemented in patients with cirrhosis. Based on retrospective studies (with older stents and protocols), PCI and DAPT appear to be safe but with a higher risk of bleeding complications with longer DAPT usage. Finally, novel methods in assessing CAD severity should be performed to avoid unnecessary PCI and potential risks associated with DAPT. When indicated, PCI should be performed over radial artery using contemporary DES. Complementary medical therapy, such as proton pump inhibitors and beta-blockers, should be prescribed for lower bleeding risk patients. Novel approaches, such as thromboelastography and "preventive" upper endoscopies in PCI circumstances, warn clinical confirmation.

Differentiation of Pancreatic Masses via Endoscopic Ultrasound Strain Ratio Elastography Using Adjacent Pancreatic Tissue as the Reference.

OBJECTIVES: The aims of this study were to evaluate diagnostic value of endoscopic ultrasound strain ratio elastography in patients with focal pancreatic masses and to determine the cutoff value between the pancreatic malignancies and inflammatory pancreatic masses using reference areas different than those used by other investigators. METHODS: In a prospective single-center study, strain ratio was measured in patients with pancreatic masses. After the diagnosis was established, statistical analysis was used to compare the group with pancreatic malignancies to the one with inflammatory masses. RESULTS: Strain ratio cutoff of 7.59 provided 100% sensitivity, 95% specificity, and 97% overall accuracy for differentiation of patients with pancreatic malignancies from those with inflammatory masses. CONCLUSIONS: Our data show high sensitivity and specificity for the calculated strain ratio. Adjacent normal pancreatic tissue is adequate as a reference area based on the inclusion criteria. Diverse cutoff values and standardization of methods in the studies published so far require further investigations, before the implementation of the method in a routine clinical practice becomes possible.

Frequency of radial artery anatomic variations in patients undergoing transradial heart catheterization.

Over the last ten years, transradial cardiac catheterization has been increasingly applied, primarily because of its lower incidence of complications compared to the femoral approach. However, one of the greatest flaws of the transradial approach is a relatively high incidence of catheterization failure (1%-5%). Anatomic variations of radial artery are ranked second among the reasons for this. Previous studies have not provided unambiguous data on the frequency of these anomalies. It was therefore the aim of this study to determine the frequency of anatomic variations using routine angiographies of radial artery during left heart catheterization. This was a retrospective study involving examination of 602 images of routine angiographies of radial artery performed during cardiac catheterization. The frequency of anatomic variations of radial artery was 8.8%, exclusive of tortuosities with a frequency of 12.7%. The most frequent anatomic variation was the high origin of radial artery, found in 31 (5.1%) subjects. Radioulnar loops, being one of the potential contraindications for the procedure, were reported in 2% of cases. Regression analysis revealed that age (p < 0.001), female sex (p = 0.015) and high origin (p = 0.034) considerably contributed to the development of tortuosity. The results indicated the incidence of tortuosity to increase linearly with age. Although it is not a contraindication for continuing with the procedure, we recommend that elderly patients have angiography of radial artery performed at the beginning of the procedure due to the higher frequency of tortuosity.

Endoscopic ultrasound elastography strain histograms in the evaluation of patients with pancreatic masses.

AIM: To investigate the accuracy of the strain histogram endoscopic ultrasound (EUS)-based method for the diagnostic differentiation of patients with pancreatic masses. METHODS: In a prospective single center study, 149 patients were analyzed, 105 with pancreatic masses and 44 controls. Elastography images were recorded using commercially available ultrasound equipment in combination with EUS linear probes. Strain histograms (SHs) were calculated by machine integrated software in regions of interest and mean values of the strain histograms were expressed as Mode 1 (over the mass) and Mode 2 (over an adjacent part of pancreatic tissue, representing the reference area). The ratio between Mode 2 and Mode 1 was calculated later, representing a new variable, the strain histogram ratio. After the final diagnosis was established, two groups of patients were formed: a pancreatic cancer group with positive cytology achieved by fine needle aspiration puncture or histology after surgery (58 patients), and a mass-forming pancreatitis group with negative cytology and follow-up after 3 and 6 mo (47 patients). All statistical analyses were conducted in SPSS 14.0 (SPSS Inc., Chicago, IL, United States). RESULTS: Results were obtained with software for strain histograms with reversed hue scale (0 represents the hardest tissue structure and 255 the softest). Based on the receiver operating characteristics (ROC) curve coordinates, the cut-off point for Mode 1 was set at the value of 86. Values under the cut-off point indicated the presence of pancreatic malignancy. Mode 1 reached 100% sensitivity and 45% specificity with overall accuracy of 66% (95%CI: 61%-66%) in detection of pancreatic malignant tumors among the patients with pancreatic masses. The positive and negative predictive values were 54% and 100%, respectively. The cut-off for the new calculated variable, the SH ratio, was set at the value 1.153 based on the ROC curve coordinates. Values equal or above the cut-off value were indicative of pancreatic malignancy. The SH ratio reached 98% sensitivity, 50% specificity and an overall accuracy of 69% (95%CI: 63%-70%). The positive and negative predictive values were 92% and 100%, respectively. CONCLUSION: SH showed high sensitivity in pancreatic malignant tumor detection but disappointingly low specificity. Slight improvements in specificity and accuracy were achieved using the SH ratio.

Diagnostic accuracy of central venous saturation in estimating mixed venous saturation is proportional to cardiac performance among cardiac surgical patients.

PURPOSE: Advanced hemodynamic monitoring in cardiac surgery translates into improvement in outcomes. We evaluated the relationship between central venous (ScvO2) and mixed venous (SvO2) saturations over the early postoperative period. The adequacy of their interchangeability was tested in patients with varying degrees of cardiac performance. METHODS: In this prospective observational study, we evaluated 156 consecutive cardiac surgical patients in an academic center. The ScvO2 and SvO2 data were harvested from 468 paired samples taken preoperatively (T0), after weaning from cardiopulmonary bypass (T1) and on postoperative day 1 (T2). RESULTS: The relationship between ScvO2 and SvO2 was inconsistent, with inferior correlations in patients with lower cardiac indices (CI) (Pearson r(2) = 0.37 if CI ≤2.0 L/min per square meter vs r(2) = 0.73 if CI >2.0 L/min per square meter, both P < .01). Patients with lower CI also had wider 95% limits of agreement between SvO2 and ScvO2. The proportion of patients with a negative SvO2-ScvO2 gradient increased over time (48/156 [31%] at T0 to 73/156 [47%] at T2; P < .01). This subgroup more frequently required inotropes at T2 than patients with a positive SvO2-ScvO2 gradient (odds ratio, 6.46 [95% confidence interval, 0.81-51.87], P = .06) and also had higher serum lactate levels (1.5 ± 0.8 vs 1.0 ± 0.4; P < .01). CONCLUSIONS: The diagnostic accuracy of ScvO2 for estimating SvO2 is proportional to cardiac performance. A negative SvO2-ScvO2 gradient at T2 correlated with inotropic support requirement, higher operative risk score, age, lactate level, and duration of cardiopulmonary bypass.