JRSM Cardiovascular Disease最新文献

A 56-year-old man who had twice previously undergone orthotopic heart transplantation was admitted with dyspnea and heart failure symptoms. A biopsy excluded rejection. Left heart catheterization revealed a coronary cameral fistula. After the patient was given mild diuretics, his condition improved. No significant fistula flow was detected, and he was discharged. Several months later, the patient was readmitted with worsening chest pain and dyspnea. Left ventricular end-diastolic pressure and flow through the fistula were increased. To correct the coronary cameral fistula, we performed a coil embolization without complications. Several months later at follow-up, the patient's symptoms had resolved, and his left ventricular end-diastolic pressure had normalized. We conclude that coronary fistulas may be caused by trauma to the heart during the de-airing process, which may be prevented in the future with the development of safer and more effective de-airing techniques.

Background: Primary hyperparathyroidism arising from parathyroid adenoma is one of the most common endocrine disorders treated by endocrine surgeons. The adenoma is commonly identified by imaging techniques. The present study evaluated the performance of a portable ultrasound machine (Sonosite MicroMaxx) operated by a surgeon, departmental ultrasound and ^99mTc-sestamibi-SPECT/CT by a radiologist in the identification of parathyroid adenomas.

Methods: Patient case notes were retrieved from medical records and imaging from picture archiving and communication system over the period from 2006 to 2012. ^99mTc-sestamibi-SPECT/CT and departmental ultrasound images were reported by a nuclear radiologist. The ability of each imaging technique in localising parathyroid adenomas was referenced against the actual adenomas identified from parathyroidectomy.

Results: With reference to the actual site of the lesion, surgeon-performed ultrasound accurately localised the site of the lesion in 30/33 (90.1%) of cases with a sensitivity of 86.7%, departmental ultrasound accurately localised the site of the lesion in 21/26 (80.1%) of cases with a sensitivity of 79.2%. In 6/75 patients where ^99mTc-sestamibi-SPECT/CT did not localise the lesion, departmental ultrasound did not localise any lesions correctly, while surgeon-performed ultrasound successfully located the adenoma in three (50%) of these six patients. Patients whose parathyroid adenomas identified by the surgeon were more likely to have shorter length of stay in hospital: odds ratio = 0.53 (95% confidence interval = 0.30-0.92, p = 0.025).

Conclusions: Surgeon-performed ultrasound for immediately pre-operative localisation improves identification of parathyroid adenomas and reduces length of stay in hospital, lending support for the use of this technique by endocrine surgeons.

Background: Despite promising epidemiological data, it remains unclear if increased blood pressure variability is associated with death after acute ischemic stroke. Our objective was to examine this association in a large cohort of acute ischemic stroke patients.

Methods: We conducted a retrospective analysis of anonymized, pooled, participant data from the Virtual International Stroke Trial Archive. We included patients with a 90-day modified Rankin Scale and blood pressure readings in the 24 h after study enrollment. The exposure was blood pressure variability during the day after study enrollment, calculated for the systolic and diastolic blood pressure using six statistical methodologies. The primary outcome was death within 90 days of stroke onset.

Results: Our cohort comprised 1891 patients of whom 277 (14.7%) died within 90 days. All indices of blood pressure variability were higher in patients who died, but the difference was more pronounced for systolic than diastolic blood pressure variability (systolic standard deviation for alive versus dead patients = 13.4 versus 15.9 mmHg, p < 0.001). Similar results were found in logistic regression models fit to the outcome of death, but only systolic blood pressure variability remained significant in adjusted models (Odds Ratio for death when comparing highest to lowest tercile of systolic blood pressure variability = 1.41-1.89, p < 0.03 for all).Conclusions and relevance: These results reinforce prior studies that found increased blood pressure variability is associated with worse neurologic outcome after stroke. These data should help guide research on blood pressure variability after stroke and advocate for the inclusion of death as a clinical outcome in future studies that therapeutically reduce blood pressure variability.

Objective: We investigated if there is I_Ks, and if there is repolarization reserve by I_Ks in human-induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs).

Design: We used a specific KCNQ1/KCNE1 channel blocker, L-000768673, with an IC₅₀ of 9 nM, and four hERG-specific blockers, astemizole, cisapride, dofetilide, and E-4031 to investigate the issue.

Results: L-000768673 concentration-dependently prolonged feature point duration (FPD)-a surrogate signal of action potential duration-from 1 to 30 nM without pacing or paced at 1.2 Hz, resulting from I_Ks blockade in hiPSC-CMs. At higher concentrations, the effect of L-000768673 on I_Ks was mitigated by its effect on I_Ca-L, resulting in shortened FPD, reduced impedance amplitude, and increased beating rate at 1 µM and above, recapitulating the self-limiting properties of L-000768673 on action potentials. All four hERG-specific blockers prolonged FPD as expected. Co-application of L-000768673 at sub-threshold (0.1 and 0.3 nM) and threshold (1 nM) concentrations failed to synergistically enhance the effects of hERG blockers on FPD prolongation, rather it showed additive effects, inconsistent with the repolarization reserve role of I_Ks in mature human myocytes that enhanced I_Kr response, implying a difference between hiPSC-CMs used in this study and mature human cardiomyocytes.

Conclusion: There was I_Ks current in hiPSC-CMs, and blockade of I_Ks current caused prolongation of action potential of hiPSC-CMs. However, we could not demonstrate any synergistic effects on action potential duration prolongation of hiPSC-CMs by blocking hERG current and I_Ks current simultaneously, implying little or no repolarization reserve by I_Ks current in hiPSC-CMs used in this study.

Introduction: Efforts were made to improve management of coronary disease as the fast-track system to the Coronary Unit. We aim to analyse case-fatality rates by acute coronary syndrome in Portugal from 2000 to 2016, mainly the impact of the fast-track system and the proportion of patients that activate the fast-track system.

Methods: We analysed monthly acute coronary syndrome case-fatality before and after the implementation of the fast-track system in 2007. Impact of the system was assessed through regression models for interrupted time-series. We calculated annual proportion of fast-track system admissions.

Results: After 2007 case-fatality by acute coronary syndrome decreased (β=-1.27, p-value < 0.01). The estimates obtained for ST Elevation Myocardial Infarction suggest a reduction of nearly 86 monthly deaths prevented after 2007. The highest percentage of patients admitted through the fast-track system was 35%.

Conclusions: Our results suggest fast-track system may have contributed to a decline in acute coronary syndrome case-fatality. However, more than half of patients were not admitted through the system. This should encourage health authorities to make efforts to ensure compliance.

Objectives: To evaluate the risk of having a stroke and the risk of bleeding in institutionalized patients with atrial fibrillation. Atrial fibrillation is a common cardiac arrhythmia associated with increased morbidity and mortality. It is necessary to develop pharmacotherapy plans to minimize the risk.

Design: A prospective study.

Setting: Institutionalized patients.

Participants: Inclusion criteria were: patients diagnosed with atrial fibrillation, with or without treatment for the prevention of stroke.

Main outcome measures: The evaluation of the CHA2DS2-VASc criteria was performed. The risk of hemorrhage was assessed using the HAS-BLED scale, based on the risk factors associated with the probability of bleeding.

Results: We included 53 patients (86.4 ± 6.4 years, 30.2% men). Of these, 37 (69.8%) were correctly anticoagulated. Of the remaining, 5 patients (31.2%) did not have any type of anticoagulant or antiaggregant treatment and 11 (68.7%) were treated with antiaggregant alone. The pharmaceutical intervention was performed in patients who did not meet stroke criteria. Of the untreated patients: two died before the intervention, two were recommended to be referred to cardiology and in one there was no intervention because of very advanced age. In the antiaggregant patients, it was decided not to modify the treatment. The reasons were: high risk of bleeding, very advanced age, advanced dementia or terminal illness, moderate risk of stroke, and clotting factor deficiency.

Conclusions: The risk of stroke in elderly patients with atrial fibrillation is high, so it is important to control the risk factors.

Introduction: Aortic calcification as detected by computed tomography is associated with arterial stiffening and is an important predictor of cardiovascular morbidity and mortality. Uptake of ¹⁸F-sodium fluoride (¹⁸F-NaF) in the aortic wall reflects metabolically active areas of calcification. The aim of this study was to determine if ¹⁸F-NaF uptake in the aorta is associated with calcification and progression of calcification as detected by computed tomography.

Methods: Twenty-one postmenopausal women (mean age 62 ± 6 years) underwent assessment of aortic ¹⁸F-NaF uptake using positron emission tomography/computer tomography at baseline and a repeat computed tomography scan after a mean follow-up of 3.8 ± 1.3 years. Tracer uptake was quantified by calculating the target-to-background (TBR) ratios at baseline and follow-up. Calcification was assessed at baseline and follow-up using computed tomography.

Results: Over the follow-up period, aortic calcium volume increased from 0.46 ± 0.62 to 0.71 ± 0.93 cm³ (P < 0.05). However, the change in calcium volume did not correlate with baseline TBR either unadjusted (r = 0.00, P = 1.00) or adjusted for age and baseline calcium volume (beta coefficient = -0.18, P = 0.42). TBR at baseline did not differ between participants with (n = 16) compared to those without (n = 5) progression in calcium volume (2.43 ± 0.46 vs. 2.31 ± 0.38, P = 0.58). In aortic segments identified to have the highest tracer uptake at baseline, calcium volume did not significantly change over the follow-up period (P = 0.41).

Conclusion: In a cohort of postmenopausal women, ¹⁸F-NaF uptake as measured by TBR in the lumbar aorta did not predict progression of aortic calcification as detected by computed tomography over a four-year follow-up.

Objectives: The aim of this study was to present a single-centre experience with EndoAnchors in patients who underwent endovascular repair for abdominal aortic aneurysms with challenging proximal neck, both in the prevention and treatment of endograft migration and type Ia endoleaks.

Methods: We retrospectively analysed 17 consecutive patients treated with EndoAnchors between June 2015 and May 2018 at our institution. EndoAnchors were applied during the initial endovascular aneurysm repair procedure (primary implant) to prevent proximal neck complications in difficult anatomies (nine patients), and in the follow-up after aneurysm exclusion (secondary implant) to correct type Ia endoleak and/or stent-graft migration (eight patients).

Results: Mean time for anchors implant was 23 min (range 12-41), with a mean of 5 EndoAnchors deployed per patient. Six patients in the secondary implant group required a proximal cuff due to stent-graft migration ≥10 mm. Technical success was achieved in all cases, with no complications related to deployment of the anchors. At a median follow-up of 13 months (range 4-39, interquartile range 9-20), there were no aneurysm-related deaths or aneurysm ruptures, and all patients were free from reinterventions. CT-scan surveillance showed no evidence of type Ia endoleak, anchors dislodgement or stent-graft migration, with a mean reduction of aneurysm diameter of 0.4 mm (range 0-19); there was no sac growth or aortic neck enlargement in any case.

Conclusions: EndoAnchors can be safely used in the prevention and treatment of type Ia endoleaks in patients with challenging aortic necks, with good results in terms of sac exclusion and diameter reduction in the mid-term follow-up.

Susac syndrome is an orphan disease characterised by encephalopathy, branch retinal artery occlusion and sensorineural hearing loss. As the clinical triad is rarely present at symptom onset, it is often initially misdiagnosed and appropriate treatment is often delayed. Herewith, we report a case of Susac syndrome in a 47-year-old man presenting with acute hemisensory loss and highlight the challenges of early diagnosis, particularly relevant in the era of hyperacute stroke management.

Primary cardiac tumors are typically benign, with myxomas being most common. We present a 32-year-old female with a chief complaint of dyspnea and a constant non-radiating chest pressure along the left sternal border. She was found to have a pulmonary embolism that was ultimately caused by embolization of a right atrial myxoma with remnants of a large, highly mobile mass attached to the right inter-atrial septum prolapsing through the tricuspid valve. The patient underwent a median sternotomy, right atrial mass resection, pulmonary embolectomy, and inter-atrial septum reconstruction using the patient's pericardium. The importance of finding the etiology of initial diagnoses is stressed with long-term outcomes for patients.