Digital pressure in haemodialysis patients with brachial arteriovenous fistula

Background & objectives

: The pathophysiological mechanisms involved in distal pressure changes following arteriovenous fistula (AVF) creation in patients with end-stage renal disease (ESRD) are not completely understood. This study was aimed to assess digital pressure changes post-AVF creation and to identify the factors that might influence these changes in ESRD patients.

Methods

: In this prospective study, 41 patients with ESRD underwent AVF creation. Basal digital pressure (BDP), digital brachial index (DBI), calcium, phosphorus and blood urea levels were assessed preoperatively. BDP, DBI, vein and artery diameters, and AVF blood flow were also evaluated at one and two month(s) post-AVF creation.

Results

: Mean BDP significantly decreased from 131.64±25.86 mmHg (baseline) to 93.15±32.14 and 94.53±32.90 mmHg at one and two months post-AVF creation, respectively (P <0.001). Mean DBI significantly decreased one month post-AVF creation versus baseline (0.70±0.18 vs. 0.89±0.17 mm, P <0.001) and remained similar at two versus one month(s) postoperatively (0.70±0.23 vs. 0.70±0.18 mm). At both postoperative timepoints, no correlation between DBI decrease and increased artery and vein diameters or fistula blood flow was observed. Mean DBI difference between patients with previous ipsilateral access versus those without was not significant from pre to one month postoperatively. No correlation was observed between baseline phosphorus, calcium and blood urea nitrogen and DBI changes.

Interpretation & conclusions

: Our findings suggest that decrease in distal pressure following AVF creation may not be influenced by the arterial remodelling degree, vein diameter or fistula flow. In uraemic patients, those with low calcium and/or increased phosphorus, no association between these parameters and DBI changes could be observed.

Correlation between preoperative vein and artery diameters and arteriovenous fistula outcome in patients with end-stage renal disease

BACKGROUND AND AIMS

Arteriovenous fistula (AVF) maturation failure rates remain high in patients with end-stage renal disease (ESRD). Although preoperative morphological and functional assessment of blood vessels by duplex ultrasonography (DUS) has been shown to improve AVF maturation, there is no consensus regarding the optimal vein (VD) and artery (AD) diameters to be universally used for AVF creation. To improve patient selection, set out to investigate if there is a correlation between preoperative VD/AD and clinical covariates, and postoperative AVF outcome.

METHODS

This was a prospective cohort study conducted during January-August 2014. ESRD patients referred to "Niculae Stăncioiu" Heart Institute Cluj-Napoca, who had a VD ≥1.9 mm and AD ≥1.5 mm, as measured by DUS, and underwent AVF creation were enrolled. We assessed whether preoperative VD/AD and clinical covariates were associated with AVF maturation rate and primary patency at 2 years after AVF creation.

RESULTS

Of 115 patients referred for AVF creation, 93 were included in the study. Mean (± standard deviation) VD was 3.3 ± 1.1 mm and VDs were distributed in quartile Q1 <2.55 mm, Q2: 2.56-3.10 mm, Q3: 3.11-3.70 mm and Q4: >3.71 mm. Mean AD was 3.3 ± 1.4 mm and ADs were distributed in Q1 <2.55 mm, Q2: 2.56-3.10 mm, Q3: 3.11-3.70 mm, and Q4, >3.71 mm. AVF maturation rate increased proportionally with VD from Q1 (62%) to Q2 (70%), Q3 (82%) to Q4 (96%) (p=0.03). Based on AD, a higher AVF maturation rate was observed in Q3 (86%), Q4 (83%) vs Q1 (71%) and Q2 (67%). Long-term primary patency of AVFs seemed not to be influenced by VD and AD. In older patients and those with peripheral arterial disease, AVF maturation failure tended to be higher.

CONCLUSIONS

Our findings suggest that a preoperative VD ≥1.9 mm and AD ≥1.5 mm have a successful maturation rate of AVF greater than 60% in ESRD patients. The maturation rate of surgical AVF increases proportionally with the size of VD used for AVF creation.

Drainage of cerebral abscesses prior to valve replacement in stable patients with acute left-sided infective endocarditis

Despite the medical and surgical advancements in the treatment of patients with acute infective endocarditis (IE), neurologic complications remain problematic. They can arise through various mechanisms consisting of stroke or transient ischemic attack, cerebral hemorrhage, mycotic aneurysm, meningitis, cerebral abscess, or encephalopathy. Most complications occur early during the course of IE and are characteristic to left-sided pathology of native or prosthetic valves. We present a case of a 46 year old male patient who presented to our clinic with mitral valve IE caused by coagulase negative staphylococcus. Although under correct antibiotic treatment, he continued to be feverish and started to present unspecific neurological symptoms (amnesia, confusion, asthenia and general malaise). The cerebral magnetic resonance imaging (MRI) revealed multiple cerebral abscesses. Because the patient was hemodynamically stable we decided to address the cerebral abscess first and the cardiac lesion second. The patient made a full recovery after undergoing antibiotic treatment and surgical procedures of drainage of the cerebral abscess and mitral valve replacement. After reviewing the literature regarding the management of patients with IE and cerebral complications and based on this particular case, we conclude that in select cases of stable patients with cerebral abscess and IE, the neurological lesion should always be addressed first and cardiac surgery should be performed second.

Ischemic acute pancreatitis with pancreatic pseudocyst in a patient with abdominal aortic aneurysm and generalized atheromatosis - case report

Background

Ischemic pancreatitis is a rare medical entity. The pancreatic tissue is susceptible to ischemia with the possibility of developing acute pancreatitis. The abdominal aortic aneurysm can be one possible cause of pancreatic hypoperfusion.

Case presentation

We report the case of a 68-year-old man, Caucasian, with a history of a cluster of severe cardiovascular conditions, who presented epigastric pain of variable intensity for about 2 weeks. The pain occurred after intense physical effort, and was associated with anorexia and asthenia. The palpation revealed epigastric pain and palpable pulsatile mass above the umbilicus. Laboratory tests showed increased serum and urine amylases. The abdominal contrast-enhanced CT scan evidenced acute lesions of the pancreas and a caudal pancreatic pseudocyst of 39x24 mm. An abdominal aortic aneurysm was also described (which extended from the kidney level to the bilateral femoral level) with a maximum diameter of 60.5 mm and generalized atheromatosis. By corroborating clinical, anamnestic, laboratory and imaging data, the case was diagnosed as moderately severe acute ischemic pancreatitis, pancreatic pseudocyst, abdominal aortic aneurysm, generalized atheromatosis. The pancreatic pseudocyst was resorbed in eight months. Surgery for the abdominal aneurysm was performed after the resorption of the pseudocyst. The patient died after aortic surgery because of a septic complication.

Conclusion

Ischemic pancreatitis is a rare condition but should be considered in a patient with upper abdominal pain and elevated amylase in the context of an abdominal aortic aneurysm and generalized atheromatosis.

Risk factors influencing the surgical outcome in 138 consecutive patients with infrarenal aortic aneurysm: experience at the Cluj-Napoca Cardiovascular Surgery Center

Abdominal aortic aneurysms represent a common pathologic condition, with an increasing incidence in the last decades. Unfortunately, the mortality rate in ruptured abdominal aortic aneurysms has also increased. The aim of this retrospective study was to determine the risk factors that could interfere with the surgical outcome of these patients, especially with the perioperative morbidity and mortality rates.

MATERIALS AND METHODS

In this study we included 138 consecutive patients with infrarenal aortic aneurysm, who underwent elective repair (for chronic aortic aneurysm) or emergency repair (for ruptured aortic aneurysm), in the Cluj-Napoca Cardiovascular Surgery Clinic between January 2003 and December 2011. We noted the most frequently associated diseases and perioperative complications among the studied population. Three types of interventions were performed:tubular graft interposition, aortobiiliac bypass and aortobifemoral bypass.

RESULTS

The perioperative mortality in the elective repair group was 5.68% (5 - 88), while in the emergency repair group it was 46% (23 - 50).

CONCLUSIONS

Ruptured abdominal aortic aneurysm continues to represent a condition associated with substantial risks and high mortality. Selective screening and elective repair are therefore necessary for the improvement of the survival rate for patients with infrarenal aortic aneurysm.

Papillary fibroelastoma of the pulmonary valve: a case report

Papillary fibroelastoma is a rare, benign cardiac tumor typically found on the heart valves, which is usually discovered incidentally on echocardiography. The clinical presentation of cardiac papillary fibroelastoma varies from no symptoms to severe embolic sequelae. We report the case of a 55-year-old female patient, with a suspicion of pulmonary embolism one year before, presently admitted to the hospital for mild respiratory symptoms; the trans-esophageal echocardiography (TEE) revealed a 10/10 mm tumoral mass attached on the pulmonary valve, confirmed also by the contrast-enhanced magnetic resonance imaging (MRI). Considering the embolization risk, we decided surgical removal, with favorable outcome. The pathologic exam of the removed tumor established the diagnosis of papillary fibroelastoma. The clinical and imaging assessment one month after surgery were within normal limits. The surgical removal of the papillary fibroelastoma of the pulmonary valve is mandatory for the elimination of embolization risk. The intervention is relatively secure, with low rates of morbidity and mortality.

Glucocorticoid receptors in human epicardial adipose tissue: role of coronary status

BACKGROUND

Epicardial adipose tissue (EAT) is in close contact with coronary vessels and therefore could alter coronary homeostasis. Glucocorticoids are pathophysiological mediators of visceral fat deposition and its associated atherogenic complications.

AIM

We investigated in EAT the expression of the glucocorticoid receptor (GR) and its various (A, B, C) promoters.

MATERIALS AND METHODS

Paired subcutaneous adipose tissue (SAT) and EAT biopsies were obtained from 15 patients with coronary artery disease (CAD) and 12 patients without CAD (NCAD). GR and 11β-hydroxysteroid dehydrogenase type 1 protein (11β-HSD-1, the enzyme which converts inactive cortisone into active cortisol) were studied by immunohistochemistry and GR and its various promoters were studied by mRNA quantitative RT-PCR.

RESULTS

GR and 11β-HSD-1 protein were expressed in adipocytes, stromal areas, isolated stromal cells close to adipocytes, and blood vessels. Total GR mRNA levels did not differ in SAT obtained from NCAD or CAD patients and were decreased in EAT, irrespectively of the coronary status, with parallel changes in promoter B- and C-, but not promoter A-associated transcripts. Total GR mRNA and adipocyte surface in EAT obtained from CAD patients were correlated negatively (p<0.035, r=0.39).

CONCLUSIONS

Our findings demonstrate that in EAT, GR gene promoters could play a role in tissue- specific GR expression levels. EAT may be less sensitive to glucocorticoids than SAT, preventing the EAT mass development in CAD patients and suggesting a protective role on coronary homeostasis.

Expression of adrenomedullin in human epicardial adipose tissue: role of coronary status

Epicardial white adipose tissue (eWAT) is in close contact with coronary vessels and therefore could alter coronary homeostasis. Adrenomedullin (AM) is a potent vasodilatator and antioxidative peptide which has been shown to play a cytoprotective role in experimental models of acute myocardial infarction. We studied, using immunohistochemistry and qRT-PCR, the expression of AM and its receptors calcitonin receptor-like receptor (CRLR), and receptor activity-modifying protein (RAMP)2 and -3 in paired biopsies of subcutaneous WAT (sWAT) and eWAT obtained from patients with coronary artery disease (CAD) or without CAD (NCAD). In eWAT obtained from NCAD or CAD patients, immunoreactivity for AM, CRLR, and RAMP2 and -3 was detected in blood vessel walls and isolated stromal cells close to adipocytes. Some of the AM positive stromal cells colocalized CD68 immunoreactivity. eWAT from CAD patients showed increased AM immunoreactivity and AM gene expression. CRLR mRNA levels were comparable in sWAT of both groups and decreased by 40-50% in eWAT, irrespectively of the coronary status. RAMP2 mRNA concentrations did not change while RAMP3 mRNA levels increased in sWAT from CAD patients. There was a positive linear relationship between eWAT 11beta-hydroxysteroid dehydrogenase type 1 mRNA (11beta-HSD-1, the enzyme that converts inactive to active glucocorticoids) and AM mRNA. In conclusion, we demonstrate that AM and its receptors are expressed in eWAT. Our data suggest that eWAT AM, which could originate from macrophages, is related to 11beta-HSD-1 expression. AM synthesis, which is increased in eWAT during chronic CAD in humans, can play a cardioprotective role.

Increased mast cell density and microvessel density in the thymus of patients with myasthenia gravis

There were investigated 15 cases with normal thymus removed during cardiac surgery and nine cases with clinical signs of myasthenia gravis. Four patients with myasthenia gravis had thymoma (three invasive, one non-invasive). Specimens were fixed in buffer formalin, embedded in paraffin and slides were stained with Hematoxylin-Eosin and Alcian blue-Safranin. Additional slides were stained for factor VIII in order to estimate microvessel density. Mast cell density was performed at magnification x400, and microvessel density at magnification x200, using the "hot spot" method. There were found intralobular mast cells in all cases, located mainly in the cortex (6.53 in the normal thymus, 21.4 in patients with myasthenia gravis, and 10 in thymoma-associated myasthenia gravis). A significant increase in the number of intralobular mast cells was noticed in patients with myasthenia gravis without thymoma (p < 0.001), and a moderate increase in patients with thymoma-associated myasthenia gravis (p < 0.023). Values of microvessel density were 10.3 for the normal thymus, 33 for myasthenia gravis without thymoma and 21.8 for myasthenia gravis with associated thymoma. A strong correlation was found between the number of mast cells and microvessel densities in all three conditions.

Structural heterogeneity and immunohistochemical profile of Hassall corpuscles in normal human thymus

The study was conducted on 27 specimens of normal thymus, removed during surgery for cardiovascular malformations. Biopsies were processed using current histological techniques, and the samples were stained using morphological and immunohistochemical methods (cytokeratin profile, vimentin, S100, CD45, CD20, CD3, CD68, CD34 protein, chromogranin A, neuronal-specific enolase, desmin). Microscopic examination focused on the structure and immunohistochemical profile of Hassall corpuscles, beginning from the hypothesis that the epithelial cells of these structures, characteristic for the thymus, participate in the negative and positive selection of thymocytes. Morphological assessment revealed the existence of four different types of Hassall corpuscles: juvenile, immature, mature and senescent. The lymphocyte-rich variant was identified in 25.92% of the cases with ages ranging between 7 days and 12 years. From the immunohistochemical point of view, the following reactions were negative: cytokeratins 7 and 8, vimentin, desmin, CD3, CD68, CD34 and neuron-specific enolase. Isolated positive chromogranin cells were found in two cases, and positive intracorpuscular CD20 cells in one case. Polyclonal cytokeratins were positive in all instances in the epithelial cells of the Hassall corpuscles, with higher intensity in high-molecular weight cytokeratin, strongly expressed in mature corpuscles. All specimens had positive S100 cells in the corpuscles, distributed among the epithelial cells, with dendritic morphology, in great numbers in juvenile and immature forms. Morphological and immunohistochemical results (corpuscle variants, the presence of positive S100 cells, concentration of positive CD20 and CD3 cells around the corpuscles) suggest the active involvement of epithelial cells of Hassall corpuscles in modulating the differentiation of thymocytes at the medullar level, a process that is mediated by protein S100 positive corpuscular dendritic cells.

[Transesophageal electrophysiology study, a simple method of investigation of unexplained illness in elderly patients]

Cardiac arrhythmias are common causes of syncope and malaise in elderly patients, but they are sometimes difficult to demonstrate without invasive procedures. The aim of this report was to demonstrate the value of transoesophageal electrophysiological investigation in cases of negative classical non-invasive studies. The authors report 18 cases of patients, aged 70 to 88, mainly in poor general condition, who were admitted for the investigation of malaise or syncope. The ECG was normal or subnormal and Holter monitoring non-contributive to the diagnosis. Transoesophageal electrophysiological study enabled initiation of an arrhythmia, bradycardia or tachycardia, which reproduced the symptoms of spontaneous malaise. In 10 cases, paroxysmal junctional tachycardia was demonstrated, by nodal reentry in 8 cases, and in a latent Kent bundle in 2 cases. The malaise was caused by tachyarrhythmia in 3 patients and by a vagal reaction or sinus arrest after the tachycardia in the other patients. In 6 other patients, atrial fibrillation reproduced the malaise either due to the rapid rhythm, or to bradycardia after the arrhythmia in 3 cases. In another 2 patients, conduction defects were demonstrated by atrial stimulation (alternating bundle branch block in one patient, complete atrioventricular block at the end of atrial stimulation in another patient). The authors conclude that transoesophageal electrophysiological study is a simple technique which allows diagnosis of unexplained malaise in elderly patients when non-invasive methods are unable to demonstrate the causal arrhythmia. Supraventricular arrhythmias seem to be a common and probably underestimated cause of malaise or syncope in elderly patients.