Subclinical myocardial dysfunction in patients with persistent dyspnea one year after COVID-19

Introduction

Coronavirus disease 2019 (COVID-19) rapidly spread across the globe,evolving into a global pandemic,with a crucial impact on healthcare systems. Several short-term follow-up studies emphasized the persistence of symptoms, referred as long COVID, in a significant number of discharged patients even without history of cardiopulmonary diseases, with dyspnea being one of the most frequent complaint [1–3]. Even though those reports on recovered COVID-19 patients did not describe major left ventricle (LV) function abnormalities, subtle cardiac changes may be present.

Purpose

We aimed to investigate the presence of subclinical cardiac dysfunction, assessed by transthoracic echocardiography (TTE) in recovered COVID-19 patients, without previous cardiopulmonary disease at 1 year follow-up.

Methods

310 COVID-19 consecutive hospitalized patients were prospectively included between March and April 2020. 66 patients out of 251 recovered patients had no previous history of coronary artery disease, arrhythmia, arterial hypertension, valvular heart disease, asthma, chronic obstructive pulmonary disease and obstructive sleep apnea, respectively and were included in the final analysis (Figure 1). The follow-up consisted in 2 parts, a 6-months visit including clinical and physical examination, chest computed tomography and spirometry and a 12-months visit including clinical and physical examination, spirometry and TTE.

Results

66 patients (mean age 51.39±11.15 years, 45 (68.2%) males) were included in the final analysis. 23 (34.8%) patients reported dyspnea at 1 year. TTE parameters were in the normal range, with a mean LV ejection fraction of 56.9±4.6%, mean global longitudinal strain (GLS) of −20.9±2.3%, global constructive work (GCW) of 2381.4±463.6 mmHg% and global work index (GWI) of 2132.5±419.2 mmHg%. Type 1 diastolic dysfunction was observed in 11 (16.7%) patients. One (1.5%) patient had type 2 diastolic dysfunction. A normal respiratory pattern was reported in 31 (47%) patients at 6 months spirometry, while 19 (28.8%) patients had a restriction pattern. No significant differences regarding clinical, laboratory or imaging findings at baseline were found between groups.

The following TTE parameters were significantly different in patients with and without dyspnea at 1 year: GLS (−19.97±2.14 vs. −21.38±2.37, p=0.039), GCW (2183.72±487.93 vs. 2483.14±422.42, p=0.024) and GWI (1960.06±396.21 vs. 2221.17±407.99, p=0.030). Multivariable logistic regression showed that GCW and GWI were inversely and independently associated with persistent dyspnea, one year after COVID-19 (p=0.035, OR 0.998, 95% CI 0.997–1.000; p=0.040, OR 0.998, 95% CI 0.997–1.000) (Table 1).

Conclusions

Persistent dyspnea one year after COVID-19 was present in more than a third of patients without known cardiovascular or pulmonary diseases. GCW and GWI were the only echocardiographic parameters independently associated with symptoms, suggesting a decrease in myocardial performance in this population and subclinical cardiac dysfunction.

Funding Acknowledgement

Type of funding sources: None.

Additional value of left atrium remodeling assessed by three-dimensional echocardiography for the prediction of atrial fibrillation recurrence after cryoballoon ablation

Background

Atrial fibrillation (AF) is the most common cardiac arrhythmia and it is associated with a high risk of cardiovascular complications [1]. Cryoballoon ablation (CBA) has emerged as a safe and efficient therapeutic option for AF [2]. However, AF recurrence occurs in more than 25% of the patients, which leads to repeated ablations and increased rates of complications and hospitalizations [3]. Previous reports on the role of left atrial (LA) diameter and LA volume assessed by two-dimensional echocardiography (2DE) as predictors of AF recurrence after ablation have shown controversial results [4,5]. This might be explained by the fact that these methods imply geometrical assumptions of the LA remodeling, which is a three-dimensional process [6].

Purpose

The purpose of this study was to evaluate the additional value of LA remodeling assessed by three-dimensional echocardiography (3DE) to predict AF recurrence after CBA.

Methods

Consecutive patients with paroxysmal/persistent AF undergoing CBA were prospectively included. Echocardiography was performed before CBA, according to standard recommendations. Blanking period was defined as the first three months post-ablation. The primary endpoint was AF recurrence after the blanking period.

Results

One hundred seventy two patients (62.2±12.2 years, 61% male) were included in the analysis. During the follow-up period of 11.7±1.6 months, fifty (29%) patients had AF recurrence after the blanking period. 3DE LA maximum volume index (LAVI) had the highest incremental predictive value for AF recurrence (HR 5.50, 95% CI 1.34–22.45, p<0.001) (Figure 1). Twenty-two percent of the AF recurrences occurred in patients with non-dilated LA diameter index and LAVI by 2DE (68 (39.5% patients)). In this category of patients, LAVI by 3DE was able to discriminate AF recurrence with a sensitivity of 90% and a specificity of 66%, for an optimal cut-off value of 30.4 ml/m2.

Conclusion

This study showed that LAVI assessed using 3DE had an additional predictive value for AF recurrence after CBA. Moreover, LAVI by 3DE was able to discriminate AF recurrence even in patients with non-dilated LA by M-Mode and 2DE. These findings suggest that 3DE might reflect better and earlier the asymmetric and variable nature of LA remodeling and could be a potential tool in clinical practice for an improved risk stratification and pre-ablation selection of AF patients.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Universitair Ziekenhuis Brussel: Wetenschappelijk Fonds Willy Gepts of the UZ Brussel

Prognostic value of left ventricle global constructive work in patients with cardiac amyloidosis

Background

Left ventricle (LV) global longitudinal strain (LVGLS) has demonstrated incremental diagnostic and prognostic value in patients with cardiac amyloidosis (CA), however it is sensitive to loading conditions (1). Therefore, myocardial work (MW) analysis emerged as a novel echocardiographic method that incorporates both GLS and afterload for a better assessment of LV performance in several pathologies (2). Nevertheless, data regarding its additional value in patients with CA remains limited.

Purpose

We aimed to evaluate the additional prognostic value of global constructive work (GCW), assessed using MW analysis, in patients with CA.

Method

Seventy-one unselected CA patients were included retrospectively between 2015 and 2021. Patients underwent comprehensive clinical, biochemical and imaging evaluation including two-dimentional (2D) echocardiography with MW analysis. The primary endpoint was defined as all-cause mortality and heart failure requiring hospitalization.

Results

The population (mean age 76,76±11.52 years, 73.2% males) consisted of 53 (74.6%) patients with transthyretin (ATTR), 14 (19.7%) patients with light-chain (AL), and 4 (5.6%) patients with unknown phenotype of CA. The primary endpoint was reached in 37 (52.1%) patients. Patient with the primary endpoint had a significantly lower LV ejection fraction (LVEF) (40.54% vs. 49.31%, p=0.003), LVGLS (−9.26% vs. −11.32%, p=0.017) and GCW (1034.47mmHg% vs. 1424.86 mmHg%, p=0.005) than those without. No significant clinical differences were found between the two groups. Multivariable analysis (Figure 1) showed that LVEF (p=0.003; odds ratio (OR): 0.881; 95% confidence interval (CI): 0.810–0.959), LVGLS (p=0.021; OR: 0.688; 95% CI: 0.502–0.944) and GCW (p=0.016; OR: 0.995; 95% CI: 0.991–0.999) were independent predictors for the primary outcome. The model including GCW had the best discriminative ability to predict the primary endpoint (C-index = 0.900; 95% CI: 0.781–1.000, p=0.001). A GCW less than 1443mmHg% was able to predict the primary endpoint with a sensitivity of 94.1% and a specificity of 64.3% (Figure 2; area under the curve (AUC): 0.771 (95% CI: 0.581–0.961; p=0.005).

Conclusion

In patients with CA, a decrease in GCW as a reflection of an impaired systolic performance of the LV was independently associated with an increase in heart failure hospitalization and all-cause mortality. Further prospective studies are warranted in order to confirm the potential role of GCW to improve the prognosis of CA patients.

Funding Acknowledgement

Type of funding sources: None.

The impact of long COVID on myocardial work performance

Background

Long COVID emerged as a new condition, following the acute episode of coronavirus disease 2019 (COVID-19),exerting a significant impact on patients' quality of life [1]. Several studies involving COVID-19 survivors emphasized the presence of cardiac abnormalities following the acute infection. However, data on possible mechanisms associated to long COVID remain limited. Clinical applications of myocardial work (MW) analysis, assessed by transthoracic echocardiography (TTE) have expended recently, showing an additional value in detecting cardiac dysfunction compared to standard parameters such as left ventricle ejection fraction (LVEF) or global longitudinal strain (GLS) in various pathologies, including COVID-19 [2]. Nevertheless, its potential role in detecting subclinical cardiac dysfunction in long COVID remained unexplored.

Purpose

We assessed the association between subclinical cardiac dysfunction evaluated by global work index (GWI) and global constructive work (GCW) and long COVID.

Methods

We included 310 COVID-19 patients hospitalized between March and April 2020. All patients were invited to a systematic one-year follow-up, including clinical evaluation, TTE with MW assessment, chest-computed tomography and spirometry. 140 patients completed the follow-up. Normal values for GWI and GCW were defined as 1926±247 mmHg% and 2224±229 mmHg% [3]. The primary endpoint was long COVID, characterized by a cluster of symptoms such as fatigue or dyspnea more than 3 months after the acute infection, without any other explanation.

Results

140 patients (57.1±13.9 years, 90 (64.3%) males) had a mean follow-up of 337.1±34.5 days.The mean values of LVEF, GWI and GCW were 55.2±3.2%, 2105.9±403.3 mmHg% and 2377.8±446.2 mmHg%. 83 (61%) patients had long COVID. No significant differences in terms of comorbidities, clinical evaluation and COVID-19 severity were found between patients with and without long COVID. GCW (2276.7±410.3 vs 2516.5±458.6, p=0.006) and GWI (2008.5±358.9 vs 2242.2±427.0, p=0.003) were the only TTE parameters different between patients with and without long COVID. Multivariable regression analysis showed that GWI <1926 mmHg% (OR 6.095; CI: 2.024–18.355, p=0.001) and GCW <2224 mmHg% (OR 3.205; CI: 1.181–8.694, p=0.022) were the only MW parameters independently associated with long COVID, irrespective of age or the severity of the acute infection, at one year. In a subgroup analysis of 77 patients without previous cardiovascular diseases, long COVID was diagnosed in 45 (58.4%)patients. GWI <1926 mmHg% (OR 8.015; CI: 2.149–29.887, p=0.002) remained independently associated with long COVID at 1 year follow-up.

Conclusions

Long COVID, frequently observed in recovered COVID-19 patients may indicate the presence of subclinical cardiac dysfunction, reflected by a decrease of the left ventricle performance, assessed by GWI and GCW.Long-term follow-up including cardiac screening should be performed in order to identify patients at risk who would benefit from cardiac rehabilitation programs.

Funding Acknowledgement

Type of funding sources: None.

Epicardial adipose tissue thickness in COVID-19 hospitalized patients: a tool for risk stratification

Funding Acknowledgements

Type of funding sources: None.

Background

Coronavirus Disease 2019 (COVID-19) impacted public health systems,overwhelming the intensive care units(ICU)(1).Epicardial adipose tissue (EAT) thickness is a potential novel parameter, which can be assessed using standard computer tomography(CT) for the prediction of worse prognosis in COVID-19(2,3). 

Purpose

We aimed to investigate the association of right ventricle (RV)-EAT thickness with the need for invasive mechanical ventilation,vasopressor support or ICU admission and in-hospital mortality in COVID-19.

Methods

We analyzed 310 consecutive hospitalized patients with confirmed COVID–19 by RT-PCR, between March and April 2020.EAT thickness was assessed during the acute setting of the disease using low dose non-contrast chest CT.Maximal EAT thickness was determined on axial image series at the level of the RV free wall perpendicular to the surface of the heart(Figure 1).Intra- and interobserver reproducibility for the RV-EAT thickness measurement was assessed in 20 random patients after two weeks,by the primary and a second investigator.Data included demographics,clinical evaluation,comorbidities,treatment and complications.Peak lactate dehydrogenase (LDH), neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP) were defined as the highest level during hospitalization.The primary combined endpoint was ICU admission,invasive mechanical ventilation and vasopressor therapy.The secondary outcome was in-hospital mortality. 

Results

Median age was 64 years (interquartile range:53 to 79 years,58.1% males).106(34.2%) patients reached the primary endpoint.In-hospital mortality rate was 19.5% (59 patients).Among patients with combined endpoint,the mortality rate was 35.8% (38 patients).RV-EAT thickness was higher in patients with combined endpoint (5.0 ±2.6 mm versus 4.3 ± 2.2 mm, p = 0.021).Additionally, patients with the composite endpoint had more diabetes mellitus (p = 0.028) and history of coronary artery disease (p = 0.020).Multivariable analysis showed that RV-EAT thickness predicted the primary endpoint,irrespective of risk factors and disease severity (p = 0.014,OR 1.157,95%CI 1.030-1.300; p = 0.031,OR 1.146,95%CI 1.013-1.298,respectively)(Figure 2).Moreover, peak CRP and peak LDH were associated with both endpoints(Figure 2).However, RV-EAT thickness was not predictive for mortality (p = 0.561, OR 1.039, 95%CI 0.913-1.183).

Intraobserver and interobserver reproducibility were good

0.88 (95%CI 0.66-0.95) and 0.86 (95%CI 0.65-0.94).

Conclusion

RV-EAT thickness,easily and rapidly assessed by standard low dose non-contrast chest CT was associated with higher incidence of ICU admission, need for mechanical ventilation and vasopressor support in hospitalized COVID-19 patients.Although no independent association between RV-EAT and in-hospital mortality was found, RV-EAT thickness may serve as surrogate marker of severity, before the rise of inflammatory biomarkers and may reflect inflammation changes within the myocardium in COVID-19. Abstract Figure 1. Examples of right ventricle ep  Abstract Figure 2. Predictors of invasive mechani

Persistent dyspnea 1 year after COVID - 19 infection in apparently healthy subjects: a potential indicator of subclinical cardiac dysfunction

Funding Acknowledgements

Type of funding sources: None.

Introduction

 Coronavirus disease 2019 (COVID-19) impacted healthcare systems worldwide, evolving into a global pandemic(1,2). Recent studies showed the presence of persistent exertional dyspnea or fatigue at one- to three-months follow-up after COVID-19(1,2). However, little is known regarding the mechanisms behind the possible cardiac-related symptoms post COVID-19 at mid- and long- term follow-up.

Purpose

 We investigated the presence of persistent dyspnea one year after the acute phase of COVID-19 in patients without previous cardiovascular or pulmonary disease. Secondly, we analyzed the potential subclinical cardiac dysfunction in these patients, assessed by echocardiography.

Methods

 310 COVID-19 patients were prospectively included between March and April 2020. 143 patients continued the follow-up at 6 months and one year.Patients with a previous history of cardiovascular or respiratory disease were excluded from the analysis.The follow-up consisted in clinical evaluation, and spirometry at 6 and 12 months, chest computed tomography and comprehensive transthoracic echocardiography (TTE) including speckle tracking and myocardial work analysis at one-year follow-up.

Results

 66 patients (mean age 49.64 ± 10.66 years, 37 (67.3%) males)were included in the final analysis.In these patients, TTE parameters were in the normal range, with a mean left ventricle ejection fraction of 56.98 ± 4.64%, mean global longitudinal strain (GLS) of -20.90 ± 2.37%, global constructive work (GCW) of 2381.45 ±463.68mmHg% and global work index (GWI) of 2132.49 ±419.22.Type 1 diastolic dysfunction was observed in 11(16.7%) patients.One (1.5%) patient had type 2 diastolic dysfunction. A normal respiratory pattern was reported in 31(47%) patients at 6 months spirometry evaluation, while 19(28.8%) patients presented pulmonary restriction patterns.23 (34.8%) patients reported exertional dyspnea at one year follow-up. No significant differences regarding clinical, laboratory or imaging findings at baseline were found between patients with and without dyspnea. TTE showed that GLS, GCW and GWI were different between symptomatic and asymptomatic patients (-19.97 ± 2.14 vs. -20.90 ± 2.37,p = 0.039; 2183.14 ± 2483.14 ± 422.42,p = 0.024; 1960.06 ± 396.21 vs 2221.17 ± 407.99, p = 0.030).(Figure 1) Multivariable analysis showed that GCW, GWI and normal respiratory pattern at 6 months were inversely associated with persistent dyspnea (p = 0.038,OR 0.998, 95% CI 0.996-1.000;  p = 0.042, OR 0.998, 95% CI 0.996-1.000;  p = 0.020, OR 0.195, 95% CI 0.049-0.773, respectively).(Figure.2) 

Conclusion

 Persistent exertional dyspnea one year after COVID-19 infection was present in more than a third of apparently healthy patients. GCW and GWI were independently associated with symptoms, suggesting a decrease in myocardial performance in this population. Further studies should focus on the long-term evolution of COVID-19 patients and the occurrence of possible cardiac consequences.

Prognostic value of coronary artery calcium score in hospitalized COVID - 19 patients

Funding Acknowledgements

Type of funding sources: None.

Background

The association of known cardiovascular risk factors with poor prognosis of coronavirus disease 2019 (COVID-19) has been recently emphasized (1). Coronary artery calcium (CAC) score is considered a risk modifier in primary prevention of cardiovascular disease and has shown to improve cardiovascular risk prediction in addition to classical risk factors (2). 

Purpose

We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients.

Methods

We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with a history of coronary artery disease were excluded. Low dose non - contrast chest computed tomography (CT) was performed in all patients at admission. Visual assessment of CAC in every coronary artery was obtained by using an ordinal scoring of 0, 1, 2 or 3 corresponding to absent, mild, moderate or severe CAC score. A total score was calculated by summing the score of each vessel, which was further categorized as 0 (undetectable), 1-3 (mild), 4-5 (moderate) and ≥ 6 (severe). (Figure 1). Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in-hospital treatment, and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined as all - cause mortality, heart failure, acute coronary syndrome, atrial fibrillation and stroke.

Results

Two hundred eighty patients (63.2 ± 16.7 years old, 57.5% male) were included in the analysis. One hundred thirty one (46.7%) patients had a CAC score of 0. MACE rate was 21.8% (61 patients). Multivariable logistic regression showed that the absence of CAC was inversely associated with MACE (OR 0.209, 95% CI 0.052–0.833, p = 0.027), with a negative predictive value of 84.5% (sensitivity 72%, specificity 55%), independent of age, risk factors or disease severity (Figure 2).

Conclusion

The absence of CAC had a high negative predictive value for MACE in patients hospitalized with COVID-19, independent of the presence of cardiac risk factors or disease severity. These findings reinforce the idea that the assessment of CAC could be a useful marker for risk stratification and management of COVID - 19 patients. Future directions should focus on the implementation of CAC score into mid - term and long - term follow - up of this particular population, to provide a more precise and earlier estimation of cardiovascular risk. Abstract Figure.  Abstract Figure.

Prognostic value of coronary artery calcium score in hospitalized COVID-19 patients

Background

The association between known cardiovascular risk factors and poor prognosis of patients diagnosed with coronavirus disease 2019 (COVID-19) has been recently emphasized (1). Coronary artery calcium (CAC) score assessed by computed tomography (CT) is considered a risk modifier in primary prevention of cardiovascular disease and has shown to improve cardiovascular risk prediction in addition to classical risk factors (2).

Purpose

We hypothesized that the absence of CAC might have an additional predictive value for an improved cardiovascular outcome of hospitalized COVID-19 patients.

Methods

We prospectively included 310 consecutive hospitalized patients with COVID-19. Thirty patients with a history of coronary artery disease were excluded.Low dose non-contrast chest CT was performed in all patients at admission. Visual assessment of CAC in every coronary artery was obtained by using an ordinal scoring of 0, 1, 2 or 3 corresponding to absent, mild, moderate or severe CAC score. A total score was calculated by summing the score of each vessel, which was further categorized as 0 (undetectable), 1–3 (mild), 4–5 (moderate) and ≥6 (severe). (Figure 1). Demographics, medical history, clinical characteristics, laboratory findings, imaging data, in–hospital treatment and outcomes were retrospectively analyzed. A composite endpoint of major adverse cardiovascular events (MACE) was defined as all-cause mortality and cardiovascular events (heart failure, myocarditis, arrhythmia, acute coronary syndrome, stroke, pulmonary embolism).

Results

Two-hundred eighty patients (63.2±16.7 years old, 57.5% male) were included in the analysis. One hundred thirty one (46.7%) patients had a CAC score of zero. MACE-rate was 24.2% (68 patients). Multivariate logistic regression showed that the absence of CAC was inversely associated with MACE (OR 0.264, 95% 0.071–0.981, p=0.047), with a negative predictive value (NPV) of 81.4%, sensitivity 70%, specificity 55%, independent of age, risk factors or disease severity (Table 1).

Conclusion

The absence of CAC translated into a low risk for MACE in COVID-19 patients, even in the presence of cardiac risk factors, which reinforces the idea that the assessment of CAC score in COVID-19 patients could be a useful marker for patients risk stratification and management. Future directions should focus on the implementation of CAC score into mid-term and long-term follow-up of this particular population, to provide a more precise and earlier estimation of cardiovascular risk

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1

Troponin T in COVID-19 hospitalized patients: kinetics matter

Background

Coronavirus disease 2019 (COVID-19) pandemic continues to overwhelm healthcare systems worldwide, due to high numbers of critical cases over a short period of time (1,2). Elevated cardiac troponin (cTn), suggestive for myocardial damage, was associated with increased mortality of COVID-19 patients (3,4). However, data addressing the role of cTn in major adverse cardiovascular events (MACE) in COVID-19 patients is scarce.

Objectives

We aimed to assess the role of baseline cTnT and cTnT kinetics in the prediction of MACE and in - hospital mortality in COVID-19 patients. Furthermore, we assessed the association between cTnT kinetics and the need of cardiac imaging evaluation.

Methods

310 patients were included prospectively (age 64.6±16.7 years, 180 (58.1%) males), between March 2020 and April 2020. Clinical data including demographics,medical history,comorbidities,clinical evaluation,laboratory exams,in-hospital treatment,complications and outcomes were collected at admission and during hospitalization by physicians in charge. Two hundred and two patients (65.1%) with at least two cTnT values assessed during hospitalization, at 24–48 hours interval were included in the final analysis. cTnT-values >0.011 micrograms/L were considered elevated, according to hospital laboratory cut-offs. Patients were divided into 3 groups according to cTnT kinetics profile: 1 – variable, 2 – descending and 3 – constant. cTnT slope was defined as the ratio of the cTnT change and the change in time. MACE were considered as the primary endpoint and were composed by all-cause mortality, acute heart failure, acute coronary syndrome, pericarditis, myocarditis, atrial fibrillation or flutter and pulmonary embolism. In-hospital mortality was considered as the secondary endpoint.

Results

Mean hospitalization was 13.9±0.9 days. MACE occurred in 60 patients (29.7%) and in-hospital mortality in 40 (19.8%) patients. Baseline cTnT independently predicted MACE, (p=0.047, HR 1.805, 95% CI 1.009–3.231) and in-hospital mortality (p=0.009, HR 2.322, 95% CI 1.234–4.369) (Figure 1A, 1B). An increased cTnT slope independently predicted in-hospital mortality (p=0.041, HR 1.006, 95% CI 1.000–1.011). Constant cTnT was associated with lower MACE and mortality rates (p=0,000, HR 3.080, 95% CI, 1.914–4.954, p=0.000, HR 2.851. 95% CI 1.828–4.447, respectively) (Figure 1C, 1D, 2). Cardiac imaging evaluation was performed in 8 (16%) patients with constant cTnT, 30 (60%) with variable cTnT, and 12 (24%) with descending cTnT.(p<0.001)

Conclusions

Increased baseline cTnT independently predicted MACE and in-hospital mortality in COVID-19 patients. The magnitude of cTnT increase over time was associated with in-hospital mortality. On the contrary, patients with constant cTnT had lower MACE and in-hospital mortality rates. These finding emphasize the additional role of cTnT testing in COVID-19 patients for risk stratification and improved diagnostic pathway and management

Funding Acknowledgement

Type of funding sources: None.

Long-term evolution of echocardiography parameters in Brugada syndrome patients

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ESC Research Grant

Background

Brugada syndrome is a heritable disorder with a high risk of sudden death. Although being a primary electrical disorder, subtle structural changes have repeatedly been described. Little is known about the long-term structural evolution in Brugada syndrome.

Purpose

We aimed to assess the evolution of echocardiographic parameters in Brugada syndrome and the presence of markers of structural evolution.

Methods

Brugada syndrome patients with minimum two complete transthoracic echocardiographic examinations were included. Clinical data were collected retrospectively. We analyzed all available echocardiographic examinations and assessed the evolution of cardiac parameters over time and its association with patient characteristics. 

Results

The study included 113 Brugada syndrome patients [47 (33-55) years, 59 (52%) female, spontaneous type 1 ECG in 26 (23%)], with a total of 258 echocardiographies, collected over a period of 6.8 (6.6-7.1) years. Proximal and distal right ventricular outflow tract and basal right ventricular diameter dilated at a rate of 0.2 (0.1-0.3) mm/year (p = 0.004), 0.4 (0.3-0.5) mm/year (p &lt; 0.001) and 0.6 (0.4-0.8) mm/year (p &lt; 0.001) respectively (Figure). Left ventricular mechanical dispersion increased from 38 (±11) ms to 42 (±12) ms (p = 0.001). Neither male sex, nor presenting a spontaneous type 1 ECG pattern were associated with worse structural evolution.

Conclusion

We observed progressive right ventricular outflow tract and basal right ventricle dilation and an increasing contractile dyssynchrony in Brugada syndrome, potentially indicating a progressive structural affection. Further research is warranted to unravel underlying mechanisms and possible clinical implications of progressive structural changes in Brugada syndrome.

Abstract Figure.

The sagittal grooves of the middle nasal turbinate determine paradoxical curvatures and bifidities

Background

Paradoxical curvature of the middle nasal turbinate (MT) is a common anatomic variant, usually found and reported on coronal CT slices. However, less attention has been paid to the sagittal groove (SG) which is determining it.

Aim

The study aimed to determine paradoxical curvatures and bifidities in the sagittal groves of middle nasal turbinate.

Material and Method

A retrospective CBCT study on the archived files of 52 adult patients was performed.

Results

Different patterns of MT bifidity were found: (1) unilateral bifid MTs; (2) bifid and trifid MTs and "wandering" single SGs; (3) bilateral bifid middle turbinates and double SGs, (4) bilateral false bifid appearance due to middle and superior turbinates fusion and (5) bifid concha bullosa media. Digital "dissections" of patients' files allowed us to conclude that paradoxical curvature as well as bifidity of MTs relate to the placement and number of the SGs on the MTs. Such SGs were previously documented in prenatal MTs since the 14th week, as well as in pædiatric patients.

Conclusions

It seems reasonable to speculate that paradoxical curvature, as well as bifidity of MT, this later being previously undocumented, are just adult vestiges of the primitive MT morphology. Nevertheless, documentation of the MT morphology should not rely exclusively on coronal CTs, as combined morphologies of that turbinate could occur.

P1275 In-hospital outcome of patients with infective endocarditis: is echocardiography enough?

Background

Despite improvements in medical and surgical therapy, infective endocarditis (IE) remains a deadly disease. Echocardiography is the first-line diagnostic tool. However, data regarding its role in the prognostic assessment of in-hospital clinical outcome of IE are scarce.

Purpose

We sought to assess the role of echocardiography to predict the in-hospital outcome in a large cohort of patients diagnosed with definite IE and its association with clinical presentation and microorganisms.

Methods

We retrospectively included patients from two centers between 2006 and 2018. Transthoracic and transesophageal echocardiography were performed in all patients. The clinical endpoints were in-hospital death, embolic events (cerebrovascular and non-cerebrovascular), shock (septic shock and cardiogenic shock) and cardiac surgery.

Results

183 patients with definite IE (age 68.9 ± 14.2 years old, 68.9% male) were evaluated. Ninety three (50.8%) patients had aortic valve IE and 81 (44.3%) patients presented with mitral valve IE. Twenty three patients had multivalvular IE. The in-hospital mortality rate was 22.4%. Sixty patients (32.8%) had embolic events and 42 (23%) patients developed shock during hospitalization. Surgery was performed in 103 (56.3%) patients. Mitral valve IE on echocardiography was an independent predictor of in-hospital mortality (p = 0.038, OR 0.38, 95% CI 0.15 – 0.94) and aortic valve IE on echocardiography was an independent predictor of embolic events (p = 0.018, OR 0.36, 95% 0.16-0.84). The presence of a new cardiac murmur upon admission was predictive for the need of cardiac surgery (p = 0.042, OR 0.51, 95% CI 0.22- 1.09) and correlated with the severity of valvular regurgitation identified by echocardiography (p = 0.024). Methicillin resistant Staphylococcus aureus (MRSA) as the causative microorganism was an independent predictor for in - hospital mortality and for the development of shock during hospitalization (p = 0.010, OR 0.13 95% CI 0.30 - 0.62 and p = 0.027, OR 6.11, 95% CI 1.22 – 30.37, respectively). No correlation was found between MRSA and echocardiographic parameters.

Conclusion

Mitral valve IE was an independent predictor of in - hospital mortality. Furthermore, aortic valve IE was an independent predictor of embolic events. The presence of a new cardiac murmur was predictive for the need of cardiac surgery and correlated with the severity of valvular regurgitation by echocardiography. Our findings suggest that a thorough physical examination upon admission is required in combination with a comprehensive echocardiographic exam for early identification of patients with IE at high - risk for in-hospital death and complications.

P4661Increased levels of sST2 in patients with mitral annulus disjunction and ventricular arrhythmias

Background

Mitral annulus disjunction (MAD), a basal displacement of the mitral valve annulus, is described as a possible aetiology of sudden cardiac death. Stretch-induced fibrosis in the sub-valvular apparatus has been suggested as the substrate of arrhythmias.

Purpose

We hypothesized that the stretch related biomarker soluble Suppression of Tumorigenicity-2 (sST2) is a marker of ventricular arrhythmias in patients with MAD.

Methods

We included patients with ≥1 mm MAD on cardiac magnetic resonance imaging, and recorded left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE) suggesting papillary muscle fibrosis. Circulating levels of sST2 were assessed by blood sampling. The occurrence of ventricular arrhythmias, defined as aborted cardiac arrest, sustained or non-sustained ventricular tachycardia, was assessed retrospectively.

Results

We included 72 patients with MAD [55 (35–62) years old, 48 (67%) female], of which 22 (31%) had ventricular arrhythmias. Patients with ventricular arrhythmias had lower LVEF (60±6% vs. 63±6%, p=0.04), more prevalent papillary muscle fibrosis [14 (64%) vs. 10 (20%), p<0.001] and higher sST2 levels [31.6±10.1 ng/mL vs. 25.3±9.2 ng/mL, p=0.01] compared to those without. Combining sST2-level, LVEF and papillary muscle fibrosis optimally detected individuals with arrhythmias (area under the curve 0.82, 95% CI 0.73–0.92) and improved the risk model (p<0.05) compared to individual parameters (Figure right panel).

Conclusion

Circulating sST2 levels were higher in patients with MAD and ventricular arrhythmias compared to patients without arrhythmias. Combining sST2, LVEF and LGE may improve risk stratification in patients with MAD.

Acknowledgement/Funding

This work was supported by public grant [203489/030] from the Norwegian Research Council, Oslo, Norway. E. Scheirlynck received an ESC research grant

TREATMENTS OF HEPATITIS C VIRUS LIVER CIRRHOSIS WITH PEGYLAT INTERFERON-RIBAVIRIN AND INTERFERON FREE – COMPARATIVE STUDY

The article describes the adverse effects and efficiency of hepatitis C virus liver cirrhosis treatments available through the National Health Insurance Services, on a population of patients hospitalized at Victor Babes Infectious and Tropical Diseases Hospital, from 2012 to 2016. The population of patients was split into two distinct groups, for which we’ve recorded and comparatively analyzed demographic, clinical and paraclinical characteristics in a database. An evident success was recorded, from the point of view of hitting a clinical SVR index, in the DAA therapy group A, 87% percent compared to 2% in group B for the traditional standard therapy of PegInterferon + Ribavirin. Likewise, the number of adverse effects was lower in Group B versus Group A. Some side effects remained specific to the current cirrhosis treatment, which should be closely monitored.

Immunohistochemical profile of the estrogen and progesterone receptors in mammary benign lesions

The immunohistochemical diagnosis for estrogen and progesterone receptors must be carried out in the tracking of every primary tumor, benign or malign, especially in the case of in situ carcinoma.

MATERIAL AND METHOD

We have studied the expression of estrogen and progesterone receptors in benign lesions, identifying phenotypes depending on the presence of estrogen and progesterone receptors.

RESULTS

The result "positive" or "negative" in the report sent to the doctor is not sufficient, the inclusion of the total score in the case of a positive result, the clone used, the usage / non-usage of antigenic exposure and also the quality control being necessary. The benign mammary lesions occur in the context of a hormonal imbalance, which, in the long run runs the risk of developing a mammary carcinoma.

CONCLUSION

The further study of the hormonal spectrum of those lesions, considered as pre-malignant, may lead to the identification of some groups of hyperplastic lesions, presenting a high risk for developing a mammary cancer.

Morphological variability of the renal artery branching pattern: a brief review and an anatomical study

The segmental branches of the renal artery vary in number and origin. The 1998, Terminologia Anatomica homologates two branches of the renal artery (anterior, posterior) and five segmental arteries: four from the anterior branch and one from the posterior one. The purpose of this study is to evaluate the renal artery branching pattern, the number and origin of the segmental arteries, as well as to review data from similar studies. The study material consisted of 60 formalin-fixed adult kidneys. Dissections and microdissections were performed on the renal arteries and their branches. The branching of the renal artery was prehilar in 81.67% of cases, hilar in 10% and intra-sinusal in 8.33%. The number branches varied as follows: two branches in 42 cases (70%), three branches in 14 cases (23.33%) and four branches in four cases (6.67%). We subsequently analyzed the origin of the segmental arteries and found that in 53% of the cases the segmental arteries arose independently from the renal artery's branches, while in 47% of the cases they derived from common trunks of type I (85%) or II (15%). Type I trunks are those that originate directly from the main renal artery. They divide either into 2-3 segmental branches, or into just 1-2 branches and a smaller trunk (type II). The type II trunks further divide into 2-3 other segmental branches. These common trunks must be taken into account to avoid confusion with the segmental arteries. Knowledge of these variations is useful not only morphologically, but also clinically.

The heterogeneity of craniofacial morphology in Prader-Willi patients

Prader-Willi syndrome is a complex genetic disorder with narrow spectrum of facial phenotypic signs, which make the clinical diagnosis difficult in some cases. There are several reports describing the craniofacial appearance of Prader-Willi patients, but there are only a few cephalometric studies for these patients. In this study were included 18 patients with Prader-Willi syndrome and a control group of 18 subjects of both sexes selected based on specific criteria. The cephalometric radiographs of the patients were taken using the standardized technique with centric teeth in occlusion and lips in relaxed position. Angular, horizontal and linear measurements were analyzed for the study group and for the control group. We established that in Prader-Willi patients, there is a decrease of the majority of parameters but the degree of this reduction varies widely between patients and clinically typical facies not always have smaller measurements which can be found in an unusual facies. Facial dysmorphism in Prader-Willi patients varies a group ranging from miss proportions that do not alter the facial architecture as regard of facial typology, skeletal class and pattern of development to a severe disturbance of those. There is a degree of clinical heterogeneity between subjects with Prader-Willi syndrome on clinical evaluation and cephalometric study confirms the heterogeneity for this patients. Because the identification of smaller dimensions for majority of parameters in children and adults, the possibility of developmental delay or growth retardation delay can be excluded. These findings are important for the orthodontist for optimum timing of orthodontic management of patients with Prader-Willi syndrome.

Macroscopic, mesoscopic and microscopic morphology of the gastric plexus--ontogeny of the celiac ganglion

The vagus trunks, anterior and posterior, and their respective branches control the parasympathetic innervation of the stomach. After giving off a few thin branches, at the lower part of the esophagus and the cardiac region of the stomach, the anterior vagal trunk divides into its main branches: four or five consecutive direct branches which supply the upper part of the lesser curvature; these nerves do not form plexuses and thus, they may be individually dissected. One of the branches is stronger than the others and is called the principal anterior nerve of the lesser curvature (anterior nerve of Latarjet). The present study was conducted on eight fetuses of different gestational age (resulting from spontaneous abortions, without malformations), observing the Romanian laws of professional ethics, and 15 adult cadavers (male and female) whose celiac region was dissected macro- and mesoscopically to reveal both the celiac ganglia and their afferent and efferent vessels. For the microscopic study, we used the Bielschowsky silver staining method. The meso- and macroscopic dissections revealed the anterior and posterior vagal trunks in all the specimens (100%), as well as a rich gastric periarterial plexus. The microscopic samples focused on the ontogeny of the celiac ganglion in various gestational stages.

Cephalometric investigation of Class III dentoalveolar malocclusion

The aim of our study was to identify the most important anatomical landmarks in the cephalometric evaluation of Class III patients and to clarify the morphological characteristics of these cases. A group of 10 Class III orthodontic patients was evaluated in this study. The control group consisted of 10 patients with average occlusion and skeletal characteristics. Digital lateral cephalometric X-rays were performed and different measurements were analyzed. Cephalometric data were evaluated with the CephX specialized software for orthodontic diagnosis and the results were statistically analyzed. The Class III group presented specific characteristics such as prognathic mandible, large gonial angle, short maxillary length, higher lower facial height. These findings can be useful for the diagnosis and treatment planning of orthodontic cases with dental÷keletal anomalies, especially in cases when surgical approach is considered. The surgical decision must be taken after an accurate investigation of the lateral cephalometric parameters.

Chondrosarcoma of the upper end of the femur

Chondrosarcoma is a malignant tumor that produces cartilage matrix. Occurs in the fourth to sixth decades and has a male to female ratio of 2/1. It is most common in the long bones and on the surface of the pelvis. The authors present a case of chondrosarcoma of the upper end of the femur of a 50-year-old female patient who has come in our Department of Orthopedics and Traumatology two month ago, complaining of severe and persistent pain in the left hip joint and presenting limitation of adduction movement, limitation of internal-external rotation movements, and also could not be able to do thigh flexion on the abdomen. The woman presented a four-month history of persistent and severe pain, not assigned at anti-inflammatory drugs. Laboratory tests not had shown any significance. On radiographies and magnetic nuclear resonance the lesion was shown very clear, deciding for biopsy. The tumor had been large surgical excised with safe limits. Histopathology indicated the histological feature as a differentiated chondrosarcoma, grade III. Our patient has started the chemotherapy and radiation.

A comparison regarding antiproliferative action between soy total extract and genistein

The aim of this study is to make a comparison between the action of genistein and total soy extract regarding anticancer action on two different in vivo models: phytobiological test and animal model, and to see which of the two tested samples present a greater antiproliferative effect. Soybean seeds were grounded and a solvent formed of DMSO-ethanol-water in rapport 5-70-25 v/v/v was prepared. The extraction was made using an ultrasonic bath (Falc LCD Series) for 30 minutes, 59 kHz. The solvent was evaporated with a rotary evaporator at 50°C. Genistein was acquired from Extrasynthèse (France), hydroxypropyl-γ-cyclodextrin (HPGCD) from Cyclolab Hungary, 7,12-dimethylbenz[a]anthracene (DMBA), dimethylsulfoxide (DMSO), and 12-O-tetradecanoylphorbol-13-acetate (TPA) from Sigma Aldrich, Germany. Because of the poor water solubility, genistein was prepared in a complex with hydroxypropyl-γ-cyclodextrin in a molar ratio 1:2 by kneading method and total soy extract in a mass ratio 1:4 also by kneading method. Phytobiological test indicated an inhibition index over 50% in case of solutions of concentration between 8-33% in both samples, suggesting a possible antiproliferative action at a superior level. Study on C57BL/6J mice was made on which it was induced cancer with physical agents like DMBA, and it was promoted with TPA. Mice where divided in four groups: Group A - blank group, Group B - mice who received total soy extract, Group C - mice who received genistein, Group D - untreated mice. Results on animal model show that both soy total extract and genistein inhibited the initiation and promotion of chemically-induced skin tumorigenesis, but genistein had a greater success in recovering skin lesions type experimental malignant melanoma.

Human epidermal growth factor receptor 2 (HER2/neu) supraexpression in the mammary tumors

A series of morphological and molecular factors can be used in order to appreciate the prognostic of mammary cancer. A multitude of molecular factors has been investigated in order to identify a prognostic factor, one of the most studied factors being HER2 (human epidermal receptor growth factor). For this purpose, we have carried out an immunohistochemical research, in order to determine the correlation between the presence of morphological factors in tumor formation, different stages of evolution, and the response to therapy. We have correlated HER2 expression with the histological type of carcinomas, the histological differential degree, ER, PR immunohistochemical expression, as well as the available clinical data. Within the studied carcinomas, we have identified a number of 98/156 (62.8%) carcinomas HER2/neu negative, out of which 74/156 (47.4%) did not reveal the presence of HER2/neu and 24/156 (15.4%) have been quantified as being 1+. The HER2/neu supraexpression was encountered in 58/156 (37.17%) cases: in 34/156 (21.8%) cases the immunostaining was interpreted as being 2+ and in 24/156 (15.4%) cases it was interpreted as being 3+. HER2/neu supraexpression should be routinely determined through immunohistochemical methods in all primary mammary tumors, especially in those poorly differentiated.

Anatomical variations of the hepatic portal vein associated with incomplete celiac trunk

An association of two anatomical variations was revealed in a 65-year-old male cadaver: the first variation concerns the forming of the trunk of the hepatic portal vein, while the second concerns the branches of the celiac trunk. In this case, the inferior and superior mesenteric veins form a common trunk that is further united with the splenic vein and gives rise to the hepatic portal vein. At the same time, the existence of an incomplete (branched) celiac trunk was revealed, the hepatosplenic trunk from which the common hepatic artery and the splenic artery arise; the left gastric artery arises separately at 0.5 cm superolaterally from the origin of the celiac trunk. Familiarity with this anatomical variation provides useful information for abdominal surgery procedures.

Diagnostic value of a negative single color duplex ultrasound in deep vein thrombosis suspicion during pregnancy

OBJECTIVE

to determine whether a negative single complete ultrasound (US) of the lower limbs veins is a safe and accurate diagnostic method to rule out deep venous thrombosis (DVT) in pregnancy.

MATERIAL AND METHODS

We performed a prospective study on 87 consecutive pregnant women with clinical suspicion of DVT in "Dr. D. Popescu" Maternity, Timişoara, between January 2007 and December 2009. All cases were investigated by color duplex ultrasound. Those who were negative but with high clinical probability of DVT underwent MR venography, the rest with negative US findings did not received anticoagulant therapy and US was repeated after seven days. All were instructed about the signs and symptoms of DVT and asked to return at six weeks postpartum when they were questioned if presented any.

RESULTS

from the 87 women 30 (34.48%) were found positive and two (2.29%) had a high clinical suspicion of DVT. 55 (63.21%) with negative findings repeated the US exam after 7 days which remained negative. Only 43 (78.18%) returned for the 6 weeks postpartum visit and none of them experienced any thromboembolic event during follow-up.

CONCLUSIONS

A single complete color duplex ultrasonography of lower limbs veins appears to be a safe method to rule out the diagnosis of deep venous thrombosis in pregnant women and if negative is safe to withhold heparin therapy.

Altered anatomy in a case with a buccally impacted maxillary canine tooth

Bilateral dissections of maxilla were performed in a human adult cadaver head, male, aged 53 years. After the en block removal of the soft tissues in the oral and infraorbital regions, the antero-lateral surface of maxilla was exposed and also the vestibular aspect of the upper alveolar process. An oblique labially impacted right upper canine was evidenced, completely submucosal: its apex was tangent to the maxillary sinus floor, while the superior side of the apical part of the root was in close relation with the floor of the laterally expanded inferior nasal meatus. Superior and adjacent to the neck of that impacted canine a follicular cyst was evidenced and the antral wall presented distally to the apex of the impacted canine a dehiscent area, where the antral mucosa was only covered by an incomplete thin bony lamella. The incisors on that side were present but no resorption was identified at their level. Within the anterior border of the wall separating the maxillary sinus, small, and the inferior nasal meatus, the nerve for that impacted canine was coursing; the nerves for the upper incisors were initially located within the antero-lateral wall of the inferior nasal meatus. Although small, the maxillary sinus presented a supero-medial recess above the enlarged inferior nasal meatus and lateral to the normally-sized middle nasal meatus.

The spermatic ganglion in humans: an anatomical update

The male gonad receives nerve fibers from the autonomic ganglionic system. By the present study, we aimed to bring detailed evidences, topographic and structural, on the spermatic ganglia (SG) in humans, as suppliers of autonomic fibers for the testis. We performed retroperitoneal dissections in 25 formalin-fixed human male adult cadavers. Histology used the Hematoxylin-Eosin and we also used Bielschowsky silver stains. Immunohistochemistry used antibodies for tyrosine hydroxylase. In 20÷10 specimens, we identified left spermatic ganglia (LSG) at the aortic origin of the left testicular artery (LTA); in five specimens the LTA left the renal artery but LSG were juxtaposed on the aorta at about the level of origin of a normal LTA. In 15÷25 cadavers, there were right spermatic ganglia (RSG) related to the right testicular artery (RTA) that in 12 cadavers had a precaval disposition. A specimen with retrocaval RTA presented an inferior renal ganglion, supplying both the renal and the RTA. The SG presented renal, lumbar and intermesenteric roots. The inferior branch of the SG connected it to the inferior mesenteric plexus while its infero-lateral branch adjoined the testicular artery. Microscopy confirmed the SG as nervous ganglia and the respective neuronal populations were tyrosine hydroxylase positive, allowing us to consider these ganglia as sympathetic. We bring here the first-time evidence of the SG topography and cathecolaminergic nature in humans; this ganglion may influence the male gonad via the inferior mesenteric plexus and via the vascular path of the testicular artery.

Preoperative ultrasonography as a mean of predicting the conversion of mini cholecystectomy into classic cholecystectomy

Cholecystectomy is considered to be the treatment of choice in symptomatic biliary lithiasis. Lately, due to medical progress, classic cholecystectomy has been gradually replaced by laparoscopic cholecystectomy and by mini cholecystectomy. Therefore, it is very important to determine certain preoperative factors which might predict the conversion of mini cholecystectomy (MC) into classic cholecystectomy (CC).

MATERIAL AND METHOD

The possibility of selecting high-risk conversion patients has important clinical implications, both for the surgeon and for the patient. Differentiating preoperative risk allows the surgeon to inform the patient about a high conversion risk to CC, and about the ensuing consequences: longer hospitalization period, longer postoperative recovery, greater costs. All the patients were examined by ultrasonography. The tests recorded six parameters: the diameter of the biliary duct (mm), the number of calculi, the diameter of the largest calculus (mm), the contracted aspect of the gallbladder, the distance between the tegument and the gallbladder fundus (cm), the distance between the tegument and the cystic duct (cm). All the variables were introduced into an initial model, which was checked using the colinearity method and significant observations, and subsequently reduced by eliminating insignificant predictive factors, revealed by Wald tests.

RESULTS

The significant predictive conversion factors to CC, quantified on the basis of regression analysis, are: age > 70, calculus with a diameter > 20 mm, biliary duct with a diameter > 6 mm, contracted gallbladder, distance between the tegument and gallbladder fundus > 7.2 cm, distance between the tegument and cystic duct > 17.1 cm.

CONCLUSION

Being a procedure that can be carried out on an outpatient basis and with rather low costs, ultrasonography plays a very important role in the preoperative prediction of converting MC to CC.

Compression and walking compared with bed rest in the treatment of proximal deep venous thrombosis during pregnancy

The purpose was to evaluate the benefits of compression and early mobilization in comparison with compression and bed rest in the acute stage of proximal deep venous thrombosis (DVT) in pregnant women.

METHOD

Thirty-two consecutive pregnant women with proximal DVT diagnosed by color duplex ultrasound were divided into two groups. Group A consisted of 15 patients who received elastic compression bandages and early mobilization, and group B including 17 patients with compression bandages and bed rest. All patients received heparin therapy. The clinical characteristics of the two groups were comparable. We assessed the reduction of subjective pain daily with a Visual Analogue Scale (VAS) and the objective pain using Lowenberg test, the reduction of edema was recorded initially and on day 2, 4 and 7. Ultrasound was repeated after seven days.

RESULTS

Resolution of subjective pain was faster during the first three days and near absent at the end of the study period in group A (p < 0.001). Objective pain seriously reduced in group A during the observation period while in group B decreased during the first three days almost by half but remained constantly present over the remaining days (p < 0.001). The same was true for the measurement of leg circumference (p < 0.05). There was no pulmonary embolism and progression of thrombus diameter.

CONCLUSION

Pregnant women with proximal deep vein thrombosis may benefit from leg compression and early mobilization for a faster resolution of the signs and symptoms and this method does not seem to be an additional risk factor for pulmonary embolism.

An anatomical study of the thyroid arteries anastomoses

Collateral circles in neck own a particular importance in compensating the symptoms due to the unilateral occlusion of the common carotid artery. In addition, surgical procedures at the level of the thyroid gland and larynx raise the problem of a good knowledge of the arterial morphology at those levels. The present study was designed to investigate the possible morphologies of the thyroid arteries anastomoses. For the present study, 20 human adult specimens were dissected, 15 in cadavers and other five on laryngeal specimens drawn at autopsies. Dissections evidenced bilateral and unilateral anastomoses of the thyroid arteries classified as extra laryngeal and intra laryngeal, the former constantly being represented by the supra isthmic arcade made by the superior thyroid arteries and the retrolobar anastomoses of the superior and inferior thyroid arteries. Constant intra laryngeal anastomoses were those of the superior laryngeal artery with the inferior laryngeal artery and, respectively, with the cricothyroid artery. The analogy with the cardiac collateral circulation, the thyroid arteries anastomoses may be classified as intrathyroid and interthyroid arterial anastomoses. We also present in this paper a rare variant that we did not find described in the references we investigated, represented by the paramedian perilaryngeal anastomose of the suprahyoid branch emerged from the lingual artery and the cricothyroid artery sent by the superior thyroid artery. The thyroid arteries supply the collateral circles in neck; the clinicians must be aware of their possible functional value and the surgeons must take into account these arterial morphologies while acting on the neck viscera.

The maxillary recess of the sphenoid sinus

The most studied recess of the sphenoid sinus seems to be the lateral one, which is highly variable. Less attention seems to be paid to the maxillary recess, extending anterior, inferior and lateral towards the maxillary sinus. Twenty patients were referred for CT of the paranasal sinuses (axial CT), during a 3-month period. After examining the morphology of the sphenoid sinuses, the authors found bilateral maxillary recesses in one patient. On either side, the maxillary recess of the sphenoid sinus was directed anterior and lateral, being separated from the maxillary sinus by a distinctive bony wall; the longitudinal size of these recesses was 1.36 cm, on the left, and 1.22 cm, on the right. As it becomes part of the antero-medial wall of the pterygopalatine fossa, the maxillary recess of the sphenoid sinus should be evaluated prior to the endoscopic endonasal approach of the fossa; the detail becomes more relevant when one takes into account the fact that in our case, on the right side, the CT-scan suggested that the sphenopalatine artery could traverse directly through the maxillary recess. Therefore, such a maxillary recess of the sphenoid sinus seems to be anatomically located in the situs of the orbital process of the palatine bone and thus, it assumes the respective topography. The differential diagnosis with a Haller cell is relevant--the surgical procedures that approach a Haller cell could lead to a misdiagnosed maxillary recess of the sphenoid sinus into the middle nasal meatus. This aspect determined us to consider the maxillary recess of the sphenoid sinus as a false Haller cell and to claim the imperative of a CT-evaluation performed prior to interventions.

Utero-adnexal damage in septic abortion. Histopathological study on 91 cases

Septic abortion represents the main causes of abortion-induced maternal death. Hysterectomy may represent a beneficial therapeutic solution for septic abortion, nevertheless with irreversible effects on a woman's reproductive condition. The study analyzes the anatomopathological damage found in ninety-one patients hospitalized for septic abortion. The patients were admitted to the "Dr. D. Popescu" Clinical Hospital, Timisoara, between 1980-1989 and 1999-2008; hysterectomy was performed in all the cases to eliminate uterine sepsis responsible for the emerging complications.

Helicobacter pylori infection and gastric MALTomas: an up-to-date and therapy highlight

During the last 20 years Helicobacter pylori (Hp) has been, undoubtly, the star of gastroenterology and microbiology, so much to deserve the "Nobel prize 2005" for biology and medicine to its discoverers. More recently, an increased interest arised on Hp and its linkages with other medical fi elds such as immunology, surgery and dentistry. The outcome of the pathologies due to such bacterium is dependent on many factors, including bacterial genotype, host physiology and genetics, and environmental factors such as diet. In spite of its clear involvement in some pathologies like acute and chronic gastritis, peptic ulcer and gastric cancer, very little is known about another pathology recently proved to be closely associated to the infection by Hp: the gastric MALToma, which account for 7% of all newly diagnosed non-Hodgkin's lymphoma. The chronic infection of the gastric mucosa from Helicobacter pylori primes a complex pathogenic process which could determine the onset of the gastric cancer through some intermediary steps. On these bases, in 1994, the International Agency for Cancer Research (IARC) defined this bacterium a "class I carcinogenic agent" for gastric cancer. The MALT lymphomas are the most frequent lymphoid neoplasms of the digestive tract; we can also observe other and more rare lymphomatous tumours with specific clinical patterns, like the T-lymphoma associated with lymphomatous polyposis and enteropathy. The development of gastric lymphomas is usually preceded by the acquisition of lymphatic tissue, after inflammatory stimuli and particularly after the infection from Hp, which organizes itself with the characteristics of the MALT. Recently, a number of papers have highlighted the remarkable efficacy of Hp eradicating therapy in patients with low-grade MALT lymphoma of the stomach without other modalities, e.g. surgery and systemic chemotherapy. The aim of this study is to be helpful for a comprehensive understanding the possible connections between Hp and gastric MALT lymphoma, evaluating the best therapy strategies, surgical and non surgical, actually available for its treatment.

Our experience in Helicobacter pylori infection and gastric MALToma

OBJECTIVE

A number of recent studies have expanded our understanding of Helicobacter pylori (Hp) infection and of the pathogenesis of MALT lymphoma. The purpose of this paper is to perform a retrospective analysis of the clinical characteristics of gastric MALT lymphoma and its relationship with H. pylori infection in authors' experience.

MATERIALS AND METHODS

We report nineteen patients observed during 10 years, presenting with gastric MALTomas at any stage. The staging classification and the presence of H. pylori infection have been assessed, and the chosen therapy also.

RESULTS

The most part of our patients underwent surgery, still now resulting the most effective therapy. None of the patients had eradicating therapy due to their poor compliance and because the most part of cases were observed before the time of clinical validation of such treatment.

CONCLUSIONS

In our series, surgery was effective for treatment of gastric MALT lymphomas. Surgery and chemotherapy remain, in accord with literature data, the best treatment for gastric MALTomas. Hence, because Hp may play a role in the development of such pathology in certain patients, antibiotic treatment for Hp eradication should not be discouraged in these patients, especially in them with low grade gastric MALT lymphomas. In fact, the failure of this therapy will not modify either survival or later recourse to surgical and/or radio- and chemotherapy.

The adult coeliac ganglion: a morphologic study

The coeliac plexus is located on the sides of the coeliac trunk and nearby the origins of the superior mesenteric and renal arteries. Afferent branches get to this plexus from the vagus nerve, splanchnic nerves and the right phrenic nerve; efferents leave for viscera through periarterial plexuses and the retroportal nerves. The coeliac plexus ganglia - coeliac, superior mesenteric, aorticorenal - are prevertebral ganglia that receive the preganglionic sympathetic fibers brought by the splanchnic nerves from the thoracic spinal cord. For studying the adult coeliac ganglia dissections were performed then pieces were drawn for silver staining by the method of Bielschowsky on blocks and HE stains. The adult coeliac ganglia consist of well-defined ganglionic subunits, of a varying number of neurons with somata ranging from 14 to 48 microns and characteristically involved in extensive dendritic fields. Individual degrees of coalescence may justify the macroscopic appearance of the coeliac ganglion but its structure keeps distinctive subunits.

Benign gastric tumors. Anatomopathological aspects of the gastric wall

Benign tumours of the stomach are quite rare and are discovered accidentally during routine endoscopy or necroscopy. They represent less than 20 per cent of gastric tumours, and their clinical picture consists in pain, bleeding and antropyloric stenosis.

MATERIAL AND METHOD

The cases were studied retrospectively over a 10-year period (1995 - 2005) and consist of patients that underwent needle biopsies and surgery in the Timiş County Hospital.

RESULTS

Benign tumoural pathology was present in 73 cases, 43 (58.9%) in women, 30 (42.1%) in men. The age of the patients ranged between 36-88 years in women, and 31-87 years in men. The material for study consisted in gastric resection pieces and specimens of needle biopsy. In order to establish the histopathological diagnosis and to define the specific type of the damage, the first specimens were stained using morphological methods. Routine morphological investigation was carried out through Hematoxylin-Eosine staining, which was the standard technique used for all the cases.

Thromboembolic risk after knee endoprosthesis

Thromboembolic complications are the most frequent associated pathologies after knee replacement. The secondary deep vein thrombosis in the knee arthroplasty is often low symptomatic or asymptomatic and, sometime, it could lead to fatal pulmonary embolism. This is the main purpose recommending an antithrombotic prophylaxis. In this study 214 patients operated for knee arthroplasty and receiving low molecular heparin therapy were enrolled. They were clinically and echo/radiologically monitored for thromboembolic and/or hemorrhagic complications on the 2nd, 7th, 14th and 45th day from surgery. Results showed that only 45% of the cases developed DVT (deep vein thrombosis) out of which 17% could be objectively verified by ultrasonography and phlebography. In only one case massive pulmonary embolism with fatal evolution was discovered. It was not found any major bleeding except in four cases in which local haematomas were discovered (most probably related to anticoagulant treatment). This study concluded that the administration of low molecular weight heparin after knee arthroplasty significantly reduces the risks of thromboembolism in conditions where the increase of hemorrhagic complications doesn't result statistically significant.

Former and present aspects in neuro-skull architecture

The classical authors considered the functional resistance of the neuro-skull to consist of arcs at the arch level, rafters at the base and pillars at the joint of the arcs and rafters, those last also connecting the neuro-skull framework and that of the viscero-skull. The new outlooks replace the term pillar with that of resistance node and assemble the arcs and rafters within common structures, named resistance belts. The belts are: one in transversal, three sagittal, two in frontal plane and two oblique positions. At the intersection of the belts, the resistance nodes are placed.

The value of radio-imaging methods in the diagnosis of chest wall metastases

The aim of the study was to reveal the value of radio-imaging methods in the diagnostic assessment of chest wall metastases. We retrospectively reviewed 48 cases of chest wall metastases examined clinically, radiologically, by ultrasound, CT-scan and MRI. All cases were histologically assessed by surgical biopsies. Plain chest radiography (X-ray) was in all cases a prerequisite for any evaluation of the chest wall being of great value in demonstration of the displaced rib fractures, localized bony destruction and the detection of most soft tissue lesions. The ultrasound examination (US) allowed real time analysis and thus the functional imaging of the chest wall metastases with special interest in vascular impairment being limited by relatively small field of view with more difficulties in anatomical orientation. With involvement of bone marrow and spinal cord, MRI became the most sensitive and the most specific imaging method, successfully diagnosing intramedullar lesions in three cases. In the detection of chest wall infiltration by primary malignancies from the lung, pleura, pericardium, breast and spinal cord we preferred the CT-scan, which revealed the presence of the lesions in 29 cases with typically obtuse angles against the adjacent chest wall and pleura. In the imaging evaluation of malignant lymphoma the CT-scan demonstrated chest wall extension in five cases. CT-scan and MRI revealed chest wall localization for distant metastases in 14 cases. The imaging methods clearly showed the number, the extent, the anatomic reports and the aggressive characteristics of chest wall metastases being of great value in the decision of adequate therapy.

Anatomic and pathological aspects in the pathology of malignant gastric tumors

Efforts in perfecting the methods of early diagnosis, in trying to assess premalignant conditions, and in properly staging malignant tumors are still in trend. The geographic area around Timişoara (Banat Region) is situated on the first place in the country as far as the gastric location of cancer is concerned. The authors aimed to deal with the initial stage in the development of gastric cancer, a stage which has been oncologically termed "precancerous damage", and with the neoplastic invasion of the gastric wall. The present paper is based on the 1995-2005 statistics of the IInd Surgical Department of the Timişoara County Hospital, the study group consisting of 802 patients admitted for gastric disorders, 522 of which being later diagnosed with a tumoral pathology. Routine morphological tests were conducted on biopsy pieces dye stained with Hematoxylin-Eosin, standard technique, the van Gieson trichromic staining, the Giemsa staining, the AA-PAS staining and the immunoreaction methods. The age for gastric tumoral pathology ranged between 36-88 years in females, and 31-87 years in males. Most gastric carcinomas are adenocarcinoma, 404 (90%) cases--could be classified as follows: 167 cases of tubular adenocarcinoma; 39 cases of papillary adenocarcinoma; 24 cases of mucinous or colloid adenocarcinoma; 141 "signet ring"-cell carcinoma; 33 cases of undifferentiated carcinoma. Currently there is an increase of the incidence of the "diffuse"-type in women and at younger ages. Attention should be given to precancerous conditions; there was a large number of premalignant or potentially malignant gastric damage: atrophic chronic gastritis (54 cases), intestinal metaplasia (104 cases), and gastric dysplasia (104 cases).

Correlations between anomalies of jugular veins and areas of vascular drainage of head and neck

The study conducted on 60 human cadavers preserved in formalin, in the Anatomy Laboratory of the "Victor Babes" University of Medicine and Pharmacy Timisoara, during 2000-2006, observed the internal and external jugular veins from the point of view of their origin, course and affluents. The morphological variability of the jugular veins (external jugular that receives as affluents the facial and lingual veins and drains into the internal jugular, draining the latter's territory--3.33%; internal jugular that receives the lingual, upper thyroid and facial veins, independent--13.33%, via the linguofacial trunk--50%, and via thyrolinguofacial trunk--33.33%) made possible the correlation of these anomalies with disorders in the ontogenetic development of the veins of the neck. Knowing the variants of origin, course and drainage area of jugular veins is important not only for the anatomist but also for the surgeon operating at this level.

Former and present aspects in upper level of viscero-skull architecture

The classical reference material describes two resistance arcs, the maxillary arc and the mandibulary arc, from which the masticatory forces direct themselves towards the functional resistance structures of the viscero-skull. From the maxillary arc, three pairs of vertical pillars ascend (that is fronto-nasal, zygomatic and pterygoid). Certain authors add to these a median arc--the bony part of the nasal septum. From the mandibulary arc, the lines of force make for the cordyle and the coronoid process of the mandible. In terms of the new outlook, at the upper level of the viscero-skull, there are five vertical blades described: one median, two medial and two lateral, those last including the pillars from the classical descriptions. These vertical blades are joined by three horizontal laminae: the upper one, the middle one--interrupted by the median line and the lower one--included in the concavity of the maxillary arc. These structures of laminae induce the formation of some resistance cylinders and cones. Within the lower level of the viscero-skull there are three mandibulary arcs described: the upper one (the classic mandibulary arc), the middle one (with an oblique direction) and the lower one.

Variation of cephalometric parameters in peri-puberty cephalometric aspects of sexual dymorphism

The data regarding the global and segmental growth and development of the child are useful in pluri-disciplinary studies which view the human body as an entity where the biological aspects (both the normal and the pathological ones) interlace with the socio-cultural ones, thus offering the possibility to any specialist in the field of humanities and morphological studies to cover a wide range in contemporary anthropological research. The development of the skull takes place in two active stages separated by a stage of relative quiet during the age of seven and puberty when the skull has a dolicocephalic aspect. During the second stage of active growth (which starts with puberty) there is a transversal growth of the basis of the cranium followed by an anteroposterior growth. The degree of gender-related differences as far as the dimensions and proportions of the skull are concerned vary greatly according to race, therefore we may say that general ethnic differences are more pronounced than gender-related ones.

The importance of CT scan in the clinical-morphological and anatomical assessment of mediastinal lymphomas

The study points out the value of CT scan in the investigative algorithm of mediastinal lymphomas. Thirty-eight cases of mediastinal malignant lymphoma were evaluated in a statistical retrospective study. CT scan was used for staging the disease in 25 cases and for post-therapeutic evaluation in the other 13 cases. The CT scan for staging purpose has shown the presence of significant isolated and confluent enlarged lymph nodes in the mediastinum in all 25 cases. Post-therapeutic evaluation of the 13 cases examined by CT showed six remissions, five reductions of lymph node masses and two extra nodal extensions. CT scan is the imaging method of choice in the clinico-morphological and anatomical assessment of mediastinal lymphomas.

Correlations between the colic branches of the mesenteric arteries and the vascular territories of the colon

The study, done on 100 corpses from the dissection rooms of anatomy laboratory, hinted the morphological variability of the colic arteries and their territories. Morphological variability of the colic branches derived from the mesenteric arteries (superior right colic artery -- 98%; middle right colic artery -- 88%; inferior right colic artery -- 100%; middle colic artery - 36%; superior left colic artery -- 100%; middle left colic artery -- 50%; inferior left colic artery -- 100%) allows us to give out a morphogenetic supposition related their ramification and number. Analyze of the results guide us to a tentative of setting down the vascular territories of the colon. In the beginning were established the territories of the mesenteric arteries (superior and inferior) and after that, were marked the subterritories for each colic artery. Establishing the vascular territories of the colic arteries have not only anatomical importance but also a surgical one, been known the difficult postoperatory colon's revitalization.

The construction of human body--from model to reality

The human body building represented a complex research topic for the scientist in the most diverse domains. Although their interests and reasons were different, the goal was always the same: establishing a relation to verify the ratio between the dimensions of the constituent segments It appears that the mystery was solved out in the XIX-th century by Adolf Zeising, a German, who, using the statistic calculus, defined the division of a segment by the gold section. This purely mathematic logic confirms the human body's integration in proportion to the finest segments, thus providing the technical instrument of building a fully harmonious human body. The present study aims to compare the ideal, the calculated perfection to the reality, namely the theoretically obtained values to the average values of an 18-year-old male. It appears that the differences refer especially to the limbs; both the superior ones and the inferior ones being longer comparing to the ideal pattern while the bust is shorter and broader.

Preliminary results of orthotopic en bloc uterus and ovary transplantation in the laboratory rat

A new experimental model of whole uterus and ovary transplantation in the laboratory rat was achieved. The main goals of this study were concerned with developing and standardizing the microsurgical technique of uterus transplantation in rats and observing the particular cellular patterns of acute allograft rejection at the level of the transplanted graft. Thirty-five orthotopic uterus transplantations were performed. An additional 20 female rats were used for dissection training sessions. Recipients were euthanasied at 24 hours, 48 hours and 72 hours. Immediate postoperative survival was 100%. Patency of the microsurgical anastomoses, checked at 24 hours, was 100%. At 72 hours thrombosis occurred in all anastomoses. The explanted uterine grafts were fixed in formaline and analyzed under light microscopy and specific imunohistochemical analysis. The acute allograft rejection has a particular cellular reaction pattern, probably due to the unique diversity of the tissues that compose it. Inflammatory cells like LTCD8+, LBCD20+ and mastocytes tend to agglomerate in the vicinity of nervous and vascular structures, showing no signs of lymphoid tissue disposition like in typical acute rejection. Uterus transplantation in rats has proven to be a valid experiment that allows us to express hope that by further research on transplantation of the uterus gynecologists will be able to introduce an adapted technique in the treatment of specific cases of human female infertility.

[Experimental model of orthotopic uterus transplantation in the laboratory rat]

This study develops and standardizes an experimental model of uterus transplantation in the laboratory rat. Twelve orthotropic uterus transplantation were done. Animals were randomized in three groups. Postoperative survival was 100% and 75% at 72 hours. Recipients were euthanased at 24 hours, 48 hours and 72 hours and the grafts were harvested. Patency of the microsurgical anastomoses was 100% at 24 hours, 63% at 48 hours and 0% at 72 hours. The explanted uterine grafts were fixed in formalize and analyzed under light microscopy. The acute allograft rejection starts during the second day after transplantation. In additional dissection, anatomy of the pelvic region with regard to the topography of the uterus, tube and ovarian vessels was studied. This model of uterus transplantation in rats proposes a standardized tool for further research regarding cellular mechanisms of the acute allograft rejection and, for future, pregnancy of the transplanted uterus.