心血管疾患と診断

Introduction: To our knowledge, there has been no conclusive evidence so far to guide the choice between impella and intra-aortic balloon pump (IABP) in patients with ischemic cardiogenic shock. Using the 2016 National Inpatient Sample (NIS), this work aims to compare in-hospital outcomes among patients presenting with ischemic cardiogenic shock treated without mechanical support, with impella, or with IABP.

Methods: Data was obtained from the 2016 NIS database. The primary outcome was in-patient mortality. Secondary outcomes were hospital length of stay and total hospital charge. A series of univariate and multivariate regression analyses were conducted on STATA 15.1.

Results: In this dataset, 11710 observations met the criteria of adults, acute ischemia and cardiogenic shock. Among these, 7727 were treated without mechanical support, 649 were treated with impella, and 3,334 were treated with IABP. Patients treated with impella had higher inpatient mortality (OR 1.75; 95% CI 1.46 - 2.11), whereas patient treated with IABP had lower inpatient mortality (OR 0.77; 95% CI 0.70 - 0.85). In addition, compared with no mechanical support and IABP, the use of impella was associated with higher hospital cost (β1=198269, p<0.001). Furthermore, the use of impella was not associated with change in length of stay when compared to no mechanical support. IABP was associated with longer length of stay (β1=1.53, p<0.001).

Conclusion: In conclusion, among patients was ischemic cardiogenic shock, compared with no mechanical support, inpatient mortality was higher with impella and lower with IABP use. In addition, impella use was associated with increase hospital cost without change in hospital length of stay. Lastly, IABP was associated with increased length of stay. Despite the limitations of the NIS dataset, including selection bias, this work should prompt further research to validate the use impella.

Objective: LBBB is not a rare complication after TAVI. Available data on the reversibility of new-onset left bundle branch block (LBBB) after transcatheter aortic valve replacement (TAVR) in relation to valve type and other factors remain controversial. We aimed to find out factors that might be responsible for the reversibility of this complication post implantation.

Method: In this retrospective observational study, we reviewed all TAVI patients operated in our institute from July 2014 to July 2019. We included patients who developed new LBBB post TAVI and excluded patients with preexisting pacemaker, preoperative LBBB and patients requiring Permanent pacemaker post-operatively during the index hospitalization. Twelve-lead electrocardiograms at baseline, immediately after TAVI and at 30-days follow-up were evaluated. Disappearance of the LBBB in follow-up was analyzed to find out patient and procedural characteristics. Out of 1247 patients operated in this 5 years period, 299 (24%) patients developed new onset LBBB. 77 patients (26%) and 179 patients (59.8%) of these patients had complete resolution before discharge and at the 30-day follow-up respectively. 40.1% showed persistent LBBB after 30 days without the need for pacemaker due to atrioventricular block during the follow up. Only one patient received a CRT pacemaker due to persistent LBBB and severely reduced ejection fraction.

Results: Reversibility of LBBB was documented in 14.3% of patients who received Sapien balloon expandable valve, in 0% of patients with Core valves and in 66.7% patients with of Symetis valve. No patients had additional conduction abnormalities at 30-day follow-up. The patients with irreversible LBBB had a lower ejection fraction (37.5% ± 7.8 vs. 69% ± 4.7, p-value 0.04), and higher proBNP (2728 ± 112 vs. 495 ± 122, p-value 0.03). Septal hypertrophy was more prominent in patients with irreversible LBBB (14 ± 2.6 vs. 13 ± 1.4, p-value 0.004). Annulus diameter was significantly larger in patients with irreversible LBBB (25 ± 1.5 mm vs. 22.5 ± 0.5 mm, p-value 0.001). Preimplantation valvoplasty OR (95% CI): 1.3 (1.1-1.9); p-value 0.04, Sapien valve: 2 (1.1-4); p-value 0.036 were predictive for persistence of LBBB. However, Symetis valve or (95% CI): 0.5 (0.2-0.8); p-value 0.02 and LAHB 0.3 (0.1-0.6); p-value 0.001 were independent predictors of reversible LBBB.

Conclusion: New onset LBBB after self-expandable valves has a reversible nature and resolve probably by 30 day follow-up with a relevant tendency to stabilization especially in patients without balloon predilataion and in patients who received Symetis valve.

Background: The coexistence of coronary heart disease and consequently acute myocardial infarction with persistent ST-segment elevation (STEMI) and glucose metabolism disorders is well known. Still, glucose metabolism disorders in the STEMI population are not fully understood. We know that diabetes mellitus (DM) is a factor disabling the function of microcirculation, which in turn may affect the outcome of a coronary intervention.

Aim: To evaluate the dynamics of ST-segment changes in ECG (electrocardiogram) in STEMI (ST-segment elevation myocardial infarction) patients with co-existing hyperglycaemia compared to those with normoglycaemia treated with percutaneous coronary intervention (PCI), as well as to determine this parameter in the assessment of reperfusion effectiveness.

Method: The study included 92 patients with the diagnosis of STEMI enrolled in the PCI treatment and was divided into groups based on the glucose levels on admission (reactive hyperglycaemia): a group with higher glucose levels on admission (Glc ≥ 7.8 mmol/L, n=46), a group with lower glucose levels on admission (Glc <7.8 mmol/L, n=46) and into groups based on the concentration of HbA1c : a group with a lower HbA1c level (<6.5% (48 mmol/mol), n=71) and a group with a higher level (≥ 6.5%, n=21).

Results: On admission there were no significant differences in terms of clinical characteristics between the groups of patients with normoglycemia and reactive hyperglycaemia. After PCI the patients with normoglycemia had significantly higher (p=0.021) dynamics of changes in the resolution of ST-segment elevation in ECG expressed in an indicator of sum STR (resolution of ST elevation). A degree of resolution of ST elevation in ECG was significantly (p=0.021) dependent on the level of blood glucose - the higher the blood glucose level, the weaker resolution. The patients with the glucose levels ≥ 7.8 mmol/L had significantly higher levels of CK and CK-MB during the first 48 hours of hospitalization. There was a statistically significant difference in the mean length of hospitalization between individuals from the group with lower and higher blood glucose levels on admission (p=0.028). A 4-month follow-up revealed no significant difference in the incidence of MACE in the study groups (p=0.063). A 4-year follow-up of patients with higher levels of blood glucose on admission showed a higher incidence of MACE (p=0.01). The patients with HbA1c ≥ 6.5% were older (p=0.004), had a greater BMI >30 kg/m2 (p=0.019) and the lower ejection fraction of the left ventricle (p=0.003) compared to those with the HbA1c levels <6.5%. The incidence of MACE in 4- month and 4-year follow-up was comparable in the study population.

Conclusion: Myocardial reperfusion after primary angioplasty in acute myocardial infarction, which is determined by the degree of resolution of ST elevation in ECG, depends on the state of the glucose metabolism. The dynamics of changes in the ST-segment in ECG, taken immediately after PCI, is lower in patients with reactive hyperglycaemia.

Objective: With the development of ECG monitoring systems, the diagnosis of cardiac arrhythmias is improved significantly. Here, we introduced our experience with another new long-term ECG patch device (Smartpatch II) for monitoring the cardiac arrhythmia.

Method: This device was applied to patients complained with a history of chest pain, palpitation or syncope and admitted to the 3 medical centers between April 13, 2017 and October 18, 2017. Patients wore both 24-hour Holter monitor and the Smartpatch II on the first day. On the second day, the 24-hour Holter monitor was removed and patients continued to wear the Smartpatch II up to 7 days. All ECGs were analyzed by 2 experienced independent observers.

Results: A total of 101 patients (mean age: 57.5 ± 15.4 years, 52.5% male patients, body mass index: 24.0 ± 2.9 kg/m²) were included. Over the first 24 hours, Both the Smartpatch II and Holter monitor documented 36 events. The sensitivity and specificity of Smartpatch II was 100% (95% CI, 90.3%, 100.0%) and 100.0% (95% CI, 94.5%, 100.0%) respectively when compared with Holter monitor on the first day. Over the total 7 days of monitoring, Smartpatch II detected significantly more arrhythmic events than one day recording (59 (58.4%) versus 36 (35.6%), p<0.001).

Conclusion: Over a total wearing time of 7 days, the patch device detected more cardiac arrhythmia than 24- hour monitoring.

Background: Para-prosthetic leaks post valvular replacement is a relatively rare complication. Burden of mortality and morbidity and recurrence increase with reoperation. Hemolysis is commonly seen in paravalvular leaks (PVL). Transcatheter repair is a less invasive technique with lower procedural mortality risk.

Case presentation: A 59-year-old male patient, presented to his primary physician for dyspnea on exertion with no known previous medical history. Cardiac ultrasound revealed an aortic and mitral valve disease. A severely calcified aortic valve with a moderately severe aortic regurgitation grade II to III and an aortic area of 1.3 cm2. On the other hand, a severely calcified mitral valve mainly the anterior leaflet and a severe mitral regurgitation grade III with a mean gradient of 7 mmHg. Patient was sent for surgery. Two months after, patient presented with signs of heart failure and hemolytic anemia. Transesophageal echocardiography (TEE) revealed a severe eccentric paravalvular mitral leak aiming to the left atrial appendage, with several paravalvular aortic leaks moderate to severe and a small ventricular septal defect. Transcatheter repair was done for the mitral paravalvular leak, 3 plugs were needed and yield excellent results, with one plug for the aortic paravalvular leak. Patient symptoms were better.

Discussion: In this case, we illustrate the need for TEE with 3D TEE to have a more accurate diagnosis of postoperative complications. Always think about post-operative leaks in the setting of hemolytic anemia. Furthermore, a wider use of the transcatheter techniques to reduce mortality and morbidity due to surgery.

Associations between high level of occupational dust and cardiovascular diseases have been known for more than half a century. This study aims to evaluate the effects of quarry dusts on the electrocardiogram of quarry workers in Abakaliki metropolis. 100 workers from quarry industry (test group) and 100 civil servants (control group) participated in this study. They were within the age of 18 to 65 years. A questionnaire was issued to obtain some vital medical and workplace information. Signed consents forms were obtained. An electrocardiogram machine was used to examine the electrical activities of their hearts. Data were presented as Mean ± SEM, analyzed using a 2- way ANOVA, and a multiple comparison test using Tukey's Post Hoc Test. Level of significance was set at p<0.05. All statistical analyses were carried out using Graph Pad prism 7 software. The result showed no significant difference in the QRS duration, QT interval, QTC interval, RV5 and SV1 amplitudes of quarry workers when compared with control. Significant increase was observed in the PR- intervals of quarry machine operators (p= 0.0219), quarry stone carriers (p=0.0316) and quarry stone crushers (p=0.0259) when compared with the control. Furthermore, significant decrease in the p value- axis of quarry machine operators (p=0.0001), quarry stone carriers (p=0.0001) and quarry stone crushers (p=0.0001) when compared with the control was detected. The result also showed a significant increase in the QRS- axis of quarry machine operators (p=0.0258), quarry stone carriers (p=0.0346) and quarry stone crushers (p=0.0467) when compared with the control. Additionally, among the different groups of quarry workers, quarry machine operators recorded prolonged PR intervals and a significant decrease in T-axis when compared with other quarry workers. In conclusion, quarry workers have inadequate PR – Interval, QRS axis and P axis than non-quarry workers thus have compromised electrical activities of their hearts. Also, prolonged PR- interval recorded by the quarry machine operators when compared with other groups of quarry workers is an indication that greater exposure to quarry dust may cause greater damage to the heart. Quarry workers need to be encouraged to adopt cardiovascular health safety strategies and also, be educated on quarry dusts hazards.