Beneficial effect of atorvastatin on erythropoietin responsiveness in maintenance haemodialysis patients

Aim: To evaluate the effect of atorvastatin on erythropoietin responsiveness and whether this effect is mediated by C‐reactive protein (CRP) reduction in prevalent dyslipidemic, haemodialysis patients. Methods: We studied prospectively 33 stable, iron‐repleted haemodialysis patients with low‐density lipoprotein cholesterol (LDL) ≥2.58 mmol/L, who received 20 mg atorvastatin aiming to achieve the target of LDL <2.58 mmol/L, over a period of 9 months. Twenty‐five patients completed the study, 15 men, with mean age 66.1 ± 8.2 years. The duration of haemodialysis was 56.6 ± 63.1 months and 5/25 patients were diabetics. Total serum cholesterol, triglycerides, high‐density lipoprotein cholesterol, LDL, haemoglobin, albumin, intact parathyroid hormone, serum iron, ferritin, total iron binding capacity, CRP and weekly dose of erythropoietin/body weight/haemoglobin were analysed. Results: Twenty of the 25 patients (80%) achieved the goal of LDL <2.58 mmol/L. There was a significant decrease in total cholesterol (5.77 ± 0.88 to 4.16 ± 0.96 mmol/L, P < 0.001) and LDL (3.59 ± 0.77 to 1.94 ± 0.77 mmol/L, P < 0.001). Haemoglobin increased from 121 ± 11 to 126 ± 7 g/L (P < 0.05), while weekly dose of erythropoietin/body weight/haemoglobin decreased significantly from 8.34 ± 3.70 to 7.87 ± 3.11 IU/kg per haemoglobin (P < 0.05). CRP decreased not significantly from 7.0 ± 6.1 to 4.5 ± 2.2 mg/L. Conclusion: Dyslipidemia of haemodialysis patients was treated safely and effectively with atorvastatin, but a fifth of the patients failed to achieve the therapeutic target. Statin therapy resulted in a significant increase of haemoglobin levels and improvement of erythropoietin responsiveness without a significant reduction in CRP levels, suggesting that the beneficial effect of statins on erythropoietin responsiveness may be driven by a mechanism other than CRP reduction.     

Circadian Modulation of Ventricular Tachycardia Cycle Length Variability in ICD Patients with Dilated Cardiomyopathy

VT is usually characterized by stability of the RR intervals after a few cycles from the onset. The aim of this study was to evaluate the VT cycle length (VTCL) variability in patients with dilated cardiomyopathy (DCM), in whom a third-generation ICD was previously implanted. Eighty-three episodes of VT were analyzed in 10 patients (8 male, 2 female, 65 ± 6 years) with DCM, and NYHA Class II (7 patients) or III (3 patients). As an index of VTCL variability, the coefficient of variance of the last 15 consecutive RR intervals (CVRR) of the detected and stored VT by the device was considered. The mean value of the RR intervals and the mean value of CVRR of the VT episodes recorded during day versus night time were compared. Fifty-five VT episodes were recorded during the day and 28 episodes during the night time. The mean RR intervals of VT episodes during day time was 335 ± 29 ms and during the night time was 350 ± 22 ms (P = NS). The mean CVRR of VT episodes during day time and night time were 2.83 ± 0.52 and 3.36 ± 0.48, respectively (P = 0.017). In conclusion, a circadian modulation of VTCL variability exists in patients with DCM. The VTCL variability is less during day time compared to night time. A possible explanation is a circadian alteration of sympathovagal balance modifying the electrophysiological properties of the arrhythmogenic substrate.     

Evaluation of coxsackievirus and adenovirus receptor expression in human benign and malignant thyroid lesions

Giaginis C, Zarros A, Alexandrou P, Klijanienko J, Delladetsima I, Theocharis S. Evaluation of coxsackievirus and adenovirus receptor expression in human benign and malignant thyroid lesions. APMIS 2010; 118: 210–21. Coxsackievirus and adenovirus receptor (CAR) expression on tumor cells is associated with sensitivity to adenoviral infection, being considered as a surrogate marker for monitoring and/or predicting adenovirus‐mediated gene therapy. The aim of this study was to evaluate the clinical significance of CAR expression in human benign and malignant thyroid lesions. CAR protein expression was assessed immunohistochemically on paraffin‐embedded thyroid tissues from 107 patients with benign and malignant lesions and was statistically analyzed in relation to histopathologic type; tumor size; lymph node metastasis; capsular, lymphatic and vessel invasion; as well as follicular cells’ proliferative capacity. CAR immunoreactivity was characterized as negative/weak in 53 (49.53%), moderate in 31 (28.97%) and strong in 23 (21.50%) of 107 thyroid cases. CAR immunoreactivity was significantly increased in malignant compared with that in benign thyroid lesions (p = 0.00002). Both malignant and benign thyroid lesions with enhanced follicular cells’ proliferative capacity showed significantly increased CAR immunoreactivity (p = 0.00027). In malignant thyroid lesions, enhanced CAR immunoreactivity was significantly associated with larger tumor size (p = 0.0067). The current data revealed that CAR immunoreactivity could be considered of diagnostic utility in thyroid neoplasia. Further research effort is warranted to delineate whether CAR could be considered clinically important for both diagnosis and future (gene) therapeutic applications in thyroid neoplasia.     

The Chicken‐Wing Morphology: An Anatomical Challenge for Left Atrial Appendage Occlusion

Objectives

To describe the particular assessment and closure strategy that was followed in patients with left atrial appendages (LAA) with an early and severe bend.

Background

The presence of a chicken‐wing morphology with an early and severe bend constitutes one of the most difficult anatomical settings for transcatheter LAA occlusion.

Methods

Between November 2009 and December 2012, patients who presented chicken‐wing LAA with an early (<20 mm from the ostium) and severe bend (<180°) were identified and included in the analysis. A particular implanting strategy consisting of deploying the distal lobe of the device inside the chicken‐wing bend was used in all cases.

Results

Among 42 patients who underwent LAA occlusion during the study period, 5 (12%) presented the pre‐specified anatomy. Following the mentioned implanting strategy, all patients underwent successful LAA occlusion using the Amplatzer Cardiac Plug (n = 2) and the Amplatzer Amulet (n = 3). Successful occlusion was achieved in all patients. None of them presented any procedural complication. Follow‐up transesophageal echocardiography at 3 months showed successful LAA sealing in all patients and no device embolization or thrombosis.

Conclusions

According to our results, the pre‐specified closing implantation technique for chicken‐wing LAAs with an early and severe bend might be a valid strategy for this challenging anatomical setting. Further cases will be necessary to confirm the results. (J Interven Cardiol 2013;26:509‐514)

     

Atrial Septal Pacing to Synchronize Atrial Depolarization in Patients with Delayed Interatrial Conduction

The current method of pacing the right atrium from the appendage or free wall is often the source of delayed intraatrial conduction and discoordinate left and right atrial mechanical function. Simultaneous activation of both atria with pacing techniques involving multisite and multilead systems is associated with suppression of supraventricular tachyarrhythmias and improved hemodynamics. In the present study we tested the hypothesis that pacing from a single site of the atrial septum can synchronize atrial depolarization. Five males and two females (mean age 58 ± 6 years) with drug refractory paroxysmal atrial fibrillation (AF) were studied who were candidates for AV junctional ablation. All patients had broad P waves (118 ± 10 ms) on the surface ECG. Multipolar catheters were inserted and the electrograms from the high right atrium (HRA) and proximal, middle, and distal coronary sinus (CS) were recorded. The atrial septum was paced from multiple sites. The site of atrial septum where the timing between HRA and distal CS (d-CS) was ≤ 10 ms was considered the most suitable for simultaneous atrial activation. An active fixation atrial lead was positioned at this site and a standard lead was placed in the ventricle. The interatrial conduction time during sinus rhythm and AAT pacing and the conduction time from the pacing site to the HRA and d-CS during septal pacing were measured. Atrial septal pacing was successful in all patients at sites superior to the CS os near the fossa ovalis. During septal pacing the P waves were inverted in the inferior leads with shortened duration from 118 ± 10 ms to 93 ± 7 ms (P < 0.001), and the conduction time from the pacing site to the HRA and d-CS was 54.3 ± 6.8 ms and 52.8 ± 2.5 ms, respectively. The interatrial conduction time during AAT pacing was shortened in comparison to sinus rhythm (115 ± 18.9 ms vs 97.8 ± 10.3 ms, P < 0.05). In conclusion, simultaneous activation of both atria in patients with prolonged interatrial conduction time can be accomplished by pacing a single site in the atrial septum using a standard active fixation lead placed under electrophysiological study guidance. Such a pacing system allows proper left AV timing and may prove efficacious in preventing various supraventricular tachyarrhythmias.     

Effect of Different AV Delays on Left Ventricular Diastolic Function and ANF Levels in DDD Paced Hypertensive Patients During Daily Activity and Exercise

Fifteen hypertensive patients (13 men) with left ventricular hypertrophy, mean age 69 6 5 years, having complete heart block and paced in the DDD mode, were studied by two-dimensional and Doppler echo in 100 and 200 ms atrioventricular delays. ANF plasma levels were measured at rest and at peak exercise, during pacing with the two different atrioventricular delays. ANF plasma levels were significantly higher at pacing with long atrioventricular delays (200 ms), at rest (152.47 6 12.38 pg/mL vs 119 6 12.38 pg/mL, P, 0.001) and at exercise (180.93 6 11.51 vs 123.67 6 16.24 pg/mL, P, 0.0001). ANF plasma levels were significantly increased at exercise, compared to those at rest during pacing with the two different atrioventricular delays, but we found a more pronounced increase of ANF levels (from 152.47 6 10.49 pg/mL to 180.93 6 11.51 pg/mL), when the atrioventricular delays was set to 200 ms (P, 0.0001). A significant decrease of isovolumic relaxation time (from 123.33 6 20.5 to 105.33 6 11.06 ms, P, 0.001) was observed, during pacing with the short atrioventricular delays. Moreover, the peak early (E) to peak atrial (A) velocity ratio (E/A) was declined (from 0.89 6 0.7 to 0.57 6 0.18, P, 0.05). We also noticed that patients with small left ventricles exhibit greater increase in ANF plasma levels during DDD pacing with long atrioventricular delays (r 5 20.792, P 5 0.000). In conclusion, left ventricular diastolic function of our patients seems to be improved during DDD pacing with short (100 ms) atrioventricular delays, as it was expressed by echocardiographic and hormonal measurements.     

Congestive Heart Failure and VVI Pacing Mode: Dynamic Behavior of the Dispersion of Ventricular Repolarization

Dynamic Behavior of the Dispersion of Ventricular Repolarization. The aim of this study was to evaluate the circadian variation in the spatial dispersion of ventricular repolarization in continuously paced patients with congestive heart failure (CHF). Fourteen patients (10 males, 4 females, aged 65 ± 5 years) with CHF due to dilated cardiomyopathy (DCM) and an echocardiographic ejection fraction of 28%± 3% were studied. All patients underwent AV functional RF ablation and permanent pacemaker implantation for drug refractory chronic atrial fibrillation (AF). Patients were evaluated at 1 month postimplant with a three-channel 24-hour Holter monitor, using the three plane Frank orthogonal leads (X, Y, and Z), in VVI pacing mode at 70 beats/min. For each hour, the mean value of spike-T interval dispersion of the first five beats was measured. The control group consisted of 20 patients without structural heart disease, but with AF and complete AV block, continuously paced in WI mode at 70 beats/min. The dispersion of the spike-T interval had a circadian behavior in the study population, with higher values at night and lower during the daytime. During the daytime, the mean value of spike-T interval dispersion was 39 ± 5 ms and during the nighttime it was 45 ± 7 ms (P = 0.003). Such a difference between day and night was not found in the control group (38 ± 6 ms and 40 ± 8 ms, respectively, P = NS), In the daytime period the mean value of spike-T interval dispersion of our study population was comparable to that of the control group (P = NS), while during the nighttime it was significantly higher (P = 0.0004). In conclusion, by evaluating the dispersion of ventricular repolarization in two dimensions, space and time, a circadian variation was found in paced patients with CHF due to DCM. The increased QT dispersion in these patients during the nighttime period was attributed to different effects of vagal activity in normal and abnormal myocardial areas.     

Radiofrequency Catheter Ablation of Three Accessory Pathways in a Single Session

Radiofrequency Ablation of Multiple Accessory Pathways. A 19-year-old patient is described having three accessory atrioventricular pathways. All three pathways were ablated using radiofrequency current in a single electrophysiologic investigation. (J Cardiovasc Electrophysiol, Vol. 3, pp. 141–149, April 1992)