Inferior Cava Research Articles

Ventricular arrhythmia characteristics after left ventricular assist device implantation

Abstract Background Ventricular arrhythmia (VA) characteristics in patients with advanced heart failure (HF) and left ventricular assist devices (LVADs) are currently poorly studied. Methods Patients with advanced HF implanted with third-generation LVADs during 2019-2023 were enrolled, and six-month post-LVAD VA events were retrospectively analyzed. Baseline characteristics, 6-month VA events, Holter monitoring and ambulatory blood pressure were also analyzed. Post-LVAD VA events were categorized as new right bundle-branch block (RBBB) superiorly directed VA and prior VA recurrence. Results Fifty-four advanced HF patients (90.7% male, 50.0±13.7 years old) who underwent LVAD (CH-VAD: n=23; Evaheart2: n=10; Corheart6: n=21) were consecutively enrolled in this study. Twenty-two patients suffered post-LVAD VA events (15 new RBBB superiorly directed VA, 7 prior VA recurrence), and 94.4% of the patients were hemodynamically stable. A total of 46.3% of the patients presented with a 50% reduction in VA burden, and amiodarone use decreased from 25.9% to 16.7%. The nighttime mean arterial pressure (MAP) and maximum inferior venous cava (IVC) diameter had opposite predictive effects on the new RBBB VA, and the post-LVAD left ventricular ejection fraction (LVEF) was negatively correlated with the prior VA recurrence. Multivariate analysis revealed that a higher nighttime MAP/IVC ratio (OR 2.24, 95% CI 2.22-4.52; P=0.025) and a lower post-LVAD LVEF (OR 0.75, 95% CI 0.57-0.99; P=0.048) were independently related to the new RBBB superiorly directed VA and prior VA recurrence, respectively. Conclusion The overall VA burden decreased after LVAD implantation. Volume deficiency and poor post-LVAD cardiac function were associated with different VA patterns.Changes in VAs pre- and 6 monthsVA distributions of patients

Central venus cannulation during cardiac surgery as a possible new additional risk factor for late post-operative atrial fibrillation insurgence.

Postoperative atrial fibrillation (POAF) is the most frequent cardiac arrhythmia following cardiac operations. It has been associated with an increased risk of postoperative cerebrovascular complications, morbidity and mortality. The aim of this study is to evaluate if the type of venous cannulation to institute the cardiopulmonary bypass (CPB) during major cardiac surgery procedures can influence the rate of POAF and late FA onset. We collected data from 2087 consecutive patients who have been operated at our Institution from January 2016 to December 2018. To obtain two homogenous groups we performed a propensity match analyzes: Group 1 for whom the blood drain of the CPB has been granted via peripheral cannulation (PC) through the right common femoral vein and Group 2 with patients who underwent central cannulation (CC) with insertion of a drainage cannula in the right atrium or in the superior and inferior vein cava. POAF has been observed as statistically similar between the two groups. At 1250-day follow-up, While the incidence of POAF was 2.9% and 8.7% in the PC and CC groups, respectively (p = .04). our data seems to show that the two groups do not differ in terms of POAF, while the CC group may have a significantly higher rate of atrial fibrillation in the follow-up period.

Endovascular thrombectomy provides durable, symptomatic relief in iliocaval tumor thrombosis

Iliocaval venous tumor thrombus is a morbid condition associated with chronic venous stasis, lower extremity edema/pain, extensive thrombus burden and high mortality secondary to critical flow obstruction, intracardiac thrombus extension and tumor embolization. Typically resistant to medical therapy, management is primarily surgical, presenting challenges for medically complex patients with widespread or end-stage disease. Mechanical or aspiration thrombectomy represents an appealing treatment strategy but data are lacking. We performed a single-center, 10-year, retrospective review of patients with pathology-confirmed, iliocaval tumor thrombus who underwent thrombectomy. 14 patients met inclusion criteria and were managed by 18 procedures over this period. The most common malignancy was renal-cell carcinoma (n=7; 50%); other types included germ cell (n=2; 14%), other genitourinary (n=2; 14%), neuroendocrine (n=1; 7%), soft tissue (n=1; 7%), and skin cell malignancies (n=1; 7%). All patients had thrombus involving the distal inferior venous cava (IVC), 50% had bilateral iliac involvement and 29% atrial involvement. Common indications were venous obstruction symptoms (n=11; 65%) and evidence of embolism (n=6; 35%). All patients tolerated the procedures without acute complication. The technical success rate was 94%, with marked improvement of flow and reduction in thrombus burden, and 79% had subjective symptomatic improvement. All patients survived for >2 weeks and 50% had long-term survival of >1 year, with 86% of these patients having renal-cell carcinoma (RCC). Three patients underwent multiple thrombectomies within days to weeks, with ultimate symptomatic improvement. Overall, our study results suggest mechanical or aspiration thrombectomy as a safe and efficacious treatment for patients with iliocaval tumor thrombus.

Hepatocellular carcinoma with metastasis to the inferior cava vein and right atrium, an unusual cause of Budd Chiari Syndrome

Hepatocellular carcinoma with metastasis to the inferior cava vein and right atrium, an unusual cause of Budd Chiari Syndrome

By using the new hemodynamic definition of pulmonary hypertension in patients with left heart disease the prognostic value of different phenotypes might be lost

Abstract Background and aims In the 2022 ECS/ERS pulmonary hypertension (PH) guidelines the threshold for increased pulmonary vascular resistance (PVR) was lowered from 3 to 2 Wood Units (WU). Consequently, in patients with PH due to left heart disease, the proportions of patients with combined pre- and postcapillary PH (CpcPH) will increase while the proportion with isolated post-capillary PH (IpcPH) will decrease. In the present study we investigate in patients with left heart disease the impact of this revision in terms of hemodynamic profile, right ventricular (RV) function and prognostication. Methods. Two-hundred and two patients consecutively referred for heart transplant or heart failure work-up were included with right heart catheterization and echocardiography within 48 hours. RV dysfunction was graded using a novel echocardiographic score allocating one point each for (1) systolic pulmonary artery pressure (PAP) >40 mmHg, (2) reduced tricuspid annular plane systolic excursion (TAPSE<17 mm), (3) RV area dilatation, (4) moderate/severe tricuspid regurgitation and (5) reduced inferior cava collapsibility. For assessment of prognostication, we studied the end-point of all-cause mortality. Results. One-hundred and seventy-three patients (86%) had left ventricular ejection fraction <40%. Eighty-nine patients (44%) underwent heart transplantation and the median (25%; 75% percentile) follow-up time (years) was 1.8 (0.35; 6.7). Sixty patients (30%) had mean PAP<20 mmHg, thus no PH. Ninety-six patients (48%) had IpcPH using PVR 3 WU as threshold. Lowering the threshold to PVR 2 WU decreased the corresponding proportion to 24%. The degree of backward failure (PA wedge pressure), forward failure (cardiac index) or RV dysfunction (RVD score) did not significantly differ by the change in hemodynamic definition (Table). With the previous hemodynamic definition, the Kaplan-Meier curves demonstrated increased mortality in CpcPH patients compared with IpcPH (Figure B). Using the new definition this difference was not present (Figure B). Conclusions. The revised hemodynamic definition of PH significantly increases the proportion with CpcPH, but does not significantly alter the hemodynamic or RV function profiles in left heart disease patients with IpcPH or CpcPH phenotype. However, our findings indicate that by using the new hemodynamic definition of IpcPH and CpcPH phenotype the prognostic value of this hemodynamic classification might be lost.Table

Stable Gastric Pentadecapeptide BPC 157 Therapy: Effect on Reperfusion Following Maintained Intra-Abdominal Hypertension (Grade III and IV) in Rats.

Given in reperfusion, the use of stable gastric pentadecapeptide BPC 157 is an effective therapy in rats. It strongly counteracted, as a whole, decompression/reperfusion-induced occlusion/occlusion-like syndrome following the worst circumstances of acute abdominal compartment and intra-abdominal hypertension, grade III and grade IV, as well as compression/ischemia-occlusion/occlusion-like syndrome. Before decompression (calvariectomy, laparotomy), rats had long-lasting severe intra-abdominal hypertension, grade III (25 mmHg/60 min) (i) and grade IV (30 mmHg/30 min; 40 mmHg/30 min) (ii/iii), and severe occlusion/occlusion-like syndrome. Further worsening was caused by reperfusion for 60 min (i) or 30 min (ii/iii). Severe vascular and multiorgan failure (brain, heart, liver, kidney, and gastrointestinal lesions), widespread thrombosis (peripherally and centrally) severe arrhythmias, intracranial (superior sagittal sinus) hypertension, portal and caval hypertension, and aortal hypotension were aggravated. Contrarily, BPC 157 therapy (10 µg/kg, 10 ng/kg sc) given at 3 min reperfusion times eliminated/attenuated venous hypertension (intracranial (superior sagittal sinus), portal, and caval) and aortal hypotension and counteracted the increases in organ lesions and malondialdehyde values (blood ˃ heart, lungs, liver, kidney ˃ brain, gastrointestinal tract). Vascular recovery promptly occurred (i.e., congested inferior caval and superior mesenteric veins reversed to the normal vessel presentation, the collapsed azygos vein reversed to a fully functioning state, the inferior caval vein-superior caval vein shunt was recovered, and direct blood delivery returned). BPC 157 therapy almost annihilated thrombosis and hemorrhage (i.e., intracerebral hemorrhage) as proof of the counteracted general stasis and Virchow triad circumstances and reorganized blood flow. In conclusion, decompression/reperfusion-induced occlusion/occlusion-like syndrome counteracted by BPC 157 therapy in rats is likely for translation in patients. It is noteworthy that by rapidly counteracting the reperfusion course, it also reverses previous ischemia-course lesions, thus inducing complete recovery.

Pentadecapeptide BPC 157 as Therapy for Inferior Caval Vein Embolization: Recovery of Sodium Laurate-Post-Embolization Syndrome in Rats.

After inferior caval vein embolization therapy, post-embolization syndrome (sodium laurate 10 mg/kg, 0.1 mL into rat inferior caval vein, assessment at 15, 30, 60 min, prime lung lesions, thromboemboli occluding lung vessels), as a severe occlusion/occlusion-like syndrome, might be resolved as a whole by stable gastric pentadecapeptide BPC 157 therapy. At 5 min after laurate injection, stable gastric pentadecapeptide BPC 157 was implemented as therapy (10 µg/kg, 10 ng/kg intraperitoneally or intragastrically). As before, confronted with the occlusion of major vessel(s) or similar noxious procedures, such as rapidly acting Virchow triad circumstances, the particular effect of the therapy (i.e., collateral pathways activation, "bypassing vascular key", i.e., direct blood flow delivery via activation of azygos vein) assisted in the recovery of the vessel/s and counteracted multiorgan failure due to occlusion/occlusion-like syndrome as a whole in the laurate-injected rats. Along with prime lung lesions and thromboemboli occluding lung vessels, post-embolization syndrome rapidly occurred peripherally and centrally as a shared multiorgan and vessel failure, brain, heart, lung, liver, kidney, and gastrointestinal tract lesions, venous hypertension (intracranial (superior sagittal sinus), portal, and caval), aortal hypotension, progressing thrombosis in veins and arteries and stasis, congested and/or failed major veins, and severe ECG disturbances. Whatever the cause, these were all counteracted, eliminated, or attenuated by the application of BPC 157 therapy. As recovery with BPC 157 therapy commonly and rapidly occurred, reversing the collapsed azygos vein to the rescuing collateral pathway might initiate rapid direct blood delivery and start blood flow reorganization. In conclusion, we suggest BPC 157 therapy to resolve further vascular and embolization injuries.

FRI146 Stereotactic Ablative Radiotherapy As A Local Valuable Therapeutic Procedure To Control Aldosterone-Secreting Adrenocortical Carcinoma

Abstract Disclosure: L.M. Mermejo: None. R.H. Zanella: None. L. Cocicov: None. C.A. Molina: None. S. Tucci Jr: None. J. Elias Jr: None. V.F. Muglia: None. G. Viani: None. P.C. Elias: None. A.C. Moreira: None. M. De Castro: None. Aldosterone-secreting adrenocortical carcinomas (ACC) are rare and usually described as large tumors. We report the case of a 44-year-old man referred to our University Hospital presenting back pain, muscular weakness and hypokalemia. A year earlier, hypertension had been diagnosed triggered by the investigation of daily headaches. Throughout this period, hypertension had been refractory to antihypertensives and patient also showed progressive weight loss of 10 kg. At the time of presentation, the patient had no signs of cortisol or androgen excess, his blood pressure was 180x120 mmHg, and there was no peripheral edema or abdominal mass detected. Due to abdominal pain and liver enzymes abnormalities, an abdominal CT was performed and revealed a heterogeneously 10 x 8 x 6 cm (volume: 256 cm³) left adrenal mass compressing the left renal vein with invasion through the inferior cava vein and extending to the liver caudate lobe. He also had a sodium of 143 mmol/L, potassium of 1.2 mmol/L and metabolic alkalosis. The serum aldosterone level of 75 ng/dL and plasma direct renin concentration < 2 mIU/L whereas urinary fractionated metanephrines were within normal limits, suggesting a probable aldosterone-secreting ACC. His family history was negative for hypertension or adrenal diseases. The patient was initially treated with spironolactone and potassium replacement with clinical improvement and an open adrenalectomy was proposed. However, patient professed to be Jehovah's Witnesses and refused the surgery due to the risk of blood transfusions. Therefore, the patient received mitotane but owing to hepatotoxity, the drug was withdrawn after two months of follow-up. A follow up abdominal MRI after 10 months of diagnosis revealed an increase in the mass (12 x 8 x 9 cm; volume: 460 cm³) and, now, extending to the left kidney. A CT-guided percutaneous biopsy showed an ACC with a Weiss score of three and the immunohistochemistry was positive for vimentin, inhibin and MART-1/ Melan A. After a multidisciplinary discussion, it was proposed to use stereotactic ablative radiotherapy (SABR) as an alternative option. The patient accepted SABR, being treated with 35Gy/5 fractions. During the follow-up, the patients had a progressive improvement of pain complaints, reduction of tumor burden after eighteen months on control abdomen CT (9.1 x 4.9 x 8.7 cm; volume of 202 cm³), improvement of blood pressure and hypokalemia levels, reduction of antihypertensive drugs defined daily dose and potassium replacement as well as reduction of a serum aldosterone to 13 ng/dL and increased of paired renin to 25 mU/L. This is the first published report of a pure aldosterone-producing ACC patient receiving SABR. The response was significant, indicating that the use of SABR should be considered as an alternative for local treatment of aldosterone-secreting ACC when the surgery cannot be indicated. Presentation: Friday, June 16, 2023

Inferior Vena Cava Filters: Adherence to Clinical Practice Guidelines Recommendations, Retrieval Rates, and Filter Complications in a Tertiary Hospital.

The present study evaluated the adherence to guideline recommendations regarding the indication for inferior vena cava filter (IVCF) placement, retrieval rates, complications, thrombotic recurrences, and mortality. Patients in whom an IVCF was placed between 2015 and 2020 in a tertiary hospital were retrospectively included. We considered absolute indication of IVCF placement if all the guidelines evaluated agreed on the indication, relative indication if only some guidelines recommended it and without indication if none of the evaluated guidelines recommended it. From the 185 patients included; 47% had an absolute indication, 15% a relative indication, and 38% had no indication. Filter-associated complications and non-removal rates were 12.4% and 41%, respectively. Venous thromboembolism recurrence rate was 17.8%, being filter-associated complications (24.2 vs 9.8%, P = .02) and thrombosis of the inferior cava or iliac veins (12.1 vs 2.6%, P = .03) more frequent in this group. The mortality rate was 40%, with higher mortality risk in patients with co-existing cancer. Previous major bleeding, filter-associated complications, and mortality were associated with a major risk of non-removal. In conclusion, the adherence to guidelines regarding the indication of IVCF placement is still low and IVCF complications are not negligible. This fact is of special concern in the elderly, comorbid, and cancer patients.

Acute post sleeve surgery bleeding as rare cause of acute renal failure: a case report

BackgroundBariatric surgeries have been considered as one of the most important treatment procedures in recent years. Being aware of the side effects of this surgery will lead to better results after the surgery.Case presentationA 37-year-old Iranian male patient presented one day after sleeve surgery with symptoms of weakness, lethargy, and shortness of breath, which hospitalization and workup to were done to rule out pulmonary embolism. Because of the high creatinine and anuria, we couldn’t perform computed tomography angiography. A bedside ultrasound was done for the patient and showed a mild to moderate amount of fluid around the spleen and some blood clots. Due to the progressive clinical findings and suspected internal bleeding, the patient was a candidate for laparoscopic revision procedure. Gradually, after performing the surgery, removing the blood clot and reducing the compressive effect of that on the inferior verna cava which was the main reason of renal failure, the patient was able to urinate afterwards and was discharged in good general condition.ConclusionSurgeons should be aware of the management of rare surgical complications after bariatric surgeries. To be best of our knowledge, this was the first case report of a patient with acute renal failure after bariatric surgery and the rare cause of clot compression on inferior vena cava and raised abdominal compartment pressure.

#5787 ALBUMINURIA IN PATIENTS ADMITTED WITH HEART FAILURE IS ASSOCIATED WITH MORE SYSTEMIC CONGESTION ASSESSED BY ULTRASOUND

Abstract Background and Aims Albuminuria is frequently observed in patients with heart failure (HF) and is associated with worse outcomes. New instrumental methods of congestion assessment in HF are superior in accuracy to physical examination and, therefore, are becoming the new standards for congestion registration. The relationship of albuminuria with congestion assessed by ultrasound in HF population is unclear. We aimed to investigate the relationship between albuminuria level and congestion measured by lung ultrasound (LUS) and Venous Excess Ultrasound (VExUS) at admission in patients with ADHF. Method In this prospective study we included 58 patients which were admitted with ADHF (typical signs and symptoms with NT-proBNP > 300 pg/ml). Patients with end-stage chronic kidney disease (CKD), malignancy were excluded. Routine clinical examination and laboratory tests, echocardiography, eight-zone LUS, and VExUS assessment of veins: cava inferior, hepatic, portal, and renal were performed. Patients were divided into two groups according to albumin/creatinine ratio at hospitalization: without albuminuria (uACR<30 mg/gCr) and with albuminuria (uACR>30 mg/gCr). Results 72% were male, mean age was 72 (55;79) (Me (IQR) years, 52% (n = 30) had reduced ejection fraction (EF), 77% - hypertension (HTN), 66% - atrial fibrillation (AF), 37% - diabetes mellites (DM), 58% - coronary artery disease (CAD), 17% (n = 10) - previously known CKD. On physical examination at admission 67% (n = 39) patients had orthopnea,69% (n = 40) - exertional dyspnea, 53.4% (n = 31) - elevated jugular venous pressure, 91.4% (n = 53) - ankle edema, 50% (n = 29) - hepatomegaly and 82.8% (n = 48) pulmonary crepitations. Mean NT-proBNP was 2062 (13443248) (Me (IQR)) pg/ml. 49 (84%) had pulmonary congestion assessed by LUS (mean number of B-lines 34 (25;48)), 86% (n = 50) – congestion by VExUS, from which the majority of patients had the most severe, 3rd, grade (1st – 32%, 2nd – 16%, 3rd – 52%). The prevalence of albuminuria was 65.5% (n = 38): 92% (n = 35/38) patients had albuminuria categories A2 and 8% (n = 3/38) had A3 category. Groups with and without albuminuria were similar in gender, age, prevalence of EF<40%, comorbidities, exertional dyspnea, orthopnea, elevated jugular venous pressure, hepatomegaly, pulmonary crepitations, levels of NT-proBNP and serum creatinine. Differences between groups with and without albuminuria were detected in the frequency of ankle swelling (100%(n = 38/38) vs 75% (n = 15/20), p = 0.003). Patients with albuminuria had a trend to more frequently having pulmonary congestion than without albuminuria (89% (n = 34/38) and 75% (n = 15/20), p = 0.15 respectively). The prevalence of congestion assessed by VExUS was higher in patients with albuminuria (95% (n = 36/38) and 70% (n = 14/20), p = 0.009 respectively). Conclusion In patients hospitalized with ADHF albuminuria is associated with systemic congestion assessed by VExUS. The relationship between pulmonary congestion by LUS and albuminuria should be a matter of future studies.

The novel left atrial anterior 'seatbelt' line reduces sustained atrial arrhythmia by 72% compared to pulmonary vein isolation alone in a cohort of 400 virtual atria models

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No.860974. Background The success-rate of pulmonary vein isolation (PVI) is modest in persistent atrial fibrillation (AF), but additional empirical ablation, such as posterior wall isolation (PWI), has not been shown to reduce the rate of AF recurrence. The "seatbelt", an anterior linear ablation lesion connecting the right superior pulmonary vein to the mitral annulus, is a novel substrate modification approach that is yet to be tested in a large-scale randomised clinical trial. Purpose To use in-silico trials with human-based modelling and simulation to compare the efficacy of (i) PVI alone, (ii) PVI and PWI (PVI+PWI), or (iii) PVI and seatbelt (PVI+SB) for the prevention of atrial arrhythmia in large populations of virtual patient models. Methods AF was simulated in a cohort of 400 virtual atrial models with anatomical and electrophysiological variability, with AF persisting for >7 seconds defined as sustained. Models which sustained AF were each independently subjected to all three ablation approaches before repeating the AF induction protocol. Results Three hundred forty-four (86%) atrial models developed sustained AF at baseline. After applying the ablation lesions, substantially fewer models sustained atrial arrhythmias in the PVI+SB group (50 [14%] vs. 134 [39%] with PVI+PWI vs. 172 [50%] with PVI). PVI+SB was more effective than PVI and PVI+PWI in preventing both AF and atrial flutter (i.e., presence of a single rotor), since PVI and PVI+PWI led to the formation of anatomical re-entries around the rings of the pulmonary veins and the posterior wall of the left atrium, respectively (Figure). Therefore, PVI+SB restricted atrial flutter mainly to the right atrium (either anatomical, around the inferior cava vein, or functional, meandering throughout the venous portion of the right atrium, Figure). Importantly, in all three ablation strategies, the likelihood of AF recurrence was directly proportional to the surface area of the right atrium (AF probability increased 0.95%/cm², 0.88%/cm² and 0.56%/cm² after PVI+SB, PVI+PWI and PVI, respectively). The role of the right atrial size was less accentuated for PVI alone, since after the ablation the entire left atrial body was still available for rotor anchoring. Moreover, an enlarged left atrium enabled the appearance of micro-re-entries in the anterior and inferior wall of the left atrium, even after applying floor and roof lines. One atrial model additionally presented a rotor in the posterior wall of the left atrium after completely isolating it from the left atrial body. Conclusion(s) In a cohort of 400 virtual atrial models, PVI+SB reduced sustained atrial arrhythmias by 72% compared to PVI alone and by 64% to PVI+PWI, but AF could still originate in an enlarged right atrium.

P420 A CANCER PATIENT WITH PULMONARY THROMBOEMBOLISM: IS IT RIGHT TO APPLY THE CRITERIA FOR DOSE REDUCTION IN THESE PATIENTS?

Abstract A 78 years old woman presented in our cardio–oncology out–patient clinic to renew apixaban treatment plan. In her medical history she was a former smoker, with a chronic kidney disease in IIIb stadium according to KDIGOI guidelines with a creatinine of 1,54 mg/dl, GFR according CKD 32 ml/min/1.73m2 and according Cockcroft e Gault 28 ml/min/1.73m2. In 2010, she had a right lobe pulmonary cancer diagnosis treated in neo–adjuvant with gemcitabine. After chemotherapy, she underwent surgical lobectomy. During hospitalization she had a deep venous thrombosis complicated by pulmonary thromboembolism, heparin sc was given with resolution of the clinical picture. In 2012 she had a recurrence of pulmonary thromboembolism. Heparin and warfarin in a second time was given. In 2016 for cancer disease progression, she underwent various oncological treatments and she found a stability disease with osimertinib and stereotaxic radiotherapy. Warfarin was switched to apixaban low–doses for low weight and chronic kidney disease. In 2021 in osimertinib therapy, cancer was under control. She was continuing low–dose apixaban. One year later, a CT scan demonstrated a disease progression and inferior cava venous thrombosis. A cardiac evaluation in our unit was required: patients was asymptomatic. EKG and Echocardiogram were normal. Apixaban low dose was changed to edoxaban 30 mg. There was a complete vein recanalization. Unfortunately, patient died after 8 months for cancer. It is important, in the direct oral anticoagulation therapy in cancer patient, to consider not only the indication for dose reduction known by the registration studies but also cancer and therapy factors.

11,12-EET suppressed LPS induced TF expression and thrombus formation by accelerating mRNA degradation rate via strengthening PI3K-Akt signaling pathway and inhibiting p38-TTP pathway

Epoxyeicosatrienoic acids (EETs), which are synthesized from arachidonic acid by cytochrome P450 epoxygenases, function primarily as autocrine and paracrine effectors in the cardiovascular system. So far, most research has focused on the vasodilatory, anti-inflammatory, anti-apoptotic and mitogenic properties of EETs in the systemic circulation. However, whether EETs could suppress tissue factor (TF) expression and prevent thrombus formation remains unknown. Here we utilized in vivo and in vitro models to investigate the effects and underlying mechanisms of exogenously EETs on LPS induced TF expression and inferior vein cava ligation induced thrombosis. We observed that the thrombus formation rate and the size of the thrombus were greatly reduced in 11,12-EET treated mice，accompanied by decreased TF and inflammatory cytokines expression. Further in vitro studies showed that by enhancing p38 MAPK activation and subsequent tristetraprolin (TTP) phosphorylation, LPS strengthened the stability of TF mRNA and induced increased TF expression. However, by strengthening PI3K-dependent Akt phosphorylation, which acted as a negative regulator of p38-TTP signaling pathway，11,12-EET reduced LPS-induced TF expression in monocytes. In addition, 11,12-EET inhibited LPS-induced NF-κB nuclear translocation by activating the PI3K/Akt pathway. Further study indicated that the inhibitory effect of 11,12-EET on TF expression was mediated by antagonizing LPS-induced activation of thromboxane prostanoid receptor. In conclusion, our study demonstrated that 11,12-EET prevented thrombosis by reducing TF expression and targeting the CYP2J2 epoxygenase pathway may represent a novel approach to mitigate thrombosis related diseases.

No Differences in Rotational Thromboelastometry Measurements between Portal and Peripheral Circulation in Cirrhotic Patients Undergoing TIPS

In patients with liver cirrhosis, transjugular intrahepatic portosystemic shunt (TIPS) is considered a standardized treatment of refractory ascites or variceal bleeding. TIPS thrombosis (TT) and/or portal vein thrombosis (PVT) are possible complications during/after TIPS placement. Previous studies suggested increased clotting activity in portal circulation (PORC). This pilot study aimed to evaluate alterations and differences of coagulation function in PORC and in peripheral circulation (PERC) via rotational thromboelastometry during TIPS. Blood samples were collected from cirrhotic patients (n = 13; median Model of End Stage Liver Disease, MELD Score: 12; median age: 60 years) undergoing TIPS (10/13 TIPSs were elective procedures due to refractory ascites) as follows: median cubital vein (MCV; PERC)-confluence of the three hepatic veins to the inferior cava vein (HV/ICV; PORC)-portal vein (PV; PORC)-TIPS (PORC). This research utilized four variables of the extrinsic test EXTEM, i.e., clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and maximum lysis (ML). EXTEM results [mean, M (range) ± standard deviation, SD (range)] showed no significant differences for CT [M (70-73) ± SD (9-13); p = 0.93] or CFT [M (137-155) ± SD (75-112); p = 0.97] or MCF [M (51-54) ± SD (9-10); p = 0.90] or ML [M (9-10) ± SD (4-5); p = 0.89] between the compartments, i.e., MCV vs. HV/ICV vs. PV vs. TIPS. Overall, we detected no differences in coagulation function between PERC and PORC. These results are in contrast to previous reports suggesting increased clotting activity in PORC vs. PERC in association with liver cirrhosis. Rotational thromboelastometry-based evaluation of coagulation function in PERC appears to reliably reflect coagulation function in PORC with respect to risk estimation for TT and/or PVT in cirrhotic patients undergoing TIPS.

Pulmonary Artery Systolic Pressure and Cava Vein Status in Acute Heart Failure with Preserved Ejection Fraction: Clinical and Prognostic Implications

Peak tricuspid regurgitation (TR) velocity and inferior cava vein (ICV) distention are two recognized features of increased pulmonary artery pressure (PASP) and right atrial pressure, respectively. Both parameters are related to pulmonary and systemic congestion and adverse outcomes. However, few data exist about the assessment of PASP and ICV in acute patients affected by heart failure with preserved ejection fraction (HFpEF). Thus, we investigated the relationship existing among clinical and echocardiographic features of congestion, and we analyzed the prognostic impact of PASP and ICV in acute HFpEF patients. We analyzed clinical congestion PASP and ICV value in consecutive patients admitted in our ward by echocardiographic examination using peak Doppler velocity tricuspid regurgitation and ICV diameter and collapse for the assessment of PASP and ICV dimension, respectively. A total of 173 HFpEF patients were included in the analysis. The median age was 81 and median left ventricular ejection fraction (LVEF) was 55% [50-57]. Mean values of PASP was 45 mmHg [35-55] and mean ICV was 22 [20-24] mm. Patients with adverse events during follow-up showed significantly higher values of PASP (50 [35-55] vs. 40 [35-48] mmHg, (p = 0.005) and increased values of ICV (24 [22-25] vs. 22 [20-23] mm, p < 0.001). Multivariable analysis showed prognostic power of ICV dilatation (HR 3.22 [1.58-6.55], p = 0.001) and clinical congestion score ≥ 2 (HR 2.35 [1.12-4.93], p = 0.023), but PASP increase did not reach statistical significance (p = 0.874). The combination of PASP > 40 mmHg and ICV > 21 mm was capable of identifying patients with increased events (45% vs. 20%). ICV dilatation provides additional prognostic information with respect to PASP in patients with acute HFpEF. A combined model adding PASP and ICV assessment to clinical evaluation is a useful tool for predicting HF related events.

Association of bilateral inferior vena cava with azygos and hemiazygos continuation and aortic coarctation in a child

Introduction. Developmental variations of the inferior cava vein (IVC) rarely cause symptoms, and they were detected during routine examinations performed for other reasons. The prevalence in the general population is between 0.07% and 8.7%. Various anomalies of the IVC can be seen depending on abnormal regression or abnormal persistence of embryonic veins. They are usually associated with more complex intracardiac and atrioventricular septal defects, partial anomalous pulmonary venous connection, and pulmonary atresia. Case Outline. We presented the 18th-month-old patient with double IVC, IVC interruption, azygos, and hemiazygos continuation associated with aortic coarctation. The vein malformation was discovered during percutaneous balloon angioplasty of the aortic re-coarctation and confirmed by using cross-sectional imaging modalities. Our patient had no symptoms of IVC malformation. Conclusion. In clinical practice, double IVC should be suspected in patients with recurrent pulmonary emboli. Another important point in practice is the identification of those anomalies to avoid potential complications of retroperitoneal surgery and cannulation during cardiac surgery

1132 CATHETER INTERVENTION TO TREAT MIGRATED TEMPORARY EPICARDIAL PACING WIRE INTO THE PULMONARY ARTERY

Abstract Catheter intervention to treat migrated temporary epicardial pacing wire into the pulmonary artery Introduction Temporary epicardial pacing wires (TEPW) are routinely inserted postoperatively for treating electrophysiological disturbances after open-heart surgeries. They are typically placed on the surface of the right ventricle and the right atrial appendage. They are usually removed before discharge, but in case of difficult removal, they are cut flush to the skin, and thus retained. Leaving TEPW can be associated to complications, especially with wires migration. As described in literature, TEPW migration is rare and typically involves the right side of the heart, even if any part of the body can be involved. A review proposed an algorithm for removal decision making, based on the risk of serious complications like infection, dissection and perforation. We present a case of a transcatheter removal of a TEPW migrated into the pulmonary artery, in an asymptomatic patient. Case presentation A 52 year-old man, with previous history of Hodgkin Lymphoma treated with radiotherapy and Chemotherapy; CAD (inferior AMI treated with CABG); constrictive pericarditis causing many on-hospital admissions for heart failure; valvular disease: together with the CABG intervention, in 2012, he underwent mitral valvular repair and aortic valvuloplasty; in 2018, because of mitral valve repair failure, he underwent mitral valve substitution with a mechanic valve together with tricuspid repair; in the same year, because of worsening aortic regurgitation, he underwent TAVI. During routine follow-up exams, three years later, in 2021, the patient underwent a total body CT scan that showed the presence of a hyperintensity signal in the region between the right atrium and the right ventricle, crossing the tricuspid valve, with a final loop in the right ventricle infundibulum, suspected to be a TEPW. A transthoracic echocardiogram confirmed the position of the extraneous body, that was causing no impingement to the leaflets of the tricuspid valve, without worsening tricuspid regurgitation. A fluoroscopy showed the presence of a metallic wire, divided into two segments, the former extended from the right atrium till the right subclavian vein passing through the superior cava vein; the latter extended from the right ventricle till the left pulmonary artery. The patient underwent a transcatheter intervention with a right femoral vein access, to try to remove the TEPWs. The former located in the right atrium had a extravascular location, so it was left inside. The other one was removed. After advancing a Swan-Ganz catheter into the pulmonary artery, it was exchanged with a multipourpose catheter and a Multi-Snare 20 mm retrieval system captured the wire and dragged till the inferior cava vein; a second retrieval system, a Snare STD 12-20 mm, was finally able to anchor firmly the wire and to carry it outside. No complications occurred after the procedure; an echocardiogram excluded intracardiac problems. The patient was discharge the day after the procedure, in good clinical conditions. Discussion In this case, a transcatheter removal of the TEPW was performed, even if the presence of the wires caused no symptoms and/or complications to the patient. Anyway, because of the presence of both a prosthetic valve and a mechanic valve, in a setting of constrictive pericarditis and the consequent possibility of several in-hospital admission in conditions of acute heart failure with worsening of tricuspid regurgitation, the persistence of the wire could represent a risk factor for infective endocarditis and for severe tricuspid regurgitation. Removing it with a fast and safe transcatheter femoral approach, a potential cause of other complications was avoided.

1002 A HEART BEYOND A MIRROR: WHEN CCTGA ENCOUNTERS SITUS VISCERUM INVERSUS

Abstract Background Congenitally corrected transposition of great arteries (ccTGA) is an uncommon complex congenital heart disease with atrio-ventricular and ventriculo-arterial connections discondance. ccTGA may be associated with a situs solitus or situs inversus (34% of cases). Situs inversus is a mirror image of normal with the systemic ventricle situated on the right side. Instead, dextrocardia represents 20% of cases. Case clinic and discussion Came to our observation a 61 years old female, symptomatic for dyspnea on exertion (NYHA II). She had no past medical history of cardiovascular events. In anamnesis two full-term pregnancies without complications. Transthoracic echocardiogram found atrioventricular and ventriculo-arterial discordance in absence of significant valvulopathy. Cardiac computed tomography showed pulmonary veins linked to right atrium, superior and inferior cava veins connected to the left atrium; right atrium with tricuspid valve was connected to a morphologically left ventricle and left atrium with mitral valve was linked to morphologically right ventricle; pulmonary artery was connected to morphologically left ventricle instead aorta with aortic valve was linked to morphologically right ventricle. Cardiac MRI confirmed cctga in situs viscerum inversus, mild subpulmonary stenosis, moderate dilatation of arterial pulmonary trunk, and also intramyocardial late gadolinium enhancement due to fibrosis involving anterior and inferior interventricular junctions. Cardiac Holter monitoring showed sinus rhythm with some brief phases of low atrial rhythm, monomorphic isolated ventricular extrasystoles in absence of significant hyperkinetic or hypokinetic arrhythmias. CcTGA represents approximately 0.5% of all congenital heart disease. If undiagnosed in childhood, people usually become symptomatic during the first decades of life. Dyspnea, syncope and fatigue are the most frequent symptoms detected. Cardiac conduction disorders such as atrioventricular blocks are common due to the abnormal development of cardiac structures. Quality of life and its expectancy are related to the latency of the onset of heart failure symptoms. Only few patients remain asymptomatic beyond 50 years old. Symptoms and signs are frequently due to right sided (systemic) heart dysfunction and tricuspid valve insufficiency. A particular clinical situation worthy of attention is pregnancy because of the hemodynamic imbalance occurring. In fact, cardiac output increases of 40–50% above baseline determining an augmentation of stroke volume and heart rate. For these reasons, echo surveillance is needed every 4-8 weeks because of the increased risk of acute heart failure. An accurate assessment of heart rhythm has to be done due to the known predisposition to bradyarrhythmic and tachyarrhythmic events in ccTGA. Conclusions CcTGA patients require a strict cardiological follow up with echocardiographic assessment and periodic heart rhythm monitoring, in order to early detect worsening of cardiac function and significant abnormalities of the rhythm.

Pilot study on the effect of grape seed proanthocyanidin extract on inferior vene cava blood flow in patients with chronic venous insufficiency using 4D flow MRI.

Four-dimensional (4D) flow magnetic resonance imaging (MRI) was used to objectively assess changes in blood flow velocity in patients with chronic venous insufficiency (CVI) who underwent stocking treatment alone and stocking combined with Grape seed proanthocyanidin extract (GSPE) treatment. Patients diagnosed with CVI were recruited from August 31, 2018 to December 31, 2020. A total of 23 participants were selected, with 10 and 13 patients in the stocking treatment and stocking + GSPE treatment groups, respectively. The blood flow velocity (Th-plane peak and average velocities) was calculated using 4D flow MRI. A paired t test was used to evaluate the differences in blood flow velocity before and after treatment. In the stocking treatment group, The Th-Plane peak velocity increased by 2.48 ± 5.05 cm/s after treatment (P = .16). In the stocking + GSPE treatment group, the Th-Plane peak velocity increased by 4.85 ± 5.57 cm/s after treatment (P < .001). The blood flow velocity on 4D flow MRI was significantly increased in participants who underwent GSPE, highlighting the potential of GSPE for CVI treatment.