CARDIOLOGIE

CENTRUM CARDIOLOGIE

ARTIKELS

ABSTRACT 1

Image focus: renovascular hypertension.

Dhont S, De Niel C, Van Mieghem C, et al. Acta Cardiologica, 2019, [Epub ahead of print], 1-2

INTRODUCTION/BACKGROUND Four out of ten adults worldwide have arterial hypertension, in about 5–10% there is an identifiable cause named as secondary hypertension. Early detection and treatment of these entities are important to minimize/prevent irreversible changes in the vasculature and target organs. Renovascular hypertension results from a lesion that impairs blood flow to one or both kidneys.

CONCLUSION A 56-year-old man was referred because of resistant arterial hypertension. Lab results showed renal impairment after recently adding an angiotensin converting enzyme inhibitor: creatinine 1.83 mg/dL (baseline creatinine 0.93 mg/dL) corresponding to a calculated clearance of 41 ml/ min/1.73m2 according to the formula of CKD-EPI. A computer tomographic examination of the abdominal blood vessels showed an osteal occlusion of the right renal artery with a hypotrophic occurrence of the right kidney (Figure 1). Renin level on serum was 24.6 ug/L/h; normal values for patients older than 40 years are 0.6–3.0 ug/L/h. Additionally, a dimercaptosuccinic acid (DMSA) renal scan was performed to measure the kidney function: the right kidney turned out to be non-functional (almost absent captation, Figure 2). Studies with DMSA-scan present high specificity and are useful in patients with high probability for renovascular hypertension. After laparoscopic nephrectomy, the antihypertensive drugs could be systematically phased out. During the operation, the renal artery was dissected and confirmed the presence of severe atherosclerosis. Peri-operative renin levels showed extremely high values at the right renal vein and immeasurably low dosage at left renal vein (Table 1). The arterial stenosis thus causes local renal ischaemia which stimulates renin release and activation of the renin-angiotensinaldosterone system, which in turn results in secondary hypertension. ABSTRACT 2

Graft patency after FFR-guided versus angiographyguided coronary artery bypass grafting: the GRAFFITI trial.

Toth G, De Bruyne B, Van Mieghem C, et al. EuroIntervention, 2019, 15(11), e999-e1005

OBJECTIVE The aim of this study was to assess prospectively the clinical benefits of fractional flow reserve (FFR) in guiding coronary artery bypass grafting (CABG).

MATERIALS/METHODS GRAFFITI is a single-blinded, prospective, multicentre, randomised controlled trial of FFR-guided versus angiography-guided CABG. We enrolled patients undergoing coronary angiography, having a significantly diseased left anterior descending artery or left main stem and at least one more major coronary artery with intermediate stenosis, assessed by FFR. Surgical strategy was defined based on angiography, blinded to FFR values prior to randomisation. After randomisation, patients were operated on either following the angiography-based strategy (angiography-guided group) or according to FFR, i.e., with an FFR ≤0.80 as cutoff for grafting (FFR-guided group). The primary endpoint was graft patency at 12 months. Between March 2012 and December 2016, 172 patients were randomised either to the angiography-guided group (84 patients) or to the FFR-guided group (88 patients). The patients had a median of three [3; 4] lesions; diameter stenosis was 65% (50%; 80%), FFR was 0.72 (0.50; 0.82). Compared to the angiography-guided group, the FFR-guided group received fewer anastomoses (3 [3; 3] vs 2 [2; 3], respectively; p=0.004). One-year angiographic follow-up showed no difference in overall graft patency (126 [80%] vs 113 [81%], respectively; p=0.885). One-year clinical follow-up, available in 98% of patients, showed no difference in the composite of death, myocardial infarction, target vessel revascularisation and stroke.

CONCLUSION FFR guidance of CABG has no impact on one-year graft patency, but it is associated with a simplified surgical procedure.

ABSTRACT 3

High-sensitivity cardiac troponin release after conventional and minimally invasive cardiac surgery.

De Mey N, Cammu G, Van Mieghem C, et al. Anaesthesia and Intensive Care, 2019, 47(3), 255–266

INTRODUCTION/BACKGROUND After cardiac surgery, a certain degree of myocardial injury is common. The arbitrarily proposed biomarker cut-off point in the Third Universal Definition for diagnosing coronary artery bypass grafting (CABG)–related perioperative myocardial infarction (PMI) is controversial and unvalidated for non-CABG surgery. Minimally invasive cardiac surgery is often thought to be associated with less myocardial damage compared to conventional surgical approaches.

OBJECTIVE We therefore conducted a real-life prospective study with serial sampling of high sensitivity cardiac troponin T (hscTnT), the preferred cardiac biomarker in our institution, to determine its postoperative release pattern after conventional as well as minimally invasive cardiac surgery. Second, we compared hs-cTnT levels with the cut-off values for PMI described in the Third Universal Definition of PMI. Third, we sought to identify outcome-associated variables related to increased hs-cTnT release.

MATERIALS/METHODS We conducted a real-life prospective study with serial sampling of high-sensitivity cardiac troponin T (hs-cTnT) in patients undergoing conventional and minimally invasive cardiac surgery. Four different types of cardiac surgery were performed in 400 patients (February 2014–January 2015): CABG, aortic valve replacement, minimally invasive mitral/tricuspid valve surgery through the HeartPort (HP) technique and combined CABG/valve surgery. Each group was further subdivided for comparison between the different surgical techniques. Blood samples were collected consecutively at intensive care unit (ICU) admission and 3, 6, 9, 12, 18, 24 and 48 h thereafter.

RESULTS The hs-cTnT values by peak timepoint differed significantly depending on the surgical approach. The overall peak timepoint for hs-cTnT occurred 6 h after ICU admission. The combined surgery and multiple-valve HP groups had the highest values (medians of 1067.5 (744.9–1455) ng/L and 1166 (743.7–2470) ng/L, respectively). The peak hs-cTnT values for patients developing PMI showed high variability. CONCLUSION Differentiation between cardiac surgery–related necrosis and PMI remains challenging. This study emphasizes the importance of a clinically reliable biomarker cut-off value in addition to electrocardiography and echocardiography to optimize PMI diagnosis.

ABSTRACT 4

Secundaire hypertensie.

Dhont S, De Niel C, Van Mieghem C, et al. Tijdschrift voor Geneeskunde, 2020, 76(4), 128-132

INTRODUCTION/BACKGROUND Het behoud van een normale bloeddruk is essentieel voor een adequate orgaanperfusie. De drie belangrijkste factoren die de bloeddruk bepalen, zijn het sympathische zenuwstelsel, het renine-angiotensine-aldosteronsysteem (RAAS) en het bloedvolume. Hypertensie of verhoogde bloeddruk blijft de best behandelbare risicofactor voor vroegtijdige cardiovasculaire ziekte. De bloeddruk is een normaal verdeelde biologische variabele. De meest gangbare Europese criteria die worden gehanteerd ter definiëring van arteriële hypertensie, zijn samengevat in tabel 1. Bij meting in het dokterskabinet moet er bij herhaling een systolische bloeddruk opgemeten worden hoger dan of gelijk aan 140 mmHg en/of een diastolische druk hoger dan of gelijk aan 90 mmHg. Boven deze waarden wegen de voordelen van therapie ontegensprekelijk op tegen de risico’s. Doorgaans kent hypertensie geen eenduidige etiologie en spreekt men over „primaire”, „idiopathische” of „essentiële hypertensie”. Bij 5% tot 10% van de patiënten kan men echter een oorzaak aantonen. In die gevallen spreekt men over „secundaire hypertensie”. Men moet hieraan in het bijzonder denken bij een jonge patiënt met verhoogde bloeddrukken die resistent blijven tegen een combinatietherapie: per definitie drie voldoende hoog gedoseerde antihypertensiva van verschillende klassen (waaronder zeker een diureticum). Tijdige doorverwijzing en vroege detectie van een secundaire oorzaak van hypertensie zijn zeer belangrijk aangezien een snelle interventie curatief kan zijn. Op die manier wordt het levenslang innemen van antihypertensiva met de daaraan geassocieerde kosten en bijwerkingen vermeden. De diagnostische screening bestaat uit bloed- en urinetesten, abdominale beeldvorming en een echocardiografie. De belangrijkste entiteiten worden verder in dit artikel uiteengezet.

CONCLUSION Slechts bij 5% tot 10% van de hypertensieve patiënten vindt

men een aanwijsbare oorzaak en kan men spreken over secundaire hypertensie. Screening is duur en tijdrovend en wordt bij voorkeur enkel uitgevoerd bij patiënten met een sterk klinisch vermoeden. Vroegdetectie en een snelle behandeling zijn essentieel om een curatieve interventie toe te laten. Indien niet gediagnosticeerd, kan secundaire hypertensie leiden tot refractair verhoogde bloeddrukken, cardiovasculaire en renale complicaties en uiteindelijk tot een verhoogde morbiditeit en cardiovasculaire mortaliteit.