Clinical Hemorheology and Microcirculation - Volume 70, issue 4

Authors: Shin, Eun-Seok | Park, Seung Gu | Saleh, Ahmed | Lam, Yat-Yin | Bhak, Jong | Jung, Friedrich | Morita, Sumio | Brachmann, Johannes

Article Type: Research Article

Abstract: BACKGROUND: Magnetocardiography (MCG) has been proposed as a non-invasive and functional technique with high accuracy for diagnosis of myocardial ischemia. OBJECTIVE: This study sought to develop a novel scoring system of MCG for predicting the presence of significant obstructive coronary artery disease (CAD). METHODS: In a training set of 108 subjects, predictors of ≥70% stenosis in at least one major coronary vessel were prospectively identified from MCG variables. The final model was then retrospectively validated in a separate set of 45 subjects. RESULTS: In the multivariable logistic regression, among those …in the training set, elevated scores were predictive of ≥70% stenosis in all subjects (OR: 40.85; 95% CI: 6.28–265.90; p  < 0.001). In the validation set, the score had an area under the receiver-operating characteristic curve of 0.91 (p  < 0.001) for ≥70% stenosis. At an optimal cutoff, the score had 89% sensitivity, 77% specificity, 74% positive predictive value (PPV), 91% negative predictive value (NPV), and 82% accuracy for ≥70% stenosis. Partitioning the score into three levels of predicted risk, 91% of subjects could be identified or excluding CAD (81% PPV and 84% NPV). CONCLUSION: We described an MCG score with high accuracy for predicting the presence of anatomically significant CAD. Show more

Keywords: Magnetocardiography, scoring, coronary artery disease, diagnosis

DOI: 10.3233/CH-189301

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 365-373, 2018

Authors: Gori, Tommaso | Anadol, Remzi

Article Type: Research Article

Abstract: Up to 50% of the patients undergoing coronary angiography present no epicardial disease. Most of these patients are women. Takotsubo cardiomyopathy, coronary microvascular dysfunction, and spontaneous coronary artery dissection are the most common syndromes that affect these patients. Their mechanisms are complex, with a interplay between neurohormonal factors and a number of other systems. The present review describes how changes in the estrogen state may lead to changes in vasomotor tone and endothelial dysfunction which result in coronary epicardial and microvascular spasm and coronary arterial wall instability in these three conditions. The sex-dependent differences in prevalence, pathogenesis, and prognosis are …described. Show more

Keywords: Tako-tsubo, microvascular disease, sex

DOI: 10.3233/CH-189302

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 375-379, 2018

Authors: Reinthaler, Markus | Jung, Friedrich | Empen, Klaus

Article Type: Research Article

Abstract: BACKGROUND: Remote ischemic preconditioning (RIPC) has been demonstrated to induce potent cardioprotection in individuals experiencing coronary ischemia. A protocol combining limb ischemia and electronic muscle stimulation of the ischemic skeletal muscle (RIPC+), performed in advance of coronary artery occlusion, was superior in terms of infarct size reduction when compared to RIPC alone. METHODS: This study was performed to evaluate the benefit of RIPC + in humans compared to a standard RIPC protocol and a control group. Patients with a single vessel coronary artery disease undergoing elective PCI were eligible to participate in this study. ST-segment elevations from an …intracoronary ECG during 3 brief episodes of coronary artery balloon occlusions/dilatation were used as the primary endpoint. RESULTS: ST-elevations significantly declined from the first to the third angioplasty in the control but remained at the same level in the RIPC and RIPC+groups. The RIPC group was characterized by the lowest ST-segment shift during coronary ischemia, which was comparable to coronary balloon occlusion number 3 in the control group, indicating successful preconditioning by the conventional RIPC method. In contrast, ST segment elevations were significantly higher in the RIPC + group. Troponin levels taken 24 h after the study procedure were significantly lower in the RIPC when compared to the control and the RIPC + group. CONCLUSION: Our results again confirm the feasibility of remote ischemic preconditioning in patients undergoing coronary angioplasty. According to our results ischemia combined with electronic skeletal muscle stimulation was not superior to conventional RIPC cycles (skeletal muscle ischemia alone). Show more

Keywords: Coronary artery disease, percutaneous coronary intervention, remote ischemic preconditioning

DOI: 10.3233/CH-189303

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 381-389, 2018

Authors: Gerk, U. | Franke, R.P. | Krüger-Genge, A. | Jung, F.

Article Type: Research Article

Abstract: BACKGROUND: Contrast-induced acute kidney injury (CI-AKI), a potentially life-threatening complication of iodinated contrast media in patients with impaired renal function, has attracted increasing attention in recent years. There is overwhelming evidence that the most important pre-disposing factor for a contrast-medium induced nephropathy is the pre-existence of a renal impairment. METHODS: The registry was performed as a part of a quality management project in the Dresden-Friedrichstadt heart catheter laboratory. In compliance with the Declaration of Helsinki/Somerset West, 9,026 patients were included between 2010 and 2015. 100 patients of these were participants in a chronic dialysis program. All …patients were dialyzed on the day before angiography. In all patients a coronary angiography, in 28 patients a stent implantation and in 12 patients a surgical reconstruction had to be performed. Prior to the intervention and one, two and three days thereafter the serum creatinine was measured. RESULTS: Up to the third day after application of the iodinated contrast medium no significant changes of the serum creatinine (baseline value: 423.3±42.6μ mol/l) occurred (ANOVA for repeated measures: p  = 0.507). On average, a slight decrease of the serum creatinine was found. All patients remained in their routine dialysis-program. 18 out of 100 died during the next three months after the procedure. CONCLUSION: The study revealed that the coronary angiography using Iodixanol as iodinated contrast medium did not result in an increase of serum creatinine, which was drastically elevated in these patients before application of the iodinated contrast medium. Show more

Keywords: Keywords: Iodixanol, renal insufficiency, dialysis, serum creatinine

DOI: 10.3233/CH-189304

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 391-398, 2018

Authors: Ahmed, Misbah Shireen | Lutze, Stine | Tembulatow, Movsar | Daeschlein, Georg | Jünger, Michael | Arnold, Andreas

Article Type: Research Article

Abstract: BACKGROUND: Chronic venous disease (CVD) is extremely common worldwide. The prevalence is increasing with age and is associated with a reduced quality of life, particularly in relation to pain, physical function and mobility. Symptomatic chronic venous insufficiency (CVI) with venous ulcer at its’ endpoint, indicates interventional surgery to cure venous reflux therewith promoting wound healing and preventing recurrence. To our knowledge up to now no coherent study has been undertaken in patients with CVI who underwent an open venous surgery concerning complications, venous hemodynamics and perioperative symptomology in one study population. This was undertaken in our retrospective, single-centre, consecutive …case-control study in a single patient population of a university clinic in northern Germany. Part I covers postoperative complications in relation with co-morbidities, co-medication and clinical presentation. Part II will focus on pre- and postoperative hemodynamics and evolution of symptoms. METHODS: Records of n  = 429 (467 extremities) patients from 2009–2013 treated with open surgery were analysed. Number and type of complication were evaluated with regards to demographic parameters, co-existing medical conditions and procedure related aspects. Complications were grouped as no events (NE), neglectable adverse events (NAE), non-neglectable adverse events (NNAE) and severe (life-threatening) adverse events (SAE). RESULTS: In 467 extremities of 429 patients with CVI 130 (27,84%) postoperative complications were observed after open surgery, thereof 64 (13,7%) NAE, 66 (14,14%) NNAE and 0 SAE. 29 (6,76%) patients developed a postoperative surgical site infection, thereof 4 (0,9%) with consecutive septicaemia. Except one case with nerval lesion and paraesthesia and hypoesthesia not resolving after 12 months all complications resolved within surveillance time span of 12 months. Patients developing NAE had a higher BMI (p  = 0.003), were more likely to have diabetes mellitus (p  < 0.001), and co-morbidities leading to the intake of anti-platelet or anticoagulation drugs (p  < 0.001). Metabolic syndrome (p  < 0.001) and anti-platelet or anticoagulation (p  < 0.001) could be defined as independent risk factors for the development of complications. Patients receiving open surgery of small saphenous veins had 8 times higher risk of calf muscle venous thrombosis (p  = 0.001). CONCLUSION: Patients with a metabolic syndrome or receiving anti-platelet therapy or anticoagulation medication should undergo open venous surgery under hospital conditions with routine postinterventional surveillance visits. Patients undergoing an open surgery of SSV are definite candidates for postoperative subcutaneous heparin thromboprophylaxis. In general stripping below knee increases the risk of postoperative sensory deficit. This resolves in almost all patients within one year. Show more

Keywords: Keywords: Venous surgery, postoperative complication, risk factors for complications, surgical site infections, post-operative thrombosis, paraesthesia

DOI: 10.3233/CH-189305

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 399-411, 2018

Authors: Preuss, Stephanie | Rother, Charlotte | Renders, Lutz | Wagenpfeil, Stefan | Büttner-Herold, Maike | Slotta-Huspenina, Julia | Holtzmann, Christopher | Kuechle, Claudius | Heemann, Uwe | Stock, Konrad Friedrich

Article Type: Research Article

Abstract: INTRODUCTION: Allograft rejection (AR), chronic allograft injury (CAI) and acute tubular necrosis (ATN) can lead to renal allograft dysfunction after kidney transplantation. Interstitial fibrosis/tubular atrophy (Banff classification 2005) describes chronic allograft injury with no specific etiology, thus explaining the common final endpoint of various (immunologic and non immunologic) etiologies. The aim of this study was to evaluate correlations between the Doppler sonographic RI-values and histopathological changes of renal allografts biopsies during rejection, acute tubular necrosis and chronic allograft injury as well as the influence of donor and recipient features on the intrarenal RI-values. METHODS: 102 allograft biopsies and …ultrasound reports of 69 patients with kidney transplantation performed at the hospital Klinikum rechts der Isar (Technische Universität München, Germany) between 2009 and 2013 were analyzed retrospectively (41 biopsies of living donors, 61 biopsies of deceased donors). Chronic allograft injury was described using the IFTA (interstitial fibrosis and tubular atrophy) or the ECAI score (extended chronic allograft injury score). The ECAI score was built out of the chronic histological lesions glomerulopathy, interstitial fibrosis, tubular atrophy and fibrous intimal thickening (cg + ci + ct + cv) of the BANFF scoring. RESULTS: Intrarenal RI-values were significantly higher in patients with allograft rejection than without rejection (median 0,79 vs. 0,73; inter quartile range: 0,20 vs. 0,13; p  = 0,018). The same was found for T-and non-T cell mediated rejection (median 0,78 vs. 0,73; inter quartile range 0,20 vs. 0,13; p  = 0,039). There were no significant differences in the RI-values between the subtypes of T-cell mediated rejection (type IA-IIB). Furthermore, there were no significant differences of RI-values regarding antibody-mediated rejection (present vs. not present) or type of rejection (T-cell- vs. antibody mediated rejection). Patients with rejection and simultaneously chronic allograft injury showed significantly higher RI-values than patients with only chronic allograft injury. Analyses using the IFTA or the ECAI score showed comparable results (IFTA p  = 0,043; Score p  = 0,021). The intrarenal RI-value was neither able to detect chronic allograft injury nor to distinguish between acute tubular necrosis and rejection. The intrarenal RI-value showed a significant correlation with recipient age (p  < 0,001) but not with donor features. CONCLUSION: In summary, the intrarenal RI-value can indicate a rejection but gives no clear hint to acute tubular necrosis and cannot differentiate from it. Since patients with rejection can have normal RI-values, a biopsy should always be performed in case of suspected rejection. The intrarenal RI-value has no unambiguous validity to determine intrinsic values of the renal allograft, but should rather be understood and interpreted as a systemic parameter influenced by multiple factors. Show more

DOI: 10.3233/CH-189306

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 413-422, 2018

Authors: Platz Batista da Silva, Natascha | Jung, Ernst Michael | Jung, Friedrich | Schlitt, Hans J. | Hornung, Matthias

Article Type: Research Article

Abstract: AIM: Aim of this study was to firstly describe reproducible, objective perfusion parameters of contrast-enhanced ultrasound (CEUS) kinetics of parathyroid gland adenoma (PA) using perfusion analysis software (VueBox® , Bracco, Italy). Thereby the efficiency of quantitative CEUS for characterization of PA should be evaluated comparing US to postoperative histopathological findings after PA resection. MATERIAL AND METHODS: 42 patients with symptoms/lab work suggestive of pHPT presented a parathyroid gland lesion in B-mode US, which was consequently analyzed by dynamic CEUS. CEUS was performed by one experienced examiner after i.v.-injection of max. 2.4 ml sulphurhexaflouride microbubbles saving digital DICOM cine …loops (up to 25 s) and images. PA were evaluated during arterial, venous and late phase (up to 3 min.) for perfusion characterization. A retrospective, blinded VueBox® perfusion analysis of arterial phase of 28/42 PA was performed by a second, independent examiner placing 3 ROIs manually in the PA (center, rim of PA, surrounding thyroid gland tissue) to objectify findings. US findings were correlated to postoperative histology after PA resection. RESULTS: Out of 42 patients with PA findings in CEUS, perfusion analysis could be performed in 28/42 cases only as some CEUS cine loops had too much moving. In three cases the second examiner could not detect PA retrospectively, in 25 cases PA were characterized correctly resulting in a sensitivity rate of 89.3 %. VueBox® perfusion analysis confirmed that PA present a persisting hypervascularization of the rim with higher TTP (mean 7.93 s centrally, 8.36 s rim-sided), mTT (mean 56.6 s centrally, 64.5 s rim-sided) and lower PE (mean 10542.93 rm2 centrally, 8909.21 rm2 rim-sided) peripherally followed by a central wash-out during later phases. RT was comparable in all defined regions. CONCLUSION: VueBox® analysis of parathyroid gland CEUS examinations seemed to be a valuable tool for quantification of a PA’s perfusion and can help to detect and localize hyperfunctional parathyroid glands prior to surgery. Show more

Keywords: Contrast-enhancend ultrasonography, 99mTechnetium-sestamibi scintigraphy, diagnostics of primary hyperparathyroidism, VueBox® , CEUS perfusion quantification, parathyroid gland adenoma

DOI: 10.3233/CH-189307

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 423-431, 2018

Authors: Schlenker, B. | Apfelbeck, M. | Buchner, A. | Stief, C. | Clevert, D.-A.

Article Type: Research Article

Abstract: INTRODUCTION: Prostate cancer (PCa) is one of the most common malignancies in men. The diagnostic standard to confirm prostate cancer is the transrectal ultrasound-guided biopsy. However, this procedure is associated with the underdetection of clinically significant prostate cancer and therefore needs to be improved. In the last years MRI fusion based targeted biopsy gained importance as consequence. In this study, we evaluated the quality of MRI ultrasound image fusion and evaluated factors influencing the image fusion quality. This was done by comparing fusion quality with the histopathological findings in the defined MRI target on the one hand and the PIRADS …score on the other hand. MATERIALS AND METHODS: Single arm study including patients with elevated prostate specific antigen (PSA) and a multiparametric MRI showing a suspicious lesion underwent a MRI fusion targeted biopsy at our institution. MRI fusion targeted biopsy and an additional 12-core transrectal ultrasound (TRUS) guided biopsy was performed using the Philips Percunav device (Philips Medical Systems, Bothell, WA). The fusion accuracy was rated by two experienced clinicians (1 radiologist, 18 years of experience, 1 urologist, 5 years of experience) using a five-point rank scale (1 = best) and comparing the result with the histological findings in the target and the PIRADS score. RESULTS: The detection rate of clinically significant cancer (Gleason 7a or greater) by MRI-ultrasound fusion targeted biopsy was 58.6% (17/29) compared to 50% (19/38) in the standard transrectal ultrasound-guided approach. PCa was found in 36.4% (4/11 patients) of patients with a PIRADS 3 lesion, in 57.7% (15/26 patients) of patients with a PIRADS 4 lesion. In 76.9% (10/13 patients) of patients with a PIRADS 5 lesion PCa was diagnosed. No statistical significance was found comparing the quality of registration either with the PIRADS (p = 0.7873) nor with the Gleason score (p = 0.4376). The study is limited by the small number of patients. CONCLUSIONS: MRI fusion based targeted biopsy improves the identification of clinical significant cancer. The Gleason score of detected PCa is not influenced by the quality of fusion. Show more

Keywords: Transrectal ultrasound-guided biopsy, image fusion, prostate, prostate cancer, multiparametric MRI

DOI: 10.3233/CH-189308

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 433-440, 2018

Authors: Aung, T. | Heidekrueger, P.I. | Geis, S. | Von Kunow, F. | Taeger, C. | Strauss, C. | Wendl, C. | Brebant, V. | Broer, P.N. | Prantl, L. | Hillmann, A.

Article Type: Research Article

DOI: 10.3233/CH-189309

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 441-447, 2018

Authors: Schwarze, V. | Mueller-Peltzer, K. | Negrão de Figueiredo, G. | Lindner, F. | Rübenthaler, J. | Clevert, D.-A.

Article Type: Research Article

Abstract: BACKGROUND: Hepatic echinococcosis (HE) is a zoonosis and depicts a rare but potentially lethal disease caused by larval infestation of E. multilocularis ( alveolar echinococcosis, AE) and E. granulosus ( cystic echinocococcosis, CE). In many countries, HE is a critical public health problem. Clinically, HE patients initially are often asymptomatic for years. Depending on the echinococcal manifestations patients can later develop unspecific symptoms as fatigue, abdominal pain and may present with elevated transaminases, jaundice and hepatomegaly. The combination of grey scale ultrasound and serological tests has been the gold standard for the screening and diagnosis of HE. Besides MRI, CT …and FDG-PET scans, safe and directly accessible contrast-enhanced ultrasound (CEUS) may easily help to indirectly describe perilesional inflammation. Upon diagnosis of HE, an appropriate therapeutical strategy should be evaluated in a multidisciplinary way. OBJECTIVE: The aim of the present retrospective monocenter study is to assess the diagnostic performance of CEUS examination in the evaluation of hepatic echinococcal manifestation by comparison with CT, MRI, FDG-PET scans and histopathology. METHODS: Out of 36 patients with echinococcal disease (16 patients with E. multilocularis infection, 12 patients with E. granulosus infection and 8 patient with unspecified Echinococcus infection) 8 HE patients (4 patients with E. multilocularis , 2 patients with E. granulosus and 2 patients with unspecified echinococcal liver disease) were included in this study on whom CEUS was performed between 2008–2016. The applied contrast agent was a second-generation blood pool agent (SonoVue ® , Bracco, Milan, Italy). CEUS examinations were performed and interpreted by a single experienced radiologist with more than 15 years of experience. RESULTS: All patients were examined without occurrence of any side effects. In all 4 AE patients, contrast enhancement could be detected by means of CEUS and was confirmed by MRI or PET-CT scan. In the remaining 4 patients (CE and unspecified echinococcosis), doppler ultrasonography, CEUS and corresponding CT or MRI scans could not detect any hypervascularization of the lesions of interest. The histopathological analysis did not reveal any viable parasite material. CEUS showed a sensitivity of 100% and a specificity of 100% compared to MRI, CT or FDG-PET-CT. CONCLUSIONS: CEUS depicts a safe method for the evaluation of echinococcal liver disease. In addition to serological tests and grey scale ultrasound, CEUS imaging could be integrated as an easily accessible tool helping to describe hypervascularization as a sonomorphological correlate for active perilesional inflammation of echinococcal manifestations. CEUS may further help to differentiate between CE and AE and also to evaluate treatment outcome. Show more

Keywords: Hepatic echinococcosis, alveolar echinococcosis, cystic echinococcosis, contrast-enhanced ultrasound, CEUS

DOI: 10.3233/CH-189310

Citation: Clinical Hemorheology and Microcirculation, vol. 70, no. 4, pp. 449-455, 2018