Exercise intolerance is an important comorbidity in patients with CKD. Anaerobic threshold (AT) determines the upper limits of aerobic exercise and is a measure of cardiovascular reserve. This study investigated the prognostic capacity of AT on survival in patients with advanced CKD and the effect of kidney transplantation on survival in those with reduced cardiovascular reserve. Using cardiopulmonary exercise testing, cardiovascular reserve was evaluated in 240 patients who were waitlisted for kidney transplantation between 2008 and 2010, and patients were followed for #5 years. Survival time was the primary endpoint. Cumulative survival for the entire cohort was 72.6% (24 deaths), with cardiovascular events being the most common cause of death (54.2%). According to Kaplan-Meier estimates, patients with AT ,40% of predicted peak VO 2 had a significantly reduced 5-year cumulative overall survival rate compared with those with AT $40% (P,0.001). Regarding the cohort with AT ,40%, patients who underwent kidney transplantation (6 deaths) had significantly better survival compared with nontransplanted patients (17 deaths) (hazard ratio, 4.48; 95% confidence interval, 1.78 to 11.38; P=0.002). Survival did not differ significantly among patients with AT $40%, with one death in the nontransplanted group and no deaths in the transplanted group. In summary, this is the first prospective study to demonstrate a significant association of AT, as the objective index of cardiovascular reserve, with survival in patients with advanced CKD. High-risk patients with reduced cardiovascular reserve had a better survival rate after receiving a kidney transplant.

BackgroundThere is currently no effective preoperative assessment for patients undergoing kidney transplantation that is able to identify those at high perioperative risk requiring admission to critical care unit (CCU). We sought to determine if functional measures of cardiovascular reserve, in particular the anaerobic threshold (VO2AT) could identify these patients.MethodsAdult patients were assessed within 4 weeks prior to kidney transplantation in a University hospital with a 37-bed CCU, between April 2010 and June 2012. Cardiopulmonary exercise testing (CPET), echocardiography and arterial applanation tonometry were performed.ResultsThere were 70 participants (age 41.7±14.5 years, 60% male, 91.4% living donor kidney recipients, 23.4% were desensitized). 14 patients (20%) required escalation of care from the ward to CCU following transplantation. Reduced anaerobic threshold (VO2AT) was the most significant predictor, independently (OR = 0.43; 95% CI 0.27–0.68; p<0.001) and in the multivariate logistic regression analysis (adjusted OR = 0.26; 95% CI 0.12–0.59; p = 0.001). The area under the receiver-operating-characteristic curve was 0.93, based on a risk prediction model that incorporated VO2AT, body mass index and desensitization status. Neither echocardiographic nor measures of aortic compliance were significantly associated with CCU admission.ConclusionsTo our knowledge, this is the first prospective observational study to demonstrate the usefulness of CPET as a preoperative risk stratification tool for patients undergoing kidney transplantation. The study suggests that VO2AT has the potential to predict perioperative morbidity in kidney transplant recipients.

We would like to draw attention to a useful radiological sign indicating that a percutaneous central venous catheter may be in the ascending lumbar vein. In our neonatal unit there have been two confirmed cases where the ascending lumbar vein had inadvertently been cannulated. In both these cases a loop in the line had been noted in the region of the ileo-femoral vein (see figs 1 and 2). This ''looping'' or bend in the line is also seen in the picture recently published by De, 5 and in other papers. 1-3 That this complication occurs almost exclusively on the left 2 has been attributed to the unique anatomy of the left ileo-femoral vein compared to the right. 1 We believe that the local anatomy of the left ileo-femoral vein may also explain why the line loops when inadvertently entering the left ascending lumbar vein (fig 3). One can appreciate that, when the ascending lumbar vein is seen on the lateral 1 and lateral-oblique view, 4 and compared with the anterior posterior view, the vein can be seen to descend into the pelvis and then enter the ascending lumbar vein at an angle. On an x ray the line will then project a loop or bend. Another factor that may contribute to the appearance of the loop or bend is that it is probably difficult to advance the line up the narrow ascending lumbar vein, and therefore when trying to thread the line to its calculated length the line will ''buckle'' at this point. Any loop or bend of a contrast filled line in the left ileo-femoral region should be regarded as a sign that the line has entered the ascending lumbar vein and pull the line back because the lumbar venous plexus will not always be visualised with contrast. There are serious complications of an unrecognised malpositioned long line. 2 We feel that awareness of this radiological sign would facilitate early recognition and would prevent serious morbidity.

Background: Coronary artery disease is the leading cause of death in the world. Advancing age is a well-recognized risk factor for acute myocardial infarction (AMI). Myocardial infarction is less common in young adults. Prevalence of acute coronary syndrome in young individuals is increasing progressively. These patients have different risk profile, presentation and prognosis. Early recognition and risk factor modification in this population sub-set is of key importance. Objectives: The purpose of the present study was to determine the differences in risk factors and coronary angiographic profile of young patients with ST-segment elevated myocardial infarction (STEMI) vs. those with non-ST-segment elevated myocardial infarction (NSTEMI). Methods: In this cross sectional analytical study total 135 patients (70 STEMI and 65 NSTEMI) aged ≤45 years were enrolled to see the differences of risk factors and angiographic profile. Results: The mean age of the study population was 39.39±5.12 years and the study showed male predominance (90.40 % was male and 9.60 % was female). Smoking/tobacco consumption was significantly higher in STEMI patients, whereas diabetes mellitus and hypertension were more prevalent in NSTEMI patients. The frequency of single vessel disease and involvement of left anterior descending artery was significantly higher in young STEMI patients. In case of young NSTEMI patients frequency of triple vessel disease, noncritical coronary artery disease and involvement of left circumflex coronary was significantly higher. The frequency of double vessel disease and involvement of left main coronary artery was also nonsignificantly higher in young NSTEMI patients. There was no significant difference regarding involvement of right coronary artery. Conclusion: There are significant differences between young STEMI and young NSTEMI patients in respect to risk factors and angiographic profile. Key words: Young patient, STEMI, NSTEMI, Risk factors, Coronary angiographic profile. Bangladesh Heart Journal 2021; 36(2): 124-132

Background: ST segment elevation myocardial infarction (STEMI) is associated with ventricular dysfunction due to ischemic myocardial damage, decrease ventricular compliance and increase filling pressure resulting in left atrial stretching, dilatation, increase left atrial volume and subsequently increase secretion of atrial natriuretic peptides. This study is aimed to determine the association between increase left atrial volume index (LAVI) and in-hospital outcome and to explore the correlation between LAVI and NT-proBNP in patients suffered from acute ST segment elevation myocardial infarction (STEMI). Methods: This cross sectional analytic study include 92 patients with acute STEMI admitted for reperfusion therapy. 2D Echocardiography was done and based on LAVI, study population were grouped as Group A:LAVI >34 ml/m2 (n=48) & Group B:LAVI d”34 ml/m2(n=44). Results: In-hospital outcome, plasma level of NT-proBNP and echcardiographic evaluation was done successfully. Mean NT-proBNP was significantly high in Group A than Group B (1234.6±738.77 vs 689.52±721.04). Statistically significant association was present between LAVI and adverse in-hospital outcome. Persistent chest pain, hypotension, acute LVF, arrhythmia, acute kidney injury were higher in Group A than Group B and acute LVF occurred significantly (p<0.05) more in Group A than Group B (38.3% vs. 9.1%). Statistically significant correlation was present between LAVI and NT-proBNP (r=0.453; p=0.001). According to receiver-operating characteristic curve (ROC) analysis, LAVI with a cut off value of 33.75 ml/m2 can predict adverse in-hospital outcome in patients of acute STEMI underwent reperfusion therapy with sensitivity 66.2% and specificity 75% and better than NT-proBNP with more sensitivity (66.2% vs 50.0%). Conclusion: Significant association present between increase LAVI and adverse in-hospital outcome and it can predict adverse in-hospital outcome better than NTproBNP. There is also positive correlation between LAVI and NT-proBNP in acute STEMI. Bangladesh Heart Journal 2023; 38(1): 46-57