Cardiovascular pathology is frequent in systemic lupus erythematosus (SLE). Left ventricular (LV) diastolic dysfunction is its common findings. The aim of the study was to assess the systolic and diastolic function of the left ventricle (LV) in SLE patients without clinically evident cardiovascular disease, using pulsed Doppler echocardiography. Another purpose was to estimate whether there is a correlation between the duration and severity of SLE and the degree of LV diastolic dysfunction. A comparison of the average values of echocardiographic measurements was made between the SLE group and control group, which constituted healthy volunteers. No statistically significant differences in systolic heart function between groups were observed, except for lower values of the fractional shortening (SF 35.9 +/- 1.2 and 37.1 +/- 0.9, P = 0.01) in SLE patients, particularly in long (more than 10 years) disease duration (34.9 +/- 0.6 vs. 37.0 +/- 0.8, P < 0.005) and the value of SLE Disease Activity Index (SLEDAI) higher than six points (35 +/- 0.9 vs. 37.1 +/- 0.5, P < 0.01) Left atrial end-systolic diameter (LA) was greater (3.69 +/- 0.37 vs. 3.5 +/- 0.28, P < 0.05) and the ejection fraction (EF) was lower (64.6 +/- 1.5 vs. 66.3 +/- 1.3, P < 0.05) in SLE subjects of long disease duration than in the controls. SLE patients demonstrated significantly higher late diastolic velocity (A') and lower E'/A' ratio than the control group. No differences were observed in A' values between SLE subset of short disease duration and the controls. Isovolumetric relaxation time in turn was significantly longer and E/A ratio as well as E'/A' ratio lower in SLE of long disease duration versus the short one. In older patients, peak velocity at the time of atrial contraction (A) and A' values were higher and peak early velocity wave (E), early diastolic velocity (E'), E/A ratio and E'/A' ratio lower than in the younger subset. Increased the value of SLEDAI correlated with increased A' and decreased E, E/A ratio and E'/A' ratio in SLE subjects. Further analysis concerning the strong connection of these parameters with patients' age, however, revealed no statistically significant correlation between SLEDAI values and LV diastolic function parameters. In long (>10 years) disease duration LV diastolic properties were worse.

IntroductionAtrial fibrillation (AF) is the most common clinically relevant arrhythmia and it is strongly associated with stroke. Left atrial appendage (LAA) is considered to be the most often source of thrombotic material. In recent decades a number surgical, percutaneous and hybrid approaches for LAA occlusion have been described revealing very different level of success and showing a variety of challenges associated with this matter. We present the first Polish experience with the stand-alone totally thoracoscopic LAA exclusion using novel clipping system.Material and methodsFour patients (one male) in mean age of 74 (± 13) years with long-standing persistent and chronic AF were admitted for totally thoracoscopic LAA exclusion. All patients had significant comorbidities and the history of the oral anticoagulation intolerance or suboptimal/unstable level (CHA2DS2-VASC > 5, HAS_BLED > 3). Three procedures were performed through totally thoracoscopic access. In one patient due to massive adhesions in the left pleura we performed minithoracotomy in fourth left intercostal space. In two months follow-up we observed no mortality, no strokes and no bleedings.ResultsIn all patient total exclusion of LAA with no residual remnant was confirmed. The “skin-to-skin” procedural time took on average 40, minimum 20 minutes. Patients were extubated directly or within two hours after procedure. All patients were discharged early in a good condition.ConclusionsOur initial first experience with the novel totally thoracoscopic clipping system for stand-alone LAA exclusion is very promising showing very high efficacy and good safety profile.

POLSKIE ARCHIWUM MEDYCYNY WEWNĘTRZNEJ 2015; 125 (9) 690 parietal-temporal-occipital region of the left brain hemisphere (FIGURE 1AB). Transthoracic echocardiography (TTE) demonstrated dilated right heart cavities with right ventricular hypokinesis, elevated arterial pulmonary pressure of 51 mmHg, and a floating echogenic mass of 10 × 40 mm in the right atrium (RA). Transesophageal echocardiography (TEE) revealed a large 55-mm long thrombus in the RA passing through PFO to the left atrium and partly moving during contraction to the left ventricle (FIGURE 1C-F). Owing to a very high probability of pulmonary embolism (PE) on TTE and TEE, we decided not to perform CT pulmonary angiography. Because the patient did not agree to surgical thrombectomy, a treatment with enoxaparine was started. After 11 days of therapy with low-molecular-weight heparin, control TEE revealed no thrombus in heart cavities (FIGURE 1D). The patient was scheduled for percutaneous closure of the PFO and discharged after the procedure on the 22nd day of hospitalization.A thrombus trapped in the PFO is a very rare finding, mainly manifesting with paradoxical Patent foramen ovale (PFO) is an increasingly studied cause of paradoxical embolism, which may lead to cryptogenic stroke. Owing to its transient nature, it is virtually impossible to identify the embolus at the time of clinical presentation. Echocardiography and other noninvasive imaging modalities remain the basic diagnostic tools in this condition. Because of its rarity, the management of PFO-trapped thrombi has not been well established so far. We report a very rare case of a large thrombus entrapped in PFO complicated by pulmonary embolism and ischemic stroke, successfully treated noninvasively.A 69-year-old extremely obese woman presented at the Department of Neurology with a 1-day history of aphasia, shortness of breath, unspecified chest pain, and dyspnea. A physical examination at baseline revealed mixed sensorimotor aphasia, right Babinski sign, heart rate of 66 bpm, blood pressure of 150/80 mmHg, and oxygen saturation of 96% without oxygen supplementation. A computed tomography (CT) scan showed acute stroke of the left half of the cerebellum and

StreszczenieW pracy przedstawiono przypadek nietypowej intermitującej niedomykalności protezy aortalnej typu Advantage firmy Medtronic stwierdzonej przypadkowo podczas kontrolnego badania echokardiograficznego u pacjenta poddanego wcześniej zabiegowi wymiany zastawki aortalnej i aorty wstępującej z powodu złożonej wady z tętniakiem aorty wstępującej. Świa-domość istnienia opisywanej wady konstrukcyjnej protezy pozwoliła uchronić pacjenta przed reoperacją. Słowa kluczowe: proteza zastawki aortalnej, intermitująca niedomykalność aortalna. AbstractWe present a case of clinical echocardiographic assessment of the Medtronic ADVANTAGE prosthetic valve in the aortic position which revealed a phenomenon identified as "intermittent regurgitation". Awareness of this pathology allowed us to avoid an unnecessary reoperation. Key words: prosthetic aortic valve, intermittent aortic regurgitation. DZIELIMY SIĘ DOŚWIADCZENIEM WstępBadanie echokardiograficzne protez zastawkowych serca jest podstawową metodą oceny ich stanu. Pozwala ocenić funkcję protezy i wykryć zaburzenia związane z takimi patologiami, jak skrzepliny, wegetacje, tworzenie się łuszczki (łac. pannus), czy pojawianiem się patologicznych fal zwrotnych. Poza schorzeniami prowadzącymi do dysfunkcji zastawki należy pamiętać o możliwości ujawnienia się fabrycznych wad protez. Opis przypadkuMężczyzna, 50 lat, został skierowany do Pracowni Echokardiografii Kliniki Kardiologii Zachowawczej i Nadciśnienia Tętniczego CSK MSWiA w Warszawie z powodu stwierdzonej w kontrolnym badaniu echokardiograficznym przezklatkowym (ang. transthoracic echocardiography -TTE) dysfunkcji wszczepionej około pół roku wcześniej sztucznej zastawki aortalnej Medtronic Advantage 23 mm ze wstawką nadaortalną Vascutec 32 mm. Pacjenta zakwalifikowano do zabiegu z powodu istotnej hemodynamicznie złożonej wady aortalnej z poszerzeniem aorty wstępującej do 5,2 cm. Wymiar koń-coworozkurczowy lewej komory wynosił wówczas 79 mm, a frakcja wyrzucania lewej komory była obniżona do 40%. Przebieg okołooperacyjny był niepowikłany. W kolejnych badaniach echokardiograficznych (TTE) wykonanych w 3. i 5. miesiącu po zabiegu stwierdzono normalizację wymiaru lewej komory i poprawę kurczliwości jej ścian. Utrzymywały się nieco podwyższone gradienty ciśnień przez ujście aortalne odpowiednio 43/25 mm Hg i 50/28 mm Hg, co mogło wynikać z relatywnie wąskiego pierścienia protezy oraz niewielki centralny strumień niedomykalności interpretowany jako nieszczelność konstrukcyjna. W kolejnym, wykonanym w 6. miesiącu po zabiegu, badaniu echokardiograficznym stwierdzono pojawianie się nietypowej fali zwrotnej o umiarkowanym nasileniu. Fala niedomykalności pojawiała się nieregularnie co kilka ewolucji serca, co sugerowało jej inne niż przeciek okołoaortalny pochodzenie. Pacjenta zakwalifiko-