146
Letters to the Editor
http://dx.doi.org/10.1016/j.ijcard.2014.03.159 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Endovascular management of splenic arterial aneurysms Konstantinos Marmagkiolis a,⁎, Freij Gobal b, David Mego b, Mehmet Cilingiroglu b, William Rollefson b a b
Citizens Memorial Hospital, Heart and Vascular Institute, Bolivar, MO, United States Arkansas Heart Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, United States
a r t i c l e
i n f o
Article history: Received 7 February 2014 Accepted 22 March 2014 Available online 29 March 2014 Keywords: Endovascular Splenic Aneurysm
Splenic artery aneurysms are the third most common arterial aneurysms ranging from 0.6 to 30 cm in diameter. They are most commonly found women and in patients with cirrhosis and portal hypertension. The majority of patients are asymptomatic [1]. The causes of splenic artery aneurysm formation remain unknown. Atherosclerosis, focal arterial inflammation, pancreatitis, hypersplenism, portal hypertension, trauma, and hormonal and hemodynamic changes due to pregnancy have been proposed as contributing mechanisms [2]. Ultrasound is the first screening imaging modality, while computed tomography (CT) and magnetic resonance imaging (MRI) angiography allow the accurate description of the morphology and location of the aneurysm along with possible adjacent anatomic pathologies. Overall, the life-time risk of rupture is 2–10% with an associated mortality of up to 25%. The risk of rupture is approximately three times more in men and in smokers [1,3]. Currently, there is no data describing risk factors for splenic artery aneurysm rupture, even in relation to the lesion location or size. Smaller, incidentally identified splenic aneurysms are benign with minimal risk of symptom development, enlargement or rupture. According to the ACC/AHA guidelines open or percutaneous management of such aneurysms is recommended for visceral aneurysms measuring 2.0 cm in diameter or larger [4]. Options include open surgical, laparoscopic and endovascular approach. In the past open laparotomy with aneurysm ligation or splenectomy with potential distal pancreatectomy was the gold standard for the treatment of SAA [5,6]. However, surgical or laparoscopic management may be technically difficult in patients with arterial anomalous variations (especially retro-pancreatic course of the SAA), severe anemia or Jehovah witnesses [5]. Emergent open surgery carries a high peri-operative mortality of 20–40% especially in patients with portal or systemic hypertension, while in elective cases it is approximately 5% [7]. Coil embolization is currently the most common endovascular technique to occlude the aneurysmal sac in SAAs with narrow necks. With optimal patient selection it appears to be simple, safe with low rates of recurrence [5,8]. Need for reintervention or major splenic infarction occurs in less than 10% of the cases in patients with normal hepatosplenic function, while complication increases in patients with portal hypertension [8]. Gelfoam, glue, thrombin or the
⁎ Corresponding author at: FSCAI Citizens Memorial Hospital, Heart and Vascular Institute 1500 N Oakland RdBolivar MO 65613 United States.
Amplatzer vascular plug (AVP) embolization have also been successfully tried [9–12]. In larger vessels with complex wide-neck aneurysms, covered stents or stent assisted coil embolization (cage– coil technique: self-expanding stent placement and delivery of the coils to the aneurysmal sac through the stent struts) has been successfully tried [13–16]. When collateral circulation is well developed the “sandwich technique” involves complete occlusion of the splenic artery with coiling of the efferent and the afferent vessel [17,18]. Pappy et al. have described a unique “modified neck remodeling technique” for large wide-neck aneurysms with temporary balloon inflation at the efferent splenic artery during coil embolization, in order to decrease the intra-aneurysm pressure and prevent distal non-target coil embolization [19]. A 65-year-old gentleman with prior history of hypertension, and chronic bronchitis was referred with a 2.7 cm narrow neck splenic artery aneurysm for endovascular management (Figs. 1, 2). The procedure was performed in the catheterization laboratory under conscious sedation. A short 6-French hydrophilic sheath was placed in the left radial artery. A Tiger catheter (Terumo Interventional Systems) was positioned at the origin of the celiac artery where selective angiography was performed (Fig. 3). A 4F Glidecath (Terumo Interventional Systems) was advanced into the aneurysm sac with the assistance of a 0.018-inch guidewire. Angiography was performed through the Glidecath to accurately describe the aneurysm location and morphology. Four AZUR peripheral hydrocoils (Terumo Interventional Systems) were delivered in the aneurysm sac. Post-intervention angiography confirmed optimal
Fig. 1. CT angiogram of the splenic arterial aneurysm.
Letters to the Editor
147
Fig. 2. CT angiogram with 3D reconstruction demonstrating the splenic arterial aneurysm.
filling of the sac with absence of flow (Fig. 4). In-hospital course was uneventful, and the patient was discharged home the same day. At 1month follow-up, the patient remained asymptomatic, and a repeat CT angiogram showed excellent sealing of the splenic artery aneurysm (Figs. 5, 6).
Splenic arterial aneurysms are still considered a “surgical” disease and they are rarely referred to interventional cardiologists or radiologists. Open surgery even for elective cases still carries mortality of up to 5% with increased morbidity and longer hospital stays. Experience over the last years has demonstrated that
Fig. 3. Selective angiogram of the celiac artery.
Fig. 4. Selective angiogram of the celiac artery after coil embolization.
148
Letters to the Editor
Fig. 5. CT angiogram after coil embolization.
endovascular management is safe and effective for the elective nonruptured SAAs. In our case with the use of transradial technique, which has evolved from an “exotic” access to the default access site in many high-volume centers throughout the world, the patient returned home the same day with excellent results.
SAAs remain a common disease with potential morbidity and mortality. Open surgery remains the gold standard for its management with non-negligible morbidity and mortality. Endovascular approaches (coils, gelfoam, glue, thrombin, AVPs, stents) have allowed their successful management with significant improvement
Fig. 6. CT angiogram with 3D reconstruction after coil embolization.
Letters to the Editor
in morbidity, length of stay and patient comfort. With the growing experience combined with the optimization of transcatheter devices, it appears that SAAs will be soon managed in the catheterization lab even as an outpatient endovascular procedure. References [1] Abbas MA, Stone WM, Fowl RJ, et al. Splenic artery aneurysms: two decades experience at Mayo clinic. Ann Vasc Surg 2002;16(4):442–9. [2] Huang YK, Hsieh HC, Tsai FC, Chang SH, Lu MS, Ko PJ. Visceral artery aneurysm: risk factor analysis and therapeutic opinion. Eur J Vasc Endovasc Surg 2007;33(3):293–301. [3] Lakin RO, Bena JF, Sarac TP, et al. The contemporary management of splenic artery aneurysms. J Vasc Surg 2011;53(4):958–64 [discussion 65]. [4] Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006;113(11):e463–654. [5] Borioni R, De Persio G, Leporace M, Di Capua C, Boggi U, Garofalo M. Endovascular treatment of multiple anomalous splenic artery aneurysms in a Jehovah witness. G Chir 2013;34(1–2):42–5. [6] Miao YD, Ye B. Intragastric rupture of splenic artery aneurysms: three case reports and literature review. Pak J Med Sci 2013;29(2):656–9. [7] Lee PC, Rhee RY, Gordon RY, Fung JJ, Webster MW. Management of splenic artery aneurysms: the significance of portal and essential hypertension. J Am Coll Surg 1999;189(5):483–90.
149
[8] Patel A, Weintraub JL, Nowakowski FS, et al. Single-center experience with elective transcatheter coil embolization of splenic artery aneurysms: technique and midterm follow-up. J Vasc Interv Radiol 2012;23(7):893–9. [9] Kemmeter P, Bonnell B, VanderKolk W, Griggs T, VanErp J. Percutaneous thrombin injection of splanchnic artery aneurysms: two case reports. J Vasc Interv Radiol 2000;11(4):469–72. [10] Zhu X, Tam MD, Pierce G, et al. Utility of the Amplatzer Vascular Plug in splenic artery embolization: a comparison study with conventional coil technique. Cardiovasc Intervent Radiol 2011;34(3):522–31. [11] Carmo M, Mercandalli G, Rampoldi A, et al. Transcatheter thrombin embolization of a giant visceral artery aneurysm. J Cardiovasc Surg (Torino) 2008;49(6):777–82. [12] Carrafiello G, Lagana D, Dizonno M, Mangini M, Fugazzola C. Endovascular ligature of splenic artery aneurysm with Amplatzer Vascular Plug: a case report. Cardiovasc Revasc Med 2007;8(3):203–6. [13] Stella N, Palombo G, Taddeo C, Rizzo L, Taurino M. Stent-assisted coil embolization of a complex wide-neck splenic artery aneurysm. Ann Vasc Surg 2013;27(8):e5–8. [14] Rossi M, Rebonato A, Greco L, Citone M, David V. Endovascular exclusion of visceral artery aneurysms with stent-grafts: technique and long-term follow-up. Cardiovasc Intervent Radiol 2008;31(1):36–42. [15] Schoppe KA, Ciacci J, Bettmann M. Modified stent-supported coil embolization for treatment of a splenic artery pseudoaneurysm. J Vasc Interv Radiol 2010;21(9):1452–6. [16] Aslam MS, Shalev Y. Treatment of splenic artery aneurysm with polytetrafluoroethylene-covered stent. Catheter Cardiovasc Interv 2010;76(2):229–32. [17] Loffroy R, Guiu B, Cercueil JP, et al. Transcatheter arterial embolization of splenic artery aneurysms and pseudoaneurysms: short- and long-term results. Ann Vasc Surg 2008;22(5):618–26. [18] Xin J, Xiao-Ping L, Wei G, et al. The endovascular management of splenic artery aneurysms and pseudoaneurysms. Vascular 2011;19(5):257–61. [19] Pappy R, Sech C, Hennebry TA. Giant splenic artery aneurysm: managed in the cardiovascular catheterization laboratory using the modified neck remodeling technique. Catheter Cardiovasc Interv 2010;76(4):590–4.
http://dx.doi.org/10.1016/j.ijcard.2014.03.158 0167-5273/© 2014 Published by Elsevier Ireland Ltd.
High BNP levels in rheumatoid arthritis may be related with right ventricular functions Cengiz Ozturk a,⁎, Sevket Balta b, Sait Demirkol a, Ahmet Ozturk c, Turgay Celik a, Atila Iyisoy a a b c
Gulhane Medical Faculty, Department of Cardiology, Ankara, Turkey Eskisehir Military Hospital, Department of Cardiology, Eskisehir, Turkey Gulhane Medical Faculty, Department of Geriatric Medicine, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 8 February 2014 Accepted 22 March 2014 Available online 28 March 2014 Keywords: B-type natriuretic peptide Rheumatoid arthritis Right ventricular functions
Dear Editor, We read the article entitled “High BNP levels in rheumatoid arthritis are related to inflammation but not to left ventricular abnormalities” by George et al. with interest [1]. They concluded that there was a relationship between inflammation and B-type natriuretic peptide (BNP) but not in left ventricular hypertrophy. The value of BNP is well known in the diagnosis of left ventricular dysfunction [2]. But there are some contradictory researches about the
BNP, inflammation and left–right systolic and diastolic dysfunctions [3–5]. In a recent study, no correlations between inflammatory and functional disease parameters of systolic and diastolic function were found [6]. On the other hand, another study revealed that left and right ventricular tissue doppler imaging parameters of rheumatoid arthritis (RA) patients were impaired [7]. It was shown that serum BNP and NT-proBNP levels may be related with elevated pulmonary arterial systolic pressure (PASP) at high altitude in another study [8]. We know that PASP may contribute to the high incidence of cardiovascular events in patients with RA and RA affects the right ventricle via pulmonary hypertension and right ventricular dysfunction [9]. However, the measurement of the degree of left ventricular hypertrophy, PASP, right systolic and diastolic dysfunction parameters were not reported by George et al. [1]. In addition, if rheumatoid arthritis patients with pulmonary hypertension, right heart dilatation and tricuspid regurgitation were included, a comparison could have been made between parameters. The contribution of serum BNP level to RA has not been fully clarified. References
⁎ Corresponding author. Tel.: +90 533 4875060. E-mail address: [email protected] (C. Ozturk).
[1] George J, Mackle G, Manoharan A, Khan F, Struthers AD. High BNP levels in rheumatoid arthritis are related to inflammation but not to left ventricular
Letters to the Editor
http://dx.doi.org/10.1016/j.ijcard.2014.03.159 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
Endovascular management of splenic arterial aneurysms Konstantinos Marmagkiolis a,⁎, Freij Gobal b, David Mego b, Mehmet Cilingiroglu b, William Rollefson b a b
Citizens Memorial Hospital, Heart and Vascular Institute, Bolivar, MO, United States Arkansas Heart Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, United States
a r t i c l e
i n f o
Article history: Received 7 February 2014 Accepted 22 March 2014 Available online 29 March 2014 Keywords: Endovascular Splenic Aneurysm
Splenic artery aneurysms are the third most common arterial aneurysms ranging from 0.6 to 30 cm in diameter. They are most commonly found women and in patients with cirrhosis and portal hypertension. The majority of patients are asymptomatic [1]. The causes of splenic artery aneurysm formation remain unknown. Atherosclerosis, focal arterial inflammation, pancreatitis, hypersplenism, portal hypertension, trauma, and hormonal and hemodynamic changes due to pregnancy have been proposed as contributing mechanisms [2]. Ultrasound is the first screening imaging modality, while computed tomography (CT) and magnetic resonance imaging (MRI) angiography allow the accurate description of the morphology and location of the aneurysm along with possible adjacent anatomic pathologies. Overall, the life-time risk of rupture is 2–10% with an associated mortality of up to 25%. The risk of rupture is approximately three times more in men and in smokers [1,3]. Currently, there is no data describing risk factors for splenic artery aneurysm rupture, even in relation to the lesion location or size. Smaller, incidentally identified splenic aneurysms are benign with minimal risk of symptom development, enlargement or rupture. According to the ACC/AHA guidelines open or percutaneous management of such aneurysms is recommended for visceral aneurysms measuring 2.0 cm in diameter or larger [4]. Options include open surgical, laparoscopic and endovascular approach. In the past open laparotomy with aneurysm ligation or splenectomy with potential distal pancreatectomy was the gold standard for the treatment of SAA [5,6]. However, surgical or laparoscopic management may be technically difficult in patients with arterial anomalous variations (especially retro-pancreatic course of the SAA), severe anemia or Jehovah witnesses [5]. Emergent open surgery carries a high peri-operative mortality of 20–40% especially in patients with portal or systemic hypertension, while in elective cases it is approximately 5% [7]. Coil embolization is currently the most common endovascular technique to occlude the aneurysmal sac in SAAs with narrow necks. With optimal patient selection it appears to be simple, safe with low rates of recurrence [5,8]. Need for reintervention or major splenic infarction occurs in less than 10% of the cases in patients with normal hepatosplenic function, while complication increases in patients with portal hypertension [8]. Gelfoam, glue, thrombin or the
⁎ Corresponding author at: FSCAI Citizens Memorial Hospital, Heart and Vascular Institute 1500 N Oakland RdBolivar MO 65613 United States.
Amplatzer vascular plug (AVP) embolization have also been successfully tried [9–12]. In larger vessels with complex wide-neck aneurysms, covered stents or stent assisted coil embolization (cage– coil technique: self-expanding stent placement and delivery of the coils to the aneurysmal sac through the stent struts) has been successfully tried [13–16]. When collateral circulation is well developed the “sandwich technique” involves complete occlusion of the splenic artery with coiling of the efferent and the afferent vessel [17,18]. Pappy et al. have described a unique “modified neck remodeling technique” for large wide-neck aneurysms with temporary balloon inflation at the efferent splenic artery during coil embolization, in order to decrease the intra-aneurysm pressure and prevent distal non-target coil embolization [19]. A 65-year-old gentleman with prior history of hypertension, and chronic bronchitis was referred with a 2.7 cm narrow neck splenic artery aneurysm for endovascular management (Figs. 1, 2). The procedure was performed in the catheterization laboratory under conscious sedation. A short 6-French hydrophilic sheath was placed in the left radial artery. A Tiger catheter (Terumo Interventional Systems) was positioned at the origin of the celiac artery where selective angiography was performed (Fig. 3). A 4F Glidecath (Terumo Interventional Systems) was advanced into the aneurysm sac with the assistance of a 0.018-inch guidewire. Angiography was performed through the Glidecath to accurately describe the aneurysm location and morphology. Four AZUR peripheral hydrocoils (Terumo Interventional Systems) were delivered in the aneurysm sac. Post-intervention angiography confirmed optimal
Fig. 1. CT angiogram of the splenic arterial aneurysm.
Letters to the Editor
147
Fig. 2. CT angiogram with 3D reconstruction demonstrating the splenic arterial aneurysm.
filling of the sac with absence of flow (Fig. 4). In-hospital course was uneventful, and the patient was discharged home the same day. At 1month follow-up, the patient remained asymptomatic, and a repeat CT angiogram showed excellent sealing of the splenic artery aneurysm (Figs. 5, 6).
Splenic arterial aneurysms are still considered a “surgical” disease and they are rarely referred to interventional cardiologists or radiologists. Open surgery even for elective cases still carries mortality of up to 5% with increased morbidity and longer hospital stays. Experience over the last years has demonstrated that
Fig. 3. Selective angiogram of the celiac artery.
Fig. 4. Selective angiogram of the celiac artery after coil embolization.
148
Letters to the Editor
Fig. 5. CT angiogram after coil embolization.
endovascular management is safe and effective for the elective nonruptured SAAs. In our case with the use of transradial technique, which has evolved from an “exotic” access to the default access site in many high-volume centers throughout the world, the patient returned home the same day with excellent results.
SAAs remain a common disease with potential morbidity and mortality. Open surgery remains the gold standard for its management with non-negligible morbidity and mortality. Endovascular approaches (coils, gelfoam, glue, thrombin, AVPs, stents) have allowed their successful management with significant improvement
Fig. 6. CT angiogram with 3D reconstruction after coil embolization.
Letters to the Editor
in morbidity, length of stay and patient comfort. With the growing experience combined with the optimization of transcatheter devices, it appears that SAAs will be soon managed in the catheterization lab even as an outpatient endovascular procedure. References [1] Abbas MA, Stone WM, Fowl RJ, et al. Splenic artery aneurysms: two decades experience at Mayo clinic. Ann Vasc Surg 2002;16(4):442–9. [2] Huang YK, Hsieh HC, Tsai FC, Chang SH, Lu MS, Ko PJ. Visceral artery aneurysm: risk factor analysis and therapeutic opinion. Eur J Vasc Endovasc Surg 2007;33(3):293–301. [3] Lakin RO, Bena JF, Sarac TP, et al. The contemporary management of splenic artery aneurysms. J Vasc Surg 2011;53(4):958–64 [discussion 65]. [4] Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease): endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation. Circulation 2006;113(11):e463–654. [5] Borioni R, De Persio G, Leporace M, Di Capua C, Boggi U, Garofalo M. Endovascular treatment of multiple anomalous splenic artery aneurysms in a Jehovah witness. G Chir 2013;34(1–2):42–5. [6] Miao YD, Ye B. Intragastric rupture of splenic artery aneurysms: three case reports and literature review. Pak J Med Sci 2013;29(2):656–9. [7] Lee PC, Rhee RY, Gordon RY, Fung JJ, Webster MW. Management of splenic artery aneurysms: the significance of portal and essential hypertension. J Am Coll Surg 1999;189(5):483–90.
149
[8] Patel A, Weintraub JL, Nowakowski FS, et al. Single-center experience with elective transcatheter coil embolization of splenic artery aneurysms: technique and midterm follow-up. J Vasc Interv Radiol 2012;23(7):893–9. [9] Kemmeter P, Bonnell B, VanderKolk W, Griggs T, VanErp J. Percutaneous thrombin injection of splanchnic artery aneurysms: two case reports. J Vasc Interv Radiol 2000;11(4):469–72. [10] Zhu X, Tam MD, Pierce G, et al. Utility of the Amplatzer Vascular Plug in splenic artery embolization: a comparison study with conventional coil technique. Cardiovasc Intervent Radiol 2011;34(3):522–31. [11] Carmo M, Mercandalli G, Rampoldi A, et al. Transcatheter thrombin embolization of a giant visceral artery aneurysm. J Cardiovasc Surg (Torino) 2008;49(6):777–82. [12] Carrafiello G, Lagana D, Dizonno M, Mangini M, Fugazzola C. Endovascular ligature of splenic artery aneurysm with Amplatzer Vascular Plug: a case report. Cardiovasc Revasc Med 2007;8(3):203–6. [13] Stella N, Palombo G, Taddeo C, Rizzo L, Taurino M. Stent-assisted coil embolization of a complex wide-neck splenic artery aneurysm. Ann Vasc Surg 2013;27(8):e5–8. [14] Rossi M, Rebonato A, Greco L, Citone M, David V. Endovascular exclusion of visceral artery aneurysms with stent-grafts: technique and long-term follow-up. Cardiovasc Intervent Radiol 2008;31(1):36–42. [15] Schoppe KA, Ciacci J, Bettmann M. Modified stent-supported coil embolization for treatment of a splenic artery pseudoaneurysm. J Vasc Interv Radiol 2010;21(9):1452–6. [16] Aslam MS, Shalev Y. Treatment of splenic artery aneurysm with polytetrafluoroethylene-covered stent. Catheter Cardiovasc Interv 2010;76(2):229–32. [17] Loffroy R, Guiu B, Cercueil JP, et al. Transcatheter arterial embolization of splenic artery aneurysms and pseudoaneurysms: short- and long-term results. Ann Vasc Surg 2008;22(5):618–26. [18] Xin J, Xiao-Ping L, Wei G, et al. The endovascular management of splenic artery aneurysms and pseudoaneurysms. Vascular 2011;19(5):257–61. [19] Pappy R, Sech C, Hennebry TA. Giant splenic artery aneurysm: managed in the cardiovascular catheterization laboratory using the modified neck remodeling technique. Catheter Cardiovasc Interv 2010;76(4):590–4.
http://dx.doi.org/10.1016/j.ijcard.2014.03.158 0167-5273/© 2014 Published by Elsevier Ireland Ltd.
High BNP levels in rheumatoid arthritis may be related with right ventricular functions Cengiz Ozturk a,⁎, Sevket Balta b, Sait Demirkol a, Ahmet Ozturk c, Turgay Celik a, Atila Iyisoy a a b c
Gulhane Medical Faculty, Department of Cardiology, Ankara, Turkey Eskisehir Military Hospital, Department of Cardiology, Eskisehir, Turkey Gulhane Medical Faculty, Department of Geriatric Medicine, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 8 February 2014 Accepted 22 March 2014 Available online 28 March 2014 Keywords: B-type natriuretic peptide Rheumatoid arthritis Right ventricular functions
Dear Editor, We read the article entitled “High BNP levels in rheumatoid arthritis are related to inflammation but not to left ventricular abnormalities” by George et al. with interest [1]. They concluded that there was a relationship between inflammation and B-type natriuretic peptide (BNP) but not in left ventricular hypertrophy. The value of BNP is well known in the diagnosis of left ventricular dysfunction [2]. But there are some contradictory researches about the
BNP, inflammation and left–right systolic and diastolic dysfunctions [3–5]. In a recent study, no correlations between inflammatory and functional disease parameters of systolic and diastolic function were found [6]. On the other hand, another study revealed that left and right ventricular tissue doppler imaging parameters of rheumatoid arthritis (RA) patients were impaired [7]. It was shown that serum BNP and NT-proBNP levels may be related with elevated pulmonary arterial systolic pressure (PASP) at high altitude in another study [8]. We know that PASP may contribute to the high incidence of cardiovascular events in patients with RA and RA affects the right ventricle via pulmonary hypertension and right ventricular dysfunction [9]. However, the measurement of the degree of left ventricular hypertrophy, PASP, right systolic and diastolic dysfunction parameters were not reported by George et al. [1]. In addition, if rheumatoid arthritis patients with pulmonary hypertension, right heart dilatation and tricuspid regurgitation were included, a comparison could have been made between parameters. The contribution of serum BNP level to RA has not been fully clarified. References
⁎ Corresponding author. Tel.: +90 533 4875060. E-mail address: [email protected] (C. Ozturk).
[1] George J, Mackle G, Manoharan A, Khan F, Struthers AD. High BNP levels in rheumatoid arthritis are related to inflammation but not to left ventricular
